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Running Time: 36 min

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Understand the relevance of data collection and correlate findings to process of care diagnosis Care planning and the value of written care plan with key components Implementation of care including referral and interdisciplinary collaboration Evaluation and success measures with documentation Release: 9/26/2014 | Expires: 9/26/2017

Release Date: September 30, 2014

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Welcome to the Dental Hygiene Process of Care, Module Number 2. In the first module, we went over the assessment criteria of dental hygiene process of care, and the remaining four of the five criteria will be covered in this dental hygiene process of care number two module. Welcome back. My name is Karima Bapoo-Mohamed. I am a dental hygienist with a clinical practice of over 20 years in Edmonton, Alberta, Canada. I’m also an associate clinical professor with the University of Alberta, where I graduated from my dental hygiene program. And I am happy to share my personal insights and knowledge and wealth with you pertaining to the dental hygiene process of care. In the preceding module, we talked about the comprehensive assessment criteria. What happens next for us in the process of care as hygienists is we are going to take that data, analyze it, synthesize it, and really create a dental hygiene diagnosis statement. This module will actually give you the steps and components of what this statement should look like, and something that you could actually very easily fabricate for your patients. And what I like about the dental hygiene diagnosis statement is it becomes a nice, clean, very expressive statement that goes into patients’ medical records as part of their legal documents. After the dental hygiene diagnosis statement, of course, we’re going to then do the care planning and the treatment sequencing for this case. Based on our findings, we will then conduct an implementation or intervention program for this patient and end with actually the evaluation part. In all those components, of course, informed consent becomes very critical prior to providing any care to this patient, as mentioned in the earlier module. So what is the rationale for a dental hygiene diagnosis? Years ago, we said, oh, dental hygienists can’t diagnose. And really, so long as we are quantifying this as a dental hygiene diagnosis and explaining to the patient as to the rationale for this, it’s really the analysis of the data we’ve gathered. And based on that, this is the findings, and this is what we’re planning for a dental hygiene intervention today. You’re also using the data to actually communicate to the patient where the health deficits may be, where the knowledge gaps may be, and how you can help that patient fulfill that health deficit. This data also becomes important, actually, in consulting with other interdisciplinary professionals. So having a crisp dental hygiene diagnosis statement is a uniform way of relaying the information about that patient. And again, for referrals, going to medical doctor, having a chart which has this amazing documentation go such a long way in really advocating for the patient. So really, we’ll take the assessment data. We will document the patient’s needs, and we’ll set the goals to really meet their needs moving forward. It’s interesting to me that the World Health Organization describes oral health as a state that’s free from chronic mouth and facial pain, that there is no oral and throat cancers, that there are no oral sores or birth defects, such as cleft palates or cleft lips, that the patient is suffering from, and that periodontal disease and tooth decay and tooth loss and other tooth disorders or diseases of the oral cavity are not affecting a human being. So oral health, the way it’s described, is so much more than just teeth. It is totally head, neck, body, and systemic issues that we are working with in our patients. We all remember this famous triangle from our psychology courses for dental hygiene, the Maslow’s Hierarchy of Needs. And we all know that patients can be in different dimensions of their needs. So really understanding where the patient is in the Maslow’s hierarchy of needs is a very critical aspect of how we’re going to construct our dental hygiene diagnosis statement. There’s also the human needs conceptual model. This is actually right from Darby and Walsh. And it talks about what that planning looks like, and that the client does have biological, psychological, and other social, intellectual cultural, spiritual needs that need to be fulfilled as a human being. And how does that apply to us as dental hygiene? Darby and Walsh talks about eight human needs, and they’re listed right here on this slide. And really of importance to me, I feel what we do day in, day out as dental hygienists is the skin and mucosal membrane integrity of the head and neck. And how about this one, the biological sound and functional dentition is a definite human need, as it relates to dental hygiene. So with that context, I want to now go on to how do we take the human needs, take the patient’s assessment, and create a dental hygiene diagnostic statement? Well, it can really cover the domain of gingivitis, which actually falls under the human need of skin and mucosal membrane integrity. Periodontitis, or periodontal disease. Periodontal disease also falls under the same category of skin and mucosal membrane integrity. And of course, caries relates then to the human need of having biologically sound and functional dentition. So here we are. A dental hygiene diagnosis statement actually has three components. One is, what is the problem that needs to be solved? So what a statement will start out with what the need is or what that problem is. The second component of the statement will talk about, what is the cause? What is the ideology behind this problem? And the third and the last component of a dental hygiene diagnosis statement is really defining the characteristics of the symptoms. Now, you probably do this on a daily basis, but maybe never thought about it writing in the three components that I’ve just highlighted because you do it intuitively. So an example of a dental hygiene diagnosis statement may be periodontal pocketing related to subgingival calculus. And those deposits are evidenced by gingival inflammation. So you’ve taken the problem, you have related it to the etiology, and then you have evidenced it by what you’re seeing the finding to be in the mouth, which is the gingival inflammation. Another example of a dental hygiene diagnosis statement may be generalized severe chronic periodontitis. So again, the review of describing where the periodontitis is a distribution of the severity. It’s generalized. It’s severe. It’s chronic, periodontitis. And how do we know this? Because we’re relating it to the deep periodontal pockets, and those are evidenced by a generalized bone loss margin on the radiograph. It may be horizontal. It may be vertical bone loss. But be as specific as you can, and you want to. So that gives you a glimpse of what that statement could look like. A potential human need absolutely can merit a dental hygiene diagnosis statement. For example, a potential health risk, and it’s related to the high blood pressure. So maybe you did the blood pressure reading, and it’s a little high. And now a fairly general statement, but you have captured the essence of what your assessment was for this patient today. And more importantly, the risk factors that you’re going to watch out for. You have to be careful when you’re linking different areas. Again, for gingivitis, it may be related to the generalized bleeding. Caries would be another good example. Something we also do is high caries risk. Again, relate it to that high exposure to acids. And how do we know that? Because maybe we did a sweet score on a 24 hour food diet record, and we found that the sweet score is fairly high for this patient. So they are high caries risk and highlighting them. So really think about the risk factors and identify them and then relate them back to that human needs model and the eight categories that’s highlighted by Darby and Walsh. Common errors in the diagnostic statements. You need to watch out for is you don’t want to use judgmental words. So you don’t want to say the client’s lazy about brushing and flossing, or there’s bad dentistry in the mouth evidenced by the overhang. These are just things that are not kosher or cool to talk about. Really base it very objectively, very nonjudgmentally, as to what those findings are. Again, moving on to the next part would be the care planning. So to review, we did the assessment in module one. We’ve talked about what the diagnosis statement should look like, what are the three components of it. Now we’re going to go to the care planning component of the process of care for dental hygiene. This, again, by Darby and Walsh, is a component where the dental hygienist and the client will together discuss what the client’s goals are, what their priorities are, and what are some of the interventions that you feel you could provide the patient with to attain that goal that the patient has. So really, you want to set the goals in a very evaluative way. You want to identify what those interventions are. You want to establish that this is the parameters of what you’re saying the priorities are to be. And then you’re going to write down that care plan. So this is a very critical component where there’s dialogue back and forth. And this is even before we’ve actually done any instrumentation. We are still in the care planning, treatment planning phase of things. So we mentioned in actually assessments module that the goals should have a cognitive, a psychomotor, and an affective goal. And how are you going to define that for that patient? How are you going to solicit their input into these goals becomes very important. And how do you link it then to your dental hygiene diagnosis statement that you just rolled out as being something that’s critical? By the way, with the dental hygiene diagnosis statement, you can have more than one statement per patient per chart. The patient may have high caries risk, but they also have perio. They may have smoking cessation issues or goals that you will then bring out in your care plan that we’re going to talk about. So goal setting, absolutely we also want to link it with the dental hygiene diagnosis statement and really the unmet human need model that we were talking about earlier. And always consulting with the patient. So what’s a cognitive goal? Cognitive goal can be something very similar to a patient now having an increased awareness of their dental hygiene situation, or their oral health condition, or their pocket depth. You can make it as specific or as general. But any increase in the knowledge is a cognitive goal for that patient. A psychomotor goal would be something that’s a skill enhancement or a retooling or a modification of what they’re doing, maybe with their brushing, flossing, and their dental cleaning. And now you have given them an extra skill. And we’re all so good, we do this so intuitively. But actually, you’re meeting a psychomotor skill of your patient. Affective goals are really that patient that I gave an example in the last module on didn’t want x-rays done because they had a certain set of belief system that they were against x-rays. Now, if you’re able to change that belief system for the positive and for the betterment of the patient’s health and human needs, that’s an affective goal, that you have reflected a change in their values or in their beliefs or their attitude for something better. So the oral health status goal is really to reflect the outcomes based on all these goals for intervention purposes. Again, linking it always to that unmet human need, what’s their desired outcome. We all know goals need to be specific. And you really need to work it together with your diagnosis statement. It has to be measurable and timely. So a good example of a goal statement for a patient may be the patient will seek tooth replacement options with the dentist by June 29, 2014. So we’ve identified who is the owner of this goal, what the action verb is, which is they’re going to seek and solicit this help, what is the action itself, is the tooth replacement therapy options from a dentist. And we put a time limit to it. That becomes very important for goal setting, is they’re going to do it by June 29, 2014. Patient’s chief complaint becomes a very critical part of that care plan as well. So maybe your goal or your care plan will revolve around what their primary need for today’s appointment is. Moving on with the planning guidelines, you really want to make sure you’re informing the patient of the benefit and the risk of this planned intervention. What are some of the alternatives? Last week actually in Edmonton, there’s this lawyer giving out a seminar, and he defends a lot of dental clinics, and I thought, that’d be interesting to know. And a lot of these lawsuits that patients have against the dentist or dental offices is, I wasn’t given any alternatives. So very important as part of our care plan for dental hygiene, this is what I’m suggesting based on my findings, based on your mouth, based on your risk factors, based on the lack of the human need model. However, these are some of the alternatives. And some of it may be no alternative, which is also something that should be presented to the patient. So some of the care plan goals would be very much related to resistance of the enamel demineralization. This is increased. You’re going to make this go into a positive thing. We’re going to increase the chances of remineralization by having a patient use remineralizing toothpaste, for example. So again, that could very much be a goal as part of your care plan. And that might be the primary objective for that patient because of that sensitivity. You’re going to do some desensitization today, and then have the patient follow up with that as a take home care plan. We talked about informed consent as being really critical. And of course, it’s part of all the components of what the informed consent should have. All the demographical data, of course, is there. But very important also to mark the sequence and cost of the treatment. A lot of lawsuits are coming up across. Patient didn’t understand it would mean for treatment, but they didn’t know the cost of it. Or really explaining to them what the effects are, what the proposed effects of this treatment is, should they do their part and you do your part. So really itemize and verbalize as much of this as you can. I alluded to this earlier on, that no treatment is also an alternative for the patient. But really, the patients have that right of refusal. So just document the consequences of no treatment. Referring back to that patient who didn’t want x-rays, if they didn’t consent to it, I would be sure to document it in the chart. Patient did not consent to radiograph today. And that way, legally you have done your professional, ethical, legal obligation. But again, it’s the patient’s right of refusal. So capture that somewhere as part of your care plan goal as well. So after the care plan and the goals are made up, the treatment sequencing is done, we are now presenting a consent to the patient. Do you agree, and do you want to proceed with this proposed treatment? We now move on to the implementation phase of our process of care for dental hygiene. And the implementation really also very heavily relies with the documentation. Implementation really, it’s relating to following the infection prevention control method. You want to make sure you have the ability to handle emergencies should they occur in the office by being CPR certified. You are disposing of the biohazards in the office in a safe and a manageable way. You’ve got the informed consent. That’s, again, a big part. It’s a good checklist to follow. Do I have a consent signed and permission from the patient before I follow through? And then we are ready for any intervention, be it counseling and what have you. The components, of course, is the treatment sequencing for periodontal therapy. And then we are then providing them with the actual definitive treatment and the activities with the time spent with the procedure code. Don’t forget to give them post op instructions and the duration of whatever, dependent on what treatment plan you are offering that patient for that day. And really individualize their instructions as to what you want them to do at the end of it. It’s just a cleaning. Those patients go, huh. Why do I need all of this? Why are you telling me all of this? Just clean my teeth. Or patients have this mindset. They have this value. They have this belief system. Or the question about, uh, nothing hurts in my mouth. It feels fine. Maybe I won’t come this time for a cleaning. Everything looks fine. The teeth look actually pretty clean. There’s a little bit of bleeding, but really it’s not that bad. There’s no pain. What an amazing opportunity. We as dental hygienists are really ambassadors of our own process of care in explaining to the patient what it is that we do. And then did you know that although nothing may hurt in your mouth, doesn’t mean that there’s no active disease taking place right now in your mouth as you speak to me. And did you know there are more and more links now created with mouth disease and the rest of your body with having diseases? Like heart disease is very positively linked with gum disease. And gum disease is a painless disease. It’s not painful. In fact, if you wait until it’s painful, it’s probably too late. And you will end up with more reparative work than preventive work. So really, dental hygiene is a practice of early disease discovery and detection. We want to intervene as soon as we can to prevent things from getting worse. And so really I tell my patients, my job when I look in your mouth is to see what could go wrong, and then prevent it from going wrong with your help. So if I see something that’s a 5 millimeter pocket or a clinical attachment loss of 4 millimeter, this is putting my antennas up, and now I’m being watchful. I’m sharing that with you. And really, with your help, we want to prevent this from ever getting beyond 4 or 5 millimeters. So really, this is a good way of overcoming. At least, this is how I do in my dental practice. Again, be systematic in your approach. If you’re consistently doing the same process of care for your patients, starting with the extraoral, the intraoral, the consent, the diagnosis statement, all the important things that we’ve talked about, patients will get this is something of value. They are being really thorough and comprehensive about it. In fact, I sometimes get referrals– not sometimes, a lot of times– I get new patient referrals from existing patients, and I’ve had new patients tell me, oh, I’ve never had this done before. Why are you doing this to me? Or, my other hygienist never did that before. So having a systematic approach and giving the importance of what you’re doing for your evaluation is very critical in changing the mindset of that patient that, oh, it’s just a cleaning. Also co-discovery is a great strategy to get patient engagement and involvement. So really, I will just show them something, a pro reading, or disclose and give them a mirror and not say anything, and see what the patient comes out with. And it’s amazing. Sometimes patients will pick up on things that my job’s done. They already got it. They got the message and the link. We mentioned about the systemic links of oral diseases to the rest of your body, and how the clinical findings are based on what we’ve seen in your mouth. A lot of times it means that I will see you for two or three appointments for dental hygiene, or I may put you in a very aggressive recall list. For example, on an average I probably have patients come see me every three or four months for their hygiene. And if I go back or reverse the life back to 8 or 10 years, the same patients would come see me maybe once every six months or once every nine months. But we also have an aging population. And as they’re getting older, they’re getting more systemic diseases. And their health history is changing. And they are needing more, not less attention and care, in their mouth and oral hygiene areas. So absolutely, independent of what the third party insurance will cover or not cover, this is my recommendation for you based on the assessment. And if your assessments are really comprehensive, patients will understand that this is for my own good. And absolutely, I have patients who will pay out of pocket for a lot of these services that aren’t covered by insurance. The strategy I also use, I mentioned earlier, is at the end of every appointment, I will recap what we’ve done today, what we’ve achieved, and what the goal is, what the plan is. So most of the time, the patients will actually book that next appointment, and it is in the chart already or on the computer there. And we also mark it. Is it active therapy? Is it preventive care? Is it just supportive maintenance? What kind of therapy is this patient booking for? So in case a patient has to call back cancel, or with my travel schedule I sometimes have to call cancel or rebook, then the front desk staff is very aware of what we’re rebooking this patient for and how critical this appointment. Especially if it’s active therapy, we want to make sure we get them in as soon as possible. A very important component before you escort and have the patient leave the office is, do they have any questions on anything that has been said, anything we’ve done, anything they’re unclear about? And press that pause button, and let the magic happen. And patients sometimes will have something or the other that, yeah, I was thinking about this, or what have you. Again, an opportunity to educate and build rapport with our patient. What I’ve done, intervention wise, a hygienist, my goodness. Look at the list of things we do for intervention on a daily basis. We might do sealant protectancy therapy for our patients, especially with deep occlusal grooves. We’re great with oral health counseling, nutritional counseling, tobacco patient counseling. Absolutely periodontal debridement is a large part of what we do in the therapeutic care of dental hygiene process, removal of hard/soft deposit. Impression taking, of course for mouth guards or whitening trays fabrication. What about desensitization and fluoride treatment? This is something that’s very much within our scope of care. And placement of chemotherapeutic agents for subgingival irrigation. I mean, this is not even a full list. But what I’d like to do in the next few slides is actually just do the one highlighted area, which is the nutritional counseling. And how could we possibly weave it into our dental hygiene process of care? When do you counsel patients on nutrition? And is it appropriate for us as hygienists to be counseling patients? And how do we counsel? Do we do a formal 24 hour food record, or do we have them write down a week long food record or diary of the foods they’ve eaten and do a sweet score? Well, the guideline for dental hygiene practice is really the diet counseling is focused on reducing the oral risks from the diet and really promoting good nutrition for their overall health. So if you have a patient that you’ve just done an odontogram on, and there’s some open caries lesions, I’d be very curious to know, what is their dietary intake and habits look like? So this would be a good candidate for nutrition counseling. And remember from our other module we talked about, we want to make the changes that are small, that we set them in a realistic way, and really taking into account patient’s behavior, cultural background, their education. What is their current health status? Where are they at right now? Is there any financial restrictions on things you’re asking them to do, which is going to cost them extra money? And maybe even making the selections that you’re asking them to do. So being cognizant of all of that, within that realm, what are some of the tips we can give them as far as counseling goes? And of course, there are different cohorts of the population. So you really want to clue into maybe it’s an elderly patient who doesn’t have enough salivary flow. Or maybe it’s pedo patient who has a high cariogenic risk based on their diet or deep occlusal fissures or grooves. How are you going to support them with their diet? So really reducing the highly retentive fermentable carbohydrates would be a good thing. Or maybe having patients limit the amount of snacks or the type of snacks that they eat from crackers and chips as their snacks. That is invitation for bacteria to form and colonize, produce acid, which will go ahead and actually give you carious lesions and reduce the pH in your mouth, making it acidic. Very curious about who the patient in the chair is, if it’s a pregnant patient, absolutely an educational component of your baby’s teeth actually start forming at six to nine weeks. Your baby’s primary dentition is actually forming in the fetal stage, anywhere between six to nine weeks. So if they’re just in the first trimester of pregnancy, nutritional deficiencies can actually create issues for the baby’s future teeth. School age children really watch out for healthy snacks, promoting raw vegetables as opposed to the chips and soda. Teenagers probably have the worst diet ever, eh, between all the stresses and some behavioral, negative effects of behavior as well. Giving them options like flavored waters or low fat milk are really good options to promote with the teenagers. So part of our nutritional assessment, absolutely if there is an adult patient in our chair between the ages of 30 to 40, we do know that the BMR, the Basal Metabolic Rate, actually does change and goes down, leading to increased body weight and gain, especially in the midriff area. So we want to make sure that we are promoting healthy habits for our patients. Elderly is another cohort of the population that we see as patients, and they have a whole bunch of different nutritional risks and dietary concerns as they get older. What about susceptible teeth? And those teeth that are very cariogenic, we want to make sure that there are some strategies we give our patients. We mentioned earlier about frequency of sugar. Every time you expose the mouth to sugar, there is that 20 minute time frame, where the pH really plummets down to a highly acidic environment. So if you have a sugary snack right now, wait for about 20 minutes, and have another bite of the sugary snack. You have now created two acid exposures to your enamel. So the idea of educating the patient would be, if you’re going to have sweets– we all like birthday cake, and you’ve got to have sweets in life. But maybe limit the number of exposures. So if you’re just limited to one exposure and be done with it instead of snacking it through the day, you are then reducing the risk of cariogenic activity on the enamel. And really, it does take that long for the bacteria to– it will hang around and create that acidic environment. So really use foods that are nonfermentable, nonretentive carbohydrates. Nutrient component also talks about the different vitamins. And I find, especially with my elderly patients or patients who live alone, really highlighting their needs on, are they eating OK? And are they eating fresh fruits and vegetables? And a lot of them maybe are reliant on canned foods because it’s so much more easier, and I don’t want to fuss cooking for one person. But really promoting the need for all these vitamins as they relate to bones and teeth and healthy oral health care becomes very important. The last component of the process of care, of course, is the evaluation. And how do we then bridge this over to a success of our dental hygiene therapy within the process of care? Well, we want to measure the outcome for sure. So we start out with our initial assessments of identify the patient’s need. We have a specific methodology that we’re following. We’d follow the same process, again, at evaluation. By evaluation, I mean– and this is probably a recare appointment, right? So we’re going to take the same plaque score or the same indices that you use at that benchmark appointment, and now compare it to evaluate, did we achieve our goals? Are we successful in doing what we needed to do? Do we need to make any adjustments or modify the intervention moving forward? And how about the patient? A lot of times, you know, we’re so busy evaluating and measuring that you’re forgetting the other piece of it. And how does the patient feel about all of this a lot of times. So how’s it going for you? And again, reality is the perception of reality. How do they feel about themselves? And a lot of times, I mean even before they come to the operatory, in the reception area, as they start talking about, wow, that’s amazing. The bleeding is gone. Or I notice a difference. Or they’ll start on and on about the changes that are positive, and they’re so excited about it. So capture that patient satisfaction as part of your evaluation component of dental hygiene process of care. And really, again, reinforce the decisions that you made based on the data, based on the evidence that we had gathered. And what’s working, what’s not working, and let’s change it should we need to change it. Again, an important part is documentation. So really make sure you document all these factors in the chart. And what I do actually, and this is just systematically have it so I don’t miss out on anything, is I use the acronym PARTS. And PARTS, the P in PARTS stands for problem. A is for the assessment. R is what was the recommendation. T was the treatment I was given. And S is for the strategy. So for every dental hygiene appointment, a chart entry for hygiene process of care will have a PARTS on it. So I’ll start with the left column as P, and probably be a couple of lines. The next one will be A. So it’s very systematic. Anyone picking up the chart knows what we’re talking about. So what was the chief complaint today? What was the problem? How did we assess it? So it may be a plaque score or a calculus index. What were the assessment criteria that was very objective and substantiated? What was my recommendation? So maybe it was bath brushing, increased frequency of rubber tipping, whatever that intervention may be. What was the treatment that we conducted today? So if it was definitive debridement of necrotic cementum in areas whatever, and which area, was a local anesthetic given to this patient today? Anything along that line for the treatment. What was the tissue response like? And then the strategy piece is really, what’s the next step? Reappoint patients for follow up visits or active therapy or maintenance therapy. So that becomes the strategy piece of documentation. So if that helps, PARTS is a good way of systematically capturing what we’ve done at that appointment. What can the outcome be from this whole process of care? We started with the assessment and did the dental hygiene diagnosis statement, did the care plan, treatment plan, got the informed consent, did our implementation intervention. We did the evaluation. And now we’re at a point where, yeah, actually, it worked pretty good. We may just want to have them continue care, come back in three months, or maybe it’ll be six months now that things are more ideal. But there’s also a possibility that things didn’t go the way we’d planned or wanted to. And now we probably need to consider maybe referring the patient out for some other treatment. Maybe they need to go see a periodontist for a gingival graft, or some kind of bony defect that a dentist may be able to help them, or a dental specialty. We may want to reevaluate the tissue in a few weeks. I’m kind of not sure. I need you to go do some chlorhexidine rinsing and come back in three weeks, and we’ll reevaluate this. And again, the important piece about the billings is you can’t be caught up on what the third party fees are. You have to do what is right in that whole process of care based on the human needs model and the deficit of the human need for that patient. So really, in a nutshell, we have recapped the other four components of the five components of the process of care. In this module, we did talk a lot about diagnosis, care planning, implementation, and evaluation. This is the Kiyomizu Temple. I want to leave you with a thought at the end of my module here. And it’s actually a quote from Buddha that really moved me. This was a lecture I was doing in Kyoto with– you see the cherry blossom season. The pink flowers are just about starting to bloom. Beautiful temple, and you walk into this dark, cool, subdued temple. You take your slippers or shoes off on a tatami mat, and as soon as you walk in, there is incense burning. And there’s beautiful, gold plated quote written in a different language, of course. And I asked my host to translate what that meant. And he said, it says, “Thousands of candles can be lit by a single candle without that candle losing its light.” And I feel any time you seek knowledge, you seek education, you further your comfort zone, you have now added to more light, and you’ve lit more candles in your light. And what happens when you light more candles, when you educate your patients, when you transfer that knowledge where they have a different level of enlightenment about their health care and their health status? You have just brightened that whole corner by lighting the extra candles. So I leave you with that powerful thought from Buddha. Thank you for joining us for Dental Hygiene Process of Care Number 2. We’ll see you next time. Good bye.

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