The Comprehensive Exam

A routine search party ensures that the dynamics of dental care is effective and efficient.

A routine search party ensures that the dynamics of dental care is effective and efficient.

by Beverly Maguire, RDH

Most patients come to us with the belief that they know what they need, either based upon their historical perspective or upon their pain and discomfort. We are more than familiar with new patients phoning our practices to schedule a "cleaning" with the hygienist. Excellent communication skills are necessary to assist potential patients in receiving care under protocols that are clinically sound, but often not compatible with the manner in which they are accustomed.

The foundation of all good dental treatment is pertinent evidence gathered and analyzed with the intention of formulating an appropriate diagnosis. In most instances, new patients realize that this information is necessary to determine their current status and appropriate care.

The examination process is detailed and thorough. It requires a fair amount of time and thought to evaluate all of the pertinent information. How does this apply to hygienists, since we cannot "legally" diagnose? For a good number of us, new patients will be placed in the hygiene schedule. In other practices, new patients are seen by the doctor. I have seen the process work effectively in both scenarios. My personal preference is for new patients to be seen by the doctor. Having the initial patient encounter with the doctor establishes a solid relationship that can tie the patient to the practice.

Once patients are thoroughly examined and a diagnosis and treatment plan established, they are often referred to the hygiene department for appropriate treatment. The patients' oral status must be evaluated and findings delivered to the doctor in a time-efficient way to maintain the flow of the workday for both staff and patients. In either case, having adequate time is critical. We simply cannot establish a relationship, gather quality information, record and analyze the information, and communicate with the patient without adequate time. Technology plays a critical role in most practices. The intraoral camera has opened a world of possibilities for patients to consider. For many, it is a first-time glimpse into their mouth. In the past, patients simply took the word of the dentist or hygienist who told them they needed dental treatment; now they can see for themselves. But it takes time to use the camera and to educate patients about the possibilities for better dental care.

One ongoing issue is that of the new patient calling in "to have their teeth cleaned." As we are well aware, most patients perceive themselves to be in need of a "cleaning." We know that without a periodontal diagnosis, proceeding with a cleaning is inappropriate. If the doctor is not doing a complete periodontal exam to make a diagnosis, a screening exam must be completed to give patients some idea of their periodontal status. Otherwise, they would most likely assume they are healthy, expecting a "cleaning" with the hygienist. A great number of adult patients have some degree of periodontitis. It is our professional responsibility to determine their status and an appropriate course of treatment before picking up scalers to "clean teeth."

One critical role of the hygienist is as a patient advocate. Our responsibility is to ensure that each patient receives a hygiene diagnosis and appropriate options for care. Hygienists who see new patients initially provide dentists with pertinent evidence and supportive thinking, which, in turn, helps them consider all factors necessary to formulate a hygiene diagnosis. Keeping a checklist of the components in a comprehensive exam can help create a protocol for both the doctor and hygienist during the new-patient exam process.

Oftentimes, hygienists gather a majority of the pertinent data and then present findings to the doctors. This can be a powerful partnership. During the exam process, a review of the findings with the doctor while the patient listens can accomplish two purposes:

  • The doctor receives the information important for evaluation and diagnosis.
  • The patient hears the exchange and is aware that the data is being evaluated. This creates value for the procedure and reinforces the diagnosis when the doctor delivers it.

As co-therapists, hygienists are capable of gathering all of the data involved in the comprehensive exam and informing the doctor of the findings. Most excellent hygienists pre-screen their patients for the doctors, identifying areas of concern that require dental intervention or treatment. Periodically, our patients of record must receive a comprehensive exam to evaluate the entire mouth thoroughly and concisely. This requires time and focus, not simply a quick overview. Age, changing health status, medications, disease, and variable home-care efficiency predictably affect the status of our patients' oral health. We can miss these indicators if we do not allow adequate time to evaluate our patients thoroughly at periodic intervals.

Without the assistance of a professional hygienist gathering preliminary data, providing patient education, and opening discussion with the patient and then the doctor, there would not be as much restorative or periodontal treatment diagnosed and accepted. While some dental professionals only see one role defined by the title and professional license, most hygienists are incredible partners in the acquisition of data, education of patients, and preparation of patients to accept both dental care and periodontal treatment. An excellent doctor in partnership with a professional hygienist makes an awesome, efficient team. Most doctors and hygienists discuss philosophy and create protocols for working together to provide excellent care and efficient use of clinical time. Good communication skills are essential as well. It is important that we evaluate all of the data, but equally important is that patients understand the data and its impact on their overall health.

The comprehensive exam process and evaluation of the findings are important steps in the care of our patients, but not to be neglected is the patients' ability to understand their status and options. Once patients are comprehensively evaluated and presented with care options, ideally a long-term relationship ensues as they accept treatment and become patients of record.

So, is that the last time patients receive a comprehensive exam? In many offices, it is. What a shame! The two-to-three-minute periodic exam dispensed at six-month intervals is hardly adequate as patients age throughout the years and significant factors alter their oral health. Medication, disease, and stress, to name a few, can significantly alter our patients' oral status.

Where did we get the idea that the "new-patient exam" is a comprehensive exam to be used once in a lifetime? Possibly from the insurance industry? Comprehensive means "evaluating at all factors thoroughly." Does it make sense, therefore, to do this only once in a lifetime? I think it is much more appropriate to examine our dental patients comprehensively every two to three years, with periodic examinations in between. Must we apologize for using the proper code as defined in the CDT 3 manual from the ADA? Must we not charge for the time needed to thoroughly collect necessary data and evaluate it in order to give proper care to our patients? Have you been to a physician's office recently? They have numerous exam codes used for varying circumstances. Dentistry has five exam codes designed to meet different circumstances. How many codes does your office actually use and charge for?

Too often, our patients get on the periodic exam treadmill and never get off. You must admit that a two-to-three-minute oral exam is superficial at best. For many of our patients of record, dental care involves a series of visits at three-, four-, or six-month intervals and a lifetime of repetitive care. We're all used to the protocol: greetings, health history review, X-rays as needed, overview exam by the hygienist, "cleaning" of the teeth, lecture on flossing, and doctor exam. Repeat over the years.

The comprehensive exam is essential for good dental care. Take a look at your exam protocols. Chances are that it might be time to re-evaluate standards of care and office protocols.

Sometimes it is our own historical pattern that drives routine patient care. We simply keep doing things the way they've always been done despite the information we learn about alternative methods. How frequently is your office comprehensively examining patients? Do your patients understand and accept their treatment plans? Are treatment plans well-organized and documented for both patient and office use? At a glance, can you easily tell what treatment has been completed and what is incomplete? Are all of the comprehensive exam components being evaluated routinely?

Now is a good time to take a look at your office procedure policy. The comprehensive exam is critical to the excellent treatment of patients. It's the foundation of good dentistry. Hygienists are able to influence the need to re-evaluate patients and have a responsibility to the standard of care delivered in the practice. It is as much the evidence and analysis of data that leads to excellent dentistry as it is the clinical skills in delivering those procedures. Together, they create our true value in caring for patients.

Beverly Maguire, RDH, is a practicing periodontal therapist. She is president and founder of Perio Advocates, a hygiene consulting company based in Littleton, Colo. She can be reached at (303) 730-8529 or by email at perioadv@aol.com


The Comprehensive Exam
Most often, the comprehensive exam is the beginning point in our care of new patients. The elements of the comprehensive exam are detailed in the CDT 3 manual from the ADA and provide an excellent format for gathering data. It is a thorough exam that includes evaluation of the following components:

  • Review of medical history, evaluating prediposing conditions
  • Review of dental history, evaluating past dental care and current status
  • Extraoral tissue exam and evaluation
  • Intraoral tissue exam and evaluation; oral cancer exam
  • Exam of the teeth and their replacements
  • Radiographic exam
  • Periodontal evaluation, including evaluation of pocket depth, recession, mobility, furcations, and bleeding
  • Documentation of clinical findings
  • Formulation of a diagnosis and treatment; plan delivered with options for care and consequences of nontreatment explained to the patient

Based upon the findings discovered in the exam process, a timely referral to other dental specialists or appropriate health-care providers should be made and documented.


The Periodontal Evaluation
Of particular importance to hygienists is the periodontal evaluation. This is our area of expertise. Very few dentists are willing to take more than 10 minutes to do a full-mouth probing. In many practices, the dentist will do a periodontal screening of new patients and refer them on to the hygienist for a complete periodontal exam. Because hygienists probe and chart daily (hopefully), we are much more proficient in this process.

The accuracy of the periodontal diagnosis is only as good as the data collected and the analysis of all factors involved. If we only consider pocket depth but not bleeding or recession, we are apt to misdiagnose the case. Good data is essential to an accurate diagnosis. Pocket depths, recession, bleeding, mobility, and furcations all must be evaluated.

Next, the doctor and the patient must be informed. Being a patient advocate means ensuring that patients understand their status and are offered appropriate care. Using words and phrases that are meaningful to patients is essential for success. Words like infection, bleeding, and bone loss are more appropriate than pockets or attachment loss if you're concerned with the patient's understanding and acceptance of appropriate care.

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