Running Time: 45 min
Review historical origin and current role of dental hygiene profession Discuss the current dental hygiene framework for standard of practice process of care Review all the assessment components Recognize the dynamic nature of assessment phase and its impact on care plan and implementation Release: 9/26/2014 | Expires: 9/26/2017
Release Date: September 30, 2014Subtitle:
Welcome. My name is Karima Bapoo-Mohamed. I’m a dental hygienist with a clinical practice in Edmonton, Alberta, Canada. I’m also an associate clinical professor at the University of Alberta, where I graduated from. And what I’m here to do today is really share with you one of my passions, which is dental hygiene. This module will discover and explore dental hygiene process of care. There is a lot of discussion on standards of care for dental hygienists. And there are five components of process of care for dental hygiene. And some of these are so critical that we’ve actually broken these modules into two. So under Dental Hygiene Process of Care One I am just going to cover one of the five components, and it’s very important as a continuation you also visit the Dental Hygiene Process of Care Two module, which will cover the remaining four of the five components. So the learning objective, really, for this module today is– I thought it would be very curious, and I got very nostalgic doing the research on the historical origin of our profession of dental hygiene, and really how it’s evolved into the current role of dental hygiene practice. We’re going to talk about the dental hygiene framework– as I mentioned, the five components of the process of care. In this module, we’ll focus on the assessment component for the process of care. And really, we’re also going to briefly chat about how important this piece– the assessment piece– is, because it then segues nicely into the remaining four components. So here we have it. The practice of dental hygiene actually made its debut when a Connecticut doctor, Dr. AC Fones– he actually opened the first dental hygiene school. And you may or may not be aware of this, but he actually opened it in his garage. It was introduced in North America in 1913. So our profession is over 100 years old– phenomenal. And the first graduating class was actually just 27 women. That’s a cute little picture with their nurses caps and gowns– I guess that must have been their uniform. And really, it was created with the vision that you want to work with a multi-disciplinary team is what Dr. Fones’ vision was. And the idea, or the notion, of the profession was very much based on prevention of disease and health promotion. The first dental hygiene graduates, actually, ended up working in public schools, and some of actually ended up creating positions, because you have to socialize as a new profession into society. And some of them created positions in hospitals or different factories in Connecticut. The benefits of their work was so amazing that they were able to reduce caries risk rates by 75%, and from then on, the profession just built a life and a momentum of its own. I love this quote by Dr. Fones where he says that dental hygiene– it’s neat, the terminology he uses, because he’s saying it’s going to open a path of usefulness and activity, and it’s going to be a source of inspiration. This is the goal that he set out our profession to be, and these inspirations undreamed of. And that it’s going to align this profession with workers of the world is how he called it. And look at this amazing BHAG, a big, audacious goal of helping humanity in the masses. He believed the dental hygienist should provide the education and the treatment, but be outside the dental office. So really, he wanted us to be where the population is, so that access to care is given. And then when needed, we would be these outreach workers that would actually bring the patients in for the restorative dental work into the dental practices. So very big, loud vision that Dr. Fones started out with. And because of that, in salute to those 27 first graduating class of hygienists, those women set it up for us today where dental hygiene is recognized and practiced worldwide. It exists in more than 50 countries, and actually, in all those six continents. So he envisioned that we would be working very collaboratively in a multidisciplinary team, and we would really be servicing the public in areas where they didn’t have access to care. And really the financial feasibility was the other piece, with the origin of our career. What is the role of a dental hygienist? Well, we are registered health care professionals, and our responsibilities absolutely include providing treatment to our patients to help with periodontal disease, for example. We want to prevent activities such as caries risk. We’re also advocates for a positive behavior change for our patients. And really over the years, even since I graduated, the scope of practice has changed so much, where in the province where I practice we have independent practice where hygienists can open up shops. I have hygienist girlfriends who actually go into nursing homes and hospitals, really fulfilling Dr. Fones’ mission of bringing access to care to the vulnerable and the marginalized population. We can now do local anesthetic injections as well as nitrous oxide in certain states and provinces. And prescription drugs is also part of our scope of practice in some provinces. And a big part, or a large thrust, is really that interprofessional consultation– that we are really part of a bigger health care team. And how do we fulfill that role of us as hygienists? Really we are a trust builder. We are big on educating and giving the patient that health benefit, and really assessing where the knowledge deficits are and filling that gap for them. We’re great at creating links between what we find in their mouth– oral diseases– and creating that link with their systemic health and systemic diseases that may be present. Tobacco cessation, nutritional counseling, lifestyle changes– these are all the domain that fall under a dental hygienist’s role and scope. We’re great with all our assessment issues of the gingival and periodontal statuses. We’re also wonderful with our scalers and doing the definitive debridement of calculus, and deplaquing the dentition. But I feel one of our biggest positive thing as a role of a hygienist, I feel, is that we are relationship builders, that patients trust us, that we do have trust and they trust us. A lot of times you see a dentist walk out of the room after a recall exam and the patient will turn around and say, what did he say? Or, what do you think of it? So it didn’t matter what the dentist presented– not that it didn’t matter– it was more the dentist presented a treatment plan, but it was very important for the patient to understand what I felt about it. And what came out of my mouth next would be very critical in how compliant the patient’s going to be with the treatment. So let’s not underestimate that role of relationship builder and a trust builder with our patients. Let’s move on to the second learning objective of our module here today. We are going to talk about the current dental hygiene framework, and what are those five process of care for dental hygienists. Those actually include assessing an oral condition, then we are assessing that condition and putting it into a diagnostic finding, where we document the patient’s needs as well. The other component, then, is coming up with a treatment plan and a customized care plan with a sequence of activities for that patient based on our assessment. And implementation, of course, is the other component of process of care. And the last component, of course, is evaluation and monitoring the change behavior there. So really the process of care for dental hygiene is very dynamic. It really evolves, and it’s very customized. It’s very customized for every patient that you work with. The fun acronym we use– and this is actually from the Wilkins textbook– we call it the ADPIE. ADPIE stands for Assessment, Dental hygiene diagnosis, Planning– and this is treatment planning and care planning, with a sequence of treatment activities– Implementation, and Evaluation. So this module, as I mentioned earlier, is just going to focus on the assessment aspect of the process of care. Let’s review all the assessment factors of dental hygiene process of care. Comprehensive exam– taking a very good health and personal history of our patient. They may look very normal, and a lot of times it’s your ability to ask the right questions will really give you the quality of that comprehensive exam. When needed, based on that comprehensive exam findings, you may want to then engage an interdisciplinary approach to the next step of the dental hygiene process of care. Assessment’s really critical, because it will allow you to actually assess any contraindications to care for today’s treatment for this patient. And of course a key part of assessment– it’s great to gather this data, but if you don’t document it in a legitimized way, it’s really not of any value. So documentation of this information, the analysis and synthesis of this information, is a large part of the assessment process. How do we assess it? Well, there’s quite a few strategies and processes and tools that we use to collect and record this data. I think most of us are really good with dialogue history, right? So really following up with the patient and understanding where they’ve been and what they’re all about. Using your professional judgment is definitely a huge part of your assessment process. What about those high risk individuals? You want to identify them and monitor them. The only way you can do it is if you’re doing a very comprehensive assessment piece. So this is why we’ve dedicated a whole module just to assessment processes. And really that social determinants of health, and what is the needs of this patient that are not being met? We’re going to talk about that in detail as well. So here is a list of all the assessment criteria that we conduct for our first visit or a recall patient exam, starting with our medical history. Medical history is interesting, because patients may not want to disclose information to you because it’s medical, and you’re just the hygienist, or you’re just the person cleaning my teeth. So why do I need to tell you all of this, right? And very important that you have that rapport and trust built with the patient, and then the patient understands your role in the whole health care disciplinary team that they will disclose information. So explaining to them that I want to be able to treat you safely, so this is why I need to know. Have you had any hospitalizations, any surgery, any new medications, anything that has changed for you? Medical history is actually a legal document. So really keep very good records of all your documentation on the medical history side. And it helps you with the communication with the medical doctor. So if the patient said something that you’re not too sure of, have the office call the medical doctor and get some confirmation or clearance on this patient’s medical history item. So really, they won’t disclose information because they feel it’s irrelevant, but once you start explaining to them that it is all interconnected– your oral health, your general health– there are oral manifestations that are related to diabetes, for example. And so I need to know if you’ve been recently diagnosed with diabetes, for example. Yes responses– of course, we all have our medical history chart. We have the patient fill it out prior to seating them in the dental chair. And any time that a patient responds yes is an opportunity for us to then follow up with the dialogue history and give us a little bit more information on there. How about what else the dialogue history does for us? While you are going through the yes responses and explaining and educating your patient, you are actually building a rapport with this patient. The patient is getting to know you, and you are getting to know the patient a little better. And by having this rapport, the patient’s narratives change, because now you’re supportive of them, by asking open ended questions and really practicing that active listening, where the patient is now divulging of the information. So the three techniques, of course, is the dialogue history we talked about, or the oral interview; the written questionnaire that we have them and follow up with the yes responses. Now we’re ready to move on with our visual assessment of the patient. And really, I do this starting from the moment I’m greeting my patient– as you all do, I’m sure– in the reception area, the waiting area. And you say, hey, hi. How are you doing, Mrs. Jones? And what they look like, how they stand, how they walk, what they’re wearing– all this gives me a feedback mechanism of understanding, hmm, maybe they’re not having such a great day, or they look rushed, or they look stressed, right? Pay attention to those little cues. There may be signs in the way they walk that maybe they’ve had a surgery recently that is making them look a little different from the way they are. What about when a patient is just walking from the reception area to your dental chair? Are they out of breath, or are they wheezing? Do they need a moment to catch their breath? These are all things we could be picking up on and tying into our medical history. I mean, these are stuff I’m sure we all do, but I’ve made a point of actually highlighting what I do in my private practice on a daily basis. As I’m taking their coat off, or helping them with their purses, or putting their cell phones away, I’m also very vigilant about watching their nails and their hands and their skin, and just looking for any signs of maybe something that’s not very healthy, or maybe something that may be abnormal looking. Patients’ eyes also reveal a lot of knowledge– especially the white part of the eye– to see if it’s healthy or not. And any kind of yellowness or non-whiteness is a good indication of some systemic disease that may be going on. Does the patient have trouble hearing or listening, or do they have a preferential ear that you should be careful and be respectful of, and maybe speak closer to that ear? What about the patient’s manual dexterity? Look at their hands. Are they arthritic? Do they have rheumatoid arthritis, or osteoarthritis? What do the knuckles and the phalanges and metacarpals look like for us? And what about the patient’s attention span? These are all things you’re probably doing in a couple of minutes as you’re walking the patient in. But all I’m saying is, being attentive to that really helps us with that comprehensive medical history. Patient communication– a large part. And there’s a lot of literature on health literacy. Patients’ health literacy is a key component in that communication. And a lot of lawsuits happen because patients are doing dentists and doctors and medical offices, saying, but I didn’t understand what they were saying. They signed a consent. Legally, they did all the right things, but this health literacy is a huge, burgeoning source of concern in health care provision. So really making sure that the patient’s understanding what you’re talking about, what the condition is, what the treatment plan or what the next steps are, and giving them a chance to really understand and reflect back. So we need to be, as dental hygienists, very objective, very nonjudgmental, and really sensitive to that patient’s needs– showing that caring by giving the eye contact, giving them the space to speak and not rush them, because a lot of sensitive information may come out. Maybe they’re HIV positive, and nobody in the family knows that, and now they’ve shared that with you. So the environment you’re creating for this very sensitive information becomes very critical on your part. And making sure that there’s not people around in the earshot will give the comfort to that patient as well. And of course, watching your nonverbal communication– that silent communication that happens by body language. So we talked about the medical history as far as the gait, posture, the alertness and anxiety of the patient. I always want to ask, have you been in the hospital recently or had any treatment medically? And they’ll say, oh, I had that tooth fixed. But you want to divert their attention to actually medical appointments that they’ve had. What about medications? You know, they say, oh, everything’s the same. And a good question to ask is, has the dosage of your medications changed since the last time I saw you? And they might remember, oh yeah. The doctor had to change this and that and the other. So really document that, because we know a lot of medications have intraoral signs and symptoms as well. When was their last physical exam? I’m curious to know. This gives me a clue as to whether they are under a medical care of a doctor, or do they actually have a physician– and document who that physician is. Is there any family history of diseases that they know of that they can share with you. And in my office I do have an oxygen sat and a blood pressure cuff that I am always measuring the patient’s blood pressure, temperature, respiration rate and the pulse. And this is just as they’re seated, and we’re just visiting and talking about the weather and what have you, and getting them relaxed. Any new allergies since they’re last here is a very important question to ask, of course. And really all offices have ASA classification, a way of documenting that for that patient, that you really want to follow. Sometimes we’ll do a nutrition guide. I don’t have a formalized one that I do for a 24-hour, but I will use the nutritional counseling as giving patients a little insight on what they should be doing. And are they smokers or not, or have they been past smokers, is important information. So basically this chart goes over all the aspects that we talked about in the body systems. And another big question is, has there been a change in their weight? Whether they gained weight or lost weight, that’s a really important thing too. You know, have they had a lot of headaches, or ringing in their ears? And that breathing– you know, when I notice some wheezing or it doesn’t sound too good, I will go ahead and ask them, have you had difficulty in breathing lately? And they might divulge some of their medical information, or chest cases that they are undergoing. And these are all the other systems that– I mean, it’s all part of our medical history, and very important to follow up with any yes responses a patient has. Hypertension– we talked about blood pressure, absolutely anything that’s beyond the norm. These are the classifications I follow. So pre-hypertension is if it’s 120 to 80 it’s fine. Actually, if it goes up to 139 to 89 I’m kind of watching for it. You could still provide the dental hygiene care, but I’m kind of watching it. I might ask them the question, did you take the stairs coming up to the office today? I’m on the second floor of a historic building. And sometimes that might elevate their blood pressure too. But we all know that anything that’s hypertension related, anything over 140, there’s caution. I want them to see a medical consult for this. And sometimes I’ll recheck their blood pressure. If they came up the stairs, let them rest for awhile, go over, do some other things– maybe your extra oral exam– and then go ahead. And they’re probably a little bit more relaxed too, that their blood pressure reading may be lower than the initial reading that you took five minutes ago. This is the ASA classification. Of course, with anything ASA 2 or higher, a patient cannot– you know, the contraindication for treatment in the dental chair, and should be actually– at least, that’s the protocol we follow in our office– is needing medical consult for that. The guideline for antibiotics– I know there’s just so much out there, and really when we think about it, it boils down to infective endocarditis. We always want to prevent that and want to give antibiotics for that reason. And of course, with the prosthetic infections we do require patients on antibiotics. There are contraindications to treatment if the patient’s undergoing active chemo or radiation therapy. If there is some kind of immunosuppression disease that the patient is going, probably a good idea not to go in the mouth and churn up the bacteria and risk bacteremia for this patient. Blood disorders– pay attention to that medical history. Have they had TB before? I know it’s making an epidemic. What about their social habits of drugs, alcohol, smoking– and that combination is a huge impact on our health care process of care. Infective endocarditis– just to review, we do give prophylactic antibiotics in our practice for patients with prosthetic valve, have had previous history, or they have some congenital heart condition. And this is always something that I will identify with the medical doctor, get guidance and clearance from him, because there are actually a lot of heart conditions that don’t require prophylactic antibiotics. And I think the big thing in the industry is we over prescribed prophylactic antibiotics for really no reason. So really check in with your medical system, and follow the criteria that’s recommended for that patient. As far as the orthopedic surgeon, the Academy says that if the joint replacement has been done within the two years of today’s date of appointment, the patient should be on prophylactic antibiotics. But if it’s beyond the two years– like it used to be five years ago, I remember– don’t need to do that anymore, according to the new guidelines. And a lot of times patients will say, oh, well I had a pin put in my knee, or I have a certain plate in one of these bones or what have you. Those actually do not require any prophylactic antibiotics according to the Orthopedic Society Other medical considerations is like things like diabetes, and especially uncontrolled diabetes. We really want to watch for those signs and symptoms. Smoking is absolutely one consideration as well. We alluded to that earlier. And then we talked about the immunosuppression. How about osteoporosis? That’s also a big one for patients on hormone replacement therapy is another consideration. These are not contraindications to dental hygiene treatment. These are considerations that you will use in your analysis and diagnosis of this patient moving forward. And you might want to tweak your care plan or your treatment sequencing based on some of these considerations. I have diabetic patients, and I know they have to have their mid-morning snack and a mid-afternoon snack. So consideration– maybe we’ll book those dental hygiene appointments so it doesn’t conflict with their behavior of eating based on their diseases. Legal consent is– again, I mentioned a huge part of what we do, because everything we’re getting from the patient is a legal document in the patient chart. And it’s not about just getting consent. I’m highlighting the word informed consent. By informed we mean that the patient actually understood the treatment that you’re prescribing, that they had the opportunity to ask the question, and they were able to give you that consent freely, without any coercion from your side. It’s not like, here’s the paper. Sign it. This is a very legal, serious, binding document. So before you present them with the care plan following your assessment, really important to take few minutes with that. Different offices have it set differently. Maybe it’s the role of the front desk that may work with the patient on this component. Talk about dental history as part of our assessment items. What is their past dental history like? I’m always curious about when was your last dental visit. Now, with the independent hygiene practice, these patients may be coming from a different dental set up. And so when was the last time they were there and what treatment did they have done? And did they have any feedback? How did that go for them, right? And maybe that’s the reason they left that dental office. I’m curious to know what their experiences were, because that’ll help me prepare in the client care for this patient today. Do they have any upcoming dental treatment is, of course, another critical piece to know under past dental history. And what’s their chief complaint today? As far as the past dental history, I’m also curious to know, do you remember if you had any itching or swelling of your eyes or runny nose after the dental treatment? And most patients will discount it, but sometimes I’ll have a patient say, come to think of it, now that you ask me that question, I did have a little tingling around my lip. Now that right away clues me into possible latex allergies, or something that we’ve done that didn’t agree with that patient. So I think most offices these days are non-latex gloves, but an important question to ask, I feel in my opinion. And they’ll be here to tell you, well, you know, everything fine except this one tooth– it’s really touchy, or it’s really sensitive to cold and it was never like that before. So capturing what their chief dental complaint is today is really important moving forward. And is there any other concern they have about their teeth, about their health, anything that’s on their mind that they want to share with you about the look of their mouth and their face. Oral cancer screening– I do this for all our patients, for our head and neck exams. I call it the three minute lifesaving routine that we do. And it just starts with having the patient seated upright and doing the extraoral exams. You really want to not only look at the overall appraisal of the patient– we talked about the face, skin, eyes and the lips, and their nails, of course– but also want to make sure that intraorally the labial buccal folds are looking healthy, and that there is no neoplasms or abnormal growth going on there. What about the tongue? Is it symmetrical? What’s the shape of it? Are there a lot of fissures that are very prominent when you do your intraoral exam. What about the floor of the mouth? Is there a lot of variscosities Is there a very deep vestibule on the floor? And what’s the saliva content like in this patient’s mouth? Saliva’s such a critical component of the oral function. And very important to also look at the hard palate, soft palate and the tonsillar region of the mouth as well. So really, we start with the lymphatic system and look at the TMJ and the salivary glands. Those are the three key components in my extraoral exam, starting with the submental, submandibular, then I’m moving to the neck area for the cervical chain. Then we’re going over to the collarbone area, which is the supraclavicular bone. We’re looking at the occipital area, and then of course, before and behind and in front of the ear, which is the posterior and anterior here auricular areas. So these are the location of your lymphatic system. And any time it’s tender or a little touchy– and ask the patient, does that feel tender when I touch it? And sure enough, if they’re fighting a cold or just gotten over a cold, the cervical chain, especially around the sternocleidomastoid muscle, can get pretty tender. Check the range of motion for their TMJ, and check for any pain or tenderness on opening or closing. Is there deviation upon opening or closing? And the salivary glands– the big ones, absolutely– the parotid glands by the masseter muscles, the sublingual and the submandibular salivary glands. Take a close look at the facial moles of the patient. And actually, I’ve been now taking pictures– I just digitize them, and it’s on the patient’s chart on the computer– as having the location and size of that facial mole. Most the time their benign and non-malignant. However, they could change over time. And what a nice way to then educate the patient that, look– two years ago, this is where we were at, and there has been a slight change in it, if so. The tongue, again, is very important intraorally. We want to look at the oral pharynx as well as the frenum attachment. And the frenum– most people falsely think that that’s the midline of the tooth. It’s not necessarily the midline, because you can have a malpositioned frenum attachment. So be aware of that as well. Floor of the mouth– of course, this is manifesting a bilateral mandibular tori. So very normal, very common for this patient to have that kind of bony exostosis. Visual inspection may even show there’s things like amalgam tattoos in that area, as well as any active canker sores the patient may be experiencing at present. We then move on to the odontogram, where we’re now going to do a hard tissue assessment. By hard tissue we’re talking about the teeth, and we’re going to capture all the decayed, missing, filled surfaces of the teeth. Is there any implant therapy presented to this patient, any active carious lesions, any demineralization? We want to check their abrasion, occlusion, attrition, and any diastemas rotations that the patient may have, is captured on the odontogram. This is showing a picture of the massive attrition wear on the anterior incisor area. And you want to investigate the bite of this patient to see what is happening there. Attrition’s different, of course, from this kind of wear around the cement to enamel junction. As you can see, there’s actual notching on the CEJ area, and this is usually from an excessive occlusal force that’s going on. And part of our dental hygiene therapy, my armamentarium has the articulating paper where we’re checking the bite of the patient to see if there’s any high spots, or asking a patient, when you put your teeth together, where do they touch first, and does it feel high to them. And patients are remarkable. If you ask the right questions, they will have some phenomenal insights of their problems and issues. So really watch out for that, and educate the patient that this is not normal, that you are doing an excessive biting force on this area. Let’s move onto gingival assessment. You know, as hygienists, we’re all big on the color, contour, texture, consistency, and tone of the gingival tissue. We’re also looking very closely at that interdental papillae. We want to see if there’s any bleeding response on this tissue, or any exudate. And of course, we’re watching out for recession and any kind of mucogingival involvement. We quantify the disease process in the following way– we want to make sure that, yes, what is a disease entity? Is it biofilm-related or is it non-plaque related? The other thing we have to have in our statement of dental hygiene diagnosis is, is it localized or generalized? So what is the definition? Some people are confused about when is a thing localized, and how do you know? So an average– if it’s less than 30% of distribution, it’s localized– gingivitis or what have you. The other way you can describe distribution, of course, is we call it either marginal or papillary or interdental, or we could call it diffused if it’s is going into the attached gingiva as well. And then with the severity, of course, we have the terminology of slight, moderate, and severe. And slight is talking about clinical attachment loss of less than two millimeters. Moderate is anywhere between three and four– I want to keep a close eye on that. And severe is anything over six millimeters. Later on we’re going to talk about what I mean by CAL– Clinical Attachment Loss. So here we have slight recession, which is very localized to some anterior dentition. The slide, also on the right, shows marginal redness, and it’s really localized just to the margins of the gingiva there. There is a shiny bulbous tissue– again, localized specifically to that one anterior incisor. So these would be good descriptive terms to give us a clinical assessment. Next we move onto our soft and hard tissue deposit assessment. How do we do that? Well, we use our wonderful plaque scores. And there’s so many plaque scores, or ways of gathering plaque scores. I remember when I first graduated, we would have disclosing solutions, and then we would actually physically mark down all the areas or surfaces on the teeth that disclosed with plaque, and then divide that number by the total surfaces and multiply by 100 to get what their plaque score was. And share that with the patient as part of your education, but then you’re also documenting it as a benchmark. This is important, because a patient’s shown in– well, my teeth look pretty white and clean. And when you disclose that same surface, you can see that the biofilm exists all along the medial interproximal line angles of quadrant one, and the patient was effective– pretty effective– on the incisal occlusal edges, and missing out on the medial line angles. So what a wonderful educational opportunity to show them, yeah, they look pretty clean. But you know, here we are. This is where the bugs are hiding in your mouth. And then the last picture on the bottom shows after the biofilm removal and patient education. Calculus index– again, there very many indices. The one I like to use is using the Ramfjord teeth– the six teeth as a proxy for the calculus deposit for the whole mouth. And again, we are checking four surfaces on those six teeth. Those four surfaces are the medial, distal, the buccal, and the lingual surfaces. And the score given to those four surfaces range from zero to three. Zero is when there’s no deposit. On my explorer it feels really smooth. If there’s a little granular deposit– and I have hygienists or people ask, how you describe granular? And the best thing I can think of is it feels like a sandpaper on your explorer. That’s a Class 1. If it’s a little heavier than that, feels like a spicule, and you actually see a slight jump on your explorer, that is a Class 2 calculus index. And then three is actually when it’s banded, or lots of ledges, and usually it’ll be visible supergingivally as well. So then you take those scores, add them up to give a calculus index for that patient, and record it on the chart. And like I mentioned, there are very many different calculus indices that I’m sure you all follow in your practices. Important thing is to follow it and document it and have a record in the chart for that. High caries risk– we’re absolutely looking out and wanting to use this assessment criteria for educating our patients. So if there’s a lot of cariogenic bacteria, there’s a lot of saliva diagnosis that will disclose that information. What does their plaque score look like? Is their oral hygiene up to snuff, or is there a risk factor there? Family history, genetics is a huge one. Is there any developmental issues? And patients who are also undergoing chemo or radiation therapy, caries risk can be very high because of the dry mouth xerostomia issues. Patients with eating disorders absolutely are high caries risk, or can be high caries risk, or moderate caries risk. And orthodontic treatments are patients who have braces. Want to make sure that they don’t then end up with cavities after they have a beautiful straight smile. And looking out for exposed root surfaces, because that can get cariogenic quite easily. It doesn’t have the enamel to protect the pulp from. All right. Moving down, then, to periodontal assessments. With periodontal assessments, this is where we are taking our periodontal probe and measuring the space between the tooth and the gum– or actually, specifically, the root and the gum in the periodontal ligament area. We are going to actually not only measure the pocket space, but we’re also measuring the recession space. So if the gums have moved away, how much have they moved away by? And really documenting that probing depth is very important. This slide is an enactment of– well, it’s showing the probe reading of about two or three millimeters, so things are looking pretty good. However, the bottom two slides show how deep that probe reading is actually disappearing there. And the very last slide on the bottom shows, actually, supergingivally how deep that probe reading is. A lot of times, depending on the patient’s dental IQ, I’ll actually bring out a hand mirror and show them that this is how much space exists below the gum line. And this is where a lot of your bacteria is living in there. And this is producing a lot of toxins, and producing a lot of inflammation in your body because of this. So don’t discount the probe reading as something– a chore we have to do, put it away. But what an amazing educational tool for us to educate our patients with. So looking into orally as well for recession, abrasion, and absolutely, erosion. This is just showing the excessive erosion on the lingual surfaces of the maxillary anteriors from the acid reflux. This is a patient who is anorexic and bulemic. So they’re emptying the contents of their stomach, and there is repeated acid exposure to this area. We can also see, again, that notching effect– and really explaining to the patient on how they’re biting and putting their teeth together. And if they’re under a lot of stress, or patients who are working out a lot, will end up putting excessive amount of force beyond the elasticity of your periodontal ligament. And the teeth will chip away and notch. What about their self care effectiveness? Let’s talk about that. Oral health counseling is a key component of what we do as dental hygienists. In fact, this is such a critical piece of patient motivation and patient compliance that we have a dedicated module just on oral health counseling that I’d like to invite you to view. Talking about self care assessment, I’m curious to know how is a patient managing based on their plaque score, their calculus index. How are they managing their deposit in the mouth, and what is their social lifestyle like? Are they smokers? What’s their nutritional requirement and use like? Part of the assessment is absolutely the radiographic interpretation of our findings there. And so we’re really looking for the level of the bone here, and what the alveolar crest looks like. You can see this massive defect with radiolucency that’s become apparent on this radiograph. Really even the trabeculation pattern of the bone, and how cancellous it is, or how dense it is, becomes a critical component of what we do. Looking out for any overhangs or margins that might interfere with patients’ home care routine, and absolutely your dental hygiene care for this patient. So these are all evidence based assessment criteria you’re going to take and then use it to actually come up and fabricate a customized care plan for this patient. You also want to look at– radiographs are critical, because it will not only– clinically, you can see there is exudate in this situation here, but radiographically it gives you an idea of the extent and the scope and depth of this defect on the alveolar ridge. This is interesting. This clinical slide shows us– it’s just a crown. Probably had a tooth that had a root canal, or a tooth that broke off, and the patient just had to have a crown done. However, if you look at the radiograph, this is a crown supported by a two-rooted implant. So these are two mini little implants that are supporting that crown. Now had I not known that, maybe my hygiene instruction would’ve been different. As it turned out for this patient, I was able to provide them with the floss threader, and curved it so they could actually manipulate the floss in between these two little mini implants in their mouth. And of course there is a whole slew of other tests as part of our assessment criteria that may go beyond the parameters of that whole dental office or dental hygiene chair. And those can include anywhere from lab tests for a biopsy you may request, or it may be some bacteriological culture you want to have analyzed. You– actually, saliva testing is also taking a breath and a force of its own, that I think it may also become widely used as well. So really important to know when to refer, when to collaborate, and when to reach out into that larger multi-disciplinary team. So really, what we’ve talked about is all those assessment components, which is one of the five areas of the process of care for dental hygiene practice. And the key thing to really recognize is how dynamic this assessment phase is– that it can change. And having a comprehensive assessment phase is so critical for a customized care for that patient, because from here on you’re going to assess and synthesize this data and make a diagnosis statement for this patient for a dental hygiene treatment plan. We’ll then talk about the care plan and the actual implementation. So really, the learning outcome for this module– we started out with a nostalgic journey of the origin of dental hygiene as a profession, which was over 100 years ago. We talked about the current framework for standard of care for dental hygiene process, which is the five components. And in this module we just addressed the first component– I think it’s the critical component– is the assessment phase of the process of care. And this is why we took the whole module to just go comprehensively through all those line items. And now I would invite you to the next module, in which we will conduct and carry out the remaining four elements of the process of care. I would like to leave you with a quote from Charles Darwin, the biologist, the evolutionary biologist. And he said, “It’s not the strongest of the species that survives, nor the most intelligent, but the one that’s most responsive to change.” So it’s not about having the knowledge and having the smarts and being intelligent. That’s all part of it for survival. But it’s interesting that your flexibility and your agility and your response to this new standard of care, and really implementing and taking this close to heart in conducting a comprehensive assessment for your patients will make you more accessible, and actually successful, in the survival of your dental hygiene practice. I wish you well with this assessment phase of your dental hygiene practice. Thank you for joining us.