Message Boards
Today's Active Topics Browse Forum Categories My Recent Activity My Messages Private Groups My Marked Threads My Subscriptions
Today's Active Images Today's Active Polls Most Active Topics Global Townie Map Advanced Message Board Search Message Board Terms of Use

Profile in Oral Health Trisha O'Hehir, RDH, BS

More by this author (282)

Sarah Cottingham, RDH
Whether encouraged or frowned upon, diagnosing the symptoms of oral disease is an integral part of your job.

by Trisha O'Hehir, RDH, BS
Editorial Director, Hygienetown Magazine

As a hygienist, just saying "the D word," aka "diagnosis," can get you into trouble. What kind of trouble? I'm not sure, but I've been warned! The funny thing is hygienists are required by state boards to "diagnose" in order to take the licensing exam. How else would you find the specific type of patient required for the exam unless you recognized the signs and symptoms of disease? That's all diagnosis is, recognizing the signs and symptoms of disease.
If I didn't diagnose disease, I would never have kept my dental hygiene jobs over the years. How can I remove subgingival calculus if I don't recognize it's there and that it's causing disease? How can I effectively treat patients if I don't distinguish between gingivitis and periodontitis? Should I ask the dentist where each piece of subgingival calculus is before removing it?

A former employer teased me one time; I was so focused on the periodontal tissues that I missed a large occlusal lesion. "How could you miss that?" he said. "I saw it from the doorway!" In other words, I was expected to "recognize the signs and symptoms of disease" and report my findings when he asked what I'd found, as he did with each exam. I was also expected to present my findings to patients and prepare them for whatever treatment might be needed. Diagnosis is a team sport, and as the saying goes, four eyes are better than two.

            
This preoccupation with "the D word" has surfaced more often in the past decade, with changes in state practice acts to state specifically that hygienists are not allowed to "diagnose," although the same state laws dictate that hygienists can examine the oral cavity and surrounding structures, perform periodontal examinations and record clinical findings. It's a game of semantics. Hygienists are licensed and expected to recognize the signs and symptoms of disease, but not allowed to use the word that means just that, "diagnose."

To clarify the obvious conflicts around the word "diagnose," the American Dental Hygienists' Association (ADHA) has defined "dental hygiene diagnosis" as something other than the "dental diagnosis." The ADHA Standards for the Clinical Dental Hygiene Practice include six broad standards: assessment, dental hygiene diagnosis, planning, implementation, evaluation and documentation. According to these draft standards, published in the July 2007 issue of Access, "The dental hygiene diagnosis is a component of overall dental diagnosis. The dental hygiene diagnosis is the identification of an existing or potential oral health problem that a dental hygienist is educationally qualified and licensed to treat. The dental hygiene diagnosis is 'the use of critical decision making skills to reach conclusions about the patient's/client's dental hygiene needs based on all available assessment data.'"

It's a simple, clear and accurate solution to the concern about using the D word. Inserting the words "dental hygiene" prior to the word "diagnosis" clarifies clearly the intent of the word. Dental hygiene diagnosis involves the three primary dental diseases: periodontal disease, caries and oral cancer. Assessing, analyzing, and interpreting the signs and symptoms of disease also includes risk assessment or determining who is most likely to suffer from the three dental diseases and what preventive measures can be taken to reduce the risk.

            
Periodontal Disease

A key responsibility of dental hygienists is to collect the patients' periodontal data and determine the level of health or disease and devise the dental hygiene treatment plan. The periodontal probe is essential for this data collection. Traditionally, stainless steel probes have been used and now plastic probes are available from Premier, PDT, Hu-Friedy and ProDentec (Zila). PerioWise from Premier uses the colors of a traffic light to provide immediate feedback on pocket depths to the clinician. Green means healthy and red means disease. The Easyview Probes from PDT are yellow with green markings. The Colorvue from Hu-Friedy is a yellow and black removable probe tip and handle system. The PDT Sensor Probe from ProDentec has a built-in pressure indicator. An extra piece of plastic is used to determine pressure. When too much pressure is used to insert the probe subgingivally, the two pieces of plastic meet and the clinician is alerted they have reached maximum desired pressure.

The Florida Probe is a constant force probe developed more than 20 years ago by researchers to produce accurate, consistent and reproducible scores without needing an assistant. It is a comprehensive treatment planning and education system, not just a probe. Using a foot switch, data is automatically entered into the computer and interfaces with all dental software programs. A color graphic printout engages the patient in the high-tech system of data and information collection and management. Also included are one-minute patient education movies, a risk assessment tool, a variety of reports, patient education handouts, a comprehensive treatment plan and an informed consent form.

The Dental R.A.T. (Remote Access Terminal), invented by Becky Logue, RDH, provides a hands-free way to record probing scores and other examination data into a computer program. Probing scores and other data are tapped into the computer using a foot-operated mouse. It's easy to use, convenient and private, because the scores are not spoken out loud for others in the office to hear.

            
PerioPal 3.5, invented by Kimberly Goodson, RDH, is a voice command software system designed specifically for dental hygienists to verbally express the probing scores and other periodontal data that are then captured by the voice command software and recorded in the periodontal chart. PerioPal stores the examination data and can provide reports for both clinicians and patients. The hygienist wears a headset with microphone for entering the data into the PerioPal program, which has a software bridge allowing it to interface with a variety of other dental software programs. PerioPal's Comparative Analysis tool allows for the comparison of probing scores from five different examinations on one screen.

Most dental software programs include a periodontal program for data collections. Some dental offices have not yet made the move to digital charts and are still using paper charts. For those offices, the Perio-Data Charting Form provides an eye pleasing, yet comprehensive form that tracks four visits on one page. This form also includes a monitoring system to provide a bottom line, two-digit score for each patient. The Periodontal Health Index is the number of bleeding points over the number of pockets. The Perio Data Form is available in hard copy form as well as a digital form that can be modified to include the dentist or practice name before printing single copies in-office or taking it to a printer for bulk printing. The Perio-Data form was designed and is owned by Cynthia Chillock, RDH.

Strawberry is a software program designed for hygienists interested in collecting, managing and monitoring more than the traditional clinical data. This software, designed by Victoria DaCosta, RDH, in collaboration with a team of experts, helps you calculate overall wellness scores for your patients.

            
PreViser 3.0 for Windows or Macintosh is an online risk and treatment analysis program. Simply enter the patient's clinical findings and the recommended periodontal treatment and estimated risk will be determined. This software is based on periodontal research and gives clinicians an objective way to measure and communicate the patients' treatment and risk scores.

A quick, easy screening test is the Eastman Interdental Bleeding Index (EIBI), which measures bleeding between the teeth. This can be done by the clinician and taught to patients for self exam at home. The original research was done with Stim-U-Dents, triangular wooden sticks from Johnson&Johnson. The stick is rubbed in and out four times in each interdental area, from the facial surface only, and bleeding after 15 seconds is recorded. Other companies such as TePe, Sunstar International, Pearson Dental and Prophy Perfect now offer triangular wooden interdental sticks of varying sizes.

Other than gathering data with a periodontal probe or an interdental wooden stick, some clinicians use a paper point to collect subgingival bacterial samples to send to a laboratory for DNA testing. Microbiological testing compares the DNA of the sample to the recognized DNA of periodontal pathogens. This information allows for the selection of a systemic antibiotic specific to the bacteria identified. The University of Southern California Oral Health Center provides DNA testing of periodontal pathogens using the Oral Microbiology Testing Laboratory (OMTL) Kit.

                
Dental Caries

The dentist is the one who will provide the restorative treatment for dental caries, so the dentist is ultimately responsible for the caries diagnosis. Hygienists gather information from patients about diet and oral hygiene and also use technology to measure tooth surface mineralization. Prevention and remineralization are part of the dental hygiene treatment plan. It's no longer a matter of finding a hole or cavitation in the enamel surface. Detecting demineralization at an early stage is now the goal for dental hygienists. This will allow for remineralization treatments and prevention of cavitation. Early detection of enamel changes allows clinicians to reverse the process. Sharp explorers have been used for decades to detect carious lesions, unfortunately, sharp explorers can also break through highly demineralized enamel, creating cavitation in a surface that might have responded well to remineralization. Cariologists suggest using a dull probe, magnification, drying the tooth and using light to evaluate the surface.

Transillumination or directing light through the tooth surface either reflected off the mirror or with a transilluminator enhances diagnosis of surface changes. Two products in this category are the battery operated MicroLux by AdDENT and the DiaLUX by KaVo.

DIAGNOdent and the DIAGNOdent pen from KaVo use laser technology for detecting changes in mineralization on occlusal surfaces. A baseline reading is taken on each patient just prior to evaluating surfaces for decay. Both an audible signal and digital number measure laser reflected light. Quantified laser reflected light can be used to detect a carious lesion. The DIAGNOdent uses quantified laser light to detect changes using the following reading:
•  0-10 Healthy
•  10-20 Early caries in the outer enamel
•  20-30 Caries extending into the inner enamel
•  30+ Dentinal caries

The Inspektor Pro from OMNI 3M ESPE is a pre-invasive caries diagnostic imaging system using Quantitative Light-induced Fluorescence (QLF). When teeth are illuminated with a specific wavelength of light they appear to be lit from within and the fluorescence level reflects the mineral content of the enamel. This increases the contrast between sound and diseased enamel, thus defining surface mineralization, plaque biofilm, calculus, and staining. The mapping and analysis software allow for capture of the images and comparison at future visits. This tool will provide data on early enamel changes, thus allowing for remineralization options.

The Midwest Caries ID by Dentsply uses fiberoptic technology and LED (light-emitting diode) lights for detection of occlusal and interproximal lesions. Both audible and visual signals are given. Green is healthy and red is carious. It is available in both a desktop and handheld models and no baseline calibration is required.

Oral Cancer

Oral cancer screening is more important than ever, especially for early diagnosis. Oral cancer screening is done in the general dental office, but the diagnosis is ultimately made by a pathologist reading the biopsy. There are several new technologies hygienists may use to identify early oral mucosal changes.

Vizilite Plus with TBlue by Zila is an oral lesion identification and marking system that is used in conjunction with the traditional head and neck, intraoral cancer exam. The patient rinses with a raspberry flavored one percent acetic acid solution and the hygienist then uses an activated light stick, looking for tissue abnormalities. Any questionable tissue is then swabbed with a blue phenothiazine dye and rinsed. The dye will attach to altered cells, defining the lesion outline, and can be seen with the naked eye. A photo of the area should be taken to share with the oral surgeon upon referral.

The Microlux/DL Kit from AdDent includes a one percent acetic acid rinse and a fiber optic illuminator for mucosal lesion detection. This is the same battery operated transilluminator used for caries and calculus detection with an interchangeable diffused glass light guide that can be autoclaved.

When a small, harmless looking red or white lesion is noted, a brush biopsy can be done using the OralCDx biopsy kit. With or without topical anesthetic, the brush is rotated firmly against the lesion for five to 15 rotations until pin-point bleeding appears. This means that cells from all layers of the epithelium have been collected. These cells are transferred to a glass slide by rotating the brush over the length of the slide. A liquid fixative is applied and when dry, the slide is packaged for shipment to the lab where it is evaluated microscopically by a pathologist. Reports back will tell you if the lesion is negative, atypical or positive.

The VELscope (Visually Enhanced Lesion scope) uses direct optical fluorescence to detect lesions before they appear on the surface. It is a hand held device emitting a blue light into the oral tissue that causes cells to absorb the light and reflect back a fluorescence distinguishing between healthy and abnormal tissue. Abnormal cells will appear darker than healthy cells. Besides screening for oral mucosal changes, the VELscope provides guidance for surgical lesion removal by defining the margins.

The head and neck visual and palpation exam is a standard part of dental hygiene visits. Eileen McQuade, RDH designed and produced a DVD and step-by-step Quick Guide instruction card to standardize the head and neck and intraoral cancer screening exam, thus allowing hygienists and dentists to follow a routine that is both thorough and comprehensive. The Go To DDS package includes both a 35-minute DVD demonstration and a chairside plastic coated Quick Guide with the 25- step examination.

Dental hygiene diagnosis is an integral part of the care you provide for each patient. New technology is making the task of gathering information about the signs and symptoms of these diseases much easier. Several message boards on www.hygienetown.com discuss various aspects of dental hygiene diagnosis. Join the discussions and share your experiences.
Sponsors
Site Menu
Message Boards Articles Continuing Education Podcasts Blogs Classifieds News Events Townie® Poll Ebooks Townie Choice Awards
Company Info
Contact Us Advertise With Us Howard Farran DDS, MBA Policies and Agreements
Site Help
Sally Gross, Member Services Specialist
Phone: +1-480-445-9710
Email: sally@farranmedia.com
©2025 Hygienetown, a division of Farran Media • All Rights Reserved
9633 S. 48th Street Suite 200 • Phoenix, AZ 85044 • Phone:+1-480-598-0001 • Fax:+1-480-598-3450