Dental Hygiene Diagnosis
Most of us are well aware that, legally, we are not allowed to "diagnose." However, as a profession, we are in the process of trying to come to terms with this issue. I invite you to go the ADHA Web site (www.adha.org) and read the Dental Hygiene Diagnosis Position Paper published in June 2005. It is the position of the ADHA that "by virtue of graduation from an accredited dental hygiene program, we are educationally prepared to conduct a dental hygiene diagnosis and that the formulation of a dental hygiene diagnosis is the responsibility of the dental hygienist in the delivery of quality oral health care".
Are you practicing your profession by the probe or by the clock? Only by gathering and properly assessing data and developing a dental hygiene diagnosis will you be able to put on the table the raw material you and the dentist need for the co-diagnosis process. While the need to perform an adequate and full exam may seem obvious; it is frequently not done. Many hygienists still provide services based upon the dictates of their daily schedule posted in their operatories and merely "poke and check" to try to quickly ascertain the patient's status before beginning the "prophy."
According to the Merriam-Webster dictionary, the word "diagnosis" originated from a Greek word meaning "to distinguish; to know". We must be able to distinguish health from disease. In order to do that, we must evaluate a great deal of scientific data. Probing and charting is the beginning. With this diagnostic procedure, we determine the presence or absence of disease, periodontal pockets, bleeding, suppuration, recession, mobility and furcations. Once raw data are obtained, the process of preliminary evaluation begins. Here, critical thinking skills come into play. Do the data reveal health or disease? Often, it is not so easily ascertained. Many patients are borderline or have had a history of chronic but relatively unchanging inflammation, bleeding and borderline home care. Is that health? The clinician must be aware of trends and be able to see patterns that have developed, often over successive visits. The ability to engage in critical thinking can bring forth excellence in the form of taking necessary interceptive action.
There are five areas to assess as we gather additional pertinent information.
1. The first area is the health history. Correlating risk factors related to periodontal disease (including heart disease, respiratory disease, diabetes, tobacco use and immune system compromise) can help in the decision-making process. When a patient is at high risk for disease, often it guides us into earlier treatment than it would in low-risk situations.
2. The most obvious area to assess is the mouth. Look for inflammation; evaluate the contour and texture of the gingiva, the presence of plaque and calculus and the overall effectiveness of the patient's oral hygiene.
3. The third area to look to is the perio chart. A complete periodontal charting (documenting pockets, recession/clinical attachment loss, mobility, furcations and bleeding) provides extensive and detailed information regarding the current periodontal status of the patient. This must be compared to previous data. Does the chart reveal health or disease? Has the status changed since previous exams? The periodontal chart certainly provides the most substantial amount of information on which to base our assessment. The quality of records obtained is of utmost importance and cannot be compromised.
4. The fourth area to evaluate is the diagnostic X-rays. We need to evaluate the supporting structures of the periodontium noting bony defects, furcations loss of crestal bone, etc. Also important is evaluation of previously taken films to look for change in periodontal status.
5. The fifth area providing pertinent information is the treatment notes/plan. The treatment notes tell a story if we take the time to review them chronologically. We will uncover a history of periodontal disease by noting repeated entries such as "moderate bleeding on scaling, poor oral hygiene, heavy calculus, patient not flossing, and patient overdue for hygiene visit." Year after year of clinical notes, added to tracking whatever periodontal documentation may be present over the years and noting changes in radiographs, one begins to piece the puzzle together ... periodontal problems have been brewing for many years, and truly, many patients have never been periodontally healthy.
By using these five areas in assessing each of your hygiene patients and looking for trends and changes in each one's status, the picture begins to unfold. The ability to use critical thinking skills will assist you in uncovering the need for periodontal treatment.
Gathering quality data is not just a ticket to be punched in order to get on with the real purpose of the visit, the "cleaning." Our ability to manage and prioritize the hygiene visit will be the difference between providing excellent hygiene care based upon today's research and standards and our continued struggle with time constraints preventing us from doing what we know to be a priority.
The co-diagnosis process begins with gathering data, evaluating the information and then communicating findings to the patient in general terms. The dentist then receives a report of the examination, which will be the basis for the dental hygiene diagnosis. It is impossible to practice diagnosis-driven hygiene without prioritizing into the patient appointment time to gather needed data. Skipping this step usually leads to an assumptive diagnosis of "health," which is often followed by the dispensing of a prophy.
The challenge of time management in dentistry is ongoing and can only be dealt with by commitment to excellence. Begin with the end in mind; if we are to provide excellent care for hygiene patients, we must ascertain their periodontal status before beginning any type of treatment. That process requires complete charting, critical thinking and collaboration with the dentist in formulation of the hygiene diagnosis and treatment plan. Begin by taking time to work with your dentist and your team to create written treatment protocols and systems for charting, information exchange, and case presentation. This preparation will assist you in managing your time effectively when an expected prophy turns into a periodontal diagnosis, and it will add tremendous value in the form of professionalism in your office.
Periodontal Parameters of Care
The "Parameters of Care" published by the AAP (American Academy of Periodontology) can be obtained from their Web site www.perio.org, and are an excellent source for creating periodontal treatment guidelines for patients with the various types of periodontal disorders. To be adept at providing treatment for early and moderate periodontal cases, it's essential that you have created treatment protocols for gingivitis, early to moderate periodontitis, and advanced periodontal cases. You will need to have guidelines for referral as well as ongoing perio maintenance. These guidelines can be developed with collaboration from other health care providers such as your extended hygiene team, the dentist and the referring periodontist.
Of major concern is your ability to modify treatment plans to properly treat the needs of each and every patient. While some patients require a comprehensive intervention with nonsurgical periodontal procedures, other patients have site-specific needs, and their treatment must be individualized. Getting your general treatment plans on paper is essential. That way, all staff has access to protocols, numbers of appointments needed, codes involved and applicable fees. Many hygiene departments use only the most basic of procedure codes. By referring to the 2007 CDT manual published by the American Dental Association, you will find over 20 pertinent codes for use in your periodontal therapy treatment programs. Become familiar with codes such as
0180 Periodontal evaluation 4341} 4342} Periodontal therapeutic codes 4355} 4381 Site-specific antibiotics 9630 Drugs and medicaments 9610 Oral irrigation 9910 Desensitizing fluoride 9920 Behavior modification 1320 Tobacco cessation counseling 1330 Oral hygiene instruction
Leadership issues begin to emerge as hygienists bring forth their full impact by providing appropriate services to the patient base. We cannot wait for permission to do the right thing for our patients; it is our professional responsibility. Our care must begin with proper assessment of all patients, which leads us to a hygiene diagnosis and appropriate treatment plan. Nearly all offices struggle with time constraints, staff issues, differences in philosophy, and pressure from patients and insurance companies to dispense hygiene care in a predictable, if incompetent, manner. Who hasn't dealt with disconcerted patients upset by the prospect of not receiving their expected "cleaning" because periodontal disease was discovered during the periodontal examination? Committed dental health care professionals are willing to take on each and every challenge encountered in the transition process to providing diagnosis-driven hygiene care.
To further evaluate your effectiveness in providing excellent care to your hygiene patients, I suggest you evaluate your prophy to perio percentages. Practices today still provide an inordinate number of prophy services to their patients. For further information on evaluating your hygiene department percentages and thus the standard of care being dispensed in your office, email me at firstname.lastname@example.org for a hygiene department assessment tool.
Many dentists assume that because the hygiene schedule is busy and the book is full that all is well within the department. I find often that hygienists know that they can do more to treat disease in their patient base, but feel frustrated when staff members are not willing to help with charting patients or there is confusion about the appropriate use of periodontal codes and fees. Hygienists and dentists are potentially good working partners when, with good communication and alignment of philosophy, they are able to manage the treatment needs of a majority of their patient population. It is through good communication that the dentist can be informed of data that demonstrate the need for periodontal treatment intervention. The dentist can piece together the puzzle you have been unraveling for the previous hour you spent with your hygiene patient, if you give them the courtesy of a professional report of findings using a checklist approach to standardize the process. (Request your copy at email@example.com).
Professional Report of Patient Findings
This oral report of findings should include information such as time elapsed since the last hygiene visit; self-care devices being used, effectiveness of self-care; current periodontal status; changes in pockets, bleeding, etc.; previous periodontal treatment; concerns about current status and possible periodontal treatment needed. Give the hygiene assessment to the dentist orally, allowing the patient to hear, once again, the concerns previously discussed with them. Presenting findings in this manner allows the co-diagnosis to unfold in a time-effective and professional manner. The dentist then gives the final diagnosis based upon evaluation of the scientific data as well as the overall assessment of numerous criteria evaluated by the hygienist.
The knowledge we possess today, based upon current research, compels us to provide only the most professional care for the patients entrusted to our care. The dental hygiene diagnosis is the foundation of such excellence.
Beverly Maguire, RDH, brings extensive experience of over 30 years in dental hygiene. She is an expert clinician, renowned hygiene consultant, author and speaker. As president and founder of PerioAdvocates, she is dedicated to achieving the highest standard of patient care.
By Beverly Maguire, RDH