The patient’s medical history revealed a car accident five years ago resulted in a broken collarbone. He does not take any medications and is not under the care of a physician. The patient does not smoke and his vital signs were within normal limits.
The patient has not had a dental exam or prophylaxis in three years. He has no restorations. He has had orthodontia and his third molars removed. The patient brushes once a day in the morning and flosses occasionally.
Patient works full time at an automotive parts store and is studying automobile mechanics part time in the evenings at a community college to earn his certifications. He does his own and his friends’ automotive repairs on weekends. He lives at home and eats out at lunch and sometimes dinner. Occasionally he will have dinner with his parents.
Head and Neck Examination
- Gingival Statement: Generalized moderate marginal and papillary redness with rolled margins and edematous papilla, localized severe redness facial of maxillary anterior #6–#11 and mandibular anterior #22–#26 (see Figure 2.1.1)
- Generalized 4 mm pocket depths, no recession present, no furcations or mobility
- Sulcular bleeding index (SBI) 65%
- Plaque control record (PCR) 90% (see Figure 2.1.2)
- Calculus classification: light to moderate supragingival and subgingival deposits
- Occlusion: Class I right/left with a mandibular lingual bar from #22 to #27
- Sealants on teeth #3, #14, #19, and #30
- Missing teeth: #1, #16, #17, and #32
- No radiographic loss of crestal bone
- Caries: low risk
- Periodontal: low risk
- Cancer: low risk
- Gingival inflammation and bleeding
- Probing depths of 4 mm
- High plaque score
Dental Hygiene Diagnosis
|Unmet human need||Evidenced (caused) by||Signs/Symptoms|
|Integrity of the skin and mucous membrane due to plaque accumulation||Biofilm accumulation
|Bleeding on probing|
|Responsibility for oral health||Last dental visit 3 years
Lack of brushing
|Oral Hygiene Instructions (OHI) toothbrushing instruction||Patient will demonstrate the proper brushing method||Immediate + next visit by reduction of PCR|
|Reduce PCR to 50%||Next visit|
|Patient will understand the disease process and the importance of routine dental visits||Patient will schedule appointment for follow up and 6‐month recare|
|Biofilm reduction||Patient will leave office plaque free||End of appointment|
- First appointment
- Assessments with dental examination and radiographs
- Oral Hygiene Instructions
- Adjunct chemotherapeutics as needed
- Full‐mouth debridement or prophylaxis
- Second appointment if necessary
- Prophylaxis as needed
- Selective polishing and fluoride as needed
Assessments should include a medical and dental history, social and cultural factors, activities of daily living, extraoral and intraoral examinations, gingival statement, periodontal assessment, plaque and bleeding indices, risk assessments, and radiographs. Through the interview process the clinician can discuss the stresses this patient might be having and how it may relate to his oral conditions. A nutritional assessment would also benefit the patient in his overall health and in the healing of gingival tissues.
A dental diagnosis of plaque‐induced gingivitis is defined as inflammation of the gingiva in the absence of clinical attachment loss (perio.org 2016). A dental diagnosis is based on clinical findings that may include: redness, edema, bleeding, and changes in gingival contour and consistency. It is a disease process that begins where plaque or biofilm is present. Clinical signs can be seen as early as four to seven days following plaque accumulation. In Figure 2.1.1 note the inflammation around the gingival margin and the associated plaque control record shown in Figure 2.1.2. This is consistent with a dental diagnosis of plaque‐induced gingivitis. Treatment considerations may include many of the same interventions as a dental hygiene diagnosis, but can also include surgical interventions.
It is important for the dental hygienist to recognize that a dental hygiene diagnosis is a part of the process of care. A dental hygiene diagnosis will include a problem list determined from the assessment data collected. The problem list may include some of the same clinical signs as a dental diagnosis. These findings may be redness, edema, bleeding, changes in gingival contour and consistency, and plaque accumulation. At this stage disruption of the plaque accumulation through patient self‐care and the host’s immune response can reverse the disease process and prevent further progression. Further interviews with the patient can determine his chief complaint and oral hygiene habits to determine an appropriate dental hygiene diagnosis based on the individual’s needs.
A dental hygiene diagnosis is key to successful prevention efforts. Why not just perform an oral prophylaxis without ascertaining a dental hygiene diagnosis, dismissal of the patient, and a six‐month recare appointment? What prevents this patient from returning in six months with the same condition or a progression of the current condition? What if the patient is not properly educated and does not return for another three years or perhaps a longer span?
From the assessments and patient interview the dental hygienist can develop a diagnosis that focuses on the problems, causes, and prevention rather than a disease entity. The dental hygiene diagnoses for this patient can include several unmet human needs; goals for care and planned interventions. For this particular patient one of the unmet human needs chosen was skin and mucous membrane integrity of the head and neck as evidenced by biofilm accumulation and bleeding on probing. An intact and functioning mucosal membrane and periodontium defend against harmful microbes. Bleeding is a key indicator of inflammation and a determinant of the human need deficit (Darby and Walsh 2015). Interventions such as detailed oral hygiene instructions, patient education so that the patient understands the need for a sound mucosal membrane and the progression of disease play a role in prevention. In Figure 2.1.1 note the inflammation around the gingival margin and the associated plaque control record. The goal to reduce the plaque puts the onus of care on the patient and not on the dental hygienist.
The second unmet human need identified was responsibility for oral health due to the patient’s high plaque control score. Utilizing the unmet human needs model and incorporating preventative interventions and goals will hopefully prevent disease progression. It is important to include the patient in the development of goals for their care. Education and oral hygiene for the promotion of health is a clear goal for plaque‐induced gingivitis to prevent its progression and to reverse the disease process. Studies have been conducted regarding self‐care, self‐efficacy, and self‐monitoring as playing roles in lasting behavioral modifications. Taking the time to develop the patient’s confidence in their ability to perform oral hygiene properly increases the likelihood they will be compliant with self‐care behaviors (Schwarzer et al. 2015).
Including a combination of therapies such as oral prophylaxis, debridement, chemotherapeutic agents, and patient education will improve expected outcomes. Assisting the patient with goals and educating the patient can eliminate gingivitis and improve the patient’s health for years to come. Scolding the patient for noncompliance with brushing will lead to a lack of understanding on the patient’s part and possible future oral health disease.
- Keep the patient involved in development of goals.
- Relate the dental hygiene care to the dental hygiene diagnosis.
- Interventions can include a variety of procedures, education, and oral hygiene instructions.