Self-Study Course Series-6 hours CE credit

Principles of Public Health and Evidence-based Guidelines for Preventive Dentistry

Introduction

Completion of this six hour online CE course will not only meet the requirement for the establishment of a Written Protocol Agreement in the state of Tennessee but also provide a well- rounded public health educational opportunity. The guidelines for a one hour online course suggest three hours of study time, so the course could take up to 18 hours of preparation.

A self-study text will be used as the reading material and test questions will include case studies

for which the textbook information will be applied. The self study text “Preventing Medical Emergencies: Use of the Medical History, 3rd Ed.” (Pickett, Gurenlian, 3rd Ed. Lippincott Williams & Wilkins, 2014) provides the self study reading material for the courses dealing with patient assessment and preventing or managing medical emergencies. The text can be secured in hard copy or in digital format, and can be ordered from Amazon.com, the LWW website (http://www.lww.com -- use SEARCH function to locate book), or from other online textbook sites. The digital download is immediate and allows the participant to begin the coursework immediately. The lowest price is usually at the Amazon.com site. When beginning the Public Health CE course, the participant should order the reading material for courses two through five so it will be available and promote continuing with the course information in a timely manner.

The six hour CE begins with a two hour section on the objectives of public health and evidence-based guidelines for preventive dentistry. Sections two through four provide one hour of credit each and will deal with patient assessment and use of the medical history to identify potential medical emergencies; and strategies to prevent the emergency, and guide proper development of a treatment plan for a variety of medically complex conditions. Section five provides the final one hour credit and will include HIPAA laws, the procedure for applying for a written protocol agreement and ethics for clinical practice.

Page 2 is the answer sheet for all sections. Please print and submit Page 2 to TDHA for grading. TDHA will grade the test and upon receiving a passing score of 75%, the course participant will be sent a Certificate of Completion. A copy of the certificate should accompany the application for a written protocol agreement submitted to the Tennessee Board of Dentistry. The TN Dental Hygienists’ Association does not submit any information on behalf of any participant.

The cost of the course is $90.00 for TNDHA/ADHA members and $100.00 for all other participants. Please send test answer sheet, appropriate payment and, if applicable, a copy of ADHA membership card to the TNDHA Treasurer:

Susan Melton, RDH 5320 Custis Lane Knoxville, TN 37920 slmrdh@comcast.net Questions regarding the course process may be addressed to the above treasurer. Questions

regarding course content cannot be answered by the treasurer.

Principles of Public Health and Evidence-based Guidelines for Preventive Dentistry

Answer Sheet

Enter answers below. Please submit this answer sheet for all 5 courses contained in the Public Health Self Study to TNDHA for

grading. Upon receiving a passing score of 75%, the course participant will be sent a Certificate of Completion. It is recommended

that a copy of the certificate accompany the application for a written protocol agreement submitted to the Tennessee Board of

Dentistry. The TN Dental Hygienists’ Association does not submit any information on behalf of any participant.

The cost of the course is $90.00 for ADHA members and $100.00 for all other participants. Please send this test answer sheet,

appropriate payment and, if applicable, a copy of ADHA membership card to the TNDHA Treasurer.

Susan Melton, RDH, 5320 Custis Lane, Knoxville, TN 37920 slmrdh@comcast.net

Participant Information

NAME ____________________________________________________________________________________

ADDRESS ________________________________________________________________________________

__________________________________________________________________ZIP_____________________

PHONE _________________________________________E-MAIL___________________________________

METHOD OF PAYMENT

o CHECK-Payable to TNDHA OR ○ CREDIT CARD

CC# ______________________________________________ Exp. ________________ CVV _______________

CHOOSE ONE:

o ADHA MEMBER $90.00-must submit copy of membership card

o NON-MEMBER $100.00

Section 1

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Section 5

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Course Objectives

1. The first course in the series will identify essential components of preventive dentistry and the

goal of public health programs.

2. Evidence based guidelines for preventive dentistry will be reviewed by using the current clinical

practice guidelines for caries control.

3. Access to high level evidence from the American Dental Association (ADA) systematic review

website will be provided.

4. The 2012 ADA/Food and Drug Administration guidelines for selection of patients for dental

radiographs will be provided.

Course Instructions

Public health programs make available basic healthcare for the majority of people. To meet this

objective, the course will direct the reader to professional evidence-based guidelines for current

prevention strategies addressing the most common oral diseases. In addition, free access to the highest

level of evidence, the systematic review (SR), will be provided and selected SRs will be accessed which

involve products used for improving oral health. A national randomized survey of practicing dental

hygienists (http://www.ncbi.nlm.nih.gov/pubmed/11318004) revealed that knowledge of caries

epidemiology and preventive techniques was low. This course will contain national guidelines for

efficacious methods (ones that work) for caries prevention.

Courses two through five will use the self-study text “Preventing Medical Emergencies: Use of the

Medical History, 3rd Ed.” (Pickett, Gurenlian. Lippincott Williams & Wilkins, 2014) as the self-directed

reading material for the courses dealing with Patient Assessment and Preventing or Managing Medical

Emergencies. Either the hard copy paperback text or the digital download version can be used.

As each section of the course is used and links accessed, there will be written instructions on

information that applies to various risk groups or ages. Objectives will be identified at the beginning of

each section and test items will relate to these objectives so reader should make sure answers for the

objectives are found as materials are examined. Most information is found at the ADA Clinical

Recommendation site at http://ebd.ada.org/en/evidence/guidelines . Your computer will need to have

internet access and be connected to the internet. Before the link is accessed from this instruction page,

place the cursor over the link; use the method of pushing the CTRL button and clicking the underlined

URL link. The internet link will open in a new window. This allows you to toggle between the course

instructions/ objectives and the information in the internet link (ADA clinical guidelines). When you

reach the ADA or American Academy of Periodontology (AAP) Clinical Guideline, right click the specific

guideline link, and select “Open Link in New Tab”. This allows the reader to toggle between the Clinical

Guideline page and the specific guideline being examined. Since several guidelines are available on the

ADA Clinical Recommendations page, this can save time when taking the course. Course participants can

toggle between the INSTRUCTION page objectives and the Clinical Guideline link to read and apply the

information to a hypothetical case.

Section 1: Basics of Public Health for Prevention of Oral Disease (Two hours)

Dental caries, pulpal infection, and periodontal disease are the most common oral diseases. Evidence-

based clinical practice guidelines will be used to guide the practitioner in identifying evidence-based

preventive strategies for caries and periodontal disease. These guidelines will also guide management of

pulpal infection and of periodontal disease. National professional guidelines will be the resources for

this information.

Dental Caries

Dental caries is a bacterial infection that results in demineralization and breakdown of hard tooth

surfaces. Current strategies to remineralize these areas with fluoride provide the basis for reversal of

caries. When irreversible caries has developed, the treatment involves restorative dentistry which

requires a visit to a dentist. The most advantageous strategy for this disease risk is to prevent dental

caries. The three most effective, evidence-based methods to prevent dental caries involve use of

fluoride therapy/products, application of sealants, and to advise against dietary practices that lead to

caries (http://jada.ada.org/content/142/9/1065.full.pdf+html) .1 The dietary practices are not defined

but can include lowering the frequency of eating sugar and eating foods between meals that do not

initiate an acid attack in the mouth. This can include elimination of between meal snacking, especially

with sweet foods; having sweet foods at the mealtime only; and eating nonretentive foods as snacks

(e.g. an apple is better than raisins or dried fruits, cheese is good and regular popcorn is not an acid

producing food). At the link above primary strategies for caries prevention are explained in the ADA

policy on Nonfluoride Caries Preventive Agents1 where the three primary strategies for prevention of

dental caries are listed. This policy published in 2011 identifies non-fluoride products which have

scientific evidence for caries prevention and those products without scientific evidence for an anticaries

effect. The guidelines stress the nonfluoride products are adjunctive agents and should be used (1) only

in patients at high risk for caries and (2) only after the primary strategies have been used, but more help

is needed. The executive summary link includes an abstract that states “The panel concluded that

certain nonfluoride agents may provide some benefit as adjunctive therapies in children and adults at

higher risk of developing caries. These recommendations are presented as a resource for dentists to

consider in the clinical decision-making process.” The important thing to note is that any “nonfluoride

anticaries product” is recommended to be used only in patients at high risk for caries and only as an

adjunct to primary therapies. The evidence for efficacy of nonfluoride agents is not strong so the word

“may” is used in the abstract. There is also a chair side summary of the recommendations which can be

printed and used as a reference at

http://ebd.ada.org/~/media/EBD/Files/6869_ChairsideGuideNonFlouride.ashx . Children typically

experience enamel caries and adults/ elderly experience both enamel and root surface caries.

Objectives for test items: List the three primary therapies to reduce dental decay.

Identify which adjunctive therapies have evidence for additional caries prevention when a high risk for caries exists and use of primary therapies did not reduce decay progression. Access the Chair side Guide link for a quick summary of the recommended products and those not recommended.

Differentiate between nonfluoride products recommended to reduce enamel caries and those to reduce root surface caries.

Sealant guidelines for caries prevention – Sealants can be used on deciduous teeth or on

permanent dentition surfaces. They have been reported to be 99% effective to reduce dental caries

when placed properly. The ADA clinical practice guidelines2 for when sealants should be placed is

available at ADA Clinical Practice Recommendation site at

http://ebd.ada.org/~/media/EBD/Files/report_sealants_summary.ashx . Scroll down the Guideline titles

and find “SEALANTS”. At the ADA Clinical Recommendations site, click the “sealant” link and select the

executive summary link from the list to find the recommendation for placement of sealants and answers

to clinical questions. An important guideline to note is in TABLE 3 (scroll down to find this table

information). The decision to place a sealant is made following a caries risk assessment and sealants can

be applied to the appropriate “at risk” tooth surfaces in children, adolescents and adults. Early,

noncavitated carious lesions are acceptable for sealant application. Two types of sealant products are

available and resin based products are recommended to be used in a traditional situation. Examine

“Placement Techniques” in Table 3 to find do’s and don’ts in technique and product selection. Clinical

pictures of early, noncavitated lesions (Fig. 1-5) are illustrated in the chair side guide for sealants at

http://ebd.ada.org/~/media/EBD/Files/report_sealants_summary.ashx .

Objectives:

Identify circumstances when a sealant should be placed. [A chair side guideline is available at http://ebd.ada.org/~/media/EBD/Files/report_sealants_summary.ashx .]

Identify which tooth surfaces should receive a sealant.

Identify the recommendation for an early noncavitated lesion in enamel surface.

Identify conditions when a resin-based sealant should be selected and situations when a glass ionomer cement sealant is best.

List techniques that improve sealant retention or reduce sealant retention

Guidelines for Topical Fluoride Application

Topical In office fluoride products are applied at dental appointments for the purpose of reducing the

risk for caries. There are ADA Clinical Practice Guidelines3 (Nov 2013) available on the Clinical

Recommendation site at http://ebd.ada.org/en/evidence/guidelines . [Hold CTRL key down and double

click the underlined link and it will open in a new tab.] Find the category labeled “Topical Fluoride” and

click on the link. A list is shown that contains the official recommendations, an executive summary of the

recommendations and a Chairside Guide that summarizes the recommendations. [You can toggle

between the guidelines and these instructions and objectives.] The ADA recommendations involve

selecting the patient who might benefit from topical fluoride application in the dental office, and are

based on having an increased risk for caries. Topical fluoride application for children at various ages and

also for adults is addressed. Look at the chair side guide [Right click the link for the chair side guide,

select “open in a different tab”] for a shorter summary of the recommendations. At the top are the

recommendations based on the strength of evidence for risk for caries (Low, Moderate, and High, Expert

Opinion) and the ages of the patients. Notice no individuals in a “low risk” are likely to benefit from

topical in-office fluoride as the statement is made “Patients at low risk of developing caries may not

need additional topical fluorides other than over-the-counter fluoridated toothpaste and fluoridated

water”. Notice also that for children <6 years of age, fluoride varnish is the only form of fluoride

recommended. Scroll down to the bottom of the chair side guide to learn the criteria for the various

caries risk categories. Access the Executive Summary of the Clinical Recommendations from the ADA

Clinical Recommendations site and look on page 1284. Table 5 identifies the variety of topical fluoride

products and the ages of the patient where each applies. Notice only the 4 minute application is the

preferred procedure. The scientific evidence for effectiveness of one minute application is not evidence-

based and is discouraged. In addition, when it has been determined that topical fluoride application is

indicated, twice yearly applications are recommended. Either sodium fluoride or acidulated phosphate

fluoride products are effective.

Objectives:

Describe criteria to determine caries risk and identify which caries risk groups are likely to benefit from in-office topical fluoride treatment, and those unlikely to benefit.

List the forms of topical fluoride products and the types recommended for use in the dental office, based on age and caries risk level.

Apply the recommendations made in the systematic review of the literature to a case.

Fluoride supplementation recommendations for communities without water fluoridation are available at

the National Clearing House site (http://www.guideline.gov/content.aspx?id=34445). These

supplements must be prescribed by a DDS and are not available over the counter. They would only be

recommended when the water being consumed is less than 0.7ppm. The recommendations are not

included in the course but available for review if the client lives in an area where fluoride concentration

in the drinking water is low and the caries risk is moderate to high. A dentist must prescribe this

product.

Management of pain and infection for pulpal infection.

There is a 2007 review of the literature4 on treatment of pulpal infection at

(http://www.medicinaoral.com/pubmed/medoralv12_i2_p154.pdf) but guidelines are only available

from the Canadian Dental Association (http://www.cda-

adc.ca/_files/dental_profession/practising/clinical_practice_guidelines/full_version.pdf) .

This information can be accessed when individuals having a

WRITTEN PROTOCOL agreement desire direction on management of

pulp infection and pain. The 2007 review, in the section on

“Treatment of Odontogenic Infection”, identifies the initial therapy

of incision and debridement to reduce the bacterial load [push Ctrl key and while holding it down push

the key F and put words “infective bacterial load” in the box, select NEXT in the lower part of the box]. In

the 2002 Canadian guidelines find the section “The Clinical Question” [ctrl F method again, put “general

dentist” in box] and look at the target population characteristics (chronic apical infection not included in

these guidelines]. Look at 6.1 Draft Key Recommendations [use ctrl F again]. Notice on page 9 of the CPG

for emergency management of acute pulp infection, antibiotics are not recommended to reduce pain

and only nonsurgical (incision/drainage) or root canal therapy is recommended. Pain can be controlled

with ibuprofen or another NSAID analgesic. Opioids (e.g. hydrocodone or hydrocodone/ibuprofen/

aspirin/acetaminophen combination products) are not the first choice for analgesia or pain relief.

When pulpal infection in children is investigated, guidelines are available from The American Academy of

Pediatric Dentistry (2009). Updated official guidelines for management of acute pulpitis/apical

periodontal infection can be found at

http://www.aapd.org/media/Policies_Guidelines/G_AntibioticTherapy.pdf. The guideline begins with a

discussion of the problems that have developed when antibiotics are overused. A section on

recommendations advises conservative use of antibiotics and general principles to consider when

deciding whether or not to use antibiotics. Those wounds determined to have an increased risk for

infection (open lacerations, fractures) are recommended for antibiotics. For pulpal infection (second

section of recommendations), the recommendation involves using a pulpotomy to remove the bacterial

burden of caries and NOT prescribing antibiotics. More information can be read at the reader’s

convenience at http://www.aapd.org/media/Policies_Guidelines/G_Pulp.pdf.

Objectives:

Identify the first line of treatment when pulpal infection or an abscessed tooth is found.

In the Canadian guidelines identify the initial therapy for acute pulp infection and if antibiotics are recommended.

Apply the American Academy of Pediatric Dentistry clinical guideline to the patient in the photo above.

These therapeutic actions can be completed only by a dentist. For adults, tooth extraction is also

recommended. In children, pulpotomy can resolve the pain and is often used until the root canal

matures and an endodontic procedure can be accomplished at a later date. This is a perfect example of

why a written protocol agreement between hygienists and a dentist is useful to provide oral care to

underserved and vulnerable populations.

Periodontal Disease

The third most common oral problem relates to periodontal disease. You will leave the ADA Clinical

Recommendations site now and [be sure to hold CTLR key down and click the URL] go to the Academy of

Periodontology website at http://www.joponline.org/doi/pdf/10.1902/jop.2011.117001. This link

includes the July 2011 American Academy Periodontology policy6 on “Comprehensive Periodontal

Therapy: A statement by the AAP”. The policy begins with the scope of therapy and states that proper

treatment, control of biofilm and regular maintenance care are the hallmarks of maintaining the

dentition. Patient values and follow through on periodontal care need to be included when risk factors

are considered. In the section describing “treatment” the first therapy is oral hygiene education

regarding how risk factors can be controlled. This is followed by the importance of removing hard and

soft deposits which, in the general practice of dentistry, involves the dental hygienist. The last treatment

recommendations include various periodontal surgical procedures and occlusal assessment, followed by

post treatment evaluation and periodontal maintenance.

A discussion of how these guidelines can be used by the practitioner is available at

http://www.dimensionsofdentalhygiene.com/2011/11_November/Features/Navigating_the_Clinical_Ro

ad_Map.aspx. This latter paper can be read on the reader’s personal time.

The AAP statement is intended to serve as a clinical road map for any dental professional who

supervises, administers, teaches, or regulates the provision of periodontal therapy. This includes dental

hygienists who are generally on the front lines of treatment and patient education. They provide a great

education tool that helps hygienists explain to patients the causes and extent of periodontal disease and

why periodontal treatment is needed. Issues to include in education programs are

What is the reason for regular periodontal maintenance treatment?

Can periodontal disease be cured with treatment or only arrested?

What are the best methods to prevent periodontal disease?

Objectives:

Identify elements of the scope of periodontal treatment.

Discuss the rationale for treatment of periodontal disease to a patient.

Identify therapeutic procedures a dental hygienist contributes in the management of periodontal disease.

List therapeutic options for management of periodontal disease. See Course Introduction for instructions on taking the Self-Test.

References 1. Council on Scientific Affairs. American Dental Association. (2011). Non-fluoride caries preventive

agents. Retrieved from http://jada.ada.org/content/142/9/1065.full.pdf+html. 2. Council on Scientific Affairs. American Dental Association. Evidence-Based Clinical

Recommendations for the Use of Pit-and-Fissure Sealants. JADA 2008; 139:257-68. Retrieved from http://ebd.ada.org/~/media/EBD/Files/report_sealants_summary.ashx.

3. Weyant RJ, Tracy SL, Anselmo T et al. Topical fluoride for caries prevention: Executive summary

of the updated clinical recommendations and supporting systematic review. JADA 2013;

144(11):1279-1291. Retrieved from

http://ebd.ada.org/~/media/EBD/Files/JADA_updated_executive_summary_Nov_2013.ashx.

4. López-Píriz R, Aguilar L, Giménez MJ. Management of odontogenic infection of pulpal and

periodontal origin. Med Oral Patol Oral Cir Bucal 2007; 12:E154-9.

5. American Academy of Pediatric Dentistry. Council on Clinical Affairs. Guideline on Use of Antibiotic Therapy for Pediatric Dental Patients. 2009. Retrieved from http://www.aapd.org/media/Policies_Guidelines/G_AntibioticTherapy.pdf.

6. American Academy of Periodontology. Comprehensive Periodontal Therapy: A Statement by the American Academy of Periodontology. J Periodontal 2011. Retrieved from http://www.joponline.org/doi/pdf/10.1902/jop.2011.117001.

PUBLIC HEALTH SELF STUDY

SECTION ONE Self Test

ANTI-CARIES STRATEGIES

1. The three evidence based methods to prevent dental caries includes all of the following EXCEPT

one. Which is the EXCEPTION?

a. Brushing and flossing

b. Dietary advice to avoid practices that promote caries

c. Fluoride therapy

d. Sealant application

2. For the client at high risk of dental caries who follows advice for caries control what adjunctive

product can be used to reduce the risk for root caries?

a. Amorphous calcium products or casein derivatives

b. Chlorhexidine/thymol varnish

c. Xylitol lozenges

d. Xylitol gum

SEALANTS

CASE: The 5 year old patient is drinking apple juice from a “sippy cup”, waiting for the dental

appointment. Oral examination reveals the patient has caries in deciduous maxillary anterior incisors.

The occlusal pits of posterior deciduous molars are stained but do not appear to have carious

involvement. The patient does not complain of pain. Patient can brush teeth effectively when asked to

demonstrate how he brushes his teeth. He has copious salivation during the examination.

3. Identify teeth that should receive a sealant.

a. Mandibular incisors

b. Maxillary incisors

c. Occlusal surfaces of deciduous teeth

d. Sealants are not indicated for this patient.

4. Can placement of a sealant on an early noncavitated lesion stop the progression of caries?

a. Yes

b. No

5. For clinical situations which pose a high risk for moisture contamination, which is the preferred

type of sealant product?

a. Glass ionomer cement sealant

b. Resin based sealant

6. Use of self-etching agents, which do not involve a separate etching step are

a. Likely to produce an inferior bond.

b. Recommended for use due to more rapid treatment time.

c. Recommended for use due to superior bonding results.

APPLICATION CHAIRSIDE TOPICAL FLUORIDE

CASE: A 70 year old patient who comes annually for a dental examination and cleaning is seated in your

chair. She has had annual oral prophylaxis treatments for the past six years since entering the practice.

She requested bite wing x-rays two years ago since she planned to leave the country and wanted to

make sure no dental disease was present before she left. No disease was found on the radiographs and

the clinical exam revealed intact margins in restorations, presence of 28 teeth, 3rd molars extracted

when patient was a teenager and probe depths 1 to 2 mm, pink firm gingivae, no bleeding on probing.

The patient chief complaint was “need teeth cleaned”.

7. What caries risk group does this patient history describe?

a. Low risk

b. Moderate risk

c. High risk

8. Which of the following forms of topical fluoride is recommended for children <6 years old?

a. Sodium fluoride foam

b. Acidulated fluoride gel

c. Sodium fluoride varnish

d. Chlorhexidine/thymol varnish

9. The clinical evidence for the effectiveness of one minute topical fluoride treatments is

a. Available in lab experiments only.

b. Of moderate quality revealing effectiveness in the mouth (in vivo).

c. Of high quality revealing effectiveness in the lab only.

10. For individuals at moderate to high risk for caries in-office fluoride applications should be

recommended

a. Every 3 to 6 months

b. Every 12 months

c. None of these

PULPAL INFECTION

11. When acute pulpal infection is found in a patient (experienced by throbbing pain, presence of

obvious caries) what is the first line of therapy to resolve the infection in the Canadian

Collaborative Practice guidelines?

a. Antibiotic therapy for 10 days

b. Incision and drainage

c. Root canal therapy

d. Both b and C are recommended

12. The American Academy Pediatric Dentistry guidelines recommend _____ for the patient in the

photo in the directions for course one.

a. Antibiotic therapy and pulpotomy

b. Pulpotomy only

c. Tooth extraction

PERIODONTAL DISEASE – AAP GUIDELINES

CASE: A 42 year old patient presents for periodontal treatment. The chief complaint is “My gums hurt

and I have some pus coming from my gums”. The medical history reveals regular use of cigarettes, no

recent medical problems, and a healthy condition. Vital signs are all within normal limits. Historical

information reveals last dental appointment five years earlier, when the patient was diagnosed with

periodontal disease and “deep scaling” was performed over four appointments. He did not return for

follow up care. Periodontal examination revealed generalized plaque along the gingival margin, probe

depths of 4 to 6 mm, generalized bleeding on probing, and purulent exudates localized to the

mandibular molar area. Supragingival and subgingival calculus deposits were generalized throughout the

mouth.

13. Which of the following findings in the case reduce the likelihood that the dentition will not last

for the patient’s lifetime?

a. Irregular dental appointments

b. Presence of biofilm and calculus

c. Failure to follow periodontal maintenance

d. All of the above

14. All of the following features should be included in the risk assessment for periodontal disease.

Patient decisions and values are included. Which risk factor can be diminished by dental

hygiene procedures?

a. Regularity of periodontal maintenance visits

b. Habit of tobacco use

c. Thorough removal of calculus

d. Regular home based plaque control

15. Treatment procedures for periodontal disease recommended in the AAP guidelines include all of

the following EXCEPT one. Which is the EXCEPTION?

a. Training on oral hygiene and how to reduce risk factors

b. Meticulous removal of calculus deposits

c. Periodontal procedures to eliminate periodontal pockets

d. Selective extraction of teeth or roots

e. Placement of fixed crown and bridge appliances to stabilize teeth

Section 2: Patient Assessment and Use of the Medical History to Identify Potential Medical

Emergency Situations (one hour credit)

This section will be completed to meet part of the requirements for establishing a written protocol

collaborative agreement. The self study text “Prevention of Medical Emergencies: Use of the Medical

History, 3rd Ed.” is used for didactic information. This text includes self-study questions to validate

understanding of information when the health history review occurs. Case studies follow at the end of

each chapter providing an avenue for information to be applied to a clinical situation. Chapters 1

through 5 will be included in SECTION TWO.

Chapters 1 through 4 - Use of the Health History Review to Identify Risks in Oral Procedures

Section one this Public Health course prepared participants to find current evidence-based information

for preventive treatments and agents related to caries. The American Dental Association (ADA)

guidelines for use of fluoride products and sealants were examined. Recent ADA/Food and Drug

Administration guidelines guiding selection of patients for dental radiographs were included.

Additionally current American Academy of Periodontology (AAP) guidelines for periodontal care were

examined. These resources provide the primary base for strategies practitioners can use to plan patient

management in a collaborative practice, both for children/adolescents and for adults/elderly.

Chapter 1 – Read pages 1 to 16. Objectives for this one hour course are in bold font. Each chapter

identifies specific objectives included.

Pages 1-2 identify key terms with definitions used in the reading. Look over these terms to ensure

understanding of the terms. Page 2 lists medical conditions included in the chapter.

The best way to prevent a medical emergency during oral procedures is to gain vital information before

the treatment begins, through a comprehensive review of the health history. This practice is often

referred to as “risk assessment”. The current guideline developed by the American College of Cardiology

for assessment of the patient with a history of serious heart disease, prior to delivery of oral care,

involves asking questions to determine the level of “functional capacity”. These questions should be

asked when the patient has experienced a heart attack (myocardial infarction), angina (substernal pain),

tachycardia or fibrillation (rapid, irregular heartbeat), or any condition in which the cardiovascular

system is seriously affected (see Box 1.2, p. 10).

Functional capacity is explained on page 3 and metabolic requirement (MET) values listed in Table 1.1.

Questions to determine if the 4 MET level has been met are on page 3 (bottom), right column. When

functional capacity meets a 4 MET level, a cardiac medical emergency risk is low and dental procedures

can be initiated. The old advice to “wait six months before dental treatment” no longer is recommended

and has been replaced with assessment of functional capacity. Professional guidelines are currently

based on a systematic review of evidence, and there was no evidence to support “waiting 6 months”.

Risk classification using ASA system is identified on pages 4-5. When it is determined patient health falls

into ASA I through III treatment can continue. For ASA IV and above medical clearance is required.

The ADA Health History two page form (pages 6-7) is used to identify important information needed

when determining risks for providing oral care. Each item on the health history will be discussed in the

self study course and those questions relating to a potential medical emergency will be identified, along

with how to prevent the emergency, and how to manage the most likely emergency, should it occur.

Blood pressure in children, adolescents and adults is discussed on pp. 5, 8 -12. Table 1.2 lists categories

for adults, aged 18 and higher. In adults, BP values equal to or greater than 180/110 should not receive

oral procedures until a medical release has been received in written form. This protects the dental team

if legal events develop. Table 1.3 includes values for children aged 3 to 17. The national guidelines

suggest BP should be measured in all health settings at age 3 and above. Use these tables to assess the

stage of blood pressure when patient assessment occurs. Pediatric patients with BP over values listed in

Table 1.3 should be referred for medical evaluation; however, a limit has not been established for “do

not treat” decisions in children. Self-study items related to this information are found on pp. 12-13.

Answers found on pg. 221 for all self study items.

The chapter concludes with guidelines on evaluating pulse, respiration, and temperature vital signs.

Stress reduction protocols are described since stress can impact all vital signs. Self study questions are

included in these sections, as well.

Consider the questions in the REVIEW section, pg. 16. Answers are on page 221.

Examine the case A study. Answer the questions which follow the case. Answers provided on page 221.

Chapter 2 explains why the ADA Health History begins with screening questions on tuberculosis (TB). TB

is reducing overall, but certain population groups have an increased prevalence of TB. Dental procedures

are contraindicated when active TB exists. When responses to screening questions suggest active TB, the

patient should be referred to the local Public Health facility for medical evaluation. This is the health

organization specially trained to identify and manage TB. For collaborative practices serving immigrant

populations this could be important, since TB is more often found in foreign born individuals. Dental

professionals are recommended to have the Mantoux TB skin test. How often the test is needed relates

to the degree of risk for TB in the community within which they live or practice. The local Public Health

Department can provide this information. Read chapter 2 and answer self-study questions, review

questions and cases A and B. Answers are on page 222 at the end of the text.

Chapter 3 discusses health history items that provide information on dental experiences and oral

hygiene habits. Read pp. 25-39, review key terms and note medical conditions discussed in chapter.

Questions are presented in red font. Each question is followed with information regarding how patient

responses apply to the clinical situation and clinical considerations are discussed on pp. 28-30. Review

the Self Study items to measure understanding of the information. Answers on pg. 222.

The question related to “problems with previous dental treatment” is very important as it directly

relates to the most common emergency to develop in the dental chair, syncope (fainting). For anxious

patients a stress reduction protocol should be considered to reduce the risk (prevent) for loss of

consciousness due to “faint”. Stress reduction is discussed and management of loss of consciousness

explained (pg. 33) and illustrated (Fig. 3-1). Hyperventilation is another potential emergency for anxious

patients (pg. 33-34). Breathing into the hands is an easy method, rather than trying to find a paper bag.

Talking the patient through slowing the breathing rate has been successful while the patient cups hands

over the mouth (Fig. 3-2).

Chapter 3 continues (pp. 34-38) with other health history questions that can impact treatment plan

decisions. Purchase of the text provides a code to access color photographs on THE POINT web site,

explained at the beginning of the text. A new resource in the 3rd edition is a collection of videos

demonstrating management of the most common emergencies to occur in dental offices. Review the

self – study questions, review questions and cases. Answers are provided pg. 222.

Chapter 4 includes medical health assessment and drug information. Read pp. 40 to 51. Before

beginning treatment the drug regimen the patient is taking should be reviewed. It can occur that the

patient forgets to report a medical condition for which a drug is being taken. Comparing the medical

information provided by the patient with the drugs being taken can help to identify this failure. Medical

problems within the past few years should be followed up to determine if the condition is resolved or

how it is being managed and stabilized. Potential side effects of drugs should be investigated in a drug

reference for relevance to oral procedures (oral side effects, postural hypotension risk, bleeding risks,

etc.). Potential emergencies related to drugs and/or herbal supplements are discussed on pp. 43-49. For

unconsciousness, the patient should be placed in the supine position so blood can get to the brain

easily. When hyperventilation develops having the patient breathe into cupped hands to re-breathe

carbon dioxide is effective, while calmly encouraging slowing of the breathing rate. Although it was

suggested in the past to delay dental procedures involving bleeding when the patient is taking aspirin,

clinical studies show this is not necessary. For excessive bleeding digital pressure usually stops the

bleeding by stimulating clot formation. High doses of aspirin prior to surgical dental procedures (but not

nonsurgical dental hygiene instrumentation) need medical laboratory evaluation to determine the effect

on platelet levels. Review the self-study items for comprehension of information, and look at the

REVIEW questions and cases. Answers are found at the end of the text.

Chapter 5 includes more drug information, specifically consideration of antibiotic prophylaxis (AP)

when the patient has a joint replacement or if the patient takes bisphosphonates (Fosamax, others) for

osteoporosis. The information in the chapter discussing total joint replacement was changed December

2012 when a new joint policy was released by the ADA and the American Academy of Orthopedic

Surgeons (AAOS).1 The new policy no longer recommends AP prior to dental procedures when knee or

hip replacements are reported. However, the new policy statement was given a “limited” value for the

scientific support since only one case control study was available on which to make the

recommendation. Practitioners were advised to use professional judgment when deciding to follow a

recommendation based on limited science. For this reason, it is likely many orthopedic M.D.s will still

require AP for their patients with prosthetic joint replacements. A new feature in the guidelines is a

Shared Decision Making Questionnaire. This can be found in the ADA link on the new guidelines. The

information in Ch. 5 can be applied when AP is requested in patients with total joint replacement.

Indications in Box 5.1 illustrate potential risks for prosthetic joint infection. Since AP is no longer

recommended, there were no antibiotics included in the current guidelines. If the orthopedist advises

AP, that physician should prescribe the drug to be taken prior to dental procedures. Given this new

guideline statement the only official organization to recommend AP prior to dental procedures is the

American Heart Association and indications have been greatly reduced (previous history of IE was

retained, but heart murmur and mitral valve prolapsed were deleted). AP for cardiac conditions will be

discussed in a later chapter.

The chapter ends with a discussion of bisphosphonate (BIS) drugs which have been reported to lead to a

rare side effect that affects bone in the jaws, called bisphosphonate-related osteonecrosis of the jaw

(BON). This condition was recently changed to anti-resorptive agent related osteonecrosis of the jaw

(ARONJ). Both bisphosphonates and denosumab, an anti-resorptive agent similar in action to BIS agents,

are implicated. The ADA developed guidance for dental treatment when oral anti-resorptive agents are

used, or intravenous bisphosphonates have been received in the past.2 Review the self study items for

the previous guidelines and examine the current guidelines supplied in the reference section and

available on the web (URL links in bibliography below). Examine the REVIEW section and the two cases

for this population of patients, remembering the updated guidelines.

See Course Introduction for instructions on taking the Self-Test.

References

1. American Academy Orthopedic Surgeons, American Dental Association (2012). Antibiotic

prophylaxis for bacteremia in patients with joint replacements. Available at

http://ebd.ada.org/~/media/EBD/Files/dentalexecsumm.ashx. Accessed August 28, 2014.

2. American Dental Association. Council on Scientific Affairs (2011). Managing care of patients

receiving anti-resorptive agents. Available at

http://www.aae.org/uploadedFiles/Publications_and_Research/Endodontics_Colleagues_for_Ex

cellence_Newsletter/BONJ_ADA_Report.pdf. Accessed August 28, 2014.

PUBLIC HEALTH SELF STUDY

SECTION TWO Self-Test

1. Which of the following blood pressure values in an adult recommend no dental procedures to

be initiated?

a. 120/80

b. 160/90

c. 180/110

d. None of these

2. When a patient has a history of myocardial infarction (heart attack) patient assessment should

begin with

a. Asking if it has been six months since the event

b. Calling the physician to ask for permission to treat

c. Determining the functional capacity to meet the 4 MET level

3. When screening questions for tuberculosis suggest active disease is present in the patient, what

is the suggested patient management procedure?

a. Refer patient immediately to public health for medical assessment.

b. Continue with oral exam but delay restorative or periodontal treatment.

c. Call the patient’s physician for permission to treat.

4. What medical test is used to monitor for TB in a dental professional?

a. Tyne skin test

b. Mantoux TB skin test

c. Blood test for antibodies to TB

d. Chest X-ray

5. If syncope develops during the dental procedure, which of the following procedures should be

implemented?

a. Place in upright position and place the head between the knees

b. Lower the chair back to place in supine position

c. Move patient to floor and use Trendelenburg position

6. When the patient wears a removable maxillary dental appliance which of the following

conditions is likely?

a. Papillary hyperplasia

b. Formation of torus palatines

c. Lingual gingival hyperplasia

7. Anxiety experienced by the dental patient leads to which of the following conditions?

a. Hyperventilation

b. Syncope

c. Loss of consciousness

d. All of these

8. The most effective procedure to stop gingival bleeding is

a. Digital pressure over the bleeding area.

b. Topical application of epinephrine.

c. Transfer to hospital for platelet infusion.

9. If patient presents with symptoms of reflux (GERD) or nausea, treatment is best completed in

a. Supine position

b. Upright position

c. Prone position

10. Antibiotic prophylaxis can be considered for which of the following situations?

a. Having a hip or knee joint replacement

b. Having a history of infective endocarditis

c. Having a port for kidney dialysis

Section 3: Allergic Reaction Emergencies (one hour credit)

Section two reviewed the importance of taking and reviewing the medical history (MH). A long standing

guideline is that the best way to prevent medical emergencies during oral procedures is to “take a good

medical history”. This involves not only identifying the potential emergency situations, but also asking

the right questions to identify the level of risk for positive responses on the MH and understanding the

significance of the patient response. This is followed by critical thinking or professional judgment to

identify risks during treatment and how to minimize those risks. In the case of screening for

tuberculosis, the risk is on the practitioner. In settings that could be established by the written protocol

collaborative agreements patients may include groups at high risk for TB. Participants in the course

should pay close attention to the follow up question discussions, the prevention section and

management of the case or the potential emergency sections. In some cases, the drug section may

identify information that has been overlooked by the person completing the MH document. These two

sections should be compared (drug information and reported health history) to ensure complete

information has been obtained.

Topics included in Section Three

In section three, the self-study text guides the participant to review potential allergic reaction

emergencies. Since many states allow dental hygienists to administer local anesthesia (LA), there is the

risk for an emergency involving unconsciousness (usually due to fear and anxiety about the procedure),

systemic effects from the vasoconstrictor if injected into the circulation (tachycardia, increased blood

pressure) and allergy to a component within the LA cartridge. Substance Abuse is included in the

chapter regarding potential clinical problems and interactions with LA agents. Resources for “stop

smoking” programs are included, as well as a prime requirement for patient interest in quitting the

tobacco habit. Issues related to the female sex (pregnancy, lactation, menopause, osteoporosis) are

discussed with a focus on medications which could be taken in this population and the clinical

consideration relationships. Antibiotic prophylaxis, in general, is included in chapter 8 of the self study

text. The section ends with consideration of potential clinical problems associated with increased

bleeding, either from disease or from use of anticoagulant/antiplatelet drugs.

Chapter 6 – Allergies to Drugs, Environmental Substances, Foods, and Metals

Read pages 63-73, examining the Key Terms and medical condition sections as you begin. Are there any

terms with which you are not acquainted? There is a question on the current ADA Health History asking

about allergies to various drugs and substances which could be used during oral procedures. When a

positive response is given the first question to ask involves why the patient thinks an allergic reaction

occurred and what response occurred. Allergy is characterized by rash, hives, erythema, itching, and

ranges from these mild reactions to the most severe, namely respiratory constriction and loss of blood

pressure (anaphylaxis) (Box 6.1). Patients often confuse allergy with a drug adverse effect, such as

nausea and vomiting. To determine if a true allergy occurred follow up questioning must include a

request to describe the allergic reaction.

In oral procedures, latex allergy is possible (pg. 69). The use of latex products can incite an allergic

reaction in those patients who are sensitive to latex. Anaphylaxis is possible in latex allergy. Some

special needs patients, such as those with cystic fibrosis, have an increased risk for latex allergy.

Collaborative agreements will likely involve individuals with special needs, so special medical problems

should be considered. Allergy to local anesthetics (LA) is most likely with topical anesthetics. There are

two main classes for anesthesia in dentistry, namely amides (low potential for allergy) and esters (high

potential for allergy). Since the only ester classification anesthetic products used in dentistry are

tetracaine and benzocaine, both topical agents, these are the most risky products. The injectable ester

anesthetic, Novocain, is no longer on the market. Few people are allergic to amide classification LAs

(lidocaine, prilocaine, articaine, etc.) Practitioners should question the patient about allergy before

applying a topical anesthetic. Symptoms of “nausea” or “fainting” are not allergic reactions. Nausea is

usually a side effect from a drug and fainting is most likely due to fear of a dental procedure. Examine

the follow up questions in the green boxes and discussion section on pages 69-72. A history of hay fever

or seasonal allergy puts a patient at increased risk for allergy from products used in dental care.

However if the patient has been exposed to the product to be used by the RDH/DDS team more than

once, and no reaction occurred, the allergy risk is minimal to none.

Examine the cases on pp. 73 and test yourself regarding implications of allergy.

Controlled Substances and Addiction, ch. 7

Read pages 74—86. When the patient admits to having a substance abuse problem, care should be

taken if a vasoconstrictor is included in the local anesthetic. If it cannot be determined the patient has

not “used” marijuana, methamphetamine, cocaine or heroin in more than 48 hours, the best LA to

select would be a LA without the vasoconstrictor or one with at least a 1:200,000 concentration. Box 7.1

lists “red flags” to identify the METH user. Box 7-2 lists treatment plan implications for substance

abusing patients. Alcohol abusers may have liver damage. Liver dysfunction leads to increased bleeding

and a medical consult about bleeding risks for an individual with cirrhosis of the liver or severe liver

dysfunction is indicated. When offering a successful smoking cessation program, it is essential to

determine if the patient has a desire to stop smoking. There are several resources to help individuals

who use tobacco products stop using. Tennessee has a free “Quit Line” available to assist individuals to

stop smoking (http://health.state.tn.us/tobaccoquitline.htm). The local community resources should be

investigated and, for those patients who want to stop smoking, referrals can be made. For practices who

want to offer smoking cessation programs, the American Dental Hygienists’ Association has an “Ask,

Advise, and Refer” program for ADHA members. Smoking cigarettes has been shown to result in

periodontal disease, as well as, a poor healing response after periodontal treatment. This may be a

factor to influence the patient to seek help to stop smoking.

Dental professionals in TN who abuse drugs or alcohol can receive assistance in treatment for addiction

from the Concerned Dental Professionals Committee, which is part of the TN Dental Association. The

Concerned Dental Professionals Committee is a peer assistance program provided by the Tennessee

Dental Association and partially funded through a grant from the State of Tennessee. The program

offers consultation, referral and monitoring for dentists, dental hygienists, and registered dental

assistants whose practice is impaired, or potentially could be impaired, due to the use of drugs or

alcohol, or from having a psychological or physiological condition. Contact information for this group is

found in the RESOURCES section at the end of this course. Self study question answers, review answers

and case study answers are at the end of the text. Answer the REVIEW section and examine the case

studies on page 87. Test yourself on the problems of addiction.

Women’s Issues and Antibiotic Prophylaxis

Read pp. 88 -98 and apply the information in Ch. 8 to the cases at the end of the chapter.

For pregnant patients most drugs should not be used. Dental agents in Pregnancy Categories A or B are

the safest ones to use. Products in Pregnancy Category C or above have greater risk for fetal deformity.

Safe agents include lidocaine for local anesthesia (Category B). Antibiotics should be investigated in a

drug reference for the pregnancy category. Tetracyclines are contraindicated (Category D). It is safe to

expose the pregnant woman to dental x-rays, so long as proper shielding is used (lead apron with

thyroid shield).

In November 2012 the Food and Drug Administration, Public Health Service division collaborated with

the American Dental Association to update guidelines for when dental x-rays can safely be taken.

Receiving dental x-rays during pregnancy was included. The “As Low As Reasonably Acceptable” rule

(ALARA) should always be applied and no dental x-rays should be taken until a clinical exam has been

completed and a need for radiographs is identified. According to the ADA, only a dentist should

prescribe dental radiographs. The RDH should not make the decision under current ADA guidelines.1

The most likely emergency situation to occur in the dental office during pregnancy is supine hypotensive

syndrome (pg. 91). Review prevention and management recommendations. Lactation considerations

and taking birth control pills are discussed on pp. 91-92.

Lactation is an issue to consider when treating the woman who is breast feeding. Clinical considerations

for medication use in a breast-feeding patient include2

1. Advise the patient to minimize the breast-fed child’s exposure to drugs the mother is receiving,

such as by timing feedings after drugs are no longer in system or pumping and discarding milk.

2. Recognize potential drug effects in the child and make recommendations to the patient about

monitoring or responding to these effects.

3. Consider adjusting dosage of needed drugs during lactation.

4. Understand the effects of the drug on milk production and explain these effects to the patient

clearly, if a drug is prescribed by the DDS. Use a drug reference.

5. Ascertain whether the drug is present in human milk and if so, how much?

6. Realize the effects of the drug on the breast-fed child and explain these effects to the patient

clearly.

Hormone replacement therapy (HRT) is less common than in past years. For women taking HRT (or

birth control pills) blood pressure (BP) should be monitored as estrogen can increase BP in some

individuals. Estrogen has been reported to increase gingival bleeding, although the mechanism is not

fully understood. Effective oral hygiene is the most reasonable recommendation.

Women who are taking antiresorptive therapy for osteoporosis should be monitored for

osteonecrosis of the jaw (ONJ). In this disorder the alveolar bone dies, the overlying gingival tissue

becomes necrotic, as well, and a disabling condition results. There are no known methods to

prevent development of ONJ, but it is felt that oral health may help reduce the risk for development

of the condition. When this disorder is observed (exposed bone will be seen), the patient should be

referred for care by an oral surgeon. There are no contraindications for dental hygiene services but

the case should be evaluated by the DDS in cooperation with an oral surgeon before tooth

extraction.3

In 2007, the American Heart Association published guidelines for the use of antibiotic prophylaxis

(AP) when the patient reports a variety of cardiovascular conditions. These are listed in Table 8.2,

along with the antibiotic regimen to follow. The guidelines no longer list heart murmur or mitral

valve prolapse as indications for AP. A case example is presented on pg.97 for a patient with

periodontal disease. Box 8.4 gives an example of the different regimen to use when dental

treatment must occur in a short period of time and multiple appointments are required. Review self-

study questions as you read the chapter, answer review questions and case study questions.

Answers at back of text.

Blood Related Abnormalities

Read pages 100 – 1118, Ch. 9 and apply information to self study items and the cases at the end of

the chapter.

Uncontrolled bleeding is most likely to occur when the patient is taking warfarin (Coumadin) an

anticoagulant drug. The antiplatelet agents (Plavix, aspirin) are less likely to cause uncontrolled

bleeding. Increased bleeding with antiplatelet agents can usually be controlled with digital pressure

over the gingival area. For patients taking warfarin (Coumadin) regular blood tests are needed to

determine the INR value. This value determines risk for excessive bleeding. Values 3.5 or less are

acceptable for periodontal treatment and oral surgery. Bleeding would be managed as for any

bleeding (direct pressure, gauze over area, GelFoam, as needed). For hereditary conditions that

reduce clotting factors (hemophilia, others) consultation with a physician is needed. Platelet infusion

may need to be completed before dental surgical procedures are attempted in an individual with

hemophilia. Periodontal procedures expected to result in heavy bleeding should be communicated

to the patient’s physician and a request for guidance made.

Blood related viral disease (hepatitis B, C, HIV, others) can be transmitted to dental personnel.

Pages 107-113 discuss considerations for dentistry. Standard precautions are established, with use

of barriers during oral procedures, to avoid transmission to health care personnel. Each year

licensed dental health professionals in TN must complete a course on infection control which

includes requirements established for safe practice in dentistry. Occupational exposure

recommendations were updated in 2013 and are included in this course (pp.112-113). These

exposures are the only emergency situation dealing with blood borne diseases. Complete all self

study items, review questions and cases. Answers are at end of text.

See Course Introduction for instructions on taking the Self-Test.

RESOURCES

Healthcare Provider Guide to Successful Tobacco Cessation Intervention. Available at

http://health.state.tn.us/Downloads/TQL_intervention.pdf. Accessed August 28, 2014.

Concerned Dental Professionals Committee. Tennessee Dental Association. Information available in

Peer Assistance tab at http://health.state.tn.us/boards/Dentistry/complaints.htm. Accessed August

28, 2014.

References

1. U.S. Department of Health and Human Services, Food and Drug Administration, Public

Health Service, American Dental Association, Council on Scientific Affairs. (2012).

Dental radiographic examinations: Recommendations for patient selection and limiting

radiation exposure. Retrieved from

http://www.ada.org/~/media/ADA/Member%20Center/FIles/Dental_Radiographic_Examination

s_2012.ashx. Accessed August 28, 2014.

2. Donaldson M. Goodchild JH. Pregnancy, breast-feeding and drugs used in dentistry. The Journal of the American Dental Association. 2012; 143(8):858-871.

3. Hellstein JW, Adler RA, Edwards B. et al. Antiresorptive therapy for prevention and treatment of osteoporosis: Executive Summary of recommendations from the American Dental Association Council on Scientific Affairs. JADA 2011; 142(11):1243-1251. Available at http://jada.ada.org/content/142/11/1243. Accessed August 28, 2014.

PUBLIC HEALTH SELF STUDY

SECTION THREE Self-Test

1. Prevention of medically related emergencies includes all of the following EXCEPT one. Which is

the EXCEPTION?

a. Identifying the most likely emergency situation(s)

b. Posing the relevant follow up questions regarding potential adverse events

c. Using critical thinking to analyze patient responses

d. Making a plan to minimize risks during treatment

e. Always taking a partner to assist during any adverse situation

2. Allergy to agents used in dental practice involves which of the following?

a. Ester-type local anesthetic agents

b. Latex

c. Penicillin

d. All of the above

3. A patient response of “nausea and vomiting” represents a (an) __________ reaction.

a. Allergic

b. Side effect

c. Poison-related

d. Stress-related

4. For the client with a history of abusing cocaine, which of the following precautions are

indicated?

a. Monitor vital signs for abnormal values

b. Instruct the client to refrain from using drugs for two days prior to dental appointment

if local anesthesia is planned

c. Use standard precautions during oral procedures

d. All of the above

5. For a client to be successful to stop smoking after a tobacco cessation program, which of the

following is most necessary?

a. A desire to quit the habit

b. Insurance program to cover program costs

c. Pharmacologic therapy

6. Oral disease associated with using tobacco products include

a. Nicotinic stomatitis

b. Hairy tongue

c. Periodontal disease

d. Squamous cell carcinoma

e. All of these

7. Dental professionals who abuse drugs or alcohol can get assistance on finding resources for

recovery through use of the Concerned Dental Professionals Committee in Tennessee.

a. True

b. False

8. Which of the following drugs used in dentistry is contraindicated for use during pregnancy?

a. Lidocaine

b. Tetracycline

c. Penicillins

9. Dental radiographs can be exposed for a pregnant client when which of the following safety

procedures is used?

a. Coverage of the body midsection with a lead apron

b. Consent form is properly completed

c. Patient is in second trimester of pregnancy

d. F speed film is used

e. Digital radiography is used

10. When antibiotic prophylaxis is recommended to prevent infective endocarditis, what

recommendation on dosing is suggested by the American Heart Association?

a. Take 30 minutes prior to dental appointment

b. Take 60 minutes prior to dental appointment

c. Take within 2 hours following the appointment

d. All of the above

11. For the patient who is allergic to penicillin and who is indicated to receive antibiotic prophylaxis

prior to a dental appointment, which of the following is an alternative antibiotic?

a. Clindamycin

b. Tetracycline

c. Metronidazole

d. Levofloxacin

12. For the client taking warfarin (Coumadin), which INR lab result is required before periodontal

debridement can safely be completed to avoid excessive bleeding?

a. INR of less than 2

b. INR of no more than 3.5

c. INR of between 3 and 5

CASE STUDY – you can use a drug reference or other resources for professional judgments

A patient in her 8th month of pregnancy presents for an emergency appointment due to pain around

tooth #30. Medical history reveals good health and vital signs of pulse 80 bpm, respiration 22

breaths/min, blood pressure 110/60 Hg, Rt. Arm, sitting. Oral exam reveals caries in tooth #30 and a

periapical radiograph reveals normal bone at the apex of the tooth. Restorative treatment is planned.

13. Which local anesthetic agent should be selected?

a. Mepivacaine (Carbocaine)

b. tetracaine (Cepacol)

c. lidocaine (Xylocaine)

14. What analgesic would be indicated for postop pain?

a. Acetaminophen

b. Ibuprofen

c. Hydrocodone/acetaminophen (Lortab)

15. Which of the following clinical judgments is appropriate for the relief of infection and pain in

this patient?

a. Delay dental procedures until after baby is born

b. Proceed with emergency restorative procedures

Section 4: Proper Development of a Treatment Plan (one hour credit)

Section Four will continue reviewing medical conditions relevant to treatment plan formulation and

dental management. The Pickett & Gurenlian text, Chapters 10 through 14 will be reviewed in this

section with a focus on treatment considerations. Updated guidelines related to medical conditions in

this section will be included in this course.

Ch. 10 Medical Conditions Involving Immunosuppression

Medical conditions discussed in this chapter are identified on pg. 121. Read pages 120-142, consider the

self study questions and the cases at the chapter end. The chapter begins with a discussion of important

considerations when treating a patient during malignancy.

When the immune system is compromised, the healing response is negatively affected. This is a prime

consideration if oral procedures will cause a tissue injury (such as tooth extraction or periodontal

debridement). Conditions discussed which may involve a specialized care plan, and physician consult,

could include receiving treatment for a malignancy, diabetes mellitus, lupus erythematosus and organ

transplant.

Cancer treatments

Malignancies are treated in various ways – surgical resection of the tumor, chemotherapy with toxic

drugs, radiation therapy to cause necrosis in tumor cells, and stem cell transplants. Each therapy has

adverse effects on the tissue cells which could potentially impact the dental management plan. Medical

consultation is essential to provide well managed care and reduce the risk for medical complications.

The “miracle mix” included on page 122 has been used for a palliative effect in dentistry for many years,

however a recent systematic review by the Oncology Nursing Association1 found no evidence the

compounded formulation provides reduction in pain, nor prevents mucositis. The group does not

recommend “Miracle Mix” and says it costs the patient extra expense, for no likely benefit. They

recommend a baking soda/water (1 T. per 1 cup water) rinse for palliative effects. Mucositis associated

with all three cancer therapies is the most distressing oral complication and new guidelines for

prevention of mucositis2,3 reveal the best way to reduce development of mucositis is implemented by

the oncology team during cancer therapies (holding ice in mouth while receiving chemo, taking a drug

that prevents mucositis before and during cancer therapy). The dental professional cannot help to

reduce the pain associated with mucositis, other than recommending the baking soda/water rinse,

according to the oncology literature.4 In 2012 the National Cancer Institute updated guidelines for

management of mucositis4 and this paper is freely available on the internet. Pages 124-25 provide

recommendations to manage potential oral effects of cancer treatment, including xerostomia and pain

in the mouth. Reviewing the blood values for platelets and the neutrophil count is essential prior to

implementing oral procedures which can result in bleeding [Box 10-1] or which may need an adequate

healing response (i.e. neutrophil count less than 1000 cell/mm3 means no oral procedures should be

implemented). The dental professional can help the patient if a supplemental fluoride product is needed

to prevent dental caries during cancer therapy. Products are discussed on page 125-26. The federal

government (National Institute for Dental and Craniofacial Research) has information available for both

the dental team and the patient regarding oral care (Box 10.2, Fig 10.1). Potential emergencies and

management considerations involve assessment of the patient needs (lab test results, oral

complications, etc.) and development of a plan that addresses that information.

Diabetes mellitus (DM)

Diabetes is fairly common in the U.S. population and the prevalence of type 2 DM is increasing each year

due to the obesity epidemic. It is estimated that the actual prevalence is higher than reported since

many individuals with DM are undiagnosed. Uncontrolled DM can result in multiple medical

complications, including cardiovascular disease, increased infections and poor healing. The relationship

to periodontal disease involves the “increased infection and poor healing” feature of uncontrolled DM.

Potential oral side effects of uncontrolled DM are illustrated on page 130 and can be accessed for the

color image on The POINT internet site of the book publisher. The most common medical emergency for

this condition involves hypoglycemia and the risk for and prevention of this emergency is discussed on

pages 132-133. The follow up questions for DM are important to investigate to identify risks during oral

care.

Systemic Lupus erythematosus (SLE)

This condition is an autoimmune (AI) disease and often is accompanied by other AI conditions. In the

past heart murmur (common in SLE) was indicated for antibiotic prophylaxis (AP), but this indication was

dropped by the American Heart Association in 2007. Glomerulonephritis is associated with SLE and in

the past was suggested as a need for AP, but there are no official recommendations for AP when the

kidney is affected. Medical consult should include the drug therapy to manage effects of SLE and the

drugs are likely to result in oral side effects. The condition cannot be cured and is managed by

pharmacologic measures.

Rheumatoid arthritis

This AI condition can accompany other AI diseases or develop on its own. The main effect on oral care is

to assess the ability to grasp the toothbrush and floss if the fingers are affected. The drug therapy

involves medications to reduce the host response and reduce pain. Many individuals with this condition

have joint replacements from damage to bone and joint areas due to the condition. Medical

consultation with the orthopedist regarding AP prior to oral procedures should be investigated.

Currently the American Academy of Orthopaedic Surgeons and the American Dental Association

guidelines (2012) do not recommend AP for hip and knee replacements.5,6,7 However, some orthopedists

may still recommend AP prior to dental procedures. A new feature in the 2012 guidelines is a shared

decision making tool that involves the patient in the decision whether to take AP prior to dental

treatment.6 The executive summary of the document clarifies the main issues in the new guidelines and

is much shorter to read.7

Organ Transplant

Individuals with an organ transplant must take antirejection drugs to prevent rejection of the

transplanted organ [pp. 139-42]. These drugs lower the immune response and may affect infection in

the oral cavity, as well as the healing response. Medical consultation is needed to determine the effect

on the patient’s body of the transplant therapy. The transplant physician should be asked for guidance

as the care plan is developed. The plan will be greatly influenced on the patient response to

antirejection therapy and the health of the transplanted organ.

Review the self –study items, Review questions and cases presented at the end of the chapter to test

your recollection of clinical applications. Answers are at the end of the text.

Chapter 11 – Cardiovascular System

Cardiovascular disease is common in older individuals and represents the #1 most common reason for

death in the U.S. This chapter discusses the important follow up questions to ask, and the importance of

assessing functional capacity (FC) to identify risks for cardiac problems during treatment. In the past,

some texts recommended delaying dental treatment for 3 to 6 months after a heart attack (also known

as myocardial infarction [MI] or acute coronary syndrome [ACS]). This suggestion was dropped in 2004

when the American College of Cardiology developed updated guidelines for noncardiac procedures in

individuals with a history of MI. Assessment of functional capacity [FC] was discussed in course two.

Read pages 144- 160, take the self study tests and review the case studies at the end of the chapter.

Angina pectoris, MI –read pp.146-48

The differentiation between angina and a MI is confusing as the two conditions involve the same initial

sign: pain in the chest. Individuals with a history of angina often carry nitroglycerin. The text identifies

the limit of no more than 3 sublingual tablets during a 10 minute period of emergency management.

Angina is usually managed by allowing the patient to rest for 5 minutes. This often will resolve the

symptom, however nitroglycerin can also be used concurrently with rest. Prior to initiating oral

procedures, ask the patient who reports angina, “How do you manage angina? When was your last

angina attack? What usually causes it?” Knowing this information prior to a possible event is important.

Since having completed training in CPR before approval for license renewal, dental professionals are

trained to respond to ACS/MI and interaction with EMS. The text discusses possible scenarios and

management procedures.

Heart murmur, valvular disease

These conditions are no longer recommended for AP however when a valve replacement is present, the

individual is indicated for AP. A risk for bleeding exists as this patient must take anticoagulant drug

therapy. Information provided in course three addresses potential bleeding problems in this situation.

An INR of 3.5 is usually the recommended limit for this medical condition. Periodontal debridement can

be provided with no risk for hemorrhage in an INR of 3.5. Simple tooth extraction can also be

completed, however for multiple tooth extractions, medical consultation should be completed to

determine the risk for excessive bleeding.

Heart failure (HF)

This condition was formerly referred to as “congestive heart failure”. The terminology was changed

several years ago to heart failure, with no designation between right sided HF and left sided HF. When

HF is reported, the most likely impact on dental treatment is to determine if the patient prefers an

upright chair position. Of course, initial investigation should involve the degree of control for the

condition, but poorly controlled HF results in fluids collecting in the lungs. It is essential to assess FC for

this cardiac condition. The disease is classified as A, B, C, D, according to the degree of disease control.

Pulmonary edema or congestion represents an ASA IV risk and dental treatment should be delayed until

the disease is better controlled. Medical consultation would provide answers to these issues.

Heart Attack (myocardial infarction)

MI is the most frightening emergency to occur in the dental office. Dental professionals in all states are

required to take cardiopulmonary resuscitation courses to manage MI. The newest guidelines call for

waiting one month before giving the patient dental treatment. Prevention and management is

discussed.

Hypertension or hypotension

Excessive blood pressure [BP] is the cause many CVD conditions. Taking BP is considered essential, a

standard of care, prior to starting dental tx. Review dental considerations of this medical condition and

the applications to clinical practice [pp. 154-55].

Implanted cardiac pacemaker or devices

In the past, it was thought ultrasonic scalers would not be used when this medical device was present.

All manufacturers of pacemakers state there is no contraindication for ultrasonic scalers as the shielding

mechanisms protect them from disruption, so long as the ultrasonic is 3 feet away from the device.

Stroke (cerebrovascular accident)

A pre-stroke condition called transient ischemic attack (TIA) should be investigated: when the event

occurred, how it was treated, and the risk for a future stroke. If the patient cannot answer the follow up

questions for this medical condition, consultation with the physician that treated the event is indicated.

Some individuals have a TIA and recover completely; others have additional events and are at risk for

stroke. The information required to develop a professional judgment when developing an oral care plan

is discussed on pages 157 -158. A weak association exists between periodontal disease (PD) and CVD but

no evidence exists that PD causes CVD. According to a systematic review published by the American

Heart Association, patients should not be told periodontal tx will improve symptoms of CVD as no

evidence shows periodontal tx improves the disease symptoms. Surrogate markers (CRP, carotid intima

media thickness) are not useful as a proof that PD improves CVD.

Migraine

This can be a debilitating condition for those affected. Follow up questions are identified and

recommendations for care would be based on the responses to those questions. Ensuring the overhead

dental light does not irritate the eyes is an issue with some patients.

Review self-study items, the Review section questions and the case studies to test your memory of

important concepts. Answers are at back of text.

Chapter 12 – Neurologic Disorders

This chapter includes abnormalities or diseases affecting the brain and nerves innervating muscles and

tissues. Management for many of the patients with special needs is discussed in this chapter. Read

pages 162 – 179 for important issues to consider and essential questions to ask before planning care, for

indicated needs based on responses to those questions, and prevention and management of possible

emergencies. Test yourself with the self study questions and answer the case questions at the end of the

chapter.

Seizure (epilepsy)

The text discusses the various types of seizures and the signs and symptoms of the various classifications

of seizures. The most difficult management is for the tonic clonic or convulsive seizure. Prevention

mainly includes the patient takes the prescribed antiseizure medication as this is the most likely reason

for recurrent seizure (not taking the drugs). Questioning about “Have you had a seizure during dental

treatment?” is important to ask. It is important to note that many etiologies can exist that manifest in

seizure. Traumatic brain injury can leave those affected with seizure. Many of the intellectually disabled

clients have seizures. The chapter provides prevention and management recommendations should this

event occur during dental treatment. There is a question on the medical history about “blackouts”. This

is a sign of epilepsy and questioning should investigate if the blackouts are recent and if they occur

multiple times. A referral for medical evaluation might be important as epilepsy may be occurring but is

not yet medically diagnosed.

Blackouts, fainting

History of “blackouts” is a sign of seizure disorder and follow up questioning to determine if symptoms

of seizure have occurred. Fainting or loss of consciousness could be related to seizure, but true “faint” is

an anxiety disorder.

Sleep Disorder, Chronic pain

These conditions may have multiple etiologies (causes). Investigate the reason for the sleep disturbance

or pain, and manage the case based on the etiologic reason. Consider the likelihood of choking during

the appointment. Alterations in dental chair positioning may be needed to make the patient with

chronic pain more comfortable.

Mental Health and Developmental neurologic conditions

This section of the chapter deals with a variety of conditions. For individuals with mental health

disorders the medications usually result in chronic dry mouth and resultant dental caries. Behavior

management may be an issue to deal with. Questioning may include a caregiver for the patient to get

accurate information. Read pages 171-179 for the various conditions discussed. Management of care for

Special Needs populations is new to the 3rd edition of the text. Box 12-5 includes resources found on the

Web for management recommendations. Various issues of this population and the variety of conditions

are discussed. The Special Care Advocates in Dentistry organization has essential information. This free

website has modules for dental management involving a variety of disabilities.8

Review self-study items, Review section questions and Case studies. Answers at end of text.

Chapter 13 GI Disorders and Respiratory Disease

Read pages 180-189, test understanding of information using the self study questions and review the

cases at the end of the chapter. Most of these conditions have probably been seen in clinical practice

and the clinician is familiar with oral signs and specific dental management considerations. Eating

disorders are discussed and recommended management provided. Respiratory conditions are included

and discussed. Asthma and cystic fibrosis are included. For chronic obstructive pulmonary disease

(COPD) the relationship to cigarette smoking is important and offering resources for smoking cessation

(discussed in an earlier course) should be offered to the patient who wants to try to quit. When COPD

develops, the patient may already have tried to stop smoking as the M.D. would likely have suggested

stopping the habit. Dental management, of course, would involve determining the risk for respiratory

obstruction during a supine chair position and making adjustments, as indicated by symptoms and

disease control. The chapter ends by discussing management for choking and airway obstruction. This

emergency situation can occur in a healthy patient, if objects fall into the airway. This can occur during

scaling, if a crown or inlay is removed and falls into the throat.

Chapter 14 Glaucoma, kidney disease and thyroid disorders

Medical conditions in this chapter are listed on pg. 191. Read pages 191—201, test yourself using the

self study questions and review the cases involving these medical disorders. There are no new guidelines

for these conditions so the information should be familiar. The client with chronic renal failure will be

very ill and unlikely to present to the regular dental office, however for collaborative written protocol

agreements that involve going out into the community and serving homebound individuals, it might be a

medical condition to deal with. Medical consultation is vital as there are many problems that may need

to be considered. For the client on dialysis, blood pressure would be taken on the arm WITHOUT the

port used for dialysis. Providing care around the days scheduled for dialysis is a question to ask the

physician. It may be best to schedule oral care for the day after dialysis as the anticoagulant used during

dialysis is no longer affecting bleeding. Management for renal transplant is included, although organ

transplant was discussed in an earlier chapter.

Hyperthyroidism

The client with thyroid disease can include an overactive thyroid (hyperthyroidism) or an underactive

thyroid (hypothyroidism). In fact medical treatment for hyperthyroid can result in making the client

develop hypothyroidism. Careful consideration of vital sign values is an important component to identify

a potential emergency of “thyroid storm”, discussed on page 200-201.

See Course Introduction for instructions on taking the Self-Test.

References

1. Harris DJ, Eilers J, Harriman A, et al. Putting evidence into practice: evidence-based

interventions for the management of oral mucositis. Clin J Oncol Nurs 2008;12(1):141-

52. Available at

http://guideline.gov/content.aspx?id=15700&search=management+of+oral+mucositis+

and+chemotherapy. Accessed August 28, 2014.

2. Migliorati C. Hewson I, Lalla RV et al. Systematic review of laser and other light therapy

for the management of oral mucositis in cancer patients. Support Care Cancer 2013;

21:333–341.

3. Peterson DE, Ohm K, Bowen J et al. Systematic review of oral cryotherapy for

management of oral mucositis caused by cancer therapy. Support Care Cancer.

2013;21:327–332.

4. National Cancer Institute. Oral Mucositis. 10/23/2012. Available at

http://www.cancer.gov/cancertopics/pdq/supportivecare/oralcomplications/HealthProfessional

/page5. Accessed August 28, 2014.

5. American Dental Association, American Academy Orthopedic Surgeons. Collaborative Guidelines

for Prevention of Prosthesis Infection and Dental Treatment. Available at

http://www.aaos.org/research/guidelines/PUDP/dentaleditorial.pdf. Accessed August 28, 2014.

6. Shared Decision Making Tool. Chairside Guide for ADA/AAOS Antibiotic Prophylaxis and

Prosthetic Joint. Available at

http://www.ada.org/~/media/ADA/Member%20Center/FIles/DentalSDMTool.ashx. Accessed

August 28, 2014.

7. Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Executive Summary on the AAOS/ADA Clinical Practice Guideline. Available at

http://www.ada.org/~/media/ADA/Member%20Center/FIles/dentalexecsumm.ashx. Accessed

August 28, 2014.

8. Special Care Advocates in Dentistry. Modules for dental management. Available at

http://saiddent.org/modules.php. Accessed August 28, 2014.

PUBLIC HEALTH SELF STUDY

SECTION FOUR Self-Test

1. For the client receiving chemotherapy the neutrophil count should be above _______before

dental treatment should proceed.

a. 1000 cells/mm3

b. 5000 cells/mm3

c. 10,000 cells/mm3

2. When therapies are received that affect platelets, what is the minimum number of platelets

needed to avoid excessive bleeding?

a. 1000/mm3

b. 10,000/mm3

c. 50,000/mm3

d. 250,000/mm3

3. Which type of diabetes involves no insulin secretion?

a. Type 1

b. Type 2

c. Gestational DM

4. The most likely medical emergency in the patient with diabetes mellitus is

a. Syncope

b. Hypoglycemia

c. Myocardial infarction

d. Stroke

5. Therapy for rheumatoid arthritis can result in all of the following medical issues EXCEPT one.

Which is the EXCEPTION?

a. Immunosuppression

b. Bleeding issues

c. Poor healing

d. Uremic toxicity

6. Individuals with rheumatoid arthritis may have other autoimmune diseases. Prophylactic

antibiotics are strongly recommended for the dental management plan.

a. Both statements are false

b. Both statements are true

c. First statement is true, second statement is false

d. First statement is false, second statement is true

7. Stable angina is characterized by which of the following?

a. Relief after sublingual use of nitroglycerin

b. Relief after rest

c. Both of these therapies

8. The client with a history of cardiac valve replacement should be evaluated for which of the

following conditions?

a. Immunosuppression

b. INR of 3.5

c. Hypertension

9. For the cardiac patient needing local anesthesia the recommended cardiac dose of

vasoconstrictor in local anesthesia is no more than

a. One cartridge of 1:100,000

b. Two cartridges of 1:50,000

c. Two cartridges of 1:100,000

10. Elective oral care should be postponed when blood pressure exceeds

a. 160/90 mm Hg

b. 170/100 mm Hg

c. 180/110 mm Hg

d. 220/220 mm Hg

11. For individuals with medical conditions classified as ASA IV, what is the dental management

recommendation?

a. Provide antianxiety meds before treatment

b. Institute a stress reduction protocol

c. Do not treat

12. Signs of stroke include all of the following EXCEPT one. Which is the EXCEPTION?

a. Headache

b. Unequal pupil size

c. Hypotension

d. Incoherent speech

13. Elderly clients taking a beta blocker or calcium-channel blocking agent for migraine may be at

risk for which of the following conditions?

a. Hypertension

b. Orthostatic hypotension

c. Syncope

d. Nausea and vomiting

14. Convulsions are characteristic in which form of seizure disorder?

a. Absence seizure

b. Complex partial seizure

c. Tonic clonic epilepsy

15. The most common oral manifestation of bulimia is

a. Erosion of enamel

b. Stomatitis

c. Tongue thrust

16. Which local anesthetic is recommended for a client who presents with an allergy to sulfites?

a. Lidocaine, 1:50,000

b. Benzocaine topical

c. Mepivacaine, plain

d. Articaine, 1:100,000

17. Prevention of airway obstruction during oral procedures can occur through

a. Use of a saliva ejector to remove oral secretions

b. Tying dental floss to cotton rolls or clamps

c. Use of a rubber dam

d. All of the above

18. For the client receiving dialysis due to kidney failure, what consideration exists during the

assessment of physical health and health history?

a. Blood pressure procedure

b. Assessment of breath odor

c. Chair position

19. Maintenance of body temperature, growth, and regulation of body functions is controlled by

which gland?

a. Adrenal

b. Thyroid

c. Parathyroid

d. Pituitary

20. Signs of uncontrolled hyperthyroidism include

a. Elevated blood pressure

b. Pulse rate over 100 bpm

c. Thyroid storm

d. All of the above

Section 5: Elements of Written Protocol and Ethics (one hour credit)

Access to care is an increasingly and complicated global issue and continues to promote passionate discussions that have been resulting in tangible results. As of January 2013, there are 4,600 dental Health Professional shortage areas (HPSA) in the country. Health Professional shortage areas are based on a dentist (DDS) to population ratio of 1:5,000, meaning that there are 5,000 more people than dentists.

The vulnerable and underserved populations face persistent and systemic barriers to accessing oral health care. These barriers are numerous, complex and include social, cultural, economic, structural, and geographic factors.1 For example, in 2008, 4.6 million children did not obtain needed dental care because their families could not afford it. In 2011, there were approximately 33.3 million underserved individuals living in dental HPSA.1 A version of this can be found in the summary of “Improving Access to Oral Health Care for Vulnerable and Underserved populations” pp. 18-33, at http://www.hrsa.gov/publichealth/clinical/oralhealth/improvingaccess.pdf.

Written protocol collaborative agreement

This agreement between a dentist and hygienist(s) was passed into legislation and signed into law on

May 10, 2012 by Governor Bill Haslam.

In August 2011, the American Dental Association published strategies outlining how to respond to the

situation when people cannot access dental care

(http://www.ada.org/~/media/ADA/Advocacy/Files/topics_access_whitepaper.ashx). These suggestions

may be helpful when establishing a collaborative agreement in a written protocol.

History of Written Protocol

In 2010, a special committee on workforce models was established to research workforce models with

greatest opportunity to benefit consumer needs in Tennessee and expand the scope of practice of

dental hygienists. The definition of a registered dental hygienist was expanded and the time period

between the examination of a patient by a supervising dentist and the service provided by a dental

hygienist was extended from seven (7) months to eleven (11) months. Revised rules governing the

practice of dental hygienists occurred in January, 2011 and can be found at

http://www.tn.gov/sos/rules/0460/0460-03.20110120.pdf.

During the term of Diana Saylor, RDH, President of TN Dental Hygienists’ Association (TDHA) 2011-2012,

TDHA association members led efforts to develop a bill allowing a collaborative practice between

dentists and hygienists. The goal was to expand the opportunity of oral care to underserved populations

in TN and models utilized in Arkansas and New Mexico were evaluated. The TN Commissioner of Health,

Dr. John Dreyzehner, supported the proposed legislation and representatives from TN Dental

Association (TDA) indicated they would help devise a bill to allow collaborative practice agreements,

later called “written protocols” to address the inability to receive oral care by disadvantaged and

underserved populations. A stakeholder meeting including representatives from TDHA, TDA, the

Academy of General Dentistry and a representative from the Commissioners’ office met to discuss,

negotiate and get final agreement on a Bill to be submitted to the Subcommittee of Health and Human

Resources Committee. The bill sponsor, Senator Jim Tracy, advocated for approval of the Bill in the

Health and Welfare Committee and the Bill was passed with amendments. This final version of the Bill

was passed unanimously in the Senate 28-0. The Bill went to the House with approved amendments

where it passed unanimously 95-0. This bill was signed by the Speaker of the House, Representative

Beth Harwell, and the Speaker of the Senate Lt. Governor, the Honorable Ron Ramsey. On May 10, 2012,

Governor Bill Haslam signed the final Bill which can be found at http://tndha.org/wp-

content/uploads/2013/04/Final-Bill2012.pdf. The Application for Dental Hygienists to Practice Under

Written Protocol form can be downloaded at http://health.state.tn.us/boards/Dentistry/PDFs/PH-

4187.pdf.

What is Written Protocol?

A written protocol is a written agreement between a dentist and hygienist that sets forth standing

orders for a working relationship to provide preventive oral health care in alternative settings. These

alternative settings can include nursing homes, skilled care facilities, nonprofit clinics, and public health

programs. A written protocol agreement describing the oral procedures to be completed and the setting

and location of the program must be submitted to the TN Board of Dentistry (BOD), although no

approval comes from the Board. The request for written protocol status, along with evidence of all

parties having completed a six (6) hour Public Health continuing education course, must be submitted in

advance of beginning the program for oral care. The board will receive each written protocol submitted

and keep those on file which meet the minimum requirements enumerated in subsection (f) of the

dental practice act. Those received by the board and determined not to be complete shall be returned

to the submitting dentist within thirty (30) days of receipt with a request for the additional information

required. The dentist may then re-submit an amended written protocol to the BOD.

Requirements for Written Protocol in Tennessee must be met before notifying the Board of Dentistry of

the collaborative agreement.

General requirements

Have evidence of active practice as a licensed dental hygienist for at least five years

Current license to practice dentistry in TN for both the dentist and hygienist

Have practiced two thousand (2,000) hours in the preceding five years of the written protocol

OR evidence of teaching dental hygiene courses for two of the preceding three years in a dental

hygiene program accredited by the American Dental Association Commission on Dental

Accreditation

Evidence of completion of six (6) hours of public health continuing education within the past

two years.

No dentist may enter into a written protocol agreement with more than three dental hygienists

at any one time. No hygienist can enter into a written protocol agreement with more than three

dentists.

The supervising dentist(s) must process all patient billings.

Each written protocol agreement will be valid for two years, after which time it must be

renewed through resubmission to the Board of Dentistry.

Each written protocol required for off-site practice under general supervision by a DDS shall be

submitted to the Board of Dentistry by certified mail/return receipt requested and shall include

at a minimum (1) the names, addresses, telephone numbers and license numbers of the

supervising dentist(s) and dental hygienist(s); (2) the name, address, telephone number and

pertinent identification of settings where the dental hygiene services are to be performed; (3) a

statement signed by the dentist(s) that the dentist(s) and the dental hygienist(s) meet all

minimum standards for general supervision, as well as those required for practice under a

written protocol as stipulated in the section 63-5-108 of the TN Code Annotated of the dental

practice act.

A member of the team will be assigned by the dentist to record Occupational Safety and Health

Administration (OSHA) exposure incidents and/or assume duties of an assigned OSHA officer.

The supervising dentist must notify the Board of Dentistry within ten (10) working days by

certified mail/return receipt requested or electronic mail when the written protocol is no longer

in force.

Settings

Nursing homes

Skilled care facilities

Public health programs

Nonprofit clinics

“Nursing home” means any institution, place, building or agency represented and advertised to the

general public for the express or implied purpose of providing care for one or more nonrelated persons

who are not acutely ill, but who require skilled nursing care or related medical services. This term

(convalescent home, long term care facility) is also used to describe a residential facility for individuals

with chronic illness or disability, particularly older people who have mobility and eating problems.

Residential care can be provided in a nursing home, convalescent home, skilled nursing facility, care

home, rest home, intermediate care facility, or “old folk’s home”. These settings are a place of residence

for people who require constant nursing care and have significant deficiencies with activities of daily

living.

Non-profit clinics may be identified as 501c3 organizations. This type of organization is also known as a

nonprofit or charitable organization approved by the Internal Revenue Service (IRS) and is given tax-

exempt status because the organization meets the requirements defined in Section 501c(3) of the IRS

code. Federally Qualified Health Centers are nonprofit centers. Non-profit clinical facilities often are

associated with a hospital or medical school, devoted to the diagnosis and care of outpatients. It can

also include a medical establishment operated by medical specialists working in cooperation and sharing

the same facilities.

Skilled Care Facilities (SCF) are health care settings used when a patient needs skilled nursing or

rehabilitation staff to manage, observe, and evaluate care. Generally, SCF offer a level of care that is

lower, or less intense, than inpatient hospital care. Medical care ordered by a physician and which must

be given or supervised by a licensed health care professional is provided in SCFs

(http://www.medicare.gov/coverage/skilled-nursing-facility-care.html . Care that can only be provided

by trained medical personnel and may require specific licensure or credentials is given in a SCF. As well,

care involving certain treatments to be provided only licensed professional practitioners may be

provided at SCF.

Public Health Programs

Public health settings are alternative settings, which can provide opportunities to collaborate with a

local Public Health Department and Worldwide Health Organization (WHO). This might include programs

focused on the science and art of preventing disease, prolonging life and promoting health through the

organized efforts and informed choices of society, organization, public and private communities and

individuals. WHO identifies core functions of public health programs by providing leadership on critical

health matters and engaging in partnerships where joint action is needed. The WHO sets norms and

standards for health by promoting and monitoring their implementation. Ethical and evidence-based

policy options are disseminated and worldwide health situations and health trends are assessed and

monitored by the WHO. A setting in this category is defined as “a setting where people actively use and

shape the environment, or create or solve problems relating to health.” 1Examples of settings include

schools, work sites, hospitals, villages, and municipalities. Actions to promote health in this setting can

be varied and often involve some level of organizational development, programs which reach the

general public, and those that gain access to community services.

Services to Provide

Educational, diagnostic, preventive and therapeutic services as defined in the rules

http://www.state.tn.us/sos/rules/0460/0460-03.20110120.pdf .

The review of the health history, dental history and chief complaint, and taking and evaluation

of vital signs

Removal of hard and soft deposits and stain from human teeth to the depth of the gingival

sulcus

Polishing natural and restored surfaces of teeth

Placing preventive materials on tooth surfaces

Taking or completing diagnostic images (radiographs) and procedures

Performing clinical examination of teeth and surrounding tissues for diagnosis by the dentist

Collection of data for diagnostic and therapeutic reasons and keeping of an adequate treatment

record

Ethical Considerations for Written Protocol

The dental team working under the written protocol shall set and maintain established protocols for

infection control by the Centers for Disease Control and Prevention. The dental hygienist(s) shall be

responsible for record keeping and compliance with Health Insurance Portability and Accountability Act

(HIPAA) regulations regarding patient privacy. Appropriate OSHA record keeping protocols will be used

and documented as required by OSHA regulations. In the case of any exposure incident(s), the dental

collaborative team will provide the appropriate documentation to the assigned OSHA officer of the

facility where the written protocol relationship takes place and to the assigned OSHA officer in the

practice of the supervising dentist. Proper documentation assigned to the HIPAA officer where the

written protocol agreement take place will be kept in a private location. Protocols for management of

medical emergencies in the written protocol setting will be established by the collaborative team. The

dental hygienist shall comply with the appropriate protocols for management of medical emergency

situations (as described in the self study text used for this online course).

Communication within the written protocol agreement

The dental hygienist(s) will maintain an appropriate level of contact, communication, and consultation

with the supervising dentist in the written protocol agreement. This can be completed by on site

meetings, via tele-dentistry devices or via telephone, facsimile, electronic mail or electronic imaging

software or devices. Communication and consultation will involve management decisions for relevant

clinical situations or health history indications.

Financial agreement

Payments will be made from funding resources to the supervising dentist. In order to file an electronic

claim to a third party payer, whether by private insurance or Medicaid, each member of the

collaborative team must obtain a National Provider Identifier (NPI). An NPI is a 10 digit number, assigned

for free by the federal government. This number serves as a permanent identifier of the healthcare

provider(s), and can be carried forward in the case of relocation or licensure in a different profession.

Dental hygienists in TN are not directly reimbursed by either Medicaid or by private insurers at the

present time. However, even if third party resources are not billed directly, dental practitioners can

apply for NPI because it may facilitate billing submitted by a health department or other entities for

services provided. For more information about the NPI and how to obtain one, contact the National Plan

and Provider Enumeration System (NPPES) directly by phone at (800)465-3203 or visit the NPPES

website at https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart

Liability Insurance

Liability insurance should be held by the employer in the written protocol agreement. This insurance

may be limited to protection of the employer/supervising dentist and patients served by the employer.

Individual employees in a written protocol agreement may have limited protection and limited access to

the legal defense services provided to the policy holder. All parties in a written protocol should have

liability insurance that provides coverage for potential lawsuits. Self-employed individuals need

individual protection and additional protection of the business. Professional liability insurance coverage

is generally restricted to matters relating to patient care and does not cocfer4 loss or damage to

equipment, or general negligence issues. For this reason, the professional guidelines included in this

course should be considered when guidelines for clinical practice in a written protocol are established.

The dental hygienist who is a member of the American Dental Hygienists’ Association can get

information from ADHA on professional liability and other types of insurance for self-employed dental

hygienists. Equipment replacement insurance can also be investigated at https://www.personal-

plans.com/adha/welcome.do

Ethics of professional care

Ethics is generally defined as the moral principles that govern a person’s or groups’ behavior. These values dictate that we engage in health promotion and disease prevention activities. When we look at the dental hygiene profession, our professional code of ethics guides us to a higher level of ethical consciousness, decision making, and practice. We are duty bound to practice our vocation in a manner that reflects our ethical and professional standard of care. According to the American Dental Hygienists’ Association, the objectives of the Dental Hygiene Code of Ethics are:

To increase our professional and ethical consciousness and sense of ethical responsibility. To lead us to recognize ethical issues and choices and to guide us in making more informed

ethical decisions. To establish a standard for professional judgment and conduct. To provide a statement of the ethical behavior the public can expect from us. We are obligated to practice our profession in a manner that supports our purpose, beliefs, and

values in accordance with the fundamental principles that support our ethics. We acknowledge the following responsibilities:

Our core values (listed below) teach us that people have the right to be treated with respect. They have the right to informed consent prior to treatment, and they have the right to full disclosure of all relevant information so that they can make informed choices about their care.

Confidentiality We respect the confidentiality of client information and relationships as a demonstration of the value we place on individual autonomy. We acknowledge our obligation to justify any violation of a confidence.

Societal Trust We value client trust and understand that public trust in our profession is based on our actions and behavior.

Non- malfeasance We accept our fundamental obligation to provide services in a manner that protects all clients and minimizes harm to them and others involved in their treatment.

Beneficence We have a primary role in promoting the well-being of individuals and the public by engaging in health promotion/disease prevention activities.

Justice and Fairness We value justice and support the fair and equitable distribution of healthcare resources. We believe all people should have access to high-quality, affordable oral healthcare.

Veracity We accept our obligation to be truthful and assume that others will do the same. We value self-knowledge and seek truth and honesty in all relationships.

Professional Negligence and Malpractice

Negligence is an example of an unintentional tort; a dental hygienist did not intend to harm the patient,

but his or her action or inaction inflicted harm. Negligence is the failure to perform a clinical action

(prophylactic or therapeutic) at the reasonable and acceptable standards of the profession with the

result of harm to the patient. A mistake without harm does not constitute negligence. In dental hygiene

practice, negligence may be an act of omission or commission; both are considered negligence.

Professional negligence is neglecting to perform a procedure or action that is part of a standard of care,

or adopting behavior that is doing or failing to do what a reasonable and prudent dental hygienist would

do under the same circumstances. It may occur at any time during the various stages of patient care,

including during assessment, treatment, and follow –up.

At times, a patient may contribute to the negligence or harm. This is contributory negligence. The

patient has not taken reasonable care to protect his or her safety and this has contributed to the injury

or harm. For example, a patient may not take prophylactic pre-medication as instructed before a

procedure. The dental hygienist who treats a patient without asking if the premedication was taken is

considered negligent. However, the patient has also contributed to negligence by not following

instructions. If harm results from not being pre-medicated, the dental hygienist is considered negligent,

but the patient is also held contributory to negligence.

Malpractice and Standard of Care

Professional negligence that causes harm is malpractice (bad practice). For malpractice to occur, it

must be established that an individual, patient was harmed because of a lack of standard of care.

Standard of care is the minimal level of care that is recognized by a professional group. Malpractice

results from ignorance, lack of skill, neglect in applying skills, professional misconduct, and practice

contrary to established rules. In other words, failing to keep informed does not protect one from being

guilty of malpractice.

Alternative Settings

In many cases, less supervision is needed in public health settings or institutions. For example, dental

hygienists in Tennessee can now provide services in nursing homes, skilled care facilities, non-profit

clinics, and public health programs without the physical presence of a dentist. However, a dentist must

have examined the patient and made the patient a patient of record prior to any dental hygiene

treatment.

See Course Introduction for instructions on taking the Self-Test.

References

1. Tennessee Dental Hygienists’ Association. Written Protocol. Available at http://tndha.org/wp-

content/uploads/2013/04/Written-Protocol-toolkit.pdf. Accessed August 28, 2014.

2. Code of Ethics. American Dental Hygienists’ Association. https://www.adha.org/resources-docs/7611_Bylaws_and_Code_of_Ethics.pdf. Accessed August 28, 2014.

3. Jurisprudence, and Practice Management in Dental Hygiene/Vickie J. Kimbrough – Walls, Charla

J. Lauter, -3rd ed., copyright 2012 by Pearson Education Inc., Upper Saddle River, New Jersey

07458

PUBLIC HEALTH SELF STUDY

SECTION FIVE Self Test

1. Allowable parties to engage in a written protocol agreement in Tennessee include all of the

following EXCEPT one. Which is the EXCEPTION?

a. A dentist and a hygienist

b. A dentist and up to three hygienists

c. Three dentists and a hygienist

d. There is no regulation against having more than three dentists or hygienists in an

agreement

2. Which of the following regulations must be included in the written protocol agreement?

a. OSHA regulations

b. HIPAA regulations

c. CDC Infection Control regulations

d. All of the above

3. All of the following settings can be involved in a written protocol agreement EXCEPT one. Which

is the EXCEPTION?

a. Nursing Home

b. Skilled Nursing Center

c. Mental Health facility

d. Nonprofit Clinics

4. The supervising dentist must notify the Board of Dentistry within ten (10) working days by

certified mail/return receipt requested or electronic mail when the written protocol is no longer

in force.

a. True

b. False

5. Who must process billings for payment for services provided in a written protocol?

a. Dentist

b. Hygienist

c. Office manager for written protocol setting

6. The causes of malpractice are professional misconduct, unreasonable lack of skill, lack of fidelity in performance of professional duties and practice contrary to established rules

a. True b. False

7. The failure to ask and document Premedication, failure to detect and document oral cancer,

failure to update health history, failure to detect, document and inform patient of perio condition and the injury of a patient are:

a. Laws pertaining to dental hygiene b. Most common lawsuits against dental hygienists c. elements in lawsuits regarding informed consent

8. Non-malfeasance is defined as

a. The dismissal of the patient without ample and proper notice

b. The term geared toward the patient’s self-determination”, the patient’s right to

make their own choice about their treatment and the freedom of choice and right to

privacy

c. The term that says the practitioner is to do no harm and provide services to protect

all patients from harm

d. The purpose of the Dental hygiene code of ethics

9. We contribute to the health of society; all people should have access to oral health care; Individuals are entitled to make health choices; We are qualified by licensure; We function interdependently and we are responsible for our actions. These concepts are known as:

a. Moral weakness b. Civil law c. Justice d. Basic beliefs

10. Ethics involves an expression of values whereas jurisprudence involves legal precepts.

a. True b. False