Pengantar

Dental Hygiene Process of Care

30 Mei 2019
 provides a logical system for
determining the health and disease
status of the client and for selecting
appropriate interventions and
The DH measuring treatment outcomes.
process of
care integrated with the client’s
comprehensive dental hygiene
diagnosis and care plan.
Dental hygiene process
Proses dental hygiene
• Faktor individu
• Faktor lingkungan;
• Tingkat pertumbahan dan maturitas;
• Kemampuan psikomotor
• Umur;
• Jenis kelamin;
• Gaya hidup;
• Budaya;
• Keyakinan;
• Tingkat pengetahuan.
 DENTAL PATIENT
HYGIENIST

CLIENT
Istilah Klien
• Merujuk pada individu, keluarga, kelompok,
komunitas atua bangsa
• Merujuk pada kesejahteraan seagaimana keadaan

Klien
sakit
• Merujuk pada seseorang sebagai partisipan aktif
di dalam pelayanan kesehatan gigi dan mulut
• Dapat bertanggung jawab atas keputusan yang
dibuat serta konsekuensi yang ditimbulkan
• Fokus utama atas pelayanan dental hygiene

• Individu yang sakit

• individu yang dependent dan membutuhkan
pengobatan

Pasien
• Terbatas untuk individu
Dental
hygiene
process of
care
a) Assessment
b) Diagnosis
c) Planning
d) Implementation
e) Evaluation
f) Documentation
a). Assessment
The collection and analysis of systemic and oral health data in
order to identify patient needs and includes:

1. Health History

2. Clinical Assessment

3. Risk Assessment
1. Health history
• Demographic information
• Vital signs
• Physical characteristics
• Social history
• Medical history
• Pharmacologic history
2. Clinical assessment
• Comprehensive oral examination
• Radiographic examination
• Dental and periodontal examination
 Identifies risks to general and oral health:
• Fluoride exposure
• Tobacco exposure
• Nutrition history
• Systemic diseases
• Prescription and over-the-counter
3. Risk assessment medications
• Salivary function
• Genetic and family history
• Habit and lifestyle behaviors
• Physical disability
• Psychological, cognitive, and social
considerations
 b) Dental hygiene diagnosis

Identification of an individual’s Requires evidence-based

health behaviors, attitudes,
and oral health care needs for
which a dental hygienist is
educationally qualified and
licensed to provide
critical analysis and
interpretation of assessments
to reach conclusions about the
patient’s dental hygiene
treatment needs
Provides the basis for the dental hygiene care plan

Multiple dental hygiene diagnoses may be made for

each patient or client
Dental hygiene diagnosis

Analyze and
Formulate Communicate Determine Identify
interpret
Analyze and interpret all Formulate the dental Communicate the dental Determine patient needs Identify referrals needed
assessment data hygiene diagnosis or hygiene diagnosis with that can be improved within dentistry and other
diagnoses patients or clients through the delivery of health care disciplines
dental hygiene care based on dental hygiene
diagnoses
 Establishing realistic goals and dental
hygiene interventions that can move the
patient closer to optimal oral health

The dental hygiene care plan should be a

vehicle for care that is safe, evidence-
c) Planning based, clinically sound, high quality and
equitable

The care plan should be individualized

• Identify needed interventions
• Prioritize the sequence of interventions
• Coordinate resources needed to facilitate
comprehensive quality care
• Collaborate with other health care providers to
provide high level, patient centered care
• Present and document dental hygiene care
plan to the patient/caregiver
• Counsel and educate the patient and/or
caregiver about the treatment rationale,
risks, benefits, anticipated outcomes,
evidence-based treatment alternatives, and
prognosis
• Obtain and document informed consent
and/or refusal
 Prevention – identifies interventions to prevent
further worsening or subsequent incidences of
the problem or disease

Treatment – therapy selected by the dental

hygienist appropriate to the patient’s diagnosis
Four-Prong
Approach Maintenance – recommendations for daily self-
care, monitoring, and scheduled intervals for
future dental hygiene care

Referral – other health care providers needed

for consultation and/or intervention
d) Implementation

• The act of carrying out the dental hygiene plan

of care
• Care should be delivered in a manner that
minimizes risk
• Focus on health promotion and self-care as part
of customized care
• Review and confirm the dental hygiene care plan with the
patient/caregiver
• Modify the plan as necessary and obtain additional
consent
• Implement the plan beginning with the first prioritized
intervention
• Monitor patient comfort
• Provide any necessary post-treatment instruction
 Implement the appropriate self-care intervention; adapt as necessary throughout
Implement future interventions

Confirm Confirm the plan for continuing care or maintenance

Maintain Maintain patient privacy and confidentiality

Follow Follow-up as necessary with the patient

e) Evaluation
• The extent to which the patient has achieved the goals specified
in the dental hygiene care plan
• Uses evidence-based decisions to continue, discontinue, or
modify the care plan based on ongoing reassessments and
subsequent diagnoses
• Use measurable assessment criteria to evaluate tangible
outcomes of dental hygiene care (probing, plaque control,
bleeding, retention of sealants, etc.)
• Communicate to the patient, dentist, and other health care
providers the outcomes of dental hygiene care
• Evaluate patient satisfaction of the care provided
• Collaborate to determine the need for additional
diagnostics, treatment, referral, education, and
continuing care based on treatment outcomes
and self-care behaviors

• Self-assess the effectiveness of the process of

providing care, identifying strengths and areas
for improvement. Develop a plan to improve
areas of weakness
Dental hygiene practice
based on a systematic process
of care that involves
assessment, diagnosis,
planning, implementation ,
and evaluation
f. Documentation
Record all components of the dental hygiene process of care including:
• Purpose of patient visit in patient’s own words
• Assessment procedures and findings
• Referrals made, to whom and follow-up
• Dental hygiene diagnosis
• Treatment plan
• All interactions with patient
• Dates and signatures
• Record in a legible, concise and accurate manner
• Use common terminology and standard abbreviations
• Ensure HIPPA compliance
• Respect and protect confidentiality of patient information
References

• Standards for clinical dental hygiene practice. Revised 2016. Chicago: American Dental Hygienists’
Association. 2016.
• Transforming dental hygiene education and the profession for the 21st century. Chicago: American
Dental Hygienists’ Association. 2015.
• Swigart DJ, Gurenlian JR. Implementing dental hygiene diagnosis into practice. Dimensions Dent
Hyg. 2015;13(9):56-59.
• Gurenlian JR, Astroth D. Diagnosis, Treatment Plan, Documentation, and Case Presentation. In
Henry R, Goldie, MP. (2016) Dental Hygiene: Applications to Clinical Practice. Philadelphia, PA: FA
Davis.