CLINICAL REFLECTIONS
How We Classify
At Niagara College, the following two tables were used to classify clients. A degree of difficulty was first selected, and then a degree of access was included and labeled as DD__-__.
Time to Reflect!
The following sections outline two different clients of mine from within the last two terms and an overall reflection on my care with them. The intension of these reflections is to analyze my assessment retrieval, my diagnoses, my appointment planning, and my implementation of treatments and education. By doing this I will be able to identify my strengths and weaknesses in supplying their care, determine what skills I need to work on, and ultimately determine how I can provide better care to these clients in the future.
Client #3
DD2-2
This client of mine was a 76-year-old male who was new to the Niagara College Dental Clinic. The major factors presented within his medical history included a heart attack in 2006, a stroke in 2010, and a left knee replacement in 2013. The client also indicated that he uses a continuous positive airway pressure (CPAP) machine at night. In regard to his dental history, he receives dental cleanings on a regular basis. His pharmaceutical history included the use of the anticoagulant Pradaxa, the cholesterol lowering agent Lipitor, the antisecretory agent rabeprazole, and a few vitamins and supplements for overall health. On the first appointment, his blood pressure was slightly elevated. A medical clearance was sent out to inform the physician on the client’s blood pressure, and also to determine if prophylactic antibiotics was necessary for invasive dental treatments due to his joint replacement. While it was determined by the next appointment that there was no need for the client to be premedicated, it was found that I had forgot to ask if the clients anticoagulant medication needed to be taken any differently prior to invasive dental care. Therefore, a second medical clearance needed to be sent out.
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With only being my 3rd client, and with having many firsts with this client, his total round of care took 7 appointments. His homecare included brushing in the morning and using Proxabrushs after meals. His overall food recall included a well-rounded diet, with very little caries promoting foods; therefore, no recommendations were made. His indices included generalized moderate biofilm (BI’s of 0-2), generalized mild inflammation (GI’s of 1 with some fibrotic tissue), localized minimal subgingival flecks of calculus, and localized interproximal supragingival calculus (CI’s of 0-2). The periodontal assessment showed localized CALs of 4 and 5mm, and one of 7mm, overgrowth within sextant 5, generalized recession of 0-3mm within the rest of the mouth, localized recession of 4 and 6mm, and almost no bleeding. 4 vertical bitewings, 4 periapicals, and 1 PAN was taken; however, 3 retakes had to be performed. Upon reviewing during the DDS exam, recurrent decay was diagnosed on 17M and 26M/D, there was an open margin at 25D, and a temporary ZOE filling needed to be replaced with permanent resin on the 16. The client was classified as having an extreme CRA due to caries, many restorations, heavy biofilm, xerostomia, and root exposure. His PRA was classified as high due to localized interdental CALs >5mm, stage 1 horizontal bone loss, and few risk factors.
Some of my goals for this client included reducing his BI’s and CI’s of 2s to 1s, halting the progression of CALs, understanding the impact of a dry mouth on caries production and therefore seeing the need for saliva stimulation, and understanding the importance of prioritizing oral health by performing adequate oral care 2 times daily, especially before bed. He was recommended xylitol products and Listerine. My appointment plan included debridement of 3 areas due to his classification of DD2-2, completed with a combination of ultrasonic scaling and hand scaling, selective coronal polish, and then a fluoride varnish application. 3 appointments were planned for this; however, he was completed in 2. The client’s denture was not cleaned as it was forgotten on his final appointment. A 3-month re-care was planned due to extreme CRA.
When looking at the standards of practice, I failed to demonstrate four of them while working on this client. For starters, I failed to demonstrate a commitment to professional responsibility by not (1a) “adhering to healthcare legislation, the CDHO regulations, code of ethics, practice standards, professional guidelines and policies”. This occurred when I failed to adhere to the CDHO guidelines on anticoagulants that recommends a medical clearance be obtained for invasive dental hygiene procedures. Not including this in my original clearance caused me to not be fully prepared for his second appointment and resulted in only being able to perform non-invasive procedures; a partial waste of time for both myself and my client.
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I also failed to demonstrate a commitment to professional responsibility by not (1j) “recognizing gaps in knowledge and taking the appropriate steps to acquire this knowledge”. This occurred when I was performing a panoramic on my client. I had never done one in clinic before, and while I felt unsure about it, I skimmed the instructions and felt okay to proceed. Unfortunately, rather than holding the button down for the entire extended beep until the rapid triple beep at the end, I believed that the initial beep was an indication to stop. My lack of knowledge caused me to only expose his molars, and rather than questioning my knowledge, I assumed the machine was on the wrong setting, told a teacher, was allowed a retake, and proceeded to make the same mistake a second time. It wasn’t until one of the technicians came around questioning if something was wrong with the machine, that I realized that I was not aware that I was to hold down the exposure button through the extended beep until the rapid triple beep. This caused unnecessary exposure to my client and wasted the technicians time.
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Lastly, I failed to demonstrate a commitment to continue competency by not (4f) “incorporating current knowledge, interventions, technology and new practice guidelines into practice”, and failed to demonstrate competence in the planning of client centered interventions by not (8.3e) “selecting and including in the plan or program appropriate health promotion strategies and interventions for individuals and communities”. This occurred when I failed to abide by the recommendations outlined by CAMBRA for my extreme caries risk client. With this classification, extra fluoride should have been a key element in my oral health coaching, goals, and overall recommendations. By not using this guideline, I missed appropriate interventions like the need for 1.1% fluoride toothpaste and a high fluoride rinse, and instead only recommended the use of xylitol, regular toothpaste, and Listerine rinse. By not doing this, my client did not receive the best client centered oral health care recommendations.
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Looking back now, I should have been more prepared, asked for more help, and taken more consideration into my recommendations. Realizing this, I plan to better prepare myself, and ensure that I include the importance of fluoride during his next round of care. Overall, I learned a lot from this client, and after some setbacks that could have been avoided, I thoroughly enjoyed providing care for this client and was immensely appreciative of him being so dedicated, as I in no way planned for his care to take 7 appointments; however, he showed up for every single one and never complained. I was relieved after completing his care, and even though he was my second client finished, I felt more accomplished when his care was completed.
Client #9
DD4-1
This client of mine was a 25-year-old female who was new to the Niagara College Dental Clinic. Her medical history included hypoglycemia, a history of heart murmurs during pregnancy, a grade II reflex as a child, and depression and OCD; therefore, no major factors that would affect her oral health or impede dental care. Her pharmaceutical history only included the use of the antidepressant Cipralex, along with multi-nutrient supplements and supplements to aid in working out. In regard to her dental history however, she had not had a professional cleaning in over 10 years; ultimately resulting in the natural build up of calculus over the years.
This client’s total round of care will end up taking 7 appointments; for she is currently within the final stages of debridement and booked for appointment #6 and then has a 6-week re-evaluation. Her homecare included only brushing in the morning for 1.5 minutes. Her overall food recall included a fairly well-rounded diet with coffee with cream and sugar being the only caries promoting item; however, no recommendations were made. Her indices included generalized heavy biofilm (BI’s of 1-3), generalized, suspected, early biofilm induced gingivitis (GI’s of 1-2), and generalized supragingival and subgingival interdental calculus (CI’s of 1-3), that ended up being far more tenacious than assumed. The periodontal assessment showed PPDs of 1-3mm, with three localized pocket depths of 4, 6, and 7mm, two localized CALs of 5 and 6mm, generalized minimal lingual overgrowth, facial gingival margins generally along the CEJ, and bleeding on probing at 15.5%. 4 horizontal bitewings, and 1 periapical was taken to diagnose exostosis facially on the maxillary arch. Upon reviewing during the DDS exam, no caries were diagnosed. The client was classified as having a moderate CRA due to heavy biofilm, pits and fissures, and very little protective factors counterbalancing no caries. Her PRA was also classified as moderate due to an interdental CAL of >5mm.
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Some of my goals for this client included reducing her BI’s and CI’s of 2s and 3s to 1s, reducing her GI’s of 2s to 1s, halting the progression of CALs, reducing BOP to <10%, understanding the effects of biofilm and how to control it, and the importance of prioritizing oral health by performing adequate oral care 2 times daily, especially before bed. Interdental aids and Listerine were recommended. My appointment plan included debridement of 4 areas due to her classification of DD4-1, completed with a combination of ultrasonic scaling and hand scaling, selective coronal polish, and then a fluoride varnish application. 3 appointments were planned for this, however, now looks to be completed in 4. A 6-week re-evaluation is scheduled to assess response to treatment. A 4-month re-care was planned due to the amount of bleeding.
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When looking at the standards of practice, I failed to demonstrate three of them while working on this client. For starters, I failed to demonstrate a commitment to continue competency by not (4e) “collaborating with other health professionals and participating in interprofessional learning opportunities”. This occurred during my second debridement appointment. While I had already started debridement in quadrant 3 at the previous appointment, I had missed a lot of deep interdental calculus and was given a NC (non-competent) grade and told to fix these areas at the next appointment. At the next appointment I spent an immense amount of time in this area, but somehow still felt calculus; unfortunately, fear prevented me from asking for help. Near the end of the appointment, the teacher came around to ask how things were going and checked for calculus. When calculus was still prevalent in some areas, the teacher questioned why I didn’t ask for help sooner and explained that multiple questions are always welcome when debriding a DD4, especially considering she was my first. Therefore, my failure to collaborate with my teachers and ask for help when I was struggling, resulted in a pretty-well wasted appointment for myself and the client.
I then failed to demonstrate competence in the planning of client centered interventions by not (8.3c) “designing a dental hygiene care plan or program based on assessment data, a client-centered approach, best practices and the best available resources”. This occurred when I didn’t accurately notice the tenacity of the calculus and only classified my client as a DD4-1 when she should have been a DD4-2. This would have divided her mouth into 6 areas rather than 4 and I could have therefore planned for more debridement time. I also originally failed to plan for a 6-week re-evaluation when this should have been planned as soon as I noticed how much bleeding was occurring during her first debridement appointment; this was added following her third debridement appointment. Overall, my dental hygiene care plan was not client specific enough and resulted in me inaccurately informing my client on the total number of appointments.
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Lastly, I failed to show competence when providing dental hygiene services and programs by not (8.4h) “providing clients with appropriate pre- and post-intervention advice to include pain management, oral self-care, use of therapeutic and preventive agents, and follow-up/recare appointments”. This occurred at the end of my third debridement appointment when my teacher had asked if I had made any recommendations for therapeutic agents for my clients bleeding gums. When I said I had not, my teacher recommended my client to rinse with warm saltwater for 3-5 days to help with tissue healing. I realized in that moment that I had failed to recommend a therapeutic agent at my two previous debridement appointments.
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Looking back now, I should have asked more questions during debridement, better reviewed my assessments, and considered therapeutic agents for my client. Realizing this, I plan to take more time in reviewing my assessments, ask for help while I still have it, and always ask myself at the end of appointments if I should be recommending at therapeutic agents for healing; and considering her care is not completed, I still have the chance to do some of these now!
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Overall, I learned a lot debridement wise from this client, thoroughly enjoyed providing care for her, and was very grateful for her enthusiasm with wanting better oral health, and her flexibility with appointment booking, and her overall dedication for we unfortunately didn’t intend for her care to take 7 appointments. While we still have two more appointments together, I know the end is near, and look forward to completing my first ever 6-week re-evaluation. While I felt defeated during my continually failed debridement of quadrant 3, only having minor misses within quadrant 2 has boosted my confidence. The road will be long, and therefore I know I will be relieved once her care is completed, for she will be my first official DD4 completed.
Post Reflection - Term 4
It still feels surreal that we are now senior dental hygiene students. At times you still feel lost and overwhelmed, but then you hear what the juniors are struggling with and realize that that was once you, but now you know more than you think, or give yourself credit for. I came into this term feeling ready to excel in clinic and in classes; this however was not exactly what I got. While classes were okay throughout the semester, clinic became a big stressor for me as the term progressed. What stressed me was client scheduling. While I was ready to plan out my appointments and aim to finish a few clients at a time prior to starting any new clients, this didn’t completely go as planned. I experienced a lot of cancellations during the second half of this term which resulted in receiving new clients which I now needed to find time for, along with rescheduling cancellations. While I am appreciative of these new clients, the whole situation of constantly playing around with my schedule, having clients with very specific availability, and being forced to move some clients to next term, made me very stressed for I feared that I would not meet my requirements. While I will now make my requirements, I need to work on scheduling clients, and hope that my luck for next term is better.
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While this term was tough, I have still surely grown! My first two clients in the previous term took me 5 and 7 appointments. I am now completing clients in around 3 appointments! My confidence has definitely grown, and I believe this is the primary reason why my time management has gotten so much better, for I am more often confident in my initial assessments and rarely feel the need to check things twice. In comparison to theory classes, while I find my growth in clinic to be more evident, I also feel my knowledge in theory is growing; however, I do hope next term will allow for more time to focus more on theory and allow for more self study time for I would like to start preparing for the board exam sooner rather than later!
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When reviewing the standards of practice, I feel I have seen the most personal growth within (7g) “keeping detailed client records that meet the College’s requirements for recordkeeping and support the continuity of client care”, and (8.3c) “designing a dental hygiene care plan or program based on assessment data, a client-centered approach, best practices and the best available resources”. I feel more confident in my documentation for I use to spend so much time reviewing my documentation, but now I know what aspects need to be included where, in order to maintain comprehensive documentation. Then, while I use to spend so much time trying to plan ahead, I am now better at quickly creating a plan that encompasses client specific aspects. Areas where I could use some work however, would be with (8.2d) “interviewing clients about their understanding of their oral conditions, what has caused them and how that relates to the determinates of health and oral health”, and (8.5c) “discussing the relevant findings with the client and including their perceptions of changes in individual oral health or community oral health in the discussion”. I find my focus at times is too much on moving through the ADPIE process quickly, and I question if I explain my assessment findings well enough to my clients during oral health coaching; do they fully understand their oral health status, the reasons behind my recommendations, and the positive and negative changes at each re-care appointment?
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Overall, while my time management within clinic improved a lot, I find my biggest struggle this term was my time management regarding classes. I feel less stress outside of clinic would promote less stress within clinic, therefore, my goal for next term is to “take better advantage of my time and plan ahead”. I plan to strive towards this by taking larger tasks and breaking them up into smaller “check-points”. I also plan to apply this to clinic by completing necessary preparations for my client as soon as possible rather than last minute. In conclusion, I'm growing to love this profession, I know this is what I want, and I want to excel in it; I plan to.
~ References found within attached documents ~