Dental Hygiene Diagnosis and Care Planning

Dental HygieneDiagnosis and CarePlanning

S E C T I O N I V

AssessData

collection

DiagnoseIdentify problems

based onassessment

data

PlanSelect, prioritizeand sequencedental hygieneinterventions

ImplementActivatingthe planEvaluate

Feedback oneffectiveness

FIGURE IV-1 DH Process of Care: Diagnosis and Planning.

INTRODUCTION

After the initial assessment is completed as described inSection III, the data are assembled, sequenced, and ana-lyzed in preparation for planning strategies that help thepatient acquire and maintain oral health. A formal writ-ten care plan is necessary for educating the patient, secur-ing informed consent for treatment, and communicatingwith other oral care team members.

THE DENTAL HYGIENE PROCESS OF CARE

Figure IV-1 shows the position of diagnosis and care plan-ning in the total Dental Hygiene Process of Care.

I. DIAGNOSEThe diagnosis segment of the Dental Hygiene Process ofCare is related to analyzing the assessment data that hasbeen collected. The dental hygiene diagnosis identifiesthose patient needs for which the dental hygienist will pro-vide interventions. Interventions within the scope of den-tal hygiene practice are implemented to solve the problemsidentified by the diagnostic statements. Dental diagnoses,on the other hand, are directed at those particular diseasesand conditions forwhich the dentist will provide treatment.

� Dental hygiene diagnosis statements focus attention onthe behavioral aspects as well as deviations from nor-mal oral health.

� Chartings, radiographs, histories, and all recorded pa-tient data are analyzed together.

� Each diagnostic statement identifies with a significantoral hygiene problem of the patient. Examples of diag-nostic statements are shown in Table 22-2 (page____).

� A blueprint care plan, such as that designed in Figure22-1 (page ____), clarifies thinking toward preparationof diagnostic statements.

II. PLANThe third component of the Dental Hygiene Process ofCare is to develop a plan for patient care. Protocols and

purposes for developing a written care plan are describedin this section.

� The dental hygiene care plan selects interventions thatare based on analysis of assessment data that has beenconsolidated into diagnostic statements that define pa-tient needs.

� The care plan is developed to conform to and be inte-grated with the total treatment plan of the patient.

� The overall objectives of the dental health care teamfocus on the oral health of the patient. The ultimategoal will be the control of oral diseases.

ETHICAL APPLICATIONS

Professional ethics is part of every component in theprovider/patient relationship between the dental hygienistand the patient. The potential for an ethical situationarises anytime a dental hygienist interacts with a patient,with members of the dental team, or with individuals in-volved in the special needs of the patient, such as family,caregivers, or members of specialty practices. A dental hy-gienist who provides ethical patient care:

� Is cognizant of the respect each patient deserves.� Maintains communication among all parties responsi-

ble for dental and dental hygiene treatment.� Attains a knowledge of current standards of care

through continuing education coursework and readingprofessional journal articles about new research.

� Is aware of ethical issues such as conflict of interestwhile treating patients, the legal scope of one’s duties,and dealing with impaired colleagues

� Possesses the ability to assess and justify the reportingof unacceptable practices.

The basic concepts in healthcare law apply to all dentalhygiene professionals. The dental hygiene practice acts ofeach state or province govern the scope of duties and thecriteria for licensure. Professional liability, standard ofcare, informed consent, privacy information, and malprac-tice are other concerns that affect the daily duties andrights of both the patient and the dental hygienist.Selected legal concepts and suggestions for applicationare described in Table IV-1.

354 SECTION 4 Dental Hygiene Diagnosis and Care Planning

CHAPTER 21 Planning for Dental Hygiene Care 355

LEGAL AND ETHICAL CONCEPTS

LEGAL CONCEPT EXPLANATION APPLICATION

Professional Liability A licensed professional is legally accountable Scope and duties of the dental hygienist arefor all actions; bound by the law. defined in each state’s Dental Hygiene

Practice Act.

Scope of Practice A dental hygienist is legally bound to provide Adherence to dental hygiene licensurecare within the dental hygiene scope of requirements and performance of functionspractice. defined as legal within in each state’s Dental

Hygiene Practice Act.

Standard of Care A professional uses the ordinary and reasonable Evaluating the patient’s charting and examinationskill that is commonly used by other reputable data before determining which radiographsdental hygienists when caring for patients; are needed according to individualizedinvolves prudent judgment and use of all maintenance intervals.available resources.

Informed Consent Voluntary affirmation by a patient to allow Involves the ongoing process of communicatingexamination or treatment by authorized and educating a patient about oral healthdental personnel. options, not only a printed form to sign.

Negligence/Malpractice Failure to perform professional duties according Patient must show that the dental hygienist has ato the accepted standard of care. “duty” to the patient, was “derelict” and

breached that duty, there was evidence of“direct cause,” and that “damages” resulted.

Not performing circumferential probing andinforming/referring a patient when periodontalconcerns exist can be considered negligence.

TABLE IV-1

Planning for DentalHygiene Care

ASSESSMENT FINDINGSI. The Chief Complaint

II. Risk FactorsIII. Patient’s Overall Health StatusIV. Oral Healthcare Knowledge Level of the PatientV. The Patient’s Self-care Ability

VI. Documention of Assessment Data

THE PERIODONTAL DIAGNOSISI. Current Periodontal Status

II. Case TypeIII. Classification of Periodontal DiseaseIV. Parameters of Care

THE DENTAL HYGIENE DIAGNOSISI. Basis for Diagnosis

II. Diagnostic StatementsIII. Diagnostic Models

THE DENTAL HYGIENE PROGNOSISI. Criteria for Various Prognoses

II. Factors That Determine PrognosisIII. Expected Outcomes

CONSIDERATIONS FOR PROVIDING CAREI. Role of the Patient

II. Tissue ConditioningIII. Preprocedural Antimicrobial RinsingIV. Pain and Anxiety ControlV. Maintenance During Dental Therapy

VI. Four-Handed Dental Hygiene

EVIDENCE-BASED SELECTION OF DENTAL HYGIENEPROTOCOLS

EVERYDAY ETHICS

FACTORS TO TEACH THE PATIENT

REFERENCES

SUGGESTED READINGS

CHARLOTTE J. WYCHE, RDH, MS

C H A P T E R 2 1

Chapter Outline

In the dental hygiene process of care described inChapter 1 and illustrated in Figure IV-1, assessment dataare used to formulate the dental hygiene diagnosis. Then,using an evidence-based approach, a dental hygiene careplan and appointment sequence can be formalized. Termsand key words used in conjunction with these steps aredefined in Box 21-1.

ASSESSMENT FINDINGS

Assessment includes the gathering of details regarding thehealth status of the patient, followed by analysis and syn-thesis of the data. The application of clinical judgmentand critical thinking skills are necessary to arrive at a den-

tal hygiene diagnosis. Assessment procedures are de-scribed in detail in Chapters 6 through 20.

I. THE CHIEF COMPLAINTThe patient’s statement regarding the reason for seekingdental and dental hygiene care is considered when plan-ning. If a patient has a significant concern, such as pain,this need is addressed prior to initiating dental hygienetreatment.

II. RISK FACTORSWhether or not the patient presents for dental hygienecare with current oral disease, several risk factors can benoted that increase the patient’s potential for diminished

oral health status. When a patient presents for dentalhygiene care exhibiting one or more risk factors, it isessential to develop a care plan that provides anticipa-tory guidance through preventive education and coun-seling.

A. Risk Factors for Periodontal Infections or PoorResponse to Periodontal Therapy1–8

� Behavioral factors (inadequate biofilm removal, diet,noncompliance with dental hygiene recommendations)

� Tobacco use� Systemic conditions (diabetes, decreased immune fac-

tors, osteoporosis, osteopenia)� Hormonal considerations (pregnancy, menopause)� Nutritional status


ADLs (Activities of Daily Living): a measure of the ability tocarry out the basic tasks needed for self-care.IADLs (Instrumental Activities of Daily Living): a measure

of the ability to perform more of the complex tasksnecessary to function in our society; tasks that requirea combination of physical and cognitive ability.

Anticipatory guidance: patient education and oral hygiene in-structions that anticipate potential oral and systemichealth problems associated with risk factors identifiedduring patient assessment.

ASA: American Society of Anesthesiologists; originally devel-oped the ASA Classifications to determine modificationsnecessary to provide general anesthetic to patients duringsurgical procedures.

Assessment: the critical analysis and evaluation or judgmentof a particular condition, situation, or other subject of ap-praisal.

Chief complaint: the patient’s concern as stated during theinitial health history preparation; may be the reason forseeking professional care; a complaint such as pain ordiscomfort may require emergency dental diagnosis.

Compromised therapy: initial therapy and continued peri-odontal maintenance provided as the therapeutic endpoint in cases where the severity and extent of the dis-ease or the age and health of the patient preclude optimalresults of periodontal therapy.

Definitive care: complete care; end point at which all treat-ment required at the time has been completed.

Diagnose: to identify or recognize a disease or problem.Diagnosis: a statement of the problem; a concise technical

description of the cause, nature, or manifestations of acondition, situation, or problem; identification of a disease

or deviation from normal condition by recognition of char-acteristic signs and symptoms.Dental hygiene diagnosis: identification of an existing or

potential oral health problem that a dental hygienist isqualified and licensed to treat.

Differential diagnosis: identification of which one of sev-eral diseases or conditions may be producing thesymptoms.

Evidence-based care: providing oral care based on relevant,scientifically sound research.

OSCAR: a mnemonic that stands for OOral, SSystemic, CCapability,AAutonomy, and RReality. Developed by the American Acad-emy of Oral Medicine to provide a convenient, systematicapproach to identifying dental, medical/pharmacologic,functional, ethical, and fiscal factors that need to be evalu-ated and weighed when planning treatment for geriatricindividuals or those with disabilities.

Prognosis: prediction of outcome; a forecast of the probablecourse and outcome of a disease and the prospects of re-covery as expected by the nature of the specific conditionand the symptoms of the case.Dental hygiene prognosis: a judgment regarding the re-

sults (outcomes) expected to be achieved from oraltreatment provided by a dental hygienist.

Risk factor: an attribute or exposure that increases the prob-ability of disease, such as an aspect of personal behavior,environmental exposure, or an inherited characteristic as-sociated with health-related conditions.Modifiable risk factor: a determinant that can be modified

by intervention, thereby reducing the probability of disease.

BOX 21-1 Key WordsKEY WORDS AND ABBREVIATIONS: Planning for Dental Hygiene Care

� Iatrogenic factors(overhangs, open contacts, residualcalculus)

� Genetic factors

B. Periodontal Disease as a Risk Factor for SystemicConditions99––1144

Current research suggests that the presence of periodon-tal infection is a contributing factor to a variety of sys-temic conditions.

� Infective endocarditis � Cardiovascular disease (CVD) and atherosclerosis� Diabetes mellitus� Respiratory disease� Adverse pregnancy outcomes

C. Risk Factors for Dental Caries1155

� Behavioral factors (inadequate biofilm removal)� Dietary factors (frequent use of cariogenic foods/bever-

ages)� Low fluoride� Tooth morphology and position (deep occlusal pits and

fissures, exposed root surfaces, rotated positioning)� Xerostomia� Personal and family history of dental caries/restorative

dentistry� Developmental factors (modifications of dental

enamel)� Genetic factors (immune response)

C. Risk Factors for Oral Cancer1166,,1177

� Tobocco use� Alcohol use� Sun exposure (lips and face)

III. PATIENTS OVERALL HEALTH STATUS

A. Physical Status

The extent of the patient’s medical, physical, and psycho-logical risk determines modifications necessary duringtreatment. Patient positioning, sequence and timing oftreatments, and prevention of medical complicationsneed consideration.

The American Society of Anesthesiologists’ (ASA)Classification System18 (Table 21-1) and the OSCARPlanning Guide19 (Table 21-2) are two examples of system-atic approaches used to help determine modificationsnecessary when providing patient care.

B. Tobacco Use

The patient’s use of tobacco will affect oral status anddental hygiene treatment outcomes. Information on plan-

ning dental hygiene interventions for the patient who usestobacco is found on pages __ to __.

IV. ORAL HEALTHCARE KNOWLEDGE LEVEL OFTHE PATIENT

Before planning individualized patient care, an attempt ismade to assess the patient’s oral health knowledge level.From that baseline, planned educational interventionscan build on current knowledge rather than provide infor-mation too far above or below the patient’s current under-standing.

V. THE PATIENT’S SELF-CARE ABILITYThe patient’s ability to manipulate a toothbrush and flossand to comply with suggested oral care regimens will de-termine the success of planned interventions. Patientswith disabilities or physical limitations will require modifi-cation to ensure adequate daily dental biofilm removal.

An Activities of Daily Living (ADL)20 classificationlevel, described in Table 21-3, can provide a guide to deter-mine whether adaptive aids or caregiver training for per-sonal oral care procedures in necessary.

VI. DOCUMENTATION OF ASSESSMENT DATAComplete and accurate records are essential. When notcomputerized data are recorded in ink. Standardized ab-breviations are used to document all findings. Misunder-standings can lead to legal involvement.

THE PERIODONTAL DIAGNOSIS

Planning for the number and length of appointments in atreatment sequence will be determined by the patient’speriodontal diagnosis.

I. CURRENT PERIODONTAL STATUSA description of past and current periodontal conditions,as well as risk factors that affect the progress of disease,determine a patient’s current periodontal status.

II. CASE TYPEFor purpose of determining the sequences and number ofappointments required for initial nonsurgical periodontaltherapy, it is useful to divide the periodontal diagnosisinto case types as described in Table 14-1 (page __).

III. CLASSIFICATION OF PERIODONTAL DISEASEThe classification of periodontal diseases is shown inTable 14-2 on pages __ and __. The extent, severity, and



TREATMENT PLANNING WITH OSCAR

A systematic approach to identifying factors to evaluate when planning dental hygiene care.

ISSUE FACTORS OF CONCERN

Oral Teeth, restorations, prostheses, periodontium, pulpal status, oral mucosa, occlusion, saliva, tongue, alveolar bone

Systemic Normative age changes, medical diagnoses, pharmacologic agents, interdisciplinary communication

Capability Functional ability, self-care, caregivers, oral hygiene, transportation to appointments, mobility within the dental office

Autonomy Decision-making ability, dependence on alternative or supplemental decision makers

Reality Prioritization of oral health, financial ability or limitations, significance of anticipated life span

TABLE 21-2

Reprinted with permission from: The American Academy of Oral Medicine (Ship, J.A. and Mohammad, A.R., eds.): The Clinician’s Guide to Oral Health in GeriatricPatients (Monograph). Baltimore, American Academy of Oral Medicine, 1999, p. 21.

ASA* PHYSICAL STATUS CLASSIFICATION SYSTEM

EXAMPLES OF PHYSICAL OR DENTAL HYGIENE TREATMENTASA CLASSIFICATION PSYCHOSOCIAL MANIFESTATIONS CONSIDERATIONS

ASA I Without systemic disease; a Able to walk one flight of stairs No modifications necessarynormal, healthy patient with with no distress little or no dental anxiety ADL/IADL level � 0

ASA II Mild systemic disease or Must stop after walking one flight of Minimal risk; minor modifications extreme dental anxiety stairs because of distress to treatment and/or patient

Well-controlled chronic conditions education may be necessaryUpper respiratory infectionsHealthy pregnant womanAllergiesADL/IADL level � 1

ASA III Systemic disease that limits Must stop en route walking one Elective treatment is not activity but is not flight of stairs contraindicated, but serious incapacitating Chronic cardiovascular conditions consideration of treatment

Controlled insulin-dependent diabetes and/or patient/caregiver Chronic pulmonary diseases education modifications may be Elevated blood pressure necessaryADL/IADL level � 2 or 3

ASA IV Incapacitating disease that is Unable to walk up one flight of stairs Conservative, noninvasive a constant threat to life Unstable cardiovascular conditions management of emergency

Extremely elevated blood pressure dental conditions; more complex Uncontrolled epilepsy dental intervention may require Uncontrolled insulin-dependent diabetes hospitalization during treatment;

caregiver training for daily oral care may be necessary

ASA V Patient is moribund and not End-stage renal, hepatic, infectious Only palliative treatment is expected to survive disease, or terminal cancer delivered; caregiver training for

daily oral care may be necessary.

TABLE 21-1

*American Society of AnesthesiologistsAdapted from: Malamed, S. F.: Medical Emergencies in the Dental Office, 5th ed. St. Louis, Mosby, 2000, pp. 41–44.

chronic or aggressive nature of the patient’s periodontaldisease can be characterized.

IV. PARAMETERS OF CAREClinical diagnosis, therapeutic goals, treatment consider-ations, and outcomes assessment for periodontal diseaseare outlined in the periodontal Parameters of Care.21

Planning considerations are graded by the severity of in-fection. Examples are listed in Table 21-4.

THE DENTAL HYGIENE DIAGNOSIS

I. BASIS FOR DIAGNOSISA. Patient interview data (chief complaint, identification

of oral problems, and comprehensive personal/social,medical, and dental health histories)

B. Physical assessment data (vital signs, extraoral and in-traoral tissue examination, and dental and periodontalchartings)

C. Treatment or education needs that may be addressedby providing oral care services within the dental hy-gienists legal scope of practice

D. Treatment needs that may be addressed by consulta-tion with another licensed healthcare professional

II. DIAGNOSTIC STATEMENTSA. Provide the basis for planning interventions that are

within the scope of dental hygiene practiceB. Reflect expected outcomes of dental hygiene interven-

tions

C. Identify patient responses that are changeable by den-tal hygiene interventions

D. Exclude diagnoses that require treatments legally de-fined as dental practice

III. DIAGNOSTIC MODELS2222––2266

Medical and dental models of diagnosis classify diagnosticstatements according to disease processes. In contrast,dental hygiene models have been developed more likenursing models that encompass a broader focus. Thesemodels:

� Address health functioning and behaviors� Describe actual or potential health problems that den-

tal hygienists are educated and licensed to treat

The dental hygiene diagnosis models, described inTable 21-5, give direction and a scientific basis from whichto determine dental hygiene interventions and formulatepatient care plans.

THE DENTAL HYGIENE PROGNOSIS

Prognosis means a look ahead to an anticipated outcome orend point. The dental hygiene prognosis is a statement ofthe possible outcomes that can be expected from the den-tal hygiene intervention selected for an individual patient.

I. CRITERIA FOR VARIOUS PROGNOSESPrognosis is expressed in general terms for either an individ-ual tooth or for the overall prognosis for the patient’s teeth.The criteria for various prognoses are listed in Box 21-2.


MEASURES OF PATIENT FUNCTIONING*

EXAMPLES OF ACTIVITIES EXAMPLES OF INSTRUMENTALOF DAILY LIVING (ADLs) ACTIVITIES OF DAILY LIVING (IADLs) LEVELS

Brushing Maintaining self-care regimens Level 0Flossing Ability to make and keep dental Ability to perform the task without assistanceApplying interdental aids appointments Level 1Feeding Writing Ability to perform the task with some human Ambulation (Walking) Cooking assistance; may need a device or Bathing Shopping mechanical aid but or still independentContinence Climbing stairs Level 2Communication Managing medication Ability to perform the task with partial assistanceDressing Reading Level 3Toileting Cleaning Requires full assistance to perform the task; Transfer (from bed to toilet) Using telephone totally dependentGrooming

TABLE 21-3

*This scale provides a simple means of summarizing a person’s ability to carry out the basic tasks needed for self-care. Modified with permission from: Resnick, B.: Care of the Older Patient, in Nettina, S.M., ed.: The Lippincott Manual of Nursing Practice, 7th ed, Philadelphia,Lippincott Williams & Wilkins, 2001, pp. 167–168.


PARAMETERS OF CARE

CLINICAL DIAGNOSIS THERAPEUTIC GOALS TREATMENT CONSIDERATIONS

Biofilm-Induced Gingivitis • To establish gingival health Dental Treatment Plan Dental Hygiene Care Planthrough elimination of • The dental treatment plan • Customized patient etiologic factors may indicate surgical education

correction of gingival • Supra- and subgingival deformities. debridement

• Antimicrobial agents, andcorrection of biofilm-retentive factors

Chronic Periodontitis • To arrest progression of Dental Treatment Plan Dental Hygiene Care Plan• With slight to moderate disease and prevent • If resolution of the • Elimination and control of loss of periodontal recurrence condition does not occur, systemic risk factorssupport. • To preserve health, comfort, consider periodontal • Biofilm control

and function. surgery. • Supra- and subgingivalscaling and root planing

• Adjunctive antimicrobialagents

• Elimination of contributinglocal factors

Chronic Periodontitis • To alter or eliminate Dental Treatment Plan Dental Hygiene Care Plan • With advanced loss microbial etiology and • May include regeneration • Initial therapy as of periodontal support. contributing risk factors of periodontal attachment described above

• To arrest the progression following the completion Compromised Therapyof disease and evaluation of initial • Severity/extent of disease,

therapy or the age/health of the patient preclude optimalresults

• Initial therapy and continued periodontalmaintenance become theendpoint

Periodontal Maintenance • To minimize the Dental Hygiene Care Planrecurrence and • Comparison of clinical progression of the data to previous baseline disease measurements

• To reduce the incidence • Assessment of personal of tooth loss oral hygiene status and

compliance withmaintenance intervals

• Oral hygiene reinstruction or modification

• Counseling on control of risk factors

Acute Periodontal • To eliminate acute signs Dental Treatment Plan Dental Hygiene Care PlanDiseases and symptoms of the • Treatment considerations • Collaborate with the

Includes condition as soon as depend on the presenting attending dentist to • Gingival abscess possible condition prioritize treatment for • Periodontal abscess the immediate need• Necrotizing diseases• Herpetic gingivostomatitis• Pericoronitis• Periodontal-endodonticlesions

TABLE 21-4

(continued)


PARAMETERS OF CARE (continued)

CLINICAL DIAGNOSIS THERAPEUTIC GOALS TREATMENT CONSIDERATIONS

AggressivePeriodontitis • To alter or eliminate Dental Treatment Plan Dental Hygiene Care Plan

microbial etiology and may include: • Care parameters planned contributing risk factors • General medical for chronic periodontitis

• To arrest or slow the evaluation and progression of the disease consultation

• Microbial identification• Antibiotic sensitivity testing • Alternative antimicrobialagents or delivery systems

• Evaluation/counseling offamily members

Mucogingival Conditions • To maintain and restore Dental Treatment Plan The Dental Hygiene • Deviations from normal function and esthetics • May include surgical Care Plananatomic relationship treatment • Careful comparison of between gingival margin baseline and follow-up and mucogingival junction findings, control of

inflammation throughbiofilm control, scalingand root planing, and/orantimicrobial agents

TABLE 21-4

Reprinted with permission from: American Academy of Periodontology: Parameters of Care, J. Periodontol., 71, pp. 849–869, May (Supplement), 2000.

DIAGNOSTIC MODELS USED IN PLANNING DENTAL HYGIENE CARE

MODEL NAME DIAGNOSTIC STATEMENTS

Dental Hygiene Diagnostic Model22,23 Developed by following six steps that form the process of diagnostic decisionmaking:(1) Initial review (2) Hypothesis formation (3) Inquiry strategy(4) Problem synthesis (5) Diagnostic decision making (6) Learning from the process

Recorded in patient treatment records using the notation “DHDX” and accompa-nied by a treatment plan or treatment goal statement

The Human Needs Model24 Based on whether specific criteria defining eight human needs are met or unmetby the patient’s current oral health status

Written by outlining goals to be obtained for resolving each observed deficit

The Dental Hygiene Process Model25 Identify patient’s problem in terms of response rather than need and state thepossible etiology

Classified into several categories, which include general systemic, soft tissue,periodontal, oral hygiene, and dental categories

Written by stating the problem and the etiologic factor joined by the phrase “re-lated to”

The Oral Health-Related Quality of Life Diagnostic statements for individuals/populations are based on the assessment (OHRQL) Model26 of domains related to health/preclinical disease; biological/physiological dis-

ease; and the broad-based sequelae to disease, such as symptom status,function status, health perceptions, and overall quality of life

Dental hygiene actions are formulated for each domain, incorporating a multidis-ciplinary approach to care

TABLE 21-5

II. FACTORS THAT DETERMINE PROGNOSIS� Assessment data regarding current disease status� The patient’s risk factors � The patient’s commitment to personal care and pre-

ventive regimens.� Interventions with the potential to reverse a patient’s

oral problem� Treatment alternatives selected� Evidence from the scientific literature

III. EXPECTED OUTCOMESSome examples of potential outcomes from dental hy-giene interventions planned in a three-part care plan arelisted below.

A. Gingival/Periodontal

� Reduced dental biofilm� No bleeding on probing � Reduced probing depths� No further loss in attachment level� Decrease or no change in mobility� Resolution of erythematous tissue� Reduced swelling and edema

B. Dental Caries

� No new demineralized areas � Demineralized areas resolved � No new carious lesions

� Reduced intake of cariogenic foods/beverages� Dental sealants placed� Increased fluoride use

C. Prevention

� Elimination of iatrogenic factors (calculus, restorationoverhangs)

� Increased percentage of biofilm-free areas� Patient demonstration of recommended oral care pro-

cedures� Compliance with daily care recommendations � Compliance with recommended maintenance care in-

terval� Tobacco-free status achieved� Modification/stabilization of systemic risk factors

CONSIDERATIONS FOR PROVIDING CARE

I. ROLE OF THE PATIENT

A. Purpose

The willingness and/or ability of the patient to participatein planned oral health behaviors will be the key to reach-ing goals set during planning.

B. Procedure

1. Determine the patient’s level of understanding of den-tal diseases, risk factors, and oral health behaviors.


GGoooodd

FFaaiirr

PPoooorr

QQuueessttiioonnaabbllee

HHooppeelleessss

� Adequate control of etiologic factors� Adequate patient self-care ability� Adequate periodontal support

� Adequate control of etiologic factors� Adequate patient self-care ability� Less than 25% attachment loss� Class I or less furcation involvement

� Greater than 50% attachment loss with Class II furcation� Patient self-care difficult due to location and depth of furcation

� Greater than 50% attachment loss with poor crown-to-root ratio� Poor root form� Inaccessible Class II furcation or Class III furcation� Greater than 2+ mobility� Significant root proximity

� Inadequate attachment to maintain the tooth

BOX 21-2 Criteria for Various Prognoses

Prognosis is assigned by the presence of one or more of the following factors.

Modified with permission from: McGuire, M.K.: Prognosis vs Outcome: Predicting Tooth Survival, Compend. Contin. Educ. Dent., 21, 217, March, 2000.

2. Determine the patient’s physical ability to manipulaterecommended oral care aids.

3. Determine lifestyle factors that impact the patient’sability to comply with oral health recommendations.

4. Educate patients regarding the importance of their rolein setting oral health goals and complying with recom-mendations.

II. TISSUE CONDITIONINGPreparation or conditioning of the gingival tissue for scal-ing can be of particular significance when there is spongy,soft tissue that bleeds on slight provocation, and when thearea is generally septic from dental biofilm and debris ac-cumulation.

A. Purpose

Anticipated outcomes of a tissue conditioning program in-clude:

1. Gingival healing� tissues become less edematous� bleeding is minimized� scaling procedures are facilitated

2. Reduced bacterial accumulation� less likelihood that bacteremias will be produced

during scaling� reduced contamination in the aerosols produced

3. Learning by the patientWhile conditioning the tissue for scaling, the patient can:� practice oral health behaviors� experience the benefits of a clean mouth� from lifetime habits for continued maintenance

B. Procedure

� Initiate a pretreatment program of daily biofilm re-moval.

� Recommend daily use of an antibacterial rinse afterthorough brushing and flossing before going to bed.

� Select affected quadrants for scaling only after patientcooperation has been demonstrated.

III. PREPROCEDURAL ANTIMICROBIAL RINSING

A. Purpose

Preprocedural removal of dental biofilm will lower thebacterial count in aerosols and decrease the potential forbacteremia.

B. Procedure

� The first choice is patient brushing and flossing.� Vigorous rinsing with an antibacterial mouthwash is

beneficial.27

� Forcing the fluid between the teeth for 1 to 2 minutescan remove loose debris and surface bacteria approxi-mately 1 mm below the gingival margin.28

� Even rinsing with water will have some effect on bacte-ria; however, chlorhexidine rinses have the most sub-stantivity.29

IV. PAIN AND ANXIETY CONTROL

A. Purpose

� Control of discomfort during treatment procedure.� More consistent patient compliance with recom-

mended interventions and need to return for additionalscheduled appointments.

B. Procedure

1. Quadrant selectionTreat the patient areas of discomfort first, unless tissue

conditioning is required. Treat either the quadrant withthe fewest teeth or the least severe periodontal infectionfirst to:

� make the first scaling less complicated� help orient an anxious patient to clinical procedures

2. AnesthesiaThe need for anesthesia is determined by:� the patient’s previous pain control experiences� severity of the periodontal infection� depth of pockets� consistency and distribution of calculus� potential patient discomfort during scaling� sensitivity of the patient’s tissues

When two quadrants are to be treated at the same ap-pointment, it will minimize patient posttreatment discom-fort to select a maxillary and mandibular quadrant on thesame side.

V. MAINTENANCE DURING DENTAL THERAPY

A. Purpose

When restorative, prosthetic, or orthodontic, treatmentextends over a period of time, periodic appointments withthe dental hygienist are needed for monitoring the contin-ued success of the patient’s self-care.

B. Procedure

Dental hygiene care provided during extended dentaltherapy follows the dental hygiene process of care and in-cludes:

� gingival tissue assessment� probing to determine bleeding� biofilm check with disclosing agent� reinforcement of daily oral care measures


� scaling and root planning to remove calculus� additional instruction for care of new prostheses� motivational encouragement

VI. FOUR-HANDED DENTAL HYGIENE

A. Purpose

Planning patient care while practicing with a dental assis-tant increase the dental hygienist’s efficiency through theuse of:

� flexible scheduling.30

� two treatment chairs in an overlapping time frame.� assistance with patient management.

B. Procedure

A well-trained dental hygiene assistant can be delegatedsuch duties as:

� patient reception and seating� medical history update prior to confirmation by the

dental hygienist� radiographs (following individual state certification

guidelines)� reinforcement of oral hygiene instruction� assistance during sealant placement and ultrasonic

scaling� cleanup/disinfection of the treatment room in prepara-

tion for the next patient

EVIDENCE-BASED SELECTION OFDENTAL HYGIENE PROTOCOLS

Dental hygiene interventions are planned using scientificevidence of efficacy and efficiency. Scientific evidencefrom dental and medical literature can improve opportu-


nities for achieving successful outcomes from dental hy-giene treatment. The patient can benefit if the dental hy-gienist has developed skills in accessing and evaluatingthe scientific literature.

THE DENTAL HYGIENE CARE PLAN

Chapter 22 outlines specific procedures for preparation ofa written dental hygiene care plan.

Victoria, the dental hygienist, is discussing the assessmentfindings for her patient, Mr. Rush, with the rest of the dentalteam. Mr. Rush has stated that he has already been told at hisgeneral dental practice that he has extensive active peri-odontal disease. He was referred to this practice because hewants all of the most compromised teeth extracted and den-tal implants placed.

Mr. Rush has a number of risk factors, such as poorlycontrolled diabetes and smoking. Because his dental insur-ance is running out in 3 months, everyone is in a rush to getthe treatment started, and the potential for a poor prognosishas not been discussed. In fact, Victoria’s concerns about thepatient’s risk factors are being pushed aside.

Question for Consideration1. What is Victoria’s obligation (duty) to make sure that Mr.Rush understands how his risk factors compromise theprognosis of his treatment plan?

2. What action can Victoria take if her concerns continue tobe ignored and treatment progresses without interventionsthat address the risk factors involved in Mr. Rush’s case?

3. How should Victoria proceed to obtain informed consentfrom Mr. Rush and ensure that his rights to optimal careare maintained?

Everyday Ethics

� A clear explanation of how assessment data are used inplanning dental hygiene care.

� The importance of using scientific evidence of successin the selection of patient-specific therapeutic and pre-ventive interventions.

� Why disease control measures are learned before and inconjunction with scaling.

� Facts of oral disease prevention and oral health promo-tion relevant to the patient’s current level of healthcareknowledge and individual risk factors.

� The long-term positive effects of comprehensive contin-uing care.

Factors to Teach The Patient

References1. MMoollllooyy,, JJ.., Wolff, L.F., Lopez-Guzman A., and Hodges, J.S.:

The Association of Periodontal Disease Parameters withSystemic Medical Conditions and Tobacco Use, J. Clin.Periodontol., 31, 625, August, 2004.

2. FFiisshheerr,, MM..AA.., Taylor, G.W., and Tilashalski, K.R.:Smokeless Tobacco and Severe Active Periodontal Disease,NHANES III, J. Dent. Res., 84, 705, August, 2005.

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4. MMuulllliiggaann,, RR.. and Sobel, S.: Osteoporosis: DiagnosticTesting, Interpretation, and Correlations with Oral Health-Implications for Dentistry, Dent. Clin. North Am., 49, 463,April, 2005.

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8. TTaattaakkiiss,, DD..NN.. and Kumar, P.S.: Etiology and Pathogenesisof Periodontal Diseases, Dent. Clin. North Am., 49, 491,July, 2005.

9. DDaallyy,, CC..GG.., Mitchell, D.H., Highfield, J.E., Grossberg,D.E., and Stewart, D.: Bacteremia Due to PeriodontalProbing: A Clinical and Microbial Investigation, J.Periodontol., 72, 210, February, 2001.

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11. IIaaccooppiinnoo,, II..MM..: Periodontitis and Diabetes Interrelation-ships: Role of Inflammation, Ann. Periodontol., 6, 125, De-cember, 2001.

12. HHoollmmssttrruupp,, PP.., Poulsen, A.H., Andersen, L., Skuldbol, T.,and Fiehn, N.E.: Oral Infections and Systemic Diseases,Dent. Clin, North Am., 47, 575, July, 2003.

13. OOffffeennbbaacchheerr,, SS.., Lieff, S., Boggess, K.A., Murtha, A.P.,Madianos, P.N., Champagne, C.M., McKaig, R.G., Jared,H.L., Mauriello, S.M., Auten, R.L. Jr., Herbert, W.N., andBeck, J.D.: Maternal Periodontitis and Prematurity. Part I:Obstetric Outcome of Prematurity and Growth Restriction,Ann. Periodontol., 6, 164, December, 2001.

14. MMoooorree,, SS.., Ide, M., Coward, P.Y., Randhawa, M.,Borkowska, E., Baylis, R., and Wilson, R.F.: A ProspectiveStudy to Investigate the Relationship Between PeriodontalDisease and Adverse Pregnancy Outcomes, Br. Dent. J.,197, 251, September, 2004.

15. RReetthhmmaann,, JJ..: Trends in Preventive Care: Caries RiskAssessment and Indications for Dental Sealants, J. Am.Dent. Assoc., 131 8S, June (Supplement), 2000.

16. SSccuullllyy,, CC.., Newman, L., and Bagan, J.V.: The Role of theDental Team in Preventing and Diagnosing Cancer: 2. OralCancer Risk Factors, Dent. Update, 32, 264, June, 2005.

17. PPeerreeaa--MMiillllaa LLooppeezz,, EE.., Minarro-Del Moral, R.M., Martinez-Garcia, C., Zanetti, R., Rosso, S., Serrano, S., Aneiros, J.F.,Jimenez-Puente, A, and Redondo, M.: Lifestyles,Environmental and Phenotypical Factors Associated withLip Cancer: A Case-Control Study in Southern Spain, Br. J.Cancer, 88, 1707, June, 2003.

18. AAmmeerriiccaann SSoocciieettyy ooff AAnneesstthheessiioollooggiissttss: New Classificationof Physical Status, Anesthesiology, 24, 111, January-February, 1963

19. TThhee AAmmeerriiccaann AAccaaddeemmyy ooff OOrraall MMeeddiicciinnee (Ship, J.A. andMohammed, A. R., eds.): The Clinician’s Guide to Oral

Health in Geriatric Patients (Monograph). Baltimore, MD,American Academy of Oral Medicine, 1999, p. 21.

20. RReessnniicckk,, BB..: Care of the Older Patient, in Nettina, S.M.,ed.: The Lippincott Manual of Nursing Practice, 7th ed.Philadelphia, Lippincott Williams & Wilkins, 2001, pp.167–168.

21. AAmmeerriiccaann AAccaaddeemmyy ooff PPeerriiooddoonnttoollooggyy: Parameters of Care.J. Periodontol., 71, 847, May (Supplement), 2000.

22. GGuurreennlliiaann,, JJ..RR..: Diagnostic Decision Making, in Woodall,I.R., ed.: Comprehensive Dental Hygiene Care, 4th ed. St.Louis, Mosby, 1993, pp. 361–370.

23. GGuurreennlliiaann,, JJ..RR..: Recording the Dental Hygiene Diagnosis,Access 8, 15, November, 1994.

24. DDaarrbbyy,, MM..LL.. and Walsh, M.M.: Application of the HumanNeeds Conceptual Model to Dental Hygiene Practice. J.Dent. Hyg., 74, 230, Summer, 2000.

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26. WWiilllliiaammss,, KK..BB.., Gadbury-Amyot, C.C., Krust Bray, K.,Manne, D., and Collins, P.: Oral Health-Related Quality ofLife: A Model for Dental Hygiene, J. Dent. Hyg., 72, 19,Spring, 1998.

27. FFiinnee,, DD..HH.., Korik, I., Furgang, D., Myers, R., Olshan, A.,Barnett, M.L., and Vincent, J.: Assessing Pre-proceduralSubgingival Irrigation and Rinsing with an AntisepticMouthrinse to Reduce Bacteremia, J. Am. Dent. Assoc.,127, 641, May 1996.

28. VVeekksslleerr,, AA..EE.., Kayrouz, G.A., and Newman, M.G.:Reduction of Salivary Bacteria by Pre-procedural Rinseswith Chlorhexidine 0.12%, J. Periodontol., 62, 649,November, 1991.

29. WWuunnddeerrlliicchh,, RR..CC.., Singleton, M., O’Brien, W.J., andCaffesse, R.G.: Subgingival Penetration of an AppliedSolution, Int. J. Periodontol. Restorative Dent., 4, 64,Number 5, 1984.

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Suggested Readings

Diagnosis and Care PlanningAAmmeerriiccaann DDeennttaall EEdduuccaattiioonn AAssssoocciiaattiioonn: Competencies for

Entry into the Profession of Dental Hygiene, J. Dent. Educ.,69, 803, July, 2005.

AAmmeerriiccaann DDeennttaall HHyyggiieenniissttss’’ AAssssoocciiaattiioonn: Dental HygieneDiagnosis Position Paper. Chicago, American DentalHygienists’ Association, June, 2005.

CCaalllleeyy,, KK..HH..: Dental Hygiene Process of Care, in Darby M.L.,ed.: Mosby’s Comprehensive Review of Dental Hygiene, 5th ed.St. Louis, Mosby, 2002, pp. 577–578.

DDooeennggeess,, MM..EE.., Moorhouse, M.F., and Geissler, A.C.: NursingCare Plans: Guidelines for Individualizing Patient Care.Philadelphia, F.A. Davis, 1997, pp. 6–10.

MMccCCuulllloouugghh,, CC..: Diagnosis and Treatment Planning, Access, 7,26, April, 1993.

MMiilllleerr,, SS..SS..: Dental Hygiene Diagnosis, RDH, 2, 46, July-August, 1982.

PPaattttiissoonn,, AA..MM.. and Pattison, G.L.: Periodontal Instrumentation,2nd ed. Norwalk, CT, Appleton & Lange, 1992, pp.329–335.



SStteeffaannaacc,, SS..JJ..: Information Gathering and Diagnosis Develop-ment, in Stefanac, S.J. and Nesbit S.P., eds.: Treatment Plan-ning in Dentistry. St. Louis, Mosby, 2001, pp. 20–25.

Risk Factors—Dental CariesAAnnddeerrssoonn,, MM..: Risk Assessment and Epidemiology of Dental

Caries: Review of the Literature, Pediatr. Dent. 24, 377,September–October, 2002.

BBrraatttthhaallll,, DD.. and Hansel Petersson, G.: Cariogram—A Multifac-torial Risk Assessment Model for a Multifactorial Disease,Community Dent. Oral Epidemiol., 33, 256, August, 2005.

CCaauuffiieelldd,, PP..WW.. and Griffen, A.L.: Dental Caries: An Infectiousand Transmissible Disease, Pediatr. Clin. North Am.,47,1001, October, 2000.

DDoorrsseeyy,, BB.. and Martin, B.S.: Implementation of a CariesPrevention Program Using Risk Assessment, Contemp. OralHyg., 2, 20, September/October, 2002.

LLeevvaattoo,, CC..MM..: Caries Management: A New Paradigm, Compend.Contin. Educ. Dent., 26, 448, June (6A Supplement), 2005.

SStteeeellee,, JJ..GG.., Sheiham, A., Marcenes, W., Fay, N., and Walls,A.W.: Clinical and Behavioral Risk Indicators for Root Cariesin Older People, Gerodontology, 18, 95, December, 2001.

Risk Factors—Periodontal DiseaseAAmmeerriiccaann AAccaaddeemmyy ooff PPeerriiooddoonnttoollooggyy: Parameter on

Periodontitis Associated with Systemic Conditions, J.Periodontol.,71, 876, May (Supplement), 2000.

AAmmeerriiccaann AAccaaddeemmyy ooff PPeerriiooddoonnttoollooggyy: Parameter on SystemicConditions Affected by Periodontal Diseases, J. Periodon-tol.,71, 880, May (Supplement), 2000.

LLooeesscchh,, WW..JJ..: Periodontal Disease: Link to CardiovascularDisease, Compend. Cont. Educ. Dent., 21, 463, June, 2000.

BBeerrggssttrroomm,, JJ..: Tobacco Smoking and Chronic DestructivePeriodontal Disease, Odontology, 92, 1, September, 2004.

LLooppeezz,, NN..JJ.., Smith, P.C. and Gutierrez, J.: Higher Risk ofPreterm Birth and Low Birth Weight in Women withPeriodontal Disease. J. Dent. Res., 81, 58, January, 2002.

MMaacchhtteeii,, EE..EE.., Mahler, D., Sanduri, H. and Peled, M.: TheEffect of Menstrual Cycle on Periodontal Health, J.Periodontol., 75, 408, March, 2004.

MMaaddiiaannooss,, PP..NN.., Lieff, S., Murtha, A.P., Boggess, K.A., Auten,R.L. Jr., Beck, J.D., and Offenbacher, S.: Maternal Periodon-titis and Prematurity. Part II: Maternal Infection and Fetal Ex-posure, Ann. Periodontol., 6, 175, December, 2001.

MMiicchhaalloowwiicczz,, BB..SS.., Diehl, S.R., Gunsolley, J.C., Sparks, B.S.,Brooks, C.N., Koertge, T.E., Califano, J.V., Burmeister, J.A.,and Schenkein, H.A.: Evidence of a Substantial GeneticBasis for Risk of Adult Periodontitis. J. Periodontol., 71,1699, November, 2000.

NNeeiivvaa,, RR..FF.., Steigenga, J., Al-Shammari, K.F. and Want, H.L.:Effects of Specific Nutrients on Periodontal Disease Onset,Progression and Treatment, J. Clin. Periodontol., 30, 579,July, 2003.

NNooaacckk,, BB.., Jachmann, I., Roscher, S., Sieber, L., Kopprasch, S.,Luck, C., Hanefeld, M., and Hoffmann, T.: MetabolicDiseases and Their Possible Link to Risk Indicators ofPeriodontitis, J. Periodontol., 71, 898, June, 2000.

PPeerrssssoonn,, RR..EE.. and Persson, G.R.: The Elderly at Risk forPeriodontitis and Systemic Diseases, Dent. Clin. North Am.,49, 279, April, 2005.

SShhaayy,, KK.., Scannapieco, F.A., Terpenning, M.S., Smith, B.J., andTaylor G.W.: Nosocomial Pneumonia and Oral Health, Spec.Care Dentist, 25, 179, July/August, 2005.

WWrriigghhtt,, JJ..TT.. and Hart, T.C.: The Genome Projects: Implicationsfor Dental Practice and Education, J. Dent. Educ., 66, 659,May, 2002.

PrognosisGGhhiiaaii,, SS.. and Bissada, N.F.: Prognosis and Actual Treatment

Outcome of Periodontally Involved Teeth, Periodontal Clin.Investig., 18, 7, Spring, 1996.

KKoorrnnmmaann,, KK..SS..: Diagnositc and Prognostic Tests for OralDiseases: Practical Applications, J. Dent. Educ., 69, 498,May, 2005.

LLllooyydd,, PP..MM..: Users’ Guide to the Dental Literature: How to Usean Article About Prognosis, Dent. Clin. North Am., 46, 127,January, 2002.

NNiieerrii,, MM.., Muzzi, L., Cattabriga, M., Rotundo, R., Cairo, F., andPini Prato, G.P.: The Prognostic Value of Several PeriodontalFactors Measured as Radiographic Bone Level Variation: A10-Year Retrospective Multilevel Analysis of Treated andMaintained Periodontal Patients, J. Periodontol., 73, 1485,December, 2002.

Evidence-based CareAAnnddeerrssoonn,, JJ..DD..: Applying Evidence Based Dentistry to Your

Patients, Dent. Clin. North Am., 46, 157, January, 2002.CCaarrrr,, AA..BB.. and McGivney, G.P.: Evidence-based Dentistry

Series: Users’ Guides to the Dental Literature: How to GetStarted, J. Prosthet. Dent., 83, 13, January, 2000.

CChhiiaappppeellllii,, FF.. and Prolo, P.: Evidence-based Dentistry for the21st Century, Gen. Dent., 50, 270, May-June, 2002.

FFoorrrreesstt,, JJ..LL.. and Miller, S.A.: Evidence-based Decision Makingin Dental Hygiene Education, Practice, and Research, J.Dent. Hyg., 75, 50, Winter, 2001.

FFoorrrreesstt,, JJ..LL.. and Miller, S.A.: Evidence-Based Decision Makingin Action: Part 1—Finding the Best Clinical Evidence, J.Contemp. Dent. Pract., 3, 10, August 15, 2002.

FFoorrrreesstt,, JJ..LL.. and Miller, S.A.: Evidence-based Decision Makingin Action: Part 1—Evaluating and Applying the ClinicalEvidence, J. Contemp. Dent. Pract., 4, 42, February 15,2003.

GGoollddsstteeiinn,, GG..RR.. and Preston, J.D.: Evidence-based DentistrySeries: How to Evaluate an Article about Therapy, J. Prosthet.Dent. 83, 599, June, 2000.

GGoollddsstteeiinn,, GG..RR.. and Preston, J.D.: Therapy: Anecdote,Experience, or Evidence?, Dent. Clin. North Am., 46, 21,January, 2002.

GGoorrddoonn,, SS..MM.. and Dionne, R.A.: The Integration of ClinicalResearch into Dental Theraputics: The Role of the AstuteClinician. J. Am. Dent. Assoc., 135, 1537, November, 2004.

JJaahhnn,, CC..: A Guide to Better Decisions in Dental Hygiene Care:Understanding the Evidence-Based Approach and ItsBenefits in Periodontal Care, J. Practical Hyg., 9, 19,May/June, 2000.

LLaasskkiinn,, DD..MM..: Finding the Evidence for Evidence-basedDentistry, J. Am. Coll. Dent., 67, 7, Spring, 2000.

NNiieeddeerrmmaann,, RR.. aand Badovinac, R.: Tradition-based Dental Careand Evidence-based Dental Care, J. Dent. Res., 78, 1288,July, 1999.

SSuutthheerrllaanndd,, SS..EE..: The Building Blocks of Evidence-basedDentistry, J. Can. Dent. Assoc., 66, 241, May, 2000.

SSuutthheerrllaanndd,, SS..EE..: Evidence-based Dentistry: Part I. GettingStarted, J. Can. Dent. Assoc., 67, 204, April, 2001.

TTaavveennddeerr,, EE..JJ.. and Glenny, A.-M.: The Cochrane Collaboration:The Oral Health Group, J. Dent. Educ., 66, 612, May, 2002.

Dental Hygiene Diagnosis and Care Planning

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