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Dental Hygiene Process of Care Dentalelle Tutoring
Ethics • Professional ethics is part of every component in the provider/patient relationship between the dental hygienist and the patient. The potential for an ethical situation arises anytime a dental hygienist interacts with a patient, with members of the dental team, or with individuals involved in the special needs of the patient, such as family, caregivers, or members of specialty practices. A dental hygienist who provides ethical patient care: • Is cognizant of the respect each patient deserves. Maintains communication among all parties responsible for dental and dental hygiene treatment. Attains a knowledge of current standards of care through continuing education coursework and reading professional journal articles about new research. Is aware of ethical issues such as conflict of interest while treating patients, the legal scope of one’s duties, and dealing with impaired colleagues Possesses the ability to assess and justify the reporting of unacceptable practices.
Basic Concepts of Law • The basic concepts in healthcare law apply to all dental hygiene professionals. The dental hygiene practice acts of each state or province govern the scope of duties and the criteria for licensure. • Professional liability, standard of care, informed consent, privacy information, and malpractice are other concerns that affect the daily duties and rights of both the patient and the dental hygienist.
Definitions to know • Professional Liability A licensed professional is legally accountablefor all actions; bound by the law. • Scope of Practice A dental hygienist is legally bound to provide care within the dental hygiene scope of practice • Standard of Care A professional uses the ordinary and reasonable skill that is commonly used by other reputable dental hygienists when caring for patients • Informed Consent Voluntary affirmation by a patient to allowexamination or treatment • Negligence/Malpractice Failure to perform professional duties according accepted standard of care.
Eight Human Needs 1. Wholesome Facial Image • Expresses dissatisfaction with appearance • Conceptualization and Understanding • Has questions about DH care and or oral disease • Responsibility for Oral Health • Plaque and calculus present, not having regular dental exams • Biologically sound and functional dentition • reports difficulty in chewing, defective restorations, ill fitting dentures • Freedom from Head and Neck Pain • Pain or sensitivity • Protection from Health Risks • BP outside of normal limits, need for pre-meds • Skin and Mucous Membrane Integrity of Head and Neck • Extra/intra oral lesion, swelling, bleeding on probing, gingival inflammation, pockets, xerostomia • Freedom from Anxiety/Stress • Anxiety of clinician, oral habits, substance abuse, concerns about infection control/fluoride/amalgams
Dental Hygiene Diagnosis • List the human needs not met, then be specific about the etiology and signs/symptoms evidencing a deficit • Unmet human need • DUE TO • Etiology • EVIDENCED BY • Signs/Symptoms
Assess - INTRO • After the initial assessment is completed, the data are assembled, sequenced, and analyzed in preparation for planning strategies that help the patient acquire and maintain oral health. • A formal written care plan is necessary for educating the patient, securing informed consent for treatment, and communicating with other oral care team members.
Diagnose • The diagnosis segment of the Dental Hygiene Process of Care is related to analyzing the assessment data that has been collected. The dental hygiene diagnosis identifies those patient needs for which the dental hygienist will provide interventions. Interventions within the scope of dental hygiene practice are implemented to solve the problems identified by the diagnostic statements. • Dental diagnoses, on the other hand, are directed at those particular diseases and conditions for which the dentist will provide treatment. • Dental hygiene diagnosis statements focus attention on the behavioral aspects as well as deviations from normal oral health. • Chartings, radiographs, histories, and all recorded patient data are analyzed together. • Each diagnostic statement identifies with a significant oral hygiene problem of the patient. • A blueprint care plan of diagnostic statements.
Plan • Purposes for developing a written care plan are described in this section. • The dental hygiene care plan selects interventions that are based on analysis of assessment data that has been consolidated into diagnostic statements that define patient needs. • The care plan is developed to conform to and be integrated with the total treatment plan of the patient. • The overall objectives of the dental health care team focus on the oral health of the patient. The ultimate goal will be the control of oral diseases.
Chief Complaint • The patient’s statement regarding the reason for seeking dental and dental hygiene care is considered when planning. If a patient has a significant concern, such as pain, this need is addressed prior to initiating dental hygiene treatment. • Whether or not the patient presents for dental hygiene care with current oral disease, several risk factors can be noted that increase the patient’s potential for diminished oral health status. When a patient presents for dental hygiene care exhibiting one or more risk factors, it is essential to develop a care plan that provides anticipatory guidance through preventive education and counseling.
Risk Factors for Perio or Infection • Behavioral factors (inadequate biofilm removal, diet, noncompliance with dental hygiene recommendations) Tobacco use Systemic conditions (diabetes, decreased immune factors, osteoporosis, osteopenia) Hormonal considerations (pregnancy, menopause) Nutritional status Iatrogenic factors(overhangs, open contacts, residual calculus) Genetic factors
Perio Disease as a Risk from Systemic Conditions • Current research suggests that the presence of periodontal infection is a contributing factor to a variety of systemic conditions. Infective endocarditis Cardiovascular disease (CVD) and atherosclerosis Diabetes mellitus Respiratory disease Adverse pregnancy outcomes
Risk Factors for Caries • Behavioral factors (inadequate biofilm removal) Dietary factors (frequent use of cariogenic foods/beverages) 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)
Risk factors for Oral Cancer • Tobacco use • Alcohol use • Sun exposure (lips and face)
Patients knowledge? • Before planning individualized patient care, an attempt is made to assess the patient’s oral health knowledge level. From that baseline, planned educational interventions can build on current knowledge rather than provide information too far above or below the patient’s current understanding.
Self-care • The patient’s ability to manipulate a toothbrush and floss and to comply with suggested oral care regimens will determine the success of planned interventions. Patients with disabilities or physical limitations will require modification to ensure adequate daily dental biofilm removal. • An Activities of Daily Living (ADL) classification level, can provide a guide to determine whether adaptive aids or caregiver training for personal oral care procedures in necessary.
Treatment Planning • 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
Basis for Diagnosis • A. 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 intraoral tissue examination, and dental and periodontal chartings) • C. Treatment or education needs that may be addressed by providing oral care services within the dental hygienists legal scope of practice • D. Treatment needs that may be addressed by consultation with another licensed healthcare professional
Diagnostic Statements • A. Provide the basis for planning interventions that are within the scope of dental hygiene practice • B. Reflect expected outcomes of dental hygiene interventions • C. Identify patient responses that are changeable by dental hygiene interventions • D. Exclude diagnoses that require treatments legally defined as dental practice
Expected Outcomes • 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
Continued • 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, restoration overhangs) Increased percentage of biofilm-free areas Patient demonstration of recommended oral care procedures Compliance with daily care recommendations Compliance with recommended maintenance care interval Tobacco-free status achieved Modification/stabilization of systemic risk factors
Role of the Patient • A. Purpose The willingness and/or ability of the patient to participate in planned oral health behaviors will be the key to reaching goals set during planning. • B. Procedure • Determine the patient’s level of understanding of dental diseases, risk factors, and oral health behaviors. • Determine the patient’s physical ability to manipulate recommended oral care aids. • Determine lifestyle factors that impact the patient’s ability to comply with oral health recommendations. • Educate patients regarding the importance of their role in setting oral health goals and complying with recommendations.
Tissue • Preparation or conditioning of the gingival tissue for scaling can be of particular significance when there is spongy, soft tissue that bleeds on slight provocation, and when the area is generally septic from dental biofilm and debris accumulation.
Purpose • Anticipated outcomes of a tissue conditioning program include: 1. Gingival healing tissues become less edematous bleeding is minimized scaling procedures are facilitated 2. Reduced bacterial accumulation less likelihood that bacteremia's will be produced during scaling reduced contamination in the aerosols produced 3. Learning by the patient While 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
Procedure • Initiate a pre treatment program of daily biofilm removal. Recommend daily use of an antibacterial rinse after thorough brushing and flossing before going to bed. Select affected quadrants for scaling only after patient cooperation has been demonstrated.
Preprecedural Rinsing • A. Purpose Preprocedural removal of dental biofilm will lower the bacterial count in aerosols and decrease the potential for bacteremia. • B. Procedure The first choice is patient brushing and flossing. Vigorous rinsing with an antibacterial mouthwash is beneficial.
Continued • Forcing the fluid between the teeth for 1 to 2 minutes can remove loose debris and surface bacteria approximately 1 mm below the gingival margin. • Even rinsing with water will have some effect on bacteria; however, chlorhexidine rinses have the most substantivity.
Pain and Anxiety • A. Purpose Control of discomfort during treatment procedure. More consistent patient compliance with recommended interventions and need to return for additional scheduled appointments.
Anxiety Continued • B. Procedure 1. Quadrant selection Treat the patient areas of discomfort first, unless tissue conditioning is required. Treat either the quadrant with the fewest teeth or the least severe periodontal infection first to: make the first scaling less complicated help orient an anxious patient to clinical procedures
Continued • 2. Anesthesia The 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 appointment, it will minimize patient post treatment discomfort to select a maxillary and mandibular quadrant on the same side.
Maintenance • A. Purpose When restorative, prosthetic, or orthodontic, treatment extends over a period of time, periodic appointments with the dental hygienist are needed for monitoring the continued success of the patient’s self-care. B. Procedure Dental hygiene care provided during extended dental therapy follows the dental hygiene process of care and includes: 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
Four handed Dental Hygiene • A. Purpose Planning patient care while practicing with a dental assistant increase the dental hygienist’s efficiency through theuseof: flexible scheduling. two treatment chairs in an overlapping time frame. assistance with patient management.
Four handed continued • B. Procedure A well-trained dental hygiene assistant can be delegated such 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 preparation for the next patient
Factors to Teach a Patient • A clear explanation of how assessment data are used in planning dental hygiene care. The importance of using scientific evidence of success in the selection of patient-specific therapeutic and preventive interventions. Why disease control measures are learned before and in conjunction with scaling. Facts of oral disease prevention and oral health promotion relevant to the patient’s current level of healthcare knowledge and individual risk factors. The long-term positive effects of comprehensive continuing care.
Health History Screening • The medical history is a tool that is used in dental and dental hygiene practices as an effective means of preventing a medical emergency. Careful interviewing, listening, and communicating with clients can provide clues to potential problems that may occur in the dental office setting. Although some emergencies are unexpected, many that occur in clinical practice can be predicted by gathering adequate information and analyzing it in terms of risk assessment. • Certain items on a medical history, if answered “yes,” require further evaluation. These are red flags or areas that warrant additional information. • The purpose of this two-part series is to highlight some of the red flags that a medical history reveals, and to provide information on preventing subsequent medical emergencies or disease transmission associated with those positive responses. The 2007 American Dental Association health history form is used as the prototype for identifying questions that can elicit red flag responses.
TB • Screening questions for active tuberculosis • Ask patients, “Do you have any of the following diseases or problems?” • Active tuberculosis (TB) • Persistent cough for more than three weeks • Cough that produces blood • Exposure to anyone with TB • “If your answer is ‘yes’ to any of the four items above, please stop and return this form to the receptionist.”
More on TB • Since elective oral health care is contraindicated in the client with active TB disease, it is important to pursue further questioning to determine the nature of positive responses to these questions. When the client responds affirmatively on any of these items, investigate to determine if the client has active TB infection. Ask these follow-up questions: • Have you seen a physician about this persistent cough? • Have you been tested recently for exposure to tuberculosis with a skin test? • Do you wake up during the night from sweating? • Have you recently had unexplained weight loss? • Do you know anyone who has had TB? • Has anyone in your family or a friend or coworker been diagnosed with tuberculosis?
Active TB or Inactive TB? • These questions give clinicians an opportunity to identify a client who may be contagious prior to beginning oral procedures. When active TB is suspected, isolate the client within the facility to perform follow-up questioning. Then refer the client for medical evaluation. A medical consultation form should request the physician to notify the office whether or not the client has active TB. • Clients who do not have active TB can receive oral health care. For clients with active TB, the Centers for Disease Control and Prevention recommends three criteria for non-infection that should be verified on the signed medical clearance form before oral health care is provided: • The client is not in the coughing stage. • The client has taken three consecutive negative sputum smears on three separate days. • The client has taken effective anti-TB medications for at least three weeks.
Negative Dental Experiences • Ask patients, “Have you had any problems associated with previous dental treatment? If so, explain.” • Case reports suggest individuals who have experienced a negative dental experience are more likely to have emergency situations during an appointment. This question may identify a client at risk for syncope (fainting) or hyperventilation, two common stress-related medical emergencies that occur during dental and dental hygiene treatment. Both conditions are often associated with anxiety and fear. Dental procedures themselves, experiencing or anticipating pain, the sight of blood, and receiving an injection of local anesthesia are predisposing factors that may result in a stress-related emergency. • Stress-reduction strategies can be used to prevent syncope. Gain the confidence and trust of the client, and help him or her to relax. Talk with the client about personal interests to serve as a distracter, ensure adequate pain control, use nitrous oxide conscious sedation, and prescribe an antianxiety medication.
We need to know about negative experiences… • Loss of consciousness in the dental office, unrelated to anxiety, may also occur when the client is placed in an upright position. When seated in the dental chair for a long time, blood can pool in the extremities and venous blood return to the heart is reduced. This leads to vasodilation and hypotension (referred to as postural hypotension) with inability of the cardiovascular system to push oxygenated blood to the brain. This type of syncopal episode can be prevented. Recognize the signs leading to unconsciousness, place the client in a prone position, and have the client lift the feet and push on a stable surface (such as your hands). • This positioning and management promotes skeletal muscle activation and venous return to the heart, increased blood leaving the heart, and oxygenated blood flow to the brain. • Hyperventilation is characterized by rapid breathing and results in excessive loss of carbon dioxide and inspiration of too much oxygen. A previous history of hyperventilation during dental treatment is a clue to anticipate this emergency. The stress-reduction strategies noted above can be used to prevent this condition.
General Health Changes • Ask patients, “Has there been any change in your general health within the past year?” • A positive response to changes in general health requires follow-up questions to investigate the change and needed medical care. A change in health may represent an improvement; i.e., when one has recovered from cancer therapy. However, if the client reports a worsening of general health, the clinician must determine how the condition and/or treatment may influence oral health care. A medical consult may be indicated to determine the appropriateness of dental treatment and additional medical care, such as the need for premedication. For example, a client may report a recent diagnosis of hypertension. • If extensive dental treatment is indicated and vital signs reveal abnormal values (i.e., blood pressure ≥180/110 or pulse ≤50 bpm or ≥120 bpm), medical evaluation should occur before treatment to determine whether the client can withstand the stress of the dental procedure and if a vasoconstrictor limitation is necessary.
Medications • Ask patients, “Are you taking or have you recently taken any prescription or over-the-counter medicines? If so, please list all, including vitamins, natural or herbal preparations, and/or diet supplements.” • This question gives the clinician an opportunity to correlate medications used with general health. In some cases, clients forget to report all of their health conditions, but will note medications prescribed for a medical condition. In addition, this question prompts the dentist or hygienist to investigate drug effects, indications for use, adverse drug events, and side effects. Drug side effects associated with a risk for medical emergency or the necessity for modified treatment include postural hypotension; anticoagulant effect or increased bleeding; hypertension; arrhythmia; nausea, vomiting, or other GI complaints; and blood dyscrasias such as leukopenia, neutropenia, or thrombocytopenia. • Any medication your client takes should be investigated using a drug reference text before initiating treatment. It is important to learn the action of the drug and how that might affect treatment, the dose the client is taking, side effects related to oral changes, interactions between the client’s drug and drugs that might be prescribed related to oral health care, and dental treatment considerations. Postural hypotension is one of the most common emergency situations and is most frequently related to taking a drug that lowers blood pressure, coupled with placing the client in the supine position for a long period of time.
INR Number • In some cases, the client cannot recall all medications used or the details related to medication management. Send the health history form to a new client’s home in advance of his or her appointment. This gives the client an opportunity to list the proper names of their medications, dosage, and use. • One potential problem is when a client presents for treatment and reports taking warfarin, an anticoagulant that requires a monthly lab test known as International Normalized Ratio (INR) to determine the risk for increased bleeding. The client may not know why this medication was prescribed, the INR, or the date of the most recent lab visit. It is essential to determine this information prior to providing treatment to identify the risk for uncontrolled bleeding. The clinician should request the most recent INR data. • If the INR is too high (over 3.5), elective oral health procedures may need to be delayed. If the INR cannot be recalled or if the physician lowered the dose of the anticoagulant at the last lab result, this might pose an increased risk for excess bleeding
Allergies • Ask patients, “Are you allergic to or have you had a reaction to the following?” • ▼ Local anesthetics • ▼ Aspirin • ▼ Penicillin, antibiotics • ▼ Barbiturates, sedatives, sleeping pills • ▼ Sulfa drugs • ▼ Codeine or other narcotics • ▼ Metals • ▼ Latex (rubber) • ▼ Iodine • ▼ Hay fever or seasonal allergy • ▼ Animals • ▼ Food • ▼ Other
Allergic Response • This question involves a variety of substances sometimes used as part of oral health care that have been associated with an allergic response. Hay fever or seasonal allergy and allergies to animals and foods are included because clients with a positive history of any allergy are at an increased risk for having an allergy to products used as part of dental care. The length of time between being exposed to an allergic substance and the development of signs of allergy can alert the health-care provider to the risk of life-threatening emergency conditions. • Typically, the more rapidly allergic signs develop, the more dangerous the situation. Mild signs of allergy include skin rash, erythema, hives, urticaria, or stomatitis. Severe signs of allergy include bronchoconstriction, asphyxiation, dyspnea, reduction of blood pressure, and cardiovascular collapse (anaphylaxis).