A clinical examination of the patient is carried out after the case history has been completed. The temptation to start treatment on a tooth without examining the remaining dentition must be resisted. Problems must not be dealt with in isolation and any treatment plan should take the entire mouth and the patient’s general medical condition and attitude into consideration.
Extra-oral examination
The patient’s face and neck are examined and any swelling, tender areas, lymphadenopathy, or extra-oral sinuses noted, as shown in Figure 1.
Intra-oral examination
An assessment of the patient’s general dental state is made, noting in particular the following aspects (Fig. 2).
Standard of oral hygiene. Amount and quality of restorative work. Prevalence of caries. Missing and unopposed teeth. General periodontal condition. Presence of soft or hard swellings. Presence of any sinus tracts. Discoloured teeth. Tooth wear and facets.
Diagnostic tests
Most of the diagnostic tests used to assess the state of the pulp and periapical tissues are relatively crude and unreliable. No single test, however positive the result, is sufficient to make a firm diagnosis of reversible or irreversible pulpitis. There is a general rule that before drilling into a pulp chamber there should be two independent positive diagnostic tests. An example would be a tooth not responding to the electric pulp tester and tender to percussion.
Palpation
Extra-oral examination
The patient’s face and neck are examined and any swelling, tender areas, lymphadenopathy, or extra-oral sinuses noted, as shown in Figure 1.
Intra-oral examination
An assessment of the patient’s general dental state is made, noting in particular the following aspects (Fig. 2).
Standard of oral hygiene. Amount and quality of restorative work. Prevalence of caries. Missing and unopposed teeth. General periodontal condition. Presence of soft or hard swellings. Presence of any sinus tracts. Discoloured teeth. Tooth wear and facets.
Diagnostic tests
Most of the diagnostic tests used to assess the state of the pulp and periapical tissues are relatively crude and unreliable. No single test, however positive the result, is sufficient to make a firm diagnosis of reversible or irreversible pulpitis. There is a general rule that before drilling into a pulp chamber there should be two independent positive diagnostic tests. An example would be a tooth not responding to the electric pulp tester and tender to percussion.
Palpation
The tissues overlying the apices of any suspect teeth are palpated to locate tender areas. The site and size of any soft or hard swellings are noted and examined for fluctuation and crepitus.
Percussion
Gentle tapping with a finger both laterally and vertically on a tooth is sufficient to elicit any tenderness. It is not necessary to strike the tooth with a mirror handle, as this invites a falsepositive reaction from the patient.
Mobility
The mobility of a tooth is tested by placing a finger on either side of the crown and pushing with one finger while assessing any movement with the other. Mobility may be graded as:
1 — slight (normal) 2 — moderate 3 — extensive movement in a lateral or
mesiodistal direction combined with a vertical displacement in the alveolus.