See Also:
The Chief Complaint
What makes it so important? In the chief complaint, the patient is simultaneously defining their problems and their perception of treatment success.
To document an accurate chief complaint, the patient should be allowed to express their problems and/or motivating factors that led to the consultation.
Letting patients express themselves freely allows the dentist to get a better impression of the priority that the patient gives to their problem.
In your patient questionnaire, you can offer a few open-ended questions. The way in which a patient explains their problem gives an indication of whether aesthetics or function ranks higher.
In the case where the problem has developed over time, ask the patient to bring older photographs to evaluate the smile.
These contributing factors can help you decide how to curate treatment for the patient's priorities, budget, and other personal motivating factors.
The Clinical Exam
The clinical examination includes extraoral and intraoral examination, supplemented with photographs and radiographs.
Extraoral
Smile – lipline
Profile
Lips
Midlines
Oral function
Opening path
Maximum opening
Lateral movements
Temporomandibular joints (TMJs)
Muscles of mastication
Tongue function
Lip catch
Mode of respiration
Mode of swallowing
Missing teeth
Morphological anomalies
Restorations
Attrition
Periodontal status
Pathological pockets
Recessions
Intraoral
Mucosa
Dental status
Positional anomalies – tipping – rotation
Occlusion – sagittal, vertical, transverse
Space analysis
Maxilla
Mandible
Arch shape
Maxilla
Mandible
Cephalometric analysis
Related Topics and Information:
Click to learn more about Special Instructions When Creating a Case and Taking Clinical Photographs.
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