11: Clinical Treatment

CHAPTER 11 Clinical Treatment


Dental hygiene is the science and practice of recognition, treatment, prevention of oral diseases. Hygienist is a preventive oral health professional who has graduated from an accredited program in an institution of higher education; a licensed professional who provides educational, clinical, research, administrative, therapeutic services supporting total health through promotion of optimal oral health. In practice, hygienists integrate roles of clinician, educator, advocate, manager, researcher to prevent oral diseases and promote health; hygienists work in partnership with dentists.

The distinct roles of the hygienist and dentist complement and augment the effectiveness of each professional and contribute to a cotherapist environment (see later discussion under “Motivation”). Hygienists are viewed as experts in their field, are consulted about appropriate dental hygiene interventions, are expected to make clinical dental hygiene decisions, and are expected to plan, implement, and evaluate the dental hygiene component of the overall care plan. Hygienist establishes the dental hygiene diagnosis, which is an integral component of the comprehensive dental diagnosis established by the dentist. Each state has defined its own specific regulations for dental hygiene licensure.


The dental record is a medicolegal document that should be complete, accurate, and legible. From the record, it should be possible to recreate the patient’s medical and dental history and oral status at initial presentation, along with periodic updates, treatment needs, treatment rendered, and any recommendations made.

See Chapters 16, Special Needs Patients: medical disabilities; 18, Ethics and Jurisprudence: HIPAA, informed consent.

Health History

Health history is BEST for gathering information regarding the medical and dental history, behavior, demographics, vital signs. Listed below is only overview of what may be noted in chart. Dental history is included under assessment of the dentition.

See Chapters 6, General and Oral Pathology: common conditions and diseases in dental setting; 8, Microbiology and Immunology: vaccinations, infectious diseases; 9, Pharmacology: antibiotic premedication; 10, Medical and Dental Emergencies: medical history, physical status classification (ASA), high blood pressure.
C. Medically compromised patients who can be seen in a dental setting but need major modification of dental treatment and/or need medical consult (drug history discussed next):

Drug History

Drug history provides information on drugs that may affect oral health, dental treatment, and oral hygiene self-care. Often requires use of reference text and/or online resource, such as Physician’s Desk Reference (PDR), or a medical consult and/or pharmacist consult for further information. PDR lists all drugs by manufacturer’s name, brand name, generic name.

See Chapters 6, General and Oral Pathology: specific conditions and diseases noted in dental setting; 9, Pharmacology: drugs that affect dental care.
A. Pharmacological record: information regarding drug action, usage, contraindications, adverse reactions, warnings, precautions is reviewed.

2. Common drug-induced oral side effects:

3. Common drugs that affect dental treatment:


Patient assessment is necessary to establish baseline information on general health; includes taking vital signs as well as performing extraoral and intraoral examination and dental and periodontal evaluations. Obtaining baseline information allows determination of treatment needs and subsequent development of treatment plan.

See Chapter 10, Medical and Dental Emergencies: vital signs.

Patient Examination

Patient examination includes both extraoral and intraoral examination of the soft and hard tissues of the head and neck as part of the assessment of the patient. Recognition of abnormal findings may be critical in preserving the overall health. MUST be recorded in chart (see documentation discussion).

See Chapters 4, Head, Neck, and Dental Anatomy: head and neck anatomy; 6, General and Oral Pathology: diagnosis.
A. Examination technique: includes visual observation, palpation, auscultation, olfaction.

Extraoral Examination

Patient SHOULD be seated in an upright position for extraoral examination of the head, face, and neck areas, unless NOT able. Good lighting and exposure of the area being assessed are essential (e.g., patient’s collar and tie loosened, glasses removed).

H. Bones, muscles, lymph nodes, glands using visual and palpation:

Intraoral Examination

Patient should be seated in a supine position (see earlier position discussion). Use preprocedural antimicrobial mouthrinse and have client remove any pigmented lipsticks. Apply nonpetroleum lubricant to cracked and dry areas to make examination more comfortable, and remove any removable appliances. Overall, note level of saliva and whether dry mouth (xerostomia) is present.

G. Tongue using visual examination and palpation:


Sex image Male image Female The patient has minimal calculus and dental biofilm with slight gingival inflammation.
Height 5’2”
Weight 135 LBS
BP 110/65
Chief Complaint “I know I have to keep my mouth healthy, since it impacts all of my health.”
Medical History

Current Medications

Social History Rock band member

Jan 1, 2015 | Posted by in Dental Hygiene | Comments Off on 11: Clinical Treatment
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