Dental Hygiene Assessment – A Fresh Start: The Comprehensive Oral Examination –

The Comprehensive Oral Examination, or ‘COE,’ is a framework for regular, systematic, thorough data collection of a client’s oral health.  It provides the foundation for safe and effective dental hygiene care and successful treatment outcomes.

Oral or medical examinations can and do induce anxiety in many of our clients.  To what degree, however, we may or may not be aware of.  During examination procedures, if the steps taken are completed from a least-invasive-to-most-invasive sequence, clients and clinicians alike may become more comfortable and the confidence in the clinician’s skills are likely to improve.

It goes without saying, that a strong foundational knowledge in both human anatomy and physiology, as well as in head and neck anatomy is a prerequisite for performing a thorough assessment.  Without knowing how the body functions in health, how homeostasis is maintained, and what occurs during homeostatic imbalance, a clinician will be at a loss for providing high quality care.  A solid understanding of the orofacial tissues in health needs to occur before conclusions can be drawn about normal, variations of normal, and potential areas of concern.

The medical, dental, and social histories are typically completed in questionnaire format.  Although the often-recommended method for history-taking is that of an interview, time constraints may prevent this.  If the history information is completed by the client, such as in a questionnaire format, be sure to thoroughly review the information with the client, filling in any blank areas, asking appropriate follow-up questions, educating the client about the oral health-systemic health connection, and providing reassurance about privacy/confidentiality protocols.

Continuing with minimally invasive procedures, the extra oral exam can next be completed, followed by the TMJ assessment.  After changing gloves, proceed to the intra oral exam to assess the soft tissues.  I strongly support Jill Nield-Gehrig’s ABCDT format¹ as a standardized, detail-oriented method to document both extra and intra oral lesions.  This format describes lesions in terms of their Area (anatomical location,) Border (demarcation, coalescence, etc.) Colour (yellow, skin-coloured, red, brown, etc.,) Diameter (size,) and the Type (macule, papule, pustule, etc.)  When using this format, a lesion is very accurately described, which is a necessity for differential diagnosis.   Using this format can also improve both intra- and interclinician calibration and collaboration.

The hard tissue assessment may next be conducted in conjunction with a radiographic assessment.  The hard tissue should be examined both before radiographic exposure and again after radiographic interpretation to correlate findings.  When exposing a full mouth series of radiographs, I still follow the least-invasive-first technique, beginning with maxillary anterior periapical films and ending with mandibular posterior periapical films.

The gingival and periodontal assessments may be completed together, and radiographs provide complimentary information.  Criterions to assess the gingival health status include colour, texture, papillary shape, consistency, marginal shape, and bleeding on gentle provocation (i.e. with an explorer/probe).  The periodontal assessment is more extensive than simply measuring the probing depth, as this in itself does not provide an accurate description of the support.  Bleeding on probing, recession, clinical attachment level, mobility, furcation involvement, and bone level all provide valuable insight into support provided to the teeth.

Occlusal assessment is an area that may vary widely between clinicians.  There is sometimes the tendency to record only one value for occlusal classification, although the right and left molars, as well as the right and left canines can all have different values.  The relationship of the anterior teeth, in overjet and overbite values, is also a quick and simple way to assess how the upper and lower teeth relate to each other.  Close attention to crossbites, crowding, and spacing must also be considered from both a functional and cosmetic perspective.

There may be confusion between deposit assessment and oral hygiene (or oral self care) assessment.  The deposit assessment is the description of the locations and types of what has accumulated on the teeth:  food debris, plaque, material alba, calculus, and stain.  Disclosing agents can assist with deposit assessment, not only for the clinician’s benefit, but more so for the client’s benefit. It’s important to remember that the presence of plaque alone is not necessarily an accurate indication of an individual’s practices, but may instead represent the accumulation developed over the last day or days.  The oral hygiene assessment involves both observing the client attempt to remove the deposits and talking to them about their knowledge level, habits, motivation, and attitudes that surround their current home care regimen. 

In conclusion, let’s not forget about technology-based assessment tools.  ViziLite®, DIAGNOdent®, Velscope®, and microbiology sampling are all assessment adjuncts that greatly compliment your data collection, and ultimately, the foundation for the dental hygiene process of care.

Reference:

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

The Spirit of Volunteer Work

The first part of this blog provided me with an opportunity to introduce you to the Good Neighbours’ Club, an organization making a difference in the downtown Toronto community.  I would like to take an opportunity now, to share the accomplishments of the day.  My hope is that by sharing the experience, more dental hygienists will feel inspired to contribute their expertise in the form of volunteer work as well.

            I was never really involved in volunteer work as a dental hygienist until about a year ago.  I have been practicing for about 5 years now.  I remember that when I was in school, I often said that volunteering is something that I wanted to do.  However, I think that my situation is not different from that of many other dental hygienists, as soon as I graduated and obtained my registration, I wanted to get to work as soon as possible.  My definition of work was limited by a private practice type of environment.  Of course I knew about the other roles that a dental hygienist could fulfill, such as:  advocate, educator and change agent, but those roles were for other dental hygienists- not me.

            It wasn’t until I became more involved and passionate about dental hygiene education and met other dental hygienists who shared the same passion for education, that I really began to realize that the dental hygienist is not bound by the private practice environment and that there is a whole world of opportunity to realize those “other” roles.  A fellow dental hygienist, Joanne, shared the spirit of volunteerism with me and we collaborated on the Good Neighbours’ Club project together.  I was intimidated at first, but quickly realized that this was the best type of dental hygiene work I have ever done. 

On our first visit to the Good Neighbours’ Club my partner was unable to join me due to an emergency at her workplace.  Luckily, we were able to contact a former student and new dental hygienist Amanda to assist on our first day (we also had some great help from my significant other, thank-you Geoff!).  Amanda’s willingness to help was a refreshing reflection on the future of the dental hygiene profession.   She was happy to help; she documented findings accurately and professionally, and compassionately communicated with the members of the club.  

I honestly thought that the first day would not provide much of turnout with the club members.  However, to my surprise we completed thirteen oral cancer screenings.  We soon found out that we could not use the words “oral cancer screening”, due this demographics sensitivity surrounding the subject.  We quickly re-thought our approach and changed it to “oral health screenings”.  Geoff, who originally thought that he was there to only help us carry boxes, quickly took on the role of administrator!  He was busy organizing club members and taking names. 

An interesting reflection of the implications of dental hygiene being a feminized profession also manifested that day.  Several of the club members assumed that Geoff was a dentist because he was a “man” that was with us.  Although, he was quick to correct their assumption, this provided me with some food for thought on the fact that, although dental hygiene has come a long way in terms of educating the public, we can always do more.  In fact, projects like this one are what educates people- dental hygienists are a lot more than tooth cleaners!

I was rather surprised at the lack of donations and response to our numerous calls for dental supplies on our blog, facebook and twitter social networking sites.  It is our hope that as we continue to promote this project in the community, more people and organizations will be willing to donate supplies.  Having said that, generous supply donations were provided by Dr. Emma Hernandez of Etobicoke, ON and Dr. Susan Johnston of Toronto, ON and for that we are very thankful. 

Since that first visit we have recently gone back to the club.  Our project continues to improve and we are continuously determining what is working and what we could potentially do differently next time around.  One thing that is surely working is the relationships that we are building with club members.  The fact that an otherwise marginalized individual takes the time to have his mouth checked demonstrates a value on oral health- no matter how small, is still worth something. 

I encourage all dental hygienists to try volunteer work at least once because I know that there will always be a second time.  Volunteer work helps the profession of dental hygiene, helps the community, but most of all strengthens the spirit of both.

I would love to hear about your volunteer experiences!

Seeing the Invisible

Over the Christmas holidays I had the opportunity to participate in the first day of the oral cancer-screening project that myself and my partner, friend and fellow dental hygienist Joanne- have been in the process of developing.  The organization that we are working to establish a long-term collaborative relationship with is The Good Neighbours’ Club in Toronto, Ontario.  I am writing this blog to give you some insight and background information as to why we have chosen to work with this organization.  This is blog is part one.  In part two, I will share the learning experiences from the first day.

  The Good Neighbours’ Club is an organization that works with homeless, unemployed, marginalized, and/or lonely older adult men. I encourage you to take an opportunity to view their website to gain an idea of the great role this organization plays in the community http://goodneighboursclub.org.

Some may ask why we have chosen to work with this organization over others.  Although there are many groups of socially isolated and marginalized individuals in society, the reason that we chose this organization is that this population demographic is often a cohort whose needs are minimized. From a societal standpoint, men are viewed as naturally empowered individuals.  Socialization evolves and fosters what is supposed to be a strong male identity. Furthermore, the older adult male is at risk for oral cancer, this risk is further compounded by smoking and drinking habits. 

Not only is this project an opportunity to improve the oral health of these men, it is also an opportunity to improve their personal wellbeing.  The personal wellbeing of these men is improved by providing an opportunity for empowerment.  Personal empowerment is a key component of health promotion and oral health is increasingly viewed as an intrinsic part of overall health.  Empowerment comes from the individual feeling a sense of control over their health and as being viewed as an active participant in the decision making process. 

Though this project, we hope to accomplish development of meaningful relationships with the members of this club. Meaningful relationships are accomplished by active listening, empathy and setting mutually agreed upon goals. Empowerment involves guiding the client and providing direction, but not necessarily telling the client what to do.  A trusting relationship facilitates the empowerment process.  (Falk-Rafael, 2001)  This project will allow us to be more visible within the Good Neighbours’ Club; with frequent visits and follow-ups we hope that this will foster a trusting relationship with the members. 

As with any new endeavor, there are bound to be bumps along the way.  Part of the success of volunteer and community development projects is dependent on the identification of areas for improvement, a determination of what works and what does not, and strategies for improvement next time around.

                        As a clinician, you are only as good as your assessment tools.  During the screenings, I found that I was consciously thinking of ways to improve our assessment form for next time around.  Regardless of setbacks encountered, this project was a success.  Taking the time a see an individual who is otherwise invisible in society could mean a world of happiness to them even if just for a few minutes to look in their mouth; you could make their day. 

I would love to hear your thoughts.

Reference List:

Falk-Rafael, A.R. (2001). Empowerment as a process of evolving consciousness: A model of empowered caring. Advances in Nursing Science.  24(1), 1-16.

Good Neighbours’ Club.  Mission Statement. Retrieved Dec 14, 2010 from http://goodneighboursclub.org/

A Beginning but No End: The Dental Hygiene Process of Care

A new client had an appointment scheduled with me this week, her first appointment within our practice.  Although our administrative department is well-versed in explaining the importance of a comprehensive oral evaluation (COE) to our clients, both new and existing, I did find myself seated with someone that “just wants a cleaning for today.”  So it began, my explanation of the dental hygiene process of care to this new smile we have welcomed into our practice. 

At times, this explanation may take me one minute, or it may take me fifteen, depending on whether or not I need to “look inside” the oral cavity (as if to confirm that yes, we do need to complete a COE), take a few intra-oral photographs, complete a PSR, or perhaps initiate a discussion of the periodontal disease process with my well-used periodontal flip-chart.

I always find myself at ease as I explain the dental hygiene process of care to people as I’m a strong supporter of it.  The dental hygiene process of care works, time and time again.

When we consider debridement, an implementation procedure, it is so much more than the seemingly simple act (for those that take it for granted) of adapting the leading third of a periodontal instrument to the tooth.  How can I even consider picking up a periodontal scaler without thorough knowledge of the periodontal status, tooth anatomy, restoration integrity, referral urgency, and other important client-specific assessment data?  Without said assessment, I have no foundation for a dental hygiene diagnosis, and certainly not even a hint of an individualized dental hygiene care plan. 

The dental hygiene process of care provides the framework, or structure, necessary to provide the highest calibre of dental hygiene care to every client (which is fair and just) yet it manages to do this in an individualized fashion.  The process needs to be followed in order to optimize oral health and the support that oral health lends to total health.  When we deviate from the process, we compromise outcomes which can and do negatively affect oral health. 

It’s important to remember that the process is a cycle, and at times, a cycle within a cycle.  At a single appointment we may complete all five components from assessment through to evaluation on a small scale. For other measures, we may need several months to complete the cycle, but in both cases, the process starts all over again to either maintain or improve the oral health.  The process has a beginning, but no end.

The initial assessment, the comprehensive oral assessment (COE), is lengthy, and may take anywhere for fourty-five to ninety minutes, but this information is vital for a solid foundation upon which the rest of the process will be supported and built.  The length of time required is often directly related to the complexity of the assessment data.

How the assessment data is analyzed and interpreted is our dental hygiene diagnosis, which often, but not always, presents itself as some type of deficit.  Errors can easily be made within the dental hygiene diagnosis, such as developing a dental diagnosis or confusing client-centered goals with dental hygiene interventions.  (For instance, the client tells you they “want a cleaning” but is this really their goal or is it a part of our intervention?  Why does the client “want a cleaning?” Isn’t their goal more accurately described as to achieve oral health, fresh breath, or a pleasing smile?) The dental hygiene diagnosis may seem abstract, at times difficult to grasp and convey, but it serves as the basis for the client-centered goals.  And it is the goals that feed the dental hygiene care plan.

The dental hygiene care plan is a strategy of all of the interventions within our scope of practice, what will be done, when to do it based on priority sequence, and how long it all will take.

And now the moment we’ve all been waiting for: implementation!  Putting the dental hygiene care plan into action isn’t always what we thought it would be; snow falls into blizzards, calculus is much more tenacious than we ever anticipated, children/spouses/pets become ill, and well, people simply change their minds.  So we amend the plan, we do the very best we can, and we move on.

And did it work? Were the interventions successful? Were the client- (not the dental hygienist) centered goals met?  Partially met?  Unmet?  Why or why not?  What is the next step?  Where do we, the client-dental hygienist team, go from here? This is why we evaluate.  And this is where I find the greatest amount of professional satisfaction in clinical practice, is evaluation.  This is where I truly feel I have made a difference.  And this is because of a process that is none short of brilliant.