Understanding and implementing the 2008 American Dental Hygienists' Association Standards for Clinical Dental Hygiene Practice.

The American Dental Hygienist's Association (ADHA) has issued Standards for Clinical Dental Hygiene Practice (SCDHP), based on standards first published in 1985 and specifically promotes "dental hygiene practice based on current and relevant scientific evidence" and its intended use to "guide the individual dental hygienist's practice."

Since 1985, the dental hygiene profession has expanded its ranks, technology has vastly changed and improved our application of techniques in practice, and research has continued to help us to achieve optimal health care. To clarify the role of the ADHA SCDHP, the document's introduction characterizes dental hygienists as "individually accountable to the standards" proscribed by federal, state and local practice regulations, adding that the SCDHP should not be considered a substitute for professional clinical judgment based upon patient type and care. The document will also be useful in explaining the important role dental hygienists play in our current health care system for the public and speaks to the knowledge we possess as dental professionals.

Let's begin with a brief summary of the SCDHP.

Purpose of the Standards

According to SCDHP, the primary purpose is to "assist dental hygiene clinicians in the provider-patient relationship" and to further educate others outside the profession (health care providers, policy makers and the public) about the practice of dental hygiene. To this end, the SCDHP offers dental hygienists a "framework for clinical practice that focuses on the provision of patient-centered comprehensive care" using the "critical thinking model known as the process of care." The original five components of the critical thinking model include assessment, diagnosis, planning, implementation and evaluation (ADPIE). These are given along with a sixth, documentation. This six-part process of care model serves as the basis for clinical decision-making and treatment in the practice of dental hygiene. With the addition of the sixth component, the model now can be referred to as ADPIED.

Along with information orienting the dental hygiene audience to the standards, the introduction contains sections titled "Definition of Dental Hygiene Practice," "Educational Preparation," and "Practice Setting," which will serve to educate the public and others outside the profession.

Professional Responsibilities and Considerations

This section outlines what is expected of dental hygienists in 16 detailed points, which I have abbreviated and categorized below for easier understanding.

Professional Obligations:

1. Maintain licenses and appropriate certification

2. Understand and adhere to ADHA Code of Ethics

3. Support the profession through ADHA membership

4. Maintain awareness of changing trends in dental hygiene, health and society that impact dental hygiene care

5. Participate in activities to enhance and maintain continued competence

6. Commit to lifelong learning to maintain competence

Professional Knowledge and Awareness:

7. Demonstrate respect for knowledge, expertise and contributions of others

8. Demonstrate professional image and demeanor

9. Contribute to a safe, supportive and professional work environment

10. Interact with peers and colleagues to create an environment that supports collegiality and teamwork

Patient Considerations:

11. Articulate roles and responsibilities of dental hygienist to patient, interdisciplinary team members, referring providers and other health care members

12. Apply problem-solving processes in decisionmaking and evaluate these processes

13. Maintain compliance with established infection control standards

14. Recognize diversity, incorporate cultural and religious sensitivity in all professional interactions

15. Access and utilize current, valid and reliable evidence

16. Take action to prevent situations where patient safety and well-being could potentially be compromised

The last section of the introductory information before the actual standards begin explains that the Dental Hygiene Process of Care is "to provide a framework where the individualized needs of the patient can be met; and to identify the causative or influencing factors of a condition that can be reduced, eliminated, or prevented by the dental hygienist."

The Actual Standards of Dental Hygiene Practice

The SCDHP are meant to be the "cookbook," the centerpiece of the document that actually itemizes, step-by-step, the procedures to be followed in the delivery of clinical patient care. To make the document more quickly accessible, I thought it might be helpful to create a quick interpretive guide that could fit on one page and be used in practice. You'll find this information above in the cut-out chart with a matching example on the opposite page showing how it could be applied to a patient case in practice.

Summary, Key Terms, References, Resources and Appendices

At the end of the new edition of the ADHA SCDHP you will find a short summary, a list of key terms and the references for the standards. Four appendices are provided: A and B are graphic treatments of Dental Hygiene Process of Care and Professional Roles of the Dental Hygienist. C comprises two diagrams, Educational Path for Entry into the Profession and Professional Specialization. Appendix D covers the development and validation process for the SCDHP themselves and lists the members of the task force, ADHA Board of Trustees and the consultant involved.

With that, the official document of the ADHA SCDHP is completed and provides a valuable contribution to the practice of dental hygiene. The document has been several years in the making and a great deal of work, cooperation and long hours of labor and thoughtful analysis went into its preparation.

I think each of us should review the ADHA SCDHP and determine how best we can use them in our professional setting. Standards are always a meaningful hallmark in any culture or organization--they tell us what we are to do and what we can aspire to. In dental hygiene where hard work and uncompromising performance are built into our education and training, these standards are a direct reflection of how committed we are to what we do.

The Quick Reference Guide and Charting Example

The following Quick Reference Guide is, of course, the way I interpret the ADHA SCDHP and by no means the only way. I am hopeful that you will adapt them with alterations, modifications and flexibility so they will fit into the recordkeeping protocol of your individual practice. I encourage you, if you like the Guide, to see how it might work for you. But remember, the statements in the Guide are by no means a substitute for the actual SCDHP nor are they, as the SCDHP themselves stipulate, "a substitute for clinical judgment."

In the interest of full disclosure, you will note that the Sample Chart Entry Using the 2008 ADHA SCDHP is very detailed. I am passionate about documentation and felt strongly about adding it as a component to the published SCDHP because after years of practice and teaching I learned how important it is to record what you see and what you do. Should you desire to do more abbreviating or condensing, keep in mind that it is acceptable to use abbreviations as long as they are documented in a master form and somewhat universally accepted. Feel free to adapt the recordkeeping component to meet your needs, style and protocol of your practice setting, always being assured that the records you write have sufficient detail to withstand close, careful examination and inspection six months, one, two, three or five years from now. The records you write may be needed long after you've left.

Quick Reference Guide for the 2008 ADHA Standards for Clinical Dental Hygiene Practice

By Marilyn Cortell, RDH, MS, FAADH, based on the American Dental Hygienist's Association Standards for Clinical Dental Hygiene Practice

I. Assessment

A. Patient History: Collecting (by patient form or inquiry) and Recording

1. Personal confidential information (e.g. age, gender, ethnicity, economic status)

2. Current and past medical history status including primary and specialty care physician

3. Pharmacological agents (e.g. prescription, recreational, OTC, herbal)

4. Current and past dental/dental hygiene oral health practices, attitudes and self-care including cultural, learning disabilities, phobia 

5. Vital signs (record and compare with previous readings)

6. Consult with appropriate health care provider(s) as indicated

B. Clinical evaluation, to include:

1. Examination of head, neck, oral cavity; conduct oral cancer screening; TMJ assessment

2. Radiographic assessment (that is, if available, review; if not, take radiographs as necessary and review findings)

3. Periodontal exam evaluation (i.e., probing depths, bleeding points, suppuration, mucogingival defects, recession, clinical attachment loss, mobility)

4. Gingival health/disease (e.g. color, size, consistency)

5. Hard tissue/dental charting (e.g. existing decayed, missing, filled teeth; prosthetics, occlusion)

6. Presence, degree and distribution of plaque and calculus

C. Risk Assessment

1. Process of utilizing data collected via the assessment process to determine high, moderate or low level of risk to general or oral health. Provides information necessary to develop and design treatment strategies for preventing or limiting disease and promoting health.

2. Factors to be evaluated should include but not be limited to: fluoride exposure, tobacco use, nutrition history/dietary practices, and systemic diseases along with pharmacologic or holistic therapies.

II. Dental Hygiene Diagnosis is a brief written summary of assessment data, utilizing critical decision-making skills to determine the patient's dental hygiene treatment needs.

III. Planning includes prioritizing and sequencing of dental hygiene intervention and treatment plan including: patient education, pain management, collaboration with dentist and other health care providers and obtaining informed consent and/or informed refusal.

IV. Implementation is the delivery of dental hygiene professional services (pain management through hand instrumentation and ultrasonic therapy, plaque and deposit removal, patient education, recommendations, etc.) based on the dental hygiene care plan, which can be modified at each appointment.

V. Evaluation--The practice of reviewing and documenting I outcomes of dental hygiene treatment on an ongoing basis.

VI. Documentation--The process of detailing all assessment data, diagnosis, planning, implementation, evaluation and treatment in a condensed, consistent format. It will represent a chronological history of the patient's care and treatment and remain in the office's permanent records.

Sample Chart Entry Using Quick Reference Guide for the 2008 ADHA Standards for Clinical Dental Hygiene Practice

Copyright Marilyn Cortell, RDH, MS, FAADH

Whether using a computer for recording clinical data or handwriting progress notes, utilize a format that is informative, condensed and consistent. This written chart entry is formatted to be consistent with the ADHA standards. It is assumed all appropriate forms have been completed; abbreviations may be used that are acceptable and universally understood.

(I Assessment, Patient History) John Doe, 61-year-old African-American w history of hypertension for 8 yrs., being managed with hydrochlorothiazide (HCTZ) 12.5 mg/day & verapamil (Calan) 80mgs. 2/day. B/P 146/90. Stage I hypertension. Past history of PD. Social History, smoker 1 pk/day X 20 yrs. Interest in stopping.

(I Assessment: Clinical Evaluation) Presence of asymptomatic 2cm x 16mm leukoplakic lesion on lft. lat. border tongue, asymptomatic. Clinical Impress: refer for biopsy. Perio. Eval: Gen. Type I w loc. Type II in rt. & lft. max. post. regions w BOP, rolled marg. & Clinical Attachment Loss (CAL) 4-6mm. Gingival Eval: Hyperplasia on facials # 6-11 & 22-27 more severe on mand. Pt. "noticed appearance of his gums & thought it was normal." Clinical Impression: Drug induced gingival hyperplasia w gen. mod. supra & sub ging. dep. Root caries present. Radiographs confirmed clinical findings of vertical bone loss & caries. Refer to complete perio. & dental charting.

(I Assessment: Risk Assessment) Pt. at risk for active PD, root caries, oral effects of hypertension meds. & tobacco use.

(II Dental Hygiene Diagnosis) Gen. Type II PD bilateral max. rt. & lft. molar regions. Root Caries active related to recession & sl. xerostomia. Ging. hyperplasia poss. related to verapamil (CCB). Ineffective OH, inconsistent dental care, tobacco use & previous history of PD are contributing factors.

(III Planning) Recommend home care protocol using power brush, floss & antimicrobial mouth rinse 2x/day. (Document specific products recommended to meet individual pt. needs & modify & document as necessary.) Discuss systemic oral disease connect. & reinforce B/P control. 4 visits quad. scaling w LA. Refer for B/P eval. biopsy & complete perio & dental exam.

(IV Implementation) Administered infiltration UR quad. 1 carp. 1.7mm 2% lido w epi. 1:100,000. Pt. reports anesthesia. Ultrasonic & handscaled in presence of heavy bleeding & cervical sensitivity. N/V Re-eval. UR & begin scaling LR

(V Evaluation) Continue to observe plaque (biofilm) present UR. SI. reduction in inflam. Reemphasized homecare, use of powerbrush, interprox aid & antimicrobial mouthrinse. Reinforced smoking cessation program.

(V. Documentation) See chart entry above & note that each observation and procedure performed is documented in a condensed, consistent format. Entries may vary in length depending upon the individual patient case type and the more we utilize a dependable entry format the more comfortable it will become. When recording clinical data keep in mind that: "No amount of documentation is too much and no amount of detail is too little."

By Marilyn Cortell, RDH, MS, FAADH

Marilyn Cortell, RDH, MS, FAADH, is a full-time associate professor at New York City College of Technology. She is an active member of the American Academy of Dental Hygiene, North East Regional Board of Dental Examiners and American Dental Hygienists' Association for which she serves on the Editorial Advisory Board of Access magazine, and has earned Professional Membership in The National Speakers Association. Her recent service to the Editorial Board of RDH magazine, contribution to three prominent dental hygiene textbooks, and recognition as an international lecturer make her a sought-out speaker on dental topics.