Patient assessment represents the most important step in the dental hygiene process of care because it provides a baseline of information, opens a dialogue between the patient and provider, and establishes trust and confidence in their relationship (Figure 1.1.1). All information collected during the assessment process is inextricably bound to each other. Information from the patient history is used to distinguish significant from insignificant findings in a clinical examination, helps generate a list of dental hygiene diagnoses, and ultimately leads to the formation of an individualized care plan.

During an examination, the dental hygienist documents findings as signs of health or disease. On the other hand, findings revealed by the patient are referred to as symptoms of their problems. The chief complaint or concern is the primary reason that patients present for treatment and should be the first diagnostic statement in the care plan (Wilkins et al. 2017). Typically, the chief complaint is a symptom or a request and may need to be elicited by asking open‐ended questions such as, “What brought you to the dental office?” or “Is there anything you hope I can do for you?” Paying close attention to a patient’s chief concern(s) serves many purposes: it alerts the provider to relevant diagnostic information; it offers insight into a patient’s perception regarding his or her problems; and finally, it provides insight into the patient’s health literacy including their level of knowledge about dentistry.

A comprehensive clinical exam is made up of five parts (Figure 1.1.2).

1. The Physical Exam or Review of Systems (ROS) is a list of questions, by organ system, intended to uncover disease or dysfunction. The list is often given to patients before treatment. Along with the medical history, the ROS assists in determining a patient’s MCS or ASA (methods for physical status classification). When using the ROS, clinicians must be aware of associations between noncommunicable diseases and oral disease because they share common risk factors as well as underlying infection/inflammation pathways (Jin et al. 2016).
2. The Extraoral and Intraoral Soft Tissue Examination evaluates head and neck structures for abnormalities or lesions. The examinations are performed systematically through a process of observation and palpation to detect variations from normal and abnormalities. Patients provide important historical context for clinical findings, such as timelines for lesions, whether the lesions are painful or tender, or can be linked to repeated exposure to sun or tobacco products.
3. The Periodontal Examination evaluates the patient’s oral hygiene and the clinical appearance of the periodontal soft tissue. Deviations from normal healthy tissue are noted such as gingival recession, redness, suppuration, and swelling. A thorough examination requires a mouth mirror, a periodontal probe, and radiographs. A periodontal assessment provides information for long‐term monitoring of a patient’s periodontal disease activity (Armitage 2004).
4. Examination of the Teeth (and Occlusion) Before beginning the dental examination, the clinician should review the dental history, particularly the chief complaint(s) involving the teeth. The exam is performed in conjunction with radiographs so that imaging findings can be correlated with those found clinically.
   1. First note any missing teeth and type of replacement such as implants, fixed and removable partial and complete dentures. If removable prostheses are present, they are evaluated in the mouth and then removed.
   2. Each tooth is evaluated visually with an excellent light source. Assess all teeth for overall condition, irregularities of color, morphology, and function.
      1. It is recommended to use the air/water syringe, with transillumination and a dull probe to detect enamel changes. However, the probe is not a better method than visual inspection alone (Newbrun 1993).
      2. A study concluded that explorers did not improve the validity of a caries diagnosis as compared to visual detection alone (Lussi 1991); and consequently, leaders in caries research no longer support the use of a sharp explorer in caries detection (Van Dorp et al. 1988; Braga et al. 2010).
   3. Document the numbers, shape, and type of existing restoration. Dental floss is used to check the integrity of interproximal contacts, and the explorer evaluates restoration margins for defects.
   4. An occlusal examination is conducted by recording the intraarch and interarch relationships of adjacent teeth in the same and opposing arches. Both right and left sides are included when classifying teeth according to Angle’s Classifications in the permanent dentition and when using the terminus of second primary molars.
5. The Radiographic Examination Radiographs are considered an essential adjunct to the visual clinical examination. They accurately detect proximal caries lesions and estimate the depth of lesion penetration into the underlying dentin (Bindra et al. 2016; Keenan and Keenan 2016). Also, radiographs are useful for monitoring the growth and development of the teeth and jaws as well as for the diagnosis and treatment of periodontal diseases and oral pathologies (American Dental Association Council on Scientific Affairs 2012).

Thorough and accurate documentation of the patient’s record occurs during the assessment process and at every phase of patient care. As a result, documentation has been adopted as the sixth standard in the Standards for Clinical Dental Hygiene Practice (Figure 1.1.3) that guide practice and are designed for hygienists as a resource for providing patient‐centered and evidence‐based care (ADHA 2016). The patient’s record should be brief and to the point, objective (nonjudgmental) and comprehensible. Taking and documenting all patient data – the list of problems, planned and provided treatment, and relevant patient conversations – in a humanistic manner (with clarity, professionalism, and empathy) is an indicator of professional competence and represents the highest standard of patient care.

Using open‐ended questions during a patient assessment (as opposed to direct or leading questions) results in a more nuanced examination picture (Iversen et al. 2014). Skillful clinicians elicit in‐depth information about previous dental experiences and what dental care and preventive care mean to the patients. They find out how and why patients did or did not adopt prescribed preventive care, and they determine ways in which social context influences their patients’ health behaviors. Humanizing the dental care experience by contextualizing clinical facts with our patients’ narratives (their personal stories about general health and oral diseases) provides a bridge between evidence‐based dental practice and the art of applying the knowledge to a single case (Kalitzkus and Matthiessen 2009), improves the visual exam and enriches dental hygiene practice.

Advances in technology such as imaging techniques, oral/facial photography and electronic health records (EHR) have brought improvements to the data collection and documentation processes. Proper documentation records:

• collected data from the patient interviews and clinical examination
• services planned and provided
• recommendations, and
• relevant information to the patient’s case.

The process accurately and concisely records all information and interactions between the patient and provider and provides evidence that the services performed reflect the patient’s specific needs. A critical part of the documentation process and a legal risk management strategy is to include the patient’s acceptance or rejection of the treatment options and recommendations (after a presentation of a proposed care plan and the consequences of not receiving care by the dental hygienist) referred to as informed consent and informed refusal. After patients have agreed to and signed for treatment, errors can be corrected. However, clinicians must initial all corrections, and any alterations to the treatment plan require a new patient signature.

A patient’s health information and clinical records are confidential and legally protected by The Health Insurance Portability and Accountability Act (https://www.hhs.gov/hipaa/for‐professionals/index.html). Additionally, the ADHA Code of Ethics provides members with professional standards for ethical and moral behavior and reminds us of our professional responsibility in that regard. Hence, maintaining patient privacy when documenting information throughout the process of care and when collaborating interprofessionally on a case is critical in the application of technology to patient care.

The patient assessment process requires attention to the facts of the case but likewise, should include meaning, context (cultural and otherwise), and understanding of the patient’s needs. Dental professionals conduct a patient‐centered interview and examination that put the patient where she/he needs to be in the process of care, front‐and‐center.

Interviewing and asking questions continue throughout the patient examination to include the patient’s point of view and to lend meaning to the process. The way in which questions are asked can encourage intimacy and frankness; and even though responses are typed on a computer, written on a page, or recorded, it is important to maintain eye contact with the patient, to be friendly, interested, to ask questions requiring more than a one‐word response, and to reiterate for clarity and understanding.

Professionals can restore a sense of narrative into the assessment process by creating a more humanistic environment during the assessment. The patient narrative is not only a description of the facts of a case. The narrative in healthcare provides meaning, context and perspective for the patient’s problem (Greenhalgh and Hurwitz 1998). Throughout the interview and examination, clinicians watch the patient’s expressions, interact comfortably, engage patients verbally while simultaneously managing documentation. Consequently, patients may be more comfortable about telling their story; they may have more confidence in their provider; and they may be more willing to share in the responsibility for their health outcomes.

Health professionals cannot be detached, removed, or uncaring in what they do. Paying attention, exploring things a little bit, getting at it slowly, but carefully and thoroughly will get results throughout the entire process of care (Pirsig 1974).