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The Dental Hygiene Process of Care:

Is Your Practice on Track?

Entry-To-Practice Competencies and Standards for Canadian Dental

Hygienists:

What are National Dental Hygiene Competencies? “Competencies are used to describe the essential knowledge, skills and attitudes important for the practice of a profession; in this particular document these competencies describe the foundation necessary for entry into the dental hygiene profession in Canada.” “They support the dental hygiene process of care by more clearly articulating the abilities inherent in the assessment, diagnosis, planning, implementation and evaluation of dental hygiene services.”

How does the DHPC relate to National Competencies? “The dental hygiene process is the foundation of professional dental hygiene practice and provides a framework for delivering high-quality dental hygiene care to all types of clients in any environment. The dental hygiene process requires decision making and assumes that dental hygienists are responsible for identifying and resolving client problems within the scope of dental hygiene practice” 1 The dental hygiene process involves dental hygiene diagnosis, assessment, planning, implementation and evaluation. The process can be applied in all settings. However, reference to the Dental Hygiene Process of Care refers specifically to direct client care and incorporates the critical thinking process in determining interventions to achieve the desired outcomes. Best Practices: Utilization of the Dental Hygiene Process of Care as the structural framework which all dental hygiene therapy should be conducted ensuring individualized needs of the client can be met. The process of care is a dynamic process that is continually evolving. All dental hygienists are expected to use their knowledge, skill and judgment regardless of their practice setting or employment arrangement.

Synopsis:

The Dental Hygiene Process of Care (DHPC) is the structural framework to which all dental hygiene practice should base client specific treatment planning upon. As a registrant our documentation is to reflect assessment, dental hygiene diagnosis, dental hygiene care plan, recording of interventions as well as the required process for evaluation.

Presented by:

Jo-Anne Jones, RDH, President, RDH Connection Inc. Corporate Partner, rdhu jjones@rdhconnection.com

Co-sponsored by:

Transforming the Dental Hygiene Experience!

www.rdhu.ca

Learning Outcomes:

Recognize the components of the Dental Hygiene Process of Care (DHPC)

Understand the relevancy of data collection and correlation of findings to aid in the remainder of the DHPC

Understand the dynamic nature of the assessment phase and how it impacts the care plan and implementation

Recognize the components of a written dental hygiene care plan

Possess an understanding of evaluation, management and referral as it pertains to individualized client needs and treatment outcomes

Assessment of competency related to suggested performance indicators

References & Resources: http://www.cdha.ca/pdfs/Profession/Resources/DefinitionScope_public.pdf Entry-To-Practice Competencies and Standards for Canadian Dental Hygienists January 2010 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf Lexi-Comp Chairside Reference Library: www.lexi.com/dentistry (Use promo code RDHC01) The Knowledge Network http://www.cdho.org/Knowledge+Network.asp www.cdha.ca/e-cps

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References & Resources: All sites accessed September 2014 http://www.cdho.org/reference/english/bestpractice.pdf Milestones, June 2010 Keir J. Portfolio and Practice Reviews: What to Expect 2010. Milestones June 2010.

Entry to practice competencies and standards for Canadian dental hygienists;

Assess, diagnose, plan, implement and evaluate services for clients

The Dental Hygiene Process of Care for Today’s Dental Hygiene Practice:

Traditional performance vs. modern day process

Template approach vs. client specific care and treatment planning

Increased knowledge coupled with science & technology

Increased awareness of impact of oral health on overall wellness

Standard of care vs. substandard of care

Demands & influences of societal change o Interdisciplinary network

Recordkeeping Deficiencies: The most common deficiencies found at an onsite review include, however are not limited to;

Failure to have complete periodontal assessments

Failure to complete treatment plan

Incomplete medical histories

Lack of documentation for consent

Failure to record time spent on dental hygiene interventions

Inappropriate billing practices

Failure to reassess outcomes of dental hygiene interventions

No documentation stating radiographic prescription obtained

Lack of client specific treatment planning

Not following DHPC (use of abbreviations is permissible; resource included in handout)

ASSESSMENT: Definition: assessment involves the systematic collection and analysis of data to identify client needs, and oral health problems involving medical and dental histories, vital signs, extraoral and intraoral examinations, radiographs, indices, and risk assessment Competencies related to a Dental Hygiene Assessment include the ability to: Therapeutic/Preventive Therapy • Collect accurate and complete data on the general, oral, and psychosocial health status of clients. • Use professional judgment and methods consistent with medico-legal-ethical principles to complete client profiles. • Identify clients for whom the initiation or continuation of treatment is contra-indicated based on the interpretation of health history and clinical data. • Identify clients at risk for medical emergencies and use strategies to minimize such risks. • Use appropriate oral health indices for the identification and monitoring of high risk individuals and groups. • Recognize the influence of the determinants of health on oral health status. • Discuss findings with other health professionals when the appropriateness of dental hygiene services is in question. Oral Health Education

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf 2014 CHEP (Canadian Hypertension Education Program) Recommendations available at Hypertension Canada www.hypertension.ca/chep http://www.cdho.org/Advisories/CDHO_Advisory_Hypertension.pdf (p. 21, 22)

• Elicit information about the clients’ perceived barriers to and support for learning when planning clients’ education. • Elicit information about the clients’ oral health knowledge, beliefs, attitudes and skills as part of the educational process. • Assess the clients’ motivation for learning new and for maintaining established health related activities. • Assess clients’ need to learn specific information or skills to achieve, restore, and maintain oral health and promote overall wellbeing. • Assess the individual client’s learning style as part of the planning process. Health Promotion • Use information systems and reports for collection, retrieval and use of data for decision making. • Identify barriers to access to oral health care for vulnerable populations. • Identify populations with high risk of diseases including oral diseases. • Analyze health issues in need of advocacy. • Recognize political, social, and economic issues in the interest of the public. The Collection of Subjective Data:

General client information

Personal profile data

Dental History

Medical History The Medical History: Client’s general health Allergies & known sensitivities Pertinent questions related to all body systems

Head, eyes, ears, nose and throat

Respiratory

Cardiovascular

Gastrointestinal

Genitourinary

Muscles, bones & joints

Central nervous system

Endocrine

Hematologic Areas of Concern as per Best Practice Guidelines:

Any cardiac condition for which antibiotic prophylaxis is recommended in the guidelines set by the American Heart Association.

Any other condition for which antibiotic prophylaxis is recommended or required.

Any unstable medical or oral health condition, where the condition may affect the appropriateness or safety of scaling teeth and root planing including curetting surrounding tissue

Active chemotherapy or radiation therapy

Significant immunosuppression caused by disease, medications or treatment modalities;

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf

Any blood disorders

Active tuberculosis

Drug or alcohol dependency of any type or extent that may affect the appropriateness or safety of scaling teeth and root planing including curetting surrounding tissue

High-risk of infective endocarditis

A medical or oral health condition with which the registrant is unfamiliar or which could affect the appropriateness, efficacy or safety of the procedure;

A drug or a combination of drugs with which the registrant is unfamiliar or which could affect the appropriateness, efficacy or safety of the procedure.

Reqiurement for Baseline Assessment: Key Points: 1. 2. 3. Access to CPS: (Compendium of Pharmaceuticals & Specialties)

Drugs in dentistry under the Clin-Info tab

Current Canadian information on more than 2000 products

Health Canada advisories and warnings

Handouts for patient drug information

Updated bi-weekly

Free access to CDHA members Considerations for Taking Vital Signs in Dental Hygiene Practice: Definition of Hypertension: A condition where blood pressure persistently exceed specified limits One of the leading health problems in Canada preceding stroke, heart attack, kidney failure, dementia and sexual dysfunction

More than 1 in 5 Canadians currently suffer from hypertension with a lifetime risk of 90%

Often asymptomatic; referred to ‘silent killer’

A blood pressure should always be taken on clients whose medical history indicates a need or history

Dental hygienists need to ensure that they are not placing their clients at risk before initiating dental hygiene treatment

If client’s history is clear, the dental hygienist is encouraged to take a baseline assessment; prudent and proactive to periodically monitor as often asymptomatic

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf

The Collection of Objective Data:

Extraoral Examination

Intraoral Examination

Dental Examination

SI

Periodontal Examination

PSR, Full mouth probing

Oral Hygiene Evaluation

PI, GI

Radiographic Examination

Laboratory Tests

Clinical Photography

Breakout Session Extraoral Examination: The ABCDE’s of Malignant Melanoma Asymmetry Border Colour Diameter Evolution Systematic Examination of Lymph Nodes

Submental

Submandibular

Cervical chain

Supraclavicular

Occipital

Posterior auricular

Anterior auricular Extraoral Palpation of Cervical Nodes

Bilateral Palpation

Palpate the superficial and deep cervical nodes

Turn the head to reposition the SCM to palpate the internal jugular chain

Clinical considerations; past/chronic infection, malignancy Extraoral Palpation of Submandibular Nodes

Cursory bilateral palpation; gentle rolling stroke

Chin down, ear to shoulder; firm pressure; unilateral palpation

Firm pressure pushing the tissue in the area from the client’s one side to the opposite side rolling it over the angle of the mandible

Note any enlargement, tenderness, hardness and asymmetry; nodes should not be clinically palpable or visible

Extraoral Palpation of Supraclavicular Nodes

Superior to the clavicle in the supraclavicular fossa directly above the collarbone

Technique; Positioned behind client

Bilateral palpation

Enlargement should always be investigated Lymphadenopathy Considerations:

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf Wilkins, Esther M. Clinical Practice of the Dental Hygienist, 9th Ed. Philadelphia, Lippincott, Williams & Wilkins, 2005, p. 232

Infection Related • Soft, often painful or tender • Moveable • Client often aware of underlying infection Neoplasia Related • Firm, usually not symptomatic • Firm and fixed • Client often unaware 7 Step Intraoral Examination: 1. Lips 2. Labial mucosa 3. Buccal mucosa 4. Gingival Tissues 5. Tongue 6. Floor of mouth 7. Oropharyngeal and Palatal Tissues Intraoral Examination of High Risk Anatomical Areas: The Tongue

Floor of Mouth:

Particularly vulnerable area

Inspect floor of mouth for any changes in; o Colour o Texture o Swelling o Surface abnormalities

Use bimanual palpation; only way to detect an area of induration or swelling

Palate, Tonsils and Oropharynx:

Visual and tactile palpation of soft palate

Examine the entire area of the oropharynx with particular attention to tonsillar area

Documentation of Lesion or Finding:

Contributory factors

Health history

Risk profile

Location

Description

Action taken

Accompaniment to referral letter

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf Wilkins, EM. Clinical Practice of the Dental Hygienist. 9th Edition. Lippincott, Williams and Wilkins. Gingival Index (Sillness and Loe. 1963): Modified by Goulding/Niagara. (1994) J Periodontol 2013;84(4 Suppl.):S106-S112 doi:10.1902/jop.2013.1340011.

Dental Examination: Follow a systematic approach whether doing computerized or manual charting including;

Missing/extracted teeth, present restorations and replacement for missing teeth, carious lesions, occlusion, abrasion, attrition, erosion, wear facets, tipping, diastemas, rotations, enamel hypoplasia, fluorosis, intrinsic staining, etc.

Sensitivity Index: (SI) Purpose Procedure Scoring 0: No sensitivity 1: Mild sensitivity-Client indicates some discomfort during air blast but not following 2: Moderate sensitivity-Client indicates discomfort with facial grimacing and expresses definitive discomfort during air blast 3: Acute Sensitivity-Client indicates sensitivity prior to air testing which is then exacerbated by air blast lingering following exposure 4: Frank Sensitivity-Client expresses sensitivity to the extent that the air blast is refused Charting of Periodontal Pocket Depths & Clinical Attachment Levels:

Document each pocket that was measured

Recession

Clinical attachment levels

Furcation

Mobility

Sensitivity Probing Depth vs. Clinical Attachment Level: Figure A represents probing depth where the pocket is measured from the gingival margin to the attached periodontal tissue Figure B is the clinical attachment level measured directly from the cementoenamel (CEJ) junction to the attached tissue Periodontal Examination and Diabetes: A diabetes management program should involve on-going comprehensive periodontal assessments Independent association between moderate to severe periodontitis and increased risk for development or progression of diabetes AAP and EFP Consensus Report…”periodontal interventions may provide beneficial effects on diabetes outcomes in some patients, so regular comprehensive periodontal evaluations should be part of an ongoing diabetes management program” Indices & Scoring Methods: (PSR scoring in handout) Periodontal screening and recording (PSR)

Rationale

Method

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf Wilkins, EM. Clinical Practice of the Dental Hygienist. 9th Edition. Lippincott, Williams and Wilkins. Gingival Index (Sillness and Loe. 1963): Modified by Goulding/Niagara. (1994) Hendricson WD, Andrieu SC, Chadwick DG, et al. Educational Strategies Associated with Development of Problem-Solving, Critical Thinking, and Self-Directed Learning. Journal of Dental Education, 2006; 70 (9): 925-936. 3. Brookfield S. Developing Critical Thinkers: Challenging Adults to Explore Alternative Ways of Thinking and Acting. San Francisco: Jossey-Bass: 1987.

Management guidelines for Code 0, 1, 2, 3, 4 and Code* Oral Hygiene Evaluation: Most often completed following periodontal evaluation Documentation of; Soft deposits, hard deposits, stain (localized/generalized) Plaque Index: (PI) Purpose Procedure Scoring 0: No biofilm 1: Biofilm adhering to the free gingival margin and adjacent area of tooth. May be recognized only after application of disclosing agent or by running explorer/probe across the tooth surface 2: Moderate accumulation of soft deposit within the gingival pocket that can be seen with the naked eye or on the tooth and gingival margin 3: Abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin Gingival Index: (GI) Purpose Procedure Scoring 0: Absence of inflammation 1: Early inflammation-slight change in colour; slight edema 2: Moderate inflammation-mod. glazing, redness, edema and bleeding on probing 3: Severe inflammation-marked redness/blueness and edema. Tendency to spontaneous bleeding and/or ulceration 4: Transitional Fibrosis-tissue is in transition: may be pale due to hyperkeratinization. May feel pebbly, rubbery, little or no elasticity 5: Established Fibrosis-tissue is granular, avascular, thickened and immobile; has progressed to attached gingiva Radiographic Examination:

Interpretation of radiographic findings is a valuable aid to dental hygiene treatment planning

Observation of any osseous loss and/or defect (horizontal/vertical), crestal lamina dura, furcation involvement, periodontal ligament space, calculus, overhanging restorations and dental caries

Observation of any radiographic finding that may alter treatment outcomes

Supplemental Tests: Biopsy or cytology of suspicious oral lesions Bacteriological cultures DNA probes Phase contrast microscopy Host response tests

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf

Saliva testing The Comparative Effects of Xylitol on Stimulated Salivary (SS) pH vs pH of Resting Saliva (SS) Jones J and 2014 Toronto Winter Clinic Workshop Attendees (n = 6) Study Objective: To evaluate the effects of xylitol on the salivary pH of resting saliva (RS) Methods: Randomized clinical study; 3 dental professionals were randomly selected from the 2014 Toronto Winter Clinic Workshop; and 3 dental professionals with known acid reflux, low pH or other contributing factors. The pH of resting saliva (RS) was evaluated for each participant utilizing a pH test strip. The group were then instructed to chew 1 gram of xylitol gum for 5 minutes. The pH was then re-evaluated on the stimulated saliva (SS) with the test strips. Results: Conclusions: Clinical Photography Application of Critical Thinking: The dental hygiene process of care is both a clinical process and a critical thinking process. The dental hygiene process of care refers to higher order thinking, processing, and problem-solving. “A critical thinker is described as an individual who: Raises questions and problems, formulating them clearly and precisely; gathers and assesses relevant information; comes to well-reasoned conclusions and then teststhem against relevant standards” “Critical thinking requires the use of self-correction and monitoring to judge the rationality of thinking. It requires the application of assumptions, knowledge, competence, and the ability to challenge one’s own thinking.” Assessment: Performance Indicators Referring client for assessment of conditions outside the dental hygiene scope of practice or personal abilities; • Investigating trends within the community that require oral health promotion strategies; • Collecting demographic information to gain a better understanding of community groups; • Facilitating communications with other professionals; • Working with cross-cultural brokers or translators to identify community needs; • Supporting best practices for client assessments; • Working with community stakeholders to complete a needs assessment prior to program planning; • Investigating the efficacy of new technology to support assessments.

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf Wilkins, EM. Clinical Practice of the Dental Hygienist. 9th Edition. Lippincott, Williams and Wilkins. Darby ML, Walsh MM. Dental Hygiene Theory and Practice. 2nd Edition. Saunders. Mueller-Joseph, L., Petersen, M. Dental Hygiene Process: Diagnosis & Care Planning. Delmar, Thompson Learning 1995, pp. 57 – 8.

Assessment Practice Check Up:

Does my office have a written policy for the collection and maintenance of client information?

Is an initial medical history and updates in the client record?

Is the clinical assessment complete* and does it support my dental hygiene diagnosis?

Collection, Use and Disclosure of Personal Information:

A section for consent should be inserted in the initial collection of data at the new client examination that affirms the practice is in compliance with both PIPEDA and PHIPA

Client is then to date and sign

Each client no longer is required to sign the entire PIPEDA, PHIPA disclosure form however it must be visible in the practice for all clients to see affirming that the practice is compliant with PIPEDA, PHIPA.

DENTAL HYGIENE DIAGNOSIS: Definition: a dental hygiene diagnosis involves the use of critical thinking skills to reach conclusions about clients’ dental hygiene needs based on all available assessment data. Competencies related to a Dental Hygiene Diagnosis include the ability to: Therapeutic/Preventive Therapy • Formulate a dental hygiene diagnosis using problem solving and decision-making skills to synthesize information. Dental vs. Dental Hygiene Diagnosis:

Dental diagnosis refers to or identifies a specific illness or need such as a restorative procedure

Dental hygiene diagnosis identifies an actual or potential response to the illness such as a need for fluoride therapy or dietary modification

The dental hygiene diagnosis is a key component of the process and involves assessment of the data collected, consultation with the dentist and other healthcare providers, and informed decision making.

The dental hygiene diagnosis and treatment plan are incorporated into the comprehensive treatment plan by the dentist that addresses the complete oral health needs of the client.

Writing a Dental Hygiene Diagnostic Statement:

Key Points: 1. Eliminate words that express emotionalism

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf J Periodontol 2013;84(4 Suppl.):S106-S112 doi:10.1902/jop.2013.1340011.

2. Avoid use of dental diagnosis. 3. Write the diagnosis in legally advisable terms. Incorrect: Periodontal pocketing related to incomplete scaling of calculus Correct: Periodontal pocketing related to subgingival calculus build-up 4. Writing the diagnosis in terms of what the dental hygienist will do. 5. Be sure that the two parts of the diagnosis do not mean the same thing. Incorrect: Inability to brush teeth related to oral home care problems Correct: Ineffective oral home care practices related to limited manual dexterity 6. The condition or etiological factors should be expressed in terms that can be changed. Incorrect: Potential for increased periodontal pocket depth related to gingivitis Correct: Potential for increased periodontal pocket depth related to increased plaque accumulation Critical Thinking Exercise: A middle-aged female client presents with a number of demineralized areas along the gingival margin of the posterior teeth. The medical history reveals the client is taking an anti-depressant known to result in xerostomia. Further investigation reveals that she is alleviating the symptoms by sucking on mints throughout the day and periodically at night when she wakes up with a dry mouth. Compose a diagnostic statement related to both of the above clinical and medical observations: 1. 2. Dental Hygiene Diagnosis: Performance Indicators A dental hygienist demonstrates competence by: • Providing clients with a visual representation of the condition being discussed • Interviewing clients about their understanding of their oral conditions and what has caused them; • Communicating expected outcomes of treatment options; • Answering client questions to ensure full understanding of condition; • Recommending involvement of other oral health care providers when dental hygiene services are not the only services required; • Ensuring a dental hygiene diagnosis is based on an appropriate assessment; • Facilitating referrals to other oral health care providers. Diagnostic Statement Exercise: Write a dental hygiene diagnostic statement related to the following clinical observations: Case 1: Client presents with moderate plaque accumulation on dorsum of tongue. Client states that he is self-conscious of his breath at present time. DHDx Statement: Potential for _______________________________

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf .

related to _________________________________________________ Case 2 Client presents with increased bleeding on probing. Plaque accumulation is minimal. Medical history update reveals client is taking a therapeutic dose of ASA daily. DHDx Statement: Potential for ________________________________ related to _________________________________________________ Dental Hygiene Diagnosis: Practice Check-up

Is there a dental hygiene diagnostic statement supporting a client specific dental hygiene treatment plan?

Practically speaking…

Problem related to cause as evidenced by characteristics or

Potential for ____________ related to ________

Make sure that the dental hygiene treatment plan is always ‘client specific’

Your DHDx statement must support this PLANNING Definition: planning involves the establishment of realistic goals and selection of dental hygiene interventions that can move a client closer to optimal oral health (Darby & Walsh, 2010). Competencies related to Planning Dental Hygiene interventions include the ability to: Therapeutic/Preventive Therapy • Prioritize clients’ needs through a collaborative process with clients and, when needed, substitute decision makers and/ or other professionals. • Establish dental hygiene care plans based on clinical data, a client-centered approach and the best available resources. • Design and implement services tailored to the unique needs of individuals, families, organizations and communities based on best practices. • Revise dental hygiene care plans in partnership with the client and, when needed, in collaboration with substitute decision makers and/ or other professionals. Oral Health Education • Negotiate mutually acceptable individual or program learning plans with clients. • Develop educational plans based on principles of change and stages of behaviour change. • Create an environment in which effective learning can take place. • Select educational interventions and develop educational materials to meet clients’ learning needs. Health Promotion

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf .

• Select and implement appropriate health promotion strategies and interventions for individuals and communities. • Recognize the role of governments and community partners in promoting oral health. The dental hygiene treatment plan for each client must include;

A complete clinical assessment

A dental hygiene diagnosis

Client centered goals/objectives

Planned sequence of activities

Client participation Planning: Performance Indicators A dental hygienist demonstrates competence by: • Recommending dental hygiene interventions that align with the client’s values and beliefs about their oral health; • Using the best evidence available when formulating individualized care plans; • Assisting clients in developing realistic and measurable goals related to oral self-care; • Reviewing the daily care plan with family members and other personal care providers; • Consulting with the client’s primary health care provider with regard to antibiotic premedication for dental hygiene services; • Ensuring the appropriate equipment and materials are available to support implementation of the proposed plan; • Presenting more than one option for treatment if appropriate; • Ensuring the client understands the personal commitment required to achieve the best outcomes of treatment; • Providing client with information on the sequencing of care and cost of care; • Achieving informed consent prior to initiating care; • Planning health promotion events in the community; • Developing resources to support tobacco use cessation programs; • Planning oral health promotion strategies to address oral health trends of groups or a community; • Establishing project timelines and identifying necessary human and other resources to support community initiatives. Presenting the Dental Hygiene Care Plan: Purpose of presentation Communication strategies

Body language

Verbal skills

Professional, CARING attitude Empowering the client through education to make an informed decision, not tailored to dental benefits Short Term Goals of Non-Surgical Periodontal Therapy:

The interruption of the progress of disease

Change the oral environment by minimizing and altering the microbial population

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf (Darby & Walsh, 2010, p.2). Customizable Assessment and Risk Evaluator Tool https://www.philipsoralhealthcare.com/en_ca/care/

Further reduce or eliminate controllable risk and etiologic factors

Behavioral modification resulting in lifestyle changes Objectives/Goals Related to Dental Caries:

Absence of any new demineralized areas

Previous demineralized areas resolved where possible

No new carious lesions or activity

Increased awareness of dietary contributory factors and reduction of cariogenic components in diet

Factors Determining Goal Attainment:

Risk factors

Client behavior and willingness to modify

Client dental I.Q.

Value of oral health

Adherence to suggested treatment plan

Commitment to daily oral care program

Evidence based treatment planning facilitating best practices Risk Assessment & Risk Management: Defining and managing risk for oral disease including periodontal disease, dental caries management & prevention and oral cancer Development of a care plan that involves preventive education and counseling Planning: Practice Check-Up Has an individual dental hygiene treatment plan been established and includes:

Goals/objectives

Sequence of activities

Client participation Care Plan Goal Statement: Increase the tooth surface resistance to demineralization through twice daily usage of remineralization toothpaste. Practically Speaking… Dental hygiene diagnosis directs the client centered goal statements Examples; Palatal irritation related to wearing dentures all night as evidenced by self report of tissue tenderness and halitosis. Goal Statement; 1. Client will remove dentures at night, clean dentures, tongue and oral cavity. IMPLEMENTATION: Definition: implementation of dental hygiene interventions involves the process of carrying out the dental hygiene care plan designed to meet the assessed needs of the client Competencies related to Implementation of Dental Hygiene services include the ability to: Therapeutic/Preventive Therapy • Provide preventive, therapeutic and supportive clinical therapy that contributes to the clients’ oral and general health. Oral Health Education

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm Sackett, D.L. et al. (1996) Evidence based medicine: what it is and what it isn't. BMJ 312 (7023), 13 January, 71-72). Hicks, C. Review: Personal protective equipment. Focus. July 2013.

• Incorporate educational theories, theoretical frameworks and psycho-social principles to inform the educational process. • Include clients, family and care providers as appropriate in the education process. • Provide health advice and assist clients in learning oral health skills by coaching them through the learning process. Health Promotion • Use a holistic and wellness approach to the promotion of oral health and optimal general health. • Apply appropriate theories to initiate change at an individual and community level. • Apply principles of health protection through prevention and control of disease and injury. • Advocate for healthy public policy with and for individuals and communities. • Apply knowledge of common health risks to inform public policy and educate practitioners and the public. • Strengthen individuals’ abilities to improve health through strategies that focus on community development and capacity building. • Participate in the development and delivery of social marketing message. The Process of Implementation: Infection control procedures including;

Personal protective equipment

Treatment room preparation and disinfection

Instrument sterilization

Process and performance of treatment Process and Performance of Treatment: Personal Protective Equipment

Mask should be changed between client or during treatment if it becomes wet

Protective eyewear with solid side shield or a face shield should be worn to protect from micro-organisms

Reusable protective eyewear must be cleaned with soap and water and when visibly soiled, disinfected between clients

Protective clothing should have sleeves long enough to protect forearms and should be changed daily or when visibly soiled. Removing protective clothing before leaving work area is imperative.

Before placing gloves on make certain to wash and dry hands thoroughly so bacteria less likely to multiply

Important to wash hands immediately after removal

Washing latex gloves with soap, CHX or alcohol can create micro-punctures therefore not recommended; surgical gloves less likely to harbour pathogens

Double gloving may be used for specific procedures however affects dexterity and tactile sensitivity.

CDC Infection Control Guidelines in Dental Healthcare Settings: Protective clothing and equipment (e.g., gowns, lab coats, gloves, masks, and protective eyewear or face shield) should be worn to prevent contamination of

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf .

street clothing and to protect the skin of DHCP from exposures to blood and body substances (2,7,10,11,13,137). OSHA bloodborne pathogens standard requires sleeves to be long enough to protect the forearms when the gown is worn as PPE (i.e., when spatter and spray of blood, saliva, or OPIM to the forearms is anticipated) (13,14). DHCP should change protective clothing when it becomes visibly soiled and as soon as feasible if penetrated by blood or other potentially infectious fluids (2,13,14,137). All protective clothing should be removed before leaving the work area (13). Implementation and Evidence-Based Decision Making: Employment of evidence-based decision making defined as; “The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual clients.” “The practice of evidence based decision making means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” Implementation: Performance Indicators A dental hygienist demonstrates competence by: • Allowing time for the client to practice a new skill with your guidance; • Using pain management strategies during dental hygiene treatments; • Providing services that are supported by evidence and/or practice guidelines; • Monitoring client’s response to care during service delivery; • Modifying approach in response to changing needs; • Recognizing when client has withdrawn consent and postponing treatment until consent is re-established; • Working with other health professionals, family and personal care providers to implement daily oral care; • Working with community partners to increase public awareness of oral health; • Taking immediate steps to stop a procedure if there is possible risk to client; • Working with other professionals and community partners to provide programs targeting specific oral health needs. Implementation: Practice Check-Up

Are my equipment, instruments and supplies sufficient to support the selection and implementation of appropriate dental hygiene services?

Has the client received appropriate recommendations and instructions in oral self-care?

Is the date and particulars of each professional contact with the client documented in the client record?

Practically speaking…

Recordkeeping once again must support client specific dental hygiene interventions

Have you recorded interventions including all interactions with client, recommendations and instructions for home care?

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References & Resources: All sites accessed September 2014 2012 CDHO Standards of Practice. www.cdho.org/reference/english/standardsofpractice.pdf Hicks, C. Review: Personal protective equipment. Focus. July 2013. http://www.cdho.org/reference/english/antibioticprophylaxis.pdf http://www.aaos.org/Research/guidelines/PUDP/dentalexecsumm.pdf http://newsroom.aaos.org/media-resources/Press-releases/evidence-insufficient-to-recommend-routine-antibiotics-for-joint-replacement-patients-who-undergo-dental-procedures.htm

Critical Thinking Exercise: Your client arrives and informs you that they have forgotten to take their premedication. They have had a hip replacement 18 months ago. Should you proceed or not? Insufficient Evidence: AAOS and ADA found there is insufficient evidence to recommend the routine use of antibiotics for patients with orthopaedic implants to prevent infections prior to having dental procedures because there is no direct evidence that routine dental procedures cause prosthetic joint infections (PJI) “…no conclusive evidence that demonstrates a need to routinely administer antibiotics to patients with an orthopaedic implant who undergo dental procedures “Research showed that invasive dental procedures, with or without antibiotics, did not increase the odds of developing a prosthetic joint infection” Recommendations: Recommendation 1: Supports that practitioners consider changing their longstanding practice of prescribing antibiotics for patients who undergo dental procedures. Limited evidence shows that dental procedures are unrelated to PJI. Recommendation 2: There is no direct evidence that the use of oral topical antimicrobials before dental procedures will prevent PJI. Recommendation 3: Only consensus recommendation in the guideline, and it supports the maintenance of good oral hygiene EVALUATION Definition: Evaluation is the measurement of the extent to which the client has achieved the goals specified in the plan of care (Darby & Walsh, 2010, p. 2). Competencies related to the Evaluation of Dental Hygiene Care include the ability to: Therapeutic/Preventive Therapy • Evaluate clients’ health and oral health status using determinants of health and risk assessment to make appropriate referral(s) to other health care professionals. • Evaluate the effectiveness of the implemented clinical therapy. • Provide recommendations in regard to clients’ ongoing care including referrals when indicated. Oral Health Education • Evaluate the effectiveness of learning activities and revise the educational process when required. Health Promotion • Use measurable criteria in the evaluation of outcomes and solicit feedback from stakeholders regarding results. • Communicate findings to stakeholders and the public. Methods of Evaluation: There are three ways to gather data for evaluation of the interventions;

Direct observation of the client by the clinician

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf

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Examination of the chart

Client interview Evaluation: Performance Indicators A dental hygienist demonstrates competence by: • Re-evaluating periodontal probing depth and tissue characteristics four to six weeks after initial therapy; • Evaluating integrity of enamel sealants at subsequent appointments; • Measuring client satisfaction with services provided and outcomes achieved; • Identifying when treatment was not effective and providing a different treatment or making the appropriate referral; • Assessing the ability of the client to maintain oral health over time; • Establishing the most appropriate interval for ongoing preventive care based on client abilities and oral presentation; • Assessing the impact of community oral health programs. • Establishing clinical practices that reinforce the need for evaluation of dental hygiene services; • Using self-reflect on the dental hygienist’s role in the process and developing goals for improvement; Evaluation Practice Check-Up:

Has a clinical re-assessment been performed and has the dental hygiene treatment plan been reviewed and modified as required?

Do I consult and/or refer to other health professionals as required?

Evaluation of Quality Assurance:

Do I have emergency protocol, emergency supplies, equipment and oxygen in place?

Do I have proof of current CPR certification?

Other Components of an Evaluative Statement:

Practically speaking… Goal Unmet Example: Client interested in pursuing teeth whitening Intervention: Refer client to DDS for cosmetic whitening consultation

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References & Resources: All sites accessed September 2014 http://www.cdha.ca/pdfs/Competencies_and_Standards.pdf

Evaluative Statement: Goal unmet. Client did not seek cosmetic consultation with DDS

or Goal Met. Client has proceeded with customized tray whitening. Documentation:

Maintenance of accurate records is a legal requirement

Often hastily done or postponed

Assisting in development of ongoing treatment plan as well as assisting other oral health care team members

Inappropriate treatment decisions may result from inadequate or omitted information in previous records

May be requested for reports, legal proceedings or disability claims Importance of Documentation: Dental hygiene recordkeeping is reflective of the dental hygiene diagnosis based on client assessment, treatment planning, the implementation of same and the evaluation or outcome of treatment. Legal document Records therefore must be;

Accurate

Legible

Comprehensive and complete

Factual

Protected from cross contamination Documentation Inclusions: The dental hygiene record is not considered complete unless it contains the following;

Client contact information including business numbers and place of employment, address, phone number(s), physician’s name and all other pertinent data

Personal, medical and dental history

Medical history update completed; does NOT have to be signed by client

Consent obtained and noted

Extraoral and intraoral examination and any findings noted

Dental chart

Periodontal examination records

Oral hygiene record

Written treatment plan

Dental radiographs plus radiographic prescription given by …

Treatment provided, time spent, fees charged, dated and initialed by the clinical provider and any conversation with the client regarding treatment

Expectations of the Public Regarding Dental Hygiene Care: The dental hygienist should:

Update your medical and dental history

Assess the condition of your teeth and gums and discuss your oral health concerns

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References & Resources: Customizable Assessment and Risk Evaluator Tool https://www.philipsoralhealthcare.com/en_ca/care/ to make an assessment today. Additional CDHO Guidelines & Resources Link to prescribed records – Registrants Handbook - Chapter 6: Recordkeeping http://www.cdho.org/Reference/English/RegistrantsHandbook.pdf Link to medical/dental history http://www.cdho.org/PracticeGuidelines/Medical_Dental_History.pdf Link to privacy legislation http://www.cdho.org/reference/english/pipedachecklist.pdf http://www.cdho.org/reference/english/pipedaguide.pdf Link to storage of off-site records http://www.cdho.org/Reference/English/OffSite.pdf Link to antibiotic protocol http://www.cdho.org/PracticeGuidelines/AntibioticProphylaxis.pdf http://www.cdho.org/Reference/English/RegistrantsHandbook.pdf http://www.cdho.org/Reference/English/RegistrantsHandbook.pdf (for complete document) To access the Jurisprudence Education Module which contains a section on record keeping, please visit www.cdho.org and follow the link on the front page to the module. www.rdhu.ca – Additional courses on DHPC/Assessment For further information on loupes, lighting for your dental hygiene practice: Contact Scott Gibson, Loupes Specialist, Orascoptic Mobile: 416-566-4425 www.orascoptic.com .

Provide a dental hygiene treatment plan that considers disease prevention a priority in achieving optimal health

Assist you or your care giver in ways to maintain your oral health

Explain how dental hygiene care can help maintain a healthy mouth and body

Obtain your permission to provide treatment

Provide dental hygiene therapies that are safe and effective and have current evidenced based research to support their use. This may include the scaling of teeth and the removal of stains.

Respect client confidentiality and privacy

Practice standard infection control including the wearing of gloves, mask and eye protection and use of sterile instruments

Refer you to another health care practitioner if s/he observes a condition s/he can not treat

Remember… If it is not written down, it has never been performed! A special thank you to the CDHA for permission to use photographs that accompanied the online oral cancer course entitled “4 Life Saving Minutes: The Extraoral and Intraoral Examination. If there is anything further I can assist you with in regards to today’s workshop, please do not hesitate to contact me. Thank you to you for your time and participation today. Sincerely, Jo-Anne Jones, RDH jjones@rdhconnection.com

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Periodontal screening and recording (PSR)

Code 0 - Code Description Coloured area of probe is completely visible in the deepest probing depth of the sextant

No calculus, no defective margins, no bleeding

Management Guidelines Dental biofilm control, preventive care

Code 1 - Code Description Coloured area of probe is completely visible in the deepest probing depth of the sextant

Smooth surfaces, no calculus, no defective margins

Bleeding after gentle probing

Management Guidelines Dental biofilm control, preventive care

Code 2 - Code Description Coloured area of probe is completely visible in the deepest probing depth of the sextant

Rough surface felt may be supragingival and/or subgingival calculus

Defective margins of restorations

Management Guidelines Dental biofilm control instruction

Complete preventive care

Calculus removal

Correction of irregular margins of restorations

Code 3 - Code Description Coloured area of probe is only partly visible in the deepest probing depth

Requirements for Codes 1 and 2 may be present

Management Guidelines Comprehensive periodontal assessment is indicated

Client is counseled concerning appropriate treatment plan

Code 4 - Code Description Coloured area of probe completely disappears

Probing depth greater than 5.5

Management Guidelines Comprehensive periodontal assessment is indicated

Client is counseled concerning appropriate treatment plan

Code * - Code Description Any notable feature such as furcation involvement

Mobility, mucogingival problem, marked recession area

Management Guidelines Abnormality in Codes 0, 1 or 2: specific treatment is planned

In Codes 3 and 4: included in comprehensive assessment and treatment plan Reference: Wilkins, Esther M. Clinical Practice of the Dental Hygienist. Ninth Edition. Lippincott, Williams & Wilkins. 2005. p. 326.

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Suggested Abbreviation KEY for Documentation Dental Hygiene Process of Care ASSESSMENT Ant – Anterior Adv - Advanced BOP – Bleeding on Probing CAL – Clinical Attachment Levels Calc - Calculus CC – Chief Complaint cm - Centimetres COE - Complete Oral Exam Cons- Consultation Dep - Deposit DHE – Dental Hygiene Examination/Assessment Emerg or E circled - Emergency Exam EO - Extra-Oral Examination FMP - Full Mouth Probe Furcation – furc GEN - Generalized HxPC – History of Present Condition IO- Intra-Oral Examination LOC - Localized M1, M2, M3 – Mobility of 1,2 or 3 Md. - Mandibular MEDS – medications MED Increase – MED + Upward Arrow (always include dosage) MED Decrease – MED + Downward Arrow (always include dosage) MHx – Medical History MHU – Medical History Update mm - Millimetres Mod – Moderate Mx. - Maxillary NSF - No Significant Findings OCS - Oral Cancer Screening OHS – Oral Hygiene Status NPE - New Patient Exam PE - Periodontal Exam PerioA – Periodontal Assessment Post - Posterior PPD - Periodontal Probing Depths PSR – Periodontal Screening and Recording RAD – radiographs RC - Recall Exam Recession – rec Rx – Prescription SI – Sensitivity Index S1, S2, S3, S4 - Sensitivity Levels Sev - Severe St – Stain SUB – Subgingival

Supra - Supragingival WNL - Within Normal Limits DENTAL HYGIENE DIAGNOSIS DHDx PLANNING DHTxP – Dental Hygiene Treatment Plan PTP – Periodontal Therapy Program Tx - Treatment VIC – Verbal Informed Consent WIC – Written Informed Consent IMPLEMENTATION CHX – Chlorhexidine CW – continuous wave Fl - Fluoride Fl XT – extended contact fluoride varnish HSc – Hand Scaling H/Us – Hand Scaling and Ultrasonic LBR – Laser Bacterial Reduction LAPT – Laser Assisted Periodontal Therapy NaF – Sodium Fluoride PPR – pre-procedural rinse PW – pulsed wave Sel pol – Selective Polish SO – Standing Order SRP – Scaling, Root Planing US – Ultrasonic EVALUATION & ORAL HYGIENE EDUCATION ACP – Amorphous Calcium Phosphate Demin - Demineralization MTB – Manual Toothbrush NM TP – NovaMin Toothpaste OH - Oral Hygiene OH - Oral Hygiene Improved OH± - Oral Hygiene Unchanged OHE – Oral Hygiene Education OHI – Oral Hygiene Instruction PFS – Pit & Fissure Sealants PTB – Power Toothbrush Remin - Remineralization TB – Toothbrush PTB – Power toothbrush DENTAL TREATMENT PLANNING A or Am – Amalgam Br – Bridge Cr - Crown EXO – extraction

Imp - Implant Prep - Preparation for treatment R or CR- Restoration or Composite Resin ADMINISTRATIVE Appt – Appointment CC – Continuing Care Cx – Cancellation DDS away – Dentist not in office Dr. X – “X” represents the initial of the last name of the DDS FTS – Failure to Show LDV – Last Dental Visit LDHV – Last Dental Hygiene Visit Min or m – Minutes N/C - No Change PreD – Pre-Determination PM – Periodontal Maintenance SNC – Short Notice Cancellation MA – Missed appointment ST – Supportive Therapy U - Units of Time (Denote actual minutes representing a unit of time in the practice schedule) RADIOGRAPHIC DOCUMENTATION BW - Bitewing Radiograph FMX or FMS - Full Mouth Series of Radiographs Horiz - Horizontal PA - Periapical Radiograph PAN - Panoramic Radiograph RRx - Radiographic Prescription RF /NSF Radiographic Findings/No significant findings RF/WNL Within Normal Limits