Transcript Dental Hygiene Process of Care

Dental Hygiene
Process of Care
Dentalelle Tutoring
ADPIE
Ethics Model
Ethics
•
Professional ethics is part of every component in the provider/patient relationship
between the dental hygienist and the patient. The potential for an ethical situation
arises anytime a dental hygienist interacts with a patient, with members of the dental
team, or with individuals involved in the special needs of the patient, such as family,
caregivers, or members of specialty practices. A dental hygienist who provides ethical
patient care:
•
Is cognizant of the respect each patient deserves.
Maintains communication among all parties responsible for dental and dental hygiene
treatment.
Attains a knowledge of current standards of care through continuing education
coursework and reading professional journal articles about new research.
Is aware of ethical issues such as conflict of interest while treating patients, the legal
scope of one’s duties, and dealing with impaired colleagues
Possesses the ability to assess and justify the reporting of unacceptable practices.
Basic Concepts of Law
•
The basic concepts in healthcare law apply to all dental hygiene
professionals. The dental hygiene practice acts of each state or
province govern the scope of duties and the criteria for licensure.
•
Professional liability, standard of care, informed consent, privacy
information, and malpractice are other concerns that affect the daily
duties and rights of both the patient and the dental hygienist.
Definitions to know
•
Professional Liability A licensed professional is legally
accountable for all actions; bound by the law.
•
Scope of Practice A dental hygienist is legally bound to provide
care within the dental hygiene scope of practice
•
Standard of Care A professional uses the ordinary and reasonable
skill that is commonly used by other reputable dental hygienists
when caring for patients
•
Informed Consent Voluntary affirmation by a patient to allow
examination or treatment
•
Negligence/Malpractice Failure to perform professional duties
according accepted standard of care.
Eight Human Needs
1.
Wholesome Facial Image

2.
Conceptualization and Understanding

3.
BP outside of normal limits, need for pre-meds
Skin and Mucous Membrane Integrity of Head and Neck

8.
Pain or sensitivity
Protection from Health Risks

7.
reports difficulty in chewing, defective restorations, ill fitting dentures
Freedom from Head and Neck Pain

6.
Plaque and calculus present, not having regular dental exams
Biologically sound and functional dentition

5.
Has questions about DH care and or oral disease
Responsibility for Oral Health

4.
Expresses dissatisfaction with appearance
Extra/intra oral lesion, swelling, bleeding on probing, gingival inflammation, pockets, xerostomia
Freedom from Anxiety/Stress

Anxiety of clinician, oral habits, substance abuse, concerns about infection control/fluoride/amalgams
Dental Hygiene Diagnosis
•
List the human needs not met, then be specific about the etiology
and signs/symptoms evidencing a deficit
•
Unmet human need
 DUE TO
 Etiology
 EVIDENCED BY
 Signs/Symptoms
Assess - INTRO
•
After the initial assessment is completed, the data are assembled,
sequenced, and analyzed in preparation for planning strategies that
help the patient acquire and maintain oral health.
•
A formal written care plan is necessary for educating the patient,
securing informed consent for treatment, and communicating with
other oral care team members.
Diagnose
•
The diagnosis segment of the Dental Hygiene Process of Care is related to
analyzing the assessment data that has been collected. The dental hygiene
diagnosis identifies those patient needs for which the dental hygienist will
provide interventions. Interventions within the scope of dental hygiene practice
are implemented to solve the problems identified by the diagnostic statements.
•
Dental diagnoses, on the other hand, are directed at those particular diseases
and conditions for which the dentist will provide treatment.
•
Dental hygiene diagnosis statements focus attention on the behavioral aspects as
well as deviations from normal oral health.
•
Chartings, radiographs, histories, and all recorded patient data are analyzed
together.
•
Each diagnostic statement identifies with a significant oral hygiene problem of
the patient.
•
A blueprint care plan of diagnostic statements.
Plan
•
Purposes for developing a written care plan are described in this
section.
•
The dental hygiene care plan selects interventions that are based on
analysis of assessment data that has been consolidated into
diagnostic statements that define patient needs.
•
The care plan is developed to conform to and be integrated with the
total treatment plan of the patient.
•
The overall objectives of the dental health care team focus on the
oral health of the patient. The ultimate goal will be the control of
oral diseases.
Chief Complaint
•
The patient’s statement regarding the reason for seeking dental and
dental hygiene care is considered when planning. If a patient has a
significant concern, such as pain, this need is addressed prior to
initiating dental hygiene treatment.
•
Whether or not the patient presents for dental hygiene care with
current oral disease, several risk factors can be noted that increase
the patient’s potential for diminished oral health status. When a
patient presents for dental hygiene care exhibiting one or more risk
factors, it is essential to develop a care plan that provides
anticipatory guidance through preventive education and counseling.
Risk Factors for Perio or
Infection
•
Behavioral factors (inadequate biofilm removal, diet, noncompliance
with dental hygiene recommendations)
Tobacco use
Systemic conditions (diabetes, decreased immune factors, osteoporosis,
osteopenia)
Hormonal considerations (pregnancy, menopause)
Nutritional status
Iatrogenic factors(overhangs, open contacts, residual
calculus)
Genetic factors
Perio Disease as a Risk from
Systemic Conditions
•
Current research suggests that the presence of periodontal infection
is a contributing factor to a variety of systemic conditions.
Infective endocarditis
Cardiovascular disease (CVD) and atherosclerosis
Diabetes mellitus
Respiratory disease
Adverse pregnancy outcomes
Risk Factors for Caries
•
Behavioral factors (inadequate biofilm removal)
Dietary factors (frequent use of cariogenic foods/beverages)
Low fluoride
Tooth morphology and position (deep occlusal pits and fissures,
exposed root surfaces, rotated positioning)
Xerostomia
Personal and family history of dental caries/restorative dentistry
Developmental factors (modifications of dental enamel)
Genetic factors (immune response)
Risk factors for Oral Cancer
•
Tobacco use
•
Alcohol use
•
Sun exposure (lips and face)
Patients knowledge?
•
Before planning individualized patient care, an attempt is made to
assess the patient’s oral health knowledge level. From that baseline,
planned educational interventions can build on current knowledge
rather than provide information too far above or below the patient’s
current understanding.
Self-care
•
The patient’s ability to manipulate a toothbrush and floss and to
comply with suggested oral care regimens will determine the success
of planned interventions. Patients with disabilities or physical
limitations will require modification to ensure adequate daily dental
biofilm removal.
•
An Activities of Daily Living (ADL) classification level, can provide a
guide to determine whether adaptive aids or caregiver training for
personal oral care procedures in necessary.
Treatment Planning
•
TREATMENT PLANNING WITH OSCAR
•
A systematic approach to identifying factors to evaluate when planning dental
hygiene care.
•
ISSUE FACTORS OF CONCERN
•
Oral - Teeth, restorations, prostheses, periodontium, pulpal status, oral mucosa,
occlusion, saliva, tongue, alveolar bone
•
Systemic - Normative age changes, medical diagnoses, pharmacologic agents,
interdisciplinary communication
•
Capability - Functional ability, self-care, caregivers, oral hygiene,
transportation to appointments, mobility within the dental office
•
Autonomy - Decision-making ability, dependence on alternative or
supplemental decision makers
•
Reality - Prioritization of oral health, financial ability or limitations,
significance of anticipated life span
Dental Hygiene
Diagnosis
Basis for Diagnosis
•
A. Patient interview data (chief complaint, identification of oral
problems, and comprehensive personal/social, medical, and dental
health histories)
•
B. Physical assessment data (vital signs, extraoral and intraoral
tissue examination, and dental and periodontal chartings)
•
C. Treatment or education needs that may be addressed by providing
oral care services within the dental hygienists legal scope of practice
•
D. Treatment needs that may be addressed by consultation with
another licensed healthcare professional
Diagnostic Statements
•
A. Provide the basis for planning interventions that are within the
scope of dental hygiene practice
•
B. Reflect expected outcomes of dental hygiene interventions
•
C. Identify patient responses that are changeable by dental hygiene
interventions
•
D. Exclude diagnoses that require treatments legally defined as
dental practice
Expected Outcomes
•
A. Gingival/Periodontal
Reduced dental biofilm
No bleeding on probing
Reduced probing depths
No further loss in attachment level
Decrease or no change in mobility
Resolution of erythematous tissue
Reduced swelling and edema
Continued
•
B. Dental Caries
No new demineralized areas
Demineralized areas resolved
No new carious lesions
Reduced intake of cariogenic foods/beverages
Dental sealants placed
Increased fluoride use
•
C. Prevention
Elimination of iatrogenic factors (calculus, restoration overhangs)
Increased percentage of biofilm-free areas
Patient demonstration of recommended oral care procedures
Compliance with daily care recommendations
Compliance with recommended maintenance care interval
Tobacco-free status achieved
Modification/stabilization of systemic risk factors
Role of the Patient
•
A. Purpose
The willingness and/or ability of the patient to participate in planned oral
health behaviors will be the key to reaching goals set during planning.
•
B. Procedure
1.
Determine the patient’s level of understanding of dental diseases, risk
factors, and oral health behaviors.
2.
Determine the patient’s physical ability to manipulate recommended
oral care aids.
3.
Determine lifestyle factors that impact the patient’s ability to comply
with oral health recommendations.
4.
Educate patients regarding the importance of their role in setting oral
health goals and complying with recommendations.
Tissue
•
Preparation or conditioning of the gingival tissue for scaling can be
of particular significance when there is spongy, soft tissue that
bleeds on slight provocation, and when the area is generally septic
from dental biofilm and debris accumulation.
Purpose
•
Anticipated outcomes of a tissue conditioning program include:
1. Gingival healing
tissues become less edematous
bleeding is minimized
scaling procedures are facilitated
2. Reduced bacterial accumulation
less likelihood that bacteremia's will be produced during scaling
reduced contamination in the aerosols produced
3. Learning by the patient
While conditioning the tissue for scaling, the patient can:
practice oral health behaviors
experience the benefits of a clean mouth
from lifetime habits for continued maintenance
Procedure
•
Initiate a pre treatment program of daily biofilm removal.
Recommend daily use of an antibacterial rinse after thorough
brushing and flossing before going to bed.
Select affected quadrants for scaling only after patient cooperation
has been demonstrated.
Preprecedural Rinsing
•
A. Purpose
Preprocedural removal of dental biofilm will lower the bacterial count
in aerosols and decrease the potential for bacteremia.
•
B. Procedure
The first choice is patient brushing and flossing.
Vigorous rinsing with an antibacterial mouthwash is beneficial.
Continued
•
Forcing the fluid between the teeth for 1 to 2 minutes can remove
loose debris and surface bacteria approximately 1 mm below the
gingival margin.
•
Even rinsing with water will have some effect on bacteria; however,
chlorhexidine rinses have the most substantivity.
Pain and Anxiety
•
A. Purpose
Control of discomfort during treatment procedure.
More consistent patient compliance with recommended interventions
and need to return for additional scheduled appointments.
Anxiety Continued
•
B. Procedure
1. Quadrant selection
Treat the patient areas of discomfort first, unless tissue conditioning is
required. Treat either the quadrant with the fewest teeth or the least
severe periodontal infection first to:
make the first scaling less complicated
help orient an anxious patient to clinical procedures
Continued
•
2. Anesthesia
The need for anesthesia is determined by:
the patient’s previous pain control experiences
severity of the periodontal infection
depth of pockets
consistency and distribution of calculus
potential patient discomfort during scaling
sensitivity of the patient’s tissues
•
When two quadrants are to be treated at the same appointment, it will
minimize patient post treatment discomfort to select a maxillary and
mandibular quadrant on the same side.
Maintenance
•
A. Purpose
When restorative, prosthetic, or orthodontic, treatment extends over a period of time, periodic appointments
with the dental hygienist are needed for monitoring the continued success of the patient’s self-care.
B. Procedure
Dental hygiene care provided during extended dental therapy follows the dental hygiene process of care and
includes:
gingival tissue assessment
probing to determine bleeding
biofilm check with disclosing agent
reinforcement of daily oral care measures
scaling and root planning to remove calculus
additional instruction for care of new prostheses
motivational encouragement
Four handed Dental Hygiene
•
A. Purpose
Planning patient care while practicing with a dental assistant increase
the dental hygienist’s efficiency through theuse of:
flexible scheduling.
two treatment chairs in an overlapping time frame.
assistance with patient management.
Four handed continued
•
B. Procedure
A well-trained dental hygiene assistant can be delegated such duties
as:
patient reception and seating
medical history update prior to confirmation by the dental hygienist
radiographs (following individual state certification guidelines)
reinforcement of oral hygiene instruction
assistance during sealant placement and ultrasonic scaling
cleanup/disinfection of the treatment room in preparation for the next
patient
Factors to Teach a Patient
•
A clear explanation of how assessment data are used in planning
dental hygiene care.
The importance of using scientific evidence of success in the selection
of patient-specific therapeutic and preventive interventions.
Why disease control measures are learned before and in conjunction
with scaling.
Facts of oral disease prevention and oral health promotion relevant to
the patient’s current level of healthcare knowledge and individual risk
factors.
The long-term positive effects of comprehensive continuing care.
Medical History
Health History Screening
•
The medical history is a tool that is used in dental and dental hygiene practices
as an effective means of preventing a medical emergency. Careful interviewing,
listening, and communicating with clients can provide clues to potential
problems that may occur in the dental office setting. Although some emergencies
are unexpected, many that occur in clinical practice can be predicted by
gathering adequate information and analyzing it in terms of risk assessment.
•
Certain items on a medical history, if answered “yes,” require further evaluation.
These are red flags or areas that warrant additional information.
•
The purpose of this two-part series is to highlight some of the red flags that a
medical history reveals, and to provide information on preventing subsequent
medical emergencies or disease transmission associated with those positive
responses. The 2007 American Dental Association health history form is used as
the prototype for identifying questions that can elicit red flag responses.
TB
•
Screening questions for active tuberculosis
•
Ask patients, “Do you have any of the following diseases or problems?”
•
Active tuberculosis (TB)
•
Persistent cough for more than three weeks
•
Cough that produces blood
•
Exposure to anyone with TB
•
“If your answer is ‘yes’ to any of the four items above, please stop and
return this form to the receptionist.”
More on TB
•
Since elective oral health care is contraindicated in the client with active
TB disease, it is important to pursue further questioning to determine
the nature of positive responses to these questions. When the client
responds affirmatively on any of these items, investigate to determine if
the client has active TB infection. Ask these follow-up questions:
•
Have you seen a physician about this persistent cough?
•
Have you been tested recently for exposure to tuberculosis with a skin
test?
•
Do you wake up during the night from sweating?
•
Have you recently had unexplained weight loss?
•
Do you know anyone who has had TB?
•
Has anyone in your family or a friend or coworker been diagnosed with
tuberculosis?
Active TB or Inactive TB?
•
These questions give clinicians an opportunity to identify a client who may be
contagious prior to beginning oral procedures. When active TB is suspected,
isolate the client within the facility to perform follow-up questioning. Then refer
the client for medical evaluation. A medical consultation form should request the
physician to notify the office whether or not the client has active TB.
•
Clients who do not have active TB can receive oral health care. For clients with
active TB, the Centers for Disease Control and Prevention recommends three
criteria for non-infection that should be verified on the signed medical clearance
form before oral health care is provided:
•
The client is not in the coughing stage.
•
The client has taken three consecutive negative sputum smears on three
separate days.
•
The client has taken effective anti-TB medications for at least three weeks.
Negative Dental Experiences
•
Ask patients, “Have you had any problems associated with previous
dental treatment? If so, explain.”
•
Case reports suggest individuals who have experienced a negative
dental experience are more likely to have emergency situations during
an appointment. This question may identify a client at risk for syncope
(fainting) or hyperventilation, two common stress-related medical
emergencies that occur during dental and dental hygiene treatment.
Both conditions are often associated with anxiety and fear. Dental
procedures themselves, experiencing or anticipating pain, the sight of
blood, and receiving an injection of local anesthesia are predisposing
factors that may result in a stress-related emergency.
•
Stress-reduction strategies can be used to prevent syncope. Gain the
confidence and trust of the client, and help him or her to relax. Talk
with the client about personal interests to serve as a distracter, ensure
adequate pain control, use nitrous oxide conscious sedation, and
prescribe an antianxiety medication.
We need to know about negative
experiences…
•
Loss of consciousness in the dental office, unrelated to anxiety, may also occur
when the client is placed in an upright position. When seated in the dental chair
for a long time, blood can pool in the extremities and venous blood return to the
heart is reduced. This leads to vasodilation and hypotension (referred to as
postural hypotension) with inability of the cardiovascular system to push
oxygenated blood to the brain. This type of syncopal episode can be prevented.
Recognize the signs leading to unconsciousness, place the client in a prone
position, and have the client lift the feet and push on a stable surface (such as
your hands).
•
This positioning and management promotes skeletal muscle activation and
venous return to the heart, increased blood leaving the heart, and oxygenated
blood flow to the brain.
•
Hyperventilation is characterized by rapid breathing and results in excessive
loss of carbon dioxide and inspiration of too much oxygen. A previous history of
hyperventilation during dental treatment is a clue to anticipate this emergency.
The stress-reduction strategies noted above can be used to prevent this
condition.
General Health Changes
•
Ask patients, “Has there been any change in your general health within the past
year?”
•
A positive response to changes in general health requires follow-up questions to
investigate the change and needed medical care. A change in health may
represent an improvement; i.e., when one has recovered from cancer therapy.
However, if the client reports a worsening of general health, the clinician must
determine how the condition and/or treatment may influence oral health care. A
medical consult may be indicated to determine the appropriateness of dental
treatment and additional medical care, such as the need for premedication. For
example, a client may report a recent diagnosis of hypertension.
•
If extensive dental treatment is indicated and vital signs reveal abnormal values
(i.e., blood pressure ≥180/110 or pulse ≤50 bpm or ≥120 bpm), medical evaluation
should occur before treatment to determine whether the client can withstand the
stress of the dental procedure and if a vasoconstrictor limitation is necessary.
Medications
•
Ask patients, “Are you taking or have you recently taken any prescription or over-thecounter medicines? If so, please list all, including vitamins, natural or herbal
preparations, and/or diet supplements.”
•
This question gives the clinician an opportunity to correlate medications used with
general health. In some cases, clients forget to report all of their health conditions,
but will note medications prescribed for a medical condition. In addition, this question
prompts the dentist or hygienist to investigate drug effects, indications for use,
adverse drug events, and side effects. Drug side effects associated with a risk for
medical emergency or the necessity for modified treatment include postural
hypotension; anticoagulant effect or increased bleeding; hypertension; arrhythmia;
nausea, vomiting, or other GI complaints; and blood dyscrasias such as leukopenia,
neutropenia, or thrombocytopenia.
•
Any medication your client takes should be investigated using a drug reference text
before initiating treatment. It is important to learn the action of the drug and how
that might affect treatment, the dose the client is taking, side effects related to oral
changes, interactions between the client’s drug and drugs that might be prescribed
related to oral health care, and dental treatment considerations. Postural hypotension
is one of the most common emergency situations and is most frequently related to
taking a drug that lowers blood pressure, coupled with placing the client in the supine
position for a long period of time.
INR Number
•
In some cases, the client cannot recall all medications used or the details related
to medication management. Send the health history form to a new client’s home
in advance of his or her appointment. This gives the client an opportunity to list
the proper names of their medications, dosage, and use.
•
One potential problem is when a client presents for treatment and reports taking
warfarin, an anticoagulant that requires a monthly lab test known as
International Normalized Ratio (INR) to determine the risk for increased
bleeding. The client may not know why this medication was prescribed, the INR,
or the date of the most recent lab visit. It is essential to determine this
information prior to providing treatment to identify the risk for uncontrolled
bleeding. The clinician should request the most recent INR data.
•
If the INR is too high (over 3.5), elective oral health procedures may need to be
delayed. If the INR cannot be recalled or if the physician lowered the dose of the
anticoagulant at the last lab result, this might pose an increased risk for excess
bleeding
Allergies
•
Ask patients, “Are you allergic to or have you had a reaction to the following?”
•
▼ Local anesthetics
•
▼ Aspirin
•
▼ Penicillin, antibiotics
•
▼ Barbiturates, sedatives, sleeping pills
•
▼ Sulfa drugs
•
▼ Codeine or other narcotics
•
▼ Metals
•
▼ Latex (rubber)
•
▼ Iodine
•
▼ Hay fever or seasonal allergy
•
▼ Animals
•
▼ Food
•
▼ Other
Allergic Response
•
This question involves a variety of substances sometimes used as part of
oral health care that have been associated with an allergic response.
Hay fever or seasonal allergy and allergies to animals and foods are
included because clients with a positive history of any allergy are at an
increased risk for having an allergy to products used as part of dental
care. The length of time between being exposed to an allergic substance
and the development of signs of allergy can alert the health-care
provider to the risk of life-threatening emergency conditions.
•
Typically, the more rapidly allergic signs develop, the more dangerous
the situation. Mild signs of allergy include skin rash, erythema, hives,
urticaria, or stomatitis. Severe signs of allergy include
bronchoconstriction, asphyxiation, dyspnea, reduction of blood pressure,
and cardiovascular collapse (anaphylaxis).
Follow Up
•
Follow-up questions to evaluate allergic reaction potential include:
•
What specific agent (i.e., local anesthetic, antibiotic, narcotic drug,
latex, etc.) caused your reaction?
•
What were your symptoms? (used to determine true allergy vs. drug
side effect)
•
How rapidly did the signs develop?
•
Are you having any symptoms today (i.e., seasonal allergies)?
•
•
Are you currently taking any medications for seasonal allergies,
pain, infection, etc.?
How was your allergic reaction treated?
Document!
•
Oral health-care professionals must document in the dental record
any allergies to drugs or products likely to be used in the dental or
dental hygiene appointment, and use of these products must be
avoided during treatment.
•
Clients who report multiple allergies are at a significant risk for
allergy to products used during treatment and must be monitored for
signs of an acute allergic reaction. Keep an emergency kit containing
1:1000 epinephrine and regularly update the kit to ensure that drugs
are not out-of-date.
ASA PHYSICAL STATUS
CLASSIFICATION SYSTEM
•
ASA I
•
Patients are considered to be normal and healthy. Patients are able to walk up
one flight of stairs or two level city blocks without distress. Little or no anxiety.
Little or no risk. This classification represents a "green flag" for treatment.
•
ASA II
•
Patients have mild to moderate systemic disease or are healthy ASA I patients
who demonstrate a more extreme anxiety and fear toward dentistry. Patients
are able to walk up one flight of stairs or two level city blocks, but will have to
stop after completion of the exercise because of distress. Minimal risk during
treatment. This classification represents a "yellow flag" for
treatment. Examples: History of well-controlled disease states including noninsulin dependent diabetes, prehypertension, epilepsy, asthma, or thyroid
conditions; ASA I with a respiratory condition, pregnancy, and/or active
allergies. May need medical consultation.
ASA III
•
ASA III
•
Patients have severe systemic disease that limits activity, but is not
incapacitating. Patients are able to walk up one flight of stairs or
two level city blocks, but will have to stop enroute because of
distress. If dental care is indicated, stress reduction protocol and
other treatment modifications are indicated. This classification
represents a "yellow flag" for treatment. Examples: History of
angina pectoris, myocardial infarction, or cerebrovascular accident,
congestive heart failure over six months ago, slight chronic
obstructive pulmonary disease, and controlled insulin dependent
diabetes or hypertension. Will need medical consultation.
ASA IV
•
ASA IV
•
Patients have severe systemic disease that limits activity and is a
constant threat to life. Patients are unable to walk up one flight of
stairs or two level city blocks. Distress is present even at rest. Patients
pose significant risk since patients in this category have a severe
medical problem of greater importance to the patient than the planned
dental treatment. Whenever possible, elective dental care should be
postponed until such time as the patient's medical condition has
improved to at least an ASA III classification. This classification
represents a "red flag" - a warning flag indicating that the risk involved
in treating the patient is too great to allow elective care to proceed.
•
Examples: History of unstable angina pectoris, myocardial infarction or
cerebrovascular accident within the last six months, severe congestive
heart failure, moderate to severe chronic obstructive pulmonary disease,
and uncontrolled diabetes, hypertension, epilepsy, or thyroid condition.
If emergency treatment is needed, medical consultation is indicated.
ASA Continued
•
ASA V
•
Patients are moribund and are not expected to survive more than 24
hours with or without an operation. These patients are almost always
hospitalized, terminally ill patients. Elective dental treatment is
definitely contraindicated; however, emergency care, in the realm of
palliative treatment may be necessary. This classification represents a
“red flag" for dental care and any care is done in a hospital situation.
•
ASA VI: Clinically dead patients being maintained for harvesting of
organs.
•
ASA-E: Emergency operation of any variety; used to modify one of the
above classifications, i.e., ASA III-E.
•
ASA-P: Pregnant patient; used to modify one of the above classifications,
i.e., ASA III-P.
Blood Glucose
Diabetes
•
Diabetes mellitus leads to persistently elevated blood sugar levels.
Over time, high sugar levels damage the body and can lead to the
multiple health problems associated with diabetes.
•
But why are high blood sugars so bad for you? How much sugar in
the blood is too much? And what are good sugar levels, anyway?
Diabetes and Normal Blood
Sugar
•
At present, the diagnosis of diabetes or prediabetes is based in an arbitrary cutoff point for a normal blood sugar level. A normal sugar level is currently
considered to be less than 100 mg/dL when fasting and less than 140 mg/dL two
hours after eating. But in most healthy people, sugar levels are even lower.
•
During the day, blood glucose levels tend to be at their lowest just before meals.
For most people without diabetes, blood sugar levels before meals hover around
70 to 80 mg/dL. In some, 60 is normal; in others, 90. Again, anything less than
100 mg/dL while fasting is considered normal by today's standards.
•
What's a low sugar level? It varies widely, too. Many people's sugar levels won't
ever fall below 60 mg/dL, even with prolonged fasting. When you diet or fast, the
liver keeps sugar levels normal by turning fat and muscle into sugar. A few
people's sugar levels may fall somewhat lower. Without taking diabetes
medicine, though, or having uncommon medical problems, it's difficult to drop
sugar levels to an unsafe point.
Sugar Levels
•
Sugar levels higher than normal mean either diabetes or pre-diabetes is
present.
•
There are several ways diabetes is diagnosed:
 The first is known as a fasting plasma glucose test. A person is said to have
diabetes if his or her fasting blood sugar level is higher than 126 mg/dL after
not eating -- fasting -- for eight hours.
 The second method is with an oral glucose tolerance test. After fasting for eight
hours, a person is given a special sugary drink. That person is said to have
diabetes if two hours after the drink he or she has a sugar level higher than
200.
 The third way is with a randomly checked blood sugar level. If it is greater
than 200, with symptoms of increased urination, thirst, and/or weight loss, that
person is said to have diabetes. A fasting sugar level or oral glucose tolerance
test will be needed to confirm the diagnosis.
Prediabetes
•
But diabetes is not like a switch that gets turned on and off -healthy one day, diabetic the next. Any sugar levels higher than
normal are unhealthy. A blood sugar higher than normal, but not
meeting the above criteria for full-blown diabetes, is called
prediabetes.
•
According to the American Diabetes Association, 79 million people in
the U.S. have prediabetes. People with prediabetes are five to six
times more likely to develop diabetes over time. Prediabetes also
increases the risk for cardiovascular disease, although not as much
as diabetes does. It's possible to prevent the progression of
prediabetes to diabetes, with diet and exercise.
Lymph Nodes
Comprehensive Oral Exam
•
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.
Remember…
•
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 healthsystemic health connection, and providing reassurance about
privacy/confidentiality protocols.
ABCDT
•
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.
•
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.
Hard Tissue
•
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
•
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.
Deposit Assessment
•
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.
Periodontal Disease
ADA Class
Periodontal
Disease
Classification
Description
Type I No loss of attachment
Gingivitis Bleeding on probing may be present
Type II Pocket depth or attachment loss: 3-4mm
Early Periodontitis Bleeding on probing may be present
Localized area of gingival recession
Possible grade I furcation involvement
Type III Pocket depths or attachment loss 4-6 mm
Moderate Periodontitis Bleeding on probing
Grade I or II furcation involvement
Class I mobility
Type IV Pocket depths or attachment loss >6 mm
Advanced Periodontitis Bleeding on probing
Grade II or III furcation involvement
Class II or III mobility
Type V Periodontitis not responding to conventional
Refractory & Juvenile Periodontitis therapy or which recurs soon after
treatment.
Juvenile forms of periodontitis.
Oral Health Products