Dental Hygiene Diagnosis and Care Planning
Dental Hygiene Diagnosis and Care Planning
This domain tests whether you can convert assessment findings into a dental hygiene diagnosis, prioritize human needs, and build a measurable, sequenced plan that the patient accepts.
Rules and concepts
- A dental hygiene diagnosis identifies actual or potential oral health problems within hygiene scope (e.g., biofilm-induced gingivitis, caries risk, xerostomia), not a dental disease diagnosis or an intervention.
- Use a human-needs framework: protection from health risks, freedom from pain, wholesome facial image, skin and mucosa integrity, and responsible participation.
- Goals must be patient-centered, measurable, time-bound, and reassessed. Sequence urgent care, then cause-related therapy, then definitive care, then maintenance.
- Informed consent requires explaining findings, options, risks, benefits, and alternatives; document refusal.
Worked example
Findings: generalized BOP, 4–5 mm pockets with CAL 2–3 mm, xerostomia from a new antihypertensive, and high caries risk. Diagnosis: “biofilm-induced gingivitis with attachment loss and high caries risk related to xerostomia.” Plan: 4–6 week nonsurgical debridement, fluoride varnish, dry-mouth counseling, medical referral for medication review, and reevaluation. Reasoning: the diagnosis names the problem and etiology; the plan addresses cause and risk rather than only “prophy.”
Traps
- Writing “perform SRP” as a diagnosis.
- Setting goals for the clinician (“patient will floss”) instead of outcomes.
- Ignoring medical findings that require referral before care.
- Failing to document patient refusal or modified consent.
- Skipping reevaluation, so the plan cannot be judged.