The Dental Hygiene Process of Care

…A Compass for Comprehensive Care Welcome to rdhu! Disclosure & Responsibility Statement: My presentation is based on my work as an educator, and colleague. This course presents an overview of the DHPC. The purpose is to take the conceptual framework of the

DHPC into your practice environment increasing knowledge, confidence and competency of care. Taking this course does not guarantee that a registrant will be successful in developing and maintaining

a professional portfolio that meets the standards set forth by the regulatory authority. Please refer to www.cdho.org for complete information regarding the quality assurance program for registrants of Ontario.

The DHPC will be balanced against the self-assessment package provided by our regulatory college . A number of clinical resources will be made available to assist in day to day practice.

Learning OutcomesUpon completion of today’s course, the participant will;

Recognize the framework of the Dental Hygiene Process of Care (DHPC) Identify the relevancy of data collection and correlation of findings to aid in the remainder of the DHPC Identify the dynamic nature of the assessment phase and how it impacts the care plan, implementation

and evaluation Demonstrate use of intra-oral camera as a means of data collection- ’12 images in 2 minutes’. Recognize the components of a written dental hygiene care plan Identify the importance of evaluation as it pertains to individualized client needs and treatment

outcomes Discuss documentation requirement in the client chart as it relates to the DHPC Interpret professional responsibility in a variety of challenging practice scenarios Self-Evaluation

and Practical Application

A portion of this course is dedicated to self-evaluation. These exercises are for self evaluation only. Typical scenarios will be addressed that we all face in day to day practice. The purpose is to take the conceptual framework of the DHPC into your practice environment

increasing knowledge, confidence and competency of care. The DHPC will be balanced against ‘practice check-up’ standards and expectations of our regulatory

college

Development of a goal statement; How is today’s learning activity going to benefit your dental hygiene practice? What is your primary learning goal for today?

Layering your goal; What other activities could you pursue that would align with your 2014 goal? Programs –Link* Online Courses –Link* Literature/Website Review - Darby/Walsh –Link*

Accessing resources;

Online search Websites of interest -Link*

Implementation of new knowledge; Identify how this learning activity aligns with the 2012 Standards of Practice reflected in your dental

hygiene practice CDHO

creating S.M.A.R.T. goals Once you have established areas of your practice that need enhancement, you will need to establish

some learning goals. Your goals should be concrete enough to guide behaviour change and growth that will make a positive impact on your dental hygiene practice. Goals are S pecific, M easurable, A ttainable, R elevant to your practice and T rackable. A well written goal contains an action word (verb) that will later help you determine whether or not you have achieved your goal. Every year you will be required to reflect on your practice and reestablish your learning goals. Each goal should be completed in one year. A large goal that would span more than one year to complete should be divided into yearly achievable milestones.

http:// www.cdho.org/otherdocuments/practicecheckup.pdf http :// www.cdho.org/reference/english/sectionc.pdf -pp guide Bloom's Taxonomy Bloom's taxonomy originated by Benjamin Bloom and collaborators in the 1950's, describes several

categories of cognitive learning. These stages can be useful when writing your goals. (included) Practically Speaking:

Goals for Dental Hygiene Practice To recognize and apply all aspects of the DHPC (Dental Hygiene Process of Care) in my daily dental

hygiene clinical practice To initiate and integrate all elements of the DHPC into my dental hygiene practice To demonstrate the inclusion of 2012 Standards of Practice into my dental hygiene practice To deliver effective client centered care and successful outcomes.

Creating a Goal Statement Goal Layering 2012 Standards of Practice – read/review www.cdho.org National Entry to Practice Competencies and Standards for Canadian Dental Hygienists www.cdha.ca www.rdhu.ca Courses

RDH Documentation: Establish a Reference Based on CDHO Best Practice Guidelines Oral Cancer Screening for Today’s Population: The Urgent NEED for Change

Online Courses: Standard & Transmission Based Precautions & Exposure Management www.rdhu.ca CDHA/ODHA online courses www.cdha.ca , www.odha.on.ca

DVD Quarterly of Dental Hygiene www.dvdquarterly.com Self Assessment Package

section 8 Dental Hygiene Process of Care 2012 Standards of Practice

The practice of dental hygiene is the assessment of teeth and adjacent tissues and treatment by preventive and therapeutic means and the provision of restorative and orthodontic procedures and services.

Dental hygiene services include all interventions performed within the dental hygiene scope of practice directed toward attaining and maintaining optimal oral health for individuals and communities.

The Dental Hygiene Process of Care is utilized to assess, diagnose, plan, implement and evaluate policies, processes, interventions and outcomes.

Before we start...

How important is a process?

https:// www.youtube.com/watch?v=i8qxExknDSw Best Practice

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. 1

Entry to practice competencies and standards for Canadian dental hygienists; Assess, diagnose, plan, implement and evaluate services for clients 2

Recordkeeping Deficiencies4

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 Insufficient time spent on QA activities and not connecting how learning benefitted practice and clients Becomes commonplace in our everyday lives…

STANDARD OF PRACTICE 8.1-ASSESSMENT

A dental hygienist demonstrates ethical and effective assessment practices by:

a) Using appropriate assessment strategies, techniques, tools, and indices to collect and record relevant data.

b) Using professional judgment and collection methods consistent with legal and ethical principles associated with accepted health care practice.

c) Using appropriate oral health indices for the identification and monitoring of high-risk individuals and groups.

d) Including client interview and feedback as part of the assessment process.

e) Including the client’s oral health knowledge, beliefs, attitudes, skills and perceived barriers into the needs analysis.

f) Recognizing the political, social and economic issues affecting the individual and the community.

g) Recognizing and incorporating the determinants of health and oral health into the analysis phase of the assessment process.

h) Identifying clients for whom the initiation or continuation of dental hygiene interventions and/or programs are contra-indicated.

i) Collaborating with other health professionals or knowledge experts in the collection and/or analysis of client data.

The Collection of Objective Data

Extraoral Examination Intraoral Examination Intra Oral Images Dental Examination

SI Periodontal Examination

PSR, Comprehensive periodontal examination/Limited P.E. Oral Hygiene Evaluation

PI, GI Radiographic Examination Shade Index

Guideline for Best Practice in Initiating Dental Hygiene Care: Assessment Thorough and comprehensive medical and dental history must be taken and discussed with the client

or the client’s substitute decision maker Further discussion with appropriate health care provider may be warranted Importance of documentation 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 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; Areas of Concern 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.

The ABCDT ‘s of Malignant Melanoma

Asymmetry

Border

Colour

Diameter

Texture

Terms to describe texture

INTRA-ORAL/EXTRA ORAL ASSESSMENT RECOMMENDATIONS:1. Establish an examination sequence follow it routinely2. TELL the patient you are performing a COMPLETE soft tissue examination3. Examine ALL areas each time4. Use visual inspection AND palpation5. Record ALL findings-Normal and Abnormal6. Remove dental appliances before the examination7. Suggested descriptive terms: hard, soft, well circumscribed, ill-defined, indurated, sessile,

pedunculated, ulcerated, edematous, normal in color, red, white, speckled, color other than normal8. Record ‘Atypical’ findings as well ‘Abnormal’9. Empower your client-have them follow along with a hand mirror! Breakout Session:

Extra/Intra Oral Examination and Images!

Criteria for effective Dental Index; Simple to use Painless to client Efficient in terms of time Cost effective Valid and reliable Translates clinical observations into numerical value Sensitivity index Legend 0 – NO SENSITIVITY Although a sensation of “cold” is noted the client expresses no feelings of discomfort. 1 – MILD SENSITIVITY Although there is no muscle tensing or grimacing the client notes that in addition to a “cold” sensation

there is some discomfort during, but not following, the air blast. 2 – MODERATE SENSITIVITY The client indicates discomfort with involuntary muscle clenching or grimacing and expresses definite

discomfort during the air blast. 3 – ACUTE SENSITIVITY The client indicates sensitivity is present prior to the air testing and the air blast exacerbates the pain

which lingers following exposure to the air. 4 – FRANK SENSITIVITY The client expresses sensitivity to the extent that the air blast is refused. Plaque index Gingival index Caries/PERIODONTAL risk assessment https:// www.philipsoralhealthcare.com/en_us/care/demo Risk Assessments:

Dental Caries Periodontal Disease Oral Pathology A-M-A-Z-I-N-G-!!!! PERIODONTAL ASSESSMENTS CPE-Comprehensive Periodontal Evaluation PPD, BOP, Furcations, mobilities, CALs, Attached ginigva.-1x yearly Add in a description of tissues to check off/CIRCLE LPE-Limited Periodontal Evaluation-PPDS and BOP only

Dental Hygiene Diagnosis 8.2 dental hygiene diagnosis links the data collected in the assessment phase to the proposed dental

hygiene treatment. After all the necessary assessment data has been collected, a dental hygiene diagnosis is formulated to provide the rationale on which the dental hygiene treatment plan will be designed, implemented, and evaluated.

http:// www.cdho.org/reference/english/bestpractice.pdf “An integral component in the dental hygiene process of care, the dental hygiene diagnosis involves

the use of critical thinking skills and the analysis of the assessment data to reach conclusions about the client’s or community’s dental hygiene needs. The dental hygiene diagnosis is a statement that ties the assessment findings to the dental hygienist’s planned interventions.”

A dental hygienist demonstrates competence in forming a dental hygiene diagnosis by:

a) Actively conceptualizing, applying, analyzing, synthesizing, and evaluating information generated by observation, experience, reflection, reasoning, and communication, as a guide to belief and action.

b) Using available literature and/or visuals and/or audio materials to aid in the discussion of the assessment findings and/or oral conditions present.

c) Communicating the determinates of health and oral health with the client.

d) Interviewing clients about their understanding of their oral conditions, what has caused them and how that relates to the determinates of health and oral health.

e) Consulting with other health professionals and knowledge experts, if appropriate, to inform conclusions about the client’s or community’s needs.

f) Facilitating referrals to other health care providers if the determination of needs is inconclusive or self-determined to be outside the dental hygienist’s area of knowledge.

Characteristics of a dental hygiene diagnosis: Focuses on client conditions, behaviors, or risk factors related to oral health and disease Is derived from client data (collected during assessment) Requires interventions within the scope of dental hygiene practice Is necessary for planning and implementing effective care and evaluating outcomes

A dental hygiene diagnosis is a clinical decision made by a dental hygienist that identifies actual or potential human needs deficits that the hygienist is licensed to treat (or to refer for care).

Making a dental hygiene diagnosis includes identifying the following: Unmet human needs that can be met through dental hygiene care Factors contributing to or causing the unmet human needs (causes and risk factors) Evidence to support the dental hygiene (signs and symptoms)

Human needs theory explains that need fulfillment dominates human activity, and behavior is organized in relation to unsatisfied needs

Maslows human needs theory Name some physiologic needs. (Food, water, sleep, exercise) What are safety needs? (Need for both physical and psychologic security; stability, protection, structure, freedom from fear and

anxiety) Identify love and belonging needs. (Need for affectionate relationships; a place within one’s culture, group, family; desire for tenderness,

affection, intimacy) What are self-esteem needs? (Feelings of confidence, usefulness, achievement, self-worth) Define self-actualization. (It is a state in which each person is fully achieving his or her potential and is able to solve problems and

cope realistically with life’s situations.)

8 human needs

1. Protection from health risks2. Freedom from fear and stress3. Wholesome facial image4. Biologically sound and functional dentition5. Skin and mucous membrane integrity of head and neck6. Freedom from head and neck pain7. Conceptualization and problem solving8. Responsibility for oral health

1-Protection from health risks

-need to be in good general health

Assessment:

-client presents with HBP

-client needs premedication (ie hip replacement)

-client plays sports-at risk for oral injuries (needs sport mouthguard)

-client has lifestyle risk (tobacco user)

Implication for DH care:

-Consult w MD if questions arise.

-Refer to MD if none

-recommend sport mouthguard

-tobacco cessation counselling

2. Freedom from Fear and Stress Assessment

Evaluate the client’s verbal and nonverbal behaviors Oral habits related to stress (bruxism or nailbiting) Excessive perspiration

Implications for dental hygiene care Initiate fear- or stress-control interventions immediately

Communicate with empathy Answer any and all questions

Freedom from fear and stress is the need to feel safe and to be free from emotional discomfort in the oral healthcare environment and to receive appreciation, attention, and respect from others.

What are some reasons that a client may be fearful or anxious about dental treatment? (These reasons could include cost, fear of pain, fear of the unknown, invasion of personal space.) Briefly discuss cultural practices that might worsen fear and/or stress. (These practices could include being alone with a member of the opposite sex, religious beliefs, and

language barriers.)

3. Freedom from Pain Assessment

Evaluate verbal and nonverbal behaviors in addition to signs of physical discomfort Speaks with hesitation Extraoral or intraoral pain sensitivity

Implications for dental hygiene care If pain is apparent at the beginning of or during the dental hygiene appointment, the dental

hygienist should initiate pain control interventions immediately

4. Wholesome Facial Image

The need to feel satisfied with one’s own oral-facial features and breath Assessment

Based on information from history, direct observation, and casual conversation. Negative facial image statements

Implications for dental hygiene care Provide information, reassurance, and referrals as needed

5. Skin and Mucous Membrane Integrity of the Head and Neck Assessment Careful observation of the client’s face, head, and neck and examination of the oral cavity and

adjacent structures before planning and implementing dental hygiene care

Implications for dental hygiene care A variety of skin and oral mucosal lesions may be observed that may or may not be symptomatic Dental hygienists may also recognize poor nutrition

Skin and mucous membrane integrity of the head and neck is the need for an intact and functioning covering of the person’s head and neck area, including the oral mucous membranes and periodontium.

Why are intact tissues of the head and neck of importance? (These tissues provide defense against harmful microbes, provide sensory information, resist injurious

substances and trauma, and reflect adequate nutrition.)

Identify factors that could indicate that this human need is unmet. (Factors could include lesions, tenderness, swelling, bleeding, inflammation, xerostomia, and evidence

of eating disorders.) Name strategies that the dental hygienist might implement in order to help the client meet and/or

satisfy this human need. (Instruction on self-care, scaling and root planing, subgingival antimicrobial agents, and referral to

specialty care.)

6. Biologically Sound and Functional Dentition

Assessment Ongoing Client may report things such as:

Difficulty in chewing Ill-fitting prosthetic restorations High daily sugar intake

Implications for dental hygiene care Document existing conditions and deviations from normal Signs of disease and/or functional problems should be reported to the dentist

Biologically sound and functional dentition refers to the need for intact teeth and restorations that defend against harmful microbes, provide for adequate functioning and esthetics, and reflect appropriate nutrition and diet.

Name factors that can indicate an unmet need of a sound and/or functional dentition. (These factors may include difficulty chewing, missing teeth, defective restorations, ill-fitting prosthetic

appliances, active disease, eating disorders, and no dental exam within the last 2 years.) List assessment procedures typically performed by the dental hygienist. (Typical assessment procedures are dental images, observations, dental history, and intraoral and

extraoral exams.) Nutritional assessment also is particularly important for clients who may be at risk for nutritional

problems related to tooth loss, ill-fitting dentures, dental caries, and periodontal diseases.

Conceptualization and Problem Solving

Assessment Listen to client’s questions and responses

Implications for dental hygiene care Present rationale and details of recommended methods for the prevention and control of oral

diseases Conceptualization and problem solving involve the need to understand ideas and abstractions to make

sound judgments about one’s oral health. Identify client behaviors that would indicate that this need is unmet.

(No participation in dental treatment; no questions, comments, or acknowledgment) Identify actions that the dental hygienist may use to ensure that the client’s needs are met.

(Provide written and verbal educational information, demonstrate techniques, have client demonstrate techniques)

8. Responsibility for Oral Health

Assessment Use data collected from direct observation in addition to health, pharmacologic, dental,

personal, and cultural histories

Implications for dental hygiene care Suggest behavior changes Provide oral health education Encourage the client

Writing diagnostic statements as three components comprise a diagnostic statement: A dental hygiene diagnosis is written as a three-part diagnostic statement:

Unmet human need: Oral health condition or potential health problem amenable to dental hygiene intervention

Cause: Probable reason or risk factors for the actual or potential deficit Signs and symptoms: Defining characteristics

Writing diagnostic statements: A diagnosis should be accompanied by noting:

Factors that led to the condition or potential problem Objective signs observed by the hygienist Subjective symptoms reported by the client

Writing Dental Hygiene Diagnostic Statements Common errors include:

Using emotional terms Including a dental or medical diagnosis Presenting the cause as the diagnosis Presenting signs and symptoms as the diagnosis rather than in terms of the client’s unmet

needs Nothing should be recorded that insinuates negligence in the treatment rendered by another

practitioner. Common errors scenarios Critical Thinking Exercise: A middle-aged male client presents with a number of abfracted areas along the gingival margin of the

posterior teeth. The medical history reveals the client is taking an anti-depressant known to cause xerostomia. Further discussion reveals that he is alleviating the symptoms by sucking on mints and chewing gum throughout the day to keep his mouth moist. He states it is sensitive where the teeth are exposed and doesn’t like to smile because he thinks it is noticeable

Compose a diagnostic statement for this client using the ‘human needs, related to, evidenced by’

DHDx Statement:

Unmet need for wholesome facial image related to abfractions (etiology) as evidence by dissatisfaction with appearance of exposed roots (sign symptom).

Unmet need skin and mucous membrane integrity of head and neck as related to dry mouth (etiology) evidenced by need to suck mints during day (sign symptom)

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 Self Assessment

Write a dental hygiene diagnostic statement related to the following clinical observations: Case 1: Client presents with thick brown and white coating on dorsum of tongue. Client states that he is self-

conscious of his breath at present time.

DHDx Statement: unmet need for wholesome facial image as related to Potential for halitosis evidenced by plaque accumulation on tongue

Case 2: Client presents with bilateral linea alba, scalloped borders of the tongue, chipping teeth, attrition generalized. His masseter muscles are enlarged and he is experiencing headaches

DHDx Statement: unmet need for biologically sound and functional dentition related to tooth grinding evidenced by chipping teeth and attrition.

Planning 8.3 Planning Defined “As part of the dental hygiene process of care, the planning phase involves the establishment of

realistic, client-centered goals and selection of interventions that can move clients and/or communities closer to optimal oral health. “ 1

“The registrant is responsible for developing an individual treatment plan for each client prior to initiating dental hygiene therapies. The client’s informed consent for treatment must be obtained and documented. A consent to treatment is informed if, before giving it, the client received the necessary information about the nature, expected benefits, material risks and effects of the treatment, alternative courses of action and the likely consequences of not having the treatment.” 2

The dental hygiene care plan for each client must include; A complete clinical assessment A dental hygiene diagnosis Client centered goals/objectives Planned sequence of activities Client participation Client or Community Centered Planning

A dental hygienist demonstrates competence in the planning of client- or community-centered interventions by:

a) Determining and prioritizing the client’s needs through a collaborative process with clients and, when needed, in collaboration with substitute decision makers and/or other health professionals.

b) Developing measurable long- and short-term goals and objectives with the client.

c) Designing a dental hygiene care plan or program based on assessment data, a client-centered approach, best practices and the best available resources.

d) Collaborating with other health professionals, if appropriate, to ensure an integrated plan or program.

e) Selecting and including in the plan or program appropriate health promotion strategies and interventions for individuals and communities.

f) Providing the client with information on the risks and benefits of planned interventions, alternative interventions, and the sequencing and cost of mutually agreed upon interventions or programs.

g) Including in the dental hygiene care plan or program a mechanism for evaluation post implementation.

h) Revising the dental hygiene care plan or program in partnership with the client as needed.

i) Recognizing the role of governments and community partners in promoting oral health.

DH CARE PLAN

Written blueprint which directs the DH and Client as they work together to meet oral health goals “roadmap” Increases likelihood the oral health care team will work collaboratively to deliver client-centered, goal

oriented care Facilitates monitoring of care Written IMMEDIATELY after assessment and diagnosis phases within process of care in conjunction with

overall dental tx prepared by DDS.

Dental Hygiene Care Plan dental hygiene care plan specifies following:

Dental hygiene diagnoses Client-centered goals (GOALS-related to what you see and what needs attention-must have

timeframe documented) Dental hygiene interventions (CARE PLAN and your rationale) Appointment schedule (APPT PLAN-# of appts required to achieve goals)

Sequence of Dental Hygiene Care Plan Development Linking Diagnosis & Care Plan A care plan may include single or multiple dental hygiene diagnoses A complete diagnosis includes:

A statement of problem Cause of problem Signs & symptoms of problem

Establishing priorities Along with DDS prioritize the following ; Threatens clients well being, safety, health, comfort.

Is client priority (chief complaint) Once these have been established, other priorities are established based on; Client values, beliefs, attitudes Healthcare provider philosophy Collaborating DDS’ goals Client health status Involving the client Goals are best established in collaboration with client viewing the client as a person establishes collaborative and co-therapeutic relationship with client. Collaborative care planning sets the stage for active participation in client identifying needs, readiness

to change, priorities, goals, and intervention, and appt. planning. Clients encouraged to participate in the process of care are more likely to communicate their wants,

needs, expectations than to relinquish decision making to RDH

The dental hygiene care plan should include; Goals/objectives Sequence of activities and client participation noted Identification of who will be performing the dental hygiene treatment plan as well as documentation of

the dental hygiene care plan itself Status of dental hygiene treatment plan if incomplete needs to be documented as well as reasons why

this is incomplete. If another member has performed the dental hygiene care plan this must be documented If a clinical re-assessment is performed, the dental hygiene care plan must be reviewed and modified

as required

Client centered goals

A client entered goal may address ; cognitive, psychomotor, affective or oral health status needs. Client centered goals must have a; subject (client) verb (the client action desired to achieve the outcome-not the RDH action) criterion for measurement (observable behavior) ,time dimension for evaluation (when will the goal be achieved by-next RC appt…?) Planning

Selecting Dental Hygiene Interventions

-Are the evidence based strategies, products, procedures that will reduce, eliminate, prevent oral health problems.

Interventions address factors contributing to client’s human need Various factors contribute to an unmet need, such as:

Skill deficit in oral self-care Low self-esteem Inadequate financial resources Culture as a barrier to professional care

Appointment Schedule Guide for implementing proposed interventions & specifies:

Number of visits Time needed for each visit Interventions to be implemented at each visit

Care Plan Presentation Presentation & discussion of dental hygiene care plan include:

Nature of condition Proposed care plan Risks involved Potential for failure Expected outcomes Alternative procedures

Informed Consent Informed consent should not be viewed as a one-time activity – it is an ongoing process in which client

is continuously reinformed & reminded of terms of care The client must:

Give consent for a specific treatment Give consent under truthful conditions (fraud, deceit, misrepresentation, trickery) use rads, IO images to provide visual evidence of factors Use images to ensure client understand nature of condition and proposed plan-improves

acceptance of plan Client has right to refuse or accept plan Failure to thoroughly discuss care plan means they have not consented and are not knowledgeable or

informed Implied consent applies to assessments, dx, planning components but nothing further. Informed refusal-only once RDH is certain the client is fully aware of what they are declining and

outcomes of their decision. Refusal of care In the event of a refusal o f care, the clinician should; acknowledge the client’s concerns clarify proposed plan discuss consequences of not receiving proposed care reco’d alt. tx options when appropriate. DOC’T; brief expl. of reco’d care, identify specific tx being declined, list risks/consequences to clients

health w/o tx (as discussed w client), date of info’d refusal, signatures of client, dentist, witness. 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 Customized Assessment Risk Evaluator Give it a try for yourself….

Customizable Assessment and Risk Evaluator ToolVisit https://www.philipsoralhealthcare.com/en_ca/care /

Practically speaking... Dental hygiene diagnosis directs the client centered goal statements

Examples;1. Human need of oral mucous membrane integrity related to related to wearing dentures all night as

evidenced by self report of tissue tenderness and halitosis.

Goal Statement;

1. Client will remove dentures nightly, clean dentures, tongue and oral cavity by the next evaluation appt Critical Thinking Exercise :

DH Dx: Unmet need of freedom from pain as related to tooth brush trauma and abrasion evidenced by painful gingival ulcerations trauma

2. client centered goal; Critical Thinking Exercise :

DH Dx: unmet need of oral mucous membrane integrity related to gingival bleeding evidenced by generalized bleeding on probing and tender gingiva reported by client.

Client centered goal; implementation Implementation Defined:

“The implementation of dental hygiene interventions involves the process of carrying out the dental hygiene care plan or program designed to meet the oral health needs of the individual client or community.” 1

“The registrant is responsible for ensuring that the dental hygiene treatment is individualized in accordance with the treatment plan presented to, and agreed to, by the client. In addition, all treatment activities, including the time spent on the procedure must be documented in accordance with the CDHO Records Regulation. Financial records must correlate with the actual time and procedure documented on the client’s chart.

The registrant should ensure that the client receives appropriate post-appointment instructions and recommendations for pain management. Individualized instructions in oral self-care should be based on the assessment and treatment plan.” 2

Implementation

A dental hygienist shows competence when providing dental hygiene services and programs by:

a) Ensuring that current scientifically accepted infection prevention and control procedures are in place and practised.

b) Ensuring that she/he is prepared to effectively respond and manage a medical emergency by being able to recognize the signs and symptoms of a medical emergency, knowing the practice environment’s emergency protocols, knowing the location of, and the protocols for the delivery of, emergency supplies, medications, equipment and oxygen.

c) Maintaining certification in CPR and basic first aid.

d) Ensuring the safe management of hazardous waste.

e) Verifying that an informed consent is present before providing any intervention.

f) Providing interventions and applying products and techniques that are supported by sound scientific principles and have been evaluated for safety and effectiveness.

g) Managing client pain and/or anxiety by discussing options for the control or pain and anxiety with the client, selecting and providing clinical techniques for the control of pain and anxiety and evaluating the effectiveness of the pain control method selected.

h) Providing clients with appropriate pre- and post-intervention advice to include pain management, oral self-care, use of therapeutic and preventive agents, and follow-up/recare appointments.

i) Providing oral health and health advice, dental hygiene services and programs that are within the defined scope of practice and avoiding unnecessary interventions, inappropriate interventions or those refused by the client.

j) Using current health promotion techniques to implement and monitor strategies that promote health and self-care.

k) Applying educational theories, theoretical frameworks, communication and mediation techniques, and psycho-social principles to initiate change at an individual and community level.

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;

Protective clothing and equipment (e.g., gowns, lab coats, gloves, masks, and protective eyewear or face shield) should be worn to prevent contamination of 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).

CDHO Public Education Fact Sheet – check reference on cdho site Scientifically accepted, evidence based infection control policy outlined in college’s Standards of

Practice CDHO promise to the public is that your office protocols are designed to prevent the spread of infection 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:self-assessment criteria 8.4

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 accordance with

the CDHO record keeping regulation? 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? Critical Thinking Exercise #5: Guidelines for Antibiotic Prophylaxis

What happens when an individual has not taken the required prophylactic antibiotics 30 to 60 minutes prior to treatment?

CDHO Guidelines for Antibiotic Prophylaxis If the dental hygienist does not feel it is in the best interest of the client to proceed with treatment,

they must not do so. It is both unethical and illegal or the dentist to insist that treatment be performed by the dental

hygienist when there are doubts as to the medical condition of the client. To provide maximum protection against sub-acute bacterial endocarditis, prophylactic antibiotics must

be administered 30 to 60 minutes prior to the commencement of any procedure that might induce bleeding.

The dental hygienist must always document whether the client has taken the medication. The dental hygienist may proceed if benefits outweigh risks and the client understanding all ramifications.

If client has innocently forgotten to take antibiotics and failed to notify, the antibiotics may be administered at this time – FOR EMERGENCIES ONLY

Evaluation 8.5

Evaluation Defined: All dental hygiene intervention plans and programs include an evaluation framework. The evaluation

framework is a plan within a plan or program that measures the outcomes using a set of key indicators that have been established based on the initial assessment and the client’s identified needs.

This phase of the DHPC measures the extent to which the client and the dental hygienist have achieved the goals specified in the care plan or program.

The evaluation process also allows the dental hygienist to modify dental hygiene intervention plans and programs based on outcome measures, changing needs, and new information.

Evaluation

A dental hygienist uses an evaluation framework effectively by:

a) Using appropriate assessment strategies, techniques, tools, indices and observations to collect and record relevant data to assess the effectiveness and efficacy of the dental hygiene interventions according to the specified goals and objectives.

b) Assessing the impact of dental hygiene interventions against baseline data.

c) Discussing the relevant findings with the client and including their perceptions of changes in individual oral health or community oral health in the discussion.

d) Measuring client satisfaction with services provided and outcomes achieved.

e) Using the assessment data, client interview, and determinants of oral health, to support decisions in the continuation, termination, revision, or modification of dental hygiene services or programs.

f) Using the evaluation results to establish the most appropriate interval for on-going preventive care based on the client’s needs and ability to access oral health care.

g) Using the evaluation results to establish the need for consultation or referral to another health professional. Evaluation

GOAL: to document success of your care plan interventions/strategies at achieving the proposed care goals.

Evaluation is a critical component of successful outcome of DH care plan and measures; Short term achievement of client centered goals and long term prognosis Determine supportive cycle of care at end of plan (appt interval?) ONGOING MONITORING Clinician continually measures progress form all aspects-goals and desired outcomes. Share client progress at each appt., reinforce review reco’d S.C strategies Client has active role in evaluation New strategy must be considered if goals not met or partially met (reassess!!) Modify plan if client;

-has difficulty achieving goals

-is not ready to achieve goals

-continue if client needs more time to implement EVALUATION OF CLIENT-CENTERED GOALS Statement of all goals-cognitive, psychomotor, affective, oral health status Ask open ended questions to determine new knowledge Have client demo new technique Determines which degree goal has been achieved GM GPM GNM Must be recorded Not doct’d leaves client unaware if plan is working for them WRITTEN EVALUATIVE STATEMENT Must contain the DH decision on the degree to which the goal was attained and concrete evidence that

supports it. Failure to evaluate and make statements leaves us unaware of the impact of the care we provided. Failure to eval. Is grounds to being negligent. Without eval. The “unknowns” may still be leading to oral health deficits Evaluative statements measure the extent to which client goals have been achieved and we can then

recommend continued care based on evaluation outcomes. FACTORS INFLUENCING CLIENT GOAL ATTAINMENT Client, DH, clinic environment interact to enhance or hinder goal attainment Reinforce positive factors and manage negative factors + factors; client values OH, motivated and sense of inquiry A DH maintains evidence based-practice A work environment that values high-quality healthcare Modifying Care Plan If little or no progress toward goal, reassess: readiness to change (TTM Stages of change), attitudes,

beliefs, practices and new findings-discuss w DDS These evaluations may lead to new dx, revised goals, alternative interventions. Reassessment identifies client barriers such as; Improperly dev’t goals-may not guarantee a resolution Unrealistic goals/immeasurable Care plan that has not been tailored/individualized

Failure to evaluate Inadequate doct Once determined why the client has failed to achieve goals, the evaluative statement is used to

redirect the care plan. Care plan is “terminated” once client achieves goals and no new problems present=the responsibility

for continued oral health care falls on the individual Written and verbal instructions are given to the client to take home, signs and symptoms should be

clearly understood by client. DH prognosis and continued care Once terminated care plan=new process of care cycle is recommended to the client for continued care.

“interval” which will support the client's efforts to maintain the OH status achieved during active therapy is determined.

DH prognosis is contingent on; overall appraisal of evaluative statement Client’s continued adherence to recommended self-care level of optimum oral health achieved Favorable prognosis occurs when risk for new disease or recurrence is low A “guarded” progn. When risk for new disease or recurrence is mod-high Client centered goals might be achieved during active therapy but progn. May still be guarded because

of risk factors (smoking diabetes, cardio.)requiring a more frequent continued care plan to adjust to client needs. This may need to be reviewed periodically. CC appts are scheduled at 2-12 mos intervals based on client need.

Outcome at continued-care visit Continued Care appt. BEGINS with reassessment of care plan, goals and need for supportive care. Outcomes eval is critical to ensure client’s continued success will be reinforced and continued need

deficits will be recognized and addressed. Doct client evidence of continued OH from prev. cycle of care Identify new condition present Formulate a care plan that supports client’s continued needs Failure to evaluate a client’s progress at each subsequent visit Is referred to as “supervised neglect” This occurs when a client requires further DH care to become healthier or control disease progression

yet the DH has ‘discharged’ the client from care. This usually happen sin service oriented offices vs client centered offices

DOCUMENT the clients acceptance or refusal of care plan Steps - EVALUATION OF CARE

Client education tips Explain import. Of developing a care plan Expl. How DH care plan is integrated w overall dental care plan Incorp. Clients chief complaint, readiness to change, goals, needs, preferences and values into care

plan. Involve client in dev’t of goals (increases commitment) Use IOC, and educational material to enhance

clients awareness Expl. Clinical outcomes of care will be related to original goals Reinforce DH/Client partnership as co-therapists to achieve goals Expl clients readiness to change, wants, needs are essential to overall success of plan! From the top! DH Dx : Unmet need of responsibility for oral health due to lack of flossing as evidenced by bleeding

gingiva

Client centered goal: The client will incorporated flossing daily by the next evaluation appt. Evaluative statement : GPM-client states he is flossing 5/weekly and that his gums rarely bleed and are no longer sore

DH Dx: Unmet need of wholesome facial image as related to crowded teeth evidenced by clients expression of dissatisfaction with his teeth

Client centered goal:

the client will seek orthodontic consultation by the next recare appt.

Evaluative statement:

GM, client attended orthodontic consultation, however is not proceeding with tx due to financial reasons Methods of Evaluation

There are three ways to gather data for evaluation of the interventions; Direct observation of the client by the clinician Examination of the chart Client interview Key Determinants of Evaluation Actual clinical appearance Specific symptoms or manifestations

health vs. disease Client Dental I.Q. Manual dexterity

accomplishments vs. limitations Behavioral modification

client attitude & compliance Evaluation of Client Progress Review of the stated goals Collection of evaluation data Comparison and Conclusions Evaluation of Quality Assurance Elements of performance of care Process in which care was delivered Adherence to Quality Assurance Program and Definition, Scope and Practice Standards Refer to CDHO Registrants Handbook, Professional Portfolio, Code of Ethics, Standards of Practice Evaluation:

self-assessment 8.5

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?Example:Client interested in pursuing teeth whiteningIntervention:Refer client to DDS for cosmetic whitening consultationEvaluative Statement:Goal unmet. Client did not seek cosmetic consultation with DDS

Goal Met

Client has proceeded with customized tray whitening. Recordkeeping Overview of Documentation Requirements Documentation Inclusions:

registrants handbook

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 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 Best Practices in all Clinical Settings Written policy for collection and maintenance of client information Current and proven infection control procedures Emergency protocol and availability of supplies Proof of current CPR certification by registrant Radiographic exposure and processing compliant with HARP Act Equipment is current and in good repair Sufficient resources to support the appropriate dental hygiene service

Documentation of each contact in accordance with the CDHO Recordkeeping Regulation Consultation and/or referral to other health care professionals as required Self-initiation vs. Standing Order As of September 2007, registrants who have been approved to self-initiate may commence ‘scaling

teeth and root planing, including curetting surrounding tissue’ without an order If a registrant is not approved for self-initiation, the order could be a standing order outlining certain

conditions which must be met prior to procedures being performed Under order from member of RCDSO Hard, accessible copy Documentation to support specific orders Record reference to order in each client entry

Client-specific order still required for provision of orthodontic and restorative procedures and services Incorporating Cultural Sensitivity into Dental Hygiene Care

Special considerations within entire process of care Assessment Planning Implementation Evaluation One final word...

Remember…

If it is not written down, it has never been performed!