so in the previous video we were looking at extraordinary intraoral assessment another type of assessment we do in clinic is the hard tissue assessment dental charting so one of the things we'll look at in the in um actually later on is in this video is biologically sound and functional dentition this is one of the um human needs that we need to look at in more detail what one thing that is important to note is in this human need biologically sound and functional dentition what we're looking at is to see if someone has any cavities to see if someone has any damage to that tooth damage to see if they have any developmental anomalies because if they do we need to address that in the care plan we need to address that in a care plan underneath under the biologically sound and functional uh human need so when we do a hard tissue charting or dental charting we are documenting everything it could be in paper or it could be like this electronically it is a graphic it's a dental chart this is a graphic representation of the patient's teeth on a specific date and then we update it regularly we're putting we're noting down all the restorations we're noting down the exact location of routine if there's any drifting if there's any uh you know tilting rotation all that is recorded in the dental charting electronic charting is honestly um a great option because it saves space in the in your office it is readily available and it allows for um incorporation of digital radiographic images so you could put like uh you could use the intraoral camera and incorporate and put that into your bot into the file same with digital radiographs you could all incorporate it all in one in one file electronically however the downside is it is expensive there is a learning curve it's not easy to learn all this as you see here there's so many different options you can do um so that is the downside however more and more offices are turning and switching to electronic charting now when you do hard tissue charting it's really important that you have basic knowledge of t classification primary teeth ha there are 20 secondary or permanent teeth we have 32. the key difference what is the key difference between primary and secondary when you look at the number of teeth they have we know that primary has less than secondary another uh key thing is that secondary teeth or permanent teeth have premolars primary teeth do not have premolars so the ones in yellow no premolars in primary teeth these um molars that are in primary teeth become they come out and they re and the premolars replace those molars here there are two in per quadrant whereas in permanent dentition we have three molars we can divide the mouth into four that is quadrants and we can also divide the mouth into six and that is seconds now i know you guys all know what measles and distals are but we did you know that you can also divide the the two into three so we have the in size we're looking at the incisor t we have the incisal third we can have the middle third and the gingival third and we can also do that for the posterior teeth where we have doesn't say that here okay so we we're actually looking at it vertically in this one but you can also look at it um horizontally where you have the occlusal third the middle third and the gingival third or cervical third in this picture what we're seeing is we see the mesial we see the distal and we see the middle third one fun fact that i want to point out is look at how the roots are curving roots almost always if they if there is a curve it would curve to the distal side so if you're ever unsure um you know if it's the right or left look at the the the curve of the root and you can figure out that if it curves distally you know that that is this side over here is the distal side apical is towards the apex of the root middle is right here and cervical means along the neck along the neck of the tooth which is right here cervical third two numbering systems are important to note for the board exam so uh in canada we use the fdi or the international numbering system but in the states for example they may use the universal numbering system palmer notation is also another notation to note so let's look at the key differences when we look this is primary t then you can tell because they there's only 20 t and there's no premolars so universal numbering what they do for primary teeth is they note that in alphabets so you start with the upper right and you go all the way down to the bottom and it's noted alphabetically in order so a b c right all the way down to t with fdi what you'll notice is you'll see two numbers the first number refers to the quadrant the second number refers to the number of the two number in that quadrant so for example when we're looking at primary dentition we have chord 5 quad 6 quad 7 quad h and so if you look at 5 5 1 5 is the fifth quadrant that's what it refers to and one refers to the first two in that quadrant this is quad seven this is quad five quad six quad seven and again when you look at this number seven seven refers to it's in quadrant seven and five refers to is the fifth two in that quadrant and polymer notation the way you do it is you box it depending on which arc it is at so if you look at this one for example this is on the top right so you have to box it like this to show that it's not on the top right if you do the top left it would look like this and then you put the appropriate number here so this is d which indicates that this is the smaller so every tooth a for the first tooth b for the second tooth has its own letter amplitude has its own letter so all in sizes central incisors are given a all lateral incisors are given the letter b and so on and so forth and the same thing applies for the um permanent teeth we could do universal we could use universal numbering where you start with one and you end all the way and it goes in clockwise motion to 32 and everything has their own number if you have a missing um or extracted wisdom teeth this is not number one this will still be one so this is number one this is number two this is number three and so on fdi we have quad 1 quad 2 quad 3 quad 4 the first number refers to the quadrant the second number refers to the two numbers so this is tooth number eight to resist empty the third molar and that's the number there important thing to note is to differentiate the universal with the fdi with universal we can say 10 11 12 13 14 for two numbers but with fdi we must say 2 6 2 5 we don't say 26 25 that's how we can differentiate um that so when we say 2 5 the first number refers to the quadrant the second number refers to the number of the fifth number of tooth within that quadrant nomenclature this is important so when you are identifying a atute what you want to be mindful of is nomenclature follow the daqt system so deeper dentition a for our for quadrant t for two so here's an example dentition refers to is it primary or is it permanent so here we have permanent arc refers to is it maxillary or mandibular here we have non-jabular quadrant refers to is it right or is it left here we have right and two refers to well which tooth is it first premolar so this is a great example of nomenclature where we have identified the two using the daqt system this is an example of permanent teeth and this is a tooth and this is an example of primary tooth if your client is in pain and you want to find out more about it remember we're talking about open-ended questions so try to ask as many open ended questions as possible so tell me about your pain is good instead of do you have pain do you have pain as a yes or no but tell me about your pain you're encouraging them to elaborate and you can see in this slide there's many different questions you can ask because you want to ask them about how intense it is is it mild moderate severe get them to rank it on a scale of 1 to 10 for example get them to point out to it get them to tell you how long it lasts get them to tell you when this pain happens is that when you're lying down or is it when you're bench over and then what is the quality of that pain is as sharp is it dull is it stabbing is it throbbing you need all that information so that when the dentist comes over to do a check you can relay that information to him or her now how do you check for cavities how do you check for carries well you could look at it directly so you could do a direct visual examination and sometimes we can tell when you see a hole under you know in the tube you know you could do trans-illumination which is where you shine a light through the tooth and when you shine a light through the tooth if you see some darkening it could be a carry it could be carries you could do tactile clinical examination where you use an explorer and you you put the explorer in that area where you see a cavity no longer recommend it though and the reason why it's no longer recommended is because let's say you find a cavity and you're poking it with an explorer and then you take that explorer and you take you put it somewhere else and you poke something else well now you've just taken the bacteria from that carious lesion the initial care use lesion and you're you're putting it elsewhere so it's not exactly an ideal thing to do anymore radiographs are huge radiograph will tell you if there are any carries on the interproximal or occlusal region and then to you know go by what the client tells you if the client is saying they're in pain then um you know figure out where they're in pain and and that can also help you narrow down what the reason is for the pain is it carries or is it something else we're also when we do a heart tissue charting we're not only looking for carries we're also looking for two damage and we need to chart those accordingly onto the um dental chart or the heart tissue chart so sometimes if they're grinding like crazy you can get attrition if they are grinding and clenching a lot over time you can get a fraction this is severe abstraction that can happen over time with grinding and clenching with bruxism if they have an acidic diet it could wear away their teeth if they have acid reflux they could cause erosion as well and an abrasion is if they're brushing really really hard it can it can cause abrasion so when you're checking for cavities there are many different types of cavities there are early childhood case which just means cavities that children get if they're under the age of five and you see caries they fall under the early childhood categories raping carries are where you see sudden where you see a huge rapid amount of destruction on the teeth that requires urgent you know immediate attention that's a rampant carries like that where oh no the poor child has cavities almost everywhere chronic hairs that's our our typical you know uh case where you would see this is extreme but where you see a decay and progresses slowly chronic means slow right so you see a cavity that is progressing slowly arrested this could be considered as an arrested carries where um you know carry started happening there was a cavity and then all of a sudden the cavity stopped growing so now it's starting to get remineralized it's starting to the enamel is starting to heal the area so arrested is when it stops progressing when the cavity has stopped from progressing and recurrent carries this is an example of recurrent care you had a cavity you got that restored and now you have a cavity underneath that restoration that's known as recurrent or secondary caries now when you look at um uh toots let's see if i can draw it in perhaps yellow so it stands out more so here we have a molar for example when you have a cavity right here on the pit and fissure that's called a pit and fissure carries when you have cavities on the mesial or on the distal that is called proximal carries because it's on the interproximal region if you have cavities on the buckle or on the lingual side um it could also even be on the meso or distort sometimes we call that smooth surface carries and then root carries if you see cave carries or cavities on the root now when you're classifying caries there are two ways of classifying you could classify it using the black classification system you could also classify it using the complexity classification system so let's start with this one complexity complexity classification system is when you identify cavities based on how many surfaces have been affected so for example if you find a cavity so if you see a cavity let's draw this again and it's just on the occlusal surface that is considered simple over occlusal it was just on the occlusal surfaces if you find um a cavity and it's on the mean zero who's also the cavities on the mesial and the occlusal side and you have two surfaces involved that is called a compound because there's two surfaces in um involved so mo this is an mo carries and complexes when you have three or more surfaces so let's say the distal is also affected so now we have mesial occlusal and distal surface affected and that is considered complex caries mod in this example m o for occlusal d for distal here's a question for you guys according to gb's blacks classifications of dental restoration what type of dental restoration is an amalgam filling located on the occlusal surface of 215. notice i say 2 15 15 means it's not 1 5 it's 15 15 is universal numbering system the fdi for this is 2 7. so occlusal surface that is a class 1. so let's look at the black classification if you have so his class one if you have an occlusal filling or a filling right here on the lingual that is class one class two is when you have interproximal cross on the molars um or posteriority class 3 is interproximal on the anterior teeth class 4 is when you have it on the incisal ridge also in the interproximal region so 2 3 4 all include interproximal regions class five is along the cervical along the neck of the tooth where you do a restoration along the neck cup titus and class six is when you do it on the cusp it can also be when you do it on the incisal ridge as well okay that's class six so be familiar with the gb black classification so curious detection how can you detect because we kind of touched on this but remember you could look at it visually to a visual assessment and check um for where it is what color it is and you know what the surface feels like what the texture is radiographs are huge bite ones and pas are excellent tools for checking for carries remember we said explorer is no longer recommended because you can transfer bacteria karyogenic bacteria to other areas and intraoral cameras use that to your advantage take pictures be um proactive when you before the dentist comes in for a check have all the pictures of take intraoral pictures of all the areas you're concerned about so that you can bring it up to the dentist the dentist would be so impressed if you have a big cavity that has progressed through the pulp it can create an abscess and that's when you need to do a root canal once it hits the pulp and creates an abscess that's a a huge problem and now you have to do it their client needs a root canal which is even more costly for them there are many developmental anomalies that can be found um on the uh on your client's teeth and it's important to be familiar with that because that's something that you may want to chart and notify in there that you do want to try to document in their uh in your client's chart so i have a video on dental anomalies it's 13 minutes long but it looks at all the different anomalies like hyperdontia mesoderms fusion hyperdonjery all the different anomalies are shown with images in that video so i do encourage you guys to have a look at that video that looks at the different anomalies all right let's look at occlusion now so another thing that we always document in the heart tissue section is occlusion and so for occlusion what we want to note is um well actually what we should be mindful of is what's what is their centric occlusion what does that look like so century occlusion is when they close how does it look like what does this the what is the relationship of the max t to the manatee when they close in a normal in a fully closed position so when the jaws are fully closed that is centric occlusion centric relation is when you're just looking at the um the jaw placement when you're just looking at the bone okay so when you're looking at how the mandible jaw and the maxilla jaw are placed more specifically you're looking at the condyle which is right here so there are three different types of classifications there's class one class two and class three let's look at them so class one what do we see in class one class one is when you have the mesial buccal cusp of the first molar aligned with the mesial buccal group of the first molar do you see that the cusp over here is aligned with the groove now what happens in class two is where you get when you get the mandibular teeth shifted in and you can see that the mandibular teeth have been shifted in pushed in and now the mesial buccal group is distal it's behind the cusp in class 3 the mesial buccal group is a head is mesial to the museum alcohol cusp of the maxillary first molar so class one is when they align when the mesiobuccal group align with the group class 2 is when the group has been pushed distal class 3 is when this group has been pushed measle you can also assess it with the canine relationship so people are missing the first molar you can also assess it with the canine relationship and look at the canine in relationship so you would look at the position of this canine in relationship to the max canine now when you have male occlusion so class one again class one is when the align so when the mesial buccal cusp align with the mesial um buccal groove male occlusion means something is wrong something else is wrong so you could have crowding you could have an overbite you could have an end bite end to end bite or crossbite so let's look at this let's say your client is biting completely and there's an open bite right here this could be because they're a tongue twister this could be because they suck their thumbs and so when they bite down you see an open area that is open bite if they bite down normally when they're biting down like normal and they have um this end-to-end bite where they're occluding their maxillary teeth are occluding with the manageability without overlapping there's no overlap typically what happens is the max overlaps demand max overlaps demand that's not happening here that is end to end byte this is crossfit because remember as i said typically what happens is the maxillary t come out mandibular teeth are in and here we see the opposite where it's not n to n but we see the max in manned out that is considered a cross byte again mand is out max is in cross byte because typically it's the other way around now when someone has class 2 occlusion so remember class 2 occlusion is when you have i'll review that slide one more time it's really important you know that when the mesial buccal groove is distal okay so when you have that distal inclination so the mesial buccal group is distal to the mesial buccal cusp now if someone has class two occlusion you could have division one or division two so you need to specify what type of division is it division one is when the when the front teeth when the maxillary incisors are you know they protrude facially they're normal but division two is when you get this happening when the maxillary essential incisors are retruded are inclined that is classed to division two and class three class three is again i'll show you that picture so we can visually see it class three is when the mesial buccal group is ahead mesial to the mesio buccal cusp now in primary teeth we can also assess for occlusion so when you have a a child that's coming to you we check for primary occlusion what we like to see what is ideal is when you have a flush terminal plane where the maxillary and mandibular second molars they can either occlude an end to end byte or you can get the um mandibular second molar is mesial to the uh primary maxillary second molar so you can get this step when the molar is mesial to the um maxillary second molar so you're looking at the second molar and it's uh musical so again just to recap when we're checking for primary occlusion we are checking for a second roller we're looking at the second roller not the first the second molar and when we're looking at the second molar we want to see what the relationship is and if you see this type of relationship or this relationship where the manned molar is mesial to the max second molar then that's normal that's ideal we like that this is when you see a distal step so this is called mesial step this is called distal step when the manned molar second molar is distal to the max second molar that is distal step and this is not ideal but these two are ideal the word parafunctional is an important word because parafunctional what that refers to is when you're using your teeth with um and you're not using your teeth to chew so all of these are examples of pair of functional habits functional is when you're using it to chew because functionalize we use our teeth normally to chew but para functional is when you're subconsciously using your teeth for reasons other than chewing so clenching when you're biting down really hard bruxism that's like grinding when you're a thumbs up you know thumb or fingers sucking or rocking up the teeth when you're playing with your teeth those are all pair of functional habits and they can cause extreme damage to your 2d dentition let's look at the difference between primary trauma and secondary trauma primary trauma is let's say you're grinding like crazy and um you're grinding in an area that has no previous bone loss okay so this has never been altered because of periodontitis and no bone loss in that area and now you're grinding and causing damage to an area that has not been previously affected by periodontitis secondary trauma is you're grinding to in an area that has already been affected by periodontitis see how the bone level is intact in primary trauma and now in secondary trauma the bone level has been reduced it has been reduced because of previous periodontal diseases because of previous periodontitis so when you are grinding or clenching and putting a lot of pressure on the occlusal surfaces you're going to do damage to that area if you're doing damage to an area that has already been damaged before because of periodontitis that is considered secondary trauma okay let's move on to dental hygiene diagnosis which is chapter 22 of the fifth edition of darby so again remember we did assessment where we're collecting data and now we're going to move on to diagnosis and diagnosis is when you're interpreting and analyzing the data that you have collected here and then you're going to figure out okay what is wrong with that client and how can we help that client so when you come up with a dental hygiene diagnosis it's important to look at all the assessment data an identity it's also important to figure out what their client's attitude is towards dental care are they willing to change or they're not willing to change and based on that you can help them um and what you're trying to do is come up with a client specific care plan or treatment plan care plan is actually a better word you may want to collaborate with their doctors and other in you know other professionals to come up with a dental hygiene diagnosis so what do you do well the first thing you do when you create a care plan is you analyze all and interpret all their assessment data so you're going to like highlight the red flies what are the areas you're concerned about then you come up with a dental hygiene diagnosis and then you're going to tell your client that dental hygiene diagnosis and then you're going to determine you know which ones you can you can actually help so which one has a hygienist we can fix so if they have cavities you might want to refer them to a dentist because that's not within our scope so determine what you can do for dental hygiene care how you can help them in within your scope of practice and then make referrals the referrals are needed for you know areas that you can't help out with like carries for example or you know seeing a social worker because they're under a lot of financial stress then you send out those referrals so the human needs modeled there are eight human needs and i don't have all of them here i'm going to show you where they are over here okay here we go there are eight human needs that we need to be mindful of and these are all related to oral health and disease and it's important that we are familiar with what all of these mean and i'm going to go over them shortly with you because when you find from the assessment data when you find information when you find red flags for example you can put them under specific categories so before i go over this let's look at this question formulating the dental hygiene diagnosis statement involves which of the following so i'll let you have a read and you tell me what you think i'm hoping you said a identification of the i the condition problem so first you're going to identify the problem i'll show you what that looks like then you're gonna figure out what the contributing factors are what caused that problem and then what signs and symptoms are there that relates to that problem so let me show you um an example so when you come up with a treatment plan once you've identified the unmet human need which i'll go over in a bit what you then need to do is you need to figure out what caused what are the contributing factors and what are the signs and symptoms so what are the contributing factors what caused that deficit and what are the signs and symptoms that cause that you know that that is related to that deficit so we're going to look at some examples of this but before i do that let's look at this these are the eight unh human needs these are the eight human needs that are important and so let's look at protection from health risk health risk is anything protection from health risks if they are not seeing a um a doctor for example and because their bp is outside of normal limits and you're concerned and they have to go see a doctor so anytime there you have health issues you put them in in this category so bp outside of normal limits they need pre-med so this is something we have to put under because they brought these are all health risks they're at risk for bacteria they're at risk for hypertension they could be at risk for injury so any risk factor puts them in this category skin and mucous membrane this is where you see swelling you see plaque index you know that are high you see deep pockets any cows dry mouth anything to do with the the skin and mucus anything to do with the mucous membranes to think about gums think about buckle mucosa think about tongue all that falls under here any red flags that you found relating to the mucous membranes or the tongue the buccal mucosa all that that falls on the gums that falls under here so bleeding freedom from fear and stress if they tell you they are very stressed about coming here if they have concerns about fluoride mercury from amalgam feelings infection control they're concerned about they're really stressed and anxious you can put them in this category and then make make a goal to help them with this biologically sound and functional dentition that is anything teat related so if they have overhangs if they have missing teeth you're going to recommend implants you're going to recommend bridges whatever it is for missing teeth that you want to recommend dentures right that's another one if they have abrasion erosion refraction attrition what can you do to help them with that so anything teeth related cavities they fall under biologically sound and functional dentition freedom from pain that is another one so if they're telling you they have pain in you know on one side of their mouth or on specific areas of their teeth you need to document that under freedom from pain so that we can make a goal pertaining to that conceptualization and problem solving this is if they have no idea about if they've never been taught for example about something so if they've never been taught about periodontitis or gingiva never ever have they ever been told anything about oral disease you put them here in conceptualization and problem solving so they have questions for you about dental hygiene care and this is where um you could put them you know those deficits within within this unmet human need and then you can create a goal to help them understand everything or understand all the all the um questions they have so maybe they don't even know that um they don't even know anything about let's say oral disease or how how cavities happen and they have no idea they've never been taught you can put that under here wholesome facial image this is when the client themselves tell you they're unhappy with something so maybe they're unhappy with how their teeth look maybe they're unhappy with how their gums look because it's so swollen maybe they're unhappy with their breath they find that they have bad breath this is not what you predict this is what the client is telling you and then lastly responsibility for oral health so if you find they have lots of plaque if they find a have lost you have you know they have lots of calculus um if you find that they've never gone to a dentist in so many years more than two years to be specific you put them under responsibility for oral health the difference between these two is responsibility for oral health is they know they know they should be seeing a dentist regularly they know they should be coming often um whereas in conceptualization and problem solving they had no idea that they were supposed to come regularly or they had no idea about the periodontal disease process so they have no idea about the kiwis process so responsibility for oral health they know the importance they just didn't have the time or money to do it to come and conceptualization and problem solving as they genuinely had no idea so when you write a dental hygiene diagnosis the first thing you do is you figure out what unmet human needs they fall under then you figure out well what is the cause and then you figure out what the signs and symptoms are and then based on that and i'll go over some examples but based on that then you can come up with the goal and you can and you can figure out how you can help them with their with their problems how you can help them with their unmatched human need okay so when you write a goal i'm just gonna click here okay so when you write a goal um sorry when you write a dental hygiene diagnosis i should say you come up with the you figure out what the unmet human need is so let's say a wholesome facial image so this means this client has told you something that they're not happy about so you come up with the cause what is the cause what caused this unmet human need well what caused it was mobility they the the client um you know said that they are very so this is the sign and symptom cyanide symptoms what you see inside the mouth and what the client has told you so here the client has told us that um they're concerned that the front teeth are loose so that's what's bothering the client and what is the cause what caused this the frontie to be you know mobile well there's class two mobility on the front teeth from periodontal disease so it's a periodontal disease that caused this um deficit and design and symptoms the client told you that skin and mucous membrane so skin and because membrane what do you see signs and symptoms are what do you see well you see bleeding on probing you see recession you see pockets right and what caused it well what caused it was the block was the calculus that caused all of these signs and symptoms that caused this unmet human need biologically sound and functional dentition that means there's something wrong with the teat itself and you notice that when you when you the sign was when you looked inside you saw that have loss of carries they had active carries that you suspected and what the dentist told you and what caused this what the cause was maybe drive out from medication maybe that the client had no idea what about the carey's process and how to take care of their mouth when um you know how to clean clean their mouth they don't know anything about the caries process so signs and symptoms are what you see ideology is what is what caused that xerostomia for example in this case what caused it placard calculus caused all this bleeding and recession what caused the loose teeth well mobility because a periodontal disease mobility from periodontal disease right that's what caused the frontie to get loose once you have identified the dental hygiene diagnosis once you've written it out then you have to come up with a goal for each and every single one and you can have multiple goals for each type of deficit so that's very common people have three or five goals per you know per deficit motivational interviewing is really important so when you're presenting the care plan to your client don't just tell them everything collaborate get them to participate get them to um give feedback get them to help you come up with strategies because that is the best way to allow them to to get a positive response you need to allow them to take part and take control of the treatment when you do a dental hygiene diagnosis it's uh great because this is a tool for measurement because then what you're going to do is you're going to look at all the goals that you have created so for example at the end of treatment you're going to look at all the goals that you have created and you're going to see whether you're going to evaluate it you're going to see whether you're the goal was met unmet or partially met so all the goals that you come up with should be measurable should be you know oh it should be outlined in such a way that you can measure whether this was met or unmet or partially met so let's look at this question the delivery of preventive and therapeutic procedures specified in the care plan to meet a patient's needs defines what is that called when you're actually delivering the preventive and therapeutic procedures when you're actually educating the client when you're doing it's preventive there are so many things we do prevent that fluoride is prevention for caries um education is prevention for further um you know so that they don't get they don't get more bioform so we're educating them to prevent periodontal disease therapeutic are things we do so we can debridement as therapeutic because we're helping them uh fluoride could really also be considered therapeutic uh polishing right is there is also a way to remove stains so what are the procedure whatever we are doing falls under what the correct answer is implementation because implementation is when we're deep writing when we're offering education when we're doing fluoride when you're doing polishing all that nutritional counseling tobacco cessation all that falls under implementation you plan it out here and then when it's actually being done that is the implementation technique a section here's another question the preliminary phase of dental care planning focuses on which of the following preliminary phase of dental care planning so it is c treating periodontal or dental emergency needs so there are phases of treatment there's like phase one phase two um you know phase three phase four and there's even phase zero phase zero or preliminary phase of dental care is when you're treating emergency conditions only so if there's a periodontal emergency like a periodontal abscess or if there's a dental emergency like someone's in this immense pain because of a cavity that needs to that's base zero that needs to be treated right away controlling risk factors that's phase one i'll talk about that surgical space two long term periodontal maintenance that's phase four so let's look at all the phases there's five phases of predominantly treatment plan so when you come up with a treatment plan there's five phases there's phase zero or preliminary phase which is just the um assessment phase you're collecting all these um data that's assessment like extra oral intraoral that's base zero and any preliminary therapy any emergency treatment can be in this section here being zero non-surgical periodontal therapy this is what we do okay this is what we as hygienists do we debride that falls under here we educate that falls under here we polish that falls under here so non-surgical periodontal therapy are things we can do and i'll show you that in the next slide surgical therapy this is when surgery actual surgery is done restorative therapy this is what dentists do they put restorations and periodontal maintenance that's phase four so when we come when they come and see us every three to four months for a week appointment and we're just maintaining their periodontal and we're just making sure that their periodontitis doesn't get worse so that's why we want to see them regularly so if you look at this one preliminary phase this is the emergency care phase you can see that it's all about pain relief emergency needs extraction of hopeless teeth what we can do the x means that this is what we can do if we see anything you know if they're in pain we need to refer them right away to the dentist or to a specialist non-surgical phase one therapy so this is phase zero this is phase one you can see we can do almost everything we can educate we can do dietary counseling we could do tobacco cessation we can do fluoride sealants debridement they all fall under non-surgical periodontal therapy polishing um and then evaluation is also part of phase one therapy so when we're when they come back for a four to six week we eval for example we will we're reassessing their inflammation their pocket depths their cal we're reassessing it we're reassessing their their oil self-care knowledge we're checking for deposits and we're coming up with a plan as to how often we should see them is it every three months is it four months is it six months we're coming up with that plan and as an fyi any periodontal client who has periodontitis we want to see them every three to four months any client that is healthy or has gingivitis we want to see them every six months phase two is surgical therapy we don't you can see there's no eggs here because we don't do any surgical therapy this is where they could see a periodontist this is implants can also be done endodontics or root canal treatment they all fall under surgical restorative is when the dentist does any um restorative care so amalgam composite that sort of thing crowns bridges maintenance phase is phase four so this we do where we get them to come back in three months for now from now for example and we assess all the conditions that are listed here so when we do they come back three months later and you're depriving you're providing prevention and therapeutic and periodontal maintenance therapy so maintenance therapy is a term used for interventions directed at sustaining oral health and controlling disease progression the application of occlusal sealants is an example of maintenance therapy so look at the options and tell me what you think so the actual answer is true so maintenance therapy is when we are maintaining their oral health so if they come every three to four months we're maintaining their oral health that way and that's um that so this is correct maintenance therapy is a term used for interventions for sustaining or for keeping their oral health you know for a long period of time and controlling their disease progression the application of occlusal sealant is an example of maintenance therapy so you might think if you look over here sealants fall under phase one therapy right so how can sealants be maintenance well it could be maintenance if we are using it for prevention if we're using any therapy whether it be a therapeutic for example a preventive can also go under maintenance so if you see your client again in three months in four months and six months for example that would fall under um maintenance phase because now what you're doing everything further along you're doing everything to prevent caries you're doing everything to prevent periodontal disease so it could also fall under this category as well sealants could also fall under here can also fall under phase one therapy where you see them for the first time really important that we as hygienists are huge are keen on interprofessional collaboration inter-professional collaboration means you are working with other professionals that are not hygienists you're working with the dentist you're working with the doctor you're working with the pharmacist you're working with i don't know the speech and language pathologist all other social care worker social workers right so all other professionals um are who we're collaborating with to make sure that our client gets all their needs met when you come up with a care plan it's really important that we come up with um a sequencing or an appointment schedule so you would say appointment one this is what you're gonna do and how um so when you come up with an appointment schedule maybe you need three appointments to see your client maybe you need five so how many visits do you need how much time will you need is it a two hour appointment is it a one hour appointment is it a half hour appointment and what exactly are you doing in each appointment so all of that this needs to be listed in the appointment um schedule so appointment one maybe you're doing an assessment for one hour and you list all the assessment that appointment two maybe you're doing more assessments care plan diagnosis that will take an hour and a half appointment three is when you're doing the non-surgical therapy so you're deep writing you're doing oral hygiene instruction so you're educating that all falls under non-surgical therapy one thing i want to note is that when you're writing a goal so one of the things we do is we always come up with goals for every unmet human needs we have an unmet human need we will come up with a goal so that we can address that unmet human need now when you're writing the goal really important that you have all four components you have the subject so the subject is your client your patient your client is your subject you have a verb what do you want the client to do understand demonstrate reduce eliminate those are the verbs so that needs to be incorporated into the goal statement you have a criteria for measurement so for example they will reduce plaque index to less than 10 percent so 10 is measurable you can measure it um they will demonstrate adequate flossing skills so flossing skills you can get them to demonstrate it again at the end and see if they unders if they can actually properly demonstrate the correct c shape flossing method and in a time dimension the fourth important thing is the time dimension always have by end of treatment by next week here you know by appointment three for example you must have a time when the patient is to have achieved the goal so again the subject is always the patient or the patient's caregiver for example if it's a child then it's up to the patient's caregiver the parents a verb is the action that you want them to do so understand demonstrate criterion for measurement this is what is the behavior you want what is the tangible outcome i want them to floss you want them to reduce their plaque index you want them to stop their bleeding eliminate their bleeding what is it that you want and then time dimension is when should the patient have achieved the goal by so by next appointment is it by next week or the next time you see them three months from now is it by the end of treatment so when you finish treatment you want them to know what periodontal disease is when is it that you want them to know so you would have to come up with that on your own just be sure that you come up you have these four things listed in your patient goals now i know we sent to use client will verbalize client will demonstrate but there are so many other ones that you can use for verbs so these are just an example of other verbs that could be used when you have come up with your entire care plan you must present it to your client you can't proceed with treatment without presenting it to your clients and getting their consent so when you do that care plan presentation and you're talking to your clients about it make sure you tell them about all these things tell them about the benefits of doing it and the risk of doing it so with debridement there's the risk of sensitivity so you need to inform them about that if they don't want let's say one of the things you talked about was missing teeth and they don't want an implant well what are the other alternative treatment options that they can get could they get a bridge could they get a denture what else could you do for missing teeth so you need to give them all options and then inform consent is what you need to get from them they need to agree to the treatment or they can disagree and we'll talk about that too which is informed refusal so informed consent is when you get their permission to proceed it's when you get their consent for a specific treatment and it is a legal um if you you need to get consent for a procedure that is legal that is within your scope of practice what is important is it has to be informed so informed is not a one-time activity but it's ongoing which means you don't tell them once you keep telling them you know you might want to review it again at each appointment that you know i have your permission to do this you you know we went over the risk and benefits and reviewed the risk and benefits with them we went over the cost tell them what the cost is and allow them the opportunity to ask questions it should be where they are given lots and lots of opportunities to make uh to ask the questions okay so it shouldn't just be a one-way conversation it should be a two-way conversation informed refusal there are times where clients will refuse fluoride reclines will refuse you know uh a few treatments that you have uh provided for them so it's okay if that happens listen to them um and then respect their decisions for declining the service the services and if they do refuse make sure you get that in and make sure you get that in writing so sign get that signed or at least document it that the client has reviews but get them to sign something so that it's part of their client dental record so as long as you've given them the benefits and the risk if they still decide to refuse it that is okay just make sure it's documented the last part of adpie or one of the last part of adpie is e for evaluation so now you have to evaluate all the goals that you made and one of the things we talked about at the very beginning of our session was that it's ongoing and as we see from this slide here evaluation is not necessarily done at the end it can be done after assessment diagnosis planning implementation we're always evaluating we're evaluating as we um go along that you know with their treatment so evaluation is ongoing i'm just going to find that slide that i was at okay so it's ongoing when you're evaluating let's see um make sure you ask open-ended questions so if they if you wanted to one of the let's say one of the goals was do they know the periodontal disease process you're not going to ask them do you know what periodontal disease is and they'll say yes or no no you're gonna turn and ask them tell me what you know about periodontal disease so now you're asking you're assessing their cognitive skills you're a goal it's a cognitive goal because you're assessing their knowledge open-ended questions are is the best way not simple yes or no um questions have the client demonstrate so if one of your goal was to get the client to demonstrate the c-shape flossing method get them to demonstrate it that is a psychomotor goal because they're using their hands um it could be uh having a patient report a change in behavior so perhaps they don't you know they never used to go to uh see a dentist they didn't realize it was so important in seeing a dentist and now they actually tell you you know what i'm gonna come see you every six months or i'm gonna come see you every three months because now i know how important that is that is an effective effective goal so you're changing their behavior that is the goal whether you've implemented behavioral change and then showing the patient clinical improvements this is an oral health status goal so at the evaluation you might want to take a post-op photo of azaria's pre-op and post-op photos and show them the before and after and when they see that when they see that the gums have become a lot more healthier there's less bleeding that is an oral health status goal so evaluation is good not only for yourself to see your treatment work but also for the client so that the client has also seen the effectiveness and the importance of you know them see going to the dentist regularly so each of the goal that you have listed in your care plan make sure you determine whether the goal has been met somewhat met or not met so there are um sometimes goals have not been met with the patient if you had like an interdental cleaning aid that you wanted them to use and they weren't able to correctly position it so that next time when you come around you can look at this and you're like okay this is what we need to work on and now documentation is huge and you all know that documentation this is a legal document and it's very important that we are writing each and everything down because if we didn't write it it's as if it didn't happen right so always document everything