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The Chief Complaint & Clinical Exam
The Chief Complaint & Clinical Exam
Dr. Alex Molayem avatar
Written by Dr. Alex Molayem
Updated over a week ago

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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.


  • 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



Periodontal status

  • Pathological pockets

  • Recessions


  • Mucosa

  • Dental status

  • Positional anomalies – tipping – rotation

  • Occlusion – sagittal, vertical, transverse

Space analysis

  • Maxilla

  • Mandible

Arch shape

  • Maxilla

  • Mandible

Cephalometric analysis

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