Dental Hygiene Diagnosis

A dental hygiene diagnosis is a clinical decision made by a dental hygienist that identifies an actual or potential human need deficit that the dental hygienist is educated and licensed to treat (meet) and/or to refer for care. A dental hygiene diagnosis has the following characteristics:

Focuses on client conditions, behaviors, or risk factors related to oral health and disease

Derives from client data collected during assessment

Requires interventions within the scope of dental hygiene practice

Is necessary for planning and implementing effective dental hygiene care and evaluating its outcomes

Therefore after the assessment phase of the dental hygiene process the diagnostic process begins (Figure 19-1). Making a dental hygiene diagnosis includes identifying the following

Unmet human needs that can be met through dental hygiene care

Factors contributing to or causing the unmet human needs (causes and risk factors)

Evidence to support the dental hygiene diagnosis (signs and symptoms)

Figure 19-1 The concept of diagnosis within the dental hygiene process. The term dental hygiene diagnosis is used to describe actual or potential oral health problems that can be prevented or resolved by dental hygiene interventions. Broken line indicates completion of care until next continued care visit.

In making a dental hygiene diagnosis the dental hygienist works within the scope of dental hygiene practice. The process requires a concrete understanding of the scope of dental hygiene and collaboration between the dental hygienist and dentist.⁵

Historically, dental hygienists were cautioned to not diagnose, but to identify dental problems and then communicate the observations using phrases such as the following

“Mr. Jones has suspicious areas on teeth 14, 19, and 32.”

“Ms. Smith has signs of gingival and periodontal disease around teeth 22 to 26.”

“There appears to be a radiolucent area at the apex of tooth 8.”

Such observations are neither dental nor dental hygiene diagnoses and create confusion for the client. If state law permits preliminary diagnostic services provided by the dental hygienist, the dental hygienist could say the following

“Mr. Jones, my preliminary diagnosis suggests dental caries on several of your teeth; the final dental diagnosis must be made by the dentist.”

“Ms. Smith, the periodontal probing depths of 5 to 7 mm, mobility of 2, and bleeding around the lower front suggest moderate periodontitis; however, the final diagnosis must be confirmed by the dentist.”

“Mrs. Carson, your son has a radiolucent area on the root tip of his top front tooth suggesting a pathologic condition; however, a dental diagnosis must be made by the dentist.”

When a dental hygienist identifies oral disease, such as gingivitis or early periodontitis, this is called a preliminary diagnosis, which must be referred to a dentist for a definitive diagnosis and treatment or for possible delegation by the dentist back to the dental hygienist for nonsurgical periodontal care. When the client displays signs and symptoms of oral conditions that require diagnosis and treatment by a dentist, a dental consultation and referral are indicated for high-quality client care. When a client displays signs and symptoms of systemic conditions that require medical diagnosis and treatment by a physician, a medical consultation and referral are indicated.

Dental Hygiene Diagnosis versus Dental Diagnosis

Legal, professional, and social responsibilities require clear distinctions between a dental hygiene diagnosis and a dental diagnosis. Diagnostic decision making and therapeutic care fall within precise legal and professional boundaries. Dental diagnoses identify diseases or conditions for which the dentist directs or provides the primary treatment; dental hygiene diagnoses identify unmet human needs (also known as human need deficits) that can be met by dental hygienists within the scope of dental hygiene practice. Both types of diagnoses serve different purposes as related to the professional's scope of practice (Table 19-1).

TABLE 19-1 Dental Hygiene Diagnosis versus Dental Diagnosis

Dental Hygiene Diagnostic Classifications⁶

Making a dental hygiene diagnosis that is recognized as separate from a dental diagnosis requires a unique system to classify relevant clinical data about the client. Currently a classification of eight possible diagnoses (i.e., eight human needs) creates a standardized language for identifying client oral health conditions amenable to dental hygiene care. The dental hygiene diagnostic classification uses descriptors that focus on the client's human needs, thus emphasizing the client as an integrated human being rather than as a disease entity. This classification, based on eight human needs, is designed to work synergistically with the diagnosis of the dentist and other healthcare professionals. The diagnostic classification allows dental hygienists to focus on client needs and to communicate this information to both the client and other health professionals (Table 19-2).

TABLE 19-2 Dental Hygiene Diagnoses: Their Definitions, Possible Causes, Defining Characteristics, and Interventions

Synthesis, Analysis, and Interpretation of Assessment Data

Dental hygienists begin data synthesis, analysis, and interpretation during assessment. Figure 19-3 provides a tool that can be used to assess the client's unmet human needs. The dental hygienist looks for significant clusters of data that signal the presence of an actual or potential unmet human need, formulates a diagnosis, and develops a care plan (see Chapter 20).

Figure 19-3 Human needs assessment form.

(Adapted from Darby ML, Walsh MM: Application of the human needs conceptual model to dental hygiene practice, J Dent Hyg 74:230, 2000.)

Using Standards to Validate Diagnoses

To arrive at a valid dental hygiene diagnosis, the dental hygienist can compare observed data (objective and subjective) with an accepted standard. Appropriate standards include normative values for the client's age and oral status. For example, a child's gingival architecture may be normal given the child's developmental level but may be considered abnormal at another age. Similarly, a blood pressure of 130/90 mm Hg might be within the expected range for an individual with hypertension under the control of a physician but abnormal for a person not under a physician's care. To recognize significant data, consider the following

Changes in a client's usual oral or systemic health patterns that are unexplained by expected norms for growth, development, and maturation

Oral and systemic health status that deviates from normal limits

Behavior or condition indicating a developmental lag or risk to health or personal safety

Recognizing Patterns

Dental hygiene diagnoses should always be based on a cluster of significant information rather than on a single sign or symptom. The danger of arriving at a dental hygiene diagnosis from a single factor is evident from this example: The dental hygienist diagnoses an Eastern Indian woman as having an unmet human need for a wholesome facial image. The diagnosis looks to be related to a lack of dental care as evidenced by malpositioned teeth and a prognathic profile, but the observed data may have been misinterpreted. The dental hygienist mistakenly identified the cause as lack of dental care when really it is rooted in the client's culture, which accepts malocclusion as within the range of normal. The woman has had regular dental care throughout her life, but no orthodontic care because of her cultural orientation. Gathering complete data to support a recognizable pattern prevents the dental hygienist from formulating an incorrect diagnosis.

Identifying Unmet Human Needs

The next step in the diagnostic process is to determine the client's unmet human needs. The dental hygienist distinguishes between oral health conditions that only a dentist is qualified to treat (dental diagnosis), which requires a dental referral, and oral health conditions that require dental hygiene care (dental hygiene diagnosis). Here, critical thinking determines whether the identified condition requires a dental diagnosis, a dental hygiene diagnosis, or a medical diagnosis.

The client may also present information during the assessment indicating that he or she is at risk for developing an unmet human need (i.e., an at-risk problem). For example, the dental hygienist records that a client has signs of possible uncontrolled diabetes mellitus, but a hemoglobin A_1c test has not been done for at least 6 months. The dental hygienist then predicts problems this client is likely to experience as a result: a diabetic emergency, longer healing period than normal, continued breakdown of collagen and alveolar bone, and elevated risk for infection. These potential problems are related to the diagnosis of unmet human needs for protection from health risks and for skin and mucous membrane integrity.

Dental hygiene diagnoses have implications for planning interventions. For example, interventions may include collaboration with and referral to the dentist and physician of record, analysis of the client's diet and nutrition, review of the client's medication schedule, reduction in length of appointment, prophylactic antibiotic premedication, use of antibacterial dentifrices and mouth rinses to control the bacterial load, and establishment of a personal oral self-care program.

Identifying Strengths (Protective Factors)

At times a client may present no unmet human needs. This situation is an opportunity for the dental hygienist to identify the client's protective factors, build on these strengths for greater levels of oral wellness, and reinforce oral health promotion interventions to maintain and augment wellness. Protective factors may include maintaining good systemic health, living a healthy lifestyle, not smoking, eating a diet rich in fruits and vegetables and low in animal fats, exercising regularly, valuing personal health, seeking regular professional medical and oral care, and meticulously performing daily oral self-care behaviors.

Writing Dental Hygiene Diagnostic Statements

After analyzing the client's data, the dental hygienist reaches one of four conclusions, all of which require different actions. These conclusions and actions are shown in Table 19-3.

TABLE 19-3 Possible Conclusions and Actions Taken by the Dental Hygienist after Analyzing Client Assessment Data

If the action requires a diagnosis, the dental hygienist formulates, validates, and prioritizes dental hygiene diagnoses before care. Formulation of the dental hygiene diagnosis is based on the identification of the client's human needs as supported by the assessment data. More than one unmet human need may be found, and multiple dental hygiene diagnoses may be identified.

Three components comprise a diagnostic statement (Figure 19-4)

Unmet human need: Oral health condition or potential (at-risk) health problem amenable to dental hygiene intervention

Cause: Probable cause or risk factors

Signs and symptoms (defining characteristics)

Figure 19-4 Three parts of a dental hygiene diagnostic statement.

(Adapted from Darby ML, Walsh MM: Application of the human needs conceptual model to dental hygiene practice, J Dent Hyg 74:230, 2000.)

A diagnostic statement links the client's problem and its cause, guides the selection of interventions, and facilitates the definition of expected outcomes to evaluate the efficacy of care (see Chapter 20 for a discussion of expected outcomes).

Table 19-4 presents examples of dental hygiene diagnostic statements. Eight diagnostic categories (i.e., eight human needs) presented in Table 19-2 outline possible dental hygiene diagnoses. In this approach to diagnosing, the organizing principle guiding the diagnosis is human needs theory. The diagnostic statement provides a focus on specific client unmet needs so that the routine approach, characteristic of traditional dental hygiene care (a 45-minute appointment for oral prophylaxis, bitewing radiographs, fluoride application, and 6-month continued care) is no longer an appropriate standard.

TABLE 19-4 Formulation of Dental Hygiene Diagnostic Statements

Each diagnosis has a cluster of defining characteristics that must be observed during client assessment. The defining characteristics are the signs and symptoms that must be evident for the diagnostic label to be used correctly (see Table 19-2). The signs and symptoms are predictors for judging the presence of an unmet human need related to an oral health condition or a potential problem. The client's signs and symptoms enable the dental hygienist to focus on the true problem and to eliminate others. (The result of this process is referred to as the differential diagnosis.)

Sometimes the client may not have a problem yet but has risk factors and risk indicators suggesting that he or she is at risk for a problem. At-risk problems are conditions that should also be diagnosed so that actions can be taken to prevent the potential problem from developing. If the client is at risk for an oral health problem, there may not be signs and symptoms because the problem has not yet occurred; however, it is still preventable if risk factors are modified.

A diagnosis should be accompanied by noting

Factors that led to the condition or at-risk problem (cause or causative factors)

The objective signs observed by the dental hygienist and the subjective symptoms reported by the client (defining characteristics as evidence of the problem)

Thus a dental hygiene diagnosis is written as a three-part diagnostic statement:

Unmet human need

Cause (related to or due to)

As evidenced by signs and symptoms

Dental hygiene diagnoses should be documented as a permanent entry on the client's record. Guidelines for writing dental hygiene diagnoses are in Box 19-1. An example of a diagnostic statement is an unmet human need for skin and mucous membrane integrity of the head and neck, related to skill deficiency in removing oral biofilm, as evidenced by plaque and gingival bleeding scores of 5 and 3, respectively.

Potential health problems may not require specification of the cause. In these situations the observed risk factors are the defining characteristics. A dental hygiene diagnosis regarding an at-risk problem is written with its presenting risk factors as the defining characteristics. For example, a potential unmet need for freedom from health risks, as manifested by the daily use of spit tobacco.

Errors in Writing a Dental Hygiene Diagnostic Statement

The most frequent errors found in dental hygiene diagnostic statements include using emotional terms, including a dental diagnosis, including a medical diagnosis, presenting the cause as the diagnosis, or presenting signs and symptoms as the diagnosis rather than phrasing the diagnosis in terms of the client's unmet needs. These common errors are listed in Table 19-5, with guidelines on how these errors can be corrected. The dental hygienist must also avoid personal beliefs and values in the diagnostic statement by always referring to the documented data as assessed and/or reported by the client and recorded in the dental chart. Nothing should be recorded that insinuates negligence in the treatment rendered by another practitioner. For example, an unmet need for a biologically sound dentition, due to poor dentistry, as manifested by overhanging restorations. Table 19-6 provides examples of conditions that are not dental hygiene diagnoses.

TABLE 19-5 Common Errors in Writing Dental Hygiene Diagnoses

TABLE 19-6 What a Dental Hygiene Diagnosis Is Not

Validation of the Dental Hygiene Diagnosis

Once the diagnosis is formulated, it must be validated. An affirmative response to each of the statements in Figure 19-5 validates the dental hygiene diagnosis⁷ (see Chapter 20). The format in Figure 19-6 can be used to practice the process of diagnostic decision making. The dental hygienist can begin by reviewing Scenarios 19-1 to 19-3, in which the dental hygiene diagnostic process is applied clinically.

Figure 19-5 “Yes” answers to all of these statements validate the dental hygiene diagnosis.

Figure 19-6 Worksheet for making a dental hygiene diagnosis.

SCENARIO 19-1 YOUNG WOMAN WHO RECENTLY OBTAINED ORTHODONTIC APPLIANCES

Brenda Smith, age 16, Asian American, and a junior in high school, received full orthodontic appliances 1 month ago. Although she wanted the orthodontic appliances to correct the severe crowding of her anterior teeth, she is now experiencing an adjustment problem. Although she was last treated for gingivitis before placement of the orthodontic appliances, she decides to visit her dental office for a 3-month checkup. On assessment, the dental hygienist finds Ms. Smith to have significant loss of weight, slight generalized plaque-induced gingivitis, and fair oral biofilm control. All other findings are within normal limits. Ms. Smith verbalizes that not very many 16-year-olds at her school wear braces, that she can't wait to get them off, and that she can't stand to look at herself in the mirror. One of her high school friends said that she looked weird. She obviously has been experiencing high anxiety since the orthodontic appliances were placed. She said that she has a difficult time eating because food sticks to the appliances, and she feels embarrassed if the appliances are retaining food. She no longer likes to eat with her friends in the school cafeteria or when she is out on weekends.

SCENARIO 19-2 CHILD WITH AGGRESSIVE PERIODONTITIS

Devan Prince, age 12, female African American, is a new client in the dental practice and has been scheduled for dental hygiene care. Devan is in the seventh grade and is one of the star players on the girls' soccer team. She is with her mother Margaret (age 32) and her sister Bridget (age 10). After completing health and dental histories, the dental hygienist initiates a baseline assessment of the head and neck, intraoral and extraoral examination, a complete dental and periodontal assessment, assessment of human needs related to dental hygiene care, and client education and skill level assessment. Significant findings include 6-mm probing depths around teeth 19 and 30 and a 4- to 5-mm loss of clinical attachment around teeth 22 to 27. Oral hygiene is generally poor, and tooth mobility of periodontally involved teeth ranges from 2 to 3. Client has a knowledge deficit regarding oral biofilm, periodontal disease process, and status of the oral cavity.

SCENARIO 19-3 YOUNG CHILD WITH EARLY CHILDHOOD CARIES

Blake Olds, age 4, Caucasian, is brought to the dental hygiene care facility by his mother Caren, age 28. Caren is unemployed and on public assistance; therefore finances are a major concern. Blake has been in pain associated with his teeth. His mother reported that “he has been crying on and off for about 4 days, saying that his mouth hurt.” She indicates that she tries to appease his discomfort with sweets to eat. The dental hygienist conducts a complete health, dental, pharmacologic, and cultural history and initiates the assessment phase of the dental hygiene process. Given the immediate need for relieving the child's pain, she collaborates with the attending dentist, who extracts J, K, and L at that visit and who prescribes an antibiotic to control the infection. Blake's significant findings includes early childhood caries and periapical abscesses on J, K, and L, with caries also on teeth A, B, E, F, I, M, O, P, S, and T. After oral surgery the client is given postoperative instructions and is dismissed, and the dental hygienist analyzes the findings. Because of extraction and interproximal caries, the maintenance of space for the permanent teeth is a major concern. Although no significant periodontal probe depths were found, green and orange extrinsic stain, heavy materia alba, and oral biofilm were present throughout the mouth.