The Dental Hygiene Pen, Part 1 – Effective Time Management With a Commitment to Records Regulations, Standards of Practice, and Ethical Principles –

It may seem as though in our pursuit as dedicated, competent dental hygienists, time may occasionally be lost for documenting the care provided.  Unfortunately, there are instances when the only form of communication that we have with other people is through what we have written down.  Can we accurately say that the quality of our documents is a reliable measure of the quality of the dental hygiene care we provide?  Many people say yes, we can.

On the surface, documentation might seem monotonous, uninteresting, and repetitive in nature.  The significance of what needs to be written down may be unknown for several years.  Perhaps it seems that there might be something more important to do at the moment, such as furthering the client’s oral health knowledge or asepsis management.

Although the topic of dental hygiene documentation is very broad, and a brief blog cannot even begin to convey its significance, I feel a quick look at documentation specifically during the periodontal maintenance appointment is time well spent.

It goes without saying that the client chart needs to reflect the various components of the dental hygiene process of care.  Assessment findings need to be thoroughly documented, both as baseline data and also as periodic updates. The dental hygiene diagnosis and client goal statements drive the dental hygiene care plan, which are also to be recorded.  The implementation procedures must include the time spent (either in minutes or units; fee codes are not an acceptable standard.)  (Remember that dental radiographs are a prescription, much like a medication, are not in the dental hygiene scope of practice; therefore, the prescription must also be written down.)  Oral self care aids and instructions have to be recorded.  Evaluation documentation completes the cycle.

This brings us to the perennial question: how do we record all of this in the client record with limited appointment times?  Perhaps the development of a periodontal maintenance sheet can help.  Preprinted sheets can be utilized that have check boxes or words to circle.  This can speed up the documentation process and also assist with intra- and interprofessional calibration. Preprinted forms require minimal work to develop but can facilitate high quality documentation.

Below is a template example of what might be included in a preprinted periodontal maintenance form, although you can tailor yours to suit your practice needs:

Name:  __________________________________________   Medical Alert: None o or ______________________________
Date:	M.H. Update Changes:  Y oNo ______________		EO:  o WNL or ________________­­­_ IO:  o WNL or _________________ TMJ: o WNL or _________________ OSC Practices: _________________  _________________		Deposits:		L	M	H	OSC: E G F P
Clinician:					Plaque
Time In:	Meds: o none ______________ ______________ ______________ ______________				Supra. Calculus
Time Out:					Sub. Calculus
Consent: o Y oN					Stain
DH DX – Human Needs Deficits: oWholesome Facial Image  oProtection From Health Risks  oFreedom from Anxiety/Stress                                                      o Biologically Sound/Functional Dentition  oResponsibility for Oral Health  oFreedom from Head/Neck Pain  oSkin/Mucous Membrane Integrity of the Head/Neck  oConceptualization/Understanding
Client Goals:	Observations: Client Informed: oY oN			Next Appt. / TX Advised:		OSC Aids Dispensed:                                   otb       ot. paste      ointerdental br.                                  ofloss  ofl. holder   othreader oother: ______________________                      OSC Instructions: _____________________________
Radiographs:                    BWs: oo  oo        FMX/PAs:                           oo  ooo  oo             oo                oo              oo  ooo  oo            PAN: o   CEPH: o    DDS/DMD: __________		Notes:
		Today’s TX Interventions:
Evaluation:							DDS/DMD:

(Some formatting has been lost during posting.)
The above template can be printed twice on each side of an 8 1/2 x 11 inch page.  You might also consider including a periodontal charting record on the reverse.  It’s quick and easy to look back at what transpired during previous periodontal maintenance appointments using a standard and comprehensive format.

A key feature to consider with your documentation is a blank area or section.  A blank area or section can be interpreted as a criterion that was not assessed or completed, so ensure that all areas have some type of notation in them, even if it’s a dash ‘-,’ ‘WNL,’ ‘N/A,’ or ‘none.’ This cannot be overemphasized, especially with regards to identifying features, such as client and clinician names.

Finally, be sure to document throughout the appointment, writing down relevant pieces of information as they arise. For this, I advocate the use of overgloves.

To this end, the purpose here was a bit of a review, sprinkled with perhaps some new information to inspire. In this ever-evolving profession, as we continue to progress in the care we provide, we must upgrade our documentation skills to reflect that progression. 

            I’d love to hear about how you successfully manage your documents.  What works well for you?

Suggested Readings:

1. CDHO Regulations Part III.I - Records  http://www.cdho.org/LegislationAndByLaws/RecordsReg.pdf
2. CDHO Registrant’s Handbook, Chapter 6, Recordkeeping http://www.cdho.org/Practice_RegistrantsHandbook.htm
3. RCDSO Dental Recordkeeping Guideline http://www.rcdso.org/pdf/guidelines/RCDSO_Guidelines_Dental_Recordkeeping_May08.pdf

Overview of Extra and Intraoral Examinations: The Foundation for Oral Cancer Detection

Evidence is ever-increasing pointing to the notion that a dental hygiene appointment, is more than simply looking at the teeth.  A dental hygiene visit may in fact save your client’s life.  The dental hygienist, a key member of the oral healthcare team, is extensively trained in completing assessments of the head and neck region and conducting an overall appraisal of a client’s health status.

            Oral cancer is an example of a life threatening disease that may be detected by a dental hygienist. With early detection and timely treatment, morbidity from oral cancer could be dramatically reduced.  The five-year survival rate for those with localized disease at diagnosis is about 80 percent compared with only 19 percent for those whose cancer has spread to other parts of the body.  Early detection of oral cancers is often possible. Tissue changes in the mouth that might signal the early signs of cancer often can be seen and felt easily. It is a known fact that early detection saves lives.

The extraoral and intra oral examinations are a physical, systematic examination of the head and neck area outside and inside the oral cavity.  The examination involves palpation or physical manipulation and detailed visual inspection of the structures of the head and neck region followed by careful documentation of significant findings.  The examination only takes a few minutes and enables the clinician to detect early changes in structure, which may be indicative of disease. 

Here are some tips to completing efficient, yet thorough extra and intraoral examinations:

·      Follow a consistent sequence

·      Use an effective palpation technique

·      Have a good knowledge and understanding of the location of all lymph nodes and anatomic landmarks

·      Document all findings accurately

            This brings us to documentation of findings.  The manner in which findings are documented is vital as assessment findings are used as baseline findings for which all other future visits are compared.  It is also commonplace, that more than one clinician will treat a client during their care.  A consistent documentation technique ensures a uniform language amongst clinicians.  A clinician should be able to pick up a client record and gain a true picture of the client’s oral health status.

 I would like to propose a uniform method of documentation of oral lesions among all dental hygiene clinicians.  I particularly like the ABCDT format that is outlined in the Patient Assessment Tutorials text by Jill Nield-Gehrig.

ABCDT is an acronym for:

·      Area

·      Border

·      Colour

·      Diameter

·      Type

The dental hygienist is adept at the recognition of conditions that are beyond his/her scope of practice.  Upon recognition of those conditions, a referral to the appropriate health care professional is indicated.  Please note that if a suspect lesion does not resolve after 2 weeks, a referral should be made to an appropriate specialist.  A prudent dental hygienist will follow up to determine the status of the lesion and what the appropriate course of action may be. 

This now brings us to variants of normal such as linea alba, mucoceles, fordyce granules etc… I propose that these findings are documented using the ABCDT format as well, with the appropriate name in parenthesis following the description. 

As a clinician myself, I can share the sentiment that there would not be enough room in the chart, or enough time in an appointment to document in this manner.  It is important to note that client and dental team education is key.  Perhaps the initial examination could be lengthened?  Note that at subsequent appointments the clinician would just complete an update, which is an abbreviated version of the initial exam.  Another thing to consider is whether standardized assessment forms for all dental hygienists could help? What do you think? I would love to hear your thoughts!

Reference List:

Darby, Michelle Leonardi, and Margaret M. Walsh. (2010) Dental Hygiene Theory and Practice Third Edition. St. Louis, MO: Saunders Elsevier.

Nield-Gehrig, J.S. (2007). Patient Assessment Tutorials: A Step by Step Guide for the Dental Hygienist . Baltimore, MA: Lippincott Williams & Wilkins.

Top 10 Tips for Successful Pit and Fissure Sealants

As dental hygienists, we strive to prevent disease and promote health.  Pit and fissure sealants are a commonly recommended preventive strategy and many of our clients benefit from their successful placement.  Sealant retention is synonymous with sealant success.

The pit and fissure sealant material is typically a lightly- or unfilled low viscosity composite resin, and behaves and is treated as such.

Below are some tips that might complement or enhance future sealant placement.

1.  Adhere to the Dental Hygiene Process of Care (DHPC)

The placement of pit and fissure sealants is a valuable component of the implementation phase in the DHPC, but skipping any of the other components may lead to sealant failure. 

Consider the level of caries risk and caries activity of the client.  Tooth characteristics to appraise include anatomical features that are conducive to caries formation, recent eruption, and operculum proximity.  Be sure to assess buccal pits of mandibular molars, lingual pits of maxillary molars, and lingual pits of maxillary anterior teeth, in addition to the occlusal surfaces of posterior teeth. As many sealant clients are children, you may also contemplate behaviour management strategies to be utilized during the procedure.

2.  Follow the Manufacturer’s Instructions

Reading instructions is always time well spent.  Thoroughly reviewing the product characteristics will provide valuable insight as various products behave differently in the oral environment.  For example, some products may be applied in a semi-wet field, whereas others require a moisture-free field.  Variations in curing times and types will also alter the manipulation of the resin material.

3.  Prophy with a Prophy Jet

More debris will be removed with a prophy jet than with a slow speed handpiece and prophy brush.  The less contaminated the tooth is, the better the retention.

4.  Overetch - Apply Etch to Extend Beyond Where the Sealant is Expected

Overetching will help to ensure that the entire area to be sealed is etched.  Unetched areas will not retain the sealant properly and the sealant may fail.

5.  Dispense the Sealant Material Into a Dappen Dish and Apply it to the Tooth with a Microbrush

This can help to improve infection control, by not placing a sealant syringe into a client’s oral cavity.  As well, the clinician may find improved control by applying the material with a microbrush.  If too much sealant material has inadvertently been placed on the tooth, simply wick the excess material with the readily accessible microbrush.  Consider placing the resin in the mesial pit first and then guide it to the distal, as this flow is naturally supported by anatomy and gravity.

6.  Guide the Sealant Material Into the Pits and Fissures with an Explorer

After the correct amount of sealant material has been placed on the tooth, gently guide the resin into the pits and fissures with a clean explorer to help improve contact and retention. 

7.  Evaluate the Integrity of the Sealant Immediately After Placement

Evaluate for air bubbles or voids with the explorer and if found, correct them immediately.  Attempt to dislodge the sealant with the explorer. A properly placed sealant will adhere to the tooth and cannot be displaced with gentle pressure.

8.  Apply Fluoride After the Sealant Procedure

This helps to remineralize the overetched areas of enamel.  Remember that acidulated phosphate fluoride is contraindicated on sealants, as they are type of composite resin; consider neutral sodium fluoride instead.

9.  Educate the Client About the Purpose, Limitations, and Expectations of a Pit and Fissure Sealant Before and After the Procedure

Clients (and parents) will need to be informed that:

• the pit and fissure sealant does not prevent interproximal decay, so flossing daily is still required
• the pit and fissure sealant will deteriorate faster with poor oral hygiene, so excellent oral hygiene is still needed
• the pit and fissure sealant won’t last indefinitely, but excellent oral hygiene and following professional recommendations for continuing care will prolong it
• the pit and fissure sealant is not a replacement for  a noncariogenic diet and fluoride therapy
• the pit and fissure sealant will not improve the condition of the gingiva

10. Practice Four-Handed Pit and Fissure Sealant Placement

Utilization of an assistant to place sealants allows for improved efficiency, better field maintenance, and reduced clinician anxiety.

What do you think?  Do you have any other tips that you find improves the success of your pit and fissure sealants?  Please share them!

Community Health in the Dental Hygiene Diploma Curriculum

The focus of the community health component in the curriculum is multidimensional.

First, the dental hygiene student gains insight into the position that dental hygienists have in community health.  This position encompasses all five of the CDHO roles and responsibilities of clinician, health promoter, educator, administrator, and researcher.  Students participate in all five of these roles through didactic instruction, assignments, in-class written tests, community field placements, and the incorporation of community health partners into the CBC student dental hygiene clinic.  Presently, our roles as registered health care providers are being further defined by the eight domains of dental hygiene, as outlined by the national dental hygiene competencies.  This new era of dental hygiene provides community health with a very exciting future and the possibilities for further enhancement of this valuable profession are bountiful.

Second, the dental hygiene student enhances his/her understanding of the social responsibility associated with the dental hygiene profession.  Dental hygienists have a specialized body of knowledge as related to their extensive understanding of oral health and the link with overall health and wellness, their continuous dedication to disease prevention, and the natural tendency towards client-centered care.  Along with the extensive body of knowledge, dental hygienists have a responsibility to the individuals that comprise the general population; the dental hygiene students are trained to seek out clients in the community, in contrast to the dental hygiene services traditionally provided to clients that seek it out themselves.

Third, the dental hygiene student will expand his/her understanding of evidence-based practice.  Studies of epidemiology, biostatistics, scientific communication, and statistical significance all contribute to competency when faced with implementing evidence supported treatment modalities into client care in a timely fashion.

Lastly, an understanding of community health programs is undertaken.  The dental hygiene students study effective community program design, and how to plan and evaluate successful community programs.  Through numerous field placements, students are then provided with the opportunity to design and implement their own community programs, an experience that consistently reports positive experiences on behalf of the students and community partners alike.

Community health is a unique aspect of the dental hygiene curriculum.  It gathers information learned from all other aspects of the dental hygiene body of knowledge, and challenges dental hygienists and future dental hygienists to rethink our perception of the client and how we apply the dental hygiene process of care.

The significance of the study of community health has greatly increased with the ability for dental hygienists in Ontario to self-initiate.  A thorough understanding of community health is mandatory for future dental hygienists to be able to successfully integrate self-initiation into practice.  Self-initiation is the bridge between dental hygiene and the people; community health provides dental hygienists with tools to succeed once that bridge has been crossed.