Assessing Patient Needs, Risk Factors, and Health Behaviors: From Assessment to Diagnosis

Components of Dental Hygiene Assessment and Diagnosis

  • The transition from assessment to diagnosis involves a comprehensive evaluation of several specific criteria:
    • Medical and health history.
    • Dental history.
    • Tobacco assessment.
    • Nutritional diary and dietary analysis.
    • Clinical oral examination.
    • Radiographic examination.

Medical, Dental, and Social History Documentation

  • Patient information must include demographic and contact data such as name, address, date of birth, gender, occupation, and emergency contact details.
  • Dental symptoms and history collection involves identifying:
    • Reason for the current visit.
    • Presence of pain or discomfort.
    • Date of the last dental exam and specific procedures performed at that appointment.
    • Date of last dental radiographs.
  • Specific functional and clinical symptoms to assess:
    • Difficulty opening the mouth.
    • History of serious head or face injury.
    • Pain during chewing, biting, or swallowing.
    • Bleeding gums during brushing or flossing.
    • History of deep cleanings or problems with dental treatments.
    • Presence of sores or growths in the mouth.
    • Bruxism (clenching or grinding teeth).
    • Jaw pain.
    • Reactions to dental anesthesia.
    • Sleep apnea indicators such as snoring or trouble breathing during sleep.
    • Dissatisfaction with the appearance of teeth or smile.

Medication and Substance Use Assessment

  • Blood thinners must be documented, including specific types such as Coumadin, Warfarin, Xarelto, Pradaxa, Plavis, or aspirin.
  • Medications for osteoporosis or Paget’s disease, including Fosamax, Actonel, and Boniva, require identification.
  • Hormonal replacements and birth control use must be noted.
  • Tobacco and nicotine product use includes cigarettes, cigars, snuff, chew, and vaping products.
  • Alcohol consumption is recorded in terms of quantity per week.
  • Controlled substance use, whether medicinal or recreational (e.g., marijuana), requires tracking of the substance type and weekly frequency.
  • Specific considerations for women include pregnancy (recorded by the number of weeks) and nursing status (recorded by the number of weeks).
  • Allergy assessment covers:
    • Aspirin.
    • Barbiturates, sedatives, or sleeping pills.
    • Codeine or other narcotics.
    • Sulfa drugs.
    • Penicillin or other antibiotics.
    • Metals and Iodine.

Clinical Oral Assessment Framework

  • Gingival color is categorized by area (General or Localized) as:
    • Pink.
    • Erythematous.
    • Cyanotic.
    • Melanin-pigmented.
  • Gingival contour and texture assessment involves:
    • Papilla shape: Pointed, Bulbous, Blunted, or Cratered.
    • Marginal shape: Flat or Rolled.
    • Presence of recession or clefts.
    • Attached gingiva texture: Stippled or Smooth.
  • Gingival consistency is evaluated as either Firm or Edematous.
  • Attachment levels must include observations of Mucogingival involvement.
  • Clinical Attachment Level (CAL) calculation requires the charting of recession within the periodontal record.
  • Dietary analysis identifies deficiencies in Vitamin C, Calcium, or H2OH_2O and excesses in sugar or soda.

Differential Diagnosis: Gingivitis vs. Periodontitis

  • A differential diagnosis involves deciding between two or more conditions that share similar signs and symptoms.
  • Key differentiators between gingivitis and periodontitis:
    • Gingivitis is characterized by red tissue and bleeding.
    • Periodontitis is confirmed by the presence of clinical attachment loss and bone loss evidenced on radiographs.
  • Probing depth (PD) ranges for periodontal assessment typically include measurements of 1−5 mm1-5\,mm.
  • Provisional diagnosis example: A patient reports bleeding gums during brushing. The hygienist observes red tissue and probing depths of 1−3 mm1-3\,mm. If radiographs show generalized bone loss, the diagnosis is Periodontitis.

Periodontal Risk Factors

  • Modifiable risk factors provide opportunities for behavioral changes through:
    • Oral hygiene instruction.
    • Smoking cessation programs.
    • Nutritional counseling.
  • Non-modifiable risk factors are outside patient control, including genetics, age, and systemic diseases that alter host response.
  • Systemic medical conditions:
    • Diabetes increases the risk of inflammation, bone loss, and oral infections while causing slow healing.
  • Dental history risk factors:
    • Mouth breathing and orthodontic appliances.
  • Clinical risk factors observed during exams:
    • Tooth position and overlapping teeth.
    • Weak contacts leading to food impaction.
    • Tooth surface irregularities and exposed cementum (roughness that retains biofilm).
    • Subgingival calculus.
    • Overhanging restorations.

Medication and Substance-Induced Gingival Enlargement

  • The "PCC" mnemonic identifies three classic medications causing gingival enlargement:
    • Phenytoin: An anti-seizure medication that cause fibrous, non-painful enlargement; severity often correlates with poor oral hygiene.
    • Cyclosporin: An anti-rejection medication for transplant patients (often kidney transplants) causing inflammatory, soft, and easily bleeding enlargement.
    • Calcium Channel Blockers: Used for angina and hypertension (e.g., Nifedipine, Amlodipine), causing enlargement ranging from mild to severe.
  • Additional substances impacting periodontal health:
    • Oral contraceptives.
    • Tobacco: Smoking accounts for 40%40\% of all periodontal disease cases.
    • Smokeless tobacco: Often leads to localized periodontal issues.
    • Marijuana: Associated with severe periodontitis.
    • Methamphetamine and Cocaine.

Formulating the Diagnostic Statement

  • Diagnostic statements must justify the treatment plan and remain within the dental hygienist’s scope of practice.
  • Formula: Problem + Risk Factor/Etiology.
  • Specific diagnostic examples:
    • Gingival bleeding related to inadequate biofilm removal at the gingival margin.
    • Enamel demineralization related to excess intake of fermentable carbohydrates.
    • Halitosis related to biofilm accumulation on the tongue.
    • Localized recession related to prolonged use of smokeless tobacco.
    • Xerostomia related to medication for seizure control.
    • Gingival inflammation related to insufficient control of blood sugar.
    • Stage II Grade B Periodontitis related to radiographically evident bone loss and smoking 1010 cigarettes a day.
  • Potential problem statements:
    • Potential for clinical attachment loss related to high levels of periodontal pathogens.
    • High risk for root caries related to numerous exposed root surfaces due to recession.
    • At risk for occlusal caries related to poor dexterity and deep occlusal pits and fissures in a pediatric patient.

Human Needs Model and Maslow’s Hierarchy

  • The Dental Hygiene Human Needs Model posits that behavior is motivated by need fulfillment.
  • Metaparadigm components include harmony between humans and environment, individual autonomy, and access to healthcare.
  • Maslow's Hierarchy of Needs dictates that basic physiological and safety needs must be met before a patient can be motivated by higher-level needs.
  • Impact of unmet needs on oral health behaviors:
    • Physiological (Food, Water, Rest): Poor nutrition leads to delayed wound healing; dehydration causes xerostomia; homelessness restricts access to water and tools for hygiene.
    • Safety (Security): Fear from unsafe environments or assault can lead to abnormal vital signs, heightened pain response, and physical trauma such as missing teeth.
    • Belongingness and Love: Intimate partner violence can cause pain or inability to open the mouth; social needs may drive a desire for whitening, braces, or concerns about halitosis.
    • Esteem (Prestige): Eating disorders like anorexia or bulimia cause tooth erosion and oral lesions; obesity increases periodontal risk; depression leads to neglect of oral hygiene.
    • Self-Actualization: A lack of purpose or self-awareness can lead to a patient being disinterested in or unaware of poor oral health status.

Questions & Discussion

  • Question: How do you decide if a condition is gingivitis or periodontitis?
  • Answer: One must still perform probing and take radiographs to look for bone loss and attachment levels.
  • Question: Can a dental hygienist diagnose caries?
  • Answer: A hygienist cannot definitively diagnose caries; they identify "suspicions" (nghi ngờ). However, caries prevention is within the dental hygiene scope of practice.
  • Scenario: If a patient has an unmet need such as difficulty chewing due to TMD as evidenced by pain, how is this diagnosed?
  • Discussion: This is framed as an unmet human need where the diagnosis identifies the deficit (TMD) and the evidence (pain).
  • Observation at 1st appointment: If a probe touches the bottom of a space (1−3 mm1-3\,mm) and indicates the tissue is not attached well, a radiograph is necessary to see if there is bone loss before concluding a "gum disease" is present.