Dental hygiene diagnosis: A qualitative descriptive study of dental hygienists

Abstract

Purpose

The purpose of this qualitative descriptive study was to explore dental hygiene diagnosis (DHDx) to gain an understanding of how dental hygienists experience this phenomenon while providing dental hygiene care.

Methods

A qualitative descriptive research design was employed using purposive sampling. Data were collected from semi-structured interviews with 10 dental hygienists actively practising in California, Oregon or Colorado. The interviews were audiorecorded, transcribed verbatim, and verified for accuracy. Data analysis included open coding and axial coding to determine larger, related segments of data called categories providing an overall descriptive summary of DHDx. Two independent peer examinations and member checks established validity of the data analysis.

Results

Four categories emerged from the study: expertise and confidence; client communication; dental hygiene care plan; and dentists’ trust. Participants revealed that expertise and confidence in performing the DHDx was gained through clinical practice. During client care, discussing the DHDx with clients helped to make them aware of their health condition. The development of the dental hygiene care plan was based on the results of the assessment data and the DHDx. Participants stated that their employer/dentist trusted them to diagnose.

Conclusions

A qualitative descriptive study was conducted to summarize dental hygienists’ experiences with DHDx in 3 US states; 4 categories emerged. The DHDx informs the client, increases understanding, and engages the client in the decision-making process. Further study is warranted to identify a more contemporary definition of DHDx and to compare how DHDx is utilized by dental hygienists in other countries.

PRACTICAL IMPLICATIONS OF THIS RESEARCH .

• Dental hygiene diagnosis is an essential step in the dental hygiene process of care and guides the creation of dental hygiene care plans.

• Graduates of entry-level programs develop expertise and confidence in implementing the dental hygiene diagnosis through clinical care experiences.

• Dentists trust dental hygienists to perform a dental hygiene diagnosis.

INTRODUCTION

Diagnosis refers to the identification of a disease based on the presentation of signs and symptoms.¹ Health care professionals in all fields use diagnosis as a means to identify and discuss diseases with patients and formulate a plan for treatment. Dental hygienists incorporate diagnosis, specifically called dental hygiene diagnosis (DHDx), into clinical practice to assist in the prevention and treatment of oral diseases.²

Historically, various models of DHDx began to appear in dental hygiene textbooks in the early 1990s. Gurenlian³ introduced a model for dental hygiene diagnostic decision making in 1993, which was followed in 1995 by the first method for formulating a DHDx by Mueller-Joseph and Peterson.⁴ At that same time, Darby and Walsh presented a DHDx model based on the Human Needs Conceptual Model.⁵ This version of the DHDx has appeared in subsequent editions of their textbook. Swigart and Gurenlian proposed a practical approach for integrating the DHDx for clinical care.^6,7

Table 1.

American Dental Hygienists’ Association: Standard 2

ADHA Standard 2: Dental Hygiene Diagnosis

The ADHA defines dental hygiene diagnosis as the identification of an individual's health behaviors, attitudes, and oral health care needs for which a dental hygienist is educationally qualified and licensed to provide. The dental hygiene diagnosis requires evidence-based critical analysis and interpretation of assessments in order to reach conclusions about the patient's dental hygiene treatment needs. The dental hygiene diagnosis provides the basis for the dental hygiene care plan. Multiple dental hygiene diagnoses may be made for each patient or client. Only after recognizing the dental hygiene diagnosis can the dental hygienist formulate a care plan that focuses on dental hygiene education, patient self-care practices, prevention strategies, and treatment and evaluation protocols to focus on patient or community oral health needs.

I. Analyze and interpret all assessment data.

II. Formulate the dental hygiene diagnosis or diagnoses.

III. Communicate the dental hygiene diagnosis with patients or clients.

IV. Determine patient needs that can be improved through the delivery of dental hygiene care.

V. Identify referrals needed within dentistry and other health care disciplines based on dental hygiene diagnoses.

Source: American Dental Hygienists’ Association. Standards for clinical dental hygiene practice. Rev. ed. Chicago (IL): ADHA; 2016 [cited 2018 Jun 30]. Available from: https://www.adha.org/resources-docs/2016-Revised-Standards-for-Clinical-Dental-Hygiene-Practice.pdf

Both the Canadian Dental Hygienists Association (CDHA) and the American Dental Hygienists’ Association (ADHA) have included DHDx in their respective standards of practice for dental hygienists.^8,9 The CDHA reference to DHDx is found in Standard 2: “Dental Hygiene Process: Assessment.” Item 2.5 states, “Analyze all information to formulate a decision or dental hygiene diagnosis”^{8 p.9} . The ADHA standard for DHDx appears in Table 1.⁹ Table 2 displays the similarities in DHDx definitions between these 2 associations; both require the dental hygienist to think critically about assessment data and formulate conclusions to address clients’ needs.^10,11 A DHDx is paramount to providing individualized, appropriate client education, dental hygiene care planning, disease prevention, and therapeutic and re-evaluation procedures.⁶

In health care globally, there has been a focus on person-centred care, which is an individualized, holistic approach to care where the decision making is shared by the clinician and the client, and at times, includes the client’s family or caregiver.^12,13 Instead of viewing the client as a collection of symptoms, person-centred care fosters communication to take into consideration the client’s values and goals.^12,13 Dental hygienists have an ethical responsibility to provide opportunities for clients to make informed decisions about their treatment.¹⁴ Communicating the DHDx to the client is part of that responsibility.⁹

In 2018, Gurenlian, Sanderson, Garland, and Swigart surveyed dental hygiene clinic coordinators in the United States to ascertain opinions regarding the importance of a DHDx and to understand how the DHDx is incorporated into educational programs.¹⁵ Of 188 survey respondents, 98% confirmed that the DHDx is a necessary component of dental hygiene care and determines dental hygiene interventions.¹⁵ Program administrators consider a DHDx a valuable and necessary element of client care.

Health care professionals in other disciplines recognize the importance of the DHDx to client overall health and collaborative care. In 2012, Jones and Boyd investigated whether a dental hygienist would be a valuable member of an interdisciplinary pediatric feeding team by assessing the importance of the dental hygiene process of care, advocacy, and health education and promotion.¹⁶ Team members surveyed included registered dietitians, speech-language pathologists, occupational therapists, registered nurses, and advanced registered nurse practitioners. The 4 areas pertaining to DHDx in the study were 1) identifying existing or potential oral problems associated with teeth, 2) periodontal disease, 3) oral lesions, and 4) sensor,y disorders. All team members rated the role of the dental hygienist on the pediatric feeding team as “very important/most relevant.”¹⁶

Table 2.

Canadian and American DHDx definitions

Country	Dental hygiene diagnosis definition
Canada (Canadian Dental Hygienists Association)	"A dental hygiene diagnosis involves the use of critical thinking skills to reach conclusions about clients" dental hygiene needs based on all available assessment data."10
United States (American Dental Hygienists' Association)	"The identification of an individual's health behaviors, attitudes, and oral health care needs for which a dental hygienist is educationally qualified and licensed to provide. The dental hygiene diagnosis requires evidence-based critical analysis and interpretation of assessments in order to reach conclusions about the patient's dental hygiene treatment needs. The dental hygiene diagnosis provides the basis for the dental hygiene care plan."11

Even though dental hygienists are ethically responsible for and qualified to recognize oral diseases and use the DHDx to formulate an appropriate individualized dental hygiene care plan,^9,11 no research has been conducted to understand the process of the DHDx as performed by dental hygienists in practice. The purpose of this qualitative study was to explore the DHDx in order to gain an in-depth understanding of how dental hygienists currently licensed and practising in the US experience this phenomenon. The following research questions guided the conduct of this study: 1) How do dental hygienists learn to value the DHDx? 2) How do dental hygienists perform the DHDx in clinical practice? 3) Why do dental hygienists perform the DHDx in clinical practice? 4) How do dental hygienists create a dental hygiene care plan based on the DHDx?

METHODS

Study design and participant recruitment

A qualitative descriptive approach was adopted to facilitate the in-depth exploration of dental hygienists’ experiences with DHDx in clinical practice. This research design is appropriate to explore phenomena where little theoretical or practical knowledge exists.¹⁷ Based on the limited knowledge of the implementation of DHDx during clinical care, this qualitative approach was used to gain an understanding of this aspect of the dental hygiene process of care and provides a foundation on which other investigations are conducted. The study design underwent full IRB review from the University’s Human Subjects Committee and received approval (IRB-FY2017-252).

Purposive sampling is commonly implemented as the sampling plan for a qualitative descriptive study.¹⁷ The recruitment of individuals who have experiences with the phenomenon (DHDx) and are able to inform data collection are important considerations of purposive sampling.¹⁸ Participants were initially recruited through personal networking by the researchers who emailed an IRB-approved announcement to colleagues in California, Oregon, and Colorado. These states were selected because the dental hygiene scope of practice includes direct access to dental hygiene care. Additionally, in Oregon and Colorado, DHDx is specifically identified in the practice act as a procedure for dental hygienists.¹⁹ Furthermore, the snowball sampling method¹⁸ was implemented to gain referrals of other dental hygiene colleagues who could be recruited for the study.

Inclusion and exclusion criteria

Inclusion criteria were dental hygienists who were actively practising at least 16 hours a week and had a minimum of 1 year of experience. Exclusion criteria eliminated dental hygienists who were currently or previously employed as educators in dental hygiene programs or worked less than 16 hours per week. When potential participants were identified, a screening questionnaire was completed to establish who met the inclusion criteria and determine procedures they completed during client care.

Participant selection

The 10 dental hygienists selected were those who collected assessment data, evaluated risk factors for oral disease, and determined dental hygiene treatment based on the assessment data and client risk factors. Additionally, demographic questions were asked on the questionnaire to establish maximum variation in the sample.

Maximum variation was implemented to gain diversity within the sample¹⁸ based on demographic (gender, age, years in practice) and type of practice (general private practice, direct access practice, corporate practice) variables. Using maximum variation in a qualitative descriptive inquiry provides researchers with the opportunity to explore similar and unique experiences across varied contexts.¹⁷ During the interview process, saturation determined the final sample size. Saturation involves increasing the sample size until no new information surfaces during the interviews.¹⁸

Data collection and data analysis

The 4 research questions directed the development of the interview guide as depicted in Table 3. The guide included major questions and subordinate questions to elicit additional detail in responses. The content validity of the questions was established by using the Standards for Clinical Dental Hygiene Practice of the ADHA and previous DHDx research.^{9 ,15} Using the guide ensured that all topics were covered in a valid and reliable manner during each interview.¹⁸ Two members of the research team conducted a pilot interview to determine whether the major and subordinate questions would collect data to answer the research questions as a validation process. The interview guide was sent to participants at least 1 week prior to the interview to help them formulate responses.

Written informed consent was obtained prior to interviews being conducted by the principal investigator through an audiorecorded phone interview. Interviews were conducted with semi-structured methodology allowing for additional follow-up questions to collect more in-depth data or new data. The conversation was audiorecorded using the Olympus WS-300M 256 MB Digital Voice Recorder and Music Player. All audiorecordings were transcribed verbatim by a professional transcriptionist. Participant pseudonyms were used during the interview and on the interview transcript to protect confidentiality and ensure anonymity. The principal investigator listened to the audiorecorded interviews to verify the accuracy of the transcriptions.

Data regarding the DHDx generated from the interviews were analysed simultaneously with data collection; both processes reciprocally influenced each other. ¹⁷ The data analysis method of choice for qualitative descriptive studies is qualitative content analysis.¹⁷ The result of this analysis is a descriptive summary of the data, which is less interpretive than data analysis other qualitative approaches use.¹⁷

Table 3.

Interview guide

Interview guide

General questions regarding dental hygiene practice experience: 1. In what type of practice are you currently employed? 2. What other types of practices have you had experience?

How do dental hygienists perform the DHDx in clinical practice? 3. How would you define a DHDx? 4. Tell me about your typical day at work with your patient? 5. What assessment data do you collect on your patients? 6. Does the dentist in your practice do a clinical exam at every dental hygiene appointment? If not, how often? 7. In your practice, are you expected to report suspicious oral lesions, caries lesions, and/or periodontal disease to the dentist? If yes, how do you report or discuss your findings with the dentist? 8. How do you perform a DHDx? Can you give an example?

Why do dental hygienists perform the DHDx in clinical practice? 9. How were you taught DHDx in the dental hygiene program where you attended? 10. What conditions were you taught to diagnosis? 11. How do you feel performing the DHDx benefits a patient?

How do dental hygienists create a dental hygiene care plan based on the DHDx? 12. In your practice, do you create the dental hygiene care plan for the treatment you would perform for the patient? a. What types of procedures, education, or referrals might be included? 13. How is the dental hygiene care plan discussed with the patient? a. Can you give an example of this discussion? 14. Is the DHDx discussed with the patient? a. Can you give an example of how the DHDx is discussed? 15. Do you document the DHDx in the patient record? If yes, how do you document the DHDx in the patient record? If no, what are your reasons for not documenting the DHDx? 16. Do you feel the DHDx improves patient outcomes? If yes, can you explain how the DHDx improves patient outcomes? If no, why do you feel the DHDx does not improve patient outcomes?

How do dental hygienists learn to value the DHDx? 17. How do you feel you learned to value a DHDx? 18. When you graduated, did you value DHDx as a part of care? 19. As you have been practicing, how do you value your ability to perform a DHDx? 20. What barriers or hindrances do you encounter with the DHDx?

Additional comments: 21. Do you have any other thoughts or comments about your experience with the DHDx? 22. Is there anything else you would like to tell me about DHDx?

Transcripts were read numerous times by the investigators to become familiar with the data and to develop a contextual understanding of factors related to perceptions of DHDx. Open coding deconstructed the data into manageable one-word or short phrases describing the participants’ experiences relevant to answering the research questions.¹⁸ During the next phase—axial coding—open codes were combined to form larger segments of data indicated as categories. Each research team member coded the same interview, compared and discussed findings until consensus was reached. Common categories were then analysed and organized to summarize the data, following Merriam and Tisdell’s¹⁸ recommendation that categories should be responsive to the purpose of the research, exhaustive, mutually exclusive, sensitizing, and conceptually congruent.

Establishing rigour

Two research team members conducted an independent peer examination of the data analysis to ensure validity. Another procedure used for validity was respondent validation.¹⁸ Member checks by participants evaluated the preliminary findings and provided feedback on the accuracy of the researchers’ interpretation of the data. All 10 participants reported they agreed with the analysis.

RESULTS

Study participants

Demographic data for the 10 participants were analysed using descriptive statistics and are presented in Table 4. Six dental hygienists from California, 2 from Oregon, and 2 from Colorado participated in the study. The majority of participants were between the ages of 34 and 44 years, female, and had over 13 years of experience. Eight participants worked in private practice under the supervision of a dentist; 2 worked in independent practices without the supervision of a dentist. These independent practitioners provided care in long-term care facilities, at a senior citizen centre, and with a mobile dental clinic.

Four categories emerged from the study: expertise and confidence; client communication; dental hygiene care plan; and dentists' trust.

Expertise, and confidence

Participants revealed that, while foundational learning of the DHDx began in dental hygiene education, expertise and confidence in performing the DHDx was gained through clinical practice. Most participants reported learning to perform the DHDx in their dental hygiene education program. Hannah described being taught in a clinical setting, with a client present, and under the guidance of the dental hygiene faculty. She learned to diagnose periodontal case types and elaborated on her oral pathology education, stating:

We were always encouraged to look out for unusual findings in the mouth. If we did see anything, we were to describe it, to actually measure it, and write it down.

Mike stated, “we’re really good at diagnosing periodontal disease,” and detailed also being taught to diagnose bruxism, wear patterns, abfractions, dental caries risk, and dental caries on radiographs. Mia explained how she was educated to assess for dental caries and determine the dental caries classification. Jane confirmed learning to diagnose not only dental caries, but also radiolucencies around tooth apices. Nikki discussed that her postgraduate advanced practitioner training developed her use of the DHDx because she would be working in independent practice without a dentist present.

I really probably learned [DHDx] through the training I received at my postgraduate AP [advanced practitioner] class. They really stressed that on us, more so than my bachelor degree dental hygiene class twenty-four years ago. A lot has changed and because we’re seeing these patients independently, you get better at evaluating things and being confident in your evaluation and referrals.

Other ways participants learned DHDx were through reading articles in professional journals and attending continuing education courses.

In contrast, Michele and Leah specifically acknowledged they did not learn to determine the DHDx during their dental hygiene education. Michele was educated to recognize different levels of periodontal disease and discuss the findings with the supervising dentist who would provide the diagnosis and referrals. Furthermore, Michele expressed, “I like the fact that I don’t have the legal responsibility of diagnosis because that is left to the doctor’s hands.” Leah stated, “We weren’t specifically taught a DHDx and how to write that up, with that title.” She explained how she was taught to do an oral assessment, oral cancer screening, and to recognize abnormal oral conditions to be diagnosed by the dentist. Even without specific terminology for the DHDx, Leah was expected to identify dental caries, both clinically and radiographically, in addition to decalcification and root caries.

Developing confidence in and appreciating the value of conducting a DHDx occurred through clinical experiences in practice. All participants confirmed that their increased confidence in diagnosing improved communication skills regarding the DHDx and strengthened the value they place on DHDx. Jane specifically credited the dentist by whom she is employed for increasing her knowledge of diagnosing and motivating her to perform the DHDx.

I had a lot of good foundational knowledge and then was able to apply it [DHDx] to all the many patients in clinical practice. It just expands upon what you’ve already learned. I’ve also learned a lot from the dentist I work for. I feel like he’s taught me a lot. I do have a lot more confidence in saying yes, this is what I think this is and explaining that to the patient. And I think that would come with time.

Multiple participants confirmed that the more years they were in practice and performing the DHDx, the more confident they became in their diagnosis. As Elizabeth explained:

When I was first out of school, if I got hesitation [about recommendations] from a patient, it would make me feel uncomfortable and make me second guess whether my diagnosis was correct or not. And now that I’ve been practicing so long, I know what my diagnosis is and it’s MY job to help the patient understand why I’m making that diagnosis. I’m not going to be talked out of what I’m recommending for a patient.

Additional supporting quotations illustrating how DHDx expertise and confidence develop through clinical experiences are presented in Table 5.

Table 4.

Participant demographic data

State	n (%)
California	6 (60%)
Oregon	2 (20%)
Colorado	2 (20%)
Age range (years)
28 to 33	3 (30%)
34 to 44	4 (40%)
45 to 53	3 (30%)
Gender
Male	2 (20%)
Female	8 (80%)
Years in practice
1 to 6	2 (20%)
7 to 13	2 (20%)
Over 13	6 (60%)
Degree
Associate	3 (30%)
Bachelor	6 (60%)
Master	0 (0%)
Doctorate	1 (10%)
Type of practice
General private practice	6 (60%)
Independent/Direct access practice	2 (20%)
Corporate practice	1 (10%)
Certified advanced practitioner working in private practice	1 (10%)

Table 5.

Supporting quotations for category 1

Expertise and confidence

I think with anything, it [DHDx) gets better with time. The more you do it, the better you become with it and the more varied the mouths are that you've been exposed to, you learn something new all the time. So I think I value it more because my-the education in practice-has always been more valuable than the education at school. (Michele)

[DHDx has] definitely gotten better over time. I wouldn't say that in the first year, second year, I was that confident. But I feel very confident about it now. Without having a dentist present I could still make that diagnosis. (Mia)

Definitely, I feel like I'm more competent now than seventeen years ago and more confident in making the diagnosis and not second-guessing myself. (Mary)

I am much more confident in my diagnoses now. I know what I am saying is truthful and I can back it with information and my own experience. (Hannah)

Patient communication

The DHDx helps to make clients aware of their health condition and provides the dental hygienist with an opportunity to explain the DHDx to the client. Albert, Hannah, and Mary each described how they present the DHDx to their clients.

An example of how I take a DHDx. I had a patient in her 60s. She had several missing teeth, crowns, and very large fillings. She had failing restored margins, pockets, clinical attachment loss, radiographic evidence of bone loss, heavy plaque, and debris on the gingival surface of those teeth. She stated disappointment with failing treatment that she attributed to herbs by her previous dentist. And she said (quote), “Dr. Oz said I don’t need fluoride.” She was on several medications for hypertension and diabetes. Her DHDx was generalized mild to moderate chronic periodontitis, high caries risk, restorative needs requiring a dentist’s attention, anxiety, high risk of perceived or actual failure of treatment, high risk of oral systemic complications, pockets of deficits related to effects of treatment, fluoride and personal health habits, affective deficits related to interaction with health professionals and sources of information, and psychomotor deficits related to home care habits.

(Albert)

To the patient I described earlier, I explained that because she had problems with her dental treatment in the past, I would like to have her release prior records to us before I begin providing treatment. To the event, to prevent the same pitfalls from happening again. I also asked her to have Dr. Oz send his diagnostic and treatment notes so I could understand why he did not think she needed fluoride. I explained the effects of fluoride on dental health, the characteristics of her periodontitis and treatments. I also explained the treatment I recommended for her would help the longevity of her restoration and interact positively with her systemic health.

(Albert)

I need to feel I’m doing the best possible thing for my patient. There needs to be honesty between the hygienist and the patient which will develop trust. The DHDx is a true representation to the best of my knowledge of the patient’s condition which is the baseline which I work from to perform the best possible care, and I value that. Because periodontal disease can have no symptoms, many people don’t realize they have it. Explaining to the patient the diagnosis is educational and they should know if there is a problem so it can be addressed as soon as possible.

(Hannah)

I would sit the patient up and we usually take photographs and radiographs and show the patient in their own mouth what’s going on. Explain to them how their systemic condition relates to their oral health. Explain to them what we’re finding as far as pocketing and bleeding and calculus and let them know what their options are for treatment.

(Mary)

In some cases, participants divulged that clients are not always informed of their oral health status. Michele, Mike, Elizabeth, and Mia reported occasions when clients had been shocked to learn their DHDx because they had never previously been told of their disease state.

I’ve had patients that are shocked. They have been going to their office and seen routinely for care, and all of a sudden, they come in, they see me for the first time, and when I tell them what the diagnosis is and the treatment plan, they are shocked. They’ll ask questions why or how did this happen? Or what do I do to prevent it?

(Mia)

Participants reported the significance of educating the client while informing them of the DHDx. When clients are made aware of their disease status through the DHDx, they are more likely to accept dental hygiene ,treatment. Mike explained, “By telling the patient and educating them, you’ll get a lot better results. They’re a lot more aware and so they’ll take more action.”

Leah discussed how dental hygienists back up the DHDx with “a lot of information for the patient to make sure the patient understands.” She further detailed her direct access practice at a senior citizen centre, stating that some clients she treated would not seek oral care at a dental office. The only care some clients were willing to have involved dental hygiene procedures completed at the senior citizen centre. Leah stressed that referrals were made to dental offices, but clients did not always follow through with them. In one case, she informed a client of an abscess. By helping the client understand the diagnosis, she was able to convince the client to seek treatment. Furthermore, Leah called a clinic to schedule an appointment, thus fulfilling the role of a case manager of oral health care to ensure the spread of infection did not affect systemic health. Additional supporting quotations for this category appear in Table 6.

Dental hygiene care plans

A dental hygiene care plan consists of formulating conclusions about dental hygiene treatment based on the results of the assessment data and the DHDx. Participants described how they relate the dental hygiene care plan to the DHDx.

I begin explaining the assessment data, the implication of that data, and the diagnoses that emanate from that data. Then I explain the diagnoses and how the recommended treatment will address the diagnoses.

(Albert)

After the initial therapy, we’ll be seeing the patient for a six-week evaluation appointment. That allows us to see what healing has occurred. It is a long-term commitment on their part because it requires them to come in every three to four months for at least the first year. If we see any inflammation, bleeding, pocketing remaining after one year, then we will keep them on a three- to four-month periodontal maintenance program. I explain the difference between periodontal maintenance and a prophylaxis. We typically go over recommendations for flossing. If they don’t like regular floss, we recommend soft picks or water flosser. We typically recommend using an electric toothbrush and tongue brushing.

(Elizabeth)

Table 6.

Supporting quotations for category 2

Client communication

Oftentimes, their response is that they had never been explained exactly what was going on in their mouth before. (Michele)

If anyone's informed and knows what going on, the majority of people in this world will take actions to get better. When you go to your doctor, he tells you that you have high blood pressure. He explains the plan and meds, and how often to follow-up with him. It's the same thing with dental hygiene. (Mike)

I think that they have more trust and I see more respect for the dental profession because it not only improves their oral health, but the systemic link. Patients feel like we're looking out for all of them just not their mouths. So, I think it's a good thing. It builds trust. (Mia)

I think it would help them have a greater understanding of, "I do have periodontal disease." Maybe they didn't know that before. Or, "Oh, I didn't know I had a cavity there. It didn't hurt." Or, "Oh, yeah, I never noticed that lesion in my mouth." By me pointing those things out to them, it gives them information that's beneficial to them. So it is addressed and treated properly and doesn't go unnoticed. (Jane)

You don't want them to lose their teeth. If they have an aggressive form of periodontal disease, we need to help the patient understand this is serious. You're going to lose your teeth. I feel like that would be very beneficial to them. This is what's going on in my mouth, this is a serious thing, and I need to address it. If it was a cavity, we don't want it progressing from a small cavity to potentially a root canal. With a pathology, that could become oral cancer. There can be long-lasting effects. I think it's extremely beneficial that we, as hygienists, point this out to our patients. Now in these conversations. (Jane)

I just think it puts everybody on the same page and allows for better communication. Because there's so many different people involved a lot of times with a client's care, it kind of gets us all on the same page. (Nikki)

Participants described many aspects of the dental hygiene treatment planning process, including the importance of the DHDx. The care plans included detailed information on what treatment, nutritional counseling, education, and referrals were recommended. Additionally, participants determined the number of appointments, length of each appointment, and what treatment would be included at each appointment. These dental hygienists proposed necessary referrals, discussed the cost of the treatment, and at times assigned insurance codes. Recommended re-evaluation and recare intervals were generally determined by the dental hygienist. This information was given to the dentist to get final approval for proposed treatment if needed, to the front office staff for financial considerations, and to the client to obtain informed consent.

Albert discussed how presenting an individualized dental hygiene treatment plan, based on the DHDx, to a client gave the client the necessary knowledge to accept or decline treatment. In regard to finances, clients gained “confidence that their money was going toward something worthwhile.” Michele emphasized that an important aspect of care planning was to explain to the client not only what treatment was recommended, but also why it was necessary. The goal of the care plan is to provide the best possible care and referrals to improve the client’s oral and overall health.

Further, participants discussed the referral of clients to medical and dental professionals in multiple disciplines as a necessary component of the care plan. Mike described interprofessional practice by referring clients to physicians to evaluate the status of diabetes, high blood pressure or medications. Jane referred to a dermatologist when a suspicious lesion was observed on a client’s face or lips. Elizabeth explained how the recognition of possible acid reflux, visible by lingual erosion, required further evaluation by a physician. She described to clients the importance of further evaluation by stating “this is a major concern because it puts you at a high risk for esophageal cancer and oral cancer, as well as eroding away the enamel.” Summing up her thoughts, Elizabeth stated, “The body is all interconnected and interlinked.”

Mia discussed the importance of referrals for emotional health and for alcohol dependency problems. She also explained the need for an interprofessional referral to a physician for a client who had excessive bleeding problems or for those who were not responding to appropriate dental hygiene treatment. She made clear to those clients that a medical examination was recommended to ascertain if a systemic problem existed. Nikki, in independent practice, stressed to the clients and to family members of cognitively impaired clients the importance of understanding the relationship between oral health and general health when recommending frequent dental hygiene visits. This recognition of the oral–systemic link confirmed the significance of including health factors when making care plan recommendations.

In addition to systemic conditions, many participants reported intraprofessional referrals to dental professionals, such as dentists, periodontists, orthodontists, endodontists, and maxillofacial surgeons. These dental hygienists recognized the need for a dentist or dental specialist referral. Intraprofessional practice was described by Elizabeth as “a partnership” between the dentist and the dental hygienists working to help one another and facilitate collaboration. Nikki, who works in independent practice, referred to a dentist or mobile dentist for conditions requiring a dental diagnosis and dental treatment. Supporting quotations pertaining to the referrals that participants make as part of the dental hygiene care plan appear in Table 7.

Dentists' trust

From the participants’ experience, dentists trust dental hygienists to diagnose. Participants related that the dentist does not perform an oral examination of the client at every dental hygiene appointment. In some cases, a dental examination is only performed once per year or if there is a chief complaint. Therefore, the dentist relies on the dental hygienist’s ability to diagnose oral conditions and inform them of relevant findings. Nikki, in independent practice, explained how the dentists rely on accurate dental hygiene diagnosing.

Table 7.

Supporting quotations for care plan referrals

Dental hygiene care plan referrals

For referrals, most often the dentists or dental specialists, frequently physicians or other medical specialists. Occasionally, nurses, chiropractors, massage therapists. I've even recommended people to see exercise instructors. (Albert)

I refer them to their medical doctor. I've had patients who I've suspect have diabetes and so that's usually the referral to set up an appointment and I bug them at every appointment until they do it...I have given some referrals to some organizations like mental health, alcoholic programs. (Mia)

We typically refer to periodontists, orthodontists, endodontists, oral surgeons. Those are kind of our top four. We also work with a sleep study place to diagnose sleep apnea. We don't do any type of nutrition or smoking cessation of adults at all. If that's an issue, we usually refer them to their general doctor or general physician. (Elizabeth)

We refer out primarily to the endodontist, the periodontist, the orthodontist, and the oral surgeon. I've seen a couple abnormalities on someone's face or on their lips and I've suggested they see a dermatologist. (Jane)

I think it's [DHDx] pretty important because it allows you to be the bridge between the patient and the family and also the dentist of referral, if there are any dental issues. And it allows me to communicate to facilities that I visit via a written form creating an oral health record so that they can place that in their chart. It's good. It kind of creates a trail that they are getting taken care of and the need is being met with their oral care. And it allows me to better educate caretakers or the CNAs in areas that need improvement with daily care. (Nikki)

I saw signs of acid reflux, like a really red like soft palate and I saw a lot of inside lingual erosion on the teeth. I would ask the patient if you aware of any acid reflux or did you go through a period where you were throwing up a lot. This is a major concern because it puts you at a high risk for esophageal cancer and oral cancer as well as erosion of the enamel on your teeth. You need to get this under control. The medication required would be provided through your general practitioner. (Elizabeth)

If a patient has diabetes, I'll ask their HbA1c. You'd be surprised how many patients don't even know or don't even know the last time they did the test. I'll tell them they need to get it checked. The one on the high blood pressure medications, I'll ask the patient when's the last time you've seen your cardiologist or your physician regarding your blood pressure meds? If they said over a year, I'll tell them you should get that checked. (Mike)

I feel that they [mobile dentists] count on us to diagnose correctly because they are making a trip based on the diagnosis that I see. And they base their treatment plan for that mobile visit based on what I see. They’re coming out [to treat the patient] with the knowledge and the anticipation that those are the lesions that they would be treating.

(Nikki)

Leah described how communicating the DHDx to the dentist and then having the dentist reinforce the DHDx to the client “solidifies in the patient’s mind what is important.” This communication between the dental hygienist and the dentist ensured that the client received the necessary care.

Lastly, participants noted they have observed important findings to assist the dentist in performing a comprehensive diagnosis, and for the most part, the dentist has agreed with the DHDx. Specific quotations supporting these concepts are provided by Mia, Michele, and Jane.

There have been times where I brought a new patient, he’s done his exam, he’s diagnosing, and then they [patients] hop in my chair and then I find things that maybe he didn’t find. He’s thanked me on several occasions when these things have happened. The hygienist is a second pair of eyes for him.

(Mia)

He [the dentist] makes my input seem valuable to the patient and that has given me a lot of confidence and makes me want to make sure my diagnosis is good and that I’m looking for those things and just not leaving it in his hands; 99 times out of a 100 my dentist does agree with what I’ve suggested for the patient.

(Michele)

The dentist says, “Good job, Jane, that’s a good catch and good eye.” More times than not, he agrees with my diagnosis. That is a cavity. That is a problem. I trust you and 99% of the time he agrees with my diagnosis and my treating plans.

(Jane)

DISCUSSION

This qualitative descriptive study explored DHDx in clinical practice and is a unique addition to the scientific body of knowledge. The findings from this investigation might expand the breadth of professional associations’ definitions of DHDx. Similarities between this study and current association definitions of DHDx exist in the areas of assessment findings determining the DHDx and the use of the DHDx to plan dental hygiene interventions.

According to the professional standards of practice established for the dental hygiene discipline, DHDx is an essential step between collecting assessment data and planning for dental hygiene care.^8,9 Participants in this study verified that DHDx is a necessary component of the dental hygiene process of care. They used their data collection findings to create a DHDx, which then supported the development of an individualized, comprehensive care plan. Further, Santana et al. explained the importance of health care providers sharing information so “patients make informed decisions in relation to their diagnosis and treatment plans.”¹³ These authors stressed the importance of “building a partnership with patients” throughout this decision-making process.¹³ Participants in our qualitative descriptive study recognized the difference in how clients responded when their DHDx and treatment plans were shared with them. Clients were more engaged in the decision making about their treatment options when they understood their diagnosis.

Although participants acknowledged the importance of the DHDx, they were confused by the instruction received during their education. They noted that dental hygiene program educators taught students how to diagnose in multiple areas. However, educators also informed students that they could not legally diagnose based on state regulations. Gurenlian et al.¹⁵ conducted a survey to determine how dental hygiene educators taught DHDx in entry-level educational programs. Results revealed that 98% of responding dental hygiene educators taught the dental hygiene process of care and DHDx, including DHDx diagnostic terms.¹⁵ There might still be opportunities to educate students in using the DHDx in clinical practice to uphold their professional standard of care.

Most participants reported needing years of experience in practice to achieve full confidence in performing the DHDx. Once experience was gained in clinical practice, the true value of DHDx was appreciated. This gap in time before fully incorporating the DHDx step in practice could be detrimental to client care especially if the dentist is relying on the dental hygienist to diagnose and plan care for dental hygiene interventions. This finding is supported by the research of Williams et al.²⁰ on dental and dental hygiene students’ knowledge of diagnosing, treating, and referring for periodontal disease. Their results demonstrated that only 40% of dental students and 36% of dental hygiene students “reported confidence in diagnosing, treating, and appropriately referring” periodontal clients.²⁰ The authors concluded that dental and dental hygiene programs might not be preparing students to transfer knowledge learned into clinical practice appropriately.²⁰

A unique finding of this research was the trust that developed between clients and dental hygienists, and between dental hygienists and dentists based on the DHDx. Clients reported feeling more informed about their oral health when dental hygienists notified them of the DHDx, and they trusted the treatment plan that was recommended based on that diagnosis. These clients appreciated the time and money that was being invested in their oral health care. In addition, dentists trusted dental hygienists to diagnose oral conditions based on clinical assessments, so they could make informed decisions about further care needed. In some cases, the DHDx enhanced the care of underserved populations including residents of long-term care facilities.

From the participants’ perspectives and experiences, DHDx included the identification of multiple oral diseases including dental caries and periodontal diseases. Dentists relied on and trusted the dental hygienists’ diagnoses. Many states within the US have expanded regulations to include direct access practice.¹⁹ Because the DHDx is critical for comprehensive dental hygiene care, it should be recognized within all state practice regulations as a necessary responsibility of the dental hygienist.

Participants reported having the responsibility in practice to create the dental hygiene care plan, which included multiple intra- and interprofessional referrals. This holistic team approach to care is at the forefront of health care. These results align with the discussion by Walji et al.¹² which included the importance of a long-term relationship between the person and the provider and the significance of a holistic approach to care. An example of interprofessional practice was reported by An and Ranson²¹ in a literature review conducted on obstructive sleep apnea (OSA), a potentially fatal condition. The researchers concluded that dental hygienists are in a primary role to perform screenings for OSA and recognize the need for referrals.²¹ In medical practice, Graber et al.²² discussed the importance of diagnosis being a “team-based activity” that involves collaboration between all health care providers involved in a particular case as well as the client. The goal of this holistic team approach was to improve the diagnostic process. This approach “takes advantage of each team member’s particular expertise and involvement” and, increasingly, the teams were led by health care professionals other than physicians.²²

Dental hygienists must become advocates to expand the scope of practice to include DHDx. Practitioners should educate state legislators about professional care standards related to DHDx and its importance to clinical practice. Compromising these DHDx standards could affect client care and treatment outcomes. Therefore, state regulations must align with the professional standards regarding DHDx to ensure that quality care is provided. Clients need to be able to consent to treatment based on having been informed of their diagnosis. This expectation is routine for other health care providers. Assisting stakeholders in understanding that diagnosis is as relevant to dental hygiene practice as it is to dental practice, nursing practice, medical practice, and other health care practices might provide the insight needed to support language changes to uphold dental hygiene standards in rules and regulations governing the practice of dental hygiene.

A noticeable missing aspect of diagnosis among the participant responses was the consideration of social determinants of health. In addition, when reviewing the CDHA and ADHA definitions of DHDx, neither mentions social determinants of health.^10,11 The World Health Organization (WHO) defines social determinants of health as:

The conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries. ²³

Health care providers, in this case dental hygienists, should be aware of the inequalities and access-to-care challenges that their clients face. They should includ,e these determinants in the DHDx and address them in the dental hygiene care plans. Gurenlian and Swigart⁷ included “social hindrance to care” as a DHDx on a process of care operatory chart model. This step in the right direction for dental hygiene care may not have reached the clinical practice of dental hygienists. The current versions of the associations’ definitions need to be revisited to include provisions related to informing the client for increased understanding and improving unmet needs and social determinants of health.

Limitations of the study pertain to only interviewing dental hygienists from 3 states from the western region of the US. Dental hygiene practice might be different in these states compared to other states. Reflexivity or researcher bias is a core characteristic of qualitative research and may also be a limitation of this type of descriptive study.¹⁸ Additionally, the qualitative descriptive study is less interpretive than other types of qualitative designs.¹⁷ Although 10 interviews might seem to be a limitation as a small sample size, this number was sufficient because saturation was reached for this exploratory study.¹⁸

Dental hygienists have the responsibility in practice to determine dental hygiene care. Further research could include a comparison study of DHDx among Canadian dental hygienists and US dental hygienists to identify similarities and differences in clinical practice specifically as it relates to DHDx. In addition, a study is needed to investigate direct access dental hygienists and how DHDx informs their intra- and interprofessional referrals. Further, a Delphi study could be conducted to construct a new definition of DHDx based on current parameters of health care, theoretical models of care, social determinants of health, and interprofessional collaborative practice.

CONCLUSION

A qualitative descriptive study was conducted to investigate dental hygienists’ experiences with DHDx. Dental hygienists in 3 US states—California, Colorado, and Oregon—were interviewed. Four categories regarding DHDx emerged: expertise and confidence, client communication, dental hygiene care plans, and dentists' trust. The DHDx informs the client, increases understanding, and engages the client in the decision-making process. A DHDx is educational, improves communication, and supports the building of trusting relationships.

CONFLICT OF INTEREST

The authors declare no conflicts of interest