Dental Hygiene Diagnosis

Added to Handbook: Prior to June 2004
Updated: September 2013

PURPOSE

To assist dental hygienists in applying the concept of dental hygiene diagnosis in their practice settings.

BACKGROUND

A dental hygiene diagnosis clarifies the actual or potential conditions or concerns of a client that can be treated within the dental hygiene scope of practice. These conditions or concerns are identified through an interpretation of the assessment data, and should take the client's needs, values and beliefs into consideration.

Other terms commonly used for "dental hygiene diagnosis" include "assessment interpretations" and "assessment findings" and would include, but are not limited to, "periodontal status statements" or "caries risk statement" in clinical settings.

There are several practice standards that relate to the dental hygiene diagnosis. These include Practice Standard Policies 4.1, 8.2 and 8.4.

Practice Standard Policy 4.1 requires the dental hygienist to analyze the assessment information and make a dental hygiene diagnosis. This includes interpreting the dental hygiene assessment findings and discussing the implications of the findings with the client or the client's representative.

Practice Standard Policy 8.2 requires that dental hygienists record accurate details of all dental hygiene care provided including an interpretation of dental hygiene assessment findings or a dental hygiene diagnostic statement using any one of the models described in credible dental hygiene literature.

Practice Standard Policy 8.4 requires dental hygienists to document discussions around pertinent conversations including those related to the client being informed of the dental hygiene diagnosis.

POLICY

The dental hygienist will analyze and interpret the dental hygiene assessment data in order to formulate a dental hygiene diagnosis. The nature of the dental hygiene diagnosis may vary between practice settings.

In direct clinical practice settings, the dental hygienist would:

  • state the abnormal or unhealthy condition(s) identified during interpretation of the assessment data (such as chronic generalized moderate periodontitis);
  • explain to the client or their representative the evidence supporting this interpretation (such as pocketing, furcations, bleeding, horizontal bone loss, etc.);
  • state any conditions that require care or attention during the dental hygiene appointment; and
  • document the above accordingly in the client's chart.

In indirect clinical dental hygiene practice settings, the dental hygienist would:

  • analyze data against established measurable outcomes
  • use assessment findings in determining a dental hygiene diagnosis
  • document a dental hygiene diagnosis, statement of the problem or results of analysis

Dental hygienists can only diagnose conditions that are within the dental hygiene scope of practice to treat. Concerns may be identified during the assessment phase that require an appropriate referral, be it to a dentist, dental specialist, physician, or other health care provider. Referrals are not part of the dental hygiene diagnosis but rather are part of the dental hygiene treatment plan. Further information can be found in the Interpretation Guideline titled "Referrals by Dental Hygienists".

REFERENCES

  • Darby LM, Walsh MM. Dental Hygiene Theory And Practice. 3rd ed. St. Louis: Saunders Elsevier; 2010.
  • Newman MG, Takei HH, Klokkevold PR, & Carranza FA. Carranza's Clinical Periodontology. 11th ed. St. Louis: Elsevier; 2012.
  • CDHBC Practice Standards and Practice Standard Policies. Victoria: College of Dental Hygienists of British Columbia; 2013.
  • CDHBC Scope of Practice. Victoria: College of Dental Hygienists of British Columbia; 2013.
  • Wilkins EM. Clinical Practice Of The Dental Hygienist. 11th ed. Philadelphia: Lippincott Williams & Wilkins; 2013.