Clinical Guideline 21 Version 1

Valid to: March 2017

Comprehensive Oral Examination

Purpose

The aim of this Clinical Guideline is to provide advice to public oral health clinicians
regarding comprehensive oral exam and treatment planning. Evidence-based clinical
guidelines are intended to provide guidance, and are not a standard of care, requirement,
or regulation. However, the application of clinical guidelines in publicly-provided oral health
services allows for consistency to occur across large patients cohorts with a variety of oral
health clinicians.
This Clinical Guideline plans to:

Standardise the way in which patients are assessed

Establish standardised sequence to assist in a thorough comprehensive examination
to reduce overlooking any area to be examined
The content summary of the topics covered in the guidelines are outlined below.

CONTENT
Limited Oral Examination
Comprehensive Oral Examination
Medical History
Dental History
-Reason for Presenting
- History of Presenting complaint
Social / Family History
Intra-Oral Soft tissues
Appearance of soft tissues
Buccal Mucosa, alveolar ridge and attached gingiva
Palate, Pharynx, soft and hard palate, tonsillar pillars, uvula
Tongue
Floor of mouth
Occlusion
Dentures
Orthodontic Appliance
Charting
Periodontal Charting
Special Investigations where necessary
Testing of pulp sensibility
Testing for cracked cusps/teeth
Radiographs
Study Models
Saliva Testing
Patient Behaviour
Diagnosis
Dental Caries
Treatment Planning
Informed Consent
Shortened Dental Arch Principle
Record Keeping
Appendix
Dental Services and Glossary (Tenth Edition, 2013)
Frankl Behavioral Rating Scale
ICDAS 11 Classification

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Guideline
Limited Oral Examination
A limited oral examination is carried out immediately prior to a required treatment and in
most instances when a patient presents as an emergency. When focussing on a particular
dental issue other areas of concern can be easily overlooked .
Therefore it is best practice to:

Check and record for presence or absence of pathology of the skin, lips, gingivae,
mucosa on the cheeks and the tongue (the lateral borders and uventral aspect),
the roof and floor of mouth and also the lymph nodes.
Screen of the rest of the hard tissues to eliminate referred pain and patient
confusion.
When radiographs are taken it is an obligation that other tissues captured on the
radiograph are recorded and pathology reported to client even of it is not the area of
concern.

The Comprehensive Oral Examination

Comprehensive dental care is a concept that includes not only traditional treatment of
dental disease but also prevention and early detection. A comprehensive oral examination is
done when a client is due for a general course of care. A detailed history taking and a
thorough examination of the extra-oral and intra-oral soft and hard tissues are an integral
component of the comprehensive examination. A thorough diagnosis and treatment plan is
sought together with the client taking into account the various factors that derive the final
plan. Record keeping and informed consent would be the legal components of any care. The
Australian Schedule of Dental Services and Glossary (Tenth Edition, 2013) outlined in
Appendix 1 details the various item codes that are available for use.
Medical History
An accurate and current general medical history should include a list of current medications
as well as all relevant medical conditions including allergy status and the type of reaction
experienced for allergy. The physician should be contacted where further clarification is
required. It would be ideal to request a medical history from the physician including any
recommendation or precautions that might be required for dental treatment.
Dental History
Reason for Presenting
Reason for presenting would usually fall into one of the following categories;
Comfort (pain, sensitivity, swelling, etc)
Function (difficulty in mastication or speech)
Social (bad taste or odour)
Appearance (fractured or unattractive teeth or restorations, discolouration)
Patient requires a dental review / general dental exam

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History of Presenting Complaint

Dental

History should include;

Previous dental experience / attendance record
Any complications during dental treatment
Radiographic History - Previous radiographs may assist in following the progress of
dental disease. Remember you will need to provide a clinical rationale for taking
radiographs
Current treatment by other clinicians e.g. orthodontic care in conjunction with dental
care

Social / Family History

Social / Family History gives the clinician an opportunity to gain information about the
clients personal life and lifestyle. It could include:
Personal history- working, schooling, retired, married, children this information will
be useful to understand client socioeconomic status, obstacle in oral health care and
motivation; it may also explain certain presentations ( e.g. wine taster erosion;
musical instrument performer/ hair dresser- attrition / mobility )
Lifestyle - History of smoking, the number of cigarettes and whether client has
considered quitting; history of substance abuse
Presence of genetic / inherited abnormalities
Parental attitude towards the child (client) and towards the dental treatment
Maternal history of usage of drugs etc e.g. tetracycline and staining of teeth
Infant feeding practice including breast and bottle feeding
Oral Habits
It is worth noting any habits that may affect the oral cavity:

Mouth Breathing
Thumb/digit sucking
Sleeping with feeding bottle
Tongue thrusting
Clenching and grinding
Swishing mouth with fizzy drinks
Biting on finger nails or foreign objects e.g. pen or pencils
Pacifier use

Oral Hygiene Habits

Indicate oral self care behaviours:

The current tooth brushing method, if parent assisting brushing (for child patients)
Brush type (manual or electric; soft or hard),
Frequency of brushing
Additional cleansing devices and frequency of use.
Mouthrinse, type and frequency of use.
Use of fluoridated water at home
Use of fluoridated toothpaste (strength - adult or child)

Diet History
Diet History would include:

Snacking habits- form and frequency

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Sugar and beverage consumption- what and frequency

Consumption of water and dairy products
Diet- balanced meal, take away, home cooked food, etc

Checking for pathology

Presence or absence of pathology should be recorded.
Checking for signs of oral pathology is an important part of comprehensive oral examination
including the skin, lips, gingivae, mucosa on the cheeks and the tongue (the lateral borders
and ventral surface ), the roof and floor of your mouth and also the lymph nodes.
Abnormal mucosal signs should be noted and a clinical description should include presence
of swelling, changes in colour, surface texture, consistency, surface ulcerations, bleeding
or crusts .
Clinicians should be alert and aware of the presentations of oral cancer, which may include:
A red, white or brown patch
An ulcer that bleeds easily or does not heal normally within 2 weeks
A thick or hard spot or a lump
A roughened or crusted area
Other signs of oral cancer include numbness, pain or tenderness, or a change in the
way the teeth occlude.
Extra- Oral Tissues
Skin and hair
An overall evaluation should be performed of the clients head, hair, neck, eyes, face, lips
and surrounding skin. The skin should be continuous, firm and pigmented in relation to the
normal variations associated with race and ethnicity, if lesions are initially observed
patients should be asked how long they have had the lesions, if the lesions have changed
and whether they cause any symptoms.
Facial Symmetry
Generally the head face and neck should have symmetry. Note the facial skeletal form from
a profile view, facial proportions and obvious dysmorphology such as cranial clefting, frontal
bossing, depressed nasal bridge, hypertelorism, low set ears or recessive chin, etc.
Lymph nodes
In healthy clients nodes are small, soft and mobile in the surrounding tissue and cannot be
visualised or palpated.
Palpable lymph nodes are those that have undergone lymphadenopathy or enlargement of the
lymph nodes resulting from an increase in size and change consistency of the lymphoid tissue.
This change in node consistency can range from firm to hard. Lymph nodes can also become
attached or fixed to the surrounding tissues as the disease progresses. They can also feel tender
to the client when palpated due to the pressure on the nerves from the node enlargement,
inflammation or fibrosis.
The nodes that are palpable may indicate where a disease process, such as infection or cancer has
progressed. Documentation of history of concerning palpable nodes will assist in the diagnosis,
treatment and outcome of any disease process that may be present in the client. It is important to
keep in mind those nodes of the head and neck drain not only from the oral structures but also the

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eyes, ears and the deeper areas of the nasopharynx.

Temporomandibular Joint (TMJ)
The clinician locates the TMJ by palpating bilaterally just anterior to the auricular tragi while
having the patient open and close. Auricular palpation with light anterior pressure helps identify
potential disorder in the posterior attachment of the disc. Tenderness, clicking, pain, crepitation on
movement is noted. Restriction of opening is noted. Any deviation from midline is noted.
Attachment of the muscles of mastication are palpated for signs of tenderness and noted.
Lips
Lips should be continuous in colour, firm in texture, free of lesions, semi moist with an
apparent border between the skin of the face. Commissures should be continuous and
intact. The lips should be able to meet at rest. Interferences from incisors- lip trap- should
be noted. Clinician should observe for tooth exposure during normal and exaggerated
smiling.
Intra-Oral Soft tissues
Appearance of soft tissues
The mouth may appear dry. Saliva examination may reveal issues with quality / quantity.
Assess the possible causes: medications / medical conditions / previous radiation therapy,
mouth breathing. Consider the presence of oral manifestations of systemic disease
Buccal Mucosa, alveolar ridge and attached gingiva
Gently pull the buccal mucosa slightly and palpate bidigitally using circular compression.
Retract mucosa to visibly inspect the vestibular area. Palpate and visually examine the
alveolar ridge and attached gingivae. Palpate the maxillary tuberosity and retromolar area
using digital compression.
Palate, Pharynx, soft and hard palate, tonsillar pillars, uvula
View the palatal and pharyngeal regions. Extend the tongue and observe the soft palate.
Ask the client to say ah. As this is done observe the uvula and visible portion of the
pharynx.
Tongue
Wrap gauze around the anterior one-third of the tongue to obtain a firm grasp. Turn the
tongue slightly on its side to inspect the base and lateral borders for any changes in tissue
e.g. white or red patch. Bidigitally palpate the lateral surfaces of the tongue looking out for
thick or hard changes to the surface. Ask the patient to lift the tongue and inspect and
digitally palpate the area. Observe swallowing.
Floor of mouth
While the patient lifts the tongue to the roof of the mouth, observe the mucosa of the floor
of the mouth. Check the lingual frenum for ankyloglossia and gingival attachment.
Bimanually palpate the sublingual area. Use bidigital palpation for the sublingual salivary
glands on the floor of the mouth

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Occlusion
Assessment for occlusion includes classifying the occlusion and documenting any
malocclusion features such as crowding, rotation, over eruption, spacing, retained primary
teeth, missing teeth, etc. Looking at the facial profile, lip seal and habits would help identify
certain malocclusion.
Dentures
Existing dentures should be assessed for retention, fit, esthetics and function. Also it is
worth noting the type of denture- acrylic, cobalt-chrome, with overlay, etc, the age of the
appliance and numbers of dentures made.
Orthodontic Appliance
Orthodontic appliance should be assessed and noted as to the type fixed or removable,
active or passive and whether the client is currently in orthodontic treatment. It is also
important to check for any dislodgement of brackets and bands, breakage of the appliance
so that the client can be alerted and seek treatment accordingly.
Charting
An accurate charting of the state of the dentition will reveal important information as to the
condition of the teeth and will facilitate treatment planning. Adequate charting must show
the presence of:

Teeth present, unerupted, retained or missing

Restored teeth tooth code, surface(s), material used
Prosthetic appliances present, including materials used, teeth replaced
Dental caries
White spot lesions (Active)
Brown spot lesions (Arrested)
Wear facets
Fractures
Traumatic occlusal contacts
Tooth surface loss from abrasion, attrition or erosion depending on diagnosis
Malformation e.g. Hypoplastic/ hypomineralised, enamel, fusion, germination, etc
Deep fissures or requirement for a fissure sealant
Vitality including endodontically treated teeth
Mobility
Furcation
Recession
Previous trauma

Comprehensive Periodontal Charting

Early detection and diagnosis are key elements in the prevention of periodontal disease.
Screening tools such as the Periodontal Screening and Recording (PSR Index), CIPTN, etc
facilitate early detection of periodontal disease with a simplified probing technique and
minimal documentation. They do not replace conventional periodontal examination but act
as a precursor to decide when a conventional periodontal examination should be performed.

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A conventional periodontal charting should be ideally completed on all patients over 15

years of age. However if the screening tools were utilised, the conventional periodontal
charting would be performed on patients at risk (the risk categories and codes would vary
with the type of screening tool employed)
Conventional periodontal charting would include:

Periodontal probing depth

Bleeding on probing
Furcation involvement
Clinical attachment loss
Tooth mobility
Plaque score

Special Investigations where necessary

Testing of pulp sensibility

Cold test (CO2, spray)
Electric Pulp test
Heat test

Testing for cracked cusps/teeth

Bite stick, tooth sleuth
Transilluminating
Microscope where available

Radiographs
Radiographs should be taken where necessary to aid in diagnosis. Radiographs
should be taken in accordance with the DHSV radiographic guidelines.

Study Models
In certain cases study models would be required for good treatment planning, patient
education, referral to specialists or diagnostic waxups (e.g. prior to orthodontic
treatment and prosthodontic treatment). Study models must be trimmed, labelled
with the patients name and stored dry.

Saliva Testing
There are two different methods of saliva testing
o Oral environment testing -Oral environment testing is typically done
chairside, taking 10 to 15 minutes and yielding immediate results. Evaluating
the oral environment should include the assessment of both stimulated and
unstimulated saliva pH, consistency of saliva, the quantity or flow production,
and the buffering capacity of saliva
o Pathogen specific testing-Pathogen specific tests require saliva sample
collection and incubation for 48 hours before results can be assessed.
With both types of tests, it is important to understand composition can vary
dependent upon time of day saliva is collected, the flow rate, how it is stimulated,
and the duration of stimulation. Ideally, testing should be done in the morning hours
and patients should not eat or drink for a minimum of an hour before the test.

Patient Behaviour
Since children exhibit a broad range of physical, intellectual, emotional, and social
development and a diversity of attitudes and temperament, it is important that clinicians
record the childs (clients) behaviour as a diagnostic aid for future visits. One of the more

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reliable and frequently used behaviour rating systems in both clinical dentistry and research
is the Frankl Scale. This scale separates observed behaviours into 4 categories ranging from
definitely negative to definitely positive.
Consideration of the level of anxiety an adult feels towards dental treatment should also be
noted and strategies discussed with the patient to decrease their anxiety.
Refer to Appendix 2
Diagnosis
Diagnosis of the oral health would be made from the outcome of examination and
investigations undertaken. Upon completion of the history and examination findings,
differential diagnose must be made. The clinician should determine the most likely causes
of the observed condition(s) and record them in order of probability. A definitive diagnosis
can usually be developed after supporting evidence has been assembled.
Dental Caries
Caries Risk Assessment Tool
Not everyone has the same risk for dental decay, and to treat each individual in the same
manner, such as exposing radiographs or administering fluoride treatments every six
months, not only is unnecessary, but wastes valuable resources such as time and money.
Evaluating risk is one way to individualize treatment based on need.
Refer to the Titanium User Manual V14, appendix
International Caries Detection and Assessment System (ICDAS II)
ICDAS II is a peer-reviewed and internationally recognized visual assessment tool that
allows a tooth's health status to be graded numerically. ICDAS II is a clinical scoring system
for use in dental education, clinical practice, research, and epidemiology.
ICDAS II is designed to: lead to better quality information to inform decisions about
appropriate diagnosis, prognosis, and clinical management at both the individual and public
health levels. It provides a framework to support and enable personalized total caries
management for improved long-term health outcomes
Refer to Appendix 3
Treatment Planning
Treatment planning consists of formulating a logical sequence of treatment (control,
conservation, reconstruction and maintenance phases of care) in steps designed to restore
the clients dentition to improved health, with optimal function and appearance. The
treatment planning consists of identifying the clients risk category, needs and prescribing
relevant therapy and discussing the risks and benefits of the proposed treatment with the
client. Treatment should be tailored to the caries risk category of each individual.
Comparison of available corrective materials and techniques should be discussed and a
professional recommendation made based on current evidence. Treatment planning also
involves evaluating what has a good prognosis and what is of doubtful benefit.
The prognosis is an estimation of the likely course of a disease. It can be difficult to make,
but its importance to patient understanding and successful treatment planning must
nevertheless be recognised.

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Once prognosis has been considered, a rational sequence of treatment may be initiated for
symptomatic relief, stabilisation, definitive therapy and follow up care. The plan should be
presented in written form and discussed in detail with the patient.
A good treatment plan informs the patient about the
present conditions
the option not to undergo treatment and the ramifications of such
the extent of dental treatment proposed
other treatment options available
possible complication/ risks involved with proposed treatment
time of treatment
cost of treatment
Level of home care and professional follow up that will be required to achieve long
term success.
Informed Consent
Informed Consent is not just a signed consent form but also the requirement of the clinician
to negotiate the proposed treatment plan, discuss any associated risks and options to the
proposed treatment plan to the patient and the parent or guardian if the client is a minor or
unable to consent. The treating clinician must make the judgment as to whether each client
is capable of understanding the above and providing informed consent. It is the clinicians
responsibility to provide all information that would be material to each patient. This
includes, therefore, judgments regarding both the complexity of care options and what may
or may not affect a patient in making decisions. This may also include referral to a
specialist in that particular discipline. Further, in the event the patient disagrees with your
professional advice and prognosis, they have the right to seek a second opinion elsewhere
or with another clinician.
The final treatment plan would be properly sequenced in consultation with the patient as
part of an ongoing program of comprehensive dental care. Throughout, the extent of
treatment is modified by the attitude of and objective of the patient. Any changes to
treatment provided or planned needs to be communicated to the patient and documented
that the change was agreed to.
It is advisable that as treatment complexity increases, that written consent be obtained and
wherever possible discussions are supplemented with additional written material that a
patient can review and have the ability to seek clarification before deciding on a particular
treatment option.
Shortened Dental Arch Principle
The shortened dental arch (SDA) concept is a valid treatment option for clients.
Please refer to the DHSV Shortened Dental Arch guidelines
Record Keeping
Clinicians must create and maintain dental records that serve the best interests of patients,
clients or consumers and that contribute to the safety and continuity of their dental care.
Please refer to the current DHSV Dental Record keeping Guide, 2012.

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Appendices

Appendix 1

011

012

013

014

015

016

017

The Australian Schedule of Dental Services and Glossary (Tenth Edition, 2013 )
Comprehensive oral examination
Evaluation of all teeth, their supporting tissues and the oral tissues in order to
record the
condition of these structures. This evaluation includes recording an appropriate
medical history
and any other relevant information.
Periodic oral examination
An evaluation performed on a patient of record to determine any changes in the
patients dental
and medical health status since a previous comprehensive or periodic examination.
Oral examination limited
A limited oral problem-focussed evaluation carried out immediately prior to required
treatment.
This evaluation includes recording an appropriate medical history and any other
relevant
information.
Consultation
A consultation to seek advice or discuss treatment options regarding a specific
dental or oral
condition. This consultation includes recording an appropriate medical history and
any other
relevant information.
Consultation extended (30 minutes or more)
An extended consultation to seek advice or discuss treatment options regarding a
specific
dental or oral complaint. This consultation includes recording an appropriate medical
history
and any other relevant information
Consultation by referral
A consultation with a patient referred by a dental or medical practitioner for an
opinion
or management of a specific dental disorder. The consultation may not necessarily
be with
a specialist. The referring practitioner should be provided with a report from the
consultant,
included within the item number.
Consultation by referral extended (30 minutes or more)
An extended consultation with a patient referred by a dental or medical practitioner
for an
opinion or management of a specific dental disorder. The consultation may not
necessarily be
with a specialist. The referring practitioner should be provided with a report from the
consultant, included within the item number.

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Appendix 2

FRANKL BEHAVIORAL RATING SCALE

--

++

Appendix 3

Code 0:

Definitely negative. Refusal of treatment, forceful crying, fearfulness,

or any other overt evidence of extreme negativism.
Negative. Reluctance to accept treatment, uncooperative, some
evidence of negative attitude but not pronounced (sullen,
withdrawn).

Positive. Acceptance of treatment; cautious behaviour at times;

willingness to comply with the dentist, at times with reservation, but
patient follows the dentists directions cooperatively.
Definitely positive. Good rapport with the dentist, interest in the
dental procedures, laughter and enjoyment.

ICDAS 11 CLASSIFICATION
No sign of caries after air drying for 5 secs or Exogenous stains- fine line;
multiple, in most or all pit and fissures

Code 3:

White or brown spot lesion which is visible only after air drying for 5 secs (not
visible when wet)
White or brown spot lesions that is wider than the natural fissure or fossa visible
when wet or dry with no surface break down (microcavitation) or underlying
shadow in dentine
Localised enamel breakdown after air drying for 5 secs with no visible dentine or
underlying shadow (discontinuity of surface enamel ( microcavitation) or widening of
fissure- ball end of WHO periodontal probe can rest in space)

Code 4:

Underlying dark shadow from dentine, with or without localised enamel breakdown

Code 5:

Frank cavitation with visible dentine, involving less than half of the tooth surface

Code 6:

Cavity is deep and wide involving more than half of the tooth surface lesion is
deep and wide and may involve pulp

Code 1:

Code 2:

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References
1. AHPRA, Dental Board of Australia, Guidelines and codes, 2010
2. American Academy of Paediatric Dentistry, Clinical Guidelines ;Guideline on
Behaviour Guidance for the Paediatric Dental Patient, 2011, V34 No 6 12/13
3. American Academy of Paediatrics Policy Statement. Oral Health Risk Assessment
Timing and Establishment of the Dental Home. Paediatrics Vol. 111 No. 5 May 2003,
p. 1113-1116.
4. Contemporary Fixed Prosthodontics, Stephen F. Rosenstiel, 4th edition
5. Dental Hygiene Theory and Practice, Michele Leonardi Darby, 2nd Edition
6. DHSV, Dental Record Keeping Audit Guide, 2012
7. DHSV Titanium Upgrade Document, 2011
8. International Dental Journal , Periodontal Screening and Recording (PSR)
Index:precursors, utility and limitations in a clinical setting 2002;52;35-40
9. Journal of Americal Dental Association, Assessment of Periodontal Status with PSR
and traditional clinical periodontal examination 1995;126;1658-1665
10. Journal of Americal Dental Association, Screening for Periodontal
Disease:Radiographs vs. PSR 1996;127;749-756
11. Medical Dictionary for the Dental Professions, Farlex , 2012
12. Registered Dental hygienist , Saliva: Of Emerging Importance in the Medical and
Dental Worlds
13. Therapeutic Guidelines Oral Dental 2012 Version2 pg 142

Definitions
Nil

Revision date
March 2017

Approved by
Director of Clinical Leadership, Education
and Research

Policy owner
Clinical Leadership Council

Date approved
March 2014

References and related documents

(1)

Stewart. Rudd. Kuebker; Clinical Removable Partial Prosthodontics, 2nd edition,

Ishiaku EuroAmerica Inc, 1992.

(2)

John D. Jones/Lily T. Garcia; Removable Partial Dentures A Clinicians Guide, 1st

edition, Wiley-Blackwell, 2009

(3)

Dr Sybille K Lechner/Prof A Roy MacGregor; Removable Partial Prosthodontics, a

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case-orientated manual of treatment planning, 1st edition, Wolfe publishing, 1994

(4)

Journal; Quintessence International, Volume 43, Number 5, May 2012; Safety of

increasing vertical dimension of occlusion: A systematic review. Dr Jaafar Abduo,
BDS, DClinDent. Associate Professor in Prosthodontics, Faculty of Dentistry,
University of Western Australia.

(5)

The Journal of Prosthetic Dentistry; Survey of partial removable dental prosthesis

(partial RDP) types in a distinct patient population. Deo K. Pun, DMD, MS,a Michael
P. Waliszewski, DDS, MsD,b Kenneth J. Waliszewski, DDS, MS,c and David Berzins,
PhDd Marquette University, Milwaukee, Wis

(6)

Dental Health Services Victoria. Waiting List Guidelines - Oral Health Program.
October 2011, pp 11.

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