1: Examination and Documentation

Case 1
Examination and Documentation

Medical History

The patient was diagnosed with scleroderma and gastroesophageal reflux disease (GERD). She is taking antacids for GERD and immunosuppressant medications and a calcium channel blocker for scleroderma.

Dental History

The patient reported that her last dental visit was one year ago. She has a history of childhood caries but has been caries free since college. Also, she has symptoms of dry mouth and difficulty opening her mouth and swallowing.

Social History

The patient is a self‐described over‐achieving professional concerned about her health and the appearance of her teeth. She lives with her husband in a suburb of Manhattan, has three adult children, and enjoys reading.

Review of Systems (Physical Examination)

Gastrointestinal Examination

The patient has difficulty swallowing (dysphagia) and GERD.

Cardiovascular Examination

The patient has a history of Raynaud’s phenomenon and hypertension (BP: 159/92).

Cutaneous Examination

The patient stated that her fingers are extremely sensitive to the cold. The skin of her hands appeared shiny and stretched with varying degrees of pigmentation. The patient struggled to hold the pen while signing consent forms.

Head and Neck Examination


The patient exhibited microstomia restricting her mouth opening (<20 mm), and the lips were thin and stretched.


Examination of the major and minor salivary gland duct openings showed loss of quality and quantity of saliva.

Periodontal charting showed areas of bleeding on probing without CAL (clinical attachment loss).

Generalized fibrotic changes in mucosal tissues were noted with mucogingival paresthesia. Oral mucosal tissues appeared pale and tight with hardening of the soft palate. The patient’s GI score was 2. Several restorations and crowns were noted. No caries present. Generalized moderate biofilm accumulation was apparent. The debris index (DI‐S) and the calculus index (CI‐S) were both scored as 1 (debris and calculus covered less than 1/3 of the examined tooth surfaces).

Class I: right and left sides; teeth #7 and #10 are in torso version and overlap slightly with #8 and #9.

Radiographic Examination

No significant findings.

Dental Hygiene Diagnosis

Problems Related to Risks and Etiology
Xerostomia Loss of quality and quantity of saliva and scleroderma
Goal: The patient will experience relief from xerostomia due to scleroderma immediately upon initiation of local and systemic measures to stimulate saliva flow
Increased periodontal disease risk Insufficient daily biofilm management, limited hand strength and mouth opening as evidenced by gingival inflammation and a high GI score
Goal: The patient will reduce the GI score from 2 to <1.0 by the next visit
Increased caries risk Low salivary flow, inadequate biofilm management and fluoride intake, an acidic environment created by GERD, and a soft, high carbohydrate diet because of dysphagia
Goal: The patient will suppress potential bacterial activity by increasing caries protective factors
Blood pressure elevated above treatment goal for patients <65 years old Blood pressure readings of 159/92
Goal: Patient will report having blood pressure evaluated by a physician before rescheduled visit

Planned Interventions

Planned Interventions (to arrest or control disease and regenerate, restore, or maintain health)
Clinical Education/Counseling Oral Hygiene Instruction
BP was taken at every visit
Initial exam, FMS radiographs, Adult prophylaxis
In‐office 5% sodium fluoride varnish
Three‐month continuing care interval because of scleroderma and associated medicine risks
Referral to primary care physician for blood pressure evaluation
Referral to occupational therapist to manage symptoms of scleroderma
Significance of management of xerostomia
Determine patient’s motivation to reduce plaque accumulation and oral disease risks:
“What are possible benefits of removing plaque?”
“On a scale of 1–10, how confident are you that you can reduce your plaque score?”
Increased risk of caries because of lack of fluoride and soft, high carbohydrate diet
Provide information on alternative self‐care aids such as an enlarged or extended toothbrush handle, a powered toothbrush and flossing device
Correlation of hypertension to general health
Use of prescribed cholinergic agonist agent
Frequent use of water and saliva substitutes (Tolle 2012)
Use of chlorhexidine for reduction of bacterial and gingival inflammation and prevention of Candida (Spolarich 2011) and a daily 1.1% sodium fluoride (prescription) mouthrinse for caries reduction (Featherstone 2000; Tolle 2012)
Use of pump‐type toothpaste dispenser and a power toothbrush with child‐size brush inserts, interdental aids with elongated and enlarged handles or flosser with a toothbrush‐like handle (Yuen et al. 2011)

Progress Notes

The patient arrived on time for her appointment and was treated without delay. A complete medical, social, and dental history was taken. An initial exam, FMS and adult prophylaxis were performed followed by an application of 5% sodium fluoride varnish. The patient was advised to see her physician for a BP evaluation and an occupational therapist for effects of scleroderma on daily living.

Discussion: Examination and Documentation in Patient Assessment

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.

Silhouette of a man wearing a cap, with a tobacco pipe on his mouth.

Figure 1.1.1: Assessment as detective work.

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).
Cycle diagram illustrating the five parts of the clinical examination: 1. Review of systems. 2. Head and neck examination. 3. Periodontal examination. 4. Dental examination. 5. Radiographic examination.

Figure 1.1.2: Five parts of the clinical examination.

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.

Continuous block process of the standards of clinical dental hygiene, from assessment to dental hygiene diagnosis, planning, implementation, evaluation, and documentation (left–right).

Figure 1.1.3: Standards for clinical dental hygiene practice.

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 (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).

Take‐Home Hints

  1. Assessment identifies patients’ needs and oral health problems and is the first of six of the Standards for Clinical Dental Hygiene Practice (Figure 1.1.3).
  2. The patient examination never stands alone. The clinical examination is tied to all information‐gathering activities. For example, a diagnosis of scleroderma elicited during the patient interview provides historical context for changes in the patient’s oral tissues.
  3. The American Dental Hygienists’ Association (ADHA) defines patient‐centered as an approach that focuses attention on the patient and recognizes the importance of their values, beliefs, and needs in the provision of care (ADHA Standards for Clinical Dental Hygiene Practice 2016).
  4. Risk assessment identifies certain behaviors, characteristics, or exposures that put our patients at risk for developing diseases. Risk factors are assessed as high, moderate, or low and are used to prevent and manage dental diseases (ADHA 2017).

Jul 18, 2020 | Posted by in Dental Hygiene | Comments Off on 1: Examination and Documentation
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