The Comprehensive Oral Examination, or ‘COE,’ is a framework for regular, systematic, thorough data collection of a client’s oral health. It provides the foundation for safe and effective dental hygiene care and successful treatment outcomes.
Oral or medical examinations can and do induce anxiety in many of our clients. To what degree, however, we may or may not be aware of. During examination procedures, if the steps taken are completed from a least-invasive-to-most-invasive sequence, clients and clinicians alike may become more comfortable and the confidence in the clinician’s skills are likely to improve.
It goes without saying, that a strong foundational knowledge in both human anatomy and physiology, as well as in head and neck anatomy is a prerequisite for performing a thorough assessment. Without knowing how the body functions in health, how homeostasis is maintained, and what occurs during homeostatic imbalance, a clinician will be at a loss for providing high quality care. A solid understanding of the orofacial tissues in health needs to occur before conclusions can be drawn about normal, variations of normal, and potential areas of concern.
The medical, dental, and social histories are typically completed in questionnaire format. Although the often-recommended method for history-taking is that of an interview, time constraints may prevent this. If the history information is completed by the client, such as in a questionnaire format, be sure to thoroughly review the information with the client, filling in any blank areas, asking appropriate follow-up questions, educating the client about the oral health-systemic health connection, and providing reassurance about privacy/confidentiality protocols.
Continuing with minimally invasive procedures, the extra oral exam can next be completed, followed by the TMJ assessment. After changing gloves, proceed to the intra oral exam to assess the soft tissues. I strongly support Jill Nield-Gehrig’s ABCDT format1 as a standardized, detail-oriented method to document both extra and intra oral lesions. This format describes lesions in terms of their Area (anatomical location,) Border (demarcation, coalescence, etc.) Colour (yellow, skin-coloured, red, brown, etc.,) Diameter (size,) and the Type (macule, papule, pustule, etc.) When using this format, a lesion is very accurately described, which is a necessity for differential diagnosis. Using this format can also improve both intra- and interclinician calibration and collaboration.
The hard tissue assessment may next be conducted in conjunction with a radiographic assessment. The hard tissue should be examined both before radiographic exposure and again after radiographic interpretation to correlate findings. When exposing a full mouth series of radiographs, I still follow the least-invasive-first technique, beginning with maxillary anterior periapical films and ending with mandibular posterior periapical films.
The gingival and periodontal assessments may be completed together, and radiographs provide complimentary information. Criterions to assess the gingival health status include colour, texture, papillary shape, consistency, marginal shape, and bleeding on gentle provocation (i.e. with an explorer/probe). The periodontal assessment is more extensive than simply measuring the probing depth, as this in itself does not provide an accurate description of the support. Bleeding on probing, recession, clinical attachment level, mobility, furcation involvement, and bone level all provide valuable insight into support provided to the teeth.
Occlusal assessment is an area that may vary widely between clinicians. There is sometimes the tendency to record only one value for occlusal classification, although the right and left molars, as well as the right and left canines can all have different values. The relationship of the anterior teeth, in overjet and overbite values, is also a quick and simple way to assess how the upper and lower teeth relate to each other. Close attention to crossbites, crowding, and spacing must also be considered from both a functional and cosmetic perspective.
There may be confusion between deposit assessment and oral hygiene (or oral self care) assessment. The deposit assessment is the description of the locations and types of what has accumulated on the teeth: food debris, plaque, material alba, calculus, and stain. Disclosing agents can assist with deposit assessment, not only for the clinician’s benefit, but more so for the client’s benefit. It’s important to remember that the presence of plaque alone is not necessarily an accurate indication of an individual’s practices, but may instead represent the accumulation developed over the last day or days. The oral hygiene assessment involves both observing the client attempt to remove the deposits and talking to them about their knowledge level, habits, motivation, and attitudes that surround their current home care regimen.
In conclusion, let’s not forget about technology-based assessment tools. ViziLite®, DIAGNOdent®, Velscope®, and microbiology sampling are all assessment adjuncts that greatly compliment your data collection, and ultimately, the foundation for the dental hygiene process of care.
Reference:
1. Nield-Gehrig, J.S. (2007). Patient Assessment Tutorials: A Step by Step Guide for the Dental Hygienist . Baltimore, MA: Lippincott Williams & Wilkins.
