Improving Patient Outcomes through the Diagnostic and Care Planning Process

As dental hygienists, we are always searching for the appropriate, evidence-based interventions for our patients.¹ Instead of skipping straight to the solutions, let’s start with the questions and determine how we decided our patient needed such solutions. In practice, we conduct many assessments on our patients searching for problems that affect oral and systemic health outcomes. These identified problems are the dental hygiene diagnoses, or DHDx, that we address in the dental hygiene care plan.^2-3 When we educate patients on their specific problems/DHDx, we are providing the patient the opportunity to understand and make the best decisions for their health.⁴

Consider this patient. Blood pressure is evaluated on a 70-year-old male dental hygiene patient and determined to be 155/95 mmHg. He states he is very nervous about dental treatment. His wife passed away 6 months ago, and he has been lonely. His chief concern is sensitivity to cold on the exposed root surfaces of his mandibular anterior teeth, and this pain is the only reason he came into the office today. What problems would you document as DHDx at this point in the appointment? What interventions would you include in the care plan to address these DHDx? We will address the answers to this case later.

The expectations of dental hygiene practice are well beyond focusing specifically on periodontal and caries diseases.² As we evaluate patient systemic diseases, behavioral health, medications, tobacco and alcohol use, head and neck cancer exam findings, oral mucosal and dentition abnormalities, and social determinants of health (SDOH) unmet needs, as well as conduct a thorough investigation of periodontal health, we have learned there are many influencing factors for patient oral health outcomes. Some practitoners might still view the DHDx as just the periodontal classification stating whether the patient has periodontal health, gingivitis, or staged and graded periodontitis.⁵ While this is still extremely important, so is the revelation that there are many interlinking components to optimal patient health and oral health that cannot be overlooked.

Because we have the responsibility to provide patients with the best evidence-based care possible, we must expand our view of our diagnostic process and the categories of DHDx.⁶ What does evidence-based care mean? Health information, as well as misinformation, is at the fingertips of every health care provider and invariably every patient.¹ Our role as health care professionals is to evaluate the research evidence for dental hygiene practice and determine the best possible diagnostic and care plan interventions available.^1,3 We make our decisions based on research evidence.^1,3

All patients present in our practices with a level of risk for head and neck cancer, periodontal disease, and dental caries whether these are low, moderate, high, or extreme risk levels.² These risks levels are documented as the DHDx.⁶ Then evidence-based interventions for those risk levels are included and documented in the patient’s care plan. According to the Food and Drug Administration (FDA), there are no safe tobacco products.⁷ In dental hygiene practice, we ask patients about their tobacco use because we have evidence-based knowledge that tobacco use negatively affects systemic and oral health.⁸ We assess for use, and document use, as DHDx of a risk for oral cancer and a risk for periodontal disease. The ultimate goal of dental hygiene practice and patient care is to prevent disease. By recognizing and addressing a risk, we have the opportunity for early intervention and prevention.

We see evidence of attrition, erosion, and abfractions and patients report dentinal hypersensitivity on a regular basis. These are documented as DHDx and any product recommendations, treatment modalities, patient education, and/or referrals are documented as interventions in the patient care plan.⁶

Additionally, if a patient presents with depression and anxiety, these behavioral health problems are invariably affecting oral health self-care and optimal oral health.^9-10 If a patient presents with housing insecurity and has been living in their car, this is most likely contributing to less-than-optimal oral health and possibly negatively influencing the ability to manage systemic diseases that affect oral health such as diabetes mellitus.¹¹ Does the patient who lives in their car have the resources to get the supplies needed for self-management of their diabetes? SDOH factors are negatively impacting systemic and oral health outcomes for many patients.^11-17 If we do not assess for social needs, do we truly know if our patients have a need?¹⁸ When we assess SDOH needs and unmet needs are discovered, we document a DHDx such as housing insecurity, and then provide resource referrals in our dental hygiene care plans.⁶ The optimal goal is to improve patient systemic and oral health outcomes. Documentation affords us the opportunity to follow-up with the patient at a future time to ascertain if help was obtained.

Patients present in our practices with problems on many fronts. A DHDx is basically a documentation of the problems the patient is presenting at a given time at a particular appointment. Let’s look back at the patient mentioned earlier. Assessment data for health history, vitals, and chief complaint was given. Even with this limited data, this patient has the following DHDx:

• Risk for emergency due to uncontrolled blood pressure and dental anxiety requiring patient education, a referral to a physician, and stress reduction protocol.

• Psychosocial hindrance to care due to loneliness requiring possible referral for mental health counseling, and referral to social services and/or a senior citizen’s center.^9-10

• Dentinal hypersensitivity due to exposed root surfaces with care planning interventions for patient education, appropriate in-office treatments, and self-care product recommendations.

Evidence is available which means the dental hygiene clinician has the responsibility to search the evidence and provide the education and appropriate person-centered interventions necessary for each patient under their care. As dental hygienists become more proactive in expanding the diagnostic process to include the documentation of the patient’s DHDx, both systemic and oral health outcomes can potentially be improved.

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