Evaluation: Patient Requiring a Comprehensive Oral Evaluation
(Adopted 1994, Revised 1995)
The key element in the design of this set of parameters for comprehensive evaluation is the professional judgment of the attending dentist, for a specific patient, at a specific time.
The patient's chief complaint, concerns and expectations should be considered by the dentist.
The dentist should perform a comprehensive oral evaluation when indicated by his or her professional judgment.
The dental and medical histories should be considered by the dentist to identify medications and predisposing conditions that may affect the prognosis, progression, and management of the oral health condition. (See: JADA article: New national guidelines on hypertension.)
The patient should be provided with appropriate information by the dentist about the diagnostic procedure(s) to be performed prior to giving consent to a comprehensive evaluation.
Medications should be prescribed, modified and/or administered for dental patients whose known conditions would affect or be affected by diagnostic procedures provided without the medication or its modification. The dentist should consult with the prescribing health care professional(s) before modifying medications being taken by the patient for known conditions. (See: ADA Statement on Antibiotic Prophylaxis, Prevention of Bacterial Endocarditis: A Statement for the Dental Profession (PDF), and A-Z Topic: Antibiotic Prophylaxis.)
Any evaluation performed should be with the concurrence of the patient and the dentist. If the patient refuses diagnostic procedures, the dentist may decline to evaluate the patient. If the patient insists upon diagnostic procedures not considered by the dentist to be necessary for evaluation, the dentist may decline to provide those procedures.
In the process of diagnosis and treatment planning, the attending dentist should review the accuracy of the data collected as part of patient evaluation.
The behavioral, psychological, anatomical, developmental and physiological limitations of the patient should be considered by the dentist in performing the comprehensive evaluation and in developing the treatment plan.
The dentist should attempt to manage the patient's pain, anxiety and behavior during evaluation to facilitate safety, efficiency, and patient cooperation. (See: ADA Policy Statement: The Use of Sedation and General Anesthesia by Dentists and Guidelines for the Use of Sedation and General Anesthesia by Dentists.)
An extra-oral examination of the head and neck should be performed by the dentist to determine the presence of disease, structural anomalies, functional anomalies and signs of physical abuse.
An intraoral examination should be performed by the dentist to determine existing conditions. These may include the presence of disease, structural anomalies, functional anomalies and signs of physical abuse. All restorations, including fixed and removable prostheses, should be examined. (See: Periodontal Screening and Recording®, (PSR®): An Early Detection System Q&A.)
Radiographs or images of diagnostic quality should be obtained. The number and type of radiographs or images required to provide the information needed for diagnostic purposes will vary according to the needs of the individual patient and should be determined by the attending dentist. (See: Professional Topic "Radiography/X-Rays," The Selection of Patients for Dental Radiographic Examinations [PDF].)
Additional diagnostic tests relevant to the evaluation of the patient may be performed and used by the dentist in diagnosis and treatment planning.
When the dentist considers it necessary, (an)other health care professional(s) should be consulted to acquire additional information.
The dentist should refer the patient to (an)other health professional(s) when the dentist determines that it is in the best interest of the patient.
Relevant and appropriate information about the patient and any necessary coordinated treatment should be communicated and coordinated between the referring dentist and the health professional(s) accepting the referral.
The patient should be informed of the findings and observations of the comprehensive evaluation.
The dentist should emphasize the prevention and early detection of oral diseases through patient education in preventive oral health practices, which may include oral hygiene instructions.
The dentist may recommend that the patient return for further evaluation. The frequency and type of evaluation(s) should be determined by the dentist, based on the patient's risk factors.
The health history, and the findings and observations of the comprehensive evaluation and general health assessment, including counseling and recommended preventive measures, as well as consultations with, and referrals to other health professionals should be included in the patient's dental record.