Criterion Referenced Evaluation

CANADIAN NATIONAL INSTITUTE OF HEALTH

Dental Hygiene Program

Fall 2011

CLINIC MANUAL

Section III – Clinical Assessment Performance Criteria CNIH - Dental Hygiene Program2011 Revised September 2011

Table of Contents

Criterion Referenced Clinical Assessment 4

Assessment of skills and/or procedures in clinical sessions 8

Clinical Assessment Performance Criteria

Case Presentations Adult minimal care 9 Adult periodontally involved 10 Child/adolescent 11 Senior adult 12

Case Decisions 13 Care Plan 14 Client/Operator Positioning 15 Client Education 16 Coronal Polish 17 Deposit Detection 18 Deposit Removal 19 Enamel Sealants 20

Examinations: Dental 21 Extra-oral 22 Health history 23 Indices 24 Intra-oral 25 Occlusal 26 Periodontal 27 Perio-reevaluation 28 Fluoride Application 30 Handpiece Maintenance 31 Impressions (alginate) 32

Instrumentation Skills: Activation 33 Adaptation 33 Fulcrums 34 Grasp 34 Insertion 34 Operating Field Maintenance 35 Sharpening 36

Ligate Arch Wires 37 Orthodontic Bands 38 Tooth Separation 39 Mouth Guards/Bleaching Trays 41 Nutrition Counselling 42 Radiographic Technique and Interpretation 42

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Sanitization of the Treatment Unit 44 Student Goals and Self Assessment 45

Ultrasonic/sonic Technique 46

Vital Signs Blood pressure 47 Pulse 48 Respiration 49

Professional Development Skills

Introduction 50 Documents management 50 Work habits 51 Professional conduct 52 Time management 53 Care of client tissues 53

Ethical Decision Making Model 54

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CLINICAL ASSESSMENT

CRITERION REFERENCED

Criterion referenced assessment means that students are evaluated consistently according to established descriptions of adequate performance. This has a number of advantages in the clinical setting. Criterion lists define standardized, observable behaviours that must be demonstrated by students as they perform basic instrumentation skills and clinical procedures. Clinical competence can be divided into three components:

1. The student must protect the client and the operator from harm during delivery of clinical service.

2. The skill or procedure must result in at least a minimally acceptable level of treatment effectiveness.

3. Client centered dental hygiene process of care and professional behaviour must be applied to all client care.

Criterion based assessment also stresses skill evaluation against objectively stated standards. The established standards stated in Section III of the Clinical Manual are also useful to students as a resource for peer and/or self-assessment of progress in developing clinical skills, application of the process of care and expected professional behaviour.

Based on these principles, performance criteria lists state behaviours to be observed at two levels:

1. Critical elements of performance: Some of the criteria are mandatory for maintenance of client and operator safety and treatment efficacy. These critical statements are written in bold face type in criteria lists and on assessment documents. To pass a skill all critical elements must be performed adequately, to the acceptable level for the term.

2. “Nice to do” standards: Some of the behavioural criteria are important for optimal delivery of service to the client but are more typically demonstrated by experienced professionals. These behaviours are listed as goals for students to achieve as early as possible. They are not required for a pass grade for the skill or procedure. They are written in ordinary type.

There is a criteria list for each of the clinical skills associated with the dental hygiene program (Reference: Clinical Manual Section III).

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FORMAT OF FORMATIVE CLINICAL SESSIONS

Clinical sessions are designed to support ongoing learning of the dental hygiene process of care by offering opportunity for guidance, verbal and written feedback and student self-assessment.

Clinical Feedback Class:

The format for learning and applying the process of care in the clinical setting begins in Clinical Feedback class. This class is directly connected to clinic in that it is a forum to address clinical procedures, expectations, student and instructor concerns and questions. This class also offers reinforcement and review of material covered in theory courses. Attendance is mandatory.

Prior to the Commencement of Clinic:

Instructors communicate with each student in their group 15 minutes prior to the seating of the clients to discuss goals for the clinic and options for optimal client care. The lead clinician may offer verbal and/or written guidance/reminders for the clinic on the central white board.

Students must set and record a goal for the clinical session on their clinical feedback sheet.

Throughout the Clinical Session:

Throughout the clinical session verbal and written feedback on treatment goals, time management and means of addressing specific client needs is offered by the instructor in discussion with the student. This is evidenced on the daily grade sheet. All communication with the student must focus on and encourage student assisted learning in the use of critical thinking skills.

Instructors observe the performance of various clinical skills/procedures as well as student behaviour and communication skills on an ongoing basis. Professional developmentskill grades are assigned at each clinical session in each of the specified areas (document management, work habits, professional conduct, time management, and care of client tissues), and recorded on the student’s clinical feedback grade sheet. Professional development skills are also evaluated in the “Case Decisions” area. The CDHO Ethical Decision Making Model is used in the assignment, documentation and discussion of all grades with the student. (Reference: Clinical Manual Section III – Clinical Assessment Performance Criteria – Professional development skills).

There is an opportunity for the students, as they feel ready, to independently exhibit their critical thinking skills in the clinic in the independent assessment and client centered treatment required of their “Case Presentations” ( Reference: Clinical Manual Section III Clinical Assessment Performance Criteria)

Professional behaviour and interaction with clients, students, and fellow team members in the clinic is expected of the instructors at all times and is required modelling for student learning. Clinic Manual, Section III – Clinical Assessment Performance Criteria 5 CNIH - Dental Hygiene Program2011 Revised September 2011

Revised September, 2010

There is a duty student assigned for each clinical session. The tasks of the duty student are performed under the supervision of the clinical instructors/front desk staff and/or the clinical technician as they learn the responsibilities in the dispensary/sterilization area and reception area.

End of Clinical Session:

Instructors review student performance individually and ensure a clear understanding of all feedback and assigned grades. This is done in a discussion format with the student. If a student is in disagreement with the grade assigned and cannot resolve it with the instructor, he/she may address it with the lead instructor. If a resolution cannot be reached the student is advised to write up a communication sheet and set an appointment with the clinical co-ordinator.

Students perform a Self-Audit of the client’s chart record(s) from the clinical session, and the chart documentation requirements are reviewed and finalized by the supervising instructor with the student.

Students are required to reflect on their clinic and make notations in the self-assessment portion of the clinical grade sheet. This is a further opportunity for the instructors to address any student learning needs.

Debriefing of the clinical session is held 10 minutes prior to the end of the clinical session either for the group as a whole or in the individual instructor session groups.

Remediation:

Students exhibiting difficulty with clinical skills may be recommended for remedial. Students exhibiting a lack of the knowledge required for safe and efficient client care may be required to complete an assignment on the deficient topic or may be referred to the theory course material applicable. If a student exhibits ongoing learning difficulties, ineffectiveness or unsafe practice the clinical co-ordinator will be advised and will take the appropriate action. If a student is determined to be in a failing position in any competency at any point in the term, that student is required to attend remedial sessions specific to the deficiency. (Reference: Clinical Manual Section I – Preclinical Protocol – Remedial/Open Lab Sessions)

Instructor Calibration

Instructor calibration is critical to standardized evaluation. It is initially achieved by providing each instructor with a faculty manual, clinical manual and student handbook for reference, as well as access to library resources and email access to all theory instructors at CNIH.

Each week the clinical co-ordinator communicates via email the results of each clinical feedback class. Weekly calibration meetings and/or email communication also support standardization.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 6 CNIH - Dental Hygiene Program2011 Revised September 2011

Revised September, 2010

For further calibration instructors are required to meet prior to each clinical session to clarify information from feedback classes and calibration meetings, as well as any immediate clinical concerns. Lead clinicians are advised of their responsibilities and expected to keep open communication with all other lead clinicians and the clinical co-ordinator. Any immediate concerns in the clinic can also be documented in the Communication Binder in the clinic for all instructors to view.

As an overseer of all clinical activities, the clinical co-ordinator monitors clinical proceedings in each clinical session on a rotational basis as needed and facilitates communication and the transfer of information to all clinical instructors, technicians, clinical receptionists and administration for the smooth operation of the clinic. A lead clinical instructor is assigned to all clinical sessions and provides the clinical co-ordinator with any and all relevant information from the clinical session.

SUMMATIVE EVALUATION OF CLINICAL PERFORMANCE

Clinical skills and procedures are assigned a grade based on the term the student is in. The grading scheme for each performance criteria is in Section III of the clinical manual. It is meant to be a guide only and instructors are advised to temper their grades based on any extenuating circumstances in each clinic and in consideration of the student’s stage of learning. The clinical appendices outline the clinical requirements for each term as well as evaluation policies.

Students are encouraged to track their own clinical requirements by maintaining a student copy of their grade sheet for each clinical session. Students have the opportunity to transcribe the grades earned during that session at the end of each clinical session for their own records. The clinical co-ordinator reviews and files all original student grade sheets and provides a summary grade sheet to each student periodically. At any time in the term if the summary sheet reveals that a student is approaching an overall failing grade in a competency or penalty area, the clinical co-ordinator will refer that student for remedial or address the behaviour.

Open Lab opportunities to practice clinical skills/procedures is available to all students in clinic at weekly scheduled times.

At midterm the students are advised of their status in clinic via written letter and orally. The students who are behind and at risk of not completing their requirements are required to meet with the clinical co-ordinator/faculty advisor to discuss a plan of action for the rest of the term.

At the end of the term the Academic Advancement Committee reviews the students’ clinical performance results as well as their performance in the supporting theory courses. (Reference 1. Clinical Manual Appendix: Academic Level 02 2. Clinical Manual Appendix: Academic Level 03 3. Student Handbook, “Academic and Due Process Policies”)

Clinic Manual, Section III – Clinical Assessment Performance Criteria 7 CNIH - Dental Hygiene Program2011 Revised September 2011

Revised September, 2010

During this dental hygiene program enough time is available in pre-clinical and clinical practice to allow students to acquire competence in assessment skills and delivery of oral care specific to client unmet needs at minimal levels or above. When students acquire sound basic skills, an appreciation of the need for continuing competency and good self-assessment skills, as graduates they will be equipped to mature in their profession. As life-long learners and with continued practice and exposure to a variety of clients, their clinical and communication expertise will improve.

ASSESSMENT OF SKILLS and/or PROCEDURES IN CLINICAL SESSIONS

Students request a skill and/or procedure assessment by placing their name and treatment unit number on the board in the dental clinic under the name of the clinical instructor who will perform the evaluation. The instructor will attend to students as soon as possible. Please be patient, each student and client deserves careful attention from the instructors. All requests for evaluation of skill and/or procedure must be placed on the white board 60 minutes before the end of a clinical session

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CLINCIAL ASSESSMENT PERFORMANCE CRITERIA

Case Presentation - Adult Minimal Care

The client chosen must be between 18 and 54 years of age. S/he should be in good general health. Oral health status should include the following:

– Scanty to light generalized supragingival and subgingival calculus deposits – minimal soft deposits – may present with localized extrinsic stain – may present with localized 4 – 5mm pockets

For the case to be considered for course requirements students must: - Complete a modified assessment to determine his/her suitability. - Advise the supervising dental hygienist that you would like to present this case for credit.

The supervising clinician will: - Examine the client to determine his/her suitability. If the client is acceptable, the student must fulfil the requirements below, to be given credit for the case. If the client is unacceptable for a case presentation the student will complete all treatment and receive a “C” grade to track the number and type of clients the student has treated.

Academic Level 02 Academic Level 03

Assignment of a failing grade in any of the Professional Development skills categories (document management, work habits, professional conduct, time management, and care of client tissues) will result in loss of credit for the case.

If the student does not complete a required component of the case successfully and loses credit for the case presentation, a grade of “F” will be assigned for “adult minimal care case presentation” in the clinical assessment documentation on the day the credit was lost. The student will be required to complete the remaining elements of the case and be assessed in the usual manner. If the student completes the case successfully, credit for the case will be recorded in the assessment documentation on the day of the final appointment with the client. A “P” or “F” will be assigned.

If at any time if the student’s management of the case poses risk of harm to the client, the supervising clinician will intervene. Clinic Manual, Section III – Clinical Assessment Performance Criteria 9 CNIH - Dental Hygiene Program2011 Revised September 2011

Case Presentation - Adult PeriodontallyInvolved

The client chosen must be 18 years of age or older. S/he should be in good general health. Oral health status should include the following:

– at least 5 teeth in each quadrant of the mouth – moderate to heavy generalized supragingival and subgingival calculus deposits – obvious soft deposits – moderate, generalized, OR heavy localized extrinsic stain – generalized 4mm periodontal pockets or greater (>30%)

The supervising clinician will: - Examine the client to determine his/her suitability.

If the client is acceptable, the student must fulfil the requirements below, to be given credit for the case. If the client is unacceptable for a case presentation the student will complete all treatment and receive a “C” grade to track the number and type of clients the student has treated.

Academic Level 02 Academic Level 03

Complete independently and successfully the Complete independently and successfully all following aspects of client care: aspects of client care. Examinations: - health history Prescribed radiographs must be completed with a - dental minimum grade of 70%. - extra-oral - intra-oral For clients with a degree of difficulty at level 3 or - occlusal 4, supervising clinicians may provide minimal - periodontal and indices direction to facilitate treatment interventions Dental hygiene care plan unique to the client. Case decisions.

If the student completes the case successfully, credit for the case will be recorded in the assessment documentation on the day of the final appointment with the client.A “P” or “F” will be assigned.

If at any time if the student’s management of the case poses risk of harm to the client, the supervising clinician will intervene. Revised March 3, 2010

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Case Presentation - Child/Adolescent

The client chosen must be between 4 and 17 years of age and in good general health.

The supervising clinician will: - Examine the client to determine his/her suitability.

Academic Level 02 Academic Level 03

Complete independently and successfully the Complete independently and successfully all following aspects of client care: aspects of client care (including sealants and sports Examinations: mouthguard). - health history - dental Prescribed radiographs must be completed with a - extra-oral minimum grade of 70%. - intra-oral - occlusal Dental hygiene care plan Case decisions.

If at any time if the student’s management of the case poses risk of harm to the client, the supervising clinician will intervene.

Revised September 22, 2011

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Case Presentation - Senior Adult

The client chosen must be 55 years of age or older. Oral assessment findings must be a DD1 or greater

The supervising clinician will: - Examine the client to determine his/her suitability.

Academic Level 03 Academic Level 02

If at any time if the student’s management of the case poses risk of harm to the client, the supervising clinician will intervene.

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Case Decisions

Critical elements are in bold type.

1. The dental hygiene student must reflect the dental hygiene role as a clinician, educator, health promoter, manager, researcher, change agent and client advocate. 2. Based on the client centered care plan interventions, the dental hygiene student will design a treatment plan that takes into consideration: - the psychosociocultural client needs - the client’s physical needs 3. The dental hygiene student will schedule appointments that reflect: - appropriate time frames for completion of each planned procedure (acceptable for present level of skill) - logical groupings of procedures that are interrelated or require specific sequence ie. Sealants prior to Fluoride treatment; scheduling debridements of sextants/quadrants when local anaesthia is involved. 4. The dental hygiene student will: - consult and refer to other health care professionals if necessary - obtain verbal and written consent (client and instructor) for accepted treatment plans prior to commencement of treatment - obtain verbal and written refusal for treatment as appropriate - record necessary information in the client’s clinical file. 5. The dental hygiene student will: - determine the need for revisions based on changing needs and new information using indices and other measurements. 6. The dental hygiene student will: - evaluate progress towards the goals and each appointment in consultation with the client determine alternate strategies to achieve goals that have not been met or goals as necessary. 7. Upon progression and completion of appointment sequence the dental hygiene student will: - determine progress towards long term goals - inform the client regarding progress towards long term treatment goals - after consultation/evaluation with the client, modify goals as necessary - determine an appropriate appointment interval for ongoing maintenance of periodontal health 8. The dental hygiene student will: - adhere to the current dental hygiene practice standards and conduct (laws and regulations) Acceptable Level Required Academic Level 02 Academic Level 03 Pass – 2 or less elements are unacceptable Pass – no more than 1 element is unacceptable Failure – 3 or more unacceptable elements Failure – 2 or more unacceptable elements

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Care Plan

Critical elements are in bold type.

1. Provide information about the procedure to the client. 2. Assemble appropriate documents. 3. Provide privacy. 4. Use assessment findings to identify the client’s unmet human needs related to dental hygiene care (within the scope of practice). 5. Establish client-centered goals in conjunction with the client. 6. Record the DH diagnosis, client-centered goals, student DH interventions and evaluation of the client’s goals which: - list the unmet human needs of the client - list the etiology or cause of the unmet human need - list the evidence of the etiology or cause of the unmet human need - list short and long term client-centered goals established by the client and the dental hygiene student - list dental hygiene student’s interventions which should meet the client’s goals - set specific dates or time frames for the evaluation of short and long term client-centered goals with the client that: -are clear and concise -are observable and measurable -include target dates for completion -are realistic given the client’s capabilities, motivation and resources 7. Verify with the client that the proposed care plan is acceptable by communicating in appropriate vocabulary for the client’s understanding. 8. Make any changes necessary after the client considers the proposed care plan. 9. Facilitate communication and collaboration among health care professionals if necessary. 10. Record the information in the client’s clinical file. NOTE: Re-evaluation of client’s progress to be recorded at each subsequent appointment (See Case Decisions).

Acceptable Level Required

Academic Level 02 Academic Level 03 Pass – 2 or less elements are unacceptable Pass – no more than 1 element is unacceptable Failure – 3 or more unacceptable elements Failure – 2 or more unacceptable elements

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Client – Operator Positioning

Critical elements are in bold type.

1. Operator’s weight distribution: a. while seated – evenly distributed over both buttocks. b. while standing – evenly distributed over both feet. 2. Operator’s stool adjusted so that: a. back is supported. b. thighs are parallel to the floor. c. both feet are flat on the floor. 3. Client’s chair adjusted: a. mandibular arch sites of operation – chair back is +10 to +20 degrees from horizontal. b. maxillary sites of operation – chair back is parallel to the floor. c. client’s head is supported near the end of the head rest. d. client’s oral cavity is oriented for visibility and access to operative sites. e. client’s back is supported. f. chair height places the client’s oral cavity at the level of operator’s waist. 4. Operator’s posture is maintained: a. comfortably erect. b. shoulders down. c. forearms parallel to the floor while working intra-orally. d. from the operating zone appropriate to the site of operation. e. operator’s face 28 – 35 cm away from client’s face. 5. Bracket table positioned: a. for easy access to instruments. b. within the range of unit balance. 6. Operating light positioned: a. within arm’s length. b. out of range of operator’s head movements.

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Client Education

Critical elements are in bold type

1. Provide information about the procedure to the client. 2. Assemble appropriate teaching aids. 3. Provide privacy. 4. Provide information relevant to the client’s needs, level of motivation, physical and mental capabilities. 5. Schedule instruction according to the client’s needs: - provide initial information immediately following assessment procedures. - introduce new information in conjunction with the dental hygiene care plan and required treatment interventions. - reinforce previously given instruction as needed. 6. Use communication techniques to establish rapport with the client and to help him/her to learn self- care skills and comply with instructions: - correct spatial orientation between student and client. - good non-verbal cues. - supportive verbal responses. - appropriate vocabulary for client’s understanding. - demonstration, monitored client practice and feedback on performance to facilitate learning. - written material to reinforce information presented. 7. Demonstrate oral-health care techniques intra-orally. 8. Verify the client’s level of understanding of the information provided. 9. Record appropriate information about the instructions given in the client’s clinical file.

Acceptable Level Required

Revised September 2010

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Coronal Polish (selective)

Critical elements are in bold type

Coronal polish is to be performed only for teeth that have removable stain/ or soft deposits present on their surfaces.

Acceptable percentage of strain removed is calculated on number of teeth presenting with stain.

Success rates for coronal polish are calculated as follows:

# of teeth successfully polished___ X 100 = percent success # of teeth that initially were stained

Percent Success Required

Academic Level 02 Academic Level 03 80 % 90 %

1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Maintain asepsis. 4. Use correct client – operator positions. 5. Maintain the operating field. 6. Perform coronal polish: - only on teeth that require the procedure. - grasp instrument with thumb and first 2 fingers (sleeve may rest against index finger or V between thumb and index finger). - fulcrum on stable tooth surface or supported mirror hand close to the site of operation. - adapt the rubber cup into embrasures, slightly subgingivally and into occlusal grooves. - sweep the cup from gingival margin to occlusal surface or incisal edge of the tooth. - use correct speed of rotary instrument. - use light to moderate pressure. - use the mildest abrasive possible to achieve the desired results. - limit the contact of the instrument with each tooth to a few seconds at a time (to reduce heat build-up in the tooth). - remove all supragingival debris and soft deposits. - remove extrinsic stain at required success percentage.

7. Provide post-operative lavage. 8. Clean the client’s face.

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Deposit (Calculus) Detection

Critical elements are in bold type

Acceptable percentage of deposits detected refers to the number of teeth (not tooth surfaces) presenting with deposits. It is calculated as follows:

Smaller number of teeth identified X 100 = percent success Larger number of teeth identified

Note: Students may be inaccurate in calculus detection by missing deposits or mistaking rough surfaces for deposits. The formula above determines accuracy regardless of which party (student or demonstrator) has determined the values.

Percent Success Required Calculus Type Academic Level 02 Academic Level 03 Supragingival 80 90 Subgingival 80 90

1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Maintain asepsis. 4. Use correct client – operator positions. 5. Maintain the operating field. 6. Complete examination circuits and indicate the hard deposits detected: - on the chart diagram designated for this purpose. - record presence of supragingival calculus in blue pencil - record the presence of subgingival calculus in red pencil 7. Describe the type and location of tooth stain. 8. Describe the type and location of soft deposits. 9. Calculate the client’s oral hygiene level using an appropriate recognized index. 10. Record findings in the client’s clinical file. 11. Record the date the examination was made or findings updated.

Note: To improve time management students who have successfully completed 15 recorded hard deposit detections may advance to a written statement. All written statements must be accurate, clear and concise.

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Deposit (Calculus) Removal

Critical elements are in bold type

Acceptable percentage of deposits removed refers to the number of teeth (not tooth surfaces) presenting with deposits. It is calculated as follows:

# of teeth in the assigned area successfully scaled __ X 100 = percent success # of teeth in the assigned area that were charted with deposits initially

Percent Success Required Calculus Type Academic Level 02 Academic Level 03 Supragingival 80 90 Subgingival 80 90

The numbers of grades that can be assigned for deposit removal while providing service for a single client are indicated in the table below.

Client Care Needs Number of Grading Opportunities Allowed (degree of difficulty of case) Academic Level of the Program Level 02 Level 03 DD1 1 - 2 1 DD2 2 - 3 1 - 2 DD3 3 - 4 3 - 4 DD4 4 - 6 4 - 6

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Enamel Sealants

Critical elements are in bold type

1. Ensure that there are no contraindications to the procedure (i.e., the tooth to be sealed is caries free on all surfaces). 2. Provide information about the procedure to the client. 3. Assemble the necessary equipment. 4. Maintain asepsis. 5. Use correct client – operator positions. 6. Maintain the operating field. 7. Following the sealant manufacturer’s directions: - prepare the tooth (i.e., clean, etch, rinse, dry). - dispense and manipulate the material. - apply the material to the prepared tooth. 8. Check the finished sealant for flash and occlusal interference. 9. Remove flash and adjust material depth to relieve occlusion if necessary. 10. Place a clinically acceptable sealant. 11. Clean the client’s face.

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Examination – Dental

Critical elements are in bold type

Acceptable Level Required

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Examination –Extra-oral

Critical elements are in bold type

1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Maintain asepsis. 4. Use correct client – operator positions. 5. Observe the client during reception and seating to note physical characteristics or abnormalities. 6. Observe and note findings of examination of the head and neck region including: - eyes. - skin of the face and neck. - lips. 7. Palpate and note findings of examination of the following: - salivary glands. - lymph nodes of the face, neck and oral regions. - muscles of mastication. 8. Palpate the temporomandibular joint during movements of the mandible and note deviations or crepitus. 9. Record findings in the client’s clinical file. 10. Record the date the examination was made or findings updated.

Acceptable Level Required

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Examination – Health History

Critical elements are in bold type

1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Provide privacy. 4. Obtain necessary detail regarding existing diseases/conditions and record pertinent information. 5. Document medications taken, risk factors for disease, allergies or unusual reactions, contraindications to care 6. Document pharmacological findings, pulse and blood pressure 7. Consult the dentist when the client’s history indicates s/he may be at risk during dental treatment. 8. Identify the risk status clearly on the client’s records. 9. Record findings in the client’s clinical file. 10. Record the date the examination was made or findings updated. 11. Review the information recorded with the client. 12. Obtain the client’s signature as verification of the information.

Acceptable Level Required

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Examination – Indices (Plaque and Gingival)

Critical elements are in bold type

1. Provide information about the procedure to the client.

2. Assemble the necessary equipment.

3. Maintain asepsis.

4. Use correct client – operator positions.

5. Maintain the operating field.

6. Observe and detect plaque – using an explorer or probe in the following areas:  gingival margin  interdental spaces

7. Observe and detect characteristics of the marginal and attached gingival tissues noting the following:  colour  edema  contour  texture  bleeding upon probing

8. Record all findings in the client’s clinical file using the correct numbered codes.

9. Record the date the examination was made or findings updated.

Acceptable Level Required of Recorded Indices

Academic Level 02 Academic Level 03 Pass – 5 or less incorrect indices Pass – 3 or less incorrect indices

Failure- 6 or more incorrect indices Failure – 4 or more incorrect indices

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Examination – Intra-oral

Critical elements are in bold type

1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Maintain asepsis. 4. Use correct client – operator positions. 5. Maintain the operating field. 6. Observe, palpate and note characteristics or abnormalities of: - lips, oral mucosa and mucobuccal folds. - Frenal attachments - the tongue (dorsum, ventral and lateral surfaces and base). - floor of the mouth. 7. Observe the hard and soft palates, tonsils and pharynx and note contour and abnormalities. 8. Observe and note the quantity and quality of saliva. 9. Note breath odour. 10. Record findings in the client’s clinical file. 11. Record the date the examination was made or findings updated.

Acceptable Level Required

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Examination – Occlusal

Critical elements are in bold type

1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Maintain asepsis. 4. Use correct client – operator positions. 5. Maintain the operating field. 6. Note the classification of occlusion as: - Angle’s classification for the permanent dentition (molar and canine relationships on right and left sides of the arch). - Terminal plane relationships for a complete primary dentition. 7. Measure vertical and horizontal overbites in millimetres. 8. Note the spacing pattern in the primary dentition. 9. Note the presence of oral habits that affect the occlusion (bruxism, extra-nutritional sucking habits, deviant swallow etc.) 10. Record findings in the client’s clinical file. 11. Record the date the examination was made or findings updated

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Examination – Periodontal

Critical elements are in bold type

1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Maintain asepsis. 4. Use correct client – operator positions. 5. Maintain the operating field. 6. Establish a series of routine examination circuits to observe and document the following: - location of free gingival tissue (note areas of recession, hypertrophy , clefts etc.) - characteristics of the attached gingiva (colour, contour, texture, width adequacy, location and description of lesions). - measure gingival sulcus depths at 6 locations for each tooth (mesio-, middle and disto- facial; mesio-, middle and disto- lingual) . - the location of periodontal pockets greater than 3 mm in depth in red . - bleeding points in tissues in response to probing procedures. - clinical attachment levels. - identify teeth with abnormal mobility and classify the degree. - identify teeth with furcation involvement and classify the degree. 7. Record findings in the client’s clinical file using recognised symbols and measurement values. 8. Record the date the examination was made or findings updated. 9. Use assessment findings to establish the client’s periodontal status in a written statement using appropriate descriptive dental terminology. For example localized/generalized, acute/chronic, aggressive, mild/moderate/severe, papillary/marginal/diffuse, slight, advanced.

Acceptable Level Required of recorded Findings

Academic Level 02 Academic Level 03 Pass - 5 or less findings recorded incorrectly Pass – 3 or less findings recorded incorrectly

Failure – 6 or more findings recorded incorrectly Failure – 4 or more findings recorded incorrectly

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Examination – Periodontal : 4-6 week Re-evaluation Appointment Guidelines  To be performed 4-6 weeks after last debridement appointment  Used to assess the state of the periodontium,  To evaluate plaque control,  Todecide on any further treatment  To determine the re-care interval for:  Periodontally involved clients who are NOT already on a regular maintenance schedule

 Clients with severe gingivitis who require OHI support and soft-tissue re-evaluation sooner than the scheduled therapeutic recare appointment

Critical elements are in bold type 1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Maintain asepsis. 4. Use correct client – operator positions. 5. Maintain the operating field. 6. Complete and document the following clinical examinations: – Medical History,

– Extra and Intra Oral Exam re-evaluation

– Plaque and Gingival Indices (compare to baseline data)

– Calculus detection

– Complete periodontal assessment and compare to baseline data (refer to Examination – Periodontal)

– Follow up regarding referrals

– Oral Hygiene re-evaluation and collaboration with client to ensure client implementation of recommended modifications needed to attain optimal plaque control.

– Determination of re-care frequency

– Removal of identified residual calculus and/or minimal new deposits

– Clients who present with significant new calculus deposits schedule next re-care in 2-4 weeks

7. Record findings in the client’s clinical file using recognised symbols and measurement values. 8. Record the date the examination was made or findings updated. 9. Ask and incorporate findings of re-evaluation questions into process of care. Clinic Manual, Section III – Clinical Assessment Performance Criteria 28 CNIH - Dental Hygiene Program2011 Revised September 2011

Grades will be given for the following procedures:  Indices

 Perio assessment

 Case decisions

 Goals & self-assessment

*4-6 week re-evaluations are part of the initial treatment plan, but will not be included as required treatment for a client complete or a client case grade to be earned*

Re-evaluation Appointment Questions:

Has the client achieved a satisfactory level of oral hygiene?

Procedure: Re-evaluate oral hygiene status using plaque and gingival indices and presence of new deposits. Compare with initial findings. Are oral hygiene modifications necessary?

Is the tissue response to initial treatment satisfactory?

Procedure: Comprehensive perio exam for comparison with initial evaluation. Was there tissue resolution? Describe it. Were there reductions in probe depths? Why did this occur? Is a referral to a periodontist indicated?

Are there any remaining local contributing factors present? Are there any remaining systemic contributing factors present? Any follow up needed for referrals?

Based on these findings and the oral hygiene of the client, what do you recommend as the re-care interval for this client?

Student response to these questions will be reflected in the case decisions grade for the re-evaluation appointment.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 29 CNIH - Dental Hygiene Program2011 Revised September 2011

Revised May 31, 2010 Fluoride Application

Critical elements are in bold type

1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Maintain asepsis. 4. Use correct client – operator positions. 5. Maintain the operating field. 6. Choose a fluoride product (type and concentration): - according to the client’s needs. - according to the technique used. 7. Choose a technique (tray, paint – on, rinse) - according to the client’s needs and level of co-operation 8. Apply fluoride to the teeth by: - measuring the amount of the product chosen accurately. - using the manufacturer’s recommended technique. - timing the length of application correctly. - monitoring the client throughout the procedure. - suctioning excess fluoride from the mouth when application is completed. 9. Provide correct post-operative instructions. 11. Clean the client’s face.

Acceptable Level Required

Academic Level 02 Academic Level 03 Pass- all elements performed adequately Pass- all elements performed adequately Failure – 1 or more element is performed Failure – 1 or more element is performed

Clinic Manual, Section III – Clinical Assessment Performance Criteria 30 CNIH - Dental Hygiene Program2011 Revised September 2011 inadequately inadequately

Clinic Manual, Section III – Clinical Assessment Performance Criteria 31 CNIH - Dental Hygiene Program2011 Revised September 2011

Handpiece Maintenance

Critical elements are in bold type

1. Assemble supplies

2. Wearing heavy duty gloves

3. Disassemble handpiece

4. Use scrub brush to remove debris

5. Lubricate the all parts in accordance with the manufacturer’s instructions

6. Reassemble the hand piece correctly.

7. Attach the hand piece to the dental unit correctly.

8. Purge the hand piece to distribute oil throughout it for 30 seconds.

9. Bag and label (name, date and clinic session) for sterilization or place on tray to be returned to sterilization area

Clinic Manual, Section III – Clinical Assessment Performance Criteria 32 CNIH - Dental Hygiene Program2011 Revised September 2011

Impressions – Alginate All impressions taken during clinical sessions will be evaluated by an instructor for usefulness according to the criteria below. The student must evaluate the impressions and determine whether or not they meet acceptable criteria. Students are not allowed to retake impressions without a clinical instructor present to assist in correcting the impression taking technique. Permission will only be granted after the student evaluates and identifies the errors made during the first attempt and suggestions are made to improve the result.

Critical elements are in bold type 1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Fill out student identifying information onthe “Impressions Rubric” and have ready for the instructor 4. Maintain asepsis. 5. Use correct client – operator positions. 6. Maintain the operating field. 7. Choose appropriate tray(s) i.e., size and design 8. Prepare the tray(s) correctly for the purpose of the impression and the client’s needs. (i.e., addition of periphery wax to increase tray depth, adapt tray to accommodate a high palate, reduce the flow of material at the post dam etc.) 9. Provide a pre-operative rinse to the client. 10. Prepare the impression material according to the manufacturer’s directions. 11. Load the tray: - with the correct amount of material. - to facilitate flow of the material. 12. Insert the tray into the mouth with care. 13. Seat the tray correctly. 14. Support the tray in the mouth while the material sets. 15. Provide psychological support to the client during the procedure. 16. Break the vacuum seal and remove the tray carefully with a snapping motion. 17. Obtain a clinically useful impression with the following: - adequately centred. - marginal roll at the periphery. - complete arch coverage. - hard and soft tissue coverage. - adequate depth of material. - material integrity (i.e., no tears or air bubbles). 18. Provide a post-operative rinse for the client. 19. Clean the client’s face. Revised May 16, 2010

Clinic Manual, Section III – Clinical Assessment Performance Criteria 33 CNIH - Dental Hygiene Program2011 Revised September 2011

Instrument Activation

Critical elements are in bold type.

1. Make exploratory strokes: - in an apical direction along the tooth surface. - by maintaining contact between the instrument blade and the tooth surface. - using a smooth rocking motion from the wrist and forearm around the fulcrum established for control of the instrument. - using light pressure so that surface irregularities can be felt.

2. Make working strokes: - in a vertical or oblique direction along the tooth surface towards the crown. - maintaining correct angulation between the instrument blade and the tooth surface. - using a smooth rocking motion from the wrist and forearm around the fulcrum established for control of the instrument. - using short, overlapping strokes. - using firm pressure so that hard deposits can be removed efficiently with the fewest possible strokes.

Instrument Adaptation

Critical elements are in bold type.

1. Adapt the instrument by: - adjusting the working blade (or aspect) of the instrument to form the correct angle with the tooth surface (tooth surface – instrument angles are instrument specific). - maintaining correct instrument angulation during motion of the instrument .

Clinic Manual, Section III – Clinical Assessment Performance Criteria 34 CNIH - Dental Hygiene Program2011 Revised September 2011

Instrument Fulcrums (Finger Rests)

Critical elements are in bold type.

1. Establish instrument fulcrums: - with the third (ring finger) of the dominant hand. - securely on solid tooth structure or supported opposite (mirror) hand. - as close as practical to the site of operation. - with the middle and third fingers in contact for strength.

Instrument Grasp

Critical elements are in bold type.

1. Grasp the instrument: - by holding it with the thumb, index and middle fingers. - keeping the pads of the fingers at the junction of the instrument shank and handle. - resting the instrument handle between the second and third knuckles of the index finger (a hand piece may rest in the V between the thumb and forefinger). - using a relaxed grip during exploratory strokes . - using a firm grip for working strokes.

Instrument Insertion

Critical elements are in bold type.

1. Protect the soft tissue from damage by: - turning face of blade towards the tooth to protect soft tissue from the cutting blade. - keeping the instrument in contact with the tooth surface during insertion. - minimizing gingival sulcus distension - using gentle pressure to determine the base of the sulcus.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 35 CNIH - Dental Hygiene Program2011 Revised September 2011

Operating Field Maintenance

Critical elements are in bold type

1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Maintain asepsis. 4. Use correct client – operator positions. 5. Retract structures (lips, tongue, cheeks) to provide: - maximum visibility. - maximum access to the operative site. 6. Retract structures: - using finger(s) of a gloved hand. - mouth mirror or other retraction instrument (e.g., oral evacuation tip, cheek retractors, etc.) as necessary. - without impinging on soft tissue (i.e., not resting the retraction device on gingival tissue or trapping soft tissue between the retractor and the teeth). 7. Use the operating light and a mouth mirror to provide optimal: - direct illumination. - reflected light. - transillumination. 8. Use compressed air to: - dry the operative site without desiccating tissue or causing discomfort. - assess tissue condition. - check for carious lesions. - improve access to subgingival deposits. 9. Use water spray to: - clean blood and debris from the operative site. - provide oral lavage post-operatively to increase client comfort. 10. Use oral evacuation systems (surgical suction tip, saliva ejector, high volume suction etc.): - without impinging on soft tissue. - to remove fluids and debris room the operative site for improved operator efficiency. - to provide maximum comfort for the client

Clinic Manual, Section III – Clinical Assessment Performance Criteria 36 CNIH - Dental Hygiene Program2011 Revised September 2011

Instrument Sharpening

Critical elements are in bold type.

1. Assemble the necessary equipment. 2. Maintain asepsis. 3. Use light effectively. 4. Identify the cutting edge to be sharpened.

5. Stabilize instrument face parallel to the countertop and the upper edge of sharpening triangle diagram during the procedure.

6. Maintain the correct angle between the stone and the blade (110 ˚ or use the side of the sharpening triangle diagram as a guide).

7. Stroke the blade up and down lightly, finishing on a down stroke.

8. Stroke to sharpen the entire working blade of the instrument, beginning at the heel and finishing at the toe of curets OR to establish a point on scalers.

9. Remove roughened edge by stroking the instrumentface lightly with the stone.

10. Wipe metal fragments from ground edge with 2x2 gauze.

11. Test sharpness using a test stick, keeping terminal shank of the instrument parallel to stick.

12. Create a sharp instrument with adequate architecture.

13. Failure to maintain instrument sharpness throughout the appointment may result in assignment of a penalty in “Poor Work Habits”.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 37 CNIH - Dental Hygiene Program2011 Revised September 2011

Ligate and Remove Arch Wires (Pre-clinical Exercise on Manikins)

Elastic Modules and Wire Ligatures

Critical elements are in bold type

Both Skills:

Ligate Arch Wires – Elastic Modules:

6. Choose modules of appropriate size and weight. 7. Grasp one side of the module with a haemostat or needle driver. 8. Support the arch wire in the bracket slot. 9. Loop module under all wings of the bracket. 10. Ensure that the arch wire is fully seated in the bracket slot. 11. Ensure that the bracket bond has not been loosened.

Ligate Arch Wires – Wire Ligatures:

6. Choose ligatures of appropriate weight. 7. Use placement sequence as described in (Modern Dental Assisting 8th ed. pp. 994 – 999.) 8. Support the arch wire in the bracket slot. 9. Loop ligature under all wings of the bracket. 10. Ensure that the arch wire is fully seated in the bracket slot. 11. Twist ligature to secure arch wire in the bracket and form a “pig tail”. 12. Trim twisted ligature (pig tail) to an appropriate length. 13. Tuck pig tails under arch wire to protect soft tissues. 14. Ensure that the bracket bond has not been loosened.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 38 CNIH - Dental Hygiene Program2011 Revised September 2011

Remove Arch Wires – Elastic Modules:

7. Use the blade end of an orthodontic scaler. 8. Catch the module between wings of the bracket. 9. Support the arch wire in the bracket. 10. Stretch the module and remove from under all bracket wings. 11. When all modules are removed, grasp arch wire with pliers and remove from bracket slots. 12. Ensure that all bracket bonds and cemented bands are secure.

Remove Arch Wires – Wire Ligatures:

6. With ligature cutter, cut the loop of the ligature opposite the site of the pig tail. 7. Support the arch wire in the bracket. 8. Grasp the cut ligature and remove from around bracket wings 9. When all ligatures are removed, grasp arch wire with pliers and remove from bracket slots. 10. Ensure that all bracket bonds and cemented bands are secure.

Both Skills:

11. Provide post-operative instruction to the client. 12. Clean client’s face.

Orthodontic Bands (Pre-clinical Exercise on Manikins)

Fit, Cement and Remove

Critical elements are in bold type.

All Skills:

1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Maintain asepsis. 4. Use correct client – operator positions. 5. Maintain the operating field.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 39 CNIH - Dental Hygiene Program2011 Revised September 2011

Fitting: Place bands that are: - well adapted to the tooth. - fit snugly i.e., cannot be removed with finger pressure. - do not extend above the level of the occlusal surface. - are free of crimps or distortion.

Cementation:

6. Mix luting agent according to manufacturer’s directions. 7. Ensure that the cemented band is placed: - with the buccal tube parallel to the occlusal surface of the tooth. - with the mesial end of buccal tube centred with the mesiobuccal cusp of the tooth.

8. Remove excess cement from gingival and occlusal aspects of the band. 9. Ensure that the cement seal is continuous and free of voids or undercuts. 10. Provide post-operative instruction to the client. 11. Clean client’s face. Removal:

6. Usedebanding pliers with the pad placed flat on the occlusal surface of the banded tooth. 7. Catch the band at the gingival border with the sharp beak of the pliers. 8. Squeeze pliers to lift band off the tooth (force is directed parallel to the long axis of the tooth). 9. Alternate approaches with pliers from facial and lingual sides of tooth until the band slides off. 10. Avoid twisting (luxating) the pliers which places undue, uncomfortable force on the tooth. 11. Scale remaining cement off teeth. 12. Provide post-operative instruction to the client. 13. Clean client’s face.

Tooth Separation Prior to Banding

Placement and Removal of Elastic Modules and Wire Separators

Critical elements are in bold type

Both Skills:

1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Maintain asepsis.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 40 CNIH - Dental Hygiene Program2011 Revised September 2011

4. Use correct client – operator positions. 5. Maintain the operating field.

Placement of Elastic Modules: 6. Choose correct size and weight of modules for area of mouth and amount of separation needed. 7. Use dental floss technique to place modules. (Modern Dental Assisting 8th ed. pp. 988 – 989.) 8. When placed, module must encircle the contact area.

Placement of Wire Separators: 6. Use placement technique described in Modern Dental Assisting 8th ed. pp. 988 – 989. 7. When placed, module must encircle the contact area snugly. 8. Twisted wire ends (“pig tails”) are not ragged. 9. Trimmed pig tails are an appropriate length. 10. Pig tails are tucked into the facial embrasures to avoid scratching the linings of the cheeks.

Removal of Elastic Modules:

6. Catch the module in the occlusal embrasure with the blade end of an orthodontic scaler. 7. Use an appropriate hard tissue finger fulcrum. 8. Remove elastic module by pulling it through the contact area. 9. Ensure that the whole module has been removed.

Removal of Wire Separators:

6. Cut the wire loop at the occlusal embrasure using ligature cutting pliers. 7. Grasp the pig tail of the separator with suitable pliers and rotate the wire loop out under the contact area. 8. Ensure that the whole device has been removed.

Both Skills:

11. Avoid undue tissue trauma during the procedure. 12. Provide post-operative instructions to the client. 13. Provide post-operative lavage, 14. Clean client’s face. Clinic Manual, Section III – Clinical Assessment Performance Criteria 41 CNIH - Dental Hygiene Program2011 Revised September 2011

Mouth Guard or Bleaching TrayFabrication and Delivery

Critical elements are in bold type.

Fabrication: 1. Create an appliance: - that is well adapted to the lab work model of the client’s dentition. - that has a smooth, rounded periphery. - terminates at the scribed boundaries. - has an attached handle if required (mouth guard).

Delivery: 1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Maintain asepsis. 4. Use correct client – operator positions. 5. Maintain the operating field. 6. Ascertain that: - the appliance does not impinge on soft tissue (i.e., mouth guard does not interfere with frena or mucobuccal fold: bleaching tray does not impinge on the gingival tissues). - correct deficiencies as necessary. 7. Provide appliance wear and care instructions to the client. (For bleaching procedures, provide written instructions). 8. Record appropriate information about the procedure in the client’s clinical file.

Grades assigned: Students who have successfully completed all of the critical elements will receive one grade for:

- one properly fitted sports mouth guard

- one set of properly fitted bleaching trays

Clinic Manual, Section III – Clinical Assessment Performance Criteria 42 CNIH - Dental Hygiene Program2011 Revised September 2011

Nutritional Counselling

Critical elements are in bold type

The client chosen should be 16 years of age or older. Client’s assessment data should indicate that poor diet as a contributing factor to the presence of oral disease observed. If the client is under the age of 16 the person responsible for the preparation of food at the child’s primary place of residence MUST be present during the delivery of the counselling. This person must be someone other than the student delivering the counselling.

1. Provide information about the procedure to the client. 2. Assemble appropriate documents. 3. Provide privacy. 4. Use assessment findings to determine the client’s need for information on diet and dental disease. 5. Provide appropriate diet record sheets to the client and explain their use. 6. Request return of the diet record one week before the client’s next scheduled appointment. 7. Analyse the client’s diet as reported: - by comparing it to the Canada Food Guide as the recommended nutritional standard. - to identify lack of basic daily nutrient requirements specific to the client - to identify eating patterns which increase the risk of oral disease . 8. Determine recommendations for improvement of the client’s eating habits. 9. Discuss the findings with the client at the follow up appointment. 10. Provide written information that is specific to the client regarding the results of the diet analysis and provide basic nutrition to the client. 11. Record pertinent information about the procedure in the client’s clinical file.

September 22, 2011

Clinic Manual, Section III – Clinical Assessment Performance Criteria 43 CNIH - Dental Hygiene Program2011 Revised September 2011

Radiographic Technique and Interpretation Critical elements are in bold type

All radiographs taken during clinical sessions will be evaluated for diagnostic usefulness according to the criteria below. The student must evaluate the radiographs and determine whether or not they meet acceptable criteria. Students are not allowed to retake a radiographic view without a prescription from the duty dentist. Permission will only be granted after the student evaluates and identifies the errors made during the first attempt and suggestions made to improve the image.

The standards below represent optimal images in diagnostic radiographs. For purposes of awarding a grade, a bite wing radiograph is NOT diagnostically acceptable if ANY of the following errors are present:

1. The occlusal plane is not centred resulting in obscured details in the maxillary and mandibular alveolar bone crest.

2. Avoidable overlap occurs in the majority of interproximal areas that obscures images of the dentinoenamel junctions.

3. The film is not placed to include the correct teeth in the intended view.

4. The film is not place to include the totality of the crowns of the teeth in the intended view.

5. Elongation that distorts the image.

6. Incorrect exposure (under or over) to the degree that anatomical landmarks (i.e., tissue junctions) and tissue detail are obscured.

7. Any avoidable processing fault that obscures tissue detail is present.

For purposes of grading, a periapical radiograph is NOT diagnostically useful if any of the following errors are present:

1. Less that 2 mm of periapical coverage surrounding the roots of all of the teeth required in the view taken. (Sometimes film borders in the area of the tooth crown must be sacrificed to provide sufficient periapical coverage, especially when teeth are impacted or out of alignment).

2. Elongation or foreshortening distorts the image.

3. Avoidable interproximal overlap that obscures images of the dentinoenamel junction(s) of the tooth(teeth) required in the view taken..

4. Incorrect exposure (under or over) to the degree that anatomical landmarks (i.e., tissue junctions) and tissue detail are obscured.

5. Any avoidable processing fault that obscures tissue detail is present.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 44 CNIH - Dental Hygiene Program2011 Revised September 2011

Revised March 3, 2010

The student will identify: 1. Lesions identified as Radiolucent or Radiopaque 2. Radiolucency in furcal areas is noted 3. Periodontal bone loss: Classified as generalized or localized, horizontal or vertical, slight, moderate or heavy 4. Triangulation is identified (wedge-shaped widening of the PDL occurs, manifesting as a radiolucent area between the tooth and the crestal bone) 5. radiographic evidence of local irritants such as calculus and overhanging restorations are identified 6. Obvious carious lesions 7. abnormalities in anatomy are identified

Note: Supervising Dentists and clinicians may choose to work with less than ideal films rather than re-expose the client to radiation.

Sanitize the Treatment Unit

Critical elements are in bold type 1. Assemble scrub brush, surface and evacuation disinfectants.

2. Discard bio-hazardous (any blood soaked contaminated item) and non-biohazardous materials in correct containers.

3. Place strainer from cuspidor in sink and spray with disinfectant.

4. Check and clean cuspidor trap.

5. Disinfect heavy duty gloves.

6. Drains and suction lines: - pour 60 ml disinfectant in cuspidor drain and run water through bowl - run 500 ml solution through HVE and saliva ejector tubing

7. Sanitize equipment and dental unit with disinfectant wipes: - light switch, handle and face (NOT light back while hot) - light arm, water bottle, post and box - bracket table, arm, equipment brackets, switches and a/w syringe

8. Cuspidor (in the following order): - cup filler, holder and switches - saliva ejector and HVE brackets and tubing - outside of cuspidor bowl - inside of cuspidor bowl

9. Dental chair and stools: - dental chair switches (if applicable) - stool adjustment levers and backs

Clinic Manual, Section III – Clinical Assessment Performance Criteria 45 CNIH - Dental Hygiene Program2011 Revised September 2011

- base of dental chair and electrical box - all leather parts of dental chair and stools Revised March 3, 2010

10. Sanitize unit counters: - counter top, drawers, handles, paper and soap dispenser - clean safety glasses with soap and water - wipe sink - disinfect gloves/place in zip lock bag - replace cleaning supplies/remove water bottle - wash hands

Student Goals and Self Assessment

Critical elements are in bold type

At every clinical session the student will identify and document their goals for the clinical session on the Grade Assessment sheet.

Recommended examples: 1. Set achievement goals 2. Set learning goals 3. Set communication goals 4. Set time goals

At every clinical session the student will document their assessment of the clinical session. It is recommended that the student document any new learning in clinic as it takes place to better reflect on it.

Recommended examples: 1. Did I achieve my goals? Reflect on why or why not 2. What can I do to improve prior to the next clinical session? 3. What did I learn? 4. How did I contribute to my own learning? 5. Did I behave/communicate in a professional manner?

Grading: Student will be assigned a “Complete” or “Incomplete”

Acceptable Level Required for Academic Level 02 and Academic Level 03

Complete – minimum of 1 goal and related self assessment statement

Incomplete – absence of at least 1 goal and related self assessment statement

Clinic Manual, Section III – Clinical Assessment Performance Criteria 46 CNIH - Dental Hygiene Program2011 Revised September 2011

Revised May 2009 Ultrasonic/sonic Technique

Critical elements are in bold type

Assignment of a grade for this skill will be based on the supervising clinician’s observation of the student’s technique, while operating in all surfaces of at least one sextant of the mouth and evaluation of the assigned area upon completion of ultrasonic use.

Percent Success Required Academic Level 02 Academic Level 03 80% 90%

1. Provide information about the procedure to the client. 2. Ascertain that the client has no contraindications for the procedure. 3. Assemble the necessary equipment. 4. Supervising clinician assesses area to be graded. 5. Technique is observed on 5 or more teeth. 6. Maintain asepsis. 7. Use correct client – operator positions. 8. Maintain the operating field. 9. Use ultrasonic/sonic technique by: - selecting appropriate instrument insert(s) for the area(s) to be debrided. - adapt the instrument tips correctly. - use light pressure. - debride the teeth in the sextant using instrumentation circuits which limit the contact of the instrument with each tooth to a few seconds at a time. - ensure adequate water flow to the instrument tip during operation for cooling of the instrument and lavage of the site of operation. - suction oral fluids adequately to maintain client safety and comfort. - remove accessible. 10. Clean the client’s face. 11. Record appropriate information regarding the procedure in the client’s clinical treatment file

Revised March 3, 2010 Clinic Manual, Section III – Clinical Assessment Performance Criteria 47 CNIH - Dental Hygiene Program2011 Revised September 2011

Vital Signs- Blood Pressure

Critical elements are in bold type

1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Maintain asepsis. 4. Use correct client positions by - positioning the client’s arm slightly flexed, palm up. - supporting the forearm on a level surface at the level of the heart. 5. Use the client’s bare arm. 6. Apply the cuff around the client’s upper arm, above the elbow. 7. Adjust the gauge for easy reading. 8. Place earpieces of the stethoscope in your ears with tips facing forward. 9. Palpate the client’s arm to locate the brachial artery and place the stethoscope over it. 10. Inflate the cuff to about 190 on the dial (unless the client reports blood pressure routinely higher, then use a value above the client’s reported systolic figure). 11. Deflate the cuff slowly and note the values on the scale: - when the first tapping sound is heard (systolic pressure). - when the last distinct tap was heard (diastolic pressure). - release remaining air in the cuff rapidly 12. Wait 30 seconds and repeat inflation/deflation process to confirm readings. 13. Record readings taken. 14. Identify deviations from normal and consult with the supervising clinician.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 48 CNIH - Dental Hygiene Program2011 Revised September 2011

Vital Signs - Pulse

1. Provide information about the procedure to the client. 2. Assemble the necessary equipment. 3. Maintain asepsis. 4. Use correct client position by: - supporting the client’s forearm comfortably, palm down 5. Use your first three fingers to locate the client’s radial pulse on the thumb side of the wrist 6. When the pulse is found: - use light finger pressure - count the beats for one clocked minute (using a second counter) 7. Observe pulse characteristics: - rhythm (regular; regularly irregular; irregularly irregular). - volume/strength (full, strong, poor, weak, thready). 8. If pulse seems abnormal, repeat observations to confirm initial impressions. 9. Record findings (date, rate and other notable characteristics) on the client’s record. 10. Report unusual finding to the supervising clinician.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 49 CNIH - Dental Hygiene Program2011 Revised September 2011

Vital Signs - Respiration

1. Count respirations when the client is not aware you are doing so. 2. Count the number of times the chest rises in one clocked minute. 3. Observe: - depth (shallow, normal, deep) - rhythm (regular, i.e., evenly spaced or irregular, i.e., pauses of different lengths between respirations) - quality (strong, easy, weak, laboured/noisy) - sounds made during inspiration, expiration or both - client position (if client assumes an unusual posture to aid in comfortable respiration) 4. Record all findings on the client’s record. 5. Report unusual finding to the supervising clinician.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 50 CNIH - Dental Hygiene Program2011 Revised September 2011

Professional Development Skills

Introduction

The dental hygiene program is designed to help students learn to think and act as competent, responsible, health care providers. In addition to acquiring relevant scientific knowledge and necessary clinical skills, students need to show behaviours that reflect values and attitudes that support the practice of healthy life style choices.

When students are observed behaving in a manner that is not consistent with good professional practice, a failing grade in the appropriate “professional development skills” area(s) (which include document management, work habits, professional conduct, time management, and care of client tissues) will be assigned. This information will appear on the clinical grade form for the session in which the behaviour occurred. TheRequired pass to tries ratioin the professional development skills areas is set at 80% for academic level 02 and 90% for academic level 03. Maintaining a pass to tries ratio less than the set minimum in this category can result in failure of a clinical course.

Any staff member who observes inappropriate behaviour is allowed to assign a grade to a student’s clinical file in the relevant Professional development skills category area.

Each of the subject areas in which grades for Professional development skills can be assigned is defined below. It is important to realize that not all infractions in an area can be included in this manual. The behaviours listed are meant to provide examples of inappropriate conduct. The lists are NOT intended to be exhaustive.

Documents Management (01,02,03)

Client files and student progress documents are important legal records. They must be maintained accurately and handled in a manner that protects confidentiality.

The following is a partial list of actions that could lead to the assignment of a failing grade in documents management.

 Incomplete or inaccurate entries on client files or student assessment records.  Inappropriate means of correcting mistakes made while recording information on client records.  Client documents (clinical files, radiographs etc.) handled in manner that leaves them available to unauthorized personnel.  Removal of client records from approved areas without permission.  Use of client records for assignments etc. without permission.  Unauthorized duplication of client records or student evaluation documents.  Unauthorized alteration or disposal of documents.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 51 CNIH - Dental Hygiene Program2011 Revised September 2011

Work Habits (01,02,03)

Providing optimal client care requires development of effective work habits. Students must learn and demonstrate an organized approach to clinical procedures. They must also abide by necessary practice standards for client and operator safety in the clinical environment.

The following is a partial list of actions that could lead to the assignment of a failing grade in “work habits”.

 Breaking the chain of asepsis during treatment procedures.  Contaminating non-treatment areas e.g., telephone, reception area, charts etc. by failing to follow infection control protocols.

 Disposing of hazardous waste incorrectly.  Failing to provide safety devices for the client during treatment e.g., safety glasses, appropriate clinical drapes etc.

 Failing to use appropriate self-protective equipment e.g., safety glasses, gloves, radiation monitoring badge etc.

 Wearing soiled clinical attire outside the clinical or dental laboratory area.  Maintaining instruments and equipment inadequately.  Working in poorly organized treatment area i.e., waste not adequately contained, instruments not easily accessible etc.

 Dismissing a client with blood or debris visible on his/her face.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 52 CNIH - Dental Hygiene Program2011 Revised September 2011

Professional Conduct (01,02,03)

Registered dental hygienists are required to take legal responsibility for their own actions in the delivery of oral care to clients. To do so they must act maturely and display concern for the well being of the clients they serve. Competent professionals behave in a manner that reflects self respect and respect for others.

The following is a partial list of actions that could lead to the assignment of a failing grade in “professional conduct”.

 Unkempt appearance during clinical sessions.

 Inadequate personal hygiene.

 Use of inappropriate communication in the learning environment such as:

o use of foul language. o voice volume that does not protect confidentiality in transfer of information. o discourteous actions towards clients, staff or fellow students. o use of inappropriate body language or gestures etc.

 Inappropriate response to constructive criticism such as: o excessive defensiveness o rationalisation o hostility o lack of self-composure.

 Dishonesty in discussing or recording information relevant to clinical practice or student assessment.

 Any unlawful action e.g., theft, threats of violence etc.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 53 CNIH - Dental Hygiene Program2011 Revised September 2011

Time Management (01,02,03)

Time management is an important skill in dental hygiene practice. In dentistry “time is money”. Clients’ time is also valuable and they should not be expected to tolerate unreasonable delay in service delivery.

When students begin clinical practice, supervising clinicians will help them determine time frames in which to accomplish procedures. Over time students are expected to be able to determine time frames for clinical activities for themselves.

At senior levels of the program, students should be simulating client management as required in practice by using clinical time to best advantage. This is particularly true in Level 03 where students are assigned to longer clinical sessions. They are expected to manage their client pool to provide services to at least two clients during a clinical period.

To remind students of the importance of this skill, a failing grade will be assigned for actions that indicate poor use of time. The following is a partial list of behaviours that could lead to the assignment of a failing grade in “time mismanagement”.

Failure to:

 begin clinical sessions on time (i.e., the student has not prepared for the session in advance of the client’s arrival).  not using time in clinic wisely  sequence procedures to make optimal use of time available.  follow time requirements for procedure completion as negotiated with supervising clinicians.  participate in suitable learning activities if a client cannot be found to fill a clinical session.  follow time guidelines regarding client dismissal, treatment unit maintenance and closing procedures.

Care of client tissues (02,03)

A fundamental principle of health care practice is to do no harm to the clients served.

If students cause avoidable injury to the client’s tissues e.g., bruising, scratches, or frank lacerations, a failing grade will be assigned in “care of client tissues”.

Clinic Manual, Section III – Clinical Assessment Performance Criteria 54 CNIH - Dental Hygiene Program2011 Revised September 2011

Ethical Decision Making Model

Step 1 - Identify the problem - Identify, in a preliminary way, the nature of the challenge or problem.

Step 2 - Gather information - Become suitably informed and gather relevant information including factual information, sequence of events, applicable policies, laws, and regulations and the views of stakeholders.

Step 3 - Clarify the problem - Clarify and elaborate the problem based on the additional information obtained. Identify the ethical principles at stake.

Step 4 - Identify options - Identify the various options for action.

Step 5 - Assess options - Assess the various options.

Step 6 - Choose a course of action - Decide on and justify/defend a course of action.

Step 7 - Implement the action - Implement one’s decision as thoughtfully and sensitively as possible.

Step 8 - Evaluate outcomes - Assess the consequence of your decision and evaluate the outcomes.

Reference: College of Dental Hygienists of Ontario; Bylaw 4 , Schedule 1

Clinic Manual, Section III – Clinical Assessment Performance Criteria 55