With dental therapists' role in the dental team currently in the limelight, Lauren Long explores the essential components of clinical examination for dental therapists, highlighting key techniques and considerations to enhance proficiency.

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In recent months, there has been an increased focus on the role of the dental therapist, with patients now able to directly access NHS care through a dental therapist; the prime minister citing dental therapists as one of the solutions to the dental access crisis; and the success of the exemptions project - spearheaded by both the British Association of Dental Therapists (BADT) and the British Society of Dental Hygiene and Therapy (BSDHT) - gaining approval from parliament.

Progressive dental practices are now embracing the skills of the entire team to offer the best care to their patients, resulting in an increased demand for dental therapists to utilise their full scope of practice.

Clinical examination is a fundamental aspect of the role of the dental therapist, essential for accurate diagnosis and effective treatment planning. As a dental therapist, the ability to conduct thorough and precise clinical examinations directly impacts the quality of care we can provide to our patients. This article aims to explore the essential components of clinical examination for dental therapists, highlighting key techniques and considerations to enhance proficiency.

Before delving into the specifics, it's important to understand why clinical examination holds such significance in dental therapy. A comprehensive examination enables us to assess the oral health status of our patients, recognise their risk levels, identify existing dental issues, detect potential future problems, and formulate appropriate treatment strategies. Examination is also key to early detection of pathologies such as oral cancers, ultimately contributing to improved patient outcomes and preventive care.1

Components of clinical examination

Patient history

Begin by obtaining a detailed history from the patient. Knowing a patient's medical history not only helps us to keep them safe when they are with us in the surgery, but can also start to give us some clues regarding their risk of disease - do they take medications that may cause a dry mouth? Or cause gingival hyperplasia? Might they be allergic to any products we may wish to use or recommend?

What is their dental history? They may be a regular attender who you have met many times, or they may not have seen a dental professional in many years. Do they have any current dental complaints? This will start to create a picture of their oral health status.

Discovering their social habits such as smoking, excessive sugar or acidic food consumption or lifestyle factors such as shift working will help enhance the picture further.

Extraoral examination

It is important that we take the entire head and neck area into consideration, not just concentrating on the intraoral. This can start from the moment you meet the patient in the waiting room - do they have any asymmetry that you notice? Any skin lesions? Once in the surgery, conduct a systematic assessment of the patient's extraoral structures, including the face, neck, and temporomandibular joint (TMJ). Assess for signs of asymmetry, swelling, or abnormalities in the soft tissues. Palpate the TMJ for tenderness or clicking, which may indicate underlying issues such as temporomandibular joint disorder (TMD). Patients can often find palpation a little disconcerting if they have not had this carried out previously, so keep them informed of what you are doing and why. An easy way to explain is to say we are looking for any abnormal lumps or bumps and by feeling rather than looking we may catch any that are present at an earlier stage. This step can also be used as an educational tool to let patients know what is abnormal and not, and that they shouldn't hesitate to contact us if they think something is unusual.

Intraoral examination

We can then move on to a thorough intraoral examination in order to assess:

Oral hygiene: Evaluate the patient's oral hygiene routine and provide personalised oral hygiene instructions as needed. Assess plaque accumulation, calculus deposits, and areas requiring improved oral care.

Soft tissues: Examine the attached gingivae, tongue, hard and soft palate, cheeks, and floor of the mouth for any lesions, ulcers, or abnormalities. Again, use this to educate your patient on how they can examine their soft tissues at home. The Mouth Cancer Foundation have some great resources on self-examination that can be shared.2

Hard tissue: With the aid of the 3in1 air syringe, inspect each tooth thoroughly for signs of caries, fractures, wear and any existing restorations. Assess the integrity of these restorations by checking for open margins, fracture lines or leakage. Are there any plaque retentive factors that are impeding the patient's oral hygiene efforts?

Also examine for any non-carious tooth surface loss at this stage - are there signs of wear to the incisal edges, indicative of bruxism? Toothbrush abrasion? Erosion from their soft drink habit that they may have disclosed in the earlier history?

Periodontium: Assess the health of the periodontal tissues, noting any necessary indices. Start with the basic periodontal examination (BPE) and move onward to further indices such as plaque and bleeding scores or a 6 point periodontal chart as necessary.3

Occlusion: Evaluate the patient's occlusal relationship to identify malocclusions, occlusal discrepancies, or signs of bruxism.

Radiographic examination: As dental therapists, we may have had the ability to prescribe radiographs included in our undergraduate training, depending on when and where we qualified. If not, there are courses available to enable us to do so. We can also report on radiographs within our scope of practice, ensuring that anything outside of this is passed to a dentist colleague for reporting. Radiographs can provide valuable diagnostic information, aiding in the detection and diagnosis of caries, periodontal disease, and other pathologies not visible during a clinical examination alone. They are also now a vital component of achieving a periodontal diagnosis.

Top tips for examination success

Introduce your role to patients: Let your patients know that you are a dental therapist, what your role entails and importantly, the limitations to your scope of practice. Advise them that they will be referred to a dentist for any assessment or treatment that you cannot offer. This sets expectations clearly from the outset and can avoid confusion further down the line.

A systematic approach: Adopt a systematic approach to your clinical examination, following a set sequence to ensure thoroughness and consistency. This approach minimises the likelihood of overlooking important findings and enhances the efficiency of your examination process. It also helps your dental nurse to assist with note taking and prompt you for more information where necessary.

Documentation: Document your clinical findings accurately and comprehensively in the patient's dental notes. Recording detailed notes allows for continuity of care, facilitates communication with other members of the dental team, and serves as a reference for future treatments. Templates can be helpful to ensure that nothing is missed but should be personalised for each patient.

Onward referral: Robust practice protocols for onward referral of items outside the dental therapist's scope of practice are essential to ensure success. One size does not fit all practices, so it is often best to discuss this with the team and ensure everyone is clear on how this will work.

Practice: If you have not previously been responsible for carrying out examinations, it is natural to feel apprehensive. Shadowing a colleague, having the space to ask questions, and requesting some ongoing mentoring is a great way to feel more confident in this role. There are also an increasing number of courses available to dental therapists to help improve examination skills.

By incorporating these principles into clinical practice, dental therapists can elevate their proficiency in clinical examination and help support patients in achieving improved oral health outcomes.