A structured clinical examination is central to safe diagnosis, treatment planning and onward referral. Lauren Long explores the process for dental hygienists and therapists.
Clinical examination is more than a routine assessment; it is a structured process that progresses from information gathering and clinical examination to diagnosis, treatment planning and, where appropriate, onward referral. Confidence in this process develops through careful assessment, sound clinical reasoning, clear documentation and an honest understanding of professional scope and competence.
Dental hygienists and dental therapists intending to provide direct access care should inform their indemnity provider and ensure patients understand both their role and any limitations of their scope of practice before treatment begins.
Pre-assessment
The process starts with a clear and accurate account of the patient’s medical history. Medication use, allergies, recent treatment, previous complications and wider health factors all contribute to a clinician’s safe decision making. A comprehensive medical history is not a one-off exercise; it should be reviewed regularly, with each update dated and signed by the patient.
Social history should also be discussed, including tobacco and alcohol use, recreational drugs, occupation, living arrangements, hobbies and other lifestyle factors that may influence oral health or treatment planning.
This information aligns with the modifiable and non-modifiable risk factors highlighted by the BSP Good Practitioners Guide to Periodontology.
The patient’s presenting complaint (in their own words) can reveal both the clinical issue and the patient’s priorities. Using a structured approach such as the SOCRATES mnemonic can help ensure all relevant information is captured; site, onset, character, radiation, alleviating factors, time, exacerbating factors and severity (on a scale of one to 10).
Clinical examination
Soft tissues
The clinical examination should follow a systematic structure. Clinicians should look for asymmetry, suspicious skin lesions or changes. The clinician should then, with the patient’s permission, palpate the lymph nodes and temporomandibular joints to assess for swelling, tenderness or other abnormalities. This should be followed by a systematic intraoral soft tissue examination using a dental mirror. Throughout the examination, clinicians should explain what they are assessing and why. Encouraging patients to report any future changes can improve awareness and support earlier identification of potentially serious pathology.
Clinical photography provides an excellent method of documenting lesions. These photographs can be used in referral and to track changes over time. Including a periodontal probe within the photograph can provide a useful size reference.
Restorative
For restorative treatment, each tooth should be assessed for caries, defective restorations, fractures or cracks as well as non-carious tooth surface loss. Clinical photographs can be used to illustrate a starting point, even if the clinician is not carrying out treatment themselves.
Radiographs and other special investigations can also be useful in restorative treatment, but must be justified appropriately and only carried out within a clinician’s scope and competence. Additional investigations may include vitality testing, tooth sleuth testing, impressions or digital scanning.
Periodontal
A clinical examination in a periodontal patient should be based on recognised BSP guidance to provide a clear understanding of disease status and risk. This should include identifying risk factors and recording a BPE. The BPE provides a recognised and reproducible screening tool, allowing consistency between clinicians and establishing a baseline for periodontal assessment. Depending on the BPE score, further assessment may include plaque and bleeding indices and/or six-point pocket charting in accordance with BSP guidance. Appropriate radiographs should be available where clinically indicated to allow a complete periodontal assessment and diagnosis.
Diagnosis and treatment planning
Restorative
Radiographs and clinical photographs can be shown to the patient to illustrate the extent of any treatment required, alongside discussions on potential post-operative discomfort, likelihood of future pulp therapy, whether a direct restoration is the optimal treatment or whether a referral to another clinician is appropriate. This promotes co-diagnosis with the patient and assists with explanation of treatment, allowing for a greater understanding of treatment being offered and ensuring valid consent is obtained.
Periodontal
Using the current BSP guidelines, the clinician can follow the diagnosis flowchart using the knowledge gathered previously on patient history, alongside the clinical examination and radiographs. Periodontal diagnosis is not possible without appropriate radiographs to assess the percentage of bone loss, so these should always be available to ensure a full assessment and diagnosis. As with restorative treatment planning, these can then be used to illustrate to the patient more clearly the treatment required and the extent of their disease.
Diagnoses – global and specific
- A global diagnosis identifies the patient’s overall disease processes and risk profile for example, risk of: oral cancer, caries, periodontal disease, occlusal dysfunction or non-carious tooth surface loss
- Specific diagnoses identify individual conditions, for example, generalised gingivitis, caries in a specific tooth or existing non-carious tooth surface loss.
The clinician and patient should be in constant discussion during the diagnosis and treatment planning process, including an explanation of findings, diagnoses, available options, prognosis, risks, benefits, costs, timing, number of appointments and likely maintenance or replacement needs. These discussions help to create a collaborative relationship, with the patient having the chance to ask as many questions as they need to.
Accurate, contemporaneous clinical records should document examination findings, diagnoses, discussions with the patient, treatment options presented and the rationale for decisions made. Good documentation is an essential component of patient care and professional practice.
Onward referral
Referral forms an important part of the examination pathway whenever treatment falls outside a clinician’s scope, the case is particularly complex, or additional expertise is required. Referrals should be timely, contain all relevant information including radiographs or photographs and be followed up appropriately.
Building confidence and competence
The NSK Ikigai Oral Hygiene Community started with one mission, to create a dedicated support network for dental hygienists and therapists.
An active community and professional development hub, NSK Ikigai’s primary goal has always been to bring people together. The community remains dedicated to unlocking your potential and increasing your career satisfaction. To view the Ikigai webinar archive, please visit Ikigai Webinars – My NSK
Continuing professional development, structured education, reflective practice, case discussion and shadowing experienced colleagues all contribute to developing clinical confidence.
Programmes such as RESTORE., supported by NSK, which focus on structured examination, diagnosis, treatment planning and clinical decision making within scope, can provide a supportive environment for clinicians looking to refresh or develop these skills. A good clinician should understand when something is outside of their scope and feel confident making an onward referral without any sense of shame. The aim is always to do what is best for the patient, even if that means referring them to another clinician.
Further information about RESTORE., a reskilling programme for dental therapists focusing on clinical examination, diagnosis, treatment planning and practical restorative skills, is available at RESTORE.
This article is sponsored by NSK.
