Process of Care: ADPIE Framework

Core Review

Overview of the Process of Care

The dental hygiene process of care is a systematic, patient-centered framework adapted from the nursing process. It provides the standard of care for dental hygiene practice and serves as the legal and ethical foundation for clinical decision-making. The five phases are sequential and cyclical — evaluation feeds back into assessment, making the process continuous rather than linear.

Phase 1: Assessment

Assessment is the systematic collection and analysis of subjective and objective data to identify patient needs. This phase is divided into two categories:

Subjective Data (Symptoms) — Information reported by the patient that cannot be directly measured:

• Chief complaint and history of present illness
• Medical and dental histories
• Medication history (prescription, over-the-counter, supplements)
• Social history (tobacco, alcohol, substance use)
• Dietary habits and nutritional status
• Patient goals, concerns, and expectations
• Pain history (location, onset, duration, quality, aggravating/alleviating factors)

Objective Data (Signs) — Measurable, observable findings collected through clinical examination:

• Vital signs: blood pressure, pulse rate, respiratory rate, temperature, oxygen saturation
• Extraoral examination: symmetry, lymph nodes, TMJ, profile
• Intraoral examination: soft tissues (oral cancer screening), hard tissues
• Periodontal assessment: probing depths, clinical attachment level, bleeding on probing, recession, furcation involvement, mobility
• Dental charting: existing restorations, caries, anomalies, occlusion
• Radiographic findings
• Risk assessments: caries risk, periodontal risk, oral cancer risk

The NBDHE often tests your ability to distinguish subjective from objective data. Remember: if the patient tells you about it, it is subjective. If you measure or observe it, it is objective.

Phase 2: Dental Hygiene Diagnosis

The dental hygiene diagnosis identifies human needs deficits that the dental hygienist is licensed to treat within the scope of practice. It is distinct from the dental diagnosis.

Dental Diagnosis (made by the dentist):

• Identifies diseases and conditions of the oral and maxillofacial region
• Examples: dental caries, pulpitis, impacted teeth, oral cancer, malocclusion
• Requires the diagnostic expertise delegated to the dentist under state dental practice acts

Dental Hygiene Diagnosis (made by the hygienist):

• Identifies human needs deficits related to oral health that can be addressed through dental hygiene interventions
• Focuses on conditions the hygienist is educated and licensed to treat
• Examples: risk for dental caries related to inadequate fluoride exposure, impaired oral self-care related to limited manual dexterity, oral mucosal tissue trauma related to ill-fitting prosthesis

Format: The dental hygiene diagnosis follows a structured format:

• Problem — the human need deficit (e.g., "risk for dental caries")
• Etiology — the contributing factors (e.g., "related to frequent fermentable carbohydrate intake and inadequate fluoride exposure")
• Signs/Symptoms — the evidence (e.g., "as evidenced by DMFT score of 8, plaque index of 85%, and dietary recall showing frequent snacking on sugar-sweetened beverages")

The NBDHE may ask you to distinguish whether a given statement is a dental diagnosis or a dental hygiene diagnosis. Key distinction: if the condition requires restorative, surgical, or endodontic treatment, it is a dental diagnosis. If the condition can be managed through preventive, educational, or non-surgical periodontal interventions, it is a dental hygiene diagnosis.

Phase 3: Planning

The planning phase involves developing a comprehensive, patient-centered care plan. This includes:

1. Prioritization — Determining the sequence of care based on urgency and patient needs. Acute conditions (pain, infection) take priority. The NBDHE expects you to recognize that emergency needs are addressed before preventive or elective care.

1. Goal Setting — Establishing specific, measurable, achievable, relevant, and time-bound (SMART) goals. Goals should state the expected outcome, conditions under which it will be achieved, and timeframe.

1. Sequencing — Arranging appointments in logical order:
   • Emergency care first
   • Disease control (non-surgical periodontal therapy)
   • Restorative care
   • Re-evaluation
   • Maintenance/continuing care

1. Informed Consent — Obtaining the patient's voluntary agreement after full disclosure of treatment options, risks, benefits, and alternatives. Consent must be documented.

1. Appointment Planning — Estimating the number and duration of appointments needed to complete the care plan.

Phase 4: Implementation

Implementation is the active delivery of dental hygiene services according to the care plan. This phase includes:

• Application of preventive agents (fluoride, sealants)
• Scaling and root debridement
• Patient education and oral hygiene instruction
• Nutritional counseling
• Tobacco cessation counseling
• Administration of local anesthesia (where permitted by state practice act)

Critical implementation concepts for the NBDHE:

• Standard precautions are used for every patient regardless of health status
• Treatment modifications may be necessary based on medical conditions (e.g., antibiotic premedication, positioning modifications)
• Documentation must be concurrent with treatment — chart as you go

Phase 5: Evaluation

Evaluation is the assessment of treatment outcomes against the goals established in the planning phase. It occurs at multiple points:

• During treatment — immediate self-evaluation during implementation
• At the end of an appointment — did you accomplish what was planned?
• At re-evaluation — 4-6 weeks after non-surgical periodontal therapy
• At continuing care visits — ongoing monitoring of oral health status

The evaluation phase determines whether:

• Goals were met → patient enters continuing care
• Goals were partially met → care plan is modified
• Goals were not met → reassess and revise

Critical re-evaluation assessment: After scaling and root debridement, re-evaluation should occur at 4-6 weeks to allow for tissue healing and resolution of inflammation. At this visit, you reassess probing depths, bleeding on probing, and clinical attachment level to determine if further treatment (such as surgical referral) is indicated.

Clinical Application

Consider this scenario: A 58-year-old patient presents for a new patient appointment. Your assessment reveals blood pressure 148/92 mmHg, generalized probing depths of 4-6 mm with bleeding on probing, and a medical history notable for type 2 diabetes (HbA1c 8.2%).

You identify multiple diagnoses: (1) risk for cardiovascular complications related to uncontrolled hypertension, (2) periodontitis (Stage III, Grade C) related to poorly controlled diabetes and bacterial biofilm, as evidenced by probing depths of 4-6 mm, BOP, and radiographic bone loss.

Your care plan prioritizes medical consultation for the elevated blood pressure before proceeding with periodontal therapy. You schedule quadrant scaling and root debridement over two appointments, with a 4-6 week re-evaluation. After the first quadrant, you evaluate whether the patient tolerated the procedure well and achieved hemostasis. At re-evaluation, you compare current probing depths against baseline to determine treatment response.

Common Traps

• TRAP: Confusing the dental diagnosis with the dental hygiene diagnosis. The NBDHE will often include the phrase "dental hygiene diagnosis" in answer choices — make sure you are selecting the appropriate scope.
• TRAP: Forgetting that implementation includes patient education. Dental hygiene is not just clinical procedures; patient self-care education is a core implementation activity.
• TRAP: Skipping evaluation. The NBDHE may present a scenario where periodontal therapy was delivered and ask "what next?" The answer is often re-evaluation, not more treatment.
• TRAP: Confusing "risk for" diagnoses with active conditions. A patient with poor oral hygiene has "impaired oral self-care," not "periodontitis" as a hygiene diagnosis.