The Art of the Complete Dental Examination II

clinical Neeraj Khanna DDS

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The Art of the Complete Dental Examination Part Two Introduction Clinical dentistry has evolved to bring patients better materials, treatment choices and outcomes, but the fundamentals of clinical practice have not changed. The art of performing a complete initial examination is the single most important experience a patient can have. This new patient comprehensive examination entails 12 aspects.

The first six parts of a systematic 12-step examination process were presented in Part One (Ontario Dentist July/August 2011). This article describes the remaining components of a complete dental examination, with suggestions for including key elements to aid in obtaining an accurate diagnosis.

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Muscle Palpation Soft and Hard Tissue Periodontal Probing

Muscle Palpation The masticatory system has two groups of muscles involved with mandibular function: a) Elevator muscles — the Masseter, Temporalis, and Medial Pterygoids — responsible for closing the mandible (Figure 11); and b) Depressor muscles — Digastrics and Lateral Pterygoids — responsible for opening the mandible (Figure 10). Both elevator and depressor muscles can be easily palpated and assessed for symptoms. The superior belly of the lateral pterygoid is attached to the articular disc and is solely responsible for keeping the Ontario Dentist • September 2011

10. Intraoral Images 11. Digital Photos 12. Diagnostic Casts/Face Bow Transfer/ Centric Bite

disc on the condylar head during rotation and translation movements. The inferior belly is responsible for protruding the mandible when both sides contract simultaneously. These two muscle groups can be defined as stable when all muscles are not tender to palpation; the patient exhibits no pain and has no limitations of mandibular movement. In other words, the infe-

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Figure 11

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rior belly of the lateral pterygoid muscle should be completely released during centric relation. An occlusal interference during centric relation will cause the inferior belly of the lateral pterygoid to contract along with the elevator muscles during closure. The result of long-term muscle in co-ordination can lead to intracapsular disorder, as well as changes to teeth (cracks, fractures, mobility). The patient is given instructions to rate the palpations on a scale of “0” to “3”. “0” is normal-no tenderness, “1” is mild, “2” is moderate, and “3” is severe tenderness. During palpation of depressor and elevator muscles (Figures 15, 16, 17, & 18), the patient gives feedback using the rating system described above. In addition, other groups of muscles are also palpated including the posterior neck, sternocleidomastoid and the base of the trapezius muscle. This exercise gives us an understanding of whether a source of muscle pain may be from parafunction and/or occlusal interferences.

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Soft and Hard Tissue The soft tissue exam consists of visual and palpation of all intra-oral soft tissue areas including the floor of the mouth, tongue, hard and soft palate and buccal mucosa (Figure 20). Any deviation in tissue colour and texture is documented thoroughly. The hard tissue exam consists of recording missing teeth, all existing restorations (stable and defective), dental caries, fractures, wear, abfractions and mobility. This information may give clues to the stability of a patient’s dentition (Figure 21).

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Figure 21

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Periodontal Probing It is well understood that establishing a stable foundation in the periodontium is essential for successful dental treatment. The patient is informed and educated about the importance of periodontal probing. Every side of every tooth is probed, and any bleeding points are documented (Figure 21). Bone loss and mobility may be associated with periodontal disease, but it must also be determined if these signs are attributed to occlusal disease. All signs and symptoms associated with an unstable periodontium must be addressed prior to beginning any restorative treatment.

10. Intraoral Images Any teeth showing signs of instability (cracks, fractures, defective restorations, decay, etc.) will have images taken with an intraoral camera (Figure 22). In addition, signs of periodontal disease and any soft tissue lesions can also be imaged as a way to monitor changes over time. These images become very valuable when the time comes to consult with the patient.

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11. Digital Photos In addition to intraoral photos, digital photos are also taken. The American Academy of Cosmetic Dentistry (AACD) has outlined a series of photos (20 total) needed for the accreditation process. These photos consist of various poses and smile positions of the patient’s dentition (Figure 23), and are used to help determine the correct restoration of incisal edge position, esthetic and functional elements of our treatment plans.

12. Diagnostic Casts/Face Bow Transfer/ Centric Bite The final piece of the puzzle is to duplicate the patient’s dentition in the seated joint position. First, upper and lower diagnostic impressions are taken with PVS material (Figure 24). This material is used for accuracy and to duplicate our models. Second, a face bow transfer record is taken (Figure 25). Third, a centric bite record is taken with Delar (Delar Corp., Portland, OR) wax. This wax is very stable and will reproduce an accurate centric bite registration (Figures 26 & 27).6 Although all of these diagnostic records including the digital photos can be done by dental auxiliary team members, the centric bite record should only be done by the doctor with the assistance of team members.

These records are transferred to an articulator, and the doctor can assess the patient’s treatment plan from a stable joint position (Figure 28).

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Conclusion The dental profession is constantly being inundated with advances in materials, equipment and tools, but the fundamental core of dentistry is diagnosis and treatment planning. In my view, to be an effective diagnostician, we must take a more comprehensive approach to the dental examination. Dentists should be looked upon as physicians of the masticatory system, and I believe the only way to practice complete dentistry is to begin with a complete comprehensive examination. It is at this moment where the clinician may have a profound impact on the patient’s view of his or her dental health. Presenting a comprehensive treatment plan with consideration to the key points of “complete dentistry” allows the doctor to deliver predictable and lasting restorations.

ACKNOWLEDGEMENT: I would like to thank my patient Amanda for giving permission to use her dental records for the use of this article. In addition, I would like to thank Jean Khanna for contributing to this article.

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Dr. Neeraj Khanna attended the University of Toronto and earned his DDS degree at the University Of Detroit Mercy — School Of Dentistry in 1993. Dr. Khanna completed a General Practice Residency at the University of Rochester-Strong Memorial Hospital in Rochester, New York in 1994 and opened his dental practice in Geneva, Illinois in 2000. He completed his training at the Dawson Academy in Florida, where he is an associate faculty member.

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Dawson P.E. Functional Occlusion: From TMJ to Smile Design. Mosby Inc. 2007 Dawson P.E. A classification system for occlusion that relates to maximum intercuspation to the position and condition of the temporomandibular joint. J Prosthet Dent. 1996; 75:60-6 McKee J.R. Comparing condylar positions achieved through bimanual manipulation to condylar positions achieved through masticatory muscle contraction against an anterior deprogrammer: A pilot study. J Prosthet Dent. 2005; 94: 389-93 Tarantola G.J., Becker I.M. and Gremillion H. The reproducibility of centric relation: a clinical approach. J Am Dent Assoc 1997; 128; 1245-1251 Lewis R.P., Buschang P.H. and Throckmorton G.S. Sex differences in mandibular movements during opening and closing. Am J Orthod Dentofacial Orthop: 120(3):294-303, 2001 Sept.

McKee J.R. Comparing condylar position repeatability for standardized versus nonstandardized methods of achieving centric relation. J Prosthet Dent. 1997Mar; 77(3):280-4.

Motoyoshi M., Hayashi A., Arimoto M., Ohnuma M., Namura S. Studies of Temporomandibular joint sounds Part 3. The clinical usefulness of TMJ Doppler. J Nihon Univ Sch Dent. 1995 Dec; 37(4):209-13

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