Examination of the Patient
If the patient attends his family dentist for orthodontic advice, the dentist—because he knows the patient’s dental background—will already be acquainted with a number of relevant matters. For example, dental mindedness, cooperation, family relations and financial circumstances. This is usually not so with the orthodontist.
This chapter is therefore based on the assumption that the general practitioner has been asked for advice by a patient he has never seen before. This means that such matters that a family dentist would normally know are discussed; in fact the procedures described here are largely the same as those used in the first consultation with the orthodontist.
A distinction is made between a first consultation and a full examination, which usually will occur at a subsequent visit. Subsequently, the collection of administrative data, taking a history, and the external and intra-oral examination will be described.
At the first consultation—and also at later visits—it is not only the dentist who provides and assembles information. The patient (and/or his parents*) also brings and collects information. For example the dentist, whilst obtaining data about the anomaly and deciding on its eventual treatment, will also be observed and assessed by the patient (whether this is subconscious or conscious). The first impression perceived by the patient will undoubtedly influence how the relationship with the dentist develops and may also have a contributory effect on the motivation needed by the patient to carry him through the orthodontic treatment. In fact, good motivation of the patient is important to the ultimate success of any orthodontic therapy.
An orthodontic examination usually begins with the consultation and within 15 to 30 minutes the experienced dentist should generally be able to reach a tentative judgement and advise accordingly. Further information (e.g., dental models, photographs and one or more radiographs) will be required in more complex situations so that a proper diagnosis may be reached. Moreover, the advantages and disadvantages of possible future orthodontic treatment will require repeated consideration of the data, which must be reviewed and discussed with the patient.
Figure 3-1 shows the procedures involved in orthodontic examination and consultation. If the treatment is obvious, then the first consultation will be short but, as a rule, an appointment should be made for a following visit in which the necessary diagnostic material for a fuller diagnosis and treatment plan can be assessed. After studying the data, a discussion should take place with the patient (and parents) about the anomaly and the “how” and “why” of the treatment plan.
If at the first consultation it is decided that treatment is not necessary—and no further information is required—the patient will expect an explanation on the reasons why this decision has been taken. This takes time. For instance the patient and/or parents may have requested a consultation because they either feel they needed professional advice or because someone suggested the problem should be looked at, or both. Therefore an explanation will be needed to outline the reasons why it is best not to treat, with the arguments for and against not treating the anomaly being examined. However, the time this takes is well compensated for by the time saved by both the patient and practitioner not being involved in a course of treatment that has little or no chance of success, or may not be necessary at all. Sometimes, it may still be occasionally necessary to collect and provide more comprehensive information before taking the responsible decision of not to treat.
Then, a second and more wide-ranging consultation should be carried out. This involves usually the demonstration of comparable cases that were treated and not treated, the explanation of the positive and negative sequela and the discomforts associated with treatment. In the judgements made from this further consultation and in the reaching of a definite conclusion the patient and parents also play a major role.
If, however, at the initial visit it is decided that treatment should be undertaken this does not necessarily mean that the complete records of the patient should be collected immediately. Rather, it is sometimes more desirable to wait for some years before actually beginning treatment, with the records being assembled at that time. Additionally, it is not essential that treatment should commence once the records are taken. Every now and then it may be wiser to wait for the right moment to start. For instance, it may be more beneficial to keep the patient under observation for a year or two and only then decide to dispense with treatment, or collect more records, before deciding whether or not to treat.
During the observation period it is also important to be alert to any unexpected changes, and it is therefore necessary that the patient be regularly checked. This waiting period does not have to be entirely passive (interceptive procedures may be applied), and it is advisable to take impressions at the start of an observation period.
Fig. 3-1 Procedures in orthodontic examination and consultation.
In the first consultation it is especially important to decide whether or not the proposed orthodontic treatment will in fact fit in with the attitudes and lifestyles of the patient, his family and peer groups. The patient will need to have a reasonable attitude—so essential to optimal cooperation if the treatment is to be cheerfully endured over the long period it will take for the therapy to be completed. There should also be cooperation evident between the patient and his/her parents.
Consultation begins the moment the patient presents, and during this first consultation there are usually no models or other materials available. The examination is made purely on a clinical basis, with the essential information being obtained directly from the patient. Therefore it is important that one has a good power of observation and the ability to carry on a conversation.
Clinical examination has, to some extent, been relegated to the background due to the increased use of radiographic data. This not only applies to orthodontics and dentistry in general, but also for practically all aspects of clinical medicine. Moreover, in the clinical situation, there is an ever-growing emphasis being placed on laboratory tests, though to counter this there is an increasing awareness of the disadvantages of radiographic and other techniques. In the light of this, the clinical examination is once again returning to the foreground.
To observe (i.e., to consciously and deliberately survey with the senses) often appears more difficult than one thinks. The skill of observation differs from person to person, so the general practitioner should practice and approach it systematically—going straight to “the abnormality” may mean, for instance, overlooking other essential matters.
In addition to having a good observation skill, one also needs to have the knowledge—and the ability to apply it—in order to track down phenomena that may be associated with something noticed in the patient, or to eliminate any possibilities. To reach a definite solution, one must be receptive to all the possible signals; a very positive approach being to keep an ear open for any incidental remarks that may pass between patient and parents.
In examining the face and mouth, it is usually best to have the patient in a position that corresponds to everyday situations. For instance, the patient should be seated relaxed, but upright, in the dental chair so that the Frankfort Horizontal Plane (see Chapter 2) is parallel to the floor and, during conversation, the patient should be seated at the same level as the practitioner.
Several aspects of the clinical examination are discussed below. The face should be scrutinized and palpated. In general, the thickness of the lips, cheeks, fleshy chin—as well as the facial musculature should be examined. Muscle power and tone should be observed. The muscles of mastication should be palpated and checked both in a relaxed and tense condition. The morphology of—and relations between—the jaws should be assessed.
Information on the temporomandibular joint may be obtained by asking the patient to perform jaw movements in all directions, whilst palpating the condyles. At the same time, attention should be given to any possible sounds produced by the movements of the joints.
As with the extra-oral examination, an examination of the oral cavity will also require visual observation, palpation and listening for sounds (e.g., percussion of teeth).
In the visual examination of the oral cavity, a mouth mirror is indispensable, especially when checking the molar occlusion. For instance, if one sits to the side (in front of the patient) and views the occlusion directly—without the mirror—one gets the impression that the buccally overhanging mesial cusp of the maxillary first permanent molar is more distally placed to the mandibular one than it really is. The mouth mirror will eliminate this illusion by orienting the direction of vision to be perpendicular to the buccal surfaces of the molars. Also, in this situation, it often becomes apparent that a mild disto-occlusion—not originally seen—will now be noticed. A mouth mirror is also useful to see rotations, contact points and other features that are not easily accessible. Of course, if dental casts are available, the occlusion and position of individual teeth may be determined by examining the casts. Moreover, the lingual aspect of the occlusion can only be seen by the examination of models.
In general, by palpating the alveolar processes and the bony structures, one can get a direct impression of their size and form. Palpation of the alveolar process can provide much information about the presence and position of—as yet—unemerged teeth. After compressing the capillaries in the overlying mucosa, one can see unerupted teeth shining white through the tissue.96 This is especially so where, prior to emergence, teeth are normally situated and in these cases they can actually be felt and “seen”. This applies particularly to incisors and canines, though to a lesser extent to premolars. It is also often possible to determine if a tooth is in an abnormal position and one is also able to watch for palatal prominences, either symmetrical or not, since this may indicate an abnormal position or path of eruption for canines or premolars. It is also possible to feel where the roots of emerged incisors—and to a lesser extent of posterior teeth—lie in the alveolar process. The relationship between teeth and bony structures may be assessed by feeling (with the fingers) both sides of the alveolar process.
An impression may be gained of the amount of space available in both jaws for the appropriate teeth, particularly in a vestibulolingual direction. The aspect is specifically important for the maxillary and mandibular incisors. The same approach will also provide information on the extent of fixation of the teeth.
Palpation of the dorsal limits of the posterior regions will give an indication of the space available for the second and third molars. It is also possible to feel how the bony contours of the mandible and maxilla relate to each other, more specifically in the anterior region.
The occlusion, articulation and path of closure should be assessed, with any premature contacts and forced bite registered.
With an adult patient, it may be necessary to make a full examination of the periodontal state of the dentition. Generally, it can be said that radiographs should not be used to obtain information that may be secured in another way. For instance, a radiograph should not be used to determine the presence or orientation of a tooth, as this can be decided by palpation. However, far worse, is to take radiographs that do not, or cannot, provide the information required.
The first visit is therefore mostly for orientation and discussion. The data available are limited, though are adequate for a first provisional impression.
A good comprehensive examination is not possible without having a check-list of points that may need investigation. Relevant findings should be systematically recorded and all the data obtained from various diagnostic aids be collated before conclusions are reached. A check-list usually serves as a record card upon which, eventually, the treatment plan will be entered and notations made as the treatment is carried through.
The record card used for patients at the Orthodontic Department of the University of Nymegen is shown here. For convenience of the reader, a loose-leaf version is added which can be perused in conjunction with the text that follows in the remainder of this chapter.
The size and contents of record cards vary from place to place. For instance, in an institute of learning a more extensive record card would be used more widely than, say, in the practice. In assessing the patient’s record card reproduced in this book—and used as a guide for discussion—this fact should be borne in mind. For example, the record card here contains also headings that would not be considered of use in the general practice.
No space is provided on the record card for entering certain data that may be obtained from a clinical examination. This applies to information that is better derived from diagnostic material yet to be collected. Occlusion is also not entered on the record card because this can better be determined by a dental cast; an analysis of the face occurs partly from the patient, partly from photographs.
In the following discussion, points are sometimes mentioned that, as such, do not appear on the record card, though they are in fact taken note of at the first visit. Moreover, sometimes the sequence of the chart differs from that followed for didactic reasons in the text. Further, it should also be noted that with some points nothing is said about why they are recorded because these are self-evident, or because they have already been dealt with in Chapter 1.
Administrative data are generally entered by the dentist’s secretary or chairside assistant. The patient, or parents, may fill in certain particulars on a separate form that may or may not have a questionnaire concerning general health and other matters. On the first visit, several details may be entered.
Most of the points of the head of the reproduced card are self explanatory. Some comments will be offered for illumination.
It is good to know how many children there are in the family and where in line the patient stands—a vertical row of small circles to the left of the heading serves to record this. The oldest child is top of the row and, by adding to the small circles, arrows or crosses, males and females are indicated, respectively. The patient’s place is marked by filling in the circle. If there are twins in the family, the circles are joined together.
The school and class are noted so one is able to know in which setting the child’s activities lie, and in order to judge his progress in relation to age. The occupations of the mother and father are asked for so as to estimate the domestic environment and see what difficulties might be encountered in accompanying the child on treatment visits—and in providing family care. Moreover, this information may reveal any special domestic circumstances (e.g., one-parent family) which can be of importance. With an adult patient, the question of the work sphere will enable better judgements being made about treatment times, visibility of orthodontic applies and the burden that is attached to any treatment.
The information obtained about the “home” will have particular value when coming to compare the patient with other children in the family and deciding whether it is reasonable for the child to have the inevitable absence from school that orthodontic treatment will demand. Additionally, this background information will help in establishing a pleasant and informative relationship with the patient and parents during their visit—something which can be enjoyab/>