Module 2

• Assess
• Diagnose
• Plan
• Implement
• Evaluate
• Document

obtained by observation and interaction with the patient; includes chief complaint, perception of health, care and the value placed on oral health

includes physical and oral assessment; records clinical and radiographic findings to show evidence of disease in teeth and periodontal attachment; dental carious lesions, and defective restorations

• –Patient’s reason for seeking dental and dental hygiene care
• If a patient has a significant concern such as pain, this need must be addressed first

attributes associated with an increased risk of disease or infection for the patient

• Behavioral factors – inadequate biofilm removal, diet, noncompliance
• Tobacco use
• Systemic conditions – diabetes, compromised immune system, osteoporosis
• Hormonal considerations – pregnancy, menopause
• Nutritional status- good nutrition is essential for a healthy immune system
• Iatrogenic factors - a factor induced by a physician
• Genetic factors – inherited predisposition

• Infective endocarditis
• Cardiovascular Disease
• Diabetes mellitus
• Respiratory disease
• Adverse pregnancy outcomes
• Osteoporosis
• Metabolic Syndrome (high blood pressure, high blood sugar, unhealthy cholesterol and abdominal fat)

• Behavioral factors – inadequate biofilm removal
• Dietary factors - frequent use of cariogenic foods/beverages
• Low fluoride - systemic as a child, topical as a child or adult
• Tooth morphology and position- deep occlusal pits and fissures, exposed root surfaces/recession, rotated positioning
• Personal and family history – dental caries/restorative dentistry
• Developmental factors - modifications of dental enamel such as hypocalcification
• Genetic factors – immune response
• Xerostomia

–medications, cancer therapy, nerve damage, tobacco use, methamphetamine use, mouth breathing, and other health conditions

• Tobacco use
• Heavy alcohol use – especially combined with tobacco
• Excessive sun exposure – lips and face
• Exposure to the human papillomavirus
• Genetic susceptibility

• ASA
• OSCAR planning guide

• normal healthy patient with little or no dental anxiety
• Can walk up a flight of stairs w/ no distress
• No modifications to dh treatment
• IADL level 0

• mild systemic disease or extreme dental anxiety
• need to stop talking after walking one flight of stairs because of distress
• Well controlled chronic conditions
• smoker
• healthy pregnant woman
• IADL level 1

• Systemic disease that limits activity but it not incapacitating
• Needs to stop en route to walking one flight of stairs
• Insulin dependent diabetes
• IADL level 2 or 3

Incapacitating disease that is a constant threat to life

Patient is moribund and not expected to survive

• Oral
• Systemic
• Capability
• Autonomy
• Reality

Measures ability to carry out basic tasks needed for self care such as brushing, flossing, and using interdental aids

Measures ability to perform more complex tasks that require a combination of physical and cognitive ability such as the ability to make and keep a dental appointment

Ability to perform the task without assistance

Ability to perform task with some human assistance; may need a device or medical aid

Ability to perform the task with partial assistance

Requires full assistance to perform the task; totally dependent

Gingivitis

Slight or early periodontitis

Moderate periodontitis

Advanced periodontitis

no calculus present

Deposits on 1-6 teeth

Deposits on 7-14 teeth

Deposits on 15-28 teeth

Class III and deposits in pockets 6mm or greater on more than 4 teeth

A dental hygiene diagnosis encompasses patient needs that can be met by implementing treatment and education interventions that are within the scope of dental hygiene practice

A dental diagnosis is directed at diseases and conditions that require treatment provided by a dentist

is the control of oral disease

–Anticipatory guidance provides the patient and/or parent with information they can use to avoid future oral health problems

• measurable
• timeframe

• Goals are broadly based statements of what changes will take place, from which specific objectives or outcomes are developed
• Ex. Eliminate BOP and inflammation

• Outcome are more specific than goals and describe, in a measurable way, the desired end result of the interventions
• Include a performance verb, condition, and criterion
• –Example:Patient will eliminate BOP and inflammation by 6mrc

• 1. Urgency
• 2. Severity and extent of condition
• 3. Individual Patient Requirements

Position the patient in an upright position, face to face with the clinician (no mask)

presumed permission based on the patient’s conduct