The Art of the Complete Dental Examination

clinical Neeraj Khanna DDS

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The Art of the Complete Dental Examination Part One Introduction Clinical dentistry has evolved to bring patients better materials, treatment choices and outcomes, but the fundamentals of clinical practice have not changed. The art of performing a complete initial examination is the single most important experience a patient can have. In my office, this new patient comprehensive examination entails 12 aspects or steps.

I will review steps 1 to 6 in this article – and steps 7 to 12 in Part Two, in the September issue of Ontario Dentist.

Part One 1. New Patient Interview(NPI) 2. Office Tour 3. Appropriate X-rays 4. TMJ Examination 5. Range of Motion 6. Centric Relation/Load Test/Occlusion

This concept of complete dentistry originated from Dr. Peter Dawson, the founder of the Dawson Academy. In order to practise complete, comprehensive dentistry, one must obtain information pertaining to the patient’s joints, muscles, occlusion and teeth. The procurement of this information is part of performing a comprehensive examination, and allows the dentist to become a physician of the entire masticatory system.

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Part Two – September 2011 7. Muscle Palpation 8. Soft/Hard Tissue 9. Periodontal Probing 10. Intraoral Images 11. Digital Photos 12. Diagnostic Casts/Face Bow/C.R. Bite Record

While the discussion of this article will focus on the importance of these various steps of the complete examination, the objective of this article is to encourage clinicians to take a more comprehensive approach to patient care.

This, in turn, will better educate our patients, and allow them to make informed treatment decisions, leading to greater patient satisfaction and patient retention.

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Discussion As mentioned above, the new patient experience begins as soon as the patient enters the office. From start to finish, this process must be consistent for all new patients. The objective is to precisely gather the correct information and use it to formulate a comprehensive treatment plan. Combining this with the patient’s desires or goals will enable the clinician to bridge the gap between ideal treatment and patient’s expectations. Below are explanations for each step in the comprehensive exam.

1.

2.

Office Tour: The patient is then taken for a complete office tour, making sure that the patient meets and greets all team members throughout the tour. Finally, the patient is seated in the appropriate operatory to begin the examination.

3.

Radiographs: Dental radiographs are necessary to correctly diagnose caries, periodontal disease and other abnormalities. Standard full-mouth series (FMX) Xrays are taken which consist of approximately 18 to 20 images (Figure 2).

New Patient Interview (NPI): One of the goals of the NPI is to fully get to know the patient on all levels.

In addition, the interview process gives the patient the opportunity to ask questions about the practice, dentist, and learn more about the practice philosophy.

This opportunity invites the team member to find a connection with the patient, and to discover personality traits that are effective in communication with the patient. This in turn creates a climate of trust between the team member and the patient.

Figure 2

The NPI begins with a series of four digital photos: 1) full-face smile, 2) close-up smile, 3) upper arch, and 4) lower arch (Figure 1). The new patient is then greeted by the designated team member (i.e. patient co-ordinator or dentist) for the interview, who asks openended questions and gathers relevant information about the patient’s goals, desires and specific needs.

The patient is asked to make reference to the photos and to express any observed concerns, which will give the team member an idea if the patient is esthetically or functionally driven. Once all questions are answered, the patient’s desires and goals are summarized.

4.

TMJ Examination: The temporomandibular joint must be examined in order to determine if there is a possibility of joint disorders. Palpation is first completed while the patient fully opens and closes (Figures 3 and 4), and the patient is asked if there is any tenderness. Any crepitus and/or clicking/popping needs

Figure 3

Figure 1

Figure 4

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to be documented either during opening or closing.

This can be further diagnosed using a Doppler auscultation device which helps the clinician visualize the activity of the condylar disc during joint sounds.7 The Piper classification is used to specifically identify the degree of disc misalignment.1 5.

6.

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Range Of Motion: It is just as important to document the range of the mandibular movements. A ruler (Great Lakes Orthodontics, Tonawanda, NY) is used to measure maximum opening, as well as lateral movements of the mandible (Figure 5). Normal ranges for opening are 48 mm to 60 mm, and lateral movements range from 10 mm to 12 mm.5 The maximum opening is measured by placing the “notched” tip of the ruler on the lower incisal edge and asking the patient to open wide to a comfortable stop (Figure 6). The lateral movements are measured by taking the opposite end of the ruler, and lining up the midline of the ruler to the lower midline of the mandible (Figure 7). The patient is asked to slide their mandible to the left, and then to the right (Figures 8 and 9).

Centric Relation/ Load Test/ Occlusion: Centric Relation is defined as the most anterior superior position of the condylar disc assembly, while the inferior belly of the lateral pterygoid muscle is released (Figure 11).I This joint position is repeatable and reproducible and is considered a reference point for dental treatment.4 “Bi-manual manipulation” is an effective method of verifying centric relation.3 As the name states, both hands are used to hold the mandible in this position. In a manner similar to turning a door knob, the joint is “loaded” with incremental pressure three times (Figure 12). With each “turn” the patient is asked if they feel “tension” or “tenderness”. Tension refers to muscle (specifically the inferior belly of the lateral pterygoid), and tenderness refers to an internal problem within the joint capsule. If both joints can be comfortably loaded with no tension or tenderness, then the patient is asked to close slowly until they feel the first point of contact (Figure 13). At the first point of contact, the patient is asked to “squeeze” their teeth together. Routinely, the mandible shifts away from the premature contact, usually anterior (Figure 14). The purpose in this exercise is to determine if the joints are healthy by loading, and to determine if the patient’s seated joint [CR] position allows all the teeth to come together. In other words, centric relation should equal maximum intercuspation. Finally, the patient’s occlusion is documented along with any working/balancing and protrusive interference.

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Figure 5

Figure 6

Figure 7

Figure 8

Figure 9

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Part Two – September 2011

Figure 11

Dr. Neeraj Khanna attended the University of Toronto and earned his DDS degree at the University Of Detroit MercySchool Of Dentistry in 1993. Dr. Khanna completed a General Practice Residency at the University of Rochester-Strong Memorial Hospital in Rochester, New York in 1994 and opened his dental practice in Geneva, Illinois in 2000. He completed his training at the Dawson Academy in Florida where he is an associate faculty member.

ACKNOWLEDGEMENT: I would like to thank my patient Amanda for giving permission to use her dental records for the use of this article. In addition, I would like to thank Jean Khanna for contributing to this article.

References 1.

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Figure 12

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Figure 13

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Dawson P.E. Functional Occlusion: From TMJ to Smile Design. Mosby Inc. 2007 Dawson P.E. A classification system for occlusion that relates to maximum intercuspation to the position and condition of the temporomandibular joint. J Prosthet Dent. 1996;75:60-6 McKee J.R. Comparing condylar positions achieved through bimanual manipulation to condylar positions achieved through masticatory muscle contraction against an anterior deprogrammer: A pilot study. J Prosthet Dent. 2005; 94: 38993 Tarantola G.J., Becker I.M. and Gremillion H. The reproducibility of centric relation: a clinical approach. J Am Dent Assoc 1997; 128; 1245-1251 Lewis R.P., Buschang P.H. andThrockmorton G.S. Sex differences in mandibular movements during opening and closing. Am J Orthod Dentofacial Orthop: 120(3):294-303, 2001 Sept.

McKee J.R. Comparing condylar position repeatability for standardized versus nonstandardized methods of achieving centric relation. J Prosthet Dent. 1997 Mar; 77(3):280-4.

Motoyoshi M., Hayashi A., Arimoto M., Ohnuma M.and Namura S. Studies of Temporomandibular joint sounds Part 3. The clinical usefulness of TMJ Doppler. J Nihon Univ Sch Dent. 1995 Dec; 37(4):209-13

Figure 14

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