Conducting Dental Examinations

Intake Questions

1. What is the patient's chief complaint in their own words?
2. Has the medical history changed since the last visit (new diagnoses, medications, allergies, hospitalizations)?
3. Is the patient taking anticoagulants, bisphosphonates, immunosuppressants, or medications causing xerostomia?
4. Does the patient have a history of infective endocarditis, prosthetic cardiac valves, or conditions requiring antibiotic prophylaxis per AHA 2021 guidelines?
5. Is there a history of head/neck radiation, chemotherapy, or organ transplant?
6. Does the patient report jaw pain, clicking, locking, or bruxism symptoms?
7. Has the patient noticed any sores, lumps, or color changes in the mouth?
8. What is the patient's tobacco, alcohol, and recreational drug use history?

Step 1 — Extraoral Examination

Perform a systematic head and neck evaluation before entering the oral cavity.

• Facial symmetry: Observe frontal and profile views for asymmetry suggesting pathology or swelling
• Lymph node palpation: Bilateral palpation of submandibular, submental, cervical chain, and supraclavicular nodes; document size, tenderness, mobility, and consistency of any palpable nodes
• TMJ assessment: Palpate bilateral TMJ during opening, closing, and lateral excursion; note clicking, crepitus, deviation on opening, and maximum interincisal opening (normal 40–55 mm)
• Salivary glands: Palpate parotid, submandibular, and sublingual glands for enlargement or tenderness; milk Stensen's and Wharton's ducts to check salivary flow
• Skin and lips: Inspect for lesions, actinic cheilitis, angular cheilitis, or suspicious pigmented areas
• Cranial nerve screen: Assess CN V (trigeminal) and CN VII (facial) function with light touch and motor tests when neuropathy is suspected

Step 2 — Intraoral Soft Tissue Examination and Oral Cancer Screening

Complete a systematic mucosal evaluation per ADA oral cancer screening recommendations.

• Labial mucosa and vestibule: Evert upper and lower lips; inspect for mucoceles, fibromas, or leukoplakia
• Buccal mucosa: Bilateral inspection with cheek retraction; note linea alba, Fordyce granules (normal variants), and any white, red, or ulcerated lesions
• Hard and soft palate: Direct and mirror-assisted inspection; palpate hard palate for tori or bony exostoses
• Tongue: Inspect dorsal, ventral, and lateral borders; lateral tongue is the highest-risk site for squamous cell carcinoma
• Floor of mouth: Bimanual palpation; note ranulas, sialoliths, or induration
• Oropharynx and tonsillar pillars: Inspect with tongue depressor; note asymmetry, exophytic lesions, or tonsillar hypertrophy
• Gingiva: Color, contour, consistency, and texture assessment on buccal and lingual of all sextants
• Documentation rule: Any lesion present > 14 days without resolution requires biopsy referral; record size (mm), color, location (using clock-face or tooth-relative notation), surface texture, and induration

Step 3 — Dental Hard Tissue Examination

Chart every tooth using Universal Numbering System (1–32 for permanent, A–T for primary).

• Existing restorations: Record type (amalgam, composite, ceramic, gold), surfaces involved (using MODBL notation), and condition (intact, defective margin, recurrent caries, fractured)
• Caries detection: Visual-tactile examination with explorer and mirror under adequate lighting and air-drying; classify as incipient (enamel only), moderate (into dentin), or advanced (pulp involvement risk); correlate with radiographic findings
• Tooth structure: Note fractures (craze lines, cracks, cuspal fractures) using ADA crack classification; document wear facets (attrition, abrasion, erosion, abfraction) with severity grading
• Missing teeth: Record with reason when known (extracted, congenitally absent, impacted)
• Tooth mobility: Grade using Miller classification (Grade I: < 1 mm horizontal, Grade II: > 1 mm horizontal, Grade III: horizontal and vertical depressibility)
• Occlusal analysis: Angle's classification (Class I, II div 1, II div 2, III), overjet/overbite measurement in mm, crossbites, open bite, premature contacts with articulating paper

Step 4 — Periodontal Charting

Record six-point probing depths and clinical attachment levels per AAP guidelines.

• Probing depths: Six sites per tooth (mesiobuccal, buccal, distobuccal, mesiolingual, lingual, distolingual) recorded in millimeters with calibrated probe (e.g., UNC-15 or Williams)
• Clinical attachment level (CAL): Calculated as probing depth + recession (or − hyperplasia) from CEJ
• Bleeding on probing (BOP): Record as present/absent at each site; > 10% BOP sites indicates active inflammation per AAP/EFP 2017 consensus
• Recession: Measured from CEJ to free gingival margin in mm; classify using Miller Classification (Class I–IV) or Cairo RT1/RT2/RT3
• Furcation involvement: Grade using Glickman classification (Grade I–IV) or Hamp classification for mandibular and maxillary molars
• Mucogingival defects: Measure width of attached gingiva (mucogingival junction to free gingival margin minus sulcus depth)
• Plaque and calculus: Record distribution using a plaque index (e.g., O'Leary Plaque Control Record) and calculus index

Step 5 — Radiographic Correlation

Integrate imaging findings with clinical examination per ADA/FDA radiographic selection criteria.

• Bitewing assessment: Interproximal caries (RI, RE, RD classifications), crestal bone levels, calculus deposits, overhanging restorations
• Periapical assessment: Periapical radiolucencies (size in mm), root morphology, root resorption, PDL widening, lamina dura continuity, endodontic treatment status
• Panoramic findings: Impacted teeth, cysts, pathologic lesions, condylar morphology, maxillary sinus pneumatization, carotid artery calcifications
• CBCT indications: Document rationale if CBCT is recommended per AAE/AAOMR position statement (e.g., complex endodontic anatomy, implant planning, impaction assessment, pathology characterization)
• Correlation rule: Every radiographic finding must have a corresponding clinical chart entry; every clinically suspicious finding must have radiographic documentation or a note explaining why imaging was deferred

Step 6 — Risk Assessment and Diagnosis Synthesis

Consolidate findings into a problem list with risk stratification.

• Caries risk assessment: Use ADA Caries Risk Assessment Form or CAMBRA protocol; classify as low, moderate, or high risk based on fluoride exposure, salivary factors, diet, bacterial challenge, and clinical indicators
• Periodontal diagnosis: Apply AAP/EFP 2018 Classification (Stage I–IV, Grade A–C) with primary descriptor and modifying factors
• Oral cancer risk: Stratify based on tobacco/alcohol use, HPV status if known, age > 40, history of prior oral lesions
• Problem list format: Each problem numbered with tooth/site reference, diagnosis, and urgency (emergent, urgent, elective)
• ASA classification: Document physical status classification (ASA I–VI) for treatment planning context

Checkpoint B — Examination Completeness Review

Before finalizing the examination record, verify:

• All teeth charted with existing restorations, caries, and missing teeth documented
• Full six-point periodontal charting completed with BOP recorded
• Extraoral and intraoral soft tissue findings documented (or "WNL" explicitly stated per region)
• Radiographic findings correlated with clinical findings
• Oral cancer screening performed and documented
• Occlusal analysis recorded
• Caries risk assessment completed
• Periodontal staging and grading assigned
• Medical history reconciled with dental findings (e.g., xerostomia medication effects noted)
• All findings entered in EHR with appropriate CDT exam code (D0150 or D0120)

Quality Audit

Guidelines

• Use Universal Numbering System (1–32) for permanent teeth and letter designation (A–T) for primary teeth throughout
• Apply ADA/FDA Selection Criteria for Dental Radiographs to justify imaging orders
• Follow AAP/EFP 2018 Classification for all periodontal diagnoses — do not use deprecated terminology (e.g., "chronic periodontitis")
• Document examination findings in real time or immediately after the appointment; retroactive charting degrades accuracy
• Any suspicious soft tissue lesion persisting > 14 days requires biopsy referral with documentation of referral date and receiving provider
• Antibiotic prophylaxis decisions must reference current AHA guidelines and document the clinical rationale
• Flag all findings requiring follow-up with [FOLLOW-UP] tag and target date
• When examination is limited by patient cooperation, medical status, or time constraints, explicitly document the limitation and scope of the exam performed
• All entries must include provider name, date, and signature per state dental board record-keeping requirements