Wilkins’ Clinical Practice of the Dental Hygienist [13th Edition] 9781496396273

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TRIBUTE TO DR. ESTHER M. WILKINS

The first edition of Dr. Esther Wilkin’s Clinical Practice of the Dental Hygienist was published in 1959. Before that, the “book” was provided for Esther’s students at the University of Washington as a series of individually copied, topic-related handouts, organized as the book is today, using an easy-to-read outline format. Over the next 60 or so years, Esther wrote and supervised the revision through 12 editions (an average of one new edition every 5 years!). Anyone who worked with Esther on any of those editions understands the effort and energy she put into making the book as up–to-date and evidence-based as possible. Even in that very first edition, every chapter contained a list of references to support the information in that chapter. A look through any of those previous editions reveals how current Esther’s thinking was as she updated each edition. Anyone fortunate enough to be invited to visit Esther in her condo overlooking Boston Common will tell you that her home

office was bursting with textbooks and copies of thousands of journal articles, stacked on every available surface and poking out of overfilled file cabinets. Such was her commitment to understanding the current science related to dental hygiene practice. Those of us who worked with her over the years can tell you about her attention to detail and insistence that everything be perfect as we submitted chapter manuscripts for publication. The editorial and contributor teams who have revised this first new edition since Esther is no longer here to guide us are proud to say that we have done our best to carry forward the integrity, attention to detail, and dedication to the science and art of dental hygiene practice that was Esther’s vision for this book.

DEDICATION The 13th edition of Clinical Practice of the Dental Hygienist is dedicated to all past and present students who have studied from the preceding editions. Gratitude is expressed to their teachers in the many different dental hygiene programs around the world, for their leadership in, and devotion to, dental hygiene education. A very special recognition goes to the students of the first 10 classes in dental hygiene at the University of Washington in Seattle for whom the original “mimeographed” syllabus was created by Dr. Esther Wilkins. They are remembered with much appreciation because their need for text study material made this book possible in the first place. —Esther M. Wilkins Gratitude to my husband, who has supported me tirelessly on my academic journey, and to my grandmother, Fay Nelson, who instilled a love of learning. Special thanks to my professional mentors who recognized my potential even when I did not: Dr. John Chirgwin, Dr. Carole Palmer, and last, but never least, Dr. Esther Wilkins. Dr. Wilkins is the wind beneath our wings as educators and dental hygienists! Never forget all she has done for our profession! —Linda D. Boyd To my husband Scott and our children, Harper and Layney, who provide me with daily inspiration, love, and support in all that I do. To Dr. Esther Wilkins—it is an honor to play an integral role in moving your legacy for the profession of dental hygiene forward. A special thanks goes to all who have mentored me throughout my career, to my Caruth School of Dental Hygiene family that provide a constant source of encouragement, and to my students—past, present, and future—who motivate me to keep evolving as an educator. —Lisa F. Mallonee To Esther, of course. —Charlotte J. Wyche

Contents Preface Contributors Reviewers

SECTION I ORIENTATION TO CLINICAL DENTAL HYGIENE PRACTICE CHAPTER 1 The Professional Dental Hygienist History of the Dental Hygiene Profession Scope of Dental Hygiene Practice Objectives for Professional Practice Standards for Clinical Dental Hygiene Practice Dental Hygiene Process of Care Dental Hygiene Ethics The Code of Ethics Core Values

Ethical Applications Legal Factors in Practice Professionalism References

CHAPTER 2 Evidence-Based Dental Hygiene Practice Evidence-Based Practice A Systematic Approach Approaches to Research Ethics in Research Documentation References

CHAPTER 3 Effective Health Communication Types of Communication Health Communication Health Literacy Communication Across the Life Span Social and Economic Aspects of Health Communication Cultural Considerations Interprofessional Communication Communication with Caregivers Documentation References

CHAPTER 4 Dental Hygiene Care in Alternative Settings Alternative Practice Settings Residence-Bound Patients

Dental Hygiene Care The Critically Ill or Unconscious Patient The Terminally Ill Patient Documentation References

SECTION II PREPARATION FOR DENTAL HYGIENE PRACTICE CHAPTER 5 Infection Control: Transmissible Diseases Standard Precautions Microorganisms of the Oral Cavity The Infectious Process Pathogens Transmissible from the Oral Cavity Tuberculosis Viral Hepatitis Human Herpesvirus Diseases Human Papillomavirus HIV/AIDS Infection Methicillin-Resistant Staphylococcus aureus Documentation References

CHAPTER 6 Exposure Control: Barriers for Patient and Clinician Infection Control Personal Protection for the Dental Team Clinical Attire Use of Face Mask: Respiratory Protection

Use of Protective Eyewear Hand Care Hand-Hygiene Principles Methods of Hand Hygiene Gloves and Gloving Latex Hypersensitivity Documentation References

CHAPTER 7 Infection Control: Clinical Procedures Infection Control Treatment Room Features Instrument Processing Center Precleaning Procedures Instrument Packing and Management System Sterilization Moist Heat: Steam under Pressure Dry Heat Chemical Vapor Sterilizer Intermediate-Use Steam Sterilization Chemical Liquid Sterilization Care of Sterile Instruments Chemical Disinfectants Barriers and Surface Covers Preparation of the Treatment Room Patient Preparation Summary of Standard Procedures Disposal of Waste Supplemental Recommendations Occupational Postexposure Management

Documentation References

CHAPTER 8 Patient Reception and Ergonomic Practice Preparation for the Patient Patient Reception Position of the Patient Position of the Clinician Neutral Working Position The Treatment Area Ergonomic Practice Self-Care for the Dental Hygienist Documentation References

CHAPTER 9 Emergency Care Emergency Preparedness Prevention of Emergencies Patient Assessment Stress Minimization Emergency Materials and Preparation BLS Certification Oxygen Administration Specific Emergencies Documentation References

SECTION III

DOCUMENTATION CHAPTER 10 Documentation for Dental Hygiene Care The Patient Record The Health Insurance Portability and Accountability Act Documenting the Extra- and Intraoral Examination Tooth Numbering Systems Charting of Hard and Soft Tissues Periodontal Records Dental Records Care Plan Records Informed Consent Documentation of Patient Visits References

SECTION IV ASSESSMENT CHAPTER 11 Medical, Dental, and Psychosocial Histories Introduction History Preparation The Questionnaire The Interview Items Included in the History Application of Patient Histories Pretreatment Antibiotic Prophylaxis American Society of Anesthesiologists Determination

Review and Update of History Documentation References

CHAPTER 12 Vital Signs Introduction Body Temperature Pulse Respiration Blood Pressure Documentation References

CHAPTER 13 Extraoral and Intraoral Examination Rationale for the Extraoral and Intraoral Examination Components of Examination Anatomic Landmarks of the Oral Cavity Sequence of Examination Morphologic Categories Oral Cancer Clinical Recommendations for Evaluation of Oral Lesions Documentation References

CHAPTER 14 Family Violence Family Violence Child Abuse and Neglect Munchausen Syndrome by Proxy

Human Trafficking Elder Abuse and Neglect Intimate Partner Violence Reporting Abuse and/or Neglect Forensic Dentistry Documentation References

CHAPTER 15 Dental Radiographic Imaging Introduction How X-Rays are Produced Digital Radiography Characteristics of an Acceptable Radiographic Image Factors That Influence the Finished Radiograph Exposure to Radiation Risk of Injury from Radiation Procedures for Image Receptor Placement and Angulation of Central Ray Image Receptor Selection for Intraoral Surveys Periapical Survey: Paralleling Technique Bitewing Survey Periapical Survey: Bisecting-Angle Technique Occlusal Survey Panoramic Radiographic Images Infection Control Traditional Film Processing Handheld X-Ray Devices Analysis of Completed Radiographs Ownership Documentation

References

CHAPTER 16 Hard Tissue Examination of the Dentition The Dentitions Hard Tissue Examination Procedure Developmental Enamel Lesions Developmental Defects of Dentin Noncarious Dental Lesions Noncarious Cervical Lesions Fractures of the Teeth Dental Caries Enamel Caries Early Childhood Caries Root Caries Testing for Pulp Vitality Occlusion Occlusion of the Primary Teeth Dynamic or Functional Occlusion Trauma from Occlusion Study Models The Interocclusal Record Documentation References

CHAPTER 17 Dental Soft Deposits, Biofilm, Calculus, and Stains Dental Biofilm and Other Soft Deposits Acquired Pellicle Dental Biofilm Supragingival and Subgingival Dental Biofilm

Composition of Dental Biofilm Clinical Aspects of Dental Biofilm Significance of Dental Biofilm Materia Alba Food Debris Calculus Calculus Composition Calculus Formation Attachment of Calculus Significance of Dental Calculus Clinical Characteristics Prevention of Calculus Dental Stains and Discolorations Significance of Dental Stains Extrinsic Stains Endogenous Intrinsic Stains Exogenous Intrinsic Stains Documentation References

CHAPTER 18 The Periodontium The Normal Periodontium The Gingival Description The Gingiva of Young Children The Gingiva after Periodontal Surgery Documentation References

CHAPTER 19 Periodontal Disease Development

Periodontal-Systemic Disease Connection Risk Assessment Etiology of Periodontal Disease Risk Factors for Periodontal Diseases Pathogenesis of Periodontal Diseases Gingival and Periodontal Pockets Complications Resulting from Periodontal Disease Progression The Recognition of Gingival and Periodontal Infections Classification of Periodontal Health Classification of Gingivitis Classification of Periodontitis Acute Periodontal Lesions Documentation References

CHAPTER 20 Periodontal Examination Basic Instruments for Examination The Mouth Mirror Air–Water Syringe Explorers Basic Procedures for Use of Explorers Explorers: Supragingival Procedures Explorers: Subgingival Procedures Periodontal Probe Guide to Periodontal Probing Preliminary Assessment Prior to Periodontal Examination Parameters of Care for the Periodontal Examination Radiographic Changes in Periodontal Disease Other Radiographic Findings Documentation

References

CHAPTER 21 Indices and Scoring Methods Types of Scoring Methods Indices Oral Hygiene Status (Biofilm, Debris, and Calculus) Gingival and Periodontal Health Dental Caries Experience Dental Fluorosis Community-Based Oral Health Surveillance Documentation References

SECTION V DENTAL HYGIENE DIAGNOSIS AND CARE PLANNING CHAPTER 22 Dental Hygiene Diagnosis Introduction Assessment Findings The Periodontal Diagnosis and Risk Level Dental Caries Risk Level The Dental Hygiene Diagnosis The Dental Hygiene Prognosis Putting It All Together Documentation References

CHAPTER 23 The Dental Hygiene Care Plan Preparation of a Dental Hygiene Care Plan Components of a Written Care Plan Additional Considerations Sequencing and Prioritizing Patient Care Presenting the Dental Hygiene Care Plan Informed Consent Documentation References

SECTION VI IMPLEMENTATION: PREVENTION CHAPTER 24 Preventive Counseling and Behavior Change Steps in a Preventive Program Patient Counseling Patient Motivation and Behavior Change Motivational Interviewing MI Implementation Exploring Ambivalence Eliciting and Recognizing Change Talk Strengthening Commitment (The Plan) MI with Pediatric Patients and Caregivers Motivational Training and Coaching Documentation References

CHAPTER 25

Protocols for Prevention and Control of Dental Caries History of Dental Caries Management The Dental Caries Process Dental Caries Classifications Caries Risk Assessment Systems Implementation of CRA in the Process of Care Caries Risk Management Systems Planning Care for the Patient’s Caries Risk Level Continuing Care Documentation References

CHAPTER 26 Oral Infection Control: Toothbrushes and Toothbrushing Development of Toothbrushes Manual Toothbrushes Power Toothbrushes Toothbrush Selection for the Patient Methods for Manual Toothbrushing The Bass and Modified Bass Methods The Stillman and Modified Stillman Methods The Roll or Rolling Stroke Method Charters Method The Horizontal (or Scrub) Method The Fones (or Circular) Method Leonard’s (or Vertical) Method Method for Power Toothbrushing Supplemental Brushing Methods Guidelines for Toothbrushing Instructions Toothbrushing for Special Conditions Adverse Effects of Toothbrushing

Care of Toothbrushes Documentation References

CHAPTER 27 Oral Infection Control: Interdental Care The Interdental Area Planning Interdental Care Selective Interdental Biofilm Removal Interdental Brushes Dental Floss and Tape Aids for Flossing Power Flossers Single-Tuft Brush (End-Tuft Brush) Interdental Tip Toothpick in Holder Wooden Interdental Cleaner Oral Irrigation Documentation References

CHAPTER 28 Dentifrices and Mouthrinses Chemotherapeutics Dentifrices Preventive and Therapeutic Benefits of Dentifrices Cosmetic Effects of Dentifrices Basic Components of Dentifrices: Inactives Active Components of Dentifrices Selection of Dentifrices Mouthrinses

Purposes and Uses of Mouthrinses Preventive and Therapeutic Agents of Mouthrinses Commercial Mouthrinse Ingredients Procedure for Rinsing Emerging Alternative Practices United States Food and Drug Administration American Dental Association Seal of Acceptance Program Documentation References

CHAPTER 29 The Patient with Orthodontic Appliances Cemented Bands and Bonded Brackets Clinical Procedures for Bonding Dental Hygiene Care Clinical Procedures for Band Removal and Debonding Postdebonding Evaluation Orthodontic Retention Postdebonding Preventive Care Documentation References

CHAPTER 30 Care of Dental Prosthesis Missing Teeth The Edentulous Mouth Purposes for Wearing a Fixed or Removable Prosthesis Fixed Partial Denture Prostheses Removable Partial Denture Prostheses Complete Denture Prosthesis Complete Overdenture Prostheses

Obturator Denture Marking for Identification Professional Care Procedures for Fixed Prostheses Patient Self-Care Procedures for Fixed Prostheses Professional Care Procedures for Removable Partial Prosthesis Patient Self-Care Procedures for Removable Partial Prostheses Professional Care Procedures for Complete Dentures Patient Self-Care Procedures for the Complete Denture Denture-Induced Oral Mucosal Lesions (OMLs) Documentation References

CHAPTER 31 The Patient with Dental Implants Bone Physiology Osseointegration Implant Interfaces Types of Dental Implants Patient Selection Evaluation for Implant Placement Post-restorative Evaluation Peri-Implant Preventive Care Continuing Care Classification of Peri-Implant Disease Documentation References

CHAPTER 32 The Patient with Nicotine Use Disorders Health Hazards and Current Trends Components of Tobacco Products and Tobacco Smoke

Metabolism of Nicotine Alternative Tobacco Products Systemic Effects Environmental Tobacco Smoke Prenatal and Children Oral Manifestations of Tobacco and Nicotine Use Tobacco and Periodontal Infections Nicotine Addiction Treatment Pharmacotherapies Used for Treatment of Nicotine Addiction Nicotine-Free Therapy Dental Hygiene Care for the Patient Who Uses Tobacco Assessment Clinical Treatment Procedures Tobacco Cessation Program Motivational Interviewing The “5 A’s” The Team Approach Advocacy Documentation References

CHAPTER 33 Diet and Dietary Analysis Nutrient Standards for Diet Adequacy in Health Promotion Oral Health Relationships Counseling for Dental Caries Control The Dietary Assessment Preparation for Additional Counseling Counseling Procedures Evaluation of Progress

Documentation References

CHAPTER 34 Fluorides Fluoride Metabolism Fluoride and Tooth Development Tooth Surface Fluoride Demineralization–Remineralization Fluoridation Effects and Benefits of Fluoridation Partial Defluoridation School Fluoridation Discontinued Fluoridation Fluorides in Foods Dietary Fluoride Supplements Professional Topical Fluoride Applications Clinical Procedures: Professional Topical Fluoride Self-Applied Fluorides Tray Technique: Home Application Fluoride Mouthrinses Brush-On Gel Fluoride Dentifrices Combined Fluoride Program Fluoride Safety Documentation References

CHAPTER 35 Sealants Introduction

Sealant Materials Indications for Sealant Placement Penetration of Sealant Clinical Procedures Maintenance School-Based Dental Sealant Programs Documentation References

SECTION VII IMPLEMENTATION: TREATMENT CHAPTER 36 Anxiety and Pain Control Components of Pain Pain Control Mechanisms Nonopioid Analgesics Nitrous Oxide–Oxygen Sedation Characteristics of Nitrous Oxide Equipment for Nitrous Oxide–Oxygen Patient Selection Clinical Procedures for Nitrous Oxide–Oxygen Administration Potential Hazards of Occupational Exposure Advantages and Disadvantages of Nitrous Oxide/Oxygen Sedation Anesthesia Local Anesthesia Pharmacology of Local Anesthetics Indications for Local Anesthesia Patient Assessment Armamentarium for Local Anesthesia

Clinical Procedures for Local Anesthetic Administration Potential Adverse Reactions to Local Anesthesia Advantages and Disadvantages of Local Anesthesia Noninjectable Anesthesia Topical Anesthesia Application of Topical Anesthetic New Developments in Pain Control Documentation References

CHAPTER 37 Instruments and Principles for Instrumentation Overview of Periodontal Instruments Instrument Design Grasps and Fulcrum Instrumentation Basics Scalers Curets Periodontal Files Powered Instruments Sonic Scalers Magnetostrictive Ultrasonic Scalers Piezoelectric Ultrasonic Scalers Powered Instrumentation Technique Dexterity Development Cumulative Trauma Documentation References

CHAPTER 38 Instrument Care and Sharpening

Instrument Sharpening Basic Sharpening Principles Sharpening Curets and Scalers Moving Flat Stone: Stationary Instrument Stationary Flat Stone: Moving Instrument Sharpening the File Scaler Care of Sharpening Equipment Documentation References

CHAPTER 39 Nonsurgical Periodontal Therapy and Adjunctive Therapy Nonsurgical Periodontal Therapy Aims and Expected Outcomes Nonsurgical Periodontal Therapy Treatment Goals Components of Nonsurgical Periodontal Therapy Dental Hygiene Treatment Care Plan for Periodontal Debridement Appointment Planning Preparation for Periodontal Therapy Advanced Instrumentation Specialized Debridement Instruments Post-Op Instruction for Periodontal Debridement Appointments Re-Evaluation of Nonsurgical Periodontal Therapy Adjunctive Therapy Antimicrobial Treatment Indications for Use of Local Delivery Agents Types of Local Delivery Agents Documentation References

CHAPTER 40

Sutures and Dressings Sutures Needles Knots Suturing Procedures Procedure for Suture Removal Periodontal Dressings Types of Dressings Clinical Application Dressing Removal and Replacement Documentation References

CHAPTER 41 Dentinal Hypersensitivity Hypersensitivity Defined Etiology of Dentinal Hypersensitivity Natural Desensitization The Pain of Dentin Hypersensitivity Differential Diagnosis Hypersensitivity Management Oral Hygiene Care and Treatment Interventions Documentation References

CHAPTER 42 Extrinsic Stain Removal Introduction Purposes for Stain Removal Science of Polishing Effects of Cleaning and Polishing

Indications for Stain Removal Clinical Application of Stain Removal Cleaning and Polishing Agents Procedures For Stain Removal (Coronal Polishing) The Power-Driven Instruments Use of the Prophylaxis Angle Air-Powder Polishing Polishing Proximal Surfaces Historical Perspective: The Porte Polisher Documentation References

CHAPTER 43 Tooth Bleaching Overview of Tooth Bleaching Vital Tooth Bleaching Nonvital Tooth Bleaching Dental Hygiene Process of Care Documentation References

SECTION VIII EVALUATION CHAPTER 44 Principles of Evaluation Principles of Evaluation Evaluation Based on Goals and Outcomes Evaluation of Clinical (Treatment) Outcomes Evaluation of Health Behavior Outcomes

Comparison of Assessment Findings Standard of Care Self-Assessment and Reflective Practice Documentation References

CHAPTER 45 Continuing Care Goals of the Continuing Care Program Continuing Care Appointment Procedures Appointment Intervals (Frequency) Methods for Continuing Care Systems Documentation References

SECTION IX PATIENTS WITH SPECIAL NEEDS CHAPTER 46 The Pregnant Patient and Infant Introduction Fetal Development Oral Findings during Pregnancy Aspects of Patient Care Patient Instruction Special Problems Requiring Referral Transitioning from Pregnancy to Infancy Infant Oral Health Documentation References

CHAPTER 47 The Pediatric Patient Pediatric Dentistry The Child as a Patient Patient Management Considerations Components of the Dental Hygiene Visit Periodontal Risk Assessment Caries Risk Assessment Anticipatory Guidance Treatment Planning and Consent Documentation References

CHAPTER 48 The Older Adult Patient Aging Normal Physiologic Aging Pathology and Disease Chronic Conditions Associated with Aging Oral Changes Associated with Aging Dental Hygiene Care for the Older Adult Patient Documentation References

CHAPTER 49 The Patient with a Cleft Lip and/or Palate Classification of Clefts Etiology General Physical Characteristics Oral Characteristics Treatment

Dental Hygiene Care Documentation References

CHAPTER 50 The Patient with a Neurodevelopmental Disorder Neurodevelopmental Disorders Overview Intellectual Disorders Down Syndrome Fragile X Syndrome Autism Spectrum Disorder Dental Hygiene Care Documentation References

CHAPTER 51 The Patient with a Disability Disabilities Overview Barrier-Free Environment Risk Assessment Oral Disease Prevention and Control Patient Management Wheelchair Transfer Instruction for Caregivers Group In-Service Education The Dental Hygienist with a Disability Documentation References

CHAPTER 52 Neurologic Disorders and Stroke

Introduction Neurologic Disorders Associated with Physical Disability Other Conditions that Limit Physical Ability Spinal Cord Injury Cerebrovascular Accident (Stroke) Bell’s Palsy (Idiopathic Temporary Facial Paralysis) Amyotrophic Lateral Sclerosis Parkinson’s Disease Postpolio Syndrome Cerebral Palsy Muscular Dystrophies Myelomeningocele Arthritis Summary of Considerations for Dental Hygiene Care Documentation References

CHAPTER 53 The Patient with an Endocrine Condition Overview of the Endocrine System Endocrine Gland Disorders Pituitary Gland Thyroid Gland Parathyroid Glands Adrenal Glands Pancreas Puberty Women’s Health Documentation References

CHAPTER 54 The Patient with Diabetes Mellitus Diabetes Mellitus Oral Health Implications of Diabetes Mellitus Basics About Insulin Identification of Individuals at Risk for Development of Diabetes Classification of Diabetes Mellitus Diagnosis of Diabetes Standards of Medical Care for Diabetes Mellitus Pharmacologic Therapy Complications of Diabetes Dental Hygiene Care Plan Documentation References

CHAPTER 55 The Patient with Cancer Description Surgery Chemotherapy Radiation Therapy Hematopoietic Stem Cell Transplantation Mucositis Management Dental Hygiene Care Plan Documentation References

CHAPTER 56 The Oral and Maxillofacial Surgery Patient Patient Preparation Dental Hygiene Care

Patient with Intermaxillary Fixation Fractured Jaw Mandibular Fractures Midfacial Fractures Alveolar Process Fracture Dental Hygiene Care Dental Hygiene Care Before General Surgery Documentation References

CHAPTER 57 The Patient with a Seizure Disorder Introduction Seizures Clinical Manifestations Treatment Oral Findings Dental Hygiene Care Plan Emergency Care Documentation References

CHAPTER 58 The Patient with a Mental Health Disorder Overview of Mental Disorders Anxiety Disorders Depressive Disorders Bipolar Disorder Feeding and Eating Disorders Schizophrenia Mental Health Emergency

Documentation References

CHAPTER 59 The Patient with a Substance-Related Disorder Introduction Alcohol Consumption Metabolism of Alcohol Health Hazards of Alcohol Fetal Alcohol Spectrum Disorders (FASDs) Alcohol Withdrawal Syndrome Treatment for AUD Abuse of Prescription and Street Drugs Risk Management for Prescription Drugs of Abuse Most Common Drugs of Abuse Medical Effects of Drug Abuse Treatment Methods Dental Hygiene Process of Care Documentation References

CHAPTER 60 The Patient with a Respiratory Disease The Respiratory System Upper Respiratory Tract Diseases Lower Respiratory Tract Diseases Acute Bronchitis Pneumonia Tuberculosis Asthma Chronic Obstructive Pulmonary Disease

Cystic Fibrosis Sleep-Related Breathing Disorders Documentation References

CHAPTER 61 The Patient with Cardiovascular Disease Introduction Classification Infective Endocarditis Congenital Heart Diseases Rheumatic Fever and Heart Disease Mitral Valve Prolapse Hypertension Ischemic Heart Disease Angina Pectoris Myocardial Infarction Heart Failure Cardiac Arrhythmias Lifestyle Management for the Patient with Cardiovascular Disease Surgical Treatment Antithrombotic Therapy Documentation References

CHAPTER 62 The Patient with a Blood Disorder Normal Blood Plasma Red Blood Cells (Erythrocytes) White Blood Cells (Leukocytes)

Platelets (Thrombocytes) Anemia Iron Deficiency Anemia Megaloblastic Anemia Sickle Cell Disease Polycythemias Disorders of White Blood Cells Platelet Disorders Bleeding or Coagulation Disorders Dental Hygiene Care Plan Documentation References

CHAPTER 63 The Patient with an Autoimmune Disease Overview of Autoimmune Diseases Connective Tissue Autoimmune Diseases Oral Lichen Planus Rheumatoid Arthritis Scleroderma Gastrointestinal Tract Autoimmune Diseases Celiac Disease Crohn’s Disease Ulcerative Colitis Neurologic System Autoimmune Diseases Multiple Sclerosis Myasthenia Gravis Systemic Autoimmune Diseases Sjögren’s Syndrome Systemic Lupus Erythematosus Documentation

References Glossary Index

Preface Dental hygienists are oral healthcare specialists with professional goals centered on the prevention and/or control of oral disease and the maintenance of oral and general health. As primary healthcare professionals, dental hygienists can apply their knowledge and skills in a wide variety of areas related to clinical practice, education, research, public health, and advocacy for health promotion and disease prevention. Dental hygienists collaborate with dentists and members of other health professions to provide oral healthcare that links with total body healthcare. New emphasis on the effect of oral health on systemic health challenges dental hygienists to widen their scope of practice.

OBJECTIVES Objectives of the 13th edition include: To help prepare the beginning dental hygiene student to recognize the requirements of evidence-based dental hygiene practice. To develop skills and knowledge for entry into the profession. To help when studying for licensure board examinations; the condensed outline form aids in making review easier. To update professional hygienists already in practice to recognize changes in practice and the responsibility to apply evidence-based

scientific approaches to patient care.

THE TEXTBOOK PLAN Highlights Highlights of Wilkins’ Clinical Practice of the Dental Hygienist, 13th edition include the following: All chapters have been extensively updated with the best available evidence, edited, and reorganized to minimize redundancy. Key words are highlighted in each chapter and available in a comprehensive glossary at the end of the textbook. Chapter 4 Dental Hygiene Care in Alternative Settings has been updated from the 12th edition Homebound Patient and moved to Section I Orientation to Clinical Dental Hygiene Practice to better prepare students for patient care in alternative settings. Chapter 14 Family Violence was extensively updated based on consultation with a PANDA (Prevent Abuse and Neglect Through Dental Awareness) expert. Chapter 16 Hard Tissue Examination of the Dentition is a combination of the 12th edition Teeth, Occlusion, and Study Model chapters to be more concise and inclusive of information students require for the hard tissue examination. Chapter 17 Dental Soft Deposits, Biofilm, Calculus, and Stains is a combination of the 12th edition chapters on biofilm, calculus, and stains to offer information on deposits in one comprehensive chapter for students. Chapter 19 Periodontal Disease Development has been updated to include the new 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. It also includes content from the 12th edition chapter on acute periodontal conditions. Chapter 25 Protocols for Prevention and Control of Caries has been updated to include the International Caries Classification and Management System as part of caries classification systems. Chapter 30 Care of Dental Prosthesis is a combination of the 12th

edition chapters for the edentulous patient and care of the dental prosthesis. Chapter 31 The Patient with Dental Implants has been updated to include the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. Chapter 37 Instruments and Principles for Instrumentation and Chapter 39 Nonsurgical Periodontal Therapy and Adjunctive Therapy were reorganized to streamline content. Chapters in Section IX were reorganized by life cycle and then by conditions associated with body systems. Chapter 51 The Patient with a Disability now contains important content from the 12th edition chapter on the patient with sensory impairment, which has been eliminated. Chapter 63 The Patient with an Autoimmune Disease is new and addresses a rapidly emerging area in the medically complex patient. Some content from the 12th edition chapter on neurological disorders and stroke were relocated to Chapter 63. Additional color images have been added throughout.

Organization of the Textbook As in past editions, sections of Clinical Practice of the Dental Hygienist are sequenced to conform to the Dental Hygiene Process of Care. There are nine sections in the 13th edition, six of which are specifically identified by name with the recognized components of the Process of Care. They are assessment, dental hygiene diagnosis, care planning, implementation, evaluation, and documentation. The textbook opens with chapters devoted to an introduction to the profession of dental hygiene and chapters related to preparation for practice. They include infection control and ergonomic health for the clinical practitioner and patient. The final large section, Section IX, applies the process of care to patients with special needs. The nine major sections are: I. Orientation to Clinical Dental Hygiene Practice II. Preparation for Dental Hygiene Practice

III. IV. V. VI. VII. VIII. IX.

Documentation Assessment Dental Hygiene Diagnosis and Care Planning Implementation: Prevention Implementation: Treatment Evaluation Patients with Special Needs

Supplementary information is available online: I. American Dental Hygienists’ Association Code of Ethics for Dental Hygienists II. National Dental Hygienists’ Association Code of Ethics III. Canadian Dental Hygienists Association Dental Hygienists’ Code of Ethics IV. International Federation of Dental Hygienists’ Code of Ethics V. Guidelines for Infection Control in Dental Health Care Settings VI. Average Measurements of Human Teeth VII. Prefixes, Suffixes, and Combining Forms VIII. Charting Symbols and Standardized Abbreviations Useful for Documenting Dental Hygiene Care

FEATURES OF THIS EDITION All chapters have been updated and many have been extensively revised. Each chapter includes the following features: Detailed outline format for the text makes it easier to study and locate information quickly. In this era of information, the condensation of printed material into outline form can provide busy, overloaded students with a new efficiency for learning. Chapter Outlines at the opening of each chapter provide a preliminary review for readers before they start to concentrate on the meat of the chapter; the outline can help readers locate material within the chapter at any time. Learning Objectives at the beginning of each chapter guide the student in studying the chapter. Key Words are bolded throughout the chapter to indicate these

words are included in an alphabetized listing in the glossary. Everyday Ethics boxes (“EEs”) provide students with the opportunity to become aware of and discuss clinical problems from real-life practice. Principles of ethical dental hygiene practice need to be brought into the curriculum at an early stage if students are to develop into ethical practitioners. This feature has been continued from previous editions because of the expressed appreciation of teachers and students. Factors to Teach the Patient boxes help students to select topics from the chapter that need special emphasis while teaching patients self-care and responsibility for oral health for their own lifetime, as well as that of their family and community. Documentation brings the clinical care of a patient full cycle. Example documentation for a variety of patients, written using the SOAP notes format outlined in Chapter 10, can increase students’ awareness of the necessary components and significance of such notes in the permanent record of each patient.

STUDENT WORKBOOK A unique study guide, Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, prepared by Jane F. Halaris and Charlotte J. Wyche for previous editions, has been recognized as a major contribution to student learning. The 13th edition workbook, revised to highlight new chapters and updated information from the textbook, also contains revised crossword and word search puzzles. Everyday Ethics boxes in the workbook include individual learning, cooperative learning, or discovery activities designed to help the student reflect on or apply ethical theory–related “Questions for Consideration” found in the textbook. Activities and questions related to patient case scenarios, patient assessment summaries, and documentation of patient care provide an emphasis on case-based application of knowledge. Boxes in each chapter contain Medical Subject Heading (MeSH) terms to help students develop effective and efficient PubMed literature searches.

ADDITIONAL RESOURCES Digital Connections Wilkins’ Clinical Practice of the Dental Hygienist, 13th edition includes additional resources for both instructors and students that are available online.

Instructors Approved adopting instructors will be given access to the following additional resources: Test bank Slides in PowerPoint format Lesson plans Image bank of images and tables from the book Answers to the exercises found in Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, by Jane F. Halaris and Charlotte J. Wyche (book available for separate purchase)

Students The following additional student resources are available online: Audio pronunciation glossary for select clinical terms Appendices Videos Flashcards See the inside front cover of this text for more details.

INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist remediates to the book. This powerful tool offers students practice tests, detailed rationales, and powerful data dashboards.

ACKNOWLEDGMENTS A textbook of the size and scope of Wilkins’ Clinical Practice of the Dental Hygienist shows the work of many contributors. Comments and suggestions come from teachers, students, and practitioners from around the world, as the book has been translated into a variety of languages. Any suggestion, whether for one word or whole chapters, is welcomed and considered. It is hoped that this new edition will bring comments and requests as in the past.

Recognition for Our Contributors We start with expressed recognition and appreciation to our listed contributors for their new or revised chapters. Each has spent much time for selective revision and to survey the literature for new material and references.

Other Appreciation Appreciation is expressed to the following: Marcia Williams of Santa Fe, New Mexico. Many illustrations for this and previous editions have been the work of our talented artist. Her personal interest and patience in preparing new drawings, revising previous ones, and adding color to enhance the line drawings are acknowledged with sincere gratitude. Our Readers. And, finally, an expression of appreciation goes to our readers over the years: students, teachers, and practicing dental hygienists. Send us your comments and suggestions. As stated in the first edition, it is hoped that through greater understanding of each patient’s oral and general health needs, more complete and effective dental hygiene services can be rendered. —Linda Boyd, Lisa Mallonee, and Charlotte Wyche

Contributors Jessica August, RDH, MS Assistant Professor Department of Dental Hygiene Idaho State University Pocatello, Idaho Lisa B. Johnson, RDH, MSDH Adjunct Faculty, Master’s Public Health Program MCPHS University Clinical Research Coordinator Division of Oral Medicine & Dentistry Brigham and Women’s Hospital Boston, Massachusetts Sara L. Beres, RDH, BA, MS Instructor and Dental Hygiene Program Manager Department of Dental Hygiene Sheridan College Sheridan, Wyoming Linda D. Boyd, RDH, RD, EdD Professor and Associate Dean

Forsyth School of Dental Hygiene MCPHS University Boston, Massachusetts Lisa M. Byrne, RDH, BS, MHSc Instructor Forsyth School of Dental Hygiene MCPHS University Boston, Massachusetts Jennifer Cullen, RDH, MPH Director, Dental Hygiene Degree Completion Program Department of Periodontics and Oral Medicine University of Michigan School of Dentistry Ann Arbor, Michigan Ernestine R. Daniels, RDH, BS Adjunct Instructor, Dental Programs Department of Dental Hygiene Florida State College at Jacksonville Jacksonville, Florida Heather Doucette, DipDH, BSc, Med Assistant Professor School of Dental Hygiene Dalhousie University Halifax, Nova Scotia Christine A. Fambely, DH, BA, MEd Instructor Dental Hygiene Department John Abbott College Sainte-Anne-de-Bellevue, Quebec, Canada Lori J. Giblin-Scanlon, RDH, MS, DHSc Associate Professor and Associate Dean, Clinical Programs Forsyth School of Dental Hygiene

MCPHS University Boston, Massachusetts Sharon M. Grisanti, RDH, BA, MCOH Assistant Professor Dental Hygiene Program St. Petersburg College St. Petersburg, Florida Janet M. Gruber, RDH, MS, MPA Professor Department of Dental Hygiene Farmingdale State College of New York Farmingdale, New York S. Kim Haslam, DipDH, BA, MEd Assistant Professor School of Dental Hygiene Dalhousie University Halifax, Nova Scotia, Canada Valerie G. Herring RDH, BsM, MEd Educational Coordinator/Didactic & Clinical Educator Vancouver, British Columbia, Canada Heather Hessheimer, RDH, MSDH Assistant Professor Department Dental Hygiene University of Nebraska Medical Center-College of Dentistry Lincoln, Nebraska Michelle Hurlbutt, RDH, MSDH, DHSc Associate Professor and Dean Dental Hygiene PROGRAM West Coast University Anaheim, California

Susan J. Jenkins, RDH, PhD Associate Professor Forsyth School of Dental Hygiene MCPHS University Boston, Massachusetts Evie F. Jesin, RDH, BSc Professor School of Dental Health George Brown College Toronto, Ontario, Canada Faizan Kabani, BSDH, MHA, MBA, PhD Assistant Professor Caruth School of Dental Hygiene Texas A&M College of Dentistry Dallas, Texas Robin L. Kerkstra, RDH, MSDH Assistant Professor Dental Hygiene Program University of New Haven New Haven, Connecticut Lisa M. LaSpina, RDH, MS, DHSc Associate Professor Forsyth School of Dental Hygiene MCPHS University Boston, Massachusetts Lory A. Libby, RDH, MSDH Assistant Professor Forsyth School of Dental Hygiene MCPHS University Boston, Massachusetts Christine R. Macarelli, RDH, MS

Assistant Professor Dental Hygiene Program New York City College of Technology Brooklyn, New York Wendy Male, MBA, BDSc, RDH Clinical Assistant Professor Dental Hygiene Program University of Alberta Edmonton, Alberta Lisa F. Mallonee, RDH, RD, LD, MPH Professor and Graduate Program Director Caruth School of Dental Hygiene Texas A&M College of Dentistry Dallas, Texas Deborah S. Manne, RDH, RN, MSN, OCN Adjunct Instructor Department of Otolaryngology—Head and Neck Surgery St. Louis University School of Medicine St. Louis, Missouri Catherine A. McConnell, RDH, BDSc, MEd Clinic Coordinator Dental Hygiene Department John Abbott College Sainte-Anne-de-Bellevue, Quebec, Canada Jill C. Moore, RDH, BSDH, MHA, EdD Adjunct Faculty Dental Hygiene Program University of New Haven New Haven, Connecticut Lisa J. Moravec, RDH, MSDH Assistant Professor, West Division Site Coordinator

Department Dental Hygiene University of Nebraska Medical Center-College of Dentistry Gering, Nebraska Janice L. Murray, DipDH, BDSc(DH), MSDH, RDH Former Program Leader Charles Sturt University School of Dentistry & Health Sciences Wagga Wagga, Australia Debra November-Rider, RDH, MSDH Adjunct Assistant Professor Forsyth School of Dental Hygiene MCPHS University Boston, Massachusetts Uhlee (Yuri) Oh, RDH, BS, MSDH Assistant Professor Forsyth School of Dental Hygiene MCPHS University Boston, Massachusetts Kristeen Perry, RDH, MSDH Assistant Professor Forsyth School of Dental Hygiene MCPHS University Boston, Massachusetts Karen M. Portillo, RDH, MSDH Adjunct Faculty Dental Hygiene Program Columbia Basin College Pasco, Washington Betty Ann Pryzdial, BSc, RDH, PID Instructor Vancouver College of Dental Hygiene

Vancouver, British Columbia, Canada Lori Rainchuso, RDH, MS, DHSc Associate Professor, Doctor of Health Sciences Program School of Healthcare Business MCPHS University Worcester, Massachusetts Catherine G. Ranson, RDH BHA, MET School of Dental Health George Brown College Toronto, Ontario Erin E. Relich, RDH, BSDH, MSA Associate Professor Division of Dental Hygiene University of Detroit Mercy School of Dentistry Detroit, Michigan Dianne Smallidge, RDH, BS, MDH, EdD Associate Professor and Interim Dean Forsyth School of Dental Hygiene MCPHS University Boston, Massachusetts Irina Smilyanski, RDH, MS, MSDH Assistant Professor Forsyth School of Dental Hygiene MCPH University Worcester, Massachusetts Amy N. Smith, RDH, MS, MPH Assistant Professor Department of Dental Hygiene Northern Arizona University Flagstaff, Arizona

Katherine Soal, RDH, MSDH Assistant Professor Department of Dental Hygiene Quinsigamond Community College Worcester, Massachusetts Lorie Speer, RDH, MSDH Assistant Professor Department of Dental Hygiene Eastern Washington State University Spokane, Washington Tammy K. Swecker, BSDH, MEd Associate Professor Division of Dental Hygiene Virginia Commonwealth University Richmond, Virginia Salima Thawer, MPH, BSc, RDH Assistant Clinical Professor, Dental Hygiene School of Dentistry University of Alberta Edmonton, Alberta Carol Tran, PhD, BOH Oral Health Therapist, Private Practice Queensland, Australia School of Dentistry, University of Queensland Brisbane, Australia Marsha A. Voelker, CDA, RDH, MS Associate Professor, Junior Clinic Coordinator Division of Dental Hygiene University of Missouri—Kansas City School of Dentistry Kansas City, Missouri Shannon K. Waldron, RDH, BSc(DH), MSc

Part-time Faculty Vancouver College of Dental Hygiene Vancouver, British Columbia Dianna S. Weikel, RDH, MS Clinical Associate Professor Department of Oncology and Diagnostic Sciences University of Maryland School of Dentistry Baltimore, Maryland Lisa Welch, RDH, BS, MSDH Associate Professor Department of Dental Hygiene Dixie State College St. George, Utah Esther M. Wilkins, BS, RDH, DMD Charlotte J. Wyche, BSDH, MS Retired Department of Periodontics and Oral Medicine University of Michigan School of Dentistry Ann Arbor, Michigan Katherine A. Yee, RDH, BSDH, MPH Carolynn A. Zeitz, RDH, BS, RDA, MA Clinical Associate Professor Pediatric Dentistry University of Detroit Mercy School of Dentistry Detroit, Michigan Denise Zwicker, BDH, MEd Faculty of Dentistry School of Dental Hygiene Dalhousie University Halifax, Nova Scotia, Canada

Reviewers Meg D. Atwood, RDH, MPS Professor Department of Dental Hygiene Orange County Community College Middletown, New York Judy Danielson, BSDH, MDH Clinical Professor Division of Periodontology University of Minnesota School of Dentistry Minneapolis, Minnesota Barbara R. Ellis, RDH, EdD Dental Studies Monroe Community College Rochester, New York Terry Larson, MA, RDH Dental Hygiene Sciences Sinclair Community College Dayton, Ohio

Leah MacPherson RDH, BS, MHP Professor Department of Dental Hygiene Middlesex Community College Bedford, Massachusetts Lynn Douglas Mouden, DDS, MPH Vice President, Quality and Performance Ave¯sis Incorporated | A Guardian Company Key Biscayne, Florida Lynn Noonan, CDA, RDH, MBA Adjunct Faculty Allied Dental Education New Hampshire Technical Institute Concord, New Hampshire Margaret Six, RDH, MSDH Professor Sarah Whitaker Glass School of Dental Hygiene West Liberty University West Liberty, West Virginia Becky Smith, CRDH, EdD Professor Dental Hygiene Program Miami Dade College Miami, Florida Maureen Strauss, CDA, RDH, MS Professor Dental Hygiene Middlesex Community College Lowell, Massachusetts Sherie L. Tynes, CDA, RDH, PHDHP, BS Assistant Professor-Dental Hygiene

Dental Hygiene CE Coordinator Harrisburg Area Community College Harrisburg, Pennsylvania

SECTION

I Orientation to Clinical Dental Hygiene Practice INTRODUCTION FOR SECTION I Professional dental hygiene practice is not defined solely by the clinical duties traditionally associated with private practice dental care settings. The professional roles, responsibilities, and ethical standards of the dental hygienist encompass both traditional clinical practice and alternative dental hygiene practice settings. The dental hygienist is: An educated and licensed primary healthcare provider who fills numerous roles to contribute to better oral health. Concerned with the general health and well-being of both individual patients and population groups. Skilled in accessing, understanding, and analyzing the validity of current health information.

THE PROFESSIONAL DENTAL HYGIENIST The professional dental hygienist is dedicated to: A dental hygiene process of care that meets standards for clinical dental hygiene practice. Ethical standards and core values outlined in professional Codes of Ethics to dental hygiene practice in every setting. Evidence-based, best-practice dental hygiene interventions. Communication approaches to build rapport with individuals and groups of all ages and across cultures. Patient education strategies to motivate positive health behavior changes. Healthcare interventions, supported by current research, which take into consideration the unique needs and requirements of each patient.

STANDARD OF CARE AND THE DENTAL HYGIENE PROCESS OF CARE The American Dental Hygienists’ Association Standards for Clinical Dental Hygiene Practice1 outlines criteria for competency in dental hygiene care, as illustrated by the components of the Dental Hygiene Process of Care. The Dental Hygiene Process of Care is the basis for providing preventive, educational, and therapeutic dental hygiene services that meet accepted standards of patient care. The process, illustrated in Figure I-1, as well as similar figures repeated on each section heading page, explains the series of interrelated steps the dental hygienist follows to provide clinical patient care.

FIGURE I-1 • The Dental Hygiene Process of Care.

Description The overall process is explained in Chapter 1. Each step in the process is described more completely throughout the sections of the textbook.

ETHICAL APPLICATIONS Basic ethical concepts are described in the introduction to each section of the textbook. Reference charts are included to summarize ethical information.

In each chapter, ethical decision making is illustrated in an Everyday Ethics scenario with questions that can be used to guide class discussions or individual reflection.

Reference 1. American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene Practice. Chicago, IL: American Dental Hygienists’ Association; 2016. https://www.adha.org/resources-docs/2016-Revised-Standards-for-ClinicalDental-Hygiene-Practice.pdf. Accessed March 3, 2019.

1 The Professional Dental Hygienist Linda D. Boyd, RDH, RD, EdD, Lisa F. Mallonee, RDH, RD, LD, MPH, Charlotte J. Wyche, RDH, MS, and Esther M. Wilkins, BS, RDH, DMD

CHAPTER OUTLINE HISTORY OF THE DENTAL HYGIENE PROFESSION SCOPE OF DENTAL HYGIENE PRACTICE I. II. III. IV. V. VI. VII. VIII. IX.

Roles of the Dental Hygienist Supervision and Scope of Practice Types of Clinical Services Patient Education Dental Hygiene Specialties Alternative Practice Settings Advanced Practice Dental Hygiene Interprofessional Collaborative Patient Care Advocacy for Oral Health

OBJECTIVES FOR PROFESSIONAL PRACTICE I. II. III.

Overall Goals Personal Goals Clinical Practice Goals

STANDARDS FOR CLINICAL DENTAL HYGIENE PRACTICE DENTAL HYGIENE PROCESS OF CARE I. II. III. IV. V. VI. VII.

Purposes of the Dental Hygiene Process of Care Assessment Dental Hygiene Diagnosis The Dental Hygiene Care Plan Implementation Evaluation Documentation

DENTAL HYGIENE ETHICS THE CODE OF ETHICS I. II.

Purposes of the Code of Ethics Dental Hygiene Codes

CORE VALUES I. II. III. IV.

Core Values in Professional Practice Personal Values The Patient First Lifelong Learning: An Ethical Duty

ETHICAL APPLICATIONS I. II. III. IV. V.

Ethical Issue Ethical Dilemma Models for Resolution of an Issue or a Dilemma Summary: The Final Decision Applications: Everyday Ethics

LEGAL FACTORS IN PRACTICE PROFESSIONALISM EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES

After studying this chapter, the student will be able to: 1. Identify and define key terms and concepts related to the professional dental hygienist. 2. Describe the scope of dental hygiene practice. 3. Identify and describe the components of the dental hygiene process of care. 4. Identify and apply components of the dental hygiene code of ethics. 5. Explain legal, ethical, and personal factors affecting dental hygiene practice. 6. Apply concepts in ethical decision making. The American Dental Hygienists’ Association (ADHA) defines the professional dental hygienist as a primary care oral health professional who1: Has graduated from an accredited dental hygiene program in an institution of higher education. Is licensed in dental hygiene to provide education, assessment, research, administrative, diagnostic, preventive, and therapeutic services. Supports overall health through the promotion of optimal oral health.

HISTORY OF THE DENTAL HYGIENE PROFESSION In the early part of the 20th century, Dr. Alfred C. Fones, a dentist in Bridgeport, Connecticut, realized that most children already had dental decay by the time they reached his dental chair.2 He trained his assistant, Irene Newman, to demonstrate the value of education and prevention to reduce dental disease.2 The name “dental hygienist” evolved because Fones felt that this term would create an association with the prevention, rather than the treatment of oral disease.2 Box 1-1 provides a timeline of major events in the development of the profession of dental hygiene.

BOX 1-1 The Development of the Profession of Dental Hygiene: A Timeline 1910– 1919

• Irene Newman, Dr. Fones’ assistant, became: • Licensed as the first dental hygienist. • The first president of an organized dental hygiene society in Connecticut. • Graduates from the first dental hygiene school, created by Dr. Fones, began working in public schools. • A dental hygienist was employed outside of a public school setting, in New Haven Hospital.

1920– 1929

• Licensed dental hygienists began to practice in numerous states, including Hawaii. • The American Dental Hygienists’ Association (ADHA):

Was incorporated in Detroit, Michigan, in • 1927. • Began publication of the Journal of the ADHA. 1930– 1939

• Dental hygienists continued working in schools, began making home visits, and most found positions in private dental practices. • Transportation was provided to Forsyth Dental Infirmary from Boston schools and children visiting the clinic received oral prophylaxis and oral health instruction from dental hygiene students. • ADHA and American Dental Association recommended minimum high school graduation as one requirement for dental hygiene licensure. • University of Michigan offered the first baccalaureate degree in dental hygiene.

1940– 1949

• ADHA recommended: • Changing a 1-year program to a 2-year course of study for dental hygiene licensure. • The term “registered dental hygienist” as the official credential for the profession. • Minimum standards for dental hygiene programs adopted. • Dr. Frank Lamons wrote the first dental hygienist oath, to be used in graduation exercises. • Grand Rapids, Michigan, became the first city to add fluoride to its drinking water.

1950– 1959

• All states granted licensure for dental hygienists. • Minimum education standards for dental

hygiene education set and the accreditation process for dental hygiene programs began. • Sigma Phi Alpha, the dental hygiene honor society, was founded. • ADHA membership restrictions based on race, creed, or color removed. • The first edition of the Clinical Practice of the Dental Hygienist textbook by Esther M. Wilkins, BS, RDH, DMD was published in 1959. 1960– 1969

• The first National Dental Hygiene Board Examination implemented. • The first Regional Board Examination (North East) given. • The first dental hygiene master’s degree program began at Columbia University in New York. • ADHA bylaws amended to allow for male dental hygienist members.

1970– 1979

• The first International Symposium on Dental Hygiene, organized and funded by the ADHA, held in Italy. • The Forsyth Experiment, a groundbreaking investigation, proved conclusively that appropriately trained dental hygienists are safely and cost-effectively able to provide a defined set of restorative services. • Some state practice acts expand to include administration of local anesthesia by dental hygienists. • Continuing education guidelines drafted. • Dental hygienists began to serve on some state boards of dental examiners.

1980–

• Washington was the first state with

1989

unsupervised dental hygiene practice in hospitals, nursing homes, and other specified settings. • Colorado allowed unsupervised practice for dental hygienists in all settings. • ADHA advocated for baccalaureate as the minimum degree for entry into the dental hygiene profession. • On the basis of research about the transmission of blood-borne infectious diseases, dental hygiene clinicians began wearing gloves during all procedures.

1990– 1999

• Occupational Safety and Health Administration’s rules on occupational exposure to blood-borne pathogens implemented; use of gloves and face masks during dental hygiene procedures became standard practice. • The Dental Hygiene Process: Diagnosis and Care Planning textbook published, establishing a standard for clinical dental hygiene practice. • The National Center for Dental Hygiene Research established. • New Mexico became the first state to allow: • Self-regulation of the profession by a dental hygiene committee. • Dental hygiene practice under a collaborative agreement with a dentist rather than supervision. • California created the Registered Dental Hygienist in Alternative Practice, allowing dental hygienists to provide unsupervised oral care to special populations in alternative settings.

2000– 2010

• The U.S. Department of Health and Human Services published Oral Health in America: A Report of the Surgeon General, which highlights the relevance of oral health to general health. • U.S. Centers for Disease Control and Prevention published Guidelines for Infection Control in Dental Health Setting. • Development of the mid-level oral health provider explored. • The ADHA adopted policy to develop the Advanced Dental Hygiene Practitioner (ADHP). • Dental Health Aide Therapists began providing dental care on tribal land in Alaska. • Minnesota passed the first law in the United States, allowing dental hygienists to be further licensed as dental therapists using ADHP competencies. • Master-level dental hygiene programs increased in number. • Many states implemented “direct access” policies that allow dental hygienists in at least some settings to initiate dental hygiene care: • Based on their assessment of the patient’s needs. • Without the specific authorization of a dentist.

2011– 2020 and Beyond— Focus on the Future

• In 2013, ADHA celebrated 100 years of dental hygiene at the 90th ADHA Annual Session meeting in Boston. • Dental hygiene degree completion programs and online education opportunities expand.

• Opportunities for alternative setting and autonomy in dental hygiene practice expand. • The dental hygiene profession affirms and pursues its commitment to: • Optimal oral health as an essential component of general health. • Access to safe, effective, oral health services for all people. • Collaborative, interprofessional partnerships and coalitions for oral health. Source: American Dental Hygienists’ Association. 100: Celebrating a Century of Professional Prides. Chicago, IL: ADHA; 2013:48.

Figure 1-1 illustrates how the appearance of the clinical dental hygienist has changed as the profession has changed and grown.

FIGURE 1-1 • There is More Difference Than Just a Uniform, but Over Time the Dental Hygienist’s Commitment to Safe and Effective Patient Care Remains. A: The dental hygienist providing patient care in the 1930s dressed in a starched white uniform and cap (as nurses also did) to indicate their commitment

to cleanliness and good care. B: The dental hygienist of today protects self and patient from cross-infection by donning personal protective equipment and surface barriers during patient care.

SCOPE OF DENTAL HYGIENE PRACTICE In the first textbook for dental hygienists, Dr. Alfred C. Fones, the “father of dental hygiene,” emphasized education as the most important role in the practice of dental hygiene. He wrote: “It is primarily to this important work of public education that the dental hygienist is called. She must regard herself as the channel through which dentistry’s knowledge of mouth hygiene is disseminated. The greatest service she can perform is the persistent education of the public in mouth hygiene and the allied branches of general hygiene.”3 While the role of education is still primary, dental hygiene has changed and the scope of practice has developed and broadened from Dr. Fones’ original concept.

I.

Roles of the Dental Hygienist Various roles of licensed dental hygienists include the following4: Education. Assessment. Diagnosis. Prevention. Nonsurgical therapy. Research. Administration. Dental hygienists support oral health through their work in many settings including4: General and specialty dental practices. Public health programs. Research centers. Educational institutions. Hospital and residential care facilities. Federal programs, including the armed services. Dental corporate industries.

Within the wide span of dental hygiene practice areas, dental hygienists may serve in a variety of capacities. Areas of responsibility in this variety of roles are defined in Table 11. TABLE 1-1 • Professional Roles of the Dental Hygienist ROLE

DESCRIPTION

Clinician

Provide direct patient care in collaboration with other health professionals

Private dental practices and community-based clinics Hospitals and long-term care facilities Schools

Corporate

Employment in a company that supports oral health through promotion of oral health products and services

Product sales and research Corporate educator or administrator

Public health

Enhance access to care in community health programs funded by government or nonprofit organizations

Clinician in: Community clinics Government health service School sealant programs Oral health program administrator

Researcher

Conduct studies to test new procedures, products, or theories for accuracy and effectiveness

Universities Corporations Government agencies

Educator

Use educational theory and methodology to educate competent oral health professionals or provide continuing education for licensed providers

Dental hygiene program clinical or classroom instruction Corporate educator

Administrator Apply organizational skills,

EXAMPLE EMPLOYMENT SETTINGS AND POSITIONS

Program director in

Entrepreneur

communicate objectives, identify and manage resources, evaluate and modify health or education programs

clinical, educational, or corporate settings

Initiate or finance new oral health– related enterprises

Practice management or product development Consulting Independent clinical practice Professional speaker or writer

American Dental Hygienists’ Association. Career Center: Career Paths. http://www.adha.org/professional-roles. Accessed February 16, 2019.

II.

Supervision and Scope of Practice The professional dental hygienist is responsible to provide only those services allowed within the scope of practice outlined within each state dental hygiene practice act.5 The type of supervision by a dentist required for delivery of dental hygiene services is also determined by individual practice acts in each state. Types of supervision commonly used for dental hygiene practice are defined in Box 1-2.6–8

BOX 1-2 Types of Supervision in Dental Hygiene Practice Direct supervision: the dentist needs to be present. Personal supervision: the dentist needs to authorize, be present, and check work before dismissal of patient. General supervision: the dentist has authorized the procedure for a patient of record but need not be present when the authorized procedure is carried out by a licensed dental hygienist. The procedure is carried out in accordance with the dentist’s diagnosis and treatment plan. Direct access supervision: the dental hygienist can provide services as determined appropriate during assessment without specific authorization.

This type of supervision is usually limited to preventive services provided in specified public health settings. Collaborative practice: the dental hygienist may practice without supervision with a collaborative agreement between a licensed dentist and a dental hygienist. Indirect supervision: the dentist must authorize procedure and be in the office while the procedures are performed. Remote supervision: the supervising dentist is not on-site. Communication between collaborating oral health practitioners is provided through use of current technologies. Sometimes referred to as teledentistry-assisted, affiliated dental hygiene practice. Independent practice: the dental hygienist can provide services within the scope of dental hygiene practice in any setting and without authorization or supervision by a dentist. Source: American Dental Hygienists’ Association. Dental hygiene practice acts overview: permitted functions and supervision levels by state. Revised January 2019. http://www.adha.org/resourcesdocs/7511_Permitted_Services_Supervision_Levels_by_State.pdf. Accessed February 15, 2019. Catlett A. A comparison of dental hygienists’ salaries to state dental supervision levels. J Dent Hyg. 2014;88(6):380-385. Summerfelt FF. Teledentistry-assisted, affiliated practice for dental hygienists: an innovative oral health workforce model. J Dent Educ. 2011;75(6):733-742.

Many states have enacted collaborative practice legislative initiatives and adopted practice rules that allow dental hygienists to provide care autonomously for underserved populations in specifically designated public health settings.9

III. Types of Clinical Services The clinical responsibilities of the dental hygienist are divided into preventive, educational, and therapeutic services. Clinical and educational activities are inseparable and overlap as patient care is planned and accomplished. Preventive services are the methods employed by the clinician and/or patient to promote and maintain oral health. Prevention is an essential component of dental hygiene practice.

The three categories of preventive services are defined in Box 13.

BOX 1-3 Three Categories of Preventive Services Primary prevention: measures carried out before disease occurs to prevent disease or injury. Examples: Sealants placed in deep grooves and pits to prevent caries; oral hygiene education; fluoridation of community water supplies; nutrition education on sugar-sweetened beverage consumption to reduce caries risk and obesity in children. Secondary prevention: treatment of early disease to prevent further progression of potentially irreversible conditions that, if not arrested, can lead eventually to extensive rehabilitative treatment or even loss of teeth. Examples: Removal of all calculus and dental biofilm while debriding a root surface in a relatively shallow periodontal pocket to prevent continued attachment loss and the formation of a deep pocket; remineralization therapy; sealants on noncavitated caries. Tertiary prevention: methods to replace lost tissues and to rehabilitate the oral cavity to a level where function is as near normal as possible after secondary prevention has not been successful. Examples: Replacement of a missing tooth using a fixed partial denture or implant and therefore restoring function; restorations; crowns; bone and tissue grafts.

Educational services are strategies developed for an individual or a group to elicit behaviors directed toward health. Educational aspects of dental hygiene service permeate the entire patient care system. Educate patients and the public about the growing body of evidence related to the association between oral and systemic disease to highlight the need to manage oral health for overall wellness. Create a partnership with the patient that is essential for success of both preventive and therapeutic services. Therapeutic services are clinical treatments designed to arrest or

control disease and maintain oral tissues in health. Dental hygiene treatment services are an integral part of the patient’s overall treatment plan. Periodontal debridement, along with the steps in posttreatment care, is a part of the therapeutic phase in the treatment of periodontal infections.

IV. Patient Education Clinical services, both dental and dental hygiene, have limited longrange probability of success if the patient does not understand the need to take responsibility in daily oral self-care and regular appointments for professional care. Educational and clinical services, therefore, are mutually dependent and inseparable in the total dental hygiene care of the patient. Scientific information about the prevention of oral diseases has been advancing steadily. The public has become increasingly aware of the need for dental hygiene care and the value of oral health instruction provided by the dental hygienist.

V.

Dental Hygiene Specialties

Entry-level dental hygiene programs prepare students for basic clinical dental hygiene practice.10 Continuing education can help build skills in advanced periodontal instrumentation. Private practice orthodontics, pediatric dentistry, and periodontics clinics particularly value dental hygienists as partners in prevention. Some educational institutions offer dental hygiene bachelor’s degree, bachelor’s degree completion programs, and master’s degree programs. Bachelor and advanced degrees enhance the ability of dental hygienists to pursue opportunities outside of clinical practice.10 Dental hygienists earn masters or doctoral degrees in a variety of

areas such as: Dental hygiene education. Health behavior and education. Public health and health policy. Nutrition and dietetics. Business and administration. Law. A dental hygienist interested in specialty areas of practice can take advantage of many learning opportunities to enhance knowledge and skills. Many continuing education opportunities exist for learning in all areas of dental hygiene practice. In other special areas, short-term courses have been developed, such as instruction in the care of patients with disabilities. In-service training may be available in long-term care institutions, hospitals, and skilled nursing facilities. Other dental hygienists have learned to practice in a specialty through private study, special conferences, and personal experience.

VI. Alternative Practice Settings In 2018, 42 states allowed dental hygienists to provide direct access care (Figure 1-2) in a variety of community settings including, but not limited to11:

FIGURE 1-2 • American Dental Hygienists’ Association (ADHA) Direct Access. Maps of the United States to show the changes in the number and location of states with direct access since 2008.

Schools. Public health settings. Headstart settings. WIC (women, infants, and children) clinics. Nursing home facilities. Free clinics. Community centers. Direct access means the dental hygienist can plan and initiate treatment based on patient assessment without specific authorization of the dentist.11 Each state practice act varies as to the scope of practice and level of supervision by a dentist.

Dental hygiene care in alternative practice settings is further described in Chapter 4.

VII. Advanced Practice Dental Hygiene The current dental care model leaves many low-income individuals, at-risk populations, and those living in rural areas and inner cities without access to dental care. A number of mid-level dental provider models with a variety of names have emerged to address basic restorative and preventive care, particularly to children and in some states/countries to adults. Internationally, the dental therapist was first introduced in 1921 in New Zealand and is found in 54 countries.12 In 1949, Forsyth Dental Infirmary began an experiment to train New Zealand–type dental nurses, but it was stopped because of pressure from the American Dental Association.13 In 1971–1972, the Forsyth Experiment (more commonly known as the Rotunda Experiment) began training dental hygienists in basic restorative dentistry and local anesthesia.14 From 1971 to 1976, the University of Iowa and the University of Kentucky both trained dental hygienists with advanced skills in restorative dentistry.15,16 A Dental Health Aide Therapist (DHAT) was introduced in tribal villages in Alaska in 2006.17 The DHAT model has also been authorized for pilots in Oregon and Washington tribal communities.

A. Advanced Dental Hygiene Practitioner or Advanced Dental Therapist A 2009 PEW Report18 first recognized that creating new mid-level oral healthcare providers, such as the Advanced Dental Hygiene Practitioner proposed by the ADHA, could enhance access to oral health services for underserved populations.

In 2009, the state of Minnesota approved the development of the master’s-level degree program for advanced dental therapists (ADT), which requires applicants to be licensed dental hygienists holding a bachelor’s degree.19–21 These providers are dual licensed as a dental hygienist and dental therapist in Minnesota to provide preventive and basic restorative dental services19–21: Directly to underserved populations. Via a collaborative management agreement with a supervising dentist. Research findings suggest the safety and efficacy of restorative care provided by mid-level dental providers.22–24 The Commission on Dental Accreditation (CODA) developed accreditation standards for dental therapy programs in 2015.25 Currently, a variety of oral health stakeholder groups in many states are exploring legislation to create new workforce models to increase access to quality oral health care for all individuals.26–29 Although no CODA-accredited dental therapy program has yet been approved, additional states that have passed dental therapy legislation include the following26: Maine passed legislation for a dental hygiene therapist in 2014. Vermont passed legislation in 2016. Arizona and Michigan passed legislation in 2018.

B. Clinical Role of the ADT In addition to the traditional process of care performed by dental hygienists, the dental therapist has the following scope of practice25: Caries removal, placement, and finishing of composite/resin and amalgam restorations. Placement of space maintainers. Fabrication and placement of stainless steel crowns and temporary crowns. Pulpotomy.

Pulp vitality testing. Simple extractions of erupted primary teeth. Other duties may be specified in the state’s scope of practice. ADT practice under a collaborative agreement with a dentist and patients who need more advanced care is referred.

C. Impact of ADT The first dental therapists graduated in Minnesota in 2011. Initial impacts of this provider as part of the dental team include the following19: An increase in the number of patients served in mobile dental clinics and community health centers, particularly the underserved and special populations. Reduction in waiting times for patients to receive services. Decreased travel time for patients because preventive and restorative care can be provided during the same appointment. Possible reduction in emergency room use for dental care. Increased productivity of the dental team. Improved patient satisfaction.

VIII. Interprofessional Collaborative Patient Care In many situations, dental hygienists provide clinical patient care as a member of a dental team. In a growing number of facilities, dental hygienists provide care in collaboration with an interprofessional team of healthcare providers to meet the needs of patients with complex medical problems. Four competency domains necessary for participating in interprofessional collaborative practice, developed by a group of medical and dental professional associations, are explained in Box 1-4.30

BOX 1-4 Four Competency Domains for Interprofessional

Collaborative Practice

Competency 1: Values/Ethics for Interprofessional Practice: Work with individuals of other professions to maintain a climate of mutual respect and shared values. Competency 2: Roles/Responsibilities Use the knowledge of one’s own role and those of other professions to appropriately assess and address the healthcare needs of patients and to promote and advance the health of populations. Competency 3: Interprofessional Communication Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease. Competency 4: Teams and Teamwork Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable. Source: Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: 2016 Update. Washington, DC: Interprofessional Education Collaborative; 2016. https://www.ipecollaborative.org/resources.html. Accessed February 15, 2019.

Based on the work of the interprofessional education collaborative, most medical and dental accreditations standards contain a standard related to the competency domains.30

IX. Advocacy for Oral Health The professional dental hygienist is an active advocate for oral health in both personal and professional situations. The dental hygienist who is an advocate for oral health: Influences legislators, health agencies, and other organizations

to bring available resources together to improve access to care. Analyzes barriers to change and helps develop mechanisms to effect change. Implements and evaluates health policy and programs that promote health for individuals, families, or communities. Promotes lifestyle changes that contribute to oral health. Examples of oral health advocacy activities include: Joining other dental hygiene professionals to meet with legislators and public officials to encourage the inclusion of dental services in healthcare legislation. Making public statements that support the oral health value of optimal fluoridation in community water systems when a community is considering defluoridation.

OBJECTIVES FOR PROFESSIONAL PRACTICE I. Overall Goals Overall professional goals of the dental hygiene profession relate to health promotion and disease prevention. The goal of each dental hygienist is to aid individuals and groups in attaining and maintaining optimum oral health. Other professional objectives are related to this primary goal. A dental hygienist’s self-assessment is essential to attain goals for service to each patient and community. Personal and professional goals are outlined and reviewed frequently in a plan for continued self-improvement.

II.

Personal Goals Exemplify the highest degree of professional ethics and conduct. Demonstrate interpersonal relationships that assure oral health information is presented effectively. Apply a continuing process of self-evaluation throughout professional life. Recognize the need for lifelong learning to acquire updated knowledge through reading professional literature and enrolling in continuing education programs. Maintain membership and participate actively in the local, national, and international dental hygiene professional associations.

III. Clinical Practice Goals Practice safe and efficient clinical routines for the application of standard precautions for infection control. Apply evidence-based knowledge and understanding of the basic and clinical sciences to: Associations between oral disease and a variety of systemic

conditions. Recognition of oral conditions. Prevention of oral diseases. Clinical and instructional procedures. Tailor care planning and interventions according to individual needs. Utilize motivational interviewing to engage the patient in becoming an active participant in their care to bring about lasting behavioral changes to support optimal oral health.

STANDARDS FOR CLINICAL DENTAL HYGIENE PRACTICE The primary purpose of standards for clinical practice is to guide dental hygiene practitioners in the development of a clinical relationship with their patients.31 A secondary purpose is to educate the public, other healthcare providers, and policy makers about the profession of dental hygiene and the scope of dental hygiene practice. The six components of the dental hygiene process of care provide: The foundation for clinical decision making and dental hygiene practice. The framework for organizing the sections in this book.

DENTAL HYGIENE PROCESS OF CARE The dental hygiene process of care includes assessment, dental hygiene diagnosis, planning, implementation, evaluation, and documentation, as illustrated in Figure 1-3.31,32

FIGURE 1-3 • The Six Interrelated Components of the Dental Hygiene Process of Care. The steps in the process are followed one after another in a cycle, beginning with assessment. Evaluation and documentation are each linked to all of the other steps.

The procedures of evaluation and documentation are integrated within each of the other components in the process. As a process, the procedures performed are continual in nature and may overlap or occur simultaneously.

I.

Purposes of the Dental Hygiene Process of Care To provide a framework to individualize the process of care for each patient. To identify the risk factors to aid in prevention and/or management of oral disease through dental hygiene interventions.

II.

Assessment The assessment phase is the first component of the dental hygiene process. This phase provides a foundation for patient care by collecting both subjective and objective data. Chapters 11–21 in this textbook are devoted to the assessment component of the dental hygiene process of care.

III. Dental Hygiene Diagnosis Dental hygiene diagnostic statements: Employ the use of critical thinking to interpret assessment data, as indicated in Box 1-5.

BOX 1-5 Critical Thinking Skills Used to Interpret Clinical Data Information gathering: pertinent information is gathered from the clinical assessments as well as from the patient to identify individual characteristics. Classification: involves sorting of information into specific categories such as general systemic, oral soft tissue, periodontal, dental, and oral hygiene. Interpretation: relies upon critical thinking to identify significance. The cognitive processes of analysis, synthesis, inductive reasoning, and deductive reasoning are the basis for determining a diagnosis.

Validation: an attempt to verify the accuracy of data interpretation. Validation can assist in recognizing errors, isolating discrepancies, and identifying the need for additional information.

Identify the health behaviors of each patient as well as the actual or potential oral health problems within the scope of practice for dental hygienists. Provide the basis on which the dental hygiene care plan is designed, implemented, and evaluated. Justify the treatment proposed to the patient. Chapter 22, Dental Hygiene Diagnosis, provides more information.

IV. The Dental Hygiene Care Plan Dental hygiene care planning is the selection of strategies and interventions that meet the needs of the patient in attaining oral health. The dental hygiene care plan is presented: To the dentist for integration with the comprehensive dental care plan. To the patient to develop understanding of the interventions needed and appointment requirements. To the patient to obtain informed consent for treatment. Chapter 23 describes care planning and provides a template for the development of a written dental hygiene care plan.

V.

Implementation

The implementation phase in the dental hygiene process of care is the activation of the care plan. Further discussion of the concepts and procedures associated with implementation of dental hygiene preventive and treatment interventions is presented in Chapters 24–43.

VI. Evaluation

The evaluation phase determines whether a specific area of a patient needs to be treated again, referred, or placed on a continuing care schedule. Evaluation of dental hygiene care is detailed in Chapter 44. Development of continuing care protocols is described in Chapter 45.

VII. Documentation The documentation of dental hygiene care: Details all assessment data, diagnosis, care plan, treatments, patient education, and evaluation in a condensed, consistent format. Represents a chronologic history of the patient’s total care. Details for documentation are described in Chapter 10 and examples of documentation for a variety of dental hygiene interventions can be found at the end of each chapter.

DENTAL HYGIENE ETHICS The ethics of a profession provide the general standards of right and wrong that guide the behavior of the members in that profession. The members of a profession: Have extensive specialized education. Possess an intellectual body of knowledge from study and research. Provide services important for the common good of society, for example, dental hygienists provide preventive, educational, and therapeutic services that protect and enhance the overall health of the public. Maintain an organization of members that sets professional standards. Exercise autonomy and judgment. Adhere to their professional code of ethics.

THE CODE OF ETHICS Describes professional conduct. Outlines responsibilities and duties of each member toward patients, colleagues, and society in general.

I.

Purposes of the Code of Ethics To increase the awareness of, and sensitivity to, ethical situations in practice. To define a standard of conduct that will give each individual a strong sense of ethical consciousness in professional practice as well as in all phases of life.

II.

Dental Hygiene Codes The Codes of the ADHA, the National Dental Hygienists’ Association, the Canadian Dental Hygienists’ Association, and the International Federation of Dental Hygienists can be accessed online. Each dental hygienist is responsible for the study and application of the codes of the particular associations in which memberships are held.

CORE VALUES Core values are selected principles of ethical behavior that are considered central to the code of a profession.

I.

Core Values in Professional Practice The core values of the profession of dental hygiene are listed and defined in Box 1-6 and in the ADHA Code of Ethics.

BOX 1-6 Core Values in Professional Dental Hygiene Practice Individual autonomy and respect for human beings 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 patient 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 patient trust and understand that public trust in our profession is based on our actions and behavior. Nonmaleficence We accept our fundamental obligation to provide services in a manner that protects all patients 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/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 health care. Veracity We accept our obligation to tell the truth and expect that others will do the same. We value self-knowledge and seek truth and honesty in all relationships. Source: American Dental Hygienists’ Association. Bylaws and Code of Ethics. Chicago, IL: ADHA; Adopted June 25, 2018:32-33. http://www.adha.org/resources-docs/7611_Bylaws_and_Code_of_Ethics.pdf. Accessed February 16, 2019.

II.

Personal Values Value development begins at an early age and is influenced by familial, social, and economic factors. Life experiences, grounded in previous successes and failures, serve as a foundation for professional virtues. Members of a health profession can benefit from periodic selfassessment of individual values, attitudes, and responsibilities.

III. The Patient First The responsibility to put the patient first is foremost. Dental hygienists are ethically, morally, and legally responsible to provide oral care for all patients without discrimination. Ethical decision making and professional behavior should be reflected in every aspect of dental hygiene practice.

IV. Lifelong Learning: An Ethical Duty To ensure optimal care for each patient. To maintain competency. To learn scientific advances from new research. To provide evidence-based patient care. To apply consistent ethical reasoning. To ensure fulfillment of each patient’s rights.

ETHICAL APPLICATIONS A dental hygienist may be involved in a variety of moral, ethical, and legal situations as part of the daily routine. In ethics, a problem situation is considered either an ethical issue or an ethical dilemma.

I.

Ethical Issue More clearly defined than a dilemma. A common problem wherein a solution is grounded in the governing practice act, recognized laws, or accepted standards of care based on the standard rules of practice.

II.

Ethical Dilemma A problem that may involve two morally correct choices or courses of action. May not have a single answer and, depending on the choice, the outcomes can differ.

III. Models for Resolution of an Issue or a Dilemma There are a number of models for resolution of an ethical issue or dilemma and all include elements of the following33: Identify the facts of the issue or dilemma. Identify who is involved in the issue or dilemma. List options or alternatives to resolve the dilemma. Rank and choose the best option or alternative to resolve the dilemma while trying to balance the various aspects of the ADHA Code of Ethics such as individual autonomy, beneficence, nonmaleficence, autonomy, and justice/fairness.34 An ethical decision-making model that can be used by the dental hygienist to resolve an ethical issue or dilemma in a clinical setting

is detailed in Box 1-7.35

BOX 1-7 A Model for Resolution of an Ethical Issue or Dilemma Step 1: Information

Gather information on the patient’s medical, dental, and social history related to the situation.

Step 2: Identification

Assess whether this is an ethical issue or whether it is an issue best addressed by other resources.

Step 3: Clarification

Does the practitioner and patient understand the information relevant to the situation? What are the patient’s rights? Is there a conflict of interest? Does an outside source need to be consulted?

Step 4: Assessment

Generate options or alternatives based on the patient situation and preferences. Consider the core values of the American Dental Hygienists’ Association Code of Ethics to assess benefits and risks related to the alternatives. Collaboration with the patient and possibly other healthcare providers is part of the process of assessment of the alternatives.

Step 5: Recommendation

Choose the best alternative and obtain informed consent from the patient.

Step 6: Documentation

Document the recommendation in the patient record. Follow-up.

Source: Enck G. Six-step framework for ethical decision making. J Health Serv Res Policy. 2014;19(1):62-64.

IV. Summary: The Final Decision Many factors can be used to solve a dilemma. All dental healthcare providers involved in the decision process can participate in a follow-up evaluation of the action taken. Questions to ask once a decision has been made include: Is the decision/action that is selected morally defensible? Can the choice to solve the dilemma be defended? A professional dental hygienist may need to defend it to the patient, the dentist, members of the dental team, a state board, or even a court of law. Most importantly, the decision must be defensible based on standards of practice established for the dental and dental hygiene profession.

V.

Applications: Everyday Ethics

Various ethical issues and dilemmas are presented throughout this book for discussion and consideration. Examples are found in special boxes called “Everyday Ethics” and usually appear at the end of the chapter where the problem may apply.

LEGAL FACTORS IN PRACTICE The law must be studied and respected by each dental hygienist practicing within the state, province, or country. Although the various practice acts have certain basic similarities, differences in scope and definition exist. Terminology varies, but each practice act regulates the patient services delivered by the licensed dental hygienist. It is the responsibility of each dental hygienist to stay current with changes to the practice act. Active engagement with the state dental hygiene association will aid in keeping the dental health professional up to date.

PROFESSIONALISM Each dental hygienist represents the entire profession to the patient, other healthcare professionals, and the community. Components of professionalism include36: Competence: acquire and maintain a high level of knowledge through lifelong learning, clinical expertise, and professional behavior for provision of patient care. Fairness: demonstrate consistency and equity when dealing with others. Promote equal access to care for the public. Integrity: be honest, do the right thing, and demonstrate strong moral principles. Responsibility: accountability for one’s actions in accordance with the ADHA Code of Ethics. Respect: value and honor others’ feelings, rights, abilities, etc. Service-mindedness: act for the benefit of the patients and public, and approach those served with compassion. The World Health Organization defines health as a state of physical, mental, and social well-being.37 As healthcare providers, we must serve as a model for our patients. Basic components of self-care include a range of daily routine habits, health maintenance, and disease prevention behaviors. These components include the following: General physical needs include personal hygiene, sleep, nutrition (Chapter 33), hydration, and disease prevention. Routine examinations annually, including tests for hearing, sight, and certain communicable diseases. Immunizations recommended for healthcare providers (Chapter 5). The maintenance of a clean, healthy mouth demonstrates by example that the dental hygienist follows recommendations for prevention and control of oral disease. Physical activity helps with weight control, maintaining mental health, prevention of chronic disease, strengthening bone and

muscle, managing stress, and even improving daily activity performance.38 Recommendations for adults are for at least 150 min/wk of moderate-intensity aerobic activity in addition to muscle strengthening activities at least 2 d/wk. Mental health: The mental health of the dental hygienist is reflected in interpersonal relationships and the ability to inspire confidence through a display of professional and emotional maturity. Stress management helps to improve and manage mental health.37 Avoid risky behaviors such as tobacco use, excessive alcohol use, illicit drug use, and risky sexual practices to prevent adverse effects and chronic diseases such as cardiovascular disease.37

EVERYDAY ETHICS The first term of the dental hygiene curriculum has just finished. The instructor asks for student volunteers to help at the college’s health fair to provide basic routine brushing and flossing instructions for people who stop at the dental hygiene information table. Three students, Alice, Annette, and Josephine, sign up to volunteer for this community service. The day before the health fair, which takes place on a Saturday, Annette is asked to work in the dental office where she is employed part-time. Since she really needs the money, she decides not to attend the health fair and instead goes to work without telling anyone. Questions for Consideration 1. In general, would this situation be described as a professionalism issue or an ethical dilemma? Explain. 2. Discuss Annette’s actions in terms of the core ethical values. 3. What aspects of the dental hygiene code of ethics can support her student colleague’s choice of action?

Factors to Teach the Patient The role of the dental hygienist as a cotherapist with each patient, with the

dentist, and with members of other health professions. The moral and ethical nature of being a dental hygiene professional. The scope of service of the dental hygienist as defined by the state practice act. The interrelationship of educational and clinical services in dental hygiene patient care. The shared responsibility of the patient for their oral health and how it can be improved and maintained.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. American Dental Hygienists’ Association. ADHA Policy Manual. Chicago, IL: ADHA. https://www.adha.org/resources-docs/7614_Policy_Manual.pdf. Updated June 25, 2018. Accessed February 16, 2019. 2. American Dental Hygienists’ Association. 100: Celebrating a Century of Professional Pride. Chicago, IL: ADHA; 2013:48. 3. Fones AC, ed. Mouth Hygiene. 4th ed. Philadelphia, PA: Lea & Febiger; 1934:248. 4. American Dental Hygienists’ Association. Career center: career paths. http://www.adha.org/professional-roles. Accessed February 16, 2019. 5. American Dental Hygienists’ Association. Advocacy: scope of practice. http://www.adha.org/scope-of-practice. Accessed February 18, 2019. 6. American Dental Hygienists’ Association. Dental hygiene practice acts overview: permitted functions and supervision levels by state. Revised January 2019. http://www.adha.org/resourcesdocs/7511_Permitted_Services_Supervision_Levels_by_State.pdf. Accessed February 15, 2019. 7. Catlett A. A comparison of dental hygienists’ salaries to state dental supervision levels. J Dent Hyg. 2014;88(6):380-385. 8. Summerfelt FF. Teledentistry-assisted, affiliated practice for dental hygienists: an innovative oral health workforce model. J Dent Educ. 2011;75(6):733-742. 9. American Dental Hygienists’ Association. Advocacy: direct access. http://www.adha.org/direct-access. Accessed February 18, 2019. 10. Battrell A, Lynch A, Steinbach P, Bessner S, Snyder J, Majeski J. Advancing education in dental hygiene. J Evid Based Dent Pract. 2014;14(suppl):209-221. 11. American Dental Hygienists’ Association. Direct access states. https://www.adha.org/sites/default/files/7527_Changes_in_Direct_Access_Map.pdf Accessed February 18, 2019. 12. Nash DA, Friedman JW, Mathu-Muju KR, et al. A review of the global literature on dental therapists. Community Dent Oral Epidemiol. 2014;42(1):1-10. 13. American Dental Association. Massachusetts dental nurse bill rescinded. J Am Dent Assoc. 1950;41:371. 14. Lobene RR. The Forsyth Experiment: An Alternative System for Dental Care. Cambridge MA: Harvard University Press; 1979. 15. Spohn EE, Chiswell LR, Davison DD. The University of Kentucky Experimental Expanded Duties Dental Hygiene Project. Lexington, KY: College of Dentistry, University of Kentucky; 1976:54. 16. Sisty NL, Henderson WG, Paule CL, Martin JF. Evaluation of student performance in the four-year study of expanded functions for dental hygienists at the University of Iowa. J Amer Dent Assoc. 1978;97:613-627. 17. Wetterhall S, Bader JD, Burrus BB, Lee JY, Shugars DA. Evaluation of the dental health aid therapist workforce model in Alaska. WK Kellogg Foundation,

Rasmussen Foundation, Bethel Community Services Foundation. 2010. https://www.rti.org/publication/evaluation-dental-health-aide-therapistworkforce-model-alaska-final-report. Accessed February 18, 2019. 18. PEW Center on the States, National Academy for State Health Policy, WK Kellogg Foundation. Help wanted: a policy maker’s guide to new dental providers. May 2009. https://www.wkkf.org/resourcedirectory/resource/2010/help-wanted-a-policy-makers-guide-to-new-dentalproviders-issue-brief. Accessed February 18, 2019. 19. Minnesota Department of Health, Minnesota Board of Dentistry. Early Impacts of Dental Therapists in Minnesota. Minneapolis, MN: Minnesota Department of Health. https://mn.gov/boards/assets/2014DentalTherapistReport_tcm2145970.pdf. Accessed February 18, 2019. 20. Gwozdek AE, Tetrick R, Shaefer HL. The origins of Minnesota’s mid-level dental practitioner: alignment of problem, political and policy streams. J Dent Hyg. 2014;88(5):292-301. 21. American Dental Hygienists’ Association. The History of Introducing a New Provider in Minnesota. Chicago, IL: American Dental Hygienists’ Association; 2009:2. https://www.adha.org/resources-docs/75113_Minnesota_Story.pdf. Accessed February 18, 2019. 22. Mathu-Muju KR. Dental therapists provide technically competent clinical care when performing irreversible restorative procedures. J Evid Based Dent Pract. 2014;14(1):25-27. 23. Phillips E, Shaefer HL. Dental therapists: evidence of technical competence. J Dent Res. 2013;92(suppl 7):11S-15S. 24. Bailit HL, Beazoglou TJ, DeVitto J, McGowan T, Myne-Joslin V. Impact of dental therapists on productivity and finances: I. Literature review. J Dent Educ. 2012;76(8):1061-1067. 25. Commission on Dental Accreditation. Accreditation Standards for Dental Therapy Education Programs. Chicago, IL: ADA; 2014. https://www.ada.org/en/~/media/CODA/Files/dental_therapy_standards. Accessed February 18, 2019. 26. Koppelman J, Vitzthum K, Simon L. Expanding where dental therapists can practice could increase Americans’ access to cost-efficient care. Health Aff. 2016;35(12):2200-2206. 27. PEW Charitable Trusts. Expanding the Dental Team: Increasing Access to Care in Public Settings. Philadelphia, PA: PEW Charitable Trusts; 2014. https://www.pewtrusts.org/en/research-andanalysis/reports/2014/06/30/expanding-the-dental-team. Accessed February 18, 2019. 28. American Association of Public Health Dentistry. Special issue: workforce development in dentistry: addressing access to care. J Public Health Dent. 2011:71(suppl 2):S1-S41. 29. Institute of Medicine. Board on Healthcare Services. The U.S. Oral Health Workforce in the Coming Decade: Workshop Summary. Washington DC: National Academic Press; 2009.

http://www.nationalacademies.org/hmd/reports/2009/oralhealthworkforce.aspx. Accessed February 18, 2019. 30. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: 2016 Update. Washington, DC: Interprofessional Education Collaborative; 2016. https://www.ipecollaborative.org/resources.html. Accessed February 15, 2019. 31. American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene Practice. Chicago, IL: ADHA; 2008. http://www.adha.org/practice. Updated June 2016. Accessed February 19, 2019. 32. American Dental Hygienists’ Association. Dental Hygiene Diagnosis. Chicago, IL: ADHA; 2008. http://www.adha.org/practice. Updated September 2015. Accessed February 19, 2019. 33. American College of Dentists. Ethics Handbook for Dentists: An Introduction to Ethics, Professionalism, and Ethical Decision Making. Gaithersburg, MD: American College of Dentists. Revised 2016. https://www.dentalethics.org/ethicshandbook.htm. Accessed February 24, 2019. 34. American Dental Hygienists’ Association. Bylaws and Code of Ethics. Chicago, IL: ADHA; Adopted June 25, 2018:32-33. http://www.adha.org/resourcesdocs/7611_Bylaws_and_Code_of_Ethics.pdf. Accessed February 16, 2019. 35. Enck G. Six-step framework for ethical decision making. J Health Serv Res Policy. 2014;19(1):62-64. 36. American Dental Education Association. ADEA statement on professionalism in dental education. March 2009. https://www.adea.org/Pages/Professionalism.aspx. Accessed February 24, 2019. 37. World Health Organization, Regional Office for South-East Asia. 201. Self Care for Health. WHO Regional Office for South-East Asia. http://www.who.int/iris/handle/10665/205887. Accessed February 24, 2019. 38. U.S. Department of Health and Human Services (HHS). 2018. Physical Activity Guidelines for Americans. Washington, DC: U.S. Department of Health and Human Services. https://health.gov/paguidelines/second-edition/. Accessed March 3, 2019.

2 Evidence-Based Dental Hygiene Practice Faizan Kabani, BSDH, MHA, MBA, PhD

CHAPTER OUTLINE EVIDENCE-BASED PRACTICE I. II. III. IV. V.

Definition Purposes The Need for EBP EBP Model for Dental Hygiene Practice Skills Needed for Evidence-Based Dental Hygiene Practice

A SYSTEMATIC APPROACH I. II. III. IV. V.

Assess: Determine the Clinical Issue Ask: Develop a Research Question Acquire: Search for Scientific Evidence Appraise: Clinically Evaluate Evidence Apply: Integrate and Apply Evidence

VI. Audit: Evaluate Outcomes

APPROACHES TO RESEARCH I. II. III. IV. V.

Research Designs Research Types Evidence Sources Levels of Evidence Time Intervals

ETHICS IN RESEARCH I. II. III. IV.

Ethical Standards Ethical Research Involving Human Subjects Informed Consent for Research Institutional Review Board

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Explain evidence-based practice and its importance in clinical dental hygiene care. 2. Discuss various approaches to research including the strength of evidence each provides. 3. Describe a systematic approach used to find credible scientific literature. 4. Describe skills needed for analyzing evidence-based health information. One of the main goals of clinical dental hygiene practice is to improve and maintain the patient’s oral health. Clinical problems occur daily and require interventions based on current, valid, and reliable evidence to improve the patient’s overall well-being.

The evidence-based clinician relies on established best practices to guide their decision-making processes. Evidence-based decision making (EBDM) is a process of making decisions that are grounded in the best available research, professional experience, and factors related to each patient’s context, including needs and preferences.1

EVIDENCE-BASED PRACTICE I. Definition An interprofessional approach to clinical care where the clinician, in consultation with the patient, uses the best scientific evidence available to make decisions about clinical interventions needed to promote health.2 Evidence-based practice (EBP) is the practical application of EBDM across diverse clinical and nonclinical professions. In health care, an interprofessional EBP approach incorporates the knowledge and expertise from diverse professions (i.e., collaboration between medical, dental, and research) to provide the best quality of care to patients. EBP assists dental hygienists in formulating a plan for objective, effective, and scientifically sound interventions that meet patient needs and provide positive health outcomes. EBP involves three major elements3 (Figure 2-1):

FIGURE 2-1 • Evidence-Based Practice (EBP) Model for Dental Hygiene. (Courtesy of Cathy J. Thompson PhD, RN, CCNS, CNE.)

Clinically relevant scientific evidence. Sensitivity to patient’s needs and preferences. Healthcare professional’s clinical expertise.

II.

Purposes To answer clinical questions quickly and efficiently. To resolve problems in patient care using current evidence. To improve patient’s health outcomes and overall well-being.

III. The Need for EBP

A professional dental hygienist understands the following concepts and embraces the role of the evidence-based practitioner. Patients frequently search for health information on the Internet and other readily available sources. Patients: Expect clinicians to be knowledgeable on the latest developments in health care. Value practitioners who can discuss and help them evaluate the relevance, validity, and reliability of information obtained elsewhere. Demand healthcare providers who remain current with evidencebased information on the most up-to-date oral health practices, techniques, technologies, and products. There are differences in practice procedures: Clinicians are not consistently knowledgeable about all new and emerging therapies. There may be inconsistencies between what is taught in dental hygiene schools and procedures tested by regional examination boards for licensure. Information management: The amount of published evidence-based research continues to increase annually. Clinicians need to be good consumers of current scientific literature and focus on higher levels of evidence to guide their decision making.

IV. EBP Model for Dental Hygiene Practice The EBP model for dental hygiene care involves interaction between three primary components,4 as illustrated in Figure 2-1. Best available research evidence. Review of relevant, current, and high-quality clinical research that identifies best-practice treatment choices. Patient preferences or values. Consider, respect, and evaluate the patient’s needs, wants, expectations, and personal context (i.e., cultural, religious, capabilities, health status, and demographics).

Clinical expertise. The dental hygienists’ clinical skill and expertise enhance their ability to identify the patient’s health, risks, needs, and potential for various interventions.

V.

Skills Needed for Evidence-Based Dental Hygiene Practice

Implementing evidence-based dental hygiene (EBDH) practice into everyday clinical practice is an ethical responsibility for the dental hygienist. Identifying and using scientific evidence to support treatment and preventive interventions and recommendations require the dental hygienist to: Understand EBDH practice. Study a tutorial (examples listed in Box 2-1) to learn more about EBP.

BOX 2-1 Evidence-Based Tutorials and Learning Opportunities • Duke University: http://guides.mclibrary.duke.edu/c.php? g=158201&p=1036002 • Boston University Medical Campus: http://medlib.bu.edu/tutorials/ebm/ • University of Massachusetts Medical School: http://libraryguides.umassmed.edu/c.php?g=499783&p=3421956 • University of North Carolina at Chapel Hill: http://www.hsl.unc.edu/Services/Tutorials/EBM/welcome.htm • University of Illinois at Chicago: http://researchguides.uic.edu/ebm • The Cochrane Collaboration: http://www.cochrane.org/About%20us/Evidencebased%20health%20care/Webliography/Tutorials-tools • PubMed Tutorial: http://www.nlm.nih.gov/bsd/disted/pubmedtutorial/cover.html

Follow a systematic approach. Develop a step-by-step approach by asking questions related to clinical practice to ensure success. Read and understand research. Recognize valid and reliable information. Determine strengths and limitations of publications, journal articles, research methods, study designs, and biostatistics.

Be computer literate. Develop the skill to search for scientific literature in an effective and efficient manner. Practice critical thinking skills to evaluate information found online. Embrace self-directed learning. Develop a plan for continuing education and reading of professional literature that will help to maintain current knowledge. Be a resource for others. Help patients and colleagues identify and value scientific support for clinical recommendations.

A SYSTEMATIC APPROACH Dental hygienists should follow a systematic approach when identifying and selecting scientific evidence related to a particular patient’s healthcare needs. The “6 A’s” approach includes Assess, Ask, Acquire, Appraise, Apply, and Audit.3 Figure 2-2 illustrates a step-by-step procedure that aids the dental hygienist in developing these crucial skills.

FIGURE 2-2 • Systematic Steps in Evidence-Based Dental Hygiene Practice. (Adapted by permission from BMJ Publishing Group Limited. [Evidence-Based Medicine, Alper BS and Haynes B, 214, 2016].)

I.

Assess: Determine the Clinical Issue The dental hygienist first completes an assessment of the patient or population. Identify what the clinical issue or problem is for the patient or population. Purpose is to clarify the clinical issue or problem.

II.

Ask: Develop a Research Question Asking the right research question is fundamental and critical to the EBP model. Research questions should be focused and not be too broad or too narrow. A researchable question includes four parts, referred to as PICO. Examples of PICO questions related to dental hygiene practice can be found in Table 2-1.

TABLE 2-1 • Example of Clinical and Public Health–Related PICO Questions SCENARIO

PICO QUESTION

Mr. Ali is a 65-year-old Asian American who presents for his periodontal maintenance appointment. He reports a chief complaint of dental hypersensitivity when drinking cold beverages. He currently uses a generic, over-the-counter fluoridated toothpaste. He is wondering if there is any particular active ingredient he should consider when purchasing a toothpaste.

For a patient with concerns of dental hypersensitivity, will a toothpaste with potassium nitrate be more effective at reducing hypersensitivity than a toothpaste with traditional fluoride? Patient/problem: Patient reports chief complaint of dental hypersensitivity Intervention: Toothpaste with potassium nitrate as active ingredient Comparison: Traditional toothpaste

with fluoride as active ingredient Outcome: Reduction in dental hypersensitivity Mrs. Sabzali is a 35-year-old AfricanAmerican superintendent of a predominately Medicaid-based school district. She reports there is a dental caries epidemic in one of her elementary school’s first-grade classrooms. Your dental office currently volunteers in an annual fluoride varnish program to help address dental caries. Mrs. Sabzali mentions that she has heard from one of her principals about placement of dental sealants as another way to address the dental caries epidemic. She is wondering which route, placement of fluoride varnish or dental sealants, best helps to address the dental caries epidemic in her school district.

For a population experiencing a dental caries epidemic, will placement of dental sealants be as effective (or more effective) as application of fluoride varnish to help reduce dental caries? Population/problem: Dental caries epidemic in first-grade classroom of a predominately Medicaid-based school district Intervention: Placement of dental sealants Comparison: Application of fluoride varnish Outcome: Reduction in dental caries epidemic

Research about comparative cost is in addition to the literature review.

Good research questions should also adhere to the FINER criteria. Include important patient demographics (i.e., age, sex, race, and ethnicity).

A. PICO Criteria5 Patient problem or population (P): What are the most important issues the patient or population of interest is facing? Intervention (I): What are you planning to do to address the patient’s or population of interest’s issues? Comparison (C): What is the main alternative being suggested? Compare the alternative with the standard intervention for the patient or population of interest. Outcome (O): What is the desired measurable outcome,

accomplishment, improvement, or effect from the proposed intervention on the patient or the population of interest?

B. FINER Criteria5 Feasibility (F): Are the necessary resources available to conduct the research study? Interesting (I): Is the research interesting, self-motivating, and/or intriguing? Novel (N): Is the research innovative? Does the research aim to address significant gaps in the literature? Ethical (E): Does the research align within ethical and legal standards/requirements? Relevant (R): Does the research advance the body of scientific knowledge in the particular healthcare field?

III. Acquire: Search for Scientific Evidence Select appropriate resources and conduct a thorough literature review. Scientific articles are available through library databases and by using appropriate search engines. Focus literature review toward current and higher level of evidence publications (Figure 23).

FIGURE 2-3 • Strength of Evidence Resources.

A. Types of Information Sources Primary sources are original accounts of events and/or publications. Primary sources are significant because they provide unfiltered access to an original record of thought and/or achievement during a specific period in history. Examples of primary sources include narratives, speeches, autobiographies, government documents, patents, raw data sets, and experimental research reports. Secondary sources are published materials that synthesize and/or analyze original sources. Examples of secondary sources include biographies, literature reviews, and nonexperimental scholarly

articles. Tertiary sources are published materials that provide overviews of particular topics with information gathered from multiple sources. Examples of tertiary sources include encyclopedias, textbooks, and websites.

B. Types of Publications The sources for obtaining scientific information are growing daily. Knowing how to determine the validity and reliability of information is critical for selecting successful patient care strategies and interventions. Refer to Box 2-2 for a checklist of questions to ask when considering the validity and/or reliability of a publication.

BOX 2-2 Questions to Ask When Considering the Validity of a Publication • • • • • • • •

Who is sponsoring? Is there an editorial review board? Are the journal articles peer-reviewed? What are the credentials of the contributors? Are there advertisements? How many? Are there good-quality production standards? Is the manuscript preparation information included? What type of articles are included? (i.e., Informational? Opinion/Editorial? Case Reports? Scientific study?)

Textbooks Generally accepted as credible basic-level resources. Drawn-out publication processes can make textbooks become outdated quickly. Commercial-based journals/magazines Often free and based on product and/or service sponsorships. Potentially written by in-house staff members without professional credentials.

Some articles summarize recent research that may contain selective reference citations, but not include all available scientific evidence. Professional journals Produced by professional organizations. Membership dues payment is required, or receiving publications is a benefit of being a member. Part or all of the publication is devoted to scientific studies. Most contain articles with supporting reference citations. Peer-reviewed (refereed) publications Subject matter experts (SMEs) critically examine all components of submitted manuscripts before recommending for or against publication. Contributing author(s) must revise the manuscript and address all significant concerns or answer questions expressed by the reviewing SMEs before receiving approval for publication. The peer-review process helps assure the validity, reliability, and objectivity of published journal articles. Peer-reviewed journals usually list all review board members and their respective credentials in each issue of the journal.

C. Online Information The Internet continues to evolve as an avenue for people to search for health-related information. American adults are increasingly using online resources to diagnose either themselves or others.6 Many popular search engines lead to newspaper and magazine articles or websites that may not provide science-based and/or research-supported information. Search engines cannot assure the validity, accuracy, and objectivity of information. Search engines display only fractions of all available resources on a specific topic. Search engines can also provide access to more valid and reliable

websites that offer a variety of health information. Be familiar with the credibility level of various domain names: Highest credibility: Governmental sources (.gov) and educational sources (.edu). Moderate credibility: Organizational sources (.org) and institutional sources (.net). Lowest credibility: Commercial sources (.com). Refer to Box 2-3 for questions to ask when assessing information found on the Internet.

BOX 2-3 Questions to Ask When Assessing Information Found on the Internet • • • • • • • • • • • • • •

Who are the authors? What are their qualifications? Is the source peer-reviewed or edited? What is the domain name and source? (i.e., .gov, .edu, .org, .net, .com, .mil) Does the site have any affiliated biases? Does the author list sources or citations? Is the information verifiable elsewhere? Does the site reflect a particular bias or viewpoint? Are obvious errors in spelling or grammar present? Who is the website targeting as their audience? When was the website created and last updated/revised? Are the links current, good, and helpful? Are any links dead? Is the site comprehensive? Is the site easy to read? Are the site and material well organized?

Search engines and databases devoted to specific professional literature provide access to information from scholarly articles in biomedical and other health-related journals. Some governmental agencies and nongovernmental associations specifically help people find credible health-related information on the web. These include: HealthFinder.7 MedlinePlus.8

Medical Library Association.9 Accrediting organizations provide certification aimed at assuring accurate and objective health information on the Internet. Health on the Net Foundation.10 URAC Health Website Accreditation Program.11 Sites that display a symbol of accreditation from these organizations have met specific guidelines intended to assure the quality of health information they provide.

D. Biomedical Databases Refer to Box 2-4 for a list of some valid and reliable biomedical databases to use when searching for evidence-based information related to oral health and patient care.

BOX 2-4 Databases for Locating Biomedical Information • MEDLINE (PubMed), http://www.ncbi.nlm.nih.gov/pubmed/: a service of the U.S. National Library of Medicine that includes over 16 million citations from MEDLINE and other life science journals for biomedical articles dating back to the 1950s; includes links to full-text articles and related resources. • CINAHL (Cumulative Index to Nursing and Allied Health Literature), https://www.ebscohost.com/nursing/products/cinahl-databases/the-cinahldatabase: a bibliographic database that includes abstracts of nursing and allied health articles. • Cochrane Library (The Cochrane Collaboration), http://www.cochrane.org/: an international nonprofit and independent organization; produces and disseminates systematic reviews of healthcare interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. • Database of Promoting Health Effectiveness Reviews (DoPHER), http://eppi.ioe.ac.uk/webdatabases4/Intro.aspx?ID=9: a database focused on covering systematic and nonsystematic reviews of effectiveness in health promotion and public health worldwide. • ADA’s EBD Website (The American Dental Association’s Evidence-Based Dentistry), http://ebd.ada.org: a dental informatics resource; provides practitioners with access to current scientific information that is easy to

comprehend and that can be quickly reviewed at the point of care. • National Institutes of Health, http://health.nih.gov: an encyclopedia of health topics. • Agency for Healthcare Research and Quality, https://www.ahrq.gov/: subsidiary of the U.S. Department of Health and Human Services; aims to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable.

The MEDLINE database is the U.S. National Library of Medicine’s (NLM) main scientific database.12 MEDLINE provides access to articles from more than 5,600 scientific journals including PubMed and the Cochrane Collaboration database. MEDLINE indexes all published records using the NLM Medical Subject Headings (MeSH) format. MeSH enable researchers to connect search terms with keywords linked with each publication.12 When journal articles or the abstract for a specific article is displayed, PubMed also provides: The complete citation in NLM format. In some cases, a link to the full text of the article. Links to access “related citations.” Systematic and effective MEDLINE searches include: Use of the “related citations” link. Checking the references listed in journal articles for additional relevant citations. Using a combination of search techniques results in more efficient and effective searches. Refer to Box 2-5 for basic MEDLINE literature searching techniques using the PubMed search engine.

BOX 2-5 Basic MEDLINE Literature Search Techniques Using the PubMed Search Engine • A text or key word search locates articles that have the relevant terms in the title, abstract, or body of an article.

A medical subject heading search locates articles indexed in the database by • specific headings. • A clinical queries search locates articles related to three specific clinical research categories: clinical studies, systematic reviews, and medical genetics.

E. The Cochrane Collaboration Database Global, independent, network working to promote access to credible and unbiased health information for both practitioners and patients.13 Produces high-quality, systematic reviews and other synthesized research evidence to support clinical decision making. Each review article includes: Complete scientifically written and well-supported analysis of search methods, data collection, and findings. Plain language summary of results for nonhealthcare providers. Has a searchable database for a large number of health-related topics, including oral health.

IV. Appraise: Clinically Evaluate Evidence Once literature on a particular topic is acquired, it is necessary for the dental hygienist to evaluate the validity, reliability, and overall credibility of the information before providing professional recommendations/interventions.

A. Critically Evaluate the Evidence for Validity Determine if the study logically follows all steps of the research process. Determine if the focus of the study relates to the patient or population’s concerns. Determine if there are major concerns with internal validity. Determine if objectivity was maintained or if bias was introduced. Determine if the study has an adequate sample size.

Determine if the most appropriate measurement scale and/or index was used. Determine if there are major concerns with external validity. Can the evidence be generalized to other similar patients or populations?

B. Critically Evaluate the Evidence for Clinical Value Analyze which specific variables the researchers used in their study. Dependent variable(s): Also termed as the outcome variable. A value that depends on other interventions and what researchers aim to predict or explain. For example, the amount of biofilm left on a tooth after brushing. Independent variable(s): Also termed as the intervention variable. Manipulating variable intended to create an effect on the dependent variable. For example, the different types of toothbrushes used to reduce biofilm left on a tooth. Extraneous variable(s): Factors not directly involved between the dependent and independent variable but having an altering effect on the overall relationship. Extraneous variables further subdivide into control and confounding variables. For example, a person’s age, sex, race, ethnicity, socioeconomic status, and/or the extent of oral hygiene instruction provided on proper brushing techniques can influence the overall relationship between the type of intervention used and observed outcome/result. Analyze both descriptive statistics and inferential statistics for significance and relevance to the current problem in question.14 Analyze the difference between statistical significance and clinical significance. Statistical significance refers to the likelihood that a relationship between two or more variables is due to something other than chance.

Clinical significance refers to the practical relevance and importance between multiple therapies. In other words, clinical significance focuses on whether the significant probability of a particular therapy has a noticeable effect on a patient or population. Researchers typically use ≤0.05 as the prespecified probability value (p-value) to determine statistical significance. In this scenario, there is a less than 5% probability that the statistically significant difference between multiple variables occurred due to chance. Researchers also report data using confidence intervals to identify minimum and maximum values for probability. Evaluate whether treatment outcomes are beneficial enough to justify treatment. Evaluate if researchers provide rational arguments for using results in clinical practice. Determine the availability and affordability of treatment to patients or populations.

V.

Apply: Integrate and Apply Evidence

Integrate and apply evidence with clinical expertise and the patient’s preferences. Consider the patient or population’s circumstances and the clinician’s ability to help obtain potential results. Document interventions in the patient’s chart as part of clinical progress notes.

VI. Audit: Evaluate Outcomes Determine whether: Application of the EBP model successfully helped the patient. There is a need for additional research strategies and information. There is a need for a modification in the original outcome goal.

Begin the EBP process again if patient outcome is not successful and/or when a new problem arises.

APPROACHES TO RESEARCH It is critical for dental hygienists to be aware of different approaches to and types of research designs, particularly when reading published literature to inform clinical EBP.14 The dental hygienist can also conduct and/or participate in original research investigations. Depending on the clinical/public health problem and/or focused research question, dental hygienists can engage with research using a critical, objective, and methodical EBP approach.

I.

Research Designs Qualitative Research Purpose is to understand and subjectively interpret complex social interactions. Sample sizes are typically smaller and not randomly selected. Data are collected and reported through participant observations, interviews, open-ended questions, field notations, and narrative reflections. Quantitative Research Purpose is to test hypotheses, view causal or correlational relationships, and make predictions. Sample sizes are typically larger and randomly selected. Data are collected and reported as quantifiable numbers and/or statistics. Mixed-Methods Research Purpose is to combine the best of both qualitative and quantitative research approaches. Sample sizes and random selection may vary. Data are collected and reported as both qualitative insight and quantitative analysis.

II.

Research Types

Descriptive Typically the first step in classifying and organizing information. Focused on describing facts of people, places, and time. Helps identify basic relationships that further studies need to examine. Examples include case studies, natural observations, and population surveys. Correlational Intended to predict and measure the relationship between multiple variables. Determine the type and strength of relationships between multiple variables. Focuses on preventing the post hoc fallacy (i.e., correlation does not mean causation). Examples include case–control studies, cohort studies, observations, population surveys, cross-sectional and longitudinal studies. Quasi-experimental Similar to the experimental approach minus the random assignment. Researchers have lesser control than on true experimental designs. Examples include correlational studies and results of case studies. Experimental Intended to test cause and effect between variables. Includes randomized assignment of study participants. Experimental group receives intervention; control group does not receive intervention. Examples include randomized controlled trials (RCTs). Review Synthesizes relevant information on a particular research topic. Intended to summarize and evaluate scientific literature. Examples include critical review, narrative review, systematic review, and meta-analysis.

III. Evidence Sources Primary research refers to original studies including individual experimental and nonexperimental studies. Examples of primary research studies include RCTs, cohort studies, and case–control studies. Secondary research refers to existing studies used for purposes (i.e., reviews on previously conducted research). Examples of secondary research studies include systematic reviews, metaanalysis, and clinical practice guidelines.

IV. Levels of Evidence The levels of evidence pyramid illustrates the hierarchy of research designs and strength of various scientific evidence.15 The pyramid layout provides a visual representation of the number of studies published in literature; in particular, researchers conduct more lowerlevel than higher-level studies. Higher-level evidences provide the strongest basis for establishing clinical practice guidelines. Figure 2-4 organizes the levels of evidence as follows:

FIGURE 2-4 • Levels of Scientific Evidence Pyramid.

A. Meta-Analysis and Systematic Reviews Highest levels of evidence. Meta-Analysis, referred to as the platinum standard, is an advanced, analytical-based, literature review that follows a systematic process with explicit inclusion and exclusion criteria. Researchers perform statistical testing on all studies included in the final analysis. Through statistical testing, meta-analysis can potentially transform gold-standard randomized controlled studies into an even stronger “platinum standard” evidence base. Systematic Reviews, referenced to as the diamond standard, are advanced, descriptive-based, literature review that follows a methodological approach with explicit inclusion and exclusion

criteria. Researchers produce a summary of all relevant studies based on preestablished criteria. Advantages of systematic reviews include: Reduce bias. Include only clinically relevant information. Follow strict protocols. Require prior determination of search methods. Focus on specific clinical questions. Have evaluation criteria. Evaluate the strength of available evidence. A meta-synthesis best describes a systematic review of qualitative studies.

B. Randomized Controlled Clinical Trials: The “Gold-Standard” Clinical Study Randomized Controlled Clinical Trials are planned experiments that test the efficacy or effectiveness of an exposure. Random assignment/allocation of patients into one of at least two treatment groups. Researchers can reduce bias in RCTs by incorporating singleblinded, double-blinded, or triple-blinded protocols in their experiments. The double-blinded protocol in RCTs is the current gold-standard approach.

C. Cohort Studies and Case–Control Studies Cohort Studies follow the same subject group from the present to a specified point in the future. This research design compares a group with exposure against a group without an exposure. Case–Control Studies explore into the past to identify common factors between two groups, one with an exposure and the other without an exposure.

The case group refers to the treatment, intervention, or exposure group. The control group refers to the group that either received the standard care (i.e., positive control group) or received no treatment/placebo (i.e., negative control group).

D. Case Studies, Case Reports, and Narrative Reviews Case Reports are professional articles that describe the diagnostic, preventive, and therapeutic services rendered to one patient with an unusual or complex condition. Case Studies are an in-depth analysis and description of a series of cases of an unusual or complex condition. Narrative Reviews are basic, descriptive-based literature reviews that synthesize information on a particular topic without a methodological approach.

E. Editorials and SME Opinions Editorials are articles in a newspaper or magazine that express the opinion of its editor or publisher. SME opinions are beliefs or conclusions held with confidence by experts in a particular field or topic but not substantiated by positive knowledge or proof.

F. Preclinical Trials (In Vitro and In Vivo) Preclinical, or nonclinical, research precedes trials involving human subjects. Purpose is to collect data to support safety of new treatment. In vitro trials refer to experimental testing completed through test tubes and other similar equipment in the laboratory. In vivo trials refer to experimental testing completed through the body of a nonhuman living organism (i.e., animal studies).

V.

Time Intervals

Prospective: A prospective study observes for outcomes, such as the development of a disease, between the present and some defined point in the future. These exposures are attributed as either risk or protective factors in the development of any given outcome. Retrospective: A retrospective study observes established outcomes, such as an existing disease, but examines by exploring potential risk or protective factors between a specified timeframe in the past. Cross-Sectional: Cross-sectional studies examine several different samples at one specified point in time (i.e., provide a snapshot). Can include annual surveys, single interventions, etc. Longitudinal: Longitudinal studies examine the same sample over an extended period (i.e., several points in time). Results from longitudinal studies can indicate potential causality claims.

ETHICS IN RESEARCH Research ethics focuses on the responsibility of researchers to conduct nonbiased research, report accurate results, and protect the rights of individuals participating as research subjects.16 Bioethics is a subdivision concerned with the ethical implications of health-related research and its application on human health and well-being.16 Over the years, several unethical research studies (i.e., Tuskegee Syphilis Study) occurred due to unregulated policies. The Nuremberg Code (1947), Declaration of Helsinki (1964), and the Belmont Report (1979) were substantial milestones in the field of bioethics. Although many dental hygienists may not actively fulfill the role of a researcher, each can look for evidence ensuring that researchers followed ethical principles when reading the report of a research study. Refer to Chapter 1 and Section Introductions throughout the book for basic ethical principles and decision-making guidelines.

I.

Ethical Standards

The same ethical theories and ethical principles that guide professional interactions of the dental hygienist with patients, dental colleagues, other healthcare providers, and community members can apply when conducting research.16 These include: Respect for persons (autonomy): Obligation to respect others and that they should be able to make their own informed decisions. Beneficence (protecting patients from harm): Obligation to “above all, do no harm.” Focusing on maximizing benefits and minimizing harm. Justice (integrity and fairness): Obligation to give each person his/her due.

II.

Ethical Research Involving Human Subjects

The term human subjects refers to people who participate in clinical trials. Examples of dental hygiene–related human subjects research include studies on extracted teeth, discarded gingiva, other tissues, saliva, blood, urine, etc., as long as they are from living individuals. Ethical standards in research protect individuals who participate as research subjects, with regard to their rights to: Self-determination. Privacy. Anonymity and confidentiality. Fair treatment. Protection from discomfort and harm. Understand the risks and benefits of participating in the study. Informed consent.

III. Informed Consent for Research Process of adequately explaining the research to prospective subjects and ensuring that they understand what will happen to them, especially the associated risks and benefits. All study participants need to volunteer and sign a standardized written consent form. Discussion of informed consent is included within the research proposal and includes: A statement that the study involves research. An explanation of the purposes of the research. The expected duration of the subject’s participation in the research. A step-by-step description of the procedures. Identification of any procedures that are experimental. A confidentiality statement assuring the participant of anonymity. Refusal to participate will involve “no penalty or loss of benefits to which the subject is otherwise entitled.” The subject may withdraw from the research at any time.

IV. Institutional Review Board Federal mandate requires that research proposals undergo evaluation by appropriately designated Institutional Review Boards (IRBs). The IRB is an independent board within the institution that reviews research proposals submitted by researchers. The group can require modifications before approving research or disapprove research based on its review. The purpose of IRB review is to protect the rights and welfare of human subject volunteers in research, in accordance with the policies of the Department of Health and Human Services. Published research articles often include an IRB preapproval statement before conducting the study.

DOCUMENTATION Include the following factors in the patient’s chart record when dental hygienists use current research findings from credible evidence sources to plan recommendations and/or interventions: Specify the issue that the patient inquired about during the appointment. List any limiting personal patient factors (i.e., disabilities, religious/cultural preferences). Articulate professional, evidence-based recommendations/interventions provided to the patient. Box 2-6 provides an example of a completed evidence-based patient progress note.

BOX 2-6 Example Documentation: Providing an Evidence-Based Recommendation S—A patient with a chief complaint of dental hypersensitivity when drinking cold beverages presents for routine periodontal maintenance appointment. He inquires about active ingredients he should consider when purchasing a toothpaste to help mitigate his dental hypersensitivity. O—This patient’s clinical attachment levels have decreased due to generalized gingival recession. Exposure of dentinal tubules places patient at higher risk for experiencing hypersensitivity. A—Review of scientific literature (P = experiencing dental hypersensitivity, I = toothpaste with potassium nitrate, C = toothpaste with fluoride, O = reduction in experience of dental hypersensitivity). Evidence found that toothpaste with potassium nitrate has successful clinical outcomes of reduced dental hypersensitivity. (Kopycka-Kedzierawski DT, Meyerowitz C, Litaker MS, et al. Management of dentin hypersensitivity by practitioners in The National Dental Practice-Based Research Network. J Am Dent Assoc. 2017;148(10):728-736.) P—Gave patient both verbal and written instructions on the importance of using toothpaste with potassium nitrate to reduce experience of dental hypersensitivity. American Dental Association’s “Preventing and treating tooth sensitivity” educational pamphlet downloaded from the Internet and given to patient:

http://www.ada.org/~/media/ADA/Publications/Files/FTDP_Sept2013_2.pdf? la=en Next Step: Patient will bring new toothpaste at his next 3-month periodontal maintenance appointment. At next appointment, assess dental hypersensitivity. Signed: ____________________________, RDH Date: ____________________________________

EVERYDAY ETHICS Salim, a dental product representative, is trying to promote their company’s newest desensitizing paste. After conducting a review of the literature related to the efficacy of the active ingredients in the new desensitizing paste, Sanya, the dental hygienist, informs Saira, the office manager, that there is not enough scientific evidence supporting the claim that this new paste is as good or superior to the current desensitizing paste used in their dental clinic. Saira, who has had a good working relationship with Salim and his company for several years, decides to order the new product anyways and tells Sanya that the newer product is considerably less expensive compared to the current product. Saira supports her decision by restating that Salim and his company claim that their desensitizing product is better. Questions for Consideration 1. Why is this situation an ethical issue and dilemma for Sanya? 2. What is the chief concern/problem related to this situation? What are the longterm implications if Sanya is not able to resolve the situation? 3. What core values (Chapter 1, Box 1-6) apply as Sanya considers alternatives for resolving this situation? What personal values might Sanya review as she considers alternative actions to pursue?

Factors to Teach the Patient A result from one study does not necessarily provide the best answer. Take into consideration the type of study, patient’s needs and preferences, and several other factors before making a decision about best-practice interventions. Research methods, study design, source of information, and many other factors can affect the validity, reliability, and usefulness of health-related information.

A statistical significance cited in a study does not necessarily mean that it is the best clinical decision for a patient.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Forrest J, Overman P. Keeping current: a commitment to patient care excellence through evidence based practice. J Dent Hyg. 2013;87(suppl 1):3340. 2. Zimmerman K. Essentials of evidence based practice. Int J Childbirth Educ. 2017;32(2):37-43. 3. Duke University Medical Center Library. Introduction to evidence-based practice. http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036021. Published 2014. Accessed September 15, 2017. 4. Frantsve-Hawley J, Clarkson J, Slot D. Using the best evidence to enhance dental hygiene decision making. J Dent Hyg. 2017;89(suppl 1):39-42. 5. O’Brien P, Broughton-Pipkin F. Introduction to Research Methodology for Specialists and Trainees. 3rd ed. Cambridge, England: Cambridge University Press; 2017. 6. Agency for Healthcare Research & Quality (ARHQ). Strategy 6D: internet access for health information and advice. https://www.ahrq.gov/cahps/qualityimprovement/improvement-guide/6-strategies-for-improving/access/strategy6dinternet.html. Published 2017. Accessed November 1, 2017. 7. U.S. Department of Health and Human Services, National Health Information Center. Your source for reliable health information. Healthfinder.gov Web site. https://healthfinder.gov/. Published 2017. Accessed November 1, 2017. 8. National Library of Medicine. Health information. https://medlineplus.gov/. Published 2017. Accessed November 1, 2017. 9. Medical Library Association. For health consumers and patients. https://www.mlanet.org/p/cm/ld/fid=397. Published 2017. Accessed November 1, 2017. 10. Health on the Net Foundation. Our commitment to reliable health and medical information on the internet. http://www.hon.ch/home1.html. Published 2017. Accessed August 21, 2017. 11. URAC. Health web site. https://www.urac.org/. Published 2017. Accessed August 21, 2017. 12. U.S. National Library of Medicine. MEDLINE fact sheet. https://www.nlm.nih.gov/pubs/factsheets/medline.html. Published 2017. Accessed September 1, 2017. 13. Cochrane. What is Cochrane? http://www.cochrane.org/. Published 2017. Accessed August 21, 2017. 14. Hazra A, Gogtay N. Biostatistics series module 1: basics of biostatistics. Indian J Dermatol. 2016;61(1):10-20. 15. University of North Carolina Health Sciences Library. Evidence based dentistry. http://guides.lib.unc.edu/ebd. Published 2017. Accessed August 25, 2017. 16. Petersen S. Human subject review standards and procedures in international

research: critical ethical and cultural issues and recommendations. Int Perspect Psychol. 2017;6(3):165-178.

3 Effective Health Communication Salima Thawer, MPH, BSc, RDH

CHAPTER OUTLINE TYPES OF COMMUNICATION I. II. III.

Verbal Nonverbal Media Communication

HEALTH COMMUNICATION I. II. III. IV. V.

Skills and Attributes of Effective Health Communicators Attributes of Effective Health Information Barriers to Effective Health Communication Web-Based Health Messages Factors That Influence Health Communication

HEALTH LITERACY I. II.

Health Learning Capacity Assess and Address Health Literacy

COMMUNICATION ACROSS THE LIFE SPAN

I. II.

Children and Adolescents Older Adults

SOCIAL AND ECONOMIC ASPECTS OF HEALTH COMMUNICATION CULTURAL CONSIDERATIONS I. II. III. IV.

Culture and Health Cross-Cultural Communication Attaining Cultural Competence Cultural Competence and the Dental Hygiene Process of Care

INTERPROFESSIONAL COMMUNICATION COMMUNICATION WITH CAREGIVERS DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Discuss the skills and attributes of effective health communication. 2. Identify factors that influence health communication. 3. Explain how the patient’s age, culture, and health literacy level affect health communication strategies. 4. Identify communication theories relevant to effective health communication and motivational interviewing. 5. Health communication is the use of communication strategies to enhance the ability to provide patient-centered health information, motivate positive changes in health behaviors, and achieve improved health outcomes. 6. In the context of dental hygiene care, good communication skills help patients embrace healthy behaviors of all types that allow them to attain and maintain oral health.

TYPES OF COMMUNICATION Communication is a process that involves at least two, and sometimes multiple, individuals. The sender, who intends to communicate some specific concept, encodes and then transmits a message to at least one receiver who decodes the message. This process can then reverse itself and the receiver becomes the sender of a return message that may or may not provide direct feedback to the original message that was sent. The effectiveness of the communication depends on how closely the encoding and decoding match. All communication is either verbal or nonverbal. Each can be subdivided into vocal and nonvocal.

I.

Verbal A form of communication based on language or words. Vocal communication is spoken language. Nonvocal communication is based on signs or signals that express language concepts, and include writing, Braille, and sign language.

II.

Nonverbal Messages expressed by body language or affect can influence or interfere with a healthcare provider’s ability to communicate, perhaps even more than the verbal method used. Nonverbal, vocal factors include: Vocal qualifiers (volume, pitch, tempo, and cadence). Vocal characterizers (crying, laughing). Nonverbal, nonvocal factors include: Body position (posture or use of social space). Movement of body parts such as hands or arms. Eye movements and facial expression.

Appearance (grooming and dress).

III. Media Communication Media communication refers to the use of tools or technology to convey information. Media communication can be directed to: An individual recipient (written care plan provided for an individual patient). A wider, more diverse target audience (patient education brochures developed by a professional association or health information on the Internet). Public health efforts to enhance the health of populations are based on a community-based media approach to providing quality health information. Commercial media efforts, such as television commercials or magazine advertisements for various products, have an astonishing effect on the health-related choices made by targeted audiences.1

HEALTH COMMUNICATION The ultimate goal of health communication is to persuade behavior change that will support optimum health. Healthy People 2020 health communication objectives2 related to direct patient care include: Shared decision making between patients and providers. Personalized, targeted, accurate, accessible, and actionable information, self-management tools, and resources. Increase of health literacy skills.

I.

Skills and Attributes of Effective Health Communicators Healthcare providers who most effectively deliver preventive interventions demonstrate the following during patient interactions3: Expertise and knowledge in health and prevention. Understanding of learning/behavior change theories and principles of good communication. Relationship building skills. Interview and role modeling skills. Assessment for readiness to change behaviors. Attention to the patient’s attitudes and beliefs. Personal attributes of confidence and flexibility. A motivational interviewing approach to patient counseling, based on development and use of those skills, is presented in Chapter 24. The use of “plain language” in both verbal and written health communication can improve patients’ understanding of, and response to, health messages.4 Plain language does not “dumb down” or “talk down” to the patient, but rather provides information in a clear and to the point manner, using words the patient can understand.

II.

Attributes of Effective Health Information

Recommendations made by a health educator are more likely to be effective if the patient perceives the information to be5: Evidence-based, accurate, balanced, and reliable. Consistent with information from other sources. Culturally and linguistically appropriate. Delivered in an easily understood and accessible way. Provided when the patient is most ready to receive it. Repeated and reinforced over time. Health information is often received from a variety of sources, some of which may be biased, incomplete, or conflicting.6 Sources of health information may include: Mainstream media (e.g., TV, newspapers). Educational institutions (e.g., schools). Interactions with other people (e.g., family, friends, colleagues). Web-based resources. Social media. Health professionals. Product labels and pamphlets.

III. Barriers to Effective Health Communication It is rare that every message coded and transmitted by a sender is decoded and understood with complete accuracy by the receiver. Multiple factors that can affect the way health messages are understood are described in Table 3-1. TABLE 3-1 • Barriers to Effective Health Communication BARRIER

DESCRIPTION

Cultural

Differences in social norms or perceptions related to differences in gender, age, language, economic, or ethnic background

Interpersonal

Discomfort related to perceptions about the individual;

appearance causes distraction; individuals do not see “eye to eye” or relate well to each other Attitudinal

Lack of sensitivity or respect; over- or underconfidence displayed by either patient or clinician

Physical

Distractions related to the physical environment; noise levels; face-to-face positioning not used

Physiologic

Inability to hear, see, touch, or vocalize as required to communicate

Psychosociologic

Emotional factors such as fear or pain cause distraction

Insufficient knowledge

Either the clinician is not well informed and cannot provide sufficient information or the patient has low health literacy and cannot understand the information provided

Lack of access to knowledge

Inability to access media or use technology to find information

Lack of interest

Patient is not ready to engage in health behavior change; clinician is experiencing “burn out” or disinterest in patient education

Information overload

Too much information on too many topics is provided at one time; no written reinforcement is provided

Poor communication skills

Either the patient or the clinician is not able to respond or provide feedback to messages received; clinician uses “jargon” or professional terminology that the patient does not understand

Many of the factors listed in the table overlap in their description; more than one barrier may exist and have an effect on any attempt at communication. All of the factors listed can provide a barrier to communication in either direction between the clinician and the patient. Dental hygienists who strive to develop good listening skills, enhance their ability to assess a patient’s needs, and approach each individual with empathy and respect can go far toward overcoming the barriers to effective health communication.

IV. Web-Based Health Messages There has been an explosion of health-related websites and an increasing number of patients of all ages who access Internetbased health information. Patients bring information they find on the Internet or via social media to the attention of their healthcare providers. Healthcare providers are responsible to keep up-to-date on Internet sources of information in order to respond to questions patients may bring to a health education discussion. Healthcare providers may also be the creators and distributors of web-based health information (e.g., websites, digital tools). Considerations should be made to ensure that information is easy for patients to access and understand. The U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion offers a guide and tips to assist in creating user-friendly websites and digital tools (available from: https://health.gov/healthliteracyonline/). The dental hygienist can help patients determine reliability and credibility of websites as well as provide recommendations for highquality resources for patients searching for additional information (see Chapter 2).

V.

Factors That Influence Health Communication

Communication skills of the caregiver and effectiveness of the health information can affect: The ability of healthcare providers to influence health behaviors. The ability of patients and populations to take advantage of new knowledge provided by the health messages. Other factors that influence health communication include: Health literacy of the patient or population receiving the health message. The age and communication preferences of individuals receiving information.

The social and economic ability of the targeted individuals to take advantage of recommendations contained in the health messages. The cultural background and health-related cultural norms of the individual receiving the message. Cultural sensitivity and the ability to establish cultural rapport of individuals providing the health messages.

HEALTH LITERACY Health literacy is the ability of a patient to obtain, process, understand, and respond to health messages and be motivated to make health decisions that promote and maintain good health.7 A large part of even an educated population may have low health literacy, and often, these are the patients with the highest treatment needs and the greatest barriers to receiving health information. Populations particularly vulnerable to low or limited health literacy include6: Older adults. Immigrant populations. Minority populations. People who speak little or no English. People with low levels of education (i.e., less than high school). Individuals living below the poverty level. Low health literacy is associated with less use of healthcare services and resources and ultimately with poorer health outcomes.8

I.

Health Learning Capacity The level of a patient’s health literacy depends on not only the reading level but also the complex interaction of cognitive and psychosocial skills.9 Individuals faced with complex health information need to be able to or learn to10: Access services and navigate complex healthcare facilities and systems. Locate and be able to understand health information. Evaluate information for credibility and quality. Communicate with healthcare providers. Analyze relative risks and benefits of treatment recommendations.

Evaluate test results. Calculate medication dosages. Skills that support health learning capacity are listed in Table 3-2. TABLE 3-2 • Skills and Attributes Necessary to Increase Health Literacy Capacity DOMAIN

SKILLS AND ATTRIBUTES

Cognitive

Knowledge and information (processing ability) Reading and writing Numeracy (mathematical ability) Visual literacy (ability to understand graphs) Comprehension and reasoning ability Appraisal, evaluation, and critical thinking ability Computer literacy (and access)

Behavioral

Information seeking and obtaining ability Communication ability Application of information Navigation ability (of the healthcare system) Civic literacy (ethics and social responsibility)

Affective

Self-control and regulation Self-efficacy Interest and motivation

Source: Bröder J, Okan O, Bauer U, et al. Health literacy in childhood and youth: a systematic review of definitions and models. BMC Public Health. 2017;17(1):361; National Network of Libraries of Medicine. Health literacy: skills needed for health literacy. http://nnlm.gov/outreach/consumer/hlthlit.html#A3. Accessed August 16, 2017.

II.

Assess and Address Health Literacy

To enhance communication with all patients regardless of oral health literacy level11,12: Assess health literacy level and provide an individualized approach for every patient. Ensure a clinic environment that is helpful and user-friendly by providing clear directions, visible and clearly written signs or

universal symbols, and color-coded maps where necessary. Encourage patients to write down and bring questions about their oral health to each appointment. Provide forms (e.g., health history, informed consent) that are written in plain language. Provide help if required in completing forms. Build on the patient’s current knowledge base to encourage healthy decision making. Provide written patient education materials that use plain language and avoid materials that use professional jargon or provide complex explanations. Excellent “plain language” oral health patient education publications have been developed by the U.S. Department of Health and Human Services and are available for free on the National Institute of Dental and Craniofacial Research website (see Figure 3-1).

FIGURE 3-1 • A variety of excellent “plain language” oral health patient education publications have been developed by the U.S. Department of Health and Human Services, National Institutes of Health, and are

available for free from the National Institute of Dental and Craniofacial Research website at: https://catalog.nidcr.nih.gov/OrderPublications/. Accessed September 2, 2017.

Use visual aids such as drawings or photographs for education materials when appropriate (see Figure 3-2).

FIGURE 3-2 • This example, which uses drawings to provide patient education, is taken from the illustrated booklet “Three Good Reasons to See a Dentist BEFORE Cancer Treatment.” Illustrated patient education materials are appropriate for adults with reading skills at the second grade level or below and for children. This entire publication can be downloaded or ordered from the NIDCR website at: https://catalog.nidcr.nih.gov/OrderPublications/. Accessed September 2, 2017.

Monitor to determine understanding of all forms and education materials. The “teach-back” method of asking patients to explain instructions to be followed is a helpful approach.

COMMUNICATION ACROSS THE LIFE SPAN Irrespective of the patient’s age, building rapport is key to effective health communication. Tips for establishing rapport with patients of all ages are found in Box 3-1.

BOX 3-1 Tips for Establishing Rapport with Patients of All Ages • Listen more than talk, especially at the beginning of a conversation. • Practice attentive listening rather than multitasking during conversations. • Sit eye to eye with the patient rather than with the patient in a reclined position or standing/sitting taller than the patient does. • Convey a nonjudgmental attitude, reinforce an atmosphere of respect and valuing of the individual, even if the behavior is not acceptable. • Maintain a calm, unhurried demeanor. • Use a normal tone of voice and vocabulary that is appropriate, but does not talk down, to the patient. • Look for clues, share your thoughts and observations, and ask questions. • Do not jump to conclusions. • Link information to activities of daily living to help provide context for recommendations.

Key points related to specific age groups are discussed in the subsequent sections.

I.

Children and Adolescents Complete information about the oral health needs of children and adolescents is found in Chapter 47. Some age-appropriate communication strategies are listed below.13

A. Infants (Birth to 12 Months)

Infants communicate primarily through their senses of touch, sight, and hearing. Techniques the clinician can use to communicate with an infant during a dental hygiene examination include: Interact playfully with a receptive infant by mimicking facial expressions, rocking, and talking softly or singing. Encourage an adult who is familiar with the infant to distract and comfort the child. Wait until the infant is calm to approach closely.

B. Toddlers and Preschoolers (Ages 1–2 and 3–5) Although dependent on adults for their care, most children appreciate and respond to being approached directly. Development of a sense of self enhances the need to assert independence and maintain control over any situation. Offer encouragement and gentle hints or engage in “parallel” actions to demonstrate, rather than directly assisting, to promote success in age-appropriate self-care tasks. Calmly distract or direct toward an alternative behavior to counter defiance or inappropriate behavior. To effectively control unwanted behavior, state specifically what the child is expected to do rather than criticize. Ask simple, specifically focused questions to help the child remember past experiences. To overcome the limited ability to process auditory information and short attention span, provide brief, truthful, and simple instructions and responses to questions. Toddlers are beginning to converse in short sentences, but if the adult becomes impatient or abrupt, the child may feel frustrated or ashamed and become unresponsive. Children of this age understand more than they are given credit for but often misinterpret language that is not familiar to them; therefore, serious discussions or use of certain words may distress them.

C. School-Age Children (6 Through 11) The ability to understand serious events logically and comprehend how it will impact themselves is developing. More aware of the needs of others but may be reluctant to state their own needs. Including the child as well as the parent/caregiver in the interaction is important; however, the level of involvement of each child will vary depending on individual factors.14 The ability and desire to respond to simple questions can allow the dental hygienist to assess knowledge and misconceptions.

D. Adolescents (12 Through 21) Marked by intense and often extreme feelings about situations and persons in their world. Strongly independent and desire to have their viewpoint considered with respect. Tendency to withdraw or become hostile if they feel they are misunderstood. A straightforward approach that explains and then solicits input into a discussion on topics that interest the adolescent is most effective to build rapport and establish trust. Confidentiality laws, which vary between jurisdictions, can help determine what behavior-related information the dental hygienist discusses with a parent or guardian. Anything that is an immediate safety issue (such as thoughts of suicide) is reported immediately. To develop a rapport and a trusting relationship with an adolescent patient: Address the adolescent directly even when parent/guardian is present. Ensure the adolescent has the opportunity to ask and answer questions independently (privately) as well as with parents/guardians.15

II.

Older Adults16,17 Oral health issues related to aging are discussed in Chapter 48. Providing effective health education for aging patients who are experiencing a communication difficulty requires respect for the needs of the individual and response to functional ability or limitations. Age-related communication difficulties can include: Visual or hearing impairment. Decreased ability to remember or formulate language. Health conditions and related medications that may alter cognitive abilities. Strategies for communicating with older individuals experiencing communication difficulty are listed in Box 3-2.

BOX 3-2 Strategies for Effective Communication with Older Adults • Identify each individual’s communication barriers (such as cognitive impairments) and modify communication approach appropriately. • Avoid patronizing “elderspeak” and respect the patient’s level of competence and independence. • Suggest that the patient write down questions ahead of time. • Practice attentive listening and avoid rushing the patient. • Face the patient and maintain eye contact; remove masks during conversations. • Speak slowly, clearly, and loud enough for the patient to hear. • Use simple, patient-appropriate language. • Present one idea at a time. • Use visual aids, teach-back techniques, and repetition of key messages. • Provide written summary or follow-up for key messages.

A. Physical and Cognitive Changes Cognitive disabilities are more likely to be present as an individual ages and to interfere with understanding health-related information.

Communication disorders such as dysarthria and aphasia are associated with conditions that are more common in an aging population. Sensory loss (particularly hearing loss) can provide challenges in interpersonal communication. Physiologic changes may occur in speech patterns, including voice tremor, pitch, loudness, and speaking rate.

B. Communication Predicament17-19 Healthcare providers often use an inappropriate overmodification of speech and language when addressing older patients. Accommodative speech refers to use of a high-pitched tone of voice, a “singsong” cadence, and relatively simplistic language when addressing an older adult. The use of terms of endearment (honey, sweetie, dearie) and diminutive forms of a patient’s name can reflect a lack of respect for the individual as an adult person. The use of plural pronouns (“Are we ready for our appointment?”) can imply that the patient cannot act alone or make independent decisions. This “baby talk” or “elderspeak” approach to communication does not enhance comprehension and can be perceived as patronizing or demeaning.

SOCIAL AND ECONOMIC ASPECTS OF HEALTH COMMUNICATION Social and economic factors, sometimes referred to as “social determinants of health,” are the circumstances in which people are born, grow up, live, work, play, and age.20 These factors: Influence the ability of individuals and communities to receive and act upon health messages received from healthcare providers or public health media. Are responsible for unfair and avoidable differences in health status seen within and between populations.20,21 Oral health professionals have a responsibility to address the needs of individuals in the context of their environment and experience when providing oral health education.21-23

CULTURAL CONSIDERATIONS Sociocultural differences can impede communication between the dental hygienist and patient.24 Culturally sensitive delivery of dental hygiene services can make a positive difference in oral health outcomes.24 A cultural awareness checklist is found in Box 3-3.

BOX 3-3 A Checklist to Enhance Cultural Awareness during Patient Care • Examine and recognize any personal bias that may affect communication when working with patients from a different culture. • Conduct all patient assessments with cultural sensitivity in mind. • Assess to determine the patient’s cultural identification and, if necessary, research to identify implications for dental hygiene practice. • Determine language barriers, identify patient’s preferred method of communication, and regularly double-check to assure comprehension. • Identify religious and health-related beliefs, views, or misconceptions that may influence dental hygiene interventions. • Identify and address cultural dietary considerations. • Double-check verbal and nonverbal signs routinely to determine the level of the patient’s trust of healthcare providers. Source: Seibert PS, Stridh-Igo P, Zimmerman CG. A checklist to facilitate cultural awareness and sensitivity. J Med Ethics. 2002;28(3):143-146.

I.

Culture and Health

A. Effects of Culture on Health Status The increasing diversity of racial and ethnic communities and linguistic groups in North America influences the delivery of oral health services. Health disparities related to racial, ethnic, and socioeconomic background exist in the healthcare system.25

Ignoring culture can lead to negative health consequences and/or poor clinical outcomes because culture and language can influence: Beliefs and behaviors related to health, healing, and wellness. Perceptions of illness, diseases, and their causes. Attitudes of patients toward accessing health services or toward healthcare providers. Attitudes and behaviors of providers who may have learned a set of values that are different from those of their patients.

B. Culturally Effective Oral Care24 Culturally effective health care is patient centered and “responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.”26 Sensitivity to the effects of culture on healthcare delivery is “critical to reducing health disparities and improving access to high-quality health care.”27 Meeting each patient’s individual oral care needs is the hallmark of dental hygiene practice. The ability to provide effective oral health education and dental hygiene services for culturally diverse patients requires assessing, being sensitive to, and respecting each patient’s cultural differences. Culturally effective dental hygiene care respects each patient’s health beliefs, practices, values, customs, and traditions in the plan for dental hygiene care.

II.

Cross-Cultural Communication Communication with patients from other cultures is enhanced when the dental hygienist develops knowledge about and avoids stereotyping traditional behaviors and values of a patient’s cultural group. Knowing general principles can enhance communication.

A. Nonverbal Communication Some culturally related differences in nonverbal communication are identified in Table 3-3. TABLE 3-3 • Nonverbal Communication and Cross-Cultural Considerations ATTRIBUTE

EXPLANATION

Facial expressions

Smiling, winking, and blinking may not signify the same intent in all cultures. People from some cultures point at an object by shifting eyes or pursing lips because pointing with a hand or finger is inappropriate. Expressions of pain and discomfort may differ among cultures or according to family experiences. Some cultures value stoicism, while others seem to emote effusively.

Gestures

Hand signs can be interpreted in many ways among cultures. Some commonly used gestures, such as the “OK” fingerthumb circle shape or the “thumbs-up” gesture, have vulgar connotations for members of some cultures.

Head movements and physical postures

Head movement signs for “yes” and “no” vary greatly in some cultures. Some cultures nod head (as in “yes”) to indicate attention to or respect for the speaker—even if the answer to the question is not yes or if they do not understand what is being said. Standing with hands on hips might indicate a challenge to members of some cultures. Many cultures consider slouching or poor posture as a sign of disrespect. Showing the bottom of the shoe (resting foot on top of knee while sitting) is considered impolite in some cultures.

Personal space and touching

Individuals from some cultures are accustomed to standing or sitting very close and sometimes touching, even during casual interactions; others may express alarm if the provider stands or sits too close. A light touch, a brief kiss on the cheek, or warm handshake is common in some cultures, even among people who have just met or individuals of the same gender. In some cultures, such physical contact may be extremely inappropriate.

In some cultures, touching or accepting an article with the left hand is considered unclean. Eye contact

In some cultures, making direct eye-to-eye contact is a sign of respect; in others, it is a sign of disrespect especially if done by a child or toward an authority figure such as a healthcare provider. The “languid” or half-closed eyes of individuals from some cultures is not necessarily a sign of disrespect or inattention.

Source: Management Sciences for Health Electronic Resource Center. The Provider’s guide to quality & culture: non-verbal communication. https://www.innovations.ahrq.gov/qualitytools/providers-guide-quality-culture-0

To communicate successfully, the dental hygienist will: Follow the patient’s lead for touching or personal space. Use hand and arm gestures with caution. Be careful interpreting facial expressions. Follow the patient’s lead for making eye contact.

B. Language Proficiency Simplify language as much as possible without speaking down to the patient. Eliminate professional jargon. Use pictures, diagrams, and demonstrations to help increase understanding. Provide “plain language” health information or publications in the patient’s primary language to reinforce and support compliance with oral health recommendations.

C. Using an Interpreter When the patient’s skills in the dominant language are not sufficient to assure informed consent or compliance with recommendations, a professional interpreter can be used to enhance communication. A professional interpreter will have proficiency in both languages as well as an ability to convey complex information completely and

accurately. Family members or friends are not the same as a professional interpreter. Informal interpreters could hinder health communication28 and are more likely to modify important information or interject their own opinions, beliefs, or prejudices. It is particularly inadvisable to ask children to interpret sensitive health information. Focus on and direct all communication to the patient, with pauses to allow the interpreter to translate.

D. Family Decision Making In many cultures, an individual’s health problem is considered to be a family problem. Involvement of certain family members in the treatment planning process may be a key factor in determining recommendations and assuring compliance. Sensitivity is needed when family members or children, even older children, are involved in the discussion.

III. Attaining Cultural Competence Achieving cultural competence in providing health care is a process29 that requires a commitment to cultural awareness, a motivation to engage in cultural encounters, and an ongoing acquisition of cultural knowledge and communication skills. The dental hygienist who strives to become adept at providing culturally effective care: Values (and not simply tolerates) diversity. Conducts honest self-assessment to determine how personal health beliefs, traditions, and biases influence the ability to relate to culturally different individuals. Actively acquires knowledge about patients’ health beliefs, behaviors, and cultural norms.

Is nonjudgmental regarding cultural traditions and beliefs. Avoids stereotypes. Routinely adapts delivery of dental hygiene care in a way that reflects understanding of each patient’s diversity and unique oral health needs.

IV. Cultural Competence and the Dental Hygiene Process of Care Respect for each patient’s cultural differences, healthcare practices, health beliefs, and values can be integrated into all areas of the dental hygiene process of care.30

A. Assessment The ability to collect accurate, complete assessment data is key to providing dental hygiene interventions that meet patient needs. Culturally effective nonverbal communication and listening skills help build trust and patient rapport that can facilitate the transfer of essential personal health information. Skillful, nonjudgmental questioning can help elicit culture-specific data such as health beliefs and values, as well as avoid misunderstandings about a patient’s culturally related health practices. Asking permission before touching a patient during the extra- and intraoral examination procedures can avoid problems with cultural differences in personal space.

B. Diagnosis A dental hygiene diagnosis is predicated on a clear understanding of the patient’s history, medical status, symptoms, and current treatment modalities. The culturally competent dental hygienist will prepare diagnostic statements that take into consideration:

Culture-specific health risks that are related to oral status. Cultural practices that may impact the patient’s oral health status.

C. Planning The dental hygiene care plan formulates oral health goals that meet the needs of each individual patient realistically. The goals identified in the plan are based on a synthesis of needs determined by the dental hygienist and those expressed by the patient. A culturally sensitive dental hygiene care plan respects and takes into consideration the patient’s current health practices and beliefs. With the patient’s input, the plan may be devised to accept, modify, or eliminate current culturally relevant healthcare practices. The plan is sensitive to the practices, products, or substances that the patient’s culture prohibits, such as mouth rinses containing alcohol for patients in some cultures. A culturally and linguistically sensitive approach to communicating the dental hygiene care plan can facilitate informed consent for dental hygiene interventions.

D. Implementation Culturally appropriate communication can enhance the patient’s cooperation during treatment. Knowledge of culturally determined expressions of pain and discomfort during treatment can help the dental hygienist determine appropriate pain control measures during treatment. Language-appropriate instructions before, during, and after each procedure can enhance patient compliance with treatment. “Plain language” oral health materials can enhance patient compliance with recommendations.

E. Evaluation

A dental hygienist who is sensitive to cultural differences evaluates treatment success on the basis of goals determined in a previously prepared culturally relevant care plan. Feedback provided for the patient respects culturally diverse beliefs and values related to oral health. Self-evaluation regarding the cultural effectiveness of the practitioner’s approach can provide insight for planning modifications to the patient’s continuing care plan.

INTERPROFESSIONAL COMMUNICATION Interprofessional collaboration is changing the way health care is delivered and resulting in positive health care outcomes.31,32 Teamwork is a vital skill that relies on collaboration between a variety of healthcare providers who have responsibility for the often complex aspects of an individual patient’s care. Sufficient and ongoing communication is a major factor in developing a collaborative practice workforce that strengthens healthcare systems, provides high-quality care, and supports positive patient outcomes.31,33,34 Continuous efforts to enhance interprofessional communication are necessary to improve the quality of patient care.34,35 The ability to communicate with other health professionals in a manner that supports a team approach to patient care requires competency in the following skills33: Select effective communication tools and techniques, including information systems and communication technologies. Organize and express information in a form that is easily understood by providers in other health disciplines. Demonstrate active listening; encourage others to share ideas and opinions. Provide timely, sensitive, and instructive feedback to other members of the team. Be open to receiving feedback in a respectful and positive manner. Use respectful language when in a difficult situation or a professional conflict. Recognize how one’s own communication style contributes to the interprofessional relationship. Consistently communicate the importance of teamwork in patient-centered care.

COMMUNICATION WITH CAREGIVERS Many patients with disabling conditions and also young children rely on someone else to help with or provide daily self-care regimens. In this situation, the dental hygienist communicates with the caregiver or parent as well as the patient. In a group conversation, keep the primary focus on the patient by maintaining eye contact and directing comments/questions to the patient, if appropriate, as well as the caregiver. Assess patient needs and caregiver relationships carefully to determine the extent of the caregiver’s role in daily self-care. Encourage the caregiver to allow the patient to maintain as much independence as possible.

EVERYDAY ETHICS Abelena Flores, a 65-year-old Mexican American female, presents to the clinic for the first time for her initial assessment appointment. Mrs. Flores speaks English moderately well, but Lisel, the dental hygienist, notices that she is not able to read the health history and seems to be confused during more complex explanations. Lisel offers to obtain a medical translator for the next appointment, but Mrs. Flores insists that her son, who speaks English, and her son’s new wife, who does not speak English, will accompany her to help interpret and make decisions about the treatment plan that Lisel will present to her at that visit. Lisel is concerned that the family members will not be knowledgeable enough to be able to explain the needed treatment so that informed consent can be obtained. Lisel considers arranging for a friend who is a medical translator to be present without telling Mrs. Flores beforehand. Lisel knows that her patient will not be charged for that service because the medical translator is a volunteer who has provided free translation services at the clinic in the past. Questions for Consideration 1. Is this an ethical issue or an ethical dilemma for Lisel? 2. Explain which core values (Chapter 1, Box 1-6) Lisel will need to consider as she determines what action to take regarding the use of a translator during Mrs. Flores next appointment. 3. How might personal values related to Lisel’s and Mrs. Flores’ cultural

differences affect Lisel’s ethical duty in resolving this situation?

DOCUMENTATION When documenting communication aspects of a patient visit, the following factors are included: Patient’s age, gender, and ethnicity. Factors or observations related to health literacy level. Cultural characteristics that can affect communication or delivery of dental hygiene care. Significant factors such as patient hearing loss, need to communicate with caregiver, use of an interpreter, and description of specific modifications made to accommodate those factors. An example of documentation for communication aspects of a patient visit is found in Box 3-4.

BOX 3-4 Example Documentation: Communication Aspects of a Patient Visit S—Following an initial data collection appointment, a 65-year-old AfricanAmerican male presents for a second appointment to receive and discuss his complex treatment plan. Patient has significant hearing loss and does not use a hearing aid but reads lips during casual conversation. He prefers to ask complex questions and receive answers by writing on a notepad. O—Written dental hygiene care plan and dental treatment plans have been developed and are ready to be presented for patient consent. A—Patient understanding is necessary for documenting informed consent. P—Sequential presentation of each written component of the dental hygiene care plan and dental treatment plan. Additional appointment time scheduled so all questions can be answered in writing, as the patient prefers. Following the presentation of each component of the plan, the patient was asked to summarize or restate in writing to demonstrate that he understood what was discussed. At the end of the discussion, the patient wrote on his notepad that all of his questions were answered. Treatment Consent form was signed and dated. Next Step: Begin implementation of phase 1 of dental hygiene care plan. Signed: ______________________________, RDH Date: ____________________________________

Factors to Teach the Patient The dental hygienist’s ability to provide good dental hygiene care is affected by the willingness and ability of the patient to communicate accurate and complete information about health status, needs, and concerns. The patient’s motivation to follow oral health recommendations is affected by the rapport established and the trust developed between the patient and the clinician.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Boyland EJ, Nolan S, Kelly B, et al. Advertising as a cue to consume: a systematic review and meta-analysis of the effects of acute exposure to unhealthy food and nonalcoholic beverage advertising on intake in children and adults. Am J Clin Nutr. 2016;103(2):519-533. 2. Office of Disease Prevention and Health Promotion. Healthy People 2020 topics and objectives: health communication and health information technology [Web page]. Washington, DC: U.S. Department of Health and Human Services. https://www.healthypeople.gov/2020/topics-objectives/topic/healthcommunication-and-health-information-technology/objectives. Accessed September 17, 2017. 3. Burke LE, Fair J. Promoting prevention: skill sets and attributes of health care providers who deliver behavioral interventions. J Cardiovasc Nurs. 2003;18(4):256-266. 4. National Institutes of Health. Plain language [Web page]. http://www.nih.gov/clearcommunication/plainlanguage/index.htm. Accessed September 17, 2017. 5. U.S. Department of Health and Human Services. Healthy People 2010: Objectives for Improving Health. Part A, Focus Area 11-Health communication:11.3–11.22. Vol 1. 2nd ed. Washington, DC: U.S. Government Printing Office; 2000. 6. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National Action Plan to Improve Health Literacy. Washington, DC: U.S. Department of Health and Human Services; 2010. https://health.gov/communication/hlactionplan/pdf/Health_Literacy_Action_Plan.pdf Accessed September 17, 2017. 7. Centers for Disease Control and Prevention. What is health literacy? [Web page] https://www.cdc.gov/healthliteracy/learn/index.html. Accessed September 17, 2017. 8. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97-107. 9. Bröder J, Okan O, Bauer U, et al. Health literacy in childhood and youth: a systematic review of definitions and models. BMC Public Health. 2017;17(1):361. 10. National Network of Libraries of Medicine. Health literacy: skills needed for health literacy [Web page]. https://nnlm.gov/priorities/topics/health-literacy#toc4. Accessed September 17, 2017. 11. Horowitz AM, Kleinman DV. Oral health literacy: the new imperative to better oral health. Dent Clin North Am. 2008;52(2):333-344, vi. 12. Horowitz AM, Kleinman DV. Creating a health literacy-based practice. J Calif Dent Assoc. 2012;40(4):331-340.

Deering C, Cody D. Communicating with children and adolescents. Am J Nurs. 13. 2002;102(3):34-41. 14. Cahill P. The Third Voice in the Consultation. Listening to Children and Young People in Healthcare Consultations. Oxford, England: Radcliffe Publishing Ltd; 2010:31-43. 15. Mappa P, Baverstock A, Finlay F, Verling W. Current practice with regard to seeing adolescents on their own’ during outpatient consultations. Int J Adolesc Med Health. 2010;22(2):301-305. 16. Yorkston KM, Bourgeois MS, Baylor CR. Communication and aging. Phys Med Rehabil Clin N Am. 2010;21(2):309-319. 17. Stein PS, Aalboe JA, Savage MW, Scott AM. Strategies for communicating with older dental patients. J Am Dent Assoc. 2014;145(2):159-164. 18. Brown A, Draper P. Accommodative speech and terms of endearment: elements of a language mode often experienced by older adults. J Adv Nurs. 2003;41(1):15-21. 19. Williams K, Kemper S, Hummert ML. Enhancing communication with older adults: overcoming elderspeak. J Gerontol Nurs. 2004;30(10):17-25. 20. World Health Organization. Social determinants of health: what are social determinants of health? [Web page]. http://www.who.int/social_determinants/sdh_definition/en/. Accessed September 17, 2017. 21. Williams DM, Sheiham A, Watt RG. Oral health professionals and social determinants. Br Dent J. 2013;214(9):427. 22. Lee JY, Divaris K. The ethical imperative of addressing oral health disparities: a unifying framework. J Dent Res. 2014;93(3):224-230. 23. Watt RG, Williams DM, Sheiham A. The role of the dental team in promoting health equity. Br Dent J. 2014;216(1):11. 24. Cadoret CA, Garcia RI. Health disparities and the multicultural imperative. J Evid Based Dent Pract. 2014;14:160-170. 25. Agency for Healthcare Research and Quality. 2016 National Healthcare Quality and Disparities Report. Rockville, MD: U.S. Department of Health and Human Services. https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/nhqdr16/2016qdr.p Accessed September 17, 2017. 26. U.S. Department of Health and Human Services Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. https://www.thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedNationalCLASStandards.pdf Accessed September 17, 2017. 27. National Institutes of Health. Clear communication: cultural respect [Web page]. https://www.nih.gov/institutes-nih/nih-office-director/officecommunications-public-liaison/clear-communication/cultural-respect. Accessed September 17, 2017. 28. Au M, Taylor EF, Gold MR. Improving Access to Language Services in Health Care: A Look at National and State Efforts. Washington, DC: Mathematica

Policy Research, Inc; 2009. 29. Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services: a model of care. J Transcult Nurs. 2002;13(3):181-184. 30. Fitch P. Cultural competence and dental hygiene care delivery: integrating cultural care into the dental hygiene process of care. J Dent Hyg. 2004;78(1):11-21. 31. World Health Organization. Framework for Action on Interprofessional Education & Collaborative Practice. Geneva, Switzerland: World Health Organization; 2010. http://www.who.int/hrh/resources/framework_action/en/. Accessed September 17, 2017. 32. Reeves S, Pelone F, Harrison R, Goldman J, Zwarenstein M. Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2017;(6):CD000072. 33. Interprofessional Education Collaborative. IPEC Core Competencies for Interprofessional Collaborative Practice: 2016 Update. Washington, DC: Interprofessional Education Collaborative; 2016. http://www.asha.org/uploadedFiles/Interprofessional-Collaboration-CoreCompetency.pdf. Accessed September 17, 2017. 34. Kishimoto M, Noda M. The difficulties of interprofessional teamwork in diabetes care: a questionnaire survey. J Multidiscip Healthcare. 2014;7:333-339. 35. Hepp SL, Suter E, Jackson K, et al. Using an interprofessional competency framework to examine collaborative practice. J Interprof Care. 2014;10:1-7.

4 Dental Hygiene Care in Alternative Settings Jennifer Cullen, RDH, MPH, and Charlotte J. Wyche, BSDH, MS

CHAPTER OUTLINE ALTERNATIVE PRACTICE SETTINGS I. II. III.

Barriers to Access Eliminating Barriers Portable Delivery of Care

RESIDENCE-BOUND PATIENTS I. II. III.

Private Homes Residential Facilities Community-Based Settings

DENTAL HYGIENE CARE I.

Common Oral Problems and Conditions

II. III. IV. V. VI. VII. VIII. IX.

Significance of Oral Health to Overall Health Objectives of Care Preparation for the Residential Visit Approach to Patient Treatment Location Additional Considerations Assessment and Care Planning Strategies for Prevention and Management

THE CRITICALLY ILL OR UNCONSCIOUS PATIENT I. II.

Instructions for Caregivers Toothbrush with Suction Attachment

THE TERMINALLY ILL PATIENT I. II.

Objectives of Care General Mouth Care Considerations

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT FACTORS TO TEACH THE CAREGIVER REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Identify and define key terms and concepts related to oral health care in alternative settings. 2. Identify materials necessary for providing dental hygiene care in alternative settings. 3. Plan and document adaptations to dental hygiene care plans and oral hygiene instructions for the patient who is residence-bound, bedridden, unconscious, or terminally ill. In recent years, increasing attention is being paid to the oral health needs of individuals who are not able to access oral health services

in a traditional dental practice setting.1 Individuals confined to hospitals, hospices, institutions, skilled nursing or long-term care facilities, or private homes: Experience barriers accessing routine dental services. Receive inadequate oral care from caregivers. Are likely to have poor oral health status and diminished quality of life. May need special adaptations for oral care. Most states now have laws that allow direct access to dental hygiene services through collaborative practice or varying levels of supervision in certain public health settings.2 An important role for the dental hygienist is to triage and ensure optimum use of available dental care resources. Key words and definitions related to caring for patients in alternative settings are found in the glossary.

ALTERNATIVE PRACTICE SETTINGS In recent years, increasing attention is being paid to the oral health needs of individuals who are not able to access oral health services in a traditional dental practice setting. Individuals confined to hospitals, hospices, institutions, skilled nursing or long-term care facilities, or private homes: Experience barriers accessing routine dental services. Receive inadequate oral care from caregivers. Are likely to have poor oral health status and diminished quality of life. May need special adaptations for oral care. Most states now have laws that allow direct access to dental hygiene services through collaborative practice or varying levels of supervision in certain public health settings. An important role for the dental hygienist is to triage and ensure optimum use of available dental care resources.

I.

Barriers to Access3,4

In addition to universal barriers such as cost and fear, providing care in alternative settings can also address unique barriers faced by this population. Barriers to access for the residence-bound population may include: Limited mobility. Lack of suitable transportation. Often inaccessible physical environment of dental offices. Few on-site dental clinics in residential facilities. Limited availability of general and specialty practitioners who provide home-based services. Limited availability of direct access allied oral health providers. Limited or nonexistent federal/state insurance coverage for dental services for adults and older adults.5

II.

Eliminating Barriers

Many services are delivered to residence-bound individuals by home health agencies. Certain allied health professionals, such as nurse practitioners, oversee programs that provide direct medical services for patients. New models of healthcare delivery, such as teledentistry, use Web-based communication tools to enhance potential for collaboration between on-site and supervising health team members. Current public health programs in numerous states allow dental hygienists to provide direct access care for certain underserved populations. Direct access care providers can address access issues related to shortage of dentists, limited availability of safety net options for lowincome populations, and need for care in nontraditional settings.6,7 Several direct access oral health provider models are currently being explored; some models are based on increased scope of practice for dental hygienists who have received additional education and certification.8

III. Portable Delivery of Care For patients who cannot be transported to a dental treatment room, dental and dental hygiene services can be provided in a variety of surroundings using mobile equipment. Dental hygiene care: Can be provided in any setting within the limits of state practice acts. Particularly lends itself to care for residence-bound individuals because most dental hygiene treatments can be completed with manual instruments.

RESIDENCE-BOUND PATIENTS Potential residence-bound patients are listed in Box 4-1.

BOX 4-1 Potential Residence-Bound Patients • • • • • •

Frail elderly Severely medically compromised Critically or terminally ill Physically or developmentally disabled Chronically ill Cognitively impaired

The individual who is residence-bound may be: Limited in one or more activities of daily living (see Chapter 22). An American Society of Anesthesiologists’ classification of III or higher (see Chapter 22). Functionally dependent on caregivers. Instruction in personal oral preventive procedures has particular significance for comfort and quality of life, as well as the systemic health of these individuals.

I.

Private Homes

Individuals who are residence-bound might live alone or with partner, spouse, friend, family members, or other caregivers. A private, traditional neighborhood residence. A variety of home-based healthcare and custodial care services are often utilized.

II.

Residential Facilities

Studies indicate individuals residing in nursing homes generally have poor oral health status, do not receive adequate daily oral care, and cannot adequately access routine dental services.3,9,10 Residential facilities can include: Skilled nursing or long-term care including memory loss care. Rehabilitation centers that provide temporary support for patients. Independent and assisted living facilities for seniors or disabled individuals. Group homes that serve adults of all ages with physical, mental, or other medical disability. Federal regulations: Require residential facilities that receive Medicaid or Medicare funding to contract with qualified dental personnel. Do not require skilled nursing facilities to cover the costs of dental care. Require facilities to assist residents in obtaining certain services (Box 4-2).

BOX 4-2 Services for Residents at Facilities That Receive Medicaid or Medicare Funding Federal regulations require a facility receiving Medicaid or Medicare funding to help residents obtain the following services11: • Comprehensive assessment of dental status • Routine as well as emergency dental services • Transportation to and from dental appointments • Prompt referral to a dentist for lost or damaged dentures • Supplies related to oral health (e.g., toothbrush, dental floss) at no cost to the individual

State regulations vary significantly: Regarding the provision of dental services for both Medicaideligible and -noneligible individuals.12 In terms of frequency of examinations or elements included in

routine or emergency care. In terms of requiring facilities contract with a dentist to advise on policies and education.

III. Community-Based Settings Community-based settings for alternative dental hygiene practice may include: Senior/adult day programs and aggregate meal sites. Work/activity centers for disabled individuals. Medical practices. Homeless shelters and transitional housing programs. Churches. Elementary and secondary schools (some already provide schoolbased medical care) (Chapter 35). Head Start and day care centers.

DENTAL HYGIENE CARE I. Common Oral Problems and Conditions Residence-bound patients often experience compromised daily oral care and/or infrequent routine dental care.9,10 Oral complications due to chronic disease, treatments, and medications can result in further pain and dysfunction.13,14 Studies have found the following problems and conditions are frequently identified on clinical examination9,10,13,14: Periodontal infections. Difficulty biting and chewing. Dental caries, especially root caries. Toothache/pain and abscess/swelling. Trauma, fractured/loose teeth, or dental restorations. Lost fillings/crowns. Angular cheilosis. Clenching/bruxism. Xerostomia. Candidiasis infection. General oral soreness (mucositis). Denture problems. Table 4-1 identifies strategies for the prevention and management of select conditions. TABLE 4-1 • Strategies for Prevention and Management: Residence-Bound, Critically Ill, and Terminally Ill Patients COMMON PROBLEMS

STRATEGIES FOR PLANNING DENTAL HYGIENE CARE (BASED ON ASSESSMENT OF INDIVIDUALIZED PATIENT NEEDS)

Barriers to professional oral care

Assess and triage patient needs Provide dental hygiene care Refer/facilitate access for dental treatment

Inadequate biofilm

Assess patient activities of daily living levels, emotional

removal

status, and knowledge related to ability to perform selfcare regimens Educate about the role of biofilm in oral and systemic disease Provide oral hygiene aids or develop adaptive measures that facilitate self-care Train caregivers, as necessary, to provide daily oral care

Increased risk for dental caries

Identify/treat/prevent xerostomia Provide professional and/or home fluoride application Provide dietary analysis Educate about reducing intake of fermentable carbohydrates Educate about effective plaque removal Engage caregivers, as necessary, to limit food/drink that promotes caries

Increased risk for periodontal infections

Provide dental hygiene care Educate about the relationship between oral disease and systemic health Provide oral hygiene aids or develop adaptive measures that facilitate self-care Train caregivers, as necessary, to provide daily oral care

Inadequate nutritional intake

Assess for oral pain or inadequate chewing function that may be affecting the patient’s nutritional intake Severe weight loss can compromise denture fit Consult with staff nutritionist, if available, in the patient’s residential setting Educate patient or caregivers, as necessary, regarding oral status and potential for compromised nutritional status

Oral pain/dysfunction

Provide oral examination to identify oral/mucosal lesions Document and follow-up on patient complaints of oral pain Collaborate with patient’s healthcare or palliative care team to advocate for dental needs Train caregivers, as necessary, to provide regular oral inspection and record observations

Trauma

Monitor patient for signs of abuse and neglect Monitor/educate about potential for facial/oral trauma during a fall Educate about protocols for oral injury emergency care

Xerostomia25,27

Identify medications with a potential for causing xerostomia Eliminate the use of oral products with alcohol, glycerin, or lemon Educate about using sips of water or ice chips to relieve dryness Use atomizer to help control the volume of water to avoid pooling or aspiration Encourage use of over-the-counter saliva substitutes Recommend use of nonsucrose-containing candies or gums Train caregiver, as necessary, to identify/treat signs and symptoms

Candidiasis (and other oral infections)25,27

Educate about increased risk with use of prolonged antibiotic therapy Educate about signs and symptoms of infections Recommend topical or systemic antifungal treatment Educate about effect of oral infections on systemic health Train caregivers, as necessary, to identify/treat signs and symptoms

General oral soreness (mucositis)25,27

Monitor and document active lesions Educate about daily inspection of tissues and need for immediate care to avoid secondary infections Select saline mouth rinses, wax- or water-based lubricants, or topical anesthetics for comfort care

Denture problems25,27

Inspect denture or prosthesis and adjacent soft tissue Educate about exacerbation of oral problems/lesions due to ill-fitting denture Educate about weight loss impact on fit of denture Educate about accumulation of pathogenic biofilm on unclean denture Soft reline material and proper daily care may address acute issues Denture-induced lesions are described in Chapter 30

II.

Significance of Oral Health to Overall Health

A growing body of evidence supports the interdependent relationship between oral health and systemic conditions.15 Residence-bound patients have additional challenges:

Physical and cognitive limitations can compromise daily personal oral care abilities. Oral pain/discomfort/dysfunction can compromise nutritional status. Pain, including oral pain, can exacerbate negative behaviors in the cognitively impaired patient. Oral health status and oral cleanliness can affect patient selfesteem, quality of life, and ability to communicate with family and caregivers.

III. Objectives of Care The objectives of dental hygiene care of residence-bound individuals will vary according to the patient’s situation and needs. A dental hygienist providing care in a residential setting may: Provide intraoral/extraoral screening to triage and refer patients who need treatment by a dentist or specialist. Assist in preventing further complication of the patient’s health status by identifying oral infections and other problems. Provide routine screening to detect lesions that may be pathologic, particularly those that may be early cancer. Provide dental hygiene treatment and education interventions to prevent dental caries and periodontal infections. Customize adaptive oral care practices that consider patients’ and/or caregivers’ unique needs (Section IX). Provide palliative care for the individual with a shortened life span. Participate in the patient’s care as a member of the healthcare team. Contribute to the patient’s general well-being and quality of life.

IV. Preparation for the Residential Visit When providing patient care in any situation, the rule is “know before you go.” The following steps will help prepare for a homebound patient visit.

A. Understanding the Patient Review the patient’s medical history. (Hint: Provide the medical history form in advance for patient to complete and return.) Monitor medication lists carefully, especially when the patient takes multiple prescription or over-the-counter preparations. Telephone before visit to clarify responses or ask questions. Consider specific characteristics and problems associated with the patient’s age, chronic medical condition, medications, mental health status, or physical/cognitive limitations. Section IX reviews considerations for a variety of individuals with special needs. Determine precautions necessary for the individual patient’s care and safety. Arrange with a dentist or attending physician when premedication or other prescription is required. Determine need for local anesthesia.

B. Instruments and Equipment Routine dental hygiene care can often be provided using manual instruments and without the need for powered equipment. Several dental equipment companies (listed in Box 4-3) manufacture portable dental delivery units, suctions, X-ray units, and autoclaves.

BOX 4-3 Commercial Sources for Portable Equipment

Dental Delivery Systems A-Dec, Inc. Website: www.a-dec.com Toll-free phone: (800) 547-1883 Aseptico

Website: www.aseptico.com Toll-free phone: (866) 244-2954 ASI Medical, Inc. Website: www.asimedical.net Toll-free phone: (800) 566-9953 Bell Dental Website: www.belldental.com Toll-free phone: (800) 920-4478 DNTLworks Equipment Corporation Website: www.dntlworks.com Toll-free phone: (800) 847-0694 Mobile Dental Systems Website: www.mobiledentalsystems.com Toll-free phone: (800) 321-6332 Safari Dental, Inc. Website: www.safaridental.com Toll-free phone: (800) 567-0013 Hand-Held X-Ray System Aribex, Inc. Website: www.aribex.com Toll-free phone: (866) 340-5522 Autoclave Alfa Medical Website: www.statimsales.com Toll-free phone: USA: (800) 839-0722 Illuminated Loupes Orascoptic Website: www.orascoptic.com Toll-free phone: (800) 369-3698 PeriOptix, Inc. Website: www.perioptix.com Toll-free phone: (800) 445-0345 Suction Toothbrushes

Sage Products, Inc. Website: www.sageproducts.com Toll-free phone: (800) 323-2220 Trademark Medical Website: www.trademarkmedical.com Toll-free phone: (800) 325-9044

Covered plastic tubs or boxes, labeled “clean” or “contaminated,” are useful for carrying materials. The Organization for Safety, Asepsis, and Prevention provides infection control guidelines for safe delivery of oral care outside the dental office.16 Additional equipment and supplies that can be transported by the clinician to the patient’s residence are listed in Box 4-4.

BOX 4-4 Instruments and Equipment to Provide Dental Hygiene Care for Residence-Bound Patients Personal Protective Equipment • See Chapter 6 Patient Education/Oral Hygiene Instruction Materials • Toothbrushes, floss, interdental aids, tongue cleaner • Denture brush, if needed • Samples of adaptive aids for demonstration • Hand mirror • Written or printed patient education materials • See Section IX for additional ideas on adaptive practices Sterile Instruments • Selection of hand instruments and other items required for patient care (i.e., mouth prop/bite block, sharpening stone, lip retractors) • Are transported before treatment in the sealed packages in which they were sterilized • Are transported after use in special plastic containers labeled for contaminated instruments

Disposable Items—Prepared in “Single Treatment” Packages That Are Convenient to Open and Use at Bedside • Patient bib • 2 × 2 gauze • Cotton rolls/applicators • Lubricant for patient lips Additional Equipment • Emesis basin (kidney-shaped basin facilitates the rinsing process) • Portable headrest (attached to wheelchair or straight back chair to provide head support during treatment) • A large plastic drape (helpful if patient’s coordination is limited during rinsing) Pharmaceuticals • Pretreatment mouth rinse (only for patients who can spit) • Disclosing agent • Fluoride varnish topical fluoride preparation (varnish) • Silver diamine fluoride17 Lighting • Dental loupe systems with light-emitting diode (LED) headlight offer a direct light source and magnification (Figure 4-1A)

FIGURE 4-1 • Lighting. A: A small light-emitting diode (LED) light with an attached headband, sometimes called a “camping” headlamp. B: Safety glasses with loupes and an attached LED headlamp. With either lighting system, the beam can be adjusted so that it is focused directly into the patient’s oral cavity.

• Alternatively, a common LED headlamp is a convenient and inexpensive form of light (Figure 4-1B) • Lighted mouth mirror • Photography spotlight or gooseneck lamp with narrow, concentrated beam and adequate wattage to facilitate visibility Miscellaneous Items—Usually Available at the Patient’s Home • Large towels (for covering pillows) • Pillows (firm enough to assist in maintaining patients’ head in stationary position) • Hospital bed (can be adjusted to position patient most effectively) • Wheelchair or chair with high back for head support • Container for prostheses • Power toothbrush

C. Appointment Time Arrange the dental hygiene visit during a time when the patient is usually awake. Coordinate with patient or caregiver to assure visit is scheduled around nursing care and meals.

D. Practice Management Dental hygienists providing direct access services in a residential setting may be working as a volunteer, employee, independent contractor, and/or business owner.18 In these cases, the dental hygienist may need to consider the following factors: Individual state practice acts19; educational requirements, direct access scope of services; practice settings, referral methods Provider claim submission; procedures for billing for services provided by a dental hygienist (Health Insurance Portability and Accountability Act: National Provider Identifier number and Healthcare Provider Taxonomy code). Payment/reimbursement methods20; private insurance, state/federal programs, facility or agency funds, public/private grants

Tax codes and policies; self-employed individuals, business owners

V.

Approach to Patient

The dental hygienist may find approaching a relatively helpless, disabled, or ill person to be difficult. In addition, patients with cognitive disorders or impairments, such as dementia, can exhibit resistance to personal care.21,22

A. Communication Clinician empathy and understanding, as well as good interpersonal and communication skills, can help project a caring attitude toward the patient and put a vulnerable patient at ease. An oversolicitous attitude may not contribute to development of a cooperative patient relationship; a gentle but firm approach is most successful. Direct communication with the patient is most appropriate; however, communication with a caregiver may be necessary.

B. Personal Factors A patient who is comfortable with home-delivered care and aware of the difficulties under which the clinician is working may show significant appreciation. Establishment of rapport with the patient may depend on whether it was the patient or caregiver who requested/arranged for the appointment. Cooperation may depend on the patient’s attitude toward the illness or disability. Residence-bound adults dependent on others for care can be at increased risk for abuse, neglect, and exploitation (see Chapter 14). Be alert to the signs and symptoms. Protocols for mandatory reporting vary by state.

Prolonged illness, suffering, the effects of inactivity, and monotonous confinement can contribute to depression. A patient who is depressed may require extra attention to communication (see Chapter 58). Caring for the cognitively impaired or mentally ill patient can present unique challenges (see Chapters 48 and 58).

C. Suggestions for General Procedure Request the caregiver to be present to assist as needed and to demonstrate current method of personal daily oral care. For the safety of the patient, clinician, and others, ask that visitors remain out of the room during treatment. Introduce each step slowly to be sure patient knows what is being done. Do not make the patient feel rushed. Listen attentively; socializing is one of the best ways to establish rapport. Plan multiple appointments when extensive scaling is required to: Avoid tiring the patient. Observe tissue response. Provide encouragement in biofilm control procedures.

VI. Treatment Location Ingenuity is needed to arrange patient position to provide access for treatment as well as maintain comfort for both the patient and the clinician (Figure 4-2).

FIGURE 4-2 • A Dental Hygiene Student Provides Patient Care Using a Headlamp and a Portable Dental Unit.

A. Patient in Bed Hospital bed: Adjust to lift patient’s head to desirable height. Ordinary bed, sofa, or cushioned chair: Use firm pillows to support and stabilize patient’s head. Small patient: Positions for biofilm control described in Chapter 51 and shown in Figure 51-12 may be applicable during treatment.

FIGURE 51-12 • Positions for Child or Disabled Patient During Biofilm Removal. A: Patient seated on floor with head turned back into the lap of the caregiver. B: Patient’s arms restrained by legs of caregiver. C: Patient reclining on couch with head in lap of caregiver. D: Two people participating with small child between. One holds patient for stabilization while the other holds the head for toothbrushing and flossing.

B. Patient in Wheelchair Kitchen or a large bathroom can provide access to water and counter space.

A portable headrest can be attached to the back of a straight chair or wheelchair (see Chapter 51). A straight chair or wheelchair can be backed against a wall to provide a stable headrest. Some wheelchairs tilt or slightly recline to facilitate patient positioning for care (Figure 4-3).

FIGURE 4-3 • A Wheelchair That Is Designed to Tilt Back, Providing Comfort and Easy Access for Dental Care. (From Frontera WR. DeLisa’s Physical Medicine and Rehabilitation. 5th ed. Philadelphia, PA: Wolters Kluwer Health; 2010.)

A firm pillow can be inserted between the chair back and the patient’s head to provide a cushioned resting surface.

VII. Additional Considerations In addition to navigating patient treatment in an alternative setting, the unique needs of the residence-bound patient, and practice

management matters, additional considerations may include: The role of the caregiver. Whether professional, family, or friend, the caregiver should be included in the care assessment, planning, and treatment according to the patient preferences and as much as they are able/willing. Pretreatment site visit. Schedule a time to visit the patient in their residence. Initial assessment of the environment, patient needs, and business agreement can be discussed before treatment is planned or rendered.

VIII. Assessment and Care Planning As in any patient care setting, dental hygiene interventions are provided using the dental hygiene process of care. Comprehensive patient assessment provides the basis for dental hygiene diagnoses. The dental hygiene diagnosis provides the foundation for planning treatment and prevention strategies that meet individualized patient needs. Follow-up appointments for maintenance and ongoing evaluation of the patient’s oral condition determine whether treatment goals are met. Also, the direct access provider refers the patient to a dentist or specialist when warranted.

IX. Strategies for Prevention and Management Table 4-1 identifies special considerations for developing a personalized prevention and management plan for residence-bound individuals. Additional strategies for preventing poor oral status can include: Training caregivers. Collaborating with members of interprofessional healthcare teams.

THE CRITICALLY ILL OR UNCONSCIOUS PATIENT Maintenance of oral cleanliness for the acutely ill or unconscious patient requires special procedures and approaches. When the patient’s illness or injury involves the oral cavity, the advice and recommendations of the attending physician and/or oral surgeon are followed. Effective oral care can reduce the risk of pneumonia by preventing debris and microorganisms in the mouth from being aspirated, particularly in patients who have received mechanical breathing assistance (see Chapter 60).15,23,24 The role of the dental hygienist is to evaluate and prioritize the patient’s immediate oral care needs and provide appropriate curative or palliative oral care as needed. Be familiar with the nature of the patient’s chronic condition. Observe the health status of the soft and hard oral tissues. Address oral pain and infection first. Determine what type of services will best improve or maintain patient’s oral health status without putting undue stress on the patient.

I.

Instructions for Caregivers

Personal oral care procedures for the unconscious or disabled patient can be accomplished by a caregiver. Assess caregiver’s willingness and ability to provide daily oral care for the patient. Encourage and empower caregivers to provide daily oral care. Include hands-on demonstration and practice. For caregivers at a facility, this may include conducting an oral health in-service training program.

A. Patients Who Are Edentulous or Dentulous Use appropriate precautions when placing fingers in mouth to avoid injury from unintentional biting. A mouth prop can be placed in one side of the mouth while the other side is being retracted and cleaned. Gently brush or wipe all surfaces of the mouth (lips, teeth, gingiva, tongue, and oral mucosa) to remove biofilm at least twice a day. This will also prevent sordes. A soft toothbrush or gauze-wrapped finger can be used to wipe the soft tissue. A power toothbrush used with a very light touch or a suction toothbrush may be more efficient and thorough on the hard tissue.

B. Patients with Removable Prosthesis If dentures or other removable prostheses are present, remove before providing oral care. Often hospital policy requires removal of dentures when a patient is unconscious. Procedure for removing dentures is described in Chapter 30. When the dentures are removed: Instruct the caregiver to clean and mark them as described in Chapter 30. Instruct the caregiver to change the water or liquid denture cleaner daily to prevent bacterial growth.

II.

Toothbrush with Suction Attachment

A specialized, single-use toothbrush often used with patients who have difficulty swallowing or spitting. Tubing is connected from the end of a hollow toothbrush handle to an aspirator outlet or portable suction unit (Figure 4-4).

FIGURE 4-4 • Commercial Suction Toothbrush. Plak-Vac/Res-Q-Vac combination features the Plak-Vac oral suction evacuator brush with the Res-QVac hand-powered suction system. (Trademark Medical, St. Louis, MO.)

During caregiver training, procedure for use is demonstrated and included in an oral care procedures manual. See Box 4-5 for instructions on how to use a suction toothbrush.

BOX 4-5 Procedure for Use of Suction Toothbrush • Prepare the patient. • Although not able to respond in a usual manner, the patient may be aware of what is going on. • Tell patient that the teeth are going to be brushed, and thereafter maintain a one-way conversation despite patient’s inability to respond verbally. • Turn patient on the side and place a pillow at the back for support. • Place a small towel behind the patient’s head and an emesis basin under patient’s chin. • Follow routine infection control and personal protective equipment guidelines. • Attach toothbrush to suction outlet and lay brush on towel near patient’s mouth. • Place a rubber bite block on one side of the patient’s mouth between the

• • •

• • • •

posterior teeth. Floss tied to the bite block is fastened to patient’s clothing with a safety pin. Dip brush in nonalcoholic, fluoridated mouth rinse or chlorhexidine; do not use toothpaste. Turn on suction. Gently retract lip and carefully apply the appropriate toothbrushing procedures; apply suction over each tooth surface with particular care at each interproximal area. Remoisten brush frequently. Move bite block to opposite side of mouth and continue brushing procedure. After brushing, place brush in a cup of clear water and allow water to be sucked through to clear and clean the tube. Remove bite block, wipe patient’s lips, and apply a water-based lubricant. Rinse and disinfect toothbrush; sterilize bite block.

THE TERMINALLY ILL PATIENT The major difference in providing dental hygiene care for a terminally ill patient is a focus on short-term palliative care rather than long-term preventive care.25 Terminal illness is no excuse for neglect of oral cleanliness; daily personal oral hygiene care is essential. Emphasis is on symptom relief and a clean oral environment, which can: Enhance the patient’s sense of dignity. Improve quality of life no matter how brief the life is to be.13 The dental hygienist is in an ideal position to be a member of an interdisciplinary palliative care team.

I.

Objectives of Care

The role of the dental hygienist is to provide oral care that emphasizes patient comfort more than preventive or restorative aspects of care. This may include: Providing relief of painful or aggravating symptoms of oral disease or lesions. Preventing aspiration of debris and oral microorganisms and reduce risk for pneumonia. Providing a “clean mouth” environment to reduce malodor and improve appearance and enhance personal interaction with caregivers and family members. Educating patients and caregivers about the importance of daily oral care. Helping develop standardized protocols for daily oral care as an integral part of the patient’s overall palliative care treatment plan.

II.

General Mouth Care Considerations

Poor oral hygiene is a common problem among terminally ill patients.

Attention to mouth care and management of pain are essential components of providing end-of-life care.

A. Cleanliness Gentle but thorough daily cleaning of teeth, tongue, and oral mucosa is necessary. Provide oral care in any way the patient will allow, using soft toothbrush, gauze, or cloth. Dentifrice or other oral products are not necessary, but can add a refreshing flavor that the patient may like. Use caution as some products can cause irritation or create a burning sensation on already fragile tissues. Be mindful of the patient’s limited swallow function or spitting ability.

B. Common Oral Conditions Xerostomia: Common among terminally ill individuals due to medications, dehydration, or mouth breathing.26 Work with palliative care team to minimize medications that increase xerostomia.27 Candidiasis infection: Oral cultures of Candida albicans were found in as many as 79% of terminally ill patients. In immunocompromised individuals, the infection can become lifethreatening.26 General oral soreness (mucositis): Approximately 75% of hospice patients examined in one study had evidence of pathologic changes in the oral mucosa, and 42% reported soreness of the oral mucosa.26 Denture problems: More than 70% of hospice patients who wore dentures reported having some kind of difficulty wearing their dentures.26

C. Visual Inspection Frequent inspection of the patient’s mouth is necessary to identify

oral lesions that can cause discomfort or lead to serious infection. Use a pen light or small flashlight and soft handle of toothbrush to examine the oral cavity.

DOCUMENTATION Key concepts for documenting dental hygiene care provided in alternative settings include: Description of location where treatment is provided. Description of the patient’s current health status and functional ability, particularly related to ability to provide self-care. Notation of whether or not caregiver assistance is needed/available for daily oral care. Summary of oral health assessment data. Specific recommendations/education for oral care techniques and adjunct oral hygiene aids. Details of dental hygiene interventions/services provided. Recommendations for follow-up care and referrals made. A sample documentation can be found in Box 4-6.

BOX 4-6 Example Documentation: Bedside Oral Care for Patient in a Nursing Home S—Routine nursing home visit for continuing care. The 89-year-old female patient is confined to a hospital bed, comfortable and alert; arm strength notably weakened since last visit and she is distressed that she can no longer support her own toothbrush for daily oral care. Nurse aide caregiver has been trying to assist but doesn’t know how. Patient states: “Every time she tries to brush my teeth she chokes me or hurts my gums.” O—Excessive dental biofilm noted on facial surfaces of maxillary molars. A—Patient can no longer engage independently, causing increased risk of oral infection and subsequent increased risk of systemic effects. Caregiver needs training to provide efficient, effective, and comfortable intraoral brushing. P—Discussed benefits of daily oral biofilm removal. Demonstrated effective oral care. Assured both patient and caregiver that oral care can be provided without discomfort. Demonstrated and supervised caregiver providing bedside oral care and biofilm removal with soft child-sized toothbrush. Next steps: Follow-up visit scheduled with patient and caregiver in 2 weeks. Signed: _____________________________, RDH Date: ____________________________________

EVERYDAY ETHICS Elena is 55 years old and is dying of esophageal cancer. She has been involved in an outpatient hospice program and receives all medical services in her home. Elena’s daughter contacts the dental office of Dr. Gray and asks if someone can please come to the house and check her mother’s teeth because they have not been able to help her brush every day and Elena’s gums are bleeding. Sandy, the dental hygienist in the practice, offers to go and provide whatever “comfort care” she can for Elena. Questions for Consideration 1. What legal and ethical concerns need to be addressed before going to Elena’s home since care will be limited? 2. Reviewing the principle of justice, if Elena’s homebound status prevents her from accessing dental care, what options can the dental team offer to her at this time? 3. Describe several core values (Chapter 1, Box 1-6) that can be exhibited by the dental team to benefit this patient.

Factors to Teach the Patient Good oral health contributes to good general health and better quality of life. Dental caries is preventable through effective daily oral care and limited consumption of sugary food and drink, especially between meals. How to use customized adaptive oral care aids to facilitate patient’s independence.

Factors to Teach the Caregiver Consider personal safety of caregiver and patient: environment, biting, infection control. Care for the patient’s natural teeth and gums. Evaluate and address unique patient needs, adapt care as needed (Section IX). Care for the patient’s removable and nonremovable prosthesis (Chapter 30). Offer food and drink that are not cariogenic. How to use a suction toothbrush, power brush, or other device that can mean

better oral care for the patient.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References

1. Gluzman R, Meeker H, Agarwal P, et al. Oral health status and needs of homebound elderly in an urban home-based primary care service. Spec Care Dentist. 2013;33(5):218-226. 2. American Dental Hygienists’ Association. Advocacy: practice issues: direct access. http://www.adha.org/direct-access. Accessed July 19, 2017. 3. Smith BJ, Ghezzi EM, Manz MC, et al. Perceptions of oral health adequacy and access in Michigan nursing facilities. Gerodontology. 2008;25(2):89-98. 4. Strayer MS. Perceived barriers to oral health care among the homebound. Spec Care Dentist. 1995;15(3):113-118. 5. Willink A, Schoen C, Davis K. Dental care and Medicare beneficiaries: access gaps, cost burdens, and policy options. Health Affairs. 2016;35(12):2241-2248. 6. Rodriguez TE, Galka AL, Lacy ES, et al. Can Midlevel dental providers be a benefit to the American public? J Health Care Poor Underserved. 2013;24(2):892-906. 7. Langelier M, Continelli T, Baker B, Surdu S. Expanded scopes of practice for dental hygienists associated with improved oral health outcomes for adults. Health Affairs. 2016;35(12):2207-2215. 8. Langelier M, Baker B, Continelli T. Development of a New Dental Hygiene Professional Practice Index by State. Rensselaer, NY: Oral Health Workforce Research Center, Center for Health Workforce Studies, School of Public Health, SUNY Albany; 2016:152. 9. Smith BJ, Ghezzi EM, Manz MC, et al. Oral healthcare access and adequacy in alternative long-term care facilities. Spec Care Dentist. 2010;30(3):85-94. 10. Chen X, Clark JJ, Naorungroj S. Oral health in nursing home residents with different cognitive statuses. Gerodontology. 2013;30(1):49-60. 11. U.S. Government Printing Office. Electronic code of federal regulations (Title 42: Public Health, Part 483—requirements for states and long term care facilities, Subpart B, Section 483.55, dental services). http://www.ecfr.gov/cgibin/text-idx? c=ecfr;sid=b97291f05d23f16ffa8e711922642bcc;rgn=div5;view=text;node=42%3A5.0.1.1.2;i Accessed July 14, 2017. 12. Medicaid.gov. Medicaid: dental care. https://www.medicaid.gov/medicaid/benefits/dental/index.html. Accessed July 14, 2017. 13. Fischer DJ, Epstein JB, Yao Y, et al. Oral health conditions affect functional and social activities of terminally ill cancer patients. Support Care Cancer. 2014;22(3):803-810. 14. Mercadante S, Aielli F, Adile C, et al. Prevalence of oral mucositis, dry mouth, and dysphagia in advanced cancer patients. Support Care Cancer. 2015;23(11):3249-3255. 15. Linden GJ, Lyons A, Scannapieco FA. Periodontal systemic associations:

review of the evidence. J Clin Periodontol. 2013;84(40 suppl):S8-S19. 16. Organization for Safety, Asepsis and Prevention. Atlanta, GA: Organization for Safety, Asepsis and Prevention; Safe delivery of oral care outside the dental office. http://www.osap.org/?page=PortableMobile. Accessed July 14, 2017. 17. Horst J, Ellenikiotis H, Milgrom PM. UCSF protocol for caries arrest using silver diamine fluoride: rationale, indications, and consent. J Calif Dent Assoc. 2016;44(1):16-28. 18. Naughton D. Expanding oral care opportunities: direct access care provided by dental hygienists in the United States. J Evid Based Dent Pract. 2014;14 suppl:171-182. 19. American Dental Hygienists’ Association. Scope of practice. http://www.adha.org/scope-of-practice. Accesses July 14, 2017. 20. American Dental Hygienists’ Association. Reimbursement. https://www.adha.org/reimbursement. Accessed July 14, 2017. 21. Jablonski R, Therrien B, Mahoney EK, et al. An intervention to reduce careresistant behaviors in persons with dementia during oral hygiene: a pilot study. Spec Care Dentist. 2011;31(3):77-88. 22. Ahn H, Horgas AL. Disruptive behaviors in nursing home residents with dementia: management approaches. J Clin Outcomes Manag. 2013;20(12):566-576. 23. Shi Z, Xie H, Wang P, et al. Oral Hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev. 2013; (8):CD008367. 24. Quinn B, Baker DL, Cohen S, et al. Basic nursing care to prevent nonventilator hospital-acquired pneumonia. J Nurs Scholarsh. 2014;46(1):11-19. 25. Bhavana S, Lakshmi CR, Mpv P, et al. Palliative dental care. J Clin Diagn Res. 2014;8(6):1-6. 26. Aldred MJ, Addy M, Bagg J, et al. Oral health in the terminally ill: a crosssectional pilot survey. Spec Care Dentist. 1991;11(2):59-62. 27. Jucan AC, Saunders RH. Maintaining oral health in palliative care patients. Ann Longterm Care. 2015;23(9):15-20.

SECTION

II Preparation for Dental Hygiene Practice INTRODUCTION FOR SECTION II Preparation for dental hygiene care is centered on the use of standard precautions for infection control to ensure the comfort and safety of patients, dental personnel, and others who come in contact with the environment of the clinic or office. Health services facilities, including dental facilities, must be places for cure and prevention, not for increasing risk of disease or discomfort following inadequate precautionary measures and habits of the professional personnel. The responsibility of the entire team is to develop and maintain work practices for all appointments that will: Prevent direct or indirect cross-infection between dental personnel and patients and from one patient to another.

Maintain comfort for both the patient and the oral health provider. Chapters in this section: Provide specific information about the chain of infection and the microorganisms that can be transmitted in the dental setting when standard precautions are not observed. Describe specific materials and procedures necessary for safe clinical practice. The Centers for Disease Control and Prevention Guidelines for Infection Control in Dental Health-Care Settings can be found on the online resource. Place emphasis on the ergonomic factors of patient positioning; body posture; and hand, wrist, and arm positions to maintain practitioner comfort and prevent musculoskeletal problems.

THE DENTAL HYGIENE PROCESS OF CARE Preparation for clinical practice does not form a specific step in the Dental Hygiene Process of Care (Figure II-1); however, practices described in this section protect the patient and the practitioner and are part of all the components of the process.

FIGURE II-1 • The Dental Hygiene Process of Care.

Description

ETHICAL APPLICATIONS A dental hygienist may be involved in a variety of moral, ethical, and legal situations during all professional actions related to the process of care. A goal of preparation for dental hygiene practice is to increase awareness of, and sensitivity to, potential ethical situations. Basic core values and principles, as outlined in the various Dental

Hygiene Codes of Ethics on the online resource, are applied in every phase of the dental hygiene appointment. Basic core values in dental hygiene are identified as selected principles of ethical behavior that can be considered integral to the code of the dental hygiene profession. Ethical principles contained in the codes clarify the standards of judgment that professionals will follow. Ethical principles are combined with philosophical theories when making a decision. An overview of the core values with definitions and applications is found in Table II-1. TABLE II-1 • Dental Hygiene Core Values ETHICAL PRINCIPLE/CORE VALUE

EXPLANATION

APPLICATION EXAMPLES

Autonomy

Patient’s right to selfdetermination and making choices for care.

Educate the patient before obtaining informed consent.

Beneficence

Performing services for the good of the patient.

Apply standards of infection control for all patients.

Nonmaleficence

Removing or preventing harm during the treatment process.

Individualize biofilm control and perform subgingival debridement.

Justice

Fair treatment for all patients.

Follow acceptable standards and provide access to care for all patients.

Confidentiality

Protection of sensitive information.

Secure patient files in locked cabinets.

Veracity

Truth-telling.

Develop trust between patient and provider to obtain the medical history.

Fidelity

Keeping promises.

Help a fearful patient feel

comfortable by using local anesthesia or nitrous oxide.

5 Infection Control: Transmissible Diseases Katherine Soal, RDH, MSDH

CHAPTER OUTLINE STANDARD PRECAUTIONS I. II.

Definition Additional Transmission-Based Precautions

MICROORGANISMS OF THE ORAL CAVITY I. II. III.

Origin Infection Potential Cross-Contamination

THE INFECTIOUS PROCESS I. II. III.

Essential Features for Disease Transmission Airborne Infection Prevention of Transmission

PATHOGENS TRANSMISSIBLE FROM THE ORAL CAVITY TUBERCULOSIS I. II.

Transmission Clinical Management

VIRAL HEPATITIS I. II. III.

Hepatitis B Hepatitis C Hepatitis D Virus

HUMAN HERPESVIRUS DISEASES I. II. III.

General Characteristics Relation to Periodontal Infections Clinical Management for HHVs

HUMAN PAPILLOMAVIRUS HIV/AIDS INFECTION I. II. III. IV. V.

Transmission HIV Testing for Diagnosis and Staging of Infection Oral Manifestations of HIV Infection Prevention and Treatment of HIV Infection Dental Hygiene Management

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Apply the concept of standard precautions to the process of dental hygiene care. 2. Describe the infectious disease process and prevention of disease transmission. 3. Describe and identify transmissible diseases that may pose a risk to patients and dental healthcare personnel.

4. Evaluate the oral healthcare needs of each patient with transmissible disease(s). For healthcare providers, infection and communicable disease can lead to illness, disability, and loss of work time. In addition, patients, family members, and community contacts can become exposed, may become ill, and lose productive time or suffer permanent aftereffects. In oral healthcare practice, the objective is to protect patients, dental healthcare personnel (DHCP), and others who may become exposed to infectious agents in the clinical environment. Health services facilities, including dental facilities, are places for cure and prevention, not for dissemination of disease due to inadequate precautionary measures and habits of the professional personnel. The first responsibility of the entire dental team is to organize and maintain a system for the disinfection, sterilization, and care of instruments and equipment. The second step is to develop and maintain work practices for all appointments that will prevent direct or indirect cross-infections between dental personnel and patients and from one patient to another.

STANDARD PRECAUTIONS I. Definition1,2 Standard precautions represent a standard of care to protect healthcare providers and their patients from pathogens spread by body fluids. Apply to all patients. Apply to contact with the following: Blood. Saliva. All body fluids, secretions, and excretions (except sweat), regardless of whether they contain blood. Nonintact (broken) skin. Mucous membranes.

II.

Additional Transmission-Based Precautions Droplet precautions Respiratory or mucous membrane contact transmitted through airborne droplets (sneezing, coughing). Examples: Mycobacterium tuberculosis, influenza virus, chickenpox virus. Contact precautions Reduce risk of transmission of organisms and specific diseases by direct skin or indirect contact. Examples: Vancomycin-resistant enterococci, methicillinresistant Staphylococcus aureus (MRSA) Airborne precautions Reduce risk of airborne transmission of infectious agents by droplet nuclei. Special air handling and ventilation required. Examples: Legionella pneumophila, M. tuberculosis. Sharps precautions Reduce risk of bloodborne pathogen transmission and infection

by percutaneous sharps injury. Examples: Hepatitis B virus (HBV) and hepatitis C virus (HCV), human immunodeficiency virus (HIV)

MICROORGANISMS OF THE ORAL CAVITY I. Origin In utero, the oral cavity is sterile, but after birth within a few hours to 1 day, a simple oral flora develops.3,4 Microorganisms are transmitted to the infant from the mother and other family members or caretakers. As the infant grows, there is continuing introduction of microorganisms that are normal for an adult oral cavity. The microbiota of the adult is very complex.5 Many of the salivary bacteria come from the dorsum of the tongue, but some are from mucous membranes and gingival/periodontal tissues. High counts of total microorganisms are found in dental biofilm, periodontal pockets, and carious lesions.

II.

Infection Potential Intact mucous membranes of the oral cavity provide some protection against infection. Pathogenic (disease-producing), potentially pathogenic, or nonpathogenic microorganisms may be present in the oral cavity of each patient. Patients may be carriers of certain diseases but show no signs or symptoms (asymptomatic carrier). Pathogenic organisms may be transient. Inadvertent transmission to subsequent susceptible patients or to dental personnel may occur because of inappropriate work practices, such as: Careless handwashing. Unhygienic personal habits. Inadequate sterilization and handling of sterile instruments and materials.

III. Cross-Contamination Spread of microorganisms from one source to another: person to person, or person to an inanimate object and then to another person. Recognition of the possible transfer of infection in a dental practice or clinic provides a basis for planning the system of disinfection, sterilization, and management of instruments and equipment.

THE INFECTIOUS PROCESS I. Essential Features for Disease Transmission A chain of events is required for the spread of an infectious agent. The six essential links are shown in Figure 5-1 and described here.

FIGURE 5-1 • Interventions to Break the Chain of Disease Transmission. A break in the chain of six major links is required to stop the spread of an infectious agent. Standard precautions are applied to interrupt the chain.

An infectious agent such as:

Bacteria, viruses, fungi, rickettsia, protozoa. Each infectious agent has its own specific reaction in an infected host. A reservoir where the infectious agents are found in their own essential environment, which may be instruments, a dental unit waterline, or human cells or blood. For example, a dental unit waterline is a potential reservoir for L. pneumophila, and humans are reservoirs for herpetic infections. A port of exit or mode of escape from the reservoir. Infectious agents exit from their reservoir(s) through various modes, such as coughing, bleeding periodontium, dental needle use, or in water from a contaminated waterline. A mode of transmission May be direct as in person to person, or indirect by contaminated hands or a dental needle. Transmission by droplet may be direct from the respiratory tract of one person to the oral cavity of the receiving host by coughing or sneezing, or indirect by transfer to hands or instruments and then to the receiving host. A port of entry or mode of entry of the infectious agent into the new host. Modes of entry may be similar to modes of escape. Examples: the respiratory tract, eyes, mucous membranes, nonintact periodontium or skin, or needle stick. A susceptible host that does not have immunity or defense to the invading infectious agent such as: A patient taking an immunosuppressant drug to control autoimmune diseases such as psoriasis and rheumatoid arthritis, prevent solid organ transplant rejection, and cancer chemotherapy. A patient who has not had or has not maintained recommended vaccinations or does not sero-convert after vaccination. A patient who is medically compromised, elderly, or has a preexisting transmissible disease.

II.

Airborne Infection

A. Dust-Borne Infectious Agents Clostridium tetani (tetanus bacillus) and enteric bacteria are among the infectious agents that may travel in dust brought in from outside and move in and about dental treatment areas. When doors are opened and closed and people pass in and out, dust is set into motion and can settle on instruments, working surfaces and equipment, or people. Infectious agents can reach dust from the oral cavities of patients by way of large airborne particles produced by coughing, sneezing, and talking. Dust-borne infectious agents may be sources of contamination for dental instruments and hands of dental personnel. Surface disinfection of all equipment contacted during an appointment contributes to control of dust-borne pathogens. Procedures for surface disinfection are described in Chapter 7.

B. Aerosol and Spatter6,7 Airborne particles are classified by size as either aerosols or spatter and are constantly being produced during dental procedures. Aerosols An aerosol is a solid or liquid particle (possibly containing infectious agents) that may remain suspended in air. The aerosol particles range in size from 1 to 100 µm. Tiny aerosol particles that are 10 µm or smaller can be breathed deep into the lungs. Larger particles can be trapped higher in the respiratory tract and may be coughed or sneezed out. Spatter Spatter is composed of particles greater than 50 µm in diameter that usually fall within 2 feet of origin.3 Heavier, larger particles may remain airborne a relatively short time because of size and weight, then drop or spatter on objects,

people, and the floor. Spatter may be visible, particularly after it has landed on skin, hair, clothing, or environmental surfaces where gross contamination can result. Spatter may come in direct contact with mucous membranes of the eyes, nose, and mouth. Origin of aerosols and spatter Produced during all intraoral procedures, including examination and treatment. Produced by air spray, air–water spray, hand piece activity, air polishing, and ultrasonic scaling. Aerosols and spatter may contain: Single or clumps of infectious agents such as Staphylococcus and Streptococcus species, M. tuberculosis, and viruses. Tooth and restoration fragments, tissue, saliva, biofilm, blood, sputum, oil from hand pieces, and water from dental unit waterlines. Concentration and distribution of aerosols and spatter: Aerosols and spatter are in greater concentration close to the site of instrumentation. Aerosols travel with air currents and may move from room to room. Spatter may be distributed on clothing, equipment, instruments, and hands and may be transferred to all areas of the dental office.

III. Prevention of Transmission A. Airborne Infection Can Be Controlled by: Elimination or limitation of infectious agents at the source. Interruption of transmission. Protection of the potentially susceptible recipient. Carefully monitored procedures for all patients with or without a known communicable disease.

B. Preprocedural Oral Hygiene Measures7 Biofilm removal: toothbrushing and flossing by patient prior to beginning of appointment. Use of an antiseptic or antimicrobial mouth rinse to reduce numbers of bacteria contained in aerosols. Swish vigorously to force mouth rinse between teeth. Hold in mouth before expectorating.

C. Interruption of Transmission Use a rubber dam and high-volume evacuation for sealants and other applicable procedures. Proper use of standard precautions and infection control protocols. Use of high-volume evacuation with ultrasonic instrumentation and air polishing. Use manual instrumentation as much as possible on patients with known or suspected infectious disease. Installation of air-control methods to supply adequate ventilation, filtration, and relative humidity in the operatory area.

D. Clean Water1,2,8 Use water that meets Environmental Protection Agency regulatory standards for drinking water (less than 500 CFU [colony-forming units]/mL of heterotrophic water bacteria). Waterlines must be flushed for at least 20–30 seconds between patients to reduce cross-contamination.1,8 Flushing dental waterlines clears planktonic microorganisms; however, the effects are transient. Additional methods to prevent and treat dental waterline biofilm are needed to assure treatment water quality.8 Self-contained water systems. Chemical treatments. In-line water filters.

Antiretraction devices to prevent backflow.

E. Protection of Clinician Use personal protective equipment as described in Chapter 6. Check and maintain personal immunizations.

F. Protection of Patient Use protective eyewear to prevent direct spatter and aerosols to face and eyes.

G. Maintain and Review Infection Control Protocols Utilize recommendations described in Chapters 6 and 7 The CDC Guidelines are available on the online resource.

PATHOGENS TRANSMISSIBLE FROM THE ORAL CAVITY Selected pathogens that may be transmitted by way of the oral cavity and their disease manifestations, mode of transfer, incubation periods, and communicability periods are provided in Table 5-1. TABLE 5-1 • Infectious Diseases Transmissible from the Oral Cavity

Description Pathogens are often present within the oral cavity without producing oral signs or symptoms, a fact of particular importance to the total consideration of prevention of disease transmission. Tuberculosis (TB), viral hepatitis, herpetic infections, and acquired immunodeficiency syndrome (HIV/AIDS) are included in this chapter because of the special problems they create in personal and patient care.

TUBERCULOSIS9 M. tuberculosis, the etiologic agent in TB, is a resistant organism requiring special consideration when sterilization and disinfection methods are selected and administered. Clinical procedures are planned to prevent exposure and infection from this serious disease. Drug-resistant TB may occur when patients are noncompliant in their required extended drug therapy or if the medication is not available. Multidrug-resistant TB refers to resistance to at least two of the firstline drugs. Extensively drug-resistant TB refers to resistance to first-line drugs and at least one of three second-line drugs.

I.

Transmission Inhalation TB is contracted when a vulnerable person inhales aerosolized droplet nuclei containing tubercle bacilli from sputum and saliva of an infected individual during coughing, sneezing, speaking, or singing (Figure 5-2).

FIGURE 5-2 • Droplet Nuclei. Many potentially pathogenic microorganisms are disseminated by aerosols and spatter. The primary mode of transmission of tubercle bacilli is by droplet nuclei breathed directly into the lung.

Use of ultrasonic, air polishing, air–water spray, and other hand pieces creates aerosols that can carry the tubercle bacilli. Droplet nuclei are small enough to pass through over 95% bacterial filtration efficiency required of standard surgical masks and may remain suspended in the air for hours. Standard precautions may be insufficient to protect the DHCP from transmission of TB in the healthcare setting. Factors affecting transmission of TB: Degree to which the infected person produces infectious droplets. Type and duration of exposure. Susceptibility of recipient. Some patients are more contagious than others. Maximum communicability is usually just before the disease is diagnosed, when a person may have a severe cough and other respiratory symptoms.

Areas of infection: Infection primarily of the lungs. Extrapulmonary TB: tubercle bacillus also infects lymph nodes, meninges (TB meningitis), kidneys, bone, skin, and the oral cavity.

II.

Clinical Management Official recommendations from the Centers for Disease Control and Prevention (CDC) include the following9: Risk assessment including community TB profile conducted annually. DHCP: Screen all newly employed DHCP for latent TB infection and TB disease. A baseline two-step tuberculin skin test (TST), followed by annual TST is recommended. DHCP with persistent cough (more than 3 weeks) or other suggestive symptoms are referred promptly for medical evaluation. Medical history: Patients are routinely questioned about TB history and symptoms suggestive of TB infection; history is updated regularly. Referral: Patients with symptoms or history suggestive of TB are referred immediately for medical evaluation. Urgent dental care: Patients suspected of active TB infection are treated only in a facility with an airborne isolation room. Respiratory protection with a minimum N95 disposable filtration mask is used when caring for a patient with active (or suspected active) TB. Separation of suspected or confirmed TB patients; patients are isolated in a separate area until referral to the appropriate facility can be made. A patient management guide is available in Chapter 60.

VIRAL HEPATITIS Hepatitis is inflammation of the liver, which can be caused by virus(es). The most common viruses that cause hepatitis are HBV, HCV, and hepatitis D virus (HDV) Chronic or carrier disease state may occur with HBV, HCV, and HDV. Directly impacts the practice of dental hygiene and patient care.

I.

Hepatitis B Virus10 HBV is a serious, endemic, worldwide disease. Effective HBV vaccines are available for everyone (including neonates), and also for preexposure (PrEP) and postexposure prophylaxis (PEP). All vaccines act to stimulate antibodies and convey immunity. Table 5-2 lists hepatitis B abbreviations and interpretation of serologic tests.

TABLE 5-2 • Hepatitis B Abbreviations and Interpretation of Serologic Tests TERM

TEST SIGNIFICANCE ABBREVIATION

Hepatitis B surface antigen

HBsAg

Protein on surface of HBV. Presence indicates person is infectious, regardless of whether the infection is acute or chronic. HBsAg is used to make HBV vaccine.

Total hepatitis B core antibody

Anti-HBc

Indicates previous or ongoing infection in an undefined time frame. Does not develop in persons whose immunity to HBV is from vaccine. Anti-HBc generally persists for life and is not a serologic marker for acute infection.

Hepatitis B surface antibody

Anti-HBs

Presence indicates recovery and immunity against reinfection. Can occur in response to HBV vaccine.

IgM antibody to hepatitis B core antigen

IgM anti-HBc

Indicates recent (95% BFE.3 Airborne droplets smaller than 3–5 µm in size can reach the alveoli of the lower respiratory tract and may potentially cause infection.4 Droplet nuclei (Mycobacterium tuberculosis) range from 0.5 to 1 µm and are a risk in healthcare settings.5 Fit: Proper fit over face is vital to protect against inhaling droplet nuclei from aerosols. Moisture absorption: Soak through is an important factor. Lining needs to be impervious. Comfort: Degree of comfort encourages compliance in wearing.

B. Materials Various materials have been used for masks, including: Gauze and other cloth. Plastic foam. Fiberglass. Synthetic fiber mat. Paper. Foam, paper, and cloth have been shown to be the least adequate filters of aerosols, whereas glass fiber and synthetic fiber mat were shown to be the most effective.6,7 Particulate respirator mask (PRM) Use the National Institute for Occupational Safety and Health– certified PRM (e.g., N95, N99, or N100) for potentially infectious patient (active tuberculosis) when ventilation is poor, and procedures likely to produce droplet spatter or aerosols of oral or respiratory fluids.5

Heavy-duty mask designed with a tight fit.

III. Use of a Mask Adjust the mask and position eyewear before performing hand hygiene. Use a new mask for each patient. Change mask each hour during routine procedures or more frequently when it becomes wet. Keep the mask on after completing a procedure while still in the presence of aerosols. Particles 1–5 µm can remain suspended for hours and can be inhaled directly into terminal lung alveoli.8 Removal of a mask in the treatment room immediately following the use of aerosol-producing procedures permits direct exposure to airborne organisms. Mask removal Grasp side elastic or tie strings to remove (Figure 6-2).

FIGURE 6-2 • Removal of Mask. Handle only by the elastic or tie strings, carefully avoiding the contaminated mask.

Never handle the outside of a contaminated mask with gloved or bare hands. Never place the mask under the chin.

IV. Respiratory Hygiene Implement respiratory hygiene protocols for patients or anyone who presents in a dental setting with signs or symptoms of a respiratory illness such as coughing, sneezing, or runny nose.9 Signs are posted to inform patients with symptoms of respiratory illness to cover their mouth and nose when sneezing or coughing.9 Tissues and receptacles with no touch technology for disposal are made available.9 Offer methods for hand hygiene (sinks with soap and disposable towels or alcohol-based rub).9

USE OF PROTECTIVE EYEWEAR Eye protection for the dental team members and patients is necessary to prevent physical injuries and infections of the eyes. Severe and disabling eye accidents and infections have been reported.10-12 Eye involvement may lead to pain, discomfort, loss of work time, and, in certain instances, permanent injury. Accidents can occur at any time, and as with most accidents, they occur when least prepared for or expected. Eye infections can follow the accidental dropping of an instrument on the face or the splashing of various materials from a patient’s oral cavity into the eye. Contamination can be introduced from saliva, biofilm, carious material, pieces of old restorative materials during cavity preparation, bacteria-laden calculus during scaling, and any other microorganisms contained in aerosols or spatter. Careful, deliberate techniques and instrument management, with evacuation and other procedures for the control of oral fluids, contribute to the prevention of accidents and infections of the eyes. All measures described for the prevention of airborne disease transmission by aerosols and spatter apply to eye protection. The most effective defense is the use of protective eyewear by all involved—dental team members and patients.

I.

Indications for Use of Protective Eyewear

A. Dental Team Members Protective eyewear is worn for all procedures. Dental personnel who do not require corrective lens for vision wear protective eyewear with clear lens.

B. General Features of Acceptable Eyewear

Sufficient eye coverage, with side shields, to protect around the eye. Shatterproof; made of strong, sturdy plastic. Lightweight. Flexible and with rounded smooth edges to prevent discomfort. Easily disinfected. Smooth surface areas to prevent accumulation of infectious material. Disinfectant used cannot damage or distort the frames or lens. A clear or lightly tinted lens, rather than a very dark lens, permits the dental team members to watch the patient’s reactions and maintain contact and response. Desirable but not required: scratch-resistant, antifog, and antistatic.

C. Types of Eyewear Many styles, including regular eyeglass shapes and those described as follows, have been used. Goggles: Shielding on all sides of the glasses may give the best protection, provided they fit closely around the edges. Goggle-style coverage is necessary for protection during laboratory work. Eyewear with side shields (Figure 6-3A): A side shield can provide added protection, but do not protect from splashes or droplets as well as goggles.13 For the member of the dental team who depends on a prescription lens, separate side shields are available that can be connected to the bows.

FIGURE 6-3 • Protective Eyewear. Protective cover for both patient and clinician may be goggles-style (A) glasses with side shields, (B) safety glasses, (C) disposable eyewear, and (D) loupes. (Courtesy of Susan Jenkins, RDH, MS.)

Eyewear with curved frames (Figure 6-3B): When the sides of the eyewear are curved back, they may provide a protection somewhat similar to that offered by those with the side shield. Postmydriatic spectacles used by ophthalmologist: Disposable

glasses are available that are made of antiultraviolet flexible plastic (Figure 6-3C). Dental loupes (Figure 6-3D): Designed to protect the eyes and magnify the oral cavity. When they are designed with a light or flipup, do not touch during clinical procedures. Child-sized: Child-sized sunglasses and children’s play spectacles have been used.

D. Face Shield A clinician needs to wear a face shield over a regular mask when aerosol-producing handpiece, power scaler, or power polishing equipment is used.

E. Protective Eyewear for Patients Protective eyewear is essential for each patient at each appointment. A patient who has not been asked to wear protective eyewear at previous appointments will appreciate a simple explanation of the reasons for doing so. Patients with their own prescription lenses may prefer to wear them, but for the safety of the patient’s glasses, the use of the protective eyewear provided in the office or clinic may be advisable. Protection against glare. Certain patients may request tinted lenses or prefer to wear their own sunglasses when their eyes are especially sensitive to the dental light.

II.

Suggestions for Clinical Application

A. Contact Lenses Dental team members and patients who wear contact lenses always need to wear protective eyewear over them during dental and dental hygiene procedures.

B. Care of Protective Eyewear Rinse eyewear under running water to remove abrasive particles. Rubbing an abrasive agent over the plastic lens can create scratches. Materials used for protective lens may be damaged by some disinfectants. Clean with detergent and rinse thoroughly. Air-dry. Check periodically for scratches on the lens and replace appropriately.

C. Eye Wash Station Eye wash station equipment needs to be attached to a sink not used by clinicians for patient preparation. It must not be connected to the regular faucets unless the hot water source is turned off permanently.

HAND CARE In the infectious process of disease transmission, the hands may serve as a means of transmission of the blood, saliva, and dental biofilm from a patient. The hands, especially under the fingernails, may serve as a reservoir for microorganisms. Skin breaks in the hands may serve as a port of entry for potentially pathogenic microorganisms. By caring properly for the hands, using effective hand-hygiene procedures, and following the basic rules for gloving, primary crosscontamination can be controlled. A conscious effort is made to keep the gloved hands from touching objects other than the instruments and disinfected parts of the equipment prepared for the immediate patient.

I.

Bacteriology of the Skin Resident bacteria Many relatively stable bacteria inhabit the surface epithelium or deeper areas in the ducts of skin glands or depths of hair follicles; ultimately, they are shed with the exfoliated surface cells or with excretions of the skin glands. Resident bacteria tend to be less susceptible to destruction by disinfection procedures. Transient bacteria Transient bacteria reflect continuous contamination by routine contacts; some bacteria are pathogens. They may be washed away or, in the event that a skin break exists, may cause an autogenous infection. Most transients can be removed with soap and water by washing thoroughly or with 60%–95% ethanol or isopropanol-based hand rubs as directed by the manufacturer.

II.

Hand Care

A. Fingernails Maintain clean, smoothly trimmed, short fingernails with well-caredfor cuticles to prevent breaks where microorganisms can enter. Effects of short nails: Make handwashing more effective because of fewer microorganisms harbored under the nails.14 Prevent cuts from long nail in disposable gloves. Permit selection of a closer fit of glove; longer glove fingers may be required to protect nails. Allow greater dexterity during instrumentation. Decrease chance of patient discomfort.

B. Artificial Nails Artificial nails or extenders are associated with fungal and bacterial pathogens in hospital settings and are not recommended for clinicians.15-18 Wearing rings and nail polish is not recommended because chipped nail polish and skin under the ring may harbor bacteria.3,19

C. Wristwatch and Jewelry Remove hand and wrist jewelry at the beginning of the day. Microorganisms can become lodged in crevices of rings, watchbands, and watches.

D. Gloves After handwashing, put on gloves. Never expose open skin lesions or abrasions to a patient’s oral tissues and fluids. After glove removal, wash hands to remove microorganisms.

HAND-HYGIENE PRINCIPLES I. Rationale Effective and frequent hand hygiene can reduce the overall bacterial flora of the skin and prevent the organisms acquired from a patient from becoming skin residents. It is impossible to sterilize the skin, but every attempt is made to reduce the bacterial flora to a minimum.

II.

Purposes

Hand hygiene, including handwashing, hand antisepsis, or surgical hand antisepsis, is critical for reducing the bacterial flora of the hands. The chosen method is dependent on the procedure and the degree of contamination. An effective hand-hygiene procedure can be expected to accomplish the following: Remove surface dirt and transient bacteria. Dissolve the normal greasy film on the skin. Rinse and remove all loosened debris and microorganisms.

III. Facilities Sink Use a sink with a foot pedal or electronic control for water flow to avoid contamination to/from faucet handles. For regular sink, turn on water at the beginning and leave on through the entire procedure. Turn faucets off with the towel after drying hands. Clean around sink rim with disinfectant. The sink must be of sufficient size so that contact with the inside of the wash basin can be avoided. A sink cannot be sterilized and can become highly contaminated. Prevent contamination of clothing by not leaning against the sink.

Use a separate area and sink reserved for instrument washing. Soap Use a liquid or foam soap. Apply from a foot- or knee-activated or electronically controlled dispenser to avoid contamination to and from a hand-operated dispenser or cake soap. Rinsing is a necessary part of the handwashing procedure. Scrub brushes Avoid overvigorous use of a brush to minimize skin abrasion. Skin irritation and abrasion can leave openings for additional cross-contamination. Disposable sponges are available commercially and may be preferred when a scrub brush is traumatic to the skin. Towels Obtain disposable towel from a dispenser that requires no contact except with the towel itself, which hangs down, or a hands-free automatic dispenser. Cloth towels are not recommended.

METHODS OF HAND HYGIENE Hand hygiene is considered the most important single procedure for the prevention of cross-contamination (Box 6-2).

BOX 6-2 Hand-Hygiene Methods and Indications

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings—2003. MMWR Recomm Rep. 2003;52(RR-17):15, 19.

I.

Indications Before and after treating each patient (before glove placement and after glove removal). Before regloving after removing gloves that are torn, cut, or punctured. After touching inanimate objects that may be contaminated with blood or saliva with ungloved hands. When hands are visibly soiled. Before leaving the treatment room.

II.

Descriptions

A. Routine Handwash Sufficient for routine dental examinations and nonsurgical dental procedures.3 Wet hands with water, apply liquid, nonantimicrobial soap (plain soap); avoid hot water. Rub hands together for at least 15 seconds; cover all surfaces of fingers, hands, and wrists. Interlace fingers and rub to cover all sides. Rinse under running water; dry thoroughly with disposable towels. Turn off faucet with the towel.

B. Antiseptic Handwash Water and liquid antimicrobial soap (e.g., chlorhexidine, iodine and iodophors, chloroxylenol [para-chloro-meta-xylenol, PCMX], triclosan).3 To remove or destroy transient microorganisms and reduce resident flora.3 1. Preliminary steps Remove watch and jewelry from hands. Fasten hair back securely.

Put on protective eyewear and mask before handwashing to prevent contamination of washed hands ready for gloving. Use cool water. 2. Handwashing procedure Lather hands, wrists, and forearms quickly with liquid antimicrobial soap. Rub all surfaces vigorously; interlace fingers and rub back and forth with pressure. Rinse thoroughly, running the water from fingertips down the hands. Keep water running. Repeat two more times. One lathering for 3 minutes is less effective than are three short latherings and three rinses in 30 seconds. The latherings serve to loosen the debris and microorganisms and the rinsings wash them away. Use paper towels for drying, taking care not to recontaminate.

C. Antiseptic Hand Rub An antiseptic hand rub is used to remove or destroy transient microorganisms and reduce resident flora.3 Wash visibly soiled hands before use. Decontaminate hands with an (60%–95% ethanol or isopropanol) alcohol-based hand rub. Apply the product (follow manufacturer’s directions for amount to use) to the palm of one hand, and vigorously rub hands together. If hands are dry after 10–15 seconds, the amount used may need to be increased.

D. Surgical Antisepsis3 (Also Called Surgical Scrub3) Water and antimicrobial liquid soap (e.g., chlorhexidine, iodine and iodophores, chloroxylenol [PCMX], triclosan). To remove or destroy transient microorganisms and reduce

resident flora with a persistent or prolonged effect that inhibits proliferation or survival of microorganisms. Each hospital or oral surgery clinic has rules and regulations for surgical antisepsis. These will be posted over the scrub sinks. The minimum duration of a surgical antisepsis is 2–6 minutes. Following treatment of a contagious or isolated patient, the procedure will take at least 5 minutes. 1. Preliminary steps Remove watch and jewelry. Place hair and beard coverings and make sure hair is completely covered. Put on protective eyewear and mask. Open sterile brush package to have ready. Wash hands and arms using surgical liquid antimicrobial soap to remove gross surface dirt before using the scrub brush. Lather vigorously with strong rubbing motions, 10 on each side of hands, wrists, and arms. Interlace the fingers and thumbs to clean the proximal surfaces. Rinse thoroughly from fingertips across hands and wrists. Hold hands higher than elbows throughout the procedure. Leave water running. Use orangewood stick from the sterile package to clean nails. Rinse. 2. First hand Lather the hands and arms and leave the lather on to increase the exposure time to the antimicrobial ingredient. Apply surgical liquid antimicrobial soap and begin the brush procedure. Scrub in an orderly sequence without returning to areas previously scrubbed. First hand and arm. Brush back and forth across nails and fingertips, passing the brush under the nails. Fingers and hand: use small circular strokes on all sides of the thumb and each finger, overlapping strokes for complete coverage. Continue to wrist. Apply more soap to maintain a good lather.

When arm is completed, leave lather on. 3. Second hand Repeat on the other arm. Some systems require the use of a second sterile brush for the second hand. When this is so, discard the first brush into the proper container and obtain the second brush. At one-half of scrub time, rinse hands and arms thoroughly, first one and then the other, starting at the fingertips and letting water pass down over the arm. Lather and repeat. At the end of time (or counts), rinse thoroughly, each arm separately, from fingertips. Apply towel from fingertips to elbow without reapplying to hand area. Hold hands up and clasped together. Proceed to dressing area for gowning and gloving.

GLOVES AND GLOVING Wearing gloves is a standard practice to protect both the patient and the clinician from cross-contamination.

I.

Criteria for Selection of Treatment/Examination Gloves

A. Safety Factors Effective barrier; evidence from manufacturer of quality control standards. Impermeable to patient’s saliva, blood, and bacteria. Strength and durability to resist tears and punctures. Impervious to materials routinely used during clinical procedures. Nonirritating or harmful to skin; use nonlatex gloves when the patient or clinician is allergic. Length: glove cuff extends to provide coverage over cuff of long sleeve.

B. Ergonomic Choice Factors Fit hand well; no interference with motion. Tactile sense not decreased. No tight pull over palm or between thumb and index finger.

II.

Types of Gloves Material Latex. Nonlatex: neoprene, block copolymer, vinyl, N-nitrile. For patient care Nonsterile single-use examination/treatment: latex, nonlatex. Presterilized single-use surgical: latex, nonlatex.

Utility gloves Heavy duty: latex, nonlatex (puncture resistant for clinic cleanup). Plastic: Food handler’s glove to wear as overglove.

III. Procedures for Use of Gloves Mask and eyewear placement Place mask and protective eyewear before performing hand hygiene and gloving. Prevent the need for manipulating the mask around the face and hair after washing the hands. Pregloving hand hygiene Use an antiseptic handwash or hand rub before gloving. Hands must be dried thoroughly to control moisture inside glove and discourage growth of bacteria. Glove placement Always glove and deglove in front of the patient; a patient may need assurance that gloves are new and used only for that appointment. Place gloves over the cuff of long-sleeved clinic wear to provide complete protection of arms from exposure to contamination. Avoiding contamination Keep gloved hands away from face, hair, clothing (pockets), telephone, patient records, clinician’s stool, and all parts of the dental equipment that have not been predisinfected and covered with a barrier material. Torn, cut, or punctured glove Remove immediately, wash hands thoroughly, and put on new gloves. Removal of gloves Develop a procedure whereby gloves can be removed without contaminating the hands from the exposed external surfaces of the gloves. Figure 6-4 illustrates one system for glove removal.

FIGURE 6-4 • Steps for Removal of Gloves. A: Use left fingers to pinch right glove near edge to fold back. B: Fold edge back without contact with clean inside surface. C: Use right fingers to contact outside of left glove at the wrist to invert and remove. D: Bunch glove into the palm. E: With ungloved left hand, grasp inner noncontaminated portion of the right glove to peel it off, enclosing the other glove as it is inverted.

Wash hands promptly after glove removal. Organisms on the hands multiply rapidly inside the warm, moist environment of the glove, even when no external contamination has occurred.

IV. Factors Affecting Glove Integrity Length of time worn New pair for each patient is the basic requirement. Total time worn is no longer than 1 hour; when gloves develop a sticky surface, remove, wash hands, and reglove with a fresh pair. Complexity of the procedure Certain procedures are more likely to promote perforations, especially when sharp instruments must be changed frequently. Packaging of the gloves Gloves in a new package are tightly packed and can be torn when removed; must be handled carefully until pressure is relieved. Size of glove When too long, the extra material at the fingertips can get caught, torn, or in the way; picking up small objects is difficult, especially sharp instruments. Pressure of time Stress; working too fast increases the risk of glove damage. Storage of gloves Keep in cool, dark place; exposure to heat, sun, or fluorescent light increases potential for deterioration and perforations. Agents used

Certain chemicals react with the glove material; for example, petroleum jelly, alcohol, and products made with alcohol tend to break down the glove integrity. Hazards from the hands Long fingernails and rings worn inside gloves.

LATEX HYPERSENSITIVITY Patients and clinicians may have or may develop sensitivity to natural rubber latex (NRL). Symptoms of a hypersensitive reaction range from a dermatitis to a life-threatening anaphylactic shock. The only available treatment for latex allergy is avoiding all contact. Latex sensitivity is due to the protein allergens and to additives used when the commercial latex is prepared. Latex allergens occur in any equipment or product used that contains NRL. Gloves are the most frequently used item that contains latex. Equipment listed in Box 6-3 may contain NRL. However, many of the items are also made of alternative materials. When the label on a product does not list the contents, the manufacturer can be contacted to identify latex-free items.

BOX 6-3 Equipment That May Contain Latex Bite blocks Blood pressure cuff Gloves Goggles Lead apron cover Masks (elastic head band) Mixing bowl Nitrous oxide nosepiece and tubing rubber dam O ring (on ultrasonic insert) Orthodontic elastics Rubber polishing cup Stethoscope Stopper in anesthesia carpule Suction adapter

I.

Clinical Manifestations Methods of exposure Direct exposure to latex products. Aeroallergen inhalation of the allergen when the powder (cornstarch) from the gloves becomes airborne. Mucosal contact. Type I hypersensitivity (immediate reaction) Urticaria: hives. Dermatitis: rash, itching. Nasal problems: sneezing, itchy nose, runny nose. Eyes: watery, itchy watery, itchy. Respiratory reaction: breathing difficulty, asthma-like wheezing, coughing. Drop in blood pressure: shock. Anaphylaxis. Type IV hypersensitivity (delayed reaction) Contact dermatitis develops 8 hours to 5 days after contact.20

II.

Individuals at High Risk for Latex Sensitivity Have had frequent exposure to latex products. Occupational exposure: Healthcare personnel who wear latex gloves regularly for patient care or have worked in a rubber manufacturing plant. Multiple medical surgeries or treatments requiring placement of rubber tubes or drains. Examples: genitourinary anomalies, spina bifida. Have other documented allergies Examples: food allergies (avocado, banana, kiwi fruit, chestnuts, papaya, peanuts).

III. Management A. Medical History

Questions in history will reveal known allergies. Questions directed to latex may not suffice. Questions about other specific products need to be asked. Advise allergic patients to obtain and wear an alert badge (bracelet).

B. Document All information is carefully recorded for continuing reference.

C. Appointment Planning for Allergic Patient Treatment in a latex-free environment. Whenever possible, use nonlatex gloves and other nonlatex products.21 Early in the day when powdered gloves are used: Appointment before glove powder contaminates the air throughout the facility or outerwear of clinical attire becomes laden with airborne latex. Clean clinical areas: Person preparing room must wear nonlatex gloves. Wipe all surfaces to remove allergen. No latex in the treatment room: Use nonlatex products for high-risk patients (whether or not specific latex sensitivity has been known and reported in the history). Prepare latex-free carts: Materials and gloves, for use when seeing high-risk patients, can be readied in advance.12

D. Emergency Treatment Equipment and Drugs Ready Inform the entire dental team of appointment. Have a latex-free emergency cart available.21 Alert for emergency.

DOCUMENTATION Documentation needs to record the following: Irregularities related to personal protection that could have influenced the procedures of a routine appointment. How the special needs were taken care of for a patient with an allergy to latex. Information in medical alert that patient is sensitive to latex. A sample progress note may be found in Box 6-4.

BOX 6-4 Example Documentation: Patient with a Latex Sensitivity S—Initial appointment for new patient to our practice. She reports sensitivity to latex gloves. O—History form and questions completed. Informed patient that the office is latex free. Radiographs taken, risk assessment, caries examination, and periodontal assessment. Pocket depths 5–6 mm in the area of #30–31 with bleeding on probing, all other areas 3 mm or less. Plaque score 30%. A—Patient has a history of skin reactions when latex gloves are used. Careful attention to avoiding use of products containing latex. Localized moderate chronic periodontitis between #30 and #31. P—Review of oral self-care with attention to optimal biofilm removal #30–31. Localized nonsurgical periodontal therapy with local anesthetic with prophylaxis full mouth. About 5% sodium fluoride varnish due to moderate caries risk. Signed: ______________________________, RDH Date: _____________________________________

EVERYDAY ETHICS After Mr. Green’s dental hygiene treatment is completed, the dentist, Dr. Root, is notified so that the final examination can be made. Dr. Root comes in shortly and sits down next to the patient. He browses through the notations made in the patient’s chart and then picks up the mirror and explorer to proceed with a

clinical examination. It is apparent that he has not washed his hands and may not even have put on a new pair of gloves since he left the other treatment room. A similar situation has happened occasionally before. Questions for Consideration 1. Mabel, the dental hygienist, notes the dentist did not change his gloves or wash his hands. Is Mable faced with an ethical dilemma or an ethical issue? Explain. 2. Read the nine “Standards of Professional Responsibility” in the American Dental Hygienists’ Association Code of Ethics. Explain which of the standards are involved and how each is violated if Mable does not address this issue with Dr. Root. 3. Use the steps for making decisions in Chapter 1 Code of Ethics section to determine some actions that Mable might take to address this situation both immediately and long term.

Factors to Teach the Patient Need for the patient’s complete history for the protection of both the patient and the professional person. Purposes for use of barriers (face mask, protective eyewear, and gloves) by the clinician for the benefit of the patient. Importance of eye protection. Significance of hand hygiene in the control of disease transmission (everywhere, not only dental office or clinic).

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. U.S. Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910.1030. Occupational exposure to bloodborne pathogens; needlesticks and other sharps injuries; final rule. Fed Regist. 2001;66:53175325. As amended from and includes 29 CFR Part 1910.1030; Occupational exposure to bloodborne pathogens; final rule. Fed Regist. 1991;56:6417464182. 2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Immunization of health-care personnel. MMWR Recomm Rep. 2011;60(RR-07):1-45. 3. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings— 2003. MMWR Recomm Rep. 2003;52(RR-17):15, 19. 4. Gordon J, Ingalls T. Preventive medicine and epidemiology. Prog Med Sci. 1957;233:334-357. 5. U.S. Centers for Disease Control. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care setting, 2005. MMWR Recomm Rep. 2005;54(RR-17):1-142. 6. Micik RE, Miller RL, Leong AC. Studies on dental aerobiology: III. Efficacy of surgical masks in protecting dental personnel from airborne bacterial particles. J Dent Res. 1971;50(3):626-630. 7. Miller RL, Micik RE. Air pollution and its control in the dental office. Dent Clin North Am. 1978;22(3):453-476. 8. Wells WF. Aerodynamics of droplet nuclei. In: Wells WF, ed. Airborne Contagion and Air Hygiene: An Ecological Study of Droplet Infections. Cambridge, MA: Harvard University Press; 1955:13-19. 9. Centers for Disease Control and Prevention. Respiratory hygiene/cough etiquette in healthcare settings. https://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm. Updated February 27, 2012. Accessed August 30, 2017. 10. Cooley RL, Cottingham AJ, Abrams H, et al. Ocular injuries sustained in the dental office: methods of detection, treatment, and prevention. J Am Dent Assoc. 1978;97(6):985-988. 11. Wesson MD, Thornton JB. Eye protection and ocular complications in the dental office. Gen Dent. 1989;37:19. 12. Roberts-Harry TJ, Cass AE, Jagger JD. Ocular injury and infection in dental practice: a survey and a review of the literature. Br Dent J. 1991;170(1):20-22. 13. Centers for Disease Control and Prevention. The National Institute for Occupational Safety and Health (NIOSH). Eye safety. https://www.cdc.gov/niosh/topics/eye/eye-infectious.html. Updated July 29, 2013. Accessed October 20, 2017. 14. Allen AL, Organ RJ. Occult blood accumulation under the fingernails: a

mechanism for the spread of blood-borne infection. J Am Dent Assoc. 1982;105(3):455-459. 15. Foca M, Jakob K, Whittier S, et al. Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. N Engl J Med. 2000;343(10):695700. 16. Moolenaar RL, Crutcher JM, San Joaquin VH, et al. A prolonged outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit: did staff fingernails play a role in disease transmission? Infect Control Hosp Epidemiol. 2000;21(2):80-85. 17. Parry MF, Grant B, Yukna M, et al. Candida osteomyelitis and diskitis after spinal surgery: an outbreak that implicates artificial nail use. Clin Infect Dis. 2001;32(3):352-357. 18. Passaro DJ, Waring L, Armstrong R, et al. Postoperative Serratia marcescens wound infections traced to an out-of-hospital source. J Infect Dis. 1997;175(4):992-995. 19. Arrowsmith VA, Taylor R. Removal of nail polish and finger rings to prevent surgical infection. Cochrane Database Syst Rev. 2012;5:CD003325. 20. Muller BA. Minimizing latex exposure and allergy: how to avoid or reduce sensitization in the healthcare setting. Postgrad Med. 2003;113(4):91-97. 21. Centers for Disease Control, National Institute for Occupational Safety and Health. Alert: Preventing Allergic Reactions to Natural Rubber Latex in the Workplace. Cincinnati, OH: Public Health Service, U.S. Department of Health and Human Services. June, 1997.

7 Infection Control: Clinical Procedures Lory A. Libby, RDH, MSDH

CHAPTER OUTLINE INFECTION CONTROL I. II.

Objectives Basic Considerations for Safe Practice

TREATMENT ROOM FEATURES I. II.

Contact Surfaces Housekeeping Surfaces

INSTRUMENT PROCESSING CENTER I.

Supplies

PRECLEANING PROCEDURES I. II.

Manual Scrubbing Instrument Washer/Thermal Disinfector

III.

Ultrasonic Processing

INSTRUMENT PACKING AND MANAGEMENT SYSTEM I. II.

Instrument Arrangement Preparation

STERILIZATION I. II. III.

Approved Methods Selection of Method Tests for Sterilization

MOIST HEAT: STEAM UNDER PRESSURE I. II. III. IV.

Autoclave Types Use Principles of Action Evaluation

DRY HEAT I. II. III. IV.

Use Principles of Action Operation Evaluation

CHEMICAL VAPOR STERILIZER I. II. III. IV. V.

Use Principles of Action Operation Care of Sterilizer Evaluation

INTERMEDIATE-USE STEAM STERILIZATION CHEMICAL LIQUID STERILIZATION CARE OF STERILE INSTRUMENTS CHEMICAL DISINFECTANTS I. II. III. IV. V.

Manufacturer’s Information Categories Uses Principles of Action Criteria for Selection of a Chemical Agent

BARRIERS AND SURFACE COVERS I. II.

Benefits Procedure

PREPARATION OF THE TREATMENT ROOM I. II.

Objective Preliminary Planning

III. Surface Disinfection Procedure IV. Clean and Disinfect Environmental Surfaces V. Unit Water Lines

PATIENT PREPARATION I. II.

Preprocedural Oral Hygiene Measures Application of a Surface Antiseptic

SUMMARY OF STANDARD PROCEDURES I. II. III. IV. V.

Patient Factors Clinic Preparation Factors for the Dental Team Treatment Factors Posttreatment

DISPOSAL OF WASTE I. II.

Regulations Guidelines for Disposal of Waste

SUPPLEMENTAL RECOMMENDATIONS I. II. III. IV. V.

Cleaning the Face Smoking and Eating Reception Area Sterilization Monitoring Office Policy Manual

OCCUPATIONAL POSTEXPOSURE MANAGEMENT I. II. III.

Significant Exposures Procedure Following Exposure Follow-Up

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Describe the basic considerations for safe infection control practices.

2. Explain methods for cleaning and sterilizing instruments. 3. Describe procedures to prepare, clean, and disinfect the treatment area. 4. Explain process for managing hypodermic needles and occupational postexposure management. 5. List types of waste disposal and explain how each type is handled.

INFECTION CONTROL The success of a planned system for control of disease transmission depends on the cooperative effort of each member of the dental team. The aim is to provide the highest level of infection control to ensure a safe environment for both patients and the clinical team. The presence of specific disease-producing organisms is rarely known; therefore, application of protective, preventive procedures is needed before, during, and following all patient appointments.

I.

Objectives

The following are guidelines necessary to prevent the transmission of infectious agents and eliminate cross-contamination: Reduction of available pathogenic microorganisms to a level at which the normal resistance mechanisms of the body can prevent infection. Elimination of cross-contamination by breaking the chain of infection (see Chapter 5). Application of standard precautions by treating each patient as if all human blood and body fluids are infectious.

II.

Basic Considerations for Safe Practice

When developing a safe practice routine, the sterilization and disinfection of patient care items are categorized into the following: Critical items: These items will come into contact with soft tissue and bone and run the highest risk of disease transition. These items should be disposable or sterilized using a heat sterilizer.1 Examples of these are surgical instruments, scalers, probes, needles, and scalpel blades. Semi-critical items: These items come into contact with nonintact skin. Semi-critical items have a lower risk of transmitting disease than do critical items; however, these should also be disposable or

be processed using heat sterilization.2 If these items are heat sensitive, they should be processed using a high-level disinfectant.3 Examples of these include mouth mirrors and impression trays. Noncritical items: These items could potentially come into contact with intact skin and pose the lowest risk of disease transmission.2

TREATMENT ROOM FEATURES A partial list of notable features is included here and illustrated in Figure 7-1. The objective is to have materials, shapes, and surface textures to facilitate the effective use of infection control measures.

FIGURE 7-1 • Optimal Treatment Room Features.

I.

Contact Surfaces

Contact surface can sometimes be referred to as noncritical items and consist of instruments and surfaces that may come into contact with intact skin.1,2 These surfaces can potentially be contaminated by spray or splatter or by hand contact by a dental healthcare personnel. Contact surfaces can be disinfected using an Environmental Protection Agency (EPA)-registered hospital disinfectant but should be covered with a barrier whenever possible. Examples of these surfaces include light switches, draw handles, faucets, pens, pencils, doorknobs, telephones as well as the following standard features of a dental treatment room.2

A. The Unit Designed for easy cleaning and disinfection, with smooth, uncluttered surfaces. Removable hoses that can be cleaned, disinfected, and covered. Syringes with autoclavable tips or fitted with disposable tips.

B. Dental Chair Foot-operated controls. Surface and seamless finish of easily cleaned plastic material that withstands chemical disinfection without damage. Cloth upholstery to be avoided.

C. Light Removable handle for sterilization or disposable barrier cover.

D. Clinician’s Chair Smooth, plastic seat cover that is easily disinfected and has a minimum of seams and creases.

E. Radiographic Equipment Constructed of a smooth material for easily disinfection or disposable barrier cover.

II.

Housekeeping Surfaces

Housekeeping surfaces consist of surfaces such as floors, wall, sinks, bathrooms, or any surface that poses no risk of disease transmission in dental care settings.2 The Centers for Disease Control and Prevention (CDC) recommends these areas be cleaned using detergent and water or an EPA-registered hospital disinfectant/detergent.2

A. Floor No cloth carpeting. Smooth floor covering, easily cleaned, nonabsorbent.

B. Sink Smooth material (stainless steel). Wide and deep enough for effective handwashing without splashing or touching sides. Automatic water faucets and soap dispensers with electronic, “hand,” “knee,” or foot-operated controls.

C. Waste Most waste is disposed with usual waste. Receptacle with opening large enough to prevent contact with sides when material is deposited. Heavy-duty plastic bag liner to be sealed tightly for disposal. Separate sharps disposal. Small biohazard receptacle near treatment area to receive

contaminated gauze and other waste, for disposal in large waste container clearly marked for contaminated waste.

INSTRUMENT PROCESSING CENTER The successful practice of standard precautions to prevent crosscontamination depends on the development of, and strict adherence to, a planned program for both critical and semi-critical instrument management. The processing center is used for care, cleaning, packaging, sterilizing, and storage of instruments. The center should be separated into respective areas of sterilized and contaminated instruments. It should be centrally located and apart from the treatment rooms.3

I.

Supplies

All critical and semi-critical supplies should be sterilizable or disposable. A good rule is to learn the most effective, safe system and then to follow it without exception. A specific routine is easier for the entire dental team to follow, and peer review should be built in. The basic steps in the recirculation of instruments from the time an appointment procedure is completed until the instruments are sterilized and ready for use in a continuing clinical appointment are shown in the flowchart in Figure 7-2. Each of the steps is described in the following sections.

FIGURE 7-2 • Recirculation of Instruments. Flowchart shows step-by-step process. At the completion of treatment, instruments are cleaned, packaged, sterilized, and stored. They are kept sealed until patient appointment begins.

PRECLEANING PROCEDURES There are three basic methods for precleaning to remove any organic or inorganic debris from instruments before sterilization: manual scrubbing, washer/thermal disinfector, and ultrasonic processing.1

I.

Manual Scrubbing The use of automated devices is the preferred method of instrument cleaning. Manual scrubbing is not a recommended cleaning method. However, if manual scrubbing is necessary, the following precautions are essential3: Wear heavy-duty gloves, protective eyewear, and mask. Dismantle instruments with detachable parts. Open jointed instruments. Use detergent and scrub with a long-handled brush under running water; hold the instruments low in the sink. Scrubbing one instrument at a time minimizes risk of puncture injury. Brush with strokes away from the body; be careful not to splash and contaminate the surrounding area. Rinse thoroughly. Air-dry resting on paper towels to avoid saturation of the sterilization package. Care of Brushes Color code instrument brushes to distinguish from handwash brushes. Soak and wash contaminated brushes in detergent; rinse thoroughly and sterilize.

II.

Instrument Washer/Thermal Disinfector The instrument washer uses high-velocity hot water and a detergent to clean instruments. Some models are equipped to dry the instruments.

Household dishwashers may look similar to instrument washers but are different and not appropriate for dental instruments.4 The instrument washer/thermal disinfector also differs from the plain washer by having a higher degree of temperature, so it disinfects as well as cleans the instruments4 (Figure 7-3A). Benefits from the use of washer/thermal disinfector and ultrasonic cleaning versus manual scrubbing include the following5:

FIGURE 7-3 • A: Instrument washer. B: Ultrasonic processor. C: Instrument

cassette in a sterilization pouch.

Increased efficiency in obtaining a high degree of cleanliness for improved disinfection. Reduced danger to clinician from direct contact with potentially pathogenic microorganisms. Elimination of possible dissemination of microorganisms through release of aerosols and droplets, which can occur during the scrubbing process. Disinfection allows the instruments in cassettes to be handled with gloves while packaging.

III. Ultrasonic Processing An Ultrasonic Processor removes debris from instruments using acoustic energy waves transmitted in liquid disrupting the attachment of debris from an object.1,5 Ultrasonic cleaning before sterilization is safer than manual cleaning. Manual cleaning of instruments is a dangerous, difficult, and time-consuming procedure. Ultrasonic equipment is maintained and used according to manufacturer’s guidelines (Figure 7-3B). Ultrasonic processing is not a substitute for sterilization; it is only a cleaning process to remove debris.

A. Procedure Guard against overloading; the solution must contact all surfaces. Instruments need to be completely immersed. Dismantle instruments with detachable parts. Open jointed instruments. Time accurately by manufacturer’s instructions. Drain, rinse, and air-dry.

B. Indications for Thorough Drying When sterilizing by dry heat or chemical vapor, non–stainless steel instruments or carbon steel require predip in rust inhibitor before steam autoclaving; water on instruments dilutes the antirust solution.

INSTRUMENT PACKING AND MANAGEMENT SYSTEM Instrument management systems are important to have in place in order to prevent contamination of newly sterilized instruments. The system should: Provide a means of organizing instrument packets for different procedures. Assure instruments are sterilized and ready for immediate use on opening. Provide a means of storing instruments packets.

I.

Instrument Arrangement Each package is dated and marked for identification of contents: for example, Adult Prophylaxis; Examination. Clear packages that self-seal and permit instrument identification without special labeling are often used (Figure 7-3C). Instruments can be organized into tray systems, dental storage containers, or cassettes customized based on various dental hygiene procedures such as an initial exam of an adult patient, child patient, or periodontal maintenance patient. Instruments and accessories held in one unit provide a sterile environment for instruments during treatment. After the treatment, they serve as packaging for the process of cleaning, disinfection, and sterilization.

II.

Preparation Cassettes can be wrapped or packaged, and single instruments are packaged. Each method of sterilization has specific requirements, and the manufacturers’ recommendations are followed. The packaging material permits the steam or chemical vapor to

pass through the contents and maintains sterility during transport and storage. Sturdy wrapping is necessary to prevent punctures or tears that break the chain of asepsis and require a repeat of the process. Seal Pins, paper clips, or other types of metal fasteners are not used to seal packages because they may create holes for the entry of microorganisms. Chemical indicator tape is used unless the package is self-seal and the wrap has built-in indicators (Figure 7-4).

FIGURE 7-4 • Built-in Chemical Indicator Before and After Sterilization.

The change of color on the indicator confirms the autoclave reached a designated temperature required for penetration. This is not a conformation of sterilization but an indication the device is working properly.3 When using indicator tape, distinct black stripes will appear. A lighter color change may be a warning signal that the autoclave function needs to be checked. The striped indicator tape is left on the sealed package and thereby serves to identify those packages ready for use. Packages are kept completely sealed until unwrapped in front of the patient.

STERILIZATION Sterilization is accomplished with equipment cleared by the U.S. Food and Drug Administration (FDA). Sterilizing equipment should be used according to the manufacturer’s specifications. Each of the methods listed here are described in the following sections. Table 7-1 summarizes the operating requirements of each. TABLE 7-1 • Comparison of Methods for Sterilization METHOD

STERILIZING REQUIREMENT TIME (MIN)

TEMPERATURE

Steam under pressure (autoclave) 1. Gravity displacement

15–30

250°F (121°C)

2. Prevacuum

3.5–10

270°F (132°C)

Dry heat oven

120

320°F (160°C)

Unsaturated chemical vapor

20

270°F (132°C)

I.

Approved Methods Steam under pressure (autoclave). Dry heat. Chemical vapor. Immediate-use steam sterilization (flash). Chemical (cold) sterilization—not recommended.

II.

Selection of Method All materials and items cannot be treated by the same system of sterilization. The method for sterilization selected provides complete destruction

of all microorganisms, viruses, and spores and yet must not damage the instruments and other materials. Incomplete sterilization frequently results from inadequate preparation of the materials to be sterilized (cleaning all debris, packaging), misuse of the equipment (overloading, timing, temperature selection), or inadequate maintenance.1

III. Tests for Sterilization Sterilization is the process by which all forms of life are destroyed. That definition provides the rationale for testing whether a sterilizer is working properly.1 Three tests are used: an external and an internal chemical indicator and a biologic monitor. Weekly testing is recommended or when changes such as repair or relocation of unit occur.1,6 Equipment can be obtained for performing the testing, or commercial mail-in services are available. External chemical indicator: to seal the package and changes color to show the autoclave temperature has been reached. Internal chemical indicator: color change assesses instrument exposure to temperature and steam for the required time. Biologic monitor (spore testing): tests for proper functioning of the autoclave. The testing system requires use of selected test microorganisms put through a regular cycle of sterilization and then cultured. When no growth occurs, the sterilizer has performed with maximum efficiency. Microorganisms used: 1. Steam autoclave: Geobacillus stearothermophilus (formerly Bacillus stearothermophilus) vials, ampules, or strips.3 2. Dry heat oven: Bacillus atrophaeus (formerly Bacillus subtilis) strips.3 3. Chemical vapor: Geobacillus stearothermophilus (formerly Bacillus stearothermophilus) strips.3

Procedures 1. Manufacturer’s directions determine the placement and location of bacterial indicators.4 If there are not any instructions, the ampule, vial, or strip is placed in the center of a package, which in turn is placed in the middle of the load of packages to be sterilized. 2. After the cycle has been completed at the customary time and temperature, the ampule or strip is incubated. Ampules and vials show the color change associated with no living microorganisms, whereas the strip organisms are cultured and show no growth if the sterilizer has performed properly. 3. Table 7-2 lists indications for performing spore tests in dental settings. Records or logs showing dates and outcomes of each test must be maintained. TABLE 7-2 • Spore Testing WHEN

WHY

Once per week

To verify proper use and functioning

Whenever a new type of packaging material or tray is used

To ensure that the sterilizing agent is getting inside to the surface of the instruments

After training of new sterilization personnel

To verify proper use of the sterilizer

New sterilizer

To make sure unfamiliar operating instructions are being followed

After repair of a sterilizer

To make sure that the sterilizer is functioning properly

With every implantable device and hold Extra precaution for sterilization of item device until results of test are known to be implanted into tissues After any other change in the sterilizing procedure

To make sure change does not prevent sterilization

Source: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care

settings—2003. MMWR Morb Mortal Wkly Rep. 2003;52(RR-17):27.

Indications for spore testing1,7,8 Once per week to verify proper use and functioning. Whenever a new type of packaging material or tray is used. After training new personnel to ensure proper use. During initial uses of a new sterilizer to make sure the directions are being followed. After sterilizer repair to check functioning. Any load containing an implantable device should be spore tested and device should remain out of service until results are known.

MOIST HEAT: STEAM UNDER PRESSURE Destruction of microorganisms by heat takes place because of inactivation and coagulation of essential cellular proteins or enzymes.

I.

Autoclave Types

Autoclaves use steam under pressure to achieve sterilization and are available in the prevacuum and gravity displacement models. The two types of autoclaves differ mostly in the manner in which the evacuation of steam occurs and the process length. A time/temperature comparison of sterilization systems is provided in Table 7-1. Gravity displacement: self-generation of steam forces out the air; steam enters to penetrate through the cassettes or packages. High-speed prevacuum: pump removes the air from the chamber and allows faster penetration of the steam for sterilizing.

II.

Use Moist heat may be used for all materials except: Oils, waxes, and powders that are impervious to steam. Materials that cannot be subjected to high temperatures.

III. Principles of Action Sterilization is achieved by action of heat; pressure serves only to attain high temperature. Sterilization depends on the penetrating ability of steam. Air must be excluded; otherwise steam penetration and heat transfer are prevented. Space between objects is essential to ensure access for the steam. Air discharge occurs in a downward direction; load must be arranged for free passage of steam toward the bottom of autoclave.

IV. Evaluation Advantages All microorganisms, spores, and viruses are destroyed quickly and efficiently. Wide variety of materials may be treated; most economical method of sterilization. Disadvantages If precautions are not taken, carbon steel instruments may corrode.

DRY HEAT Dry heat sterilizers achieve sterilization by oxidation of molecules, resulting in death of the organism. The most common dry sterilizers include: Static air sterilizers: like an oven, the chamber is brought to temperature by heating coils located within the unit. Forced air sterilizers: heated forced air is circulated at a high velocity, rapidly bringing the sterilizer to the appropriate temperature.

I.

Use Primarily for materials that cannot be safely sterilized with steam under pressure. For small metal instruments enclosed in special containers or that might be corroded or rusted by moisture.

II.

Principles of Action Sterilization is achieved by heat conducted from the exterior surface to the interior of the object; the penetration time varies among materials. Sterilization can result when the material is treated for a sufficient length of time at the required temperature; therefore, timing for sterilization must start when the entire contents of the sterilizer have reached the peak temperature needed for the load.

III. Operation Temperature A temperature of 160°C (320°F) maintained for 2 hours; 170°C (340°F) for 1 hour.9 Timing starts after the desired temperature has been reached.

Penetration time: Heat penetration varies with different materials. Nature and properties of various materials are considered. Care Care is taken not to overheat because certain materials can be affected. Temperatures over 160°C (320°F) may destroy the sharp edges of cutting instruments.

IV. Evaluation Advantages Useful for materials that cannot be subjected to steam under pressure, such as heat-sensitive handpieces, burs, or plastics. When maintained at correct temperature, this method is well suited for sharp instruments. No corrosion compared with steam under pressure. Disadvantages Long exposure time required; penetration slow and uneven. High temperature critical to certain materials.

CHEMICAL VAPOR STERILIZER A combination of alcohols, formaldehyde, ketone, water, and acetone heated under pressure produces a gas that is effective as a sterilizing agent.

I.

Use

Chemical vapor sterilization cannot be used for materials or objects that can be altered by the chemicals that make the vapor or that cannot withstand the high temperature. Examples are low-melting plastics, liquids, or heat-sensitive handpieces.

II.

Principles of Action

Microbial and viral destruction results from the permeation of the heated formaldehyde and alcohol. Heavy, tightly wrapped, or sealed packages would not permit the penetration of the vapors.

III. Operation Temperature From 132°C (270°F) with 20–40 pounds’ pressure in accord with the manufacturer’s directions.9 Time Minimum of 20 minutes after the correct temperature and pressure have been attained. Time is extended for a large load or a heavy wrap. Cooling at the completion of the cycle Instruments are dry. Instruments need a short period for cooling.

IV. Care of Sterilizer Refilling depends on the amount of use and is needed at least

every 30 cycles. In accord with manufacturer’s instructions, the condensate tray is removed, the exhausted solution emptied, and the tray cleaned.

V.

Evaluation

Advantages Corrosion- and rust-free operation for carbon steel instruments. Ability to sterilize in a relatively short total cycle. Ease of operation and care of the equipment. Disadvantages Adequate ventilation is needed; cannot use in a small room. Slight odor, which is rarely objectionable.

INTERMEDIATE-USE STEAM STERILIZATION Sometimes called flash sterilization, this form of rapid steam heat sterilization is a method used to sterilize unwrapped instruments for immediate use. The rapid contact with steam allows for shorter sterilization times.1 Use Should only be used when there is urgent need to sterilize an item. Not recommended for items that require biologic spore test results before use, that is, implantable items.3 Care Follow manufacturer’s temperature and setting directions for immediate-use sterilizing. Monitors and indicators should be used and checked for each cycle. Items are to be used immediately after sterilizing. Items are hot upon removal, so care must be used in handling. Caution must be used in the transport of instruments to avoid contamination. Items are meant for immediate use and should not be stored.

CHEMICAL LIQUID STERILIZATION Chemical liquid sterilization is often referred to as “cold sterile.” Many chemicals have been FDA approved for sterilization; however, biologic monitoring to verify sterility with this method is not possible. The CDC recommends this method of sterilization only when other methods of sterilization cannot be used.9

CARE OF STERILE INSTRUMENTS Instruments stored without sealed wrappers are only momentarily sterile because of airborne contamination. Labeled, sterilized, and sealed packages are stored unopened in clean, dry cabinets or drawers. All stored packages are dated and used in rotation. Paper-wrapped packages are handled carefully to prevent tearing. Packages wrapped and sealed in paper may not need resterilizing for several months to 1 year. Plastic or nylon wrap with a tape or heat seal may be expected to remain sterile longer. The expected shelf life before resterilizing depends on the area surrounding the stored packages. A closed, protected area without exposure, such as a cabinet or drawer that can be disinfected routinely, is preferred for storage.

CHEMICAL DISINFECTANTS There is no evidence bloodborne infections can be transmitted through housekeeping surfaces; however, healthcare facilities are expected to be kept clean and have cleaning protocol and procedures in place for all surface types.1 Chemical disinfectants are used in several forms, including: Surface disinfectants. Immersion disinfectants, immersion sterilants. Hand antimicrobial agent. Each variety has specific chemicals, dilutions, and directions for application.

I.

Manufacturer’s Information All manufacturers of products should include or supply a Manufacturer’s Safety Data Sheet (MSDS). An MSDS provides facts about the safety and effectiveness of the product including: Effectiveness and stability expressed by: a. Shelf life: the expiration date indicating the termination of effectiveness of the unopened container. b. Use life: the life expectancy for the solution once it has been activated. c. Reuse life: the amount of time a solution can be used and reused while being challenged with instruments that are wet or coated with contaminants. Directions for activation (mixing directions). Type of container for use and storage. Storage directions (light and temperature). Directions for use: a. Precleaning and drying of items. b. Time/temperature ratio. Instructions for disposal of used solution. Warnings

a. Toxic effects (eyes, skin). b. Directions for emergency care (e.g., splash in eye).

II.

Categories Disinfectants are categorized by their biocidal activity as high level, intermediate level, or low level. Biocidal activity refers to the ability of the chemical disinfectant to destroy or inactivate living organisms. High-level disinfectants inactivate spores and all forms of bacteria, fungi, and viruses. Applied at different time schedules, the high-level chemical is either a disinfectant or a sterilant. Intermediate-level disinfectants inactivate all forms of microorganisms but do not destroy spores. Low-level disinfectants inactivate vegetative bacteria and certain lipid-type viruses but do not destroy spores, tubercle bacilli, or nonlipid viruses.

III. Uses Environmental surfaces disinfection: Following each appointment, the treatment area is cleaned and disinfected. Dental laboratory impressions and prostheses: Impressions can be carriers of infectious material to a dental laboratory. Completed prostheses must be disinfected before delivery to a patient.

IV. Principles of Action Disinfection is achieved by: Coagulation, precipitation, or oxidation of protein of microbial cells. Denaturation of the enzymes of the cells. Disinfection depends on the contact of the solution at the known

effective concentration for the optimum period of time. Items are thoroughly cleaned and dried because action of the agent is altered by foreign matter and dilution. A solution has a specific shelf life, use life, and reuse life. Some may be altered by changes in pH, or the active ingredient may decrease in potency. Check manufacturer’s directions.

V.

Criteria for Selection of a Chemical Agent

Objective: To select a product that is effective in the control of microorganisms and practical to use. No one product is the best choice for all dental setting. Properties of an ideal disinfectant are shown in Box 7-1. When choosing a product, consider the level of contamination and surface type.

BOX 7-1 Properties of a Disinfectant 1

Broad spectrum

Wide antimicrobial spectrum

2

Fast acting

A rapid lethal action on all vegetative forms and spores of bacteria and fungi, protozoa, and viruses

3

Unaffected by physical factors

Active in the presence of organic matter, such as blood, sputum, and feces. Compatible with soaps, detergents, and other chemicals encountered in use

4

Nontoxic

5

Surface compatibility

Will not corrode instruments and other metallic surfaces. Will not cause the disintegration of cloth, rubber, plastics, or

other materials 6

Residual effect on treated surfaces

7

Easy to use

8

Odorless

Inoffensive odor to facilitate routine use

9

Economical

Reasonable cost

Identify contamination type Blood. No blood. Clinical contact surfaces No blood: Use EPA-registered hospital-grade disinfectant plus hepatitis B virus (HBV) and human immunodeficiency virus (HIV) kill claim or tuberculocidal activity. Blood: Use EPA-registered hospital disinfectant plus tuberculocidal activity. Housekeeping surfaces No blood: Use EPA-registered hospital disinfectant or detergent and water. Blood: Use EPA-registered hospital disinfectant plus tuberculocidal activity.

BARRIERS AND SURFACE COVERS Barriers and surface covers are used to protect a surface from contaminants. They come in different sizes and shapes and are available in sheets, wrap, pre-cut, and fitted for different items, such as hoses, light handles, keyboards, and head rests. Covers should be moisture resistant, easily removable, and disposable (Figure 7-5).

FIGURE 7-5 • Surface Covers and Barriers.

I.

Benefits

There are many benefits to using surface barriers not only on hard-toclean surfaces but also on any contact surfaces. Barriers and surface covers eliminate the contact time required by disinfectants and are chemical free, efficient, and safe. A comparison of barriers versus cleaning and disinfecting spray is shown in Figure 7-6.

FIGURE 7-6 • Comparison of Disinfecting versus Barriers Diagram.

II.

Procedure Before treatment Identify areas where barriers and covers can be used. Apply the appropriate barrier prior to patient visit. Be sure the barrier is secure and will not be dislodged during patient treatment.

After treatment Wear appropriate personal protective equipment (PPE) when removing contaminated barriers. Be careful not to contaminate surfaces with gloves or unclean barriers. If surfaces are contaminated, clean and disinfect surface. Discard used barriers and covers in trash according to state law. Remove contaminated gloves, perform hand hygiene, and apply fresh surface covers and barriers.

PREPARATION OF THE TREATMENT ROOM The cleanliness and neatness of the treatment room reflect the character and conscientiousness of the dental team. Patients may have limited knowledge of sterilization and infection control procedures and may request information. The continued orderliness and cleanliness of treatment rooms is necessary to create an environment to minimize crosscontamination. An excellent test for effectiveness is for dental personnel to occasionally view the operatory from the patient’s vantage point by becoming the patient.

I.

Objective

Effective care of instruments and equipment is essential in order to control disease transmission by way of environmental surfaces and maintenance of equipment and instruments.

II.

Preliminary Planning All surfaces and items that will be used or contacted during the appointment can be categorized as critical, semi-critical, and noncritical. The classification of inanimate objects (Table 7-3) provides a guide for analysis. TABLE 7-3 • Classification of Inanimate Objects

Description All surfaces should be cleaned at the end of every work day. Preparation of treatment room when time between appointments is limited requires an efficient procedural system.

III. Surface Disinfection Procedure The most logical and scientific sequence for preparation for the appointment can then be outlined. Hand “Touch Contacts” Only contacts essential to the service to be performed are made. Planning ahead to have materials ready so cabinet knobs or drawer handles do not have to be contacted is an example. Sterilizable items Critical and semi-critical items are sterilized or are disposable. Disposable items Disposable items are used wherever possible. Items that may be covered Barrier coverings prevent contamination from reaching surfaces. Covers for light handles, counter tops, X-ray machine parts, computer keyboard, and mouse are examples. Care is taken when removing the covers not to contaminate the object beneath.

Items that require chemical disinfection Objects and surfaces that cannot be included in one of the preceding categories are treated with a chemical disinfectant. When the material is not compatible with the chemical action of the disinfectant, a disposable or coverable substitute is needed.

IV. Clean and Disinfect Environmental Surfaces1,10 A. Agent The effectiveness of the disinfection procedure is the result of two actions: The physical rubbing and removal of contaminated material. The chemical inactivation of the living microorganisms. Surface disinfectants are concentrated, premixed solutions, sprays, foams, impregnated wipes, and dissolved tablets. Do not store gauze sponges in the solution because cotton fibers contained in gauze may shorten the effectiveness of disinfectants when stored in containers.10

B. Procedure 1. Wear your PPE as needed including: protective eyewear, surgical mask, protective apparel, medical gloves, or chemical/punctureresistant utility gloves. 2. Determine the degree of disinfection required. 3. Be sure the product has been prepared correctly and is not expired. 4. Check the label to be sure the disinfectant is compatible with the surface to be disinfected. 5. Clean blood or other potentially infectious material with a low-level or intermediate-level disinfectant effective against HBV and HIV. 6. Clean and scrub surfaces with soap and water, EPS-registered detergent, or low-level disinfectant.

7. Disinfectant must be followed by vigorous scrubbing in order to remove the film of microorganisms. 8. Once cleaned, spray surface again leaving the disinfectant on the surface for the recommended amount of time. 9. Scrub the disinfectant over the entire surface, with attention to irregularities where contaminated material can aggregate. 10. A disinfectant-soaked sponge or wipe in each hand can decrease the time of cleaning certain objects. Contaminated objects, such as tubings, can be held with one sponge while scrubbing with the other sponge. 11. Use a brush if surfaces do not become visibly clean from rubbing. 12. Used product according to manufacturer’s directions leaving the surfaces wet for the recommended period of time. 13. Wipe surfaces dry.

V.

Unit Water Lines

A biofilm of microorganisms can form on the inside of the waterline tubing during overnight standing. Tests have been conducted on tubing to hand pieces, water syringes, and ultrasonic scalers. When the lines were flushed for 2 minutes, the microbial counts were reduced.1,3 Contaminated water cannot be used for surgical purposes or during the irrigation of pocket areas because infective microorganisms can be introduced. If contaminated water is directed forcefully into a pocket, microorganisms can enter the tissue and infection or bacteremia can result. The procedure for clinical use is to flush all water lines at least 2 minutes at the beginning of each day. Run water through water tubing for 30 seconds before and 30 seconds after each patient appointment. Refer to the CDC Infection Prevention and Control Guidelines and Recommendations. If dental unit is more than 20 years old, contact the manufacturer to

determine if antiretraction valves are present.

PATIENT PREPARATION Oral procedures that penetrate tissue, such as giving anesthesia by injection or scaling subgingival pocket surfaces, can introduce bacteria into the tissues and hence into the bloodstream. Organisms injected into the tissue could multiply and create an abscess. Natural resistance helps the body handle and destroy invading microorganisms, provided the numbers can be kept to a minimum. Though clinical research has not proven this prevents or reduces the incidence of disease transmission, it has been shown to reduce the number of microorganisms in the oral cavity, aerosols or introduced into the patient’s bloodstream.1,3 Practical procedures for the preparation of a patient include preprocedural oral hygiene measures and rinsing with an antimicrobial mouthrinse.

I.

Preprocedural Oral Hygiene Measures Toothbrushing Demonstration of biofilm removal from the teeth, tongue, and gingiva contributes to lowering the microbial count before treatment procedures. Rinsing11 The numbers of bacteria on the gingival or mucosal surfaces can be reduced by the use of a preprocedural antiseptic mouthrinse.11,12 The substantivity of 0.2% chlorhexidine provides a lowered bacterial count for more than 60 minutes. Preprocedural rinsing before injections is advised.

II.

Application of a Surface Antiseptic Before injection of anesthetic13

As a needle is introduced into the mucosa for penetration to deeper tissues, microorganisms on the surface can be carried into the tissue. A topical antiseptic applied before the injection can decrease the risk of introducing septic material into the soft tissue. Before scaling and other dental hygiene instrumentation12 Instrumentation in a sulcus or pocket and around the gingival margin can create breaks in the tissue where bacteria can enter. Subgingival instrumentation in a pocket with broken-down sulcular epithelium contributes to the entrance of bacteria into the underlying tissues and bacteremia.13 Evidence does not currently support use of subgingival irrigation with antiseptic solutions to reduce bacteremia posttreatment, but recommend the use of a preprocedural 2% chlorhexidine rinse.14

SUMMARY OF STANDARD PROCEDURES Basic procedures for clinical management are listed here.

I.

Patient Factors Prepare a comprehensive patient history and make necessary referrals. Ask the patient to rinse with an antimicrobial mouthrinse to reduce the numbers of oral microorganisms. Provide protective eyewear. Avoid elective procedures for a patient who is suffering from a communicable condition, such as a respiratory infection, or who has an open lesion on or about the lips or oral tissues.

II.

Clinic Preparation Run water through all water lines, including the air–water syringe, hand pieces, and ultrasonic unit, for 2 minutes at the start of the day and for at least 30 seconds before and after each use during the day. Disinfect all environmental surfaces that may be “touch surfaces” during the appointment. Make an orderly sequence for surface cleaning and disinfection. Apply barrier covers as indicated. Sterilize instruments and all other equipment that can be sterilized by one of the methods for complete sterilization. Maintain closed sterilized packages until ready for use.

III. Factors for the Dental Team Have medical examinations; keep immunizations up to date; have appropriate testing on a periodic basis. Always use mask, protective eyewear, gloves, and a clean closedfront gown with fitted wrist cuffs.

Utilize thorough hand hygiene and cleansing before putting on and after removing gloves. Develop habits to minimize contact with switches and other parts of the dental unit, dental chair, light, and clinician’s stool, and avoid all environmental contacts unrelated to the procedure at hand.

IV. Treatment Factors A. Syringe Needles Use a safe recapping and disposal methods (Chapter 36) to prevent accidental penetration or self-inoculation.

B. Removable Oral Prostheses Gloves are worn to receive a prosthesis from a patient. Place the prosthesis in a disposable cup or plastic resealable zipper bag and cover with a disinfectant. Use a fresh solution of 0.05% iodophor in water, or a 1:5 dilution of 5% sodium hypochlorite. Place cup or bag alone in an ultrasonic cleaner, making sure it does not tip and spill.

V.

Posttreatment

Use heavy puncture-resistant gloves to handle contaminated, unsterile instruments. Follow routines to disinfect, clean, and prepare the instruments for sterilization. Contaminated waste is secured in disposable plastic bag and infectious waste in a container with a secure lid.1 Disinfect safety eyewear for patient and dental team members.

DISPOSAL OF WASTE Wastes created in a dental setting can include contaminated, hazardous, or infectious/regulated waste.

I.

Regulations Investigate the regulations of each town or city sanitation division (or health department) for rules concerning disposal of contaminated waste. Figure 7-7 illustrates the universal label required by the U.S. Occupational Safety and Health Administration (OHSA). The labels must be attached to containers used to store or transport hazardous waste materials.

FIGURE 7-7 • Universal Label for Hazardous Material. A hazard-warning label is fluorescent orange or orange-red with lettering or a symbol in a contrasting color.

The label must be attached to containers used to store or transport waste. A label is not required for regulated waste that has been decontaminated (such as dental waste that has been autoclaved).

II.

Guidelines for Disposal of Waste Disposable materials, such as gloves, masks, wipes, paper drapes, or surface covers, that are contaminated with blood or body fluids but not saturated are carefully handled and discarded in sturdy, impervious plastic bags to minimize human contact.1 Blood, suctioned fluids, or other liquid waste may be carefully poured into a drain connected to a sanitary sewer system in compliance with applicable local regulations. Sharp items, such as needles and scalpel blades, are placed intact into a puncture-resistant, leak-proof biohazard container (see Chapter 36). Human tissue, extracted teeth, and contaminated solid wastes can be disposed of according to the requirements established by local or state environmental regulatory agencies and published recommendations. Disposable bags need to be color coded or identified as biohazard.1 Disposal methods for both liquid and solid chemicals vary with the type of chemical and local regulations governing wastemanagement practices.

SUPPLEMENTAL RECOMMENDATIONS I. Cleaning the Face Check and clean the exposed parts of the face not covered by mask or protective eyewear, where spatter collects, as an aid to disease control as well as for general sanitation.

II.

Smoking and Eating Smoking, drinking, and eating are banned in treatment areas.

III. Reception Area Select toys and other reception area items that can be cleaned and disinfected. Provide hand sanitizer gel in the reception area.

IV. Sterilization Monitoring Keep a written record of dates when processing tests and biologic monitor tests are performed for each sterilizer. Indicate advance dates for the next testing clearly on a calendar or other reference point. Perform tests made weekly on the same day to ensure compliance.

V.

Office Policy Manual

The clinic or office policy manual should outline procedures including the following: Standard precautions. Emergency procedures to follow when accidentally exposed are defined clearly.

OCCUPATIONAL POSTEXPOSURE MANAGEMENT Accidents happen even to the most skillful clinician. Accidental percutaneous (laceration, needle stick) or permucosal (splash to eye or mucosa) exposure to blood or other body fluids requires prompt action.

I.

Significant Exposures Percutaneous or permucosal stick or wound with needle or sharp instrument contaminated with blood, saliva, or other body fluids. Contamination of any obviously open wound, nonintact skin, or mucous membrane with blood, saliva, or a combination. Exposure of patient’s body fluids to unbroken skin is not considered a significant exposure.

II.

Procedure Following Exposure Perform basic first aid to clean the area affected. Immediately wash the wound with soap and water; rinse well. Flush nose, mouth, eyes, or skin with clear water, saline, or a sterile irrigator. Report to designated official. Complete an incident report as required. Follow the required predetermined, posted procedures of the clinic, institution, or individual practice setting. The University of California, San Francisco maintains a Clinician Consultation Center with a PEP (postexposure prophylaxis) Quick Guide for Occupational Exposures based on the most current U.S. Public Health Services and CDC guidelines. Consultations can be obtained by calling the Clinicians’ PostExposure PEPline (888-448-4911).15 Immediately obtain medical evaluation so if treatment is

recommended, it can be initiated quickly. If the source (patient) is present and agrees, the patient should accompany the dental provider for medical evaluation and testing. If the source is not known or unwilling to go for medical evaluation, baseline testing would be performed on the dental provider. If baseline testing is negative, no other follow-up may be necessary, but often 6-week follow-up testing is recommended. Obtain counseling services if necessary.

III. Follow-Up Report signs and symptoms associated with infectious disease such as hepatitis or HIV. Obtain medical evaluation of any illness involving fever, rash, and lymphadenopathy. Pursue counseling and further testing.

DOCUMENTATION Documentation for a patient with concerns about infection control procedures would include: Name, record number, address, telephone (home and cell), e-mail. Medical history for history of HBV, hepatitis C virus (HCV), or HIV; high-risk history associated with these diseases; patient consent to be tested for HBV, HCV, and HIV. HIV-positive patient: current medications and previously taken, if they were ineffective; most recent viral load, current CD4 if known. A sample progress note for a patient with concerns about infection control procedures can be reviewed in Box 7-2.

BOX 7-2 Example Documentation: Patient with Concerns About Infection Control S—Patient presents for routine periodontal maintenance appointment. Patient asked how instruments were “cleaned” between patients. O—Health history update indicates patient has been recently diagnosed as human immunodeficiency virus positive. A—She was concerned about an increased risk for opportunistic infections as well as the fact that her condition might increase risk for other patients seen in the office. P—Explained that standard precautions and infection control procedures used during all patient treatment are designed to protect all patients from crosscontamination. Explained each set of instruments is sterilized utilizing steam under pressure (autoclave). Tests for sterilization are done for each cycle of instruments, in addition to weekly and monthly tests to ensure the autoclave is functioning properly. Opened all sterilized instrument kits in her presence. Signed: _____________________________, RDH Date: ____________________________________

EVERYDAY ETHICS

Kimberly, the dental hygienist, is about to begin the patient examination when she notices that the indicator tape on the sterilizing cassette had not changed color. She excuses herself and finds out from the receptionist that a call to the repair service has been made because the autoclave has been shutting down before completion of the cycle. It is after 1:00 PM, and patients are scheduled all afternoon. Questions for Consideration 1. When proper sterile technique is not followed, what ethical principles and core values are involved? Describe Kimberly’s duty to her patients. 2. Use the steps to decision making in Chapter 1 to determine possible solutions for this situation. Describe how each could be defended to the patient, the dentist, and other dental team members. 3. Which American Dental Hygienists’ Association professional roles (Chapter 1) does Kimberly serve in when she plans to make changes that ensure that this kind of situation does not happen again? Explain each role and how it applies for Kimberly.

Factors to Teach the Patient The meaning of “standard precautions” and what is included under the term; how these precautions protect the patient and the dental team members. The contribution of the accurately completed medical and dental personal history to the provision of the best, safest treatment possible. Methods for sterilization of instruments, including handpieces; how the autoclave or other sterilizer is tested daily or weekly. Facts about the normal oral flora and the factors that influence an increased number of bacteria on the tongue, mucosa, and in the dental biofilm on the teeth. Methods for personal daily control of the oral bacteria through biofilm control and tongue brushing. Reasons for preprocedural rinsing. Method for thorough rinsing.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices

SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Organization for Safety & Asepsis Procedures, Centers for Disease Control and Prevention. From Policy to Practice: OSAP’s Guide to the CDC Guidelines: A Step-by-Step Implementation Workbook. Atlanta, GA: OSAP; 2016. http://c.ymcdn.com/sites/www.osap.org/resource/resmgr/issues_files/Boilwater_2016.pdf Accessed October 22, 2017. 2. Centers for Disease Control and Prevention, Division of Oral Health. Guidelines and Recommendations: Infection Prevention & Control in Dental Settings. Atlanta, GA: CDC; September, 2017. https://www.cdc.gov/oralhealth/infectioncontrol/guidelines/index.htm. Accessed September 21, 2017. 3. Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion. Recommendations from the Guidelines for Infection Control in Dental Health-Care Settings. Atlanta, GA: CDC; 2003. https://www.cdc.gov/oralhealth/infectioncontrol/pdf/recommendationsexcerpt.pdf. Accessed October 22, 2017. 4. Miller CH, Tan CM, Beiswanger MA, Gaines DJ, Setcos JC, Palenik CJ. Cleaning dental instruments: measuring the effectiveness of an instrument washer/disinfector. Am J Dent. 2000;13(1):39-43. 5. Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Atlanta, GA: CCDC, USDHHS; October, 2016. https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care2.pdf. Accessed October 22, 2017. 6. Miller CH, Palenik CJ. Infection Control and Management of Hazardous Materials for the Dental Team. 4th ed. St Louis, MO: Mosby Elsevier; 2010. 7. Miller CH. Use of spore tests for quality assurance in infection control. Am J Dent. 2001;14(2):114. 8. Spry C. Understanding current steam sterilization recommendations and guidelines. AORN J. 2008;88(4):537-550; quiz 551-4. 9. Centers for Disease Control and Prevention. Guidelines for Disinfection & Sterilization Guidelines in Healthcare Facilities. Atlanta, GA: CDC; 2008. https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelinesH.pdf. Accessed June 7, 2019. 10. Cottone J, Terezhalmy G, Molinari J. Practical Infection Control in Dentistry. 5th ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2009. 11. Gupta G, Mitra D, Ashok KP, et al. Efficacy of preprocedural mouth rinsing in reducing aerosol contamination produced by ultrasonic scaler: a pilot study. J Periodontol. 2014;85(4):562-568. 12. Reddy S, Prasad MGS, Kaul S, Satish K, Kakarala S, Bhowmik N. Efficacy of 0.2% tempered chlorhexidine as a pre-procedural mouth rinse: a clinical study.

J Indian Soc Periodontol. 2012;16(2):213-217. 13. Johnson SM, Saint John BE, Dine AP. Local anesthetics as antimicrobial agents: a review. Surg Infect. 2008;9(2):205-213. 14. Barbosa M, Prada-López I, Álvarez M, Amaral B, de los Angeles CD, Tomás I. Post-tooth extraction bacteraemia: a randomized clinical trial on the efficacy of chlorhexidine prophylaxis. PLoS One. 2015;10(5):e0124249. 15. UCSF, Clinician Care Center. PEP Quick guide for occupational exposures. June, 2017. http://nccc.ucsf.edu/clinical-resources/pep-resources/pep-quickguide/. Accessed October 22, 2017.

8 Patient Reception and Ergonomic Practice Irina Smilyanski, RDH, MS, MSDH

CHAPTER OUTLINE PREPARATION FOR THE PATIENT I. II.

Treatment Area Records

PATIENT RECEPTION I. II.

Introduction Escort Patient to Dental Chair

POSITION OF THE PATIENT I. II. III.

General Positions The Dental Chair Use of Dental Chair

POSITION OF THE CLINICIAN

NEUTRAL WORKING POSITION I. II. III. IV.

Objectives The Effects of NWP Description of Neutral Seated Position Clinician–Patient Positioning

THE TREATMENT AREA I. II. III. IV. V.

The Clinician’s Chair Vision: Lighting Vision: Magnification Handpieces Cords

ERGONOMIC PRACTICE I. II. III.

Scope of Ergonomic Dental Hygiene Related Occupational Problems Ergonomic Risk Factors

SELF-CARE FOR THE DENTAL HYGIENIST I.

Daily Functional Movement Exercises

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Describe the rules of etiquette in relationship to patient reception and care. 2. Describe the components of ergonomic practice and relationship to career longevity. 3. Identify the range of working positions for a right-handed and lefthanded clinician. 4. Describe the elements of a neutral working position. 5. Explain the musculoskeletal disorders and their causes and symptoms most often associated with the clinical practice of

dental hygiene. 6. Explain the ergonomic risk factors of clinical dental hygiene practice. The patient’s presence in the office or clinic is an expression of confidence in the dentist and the dental hygienist. Confidence is inspired by the reputation for professional knowledge and skill, the appearance of the office, and the actions of the workers in it. The physical arrangement and interpersonal relationships provide the setting for specific services to be performed. The patient’s well-being is the all-important consideration throughout the appointment. At the same time, the clinician must function effectively and efficiently in a manner that minimizes stress and fatigue to ensure personal health. Musculoskeletal disorders, repetitive stress injuries, and cumulative trauma disorders are common work-related conditions that require continuing preventive physical and mental energy on the part of each clinical dental hygienist. The science of ergonomics has provided information for the development of standards for human performance and workplace design that can maximize health, comfort, and efficiency for dental hygienists in clinical practice.

PREPARATION FOR THE PATIENT I. Treatment Area The requirements for preparation of the treatment area are standard precautions for all patients whether or not the presence of a communicable disease is known. Environmental surfaces: All clinical contact areas are thoroughly disinfected or covered to control cross-contamination. Instruments: Sterile packaged instruments remain sealed until the start of the actual treatment. Equipment: Prepare and make ready other materials that will be used, such as for the determination of blood pressure and patient instruction. Anticipate specific needs for procedures being delivered. Patient’s dental chair: Upright for current patient reception; chair arm adjusted for ease of access. Clinician’s chair: Set at proper height for the entire day.

II.

Records For the patient of record, review the patient’s medical and dental history for pertinent appointment information, updating, and assessment. Read previous appointment progress notes to focus the current treatment plan. Anticipate examination procedures and new record making for a new patient.

PATIENT RECEPTION I. Introduction The dental assistant or the dentist may introduce the new patient to the dental hygienist, but more frequently, a self-introduction is in order. The patient is greeted by name, and the hygienist’s name is clearly stated, for example, “Good morning, Mrs. Smith; I am Anna Jones, the dental hygienist.” Procedure for introducing the patient to others: A woman’s name always precedes a gentleman’s. An older person’s name precedes the younger person’s (when of the same sex and when the difference in age is obvious). In general, the patient’s name precedes that of a member of the dental personnel. An older patient is not called by the first name except at the patient’s request.

II.

Escort Patient to Dental Chair Invite patient to be seated and adjust the chair as needed. Assist the elderly, disabled, or very small children; guide into the chair (support the patient’s arm when patient requests or accepts it). Assist with wheelchair. Bring wheelchair adjacent to the dental chair. Wheelchair procedures are described in the Wheelchair Transfer section in Chapter 51. Suggestions for helping the patient with a vision impairment may be found in Chapter 51. Place handbag in a safe place, if possible within the patient’s view. Provide protective eyewear. When a patient removes personal corrective eyeglasses to substitute those provided, make sure the personal glasses are placed in their case in a safe place.

POSITION OF THE PATIENT I. General Positions Four body positions for delivery of care are shown in Figure 8-1.

FIGURE 8-1 • Basic Patient Positions. A: Upright. B: Semi-upright. C: Supine or horizontal with the brain on the same level as the heart. D: Trendelenburg, with the brain lower than the heart and the feet slightly elevated.

A. Upright This is the initial position for patient reception from which chair adjustments are made.

B. Semi-Upright The back of the chair is reclined at approximately 45° angle. Patients with certain types of cardiovascular, respiratory, or vertigo problems may need this position. Figure 8-2 illustrates the patient and clinician using a semi-upright position during patient care.

FIGURE 8-2 • Patient in a Semi-Upright Position. This photograph illustrates ergonomic patient and clinician position for patient care in a semi-upright position when the clinician stands to provide care for the patient who cannot be moved to the supine position.

C. Supine The chair is in a supine or flat position, the brain is at the same level as the heart.

A patient is ideally situated for support of the circulation; rarely could a patient faint while lying in a supine position. The back of the chair is parallel to the floor. Position used most for treatment procedures. Figure 8-3 illustrates the patient and clinician while using the supine position.

FIGURE 8-3 • Patient in a Supine Position. This photo illustrates ergonomic patient and clinician position for patient care in a supine position. Note the neutral seating position of the clinician and the use of loupes magnifying system with attached headlamp.

D. Trendelenburg The person is said to be placed in the Trendelenburg position if they are in the supine position and tipped back and down 10°–15° so that the brain is lower than the heart. The back of the chair is less than parallel to the floor. The basic position in management of some medical emergencies.1

II.

The Dental Chair

A dental chair provides complete body support for the patient, which increases patient relaxation. A comfortable patient is more compliant and allows the procedure to be completed more efficiently. Seat and leg support move as a unit; back and headrest move as a unit; both are power controlled. Has a thin back so that the chair may be lowered close to the clinician’s elbow height. Chair base permits the chair to be lowered as needed for appropriate treatment position. Chair controls need to be available to both the assistant and clinician.

III. Use of Dental Chair A. Prepositioning for Patient Reception Chair at low level; back upright. Chair arm is moved out of patient’s way on side of approach.

B. Adjustment Steps Patient is seated with back upright. Chair seat and foot portion are raised first to help the patient settle back. Lower back to the supine position for maxillary instrumentation and to a 20° angle with the floor for mandibular treatment. Request patient to slide up to rest the head at upper edge of the headrest or backrest and turn head to left or right as needed for visibility and access. Adjust chair height until patient’s mouth is at the clinician’s elbow height with shoulder relaxed (Figure 8-3).

C. Conclusion of Appointment

Secure instruments on the instrument tray. Move instrument tray away and turn off light. Slowly raise back of chair and tilt chair forward. Request patient to remain seated in an upright position briefly to avoid postural hypotension.

D. Contraindications for Supine Position Review patient history for indications of need for adaptation. Patient may request a position variation. Conditions that may contraindicate the supine position include congestive heart failure, vertigo, and respiratory conditions such as emphysema, severe asthma, or sinusitis. During the second and third trimester of pregnancy, supine position might need to be modified.2 Chair positioning for the pregnant patient is described in Chapter 46.

POSITION OF THE CLINICIAN The clinician is in the neutral working position (NWP), with good access, light, and visibility, which in turn contribute to an efficient procedure. The patient is positioned so that a thorough, biologically oriented service may be performed conveniently and efficiently within a reasonable length of time. The positions of the patient and the clinician are interdependent. When clinician and patient positioning is considered, it is realistic to remember that the patient’s position will be assumed for a relatively short time compared with that of the clinician.

NEUTRAL WORKING POSITION I. Objectives Objectives concern the health of the clinician, the service to be performed, and the effect on the patient. The preferred neutral position attempts to accomplish the following: Contribute to and preserve rather than detract from clinician’s health and wellness. Contribute to ease and efficacy of performance that encourages patient cooperation. Allow endurance for prolonged periods of peak efficiency. Reduce potential for overexertion and injury from mental and physical stress and fatigue. Give the patient a sense of well-being, security, and confidence. Accommodate a patient with special needs.

II.

The Effects of NWP NWP needs to be developed, practiced daily, and made habitual. Habitual neutral position will translate to all activities, outside of work as well. An internal environment can be created for ongoing physical ease, comfort, safety, and activity. Without practicing the principles of neutral position on a regular daily basis, a clinician can experience discomfort, pain, and workrelated stress disorders. The long-term result can be shortened or compromised career longevity with changes in daily life activities. Analysis and assessment of posture can give direction to corrections for treatment. A posture assessment instrument is available.3

III. Description of Neutral Seated Position4,5 A neutral seated position is illustrated in Figure 8-4A.

FIGURE 8-4 • Clinician’s Working Distance. A: Clinician in 12:00 working position and drawing. B: Clinician in 8:00 working position. Both illustrate acceptable positioning, which shows the patient at the clinician’s elbow level and the oral cavity of the patient between 15 and 22 inches from the clinician’s eyes.

Back: in neutral alignment with natural spinal curves, including cervical lordosis, thoracic kyphosis, and lumbar lordosis. Head: on top of neutral spine with forward neck flexion between 15° and 20° or less. Eyes: directed downward to prevent neck and eye strain. Shoulders: relaxed and parallel with the hips and floor. Elbows: close to the body. Forearms: parallel with the floor. Wrist: forearm and wrist are in a straight line. Hips: slightly higher than knees. Thighs: full body weight distributed evenly on seat; comfortable space (about 3 inches) between edge of seat and back of knee. Knees: slightly apart. Feet: flat on the floor.

IV. Clinician–Patient Positioning

A. Distance Patient’s oral cavity is adjusted to clinician’s elbow height. Distance from clinician’s eyes to the patient’s oral cavity when the clinician is seated in neutral position will be within the range of 15– 22 inches (Figure 8-4B). The distance is defined as the “working distance,” which is a significant measurement when fitting magnification loupes for an individual clinician.

B. Selection NWP is combined with effective access to the patient for treatment procedures. Orientation of position of the clinician to patient can be compared to the hours of a clock around the patient’s head with 12:00 at the top of the patient’s head as shown in Figure 8-5.

FIGURE 8-5 • Range of Positions for Clinician. The patient’s head is placed at the upper edge of the backrest or headrest for convenient access by the clinician during treatment. The range of positions is compared with the numbers on a clock.

Clock hours correspond with clinician–patient relation associated with instrumentation in different areas of the patient’s oral cavity.

C. Flexibility4 Orientation for the right-handed clinician is associated with the 8–12 o’clock position; for the left-handed clinician, orientation is associated with the 12–4 o’clock position.5 Access and visual adjustment determines which side the clinician will select for a given procedure. Movement of the clinician’s chair freely on wheels and turning of the patient’s head facilitate positioning and patient treatment from either side. Moving past 12 o’clock clockwise for right-handed clinicians and counterclockwise for left-handed clinicians improves access and visibility in certain areas. In treatment rooms with limited space, the dental chair may be swiveled to change the angle of the chair to allow the clinician space to move past 12 o’clock.

THE TREATMENT AREA The treatment area centers on the patient’s oral cavity. The entire “work area” refers to the dental chair with patient, the unit, and the instrument tray as they are positioned for the convenience and accessibility of the clinician and assistant for fourhanded dental hygiene. For the clinician, the essentials for access and visibility for patient care are provided by the flexibility of movement of the clinician’s stool and appropriate lighting, supplemented by the clinician’s own visibility enhanced by wearing magnification loupes with head light.

I.

The Clinician’s Chair The chair is a significant adjunct to implement ergonomic practice. Optimal design provides adequate support and the opportunity and means to change body posture frequently during the workday as clinicians, patients, and procedures change. The clinician adjusts the chair to personal specifications.

A. Characteristics of an Acceptable Chair6,7 Base: broad and heavy with five casters; a chair with five casters provides greater stability. Seat design: Traditional: Size needs to support thighs without back of knees touching edge, seamless, textured upholstery, padded firmly, with ability to tilt the seat 5°–15°; accommodates requirements for neutral seated position. Saddle chair: This is a relatively new type of chair modeled after a riding saddle; promotes neutral spine position and reduces muscle strain.

Armrests: adjustable at a height that supports the forearm while maintaining NWP. Height: adjustable for wide personal variability. Back: adjustable lumbar support to accommodate different positions, procedures, and clinicians while maintaining the spinal curve. Mobility: completely mobile; built with free-rolling casters; not connected to other dental equipment; free movement around the patient’s head for instrumentation from either side. Adjustment: multiple adjustments for different positions, procedures, and clinicians; mechanisms easy to learn and use. Infection control friendly: all surfaces able to withstand standard precautions regimen.

II.

Vision: Lighting During treatment, visibility in the oral cavity is prerequisite to thoroughness without undue trauma to the tissues. With adequate light, efficiency increases, treatment time is decreased, and patient cooperation increases. Many lighting options are available. All need to be directed properly to the oral cavity for adequate visualization, optimal patient care, and clinician comfort and safety.

A. Dental Light: Suggested Features Is readily adjustable both vertically and horizontally. Beam of light is capable of being focused. Set within a comfortable arm’s reach. Does not require awkward or forceful movement to position it for visualization.

B. Dental Light: Location Attachment

Unit attachment. Ceiling-mounted light on a track is most versatile. Coaxial headlight can be added to improve visualization with targeted illumination. Dual lighting Advantages of the use of two clinic lights have been demonstrated with a supine patient position in a contoured chair. One light directed from the front of the patient may be attached to the dental unit; the other light is mounted on a ceiling track. Dental light: adjustment principles Light allows clear illumination of entire treatment area. Figure 8-6 shows position of light for maxillary and mandibular treatment.

FIGURE 8-6 • Lighting. Light does not obstruct clinician, allows clear illumination of the treatment area. A: Maxillary arch; chin up position; beam of light often between 60° and 45° angle to floor. B: Mandibular arch; chin down position; beam of light nearly perpendicular to floor.

III. Vision: Magnification8-11

Magnification is needed to improve visualization, support NWP, and enhance treatment procedures.

A. Choice of Loupe Systems Fixed through the lens: customized for individuals Adjusted with the clinician’s prescription as needed. Magnifying lenses mounted directly into the lens. Fixed interpupillary distance; angle of the lens not adjustable. Not adjustable; enables the clinician to maintain correct posture. Front lens mounted without vertical adjustment Prescription lenses are available. Magnifying lenses mounted to a hinge on the frame; loupes can be adjusted up or down. Interpupillary distance can be adjusted; angle of lens not adjustable. Front lens mounted with vertical adjustment Prescription lenses are available. Magnifying lenses mounted to a hinge on the frame; loupes can be adjusted up or down. Interpupillary distance can be adjusted; angle of lens can be adjusted.

B. Features Proper fit is essential to successful incorporation of magnification into the clinician’s treatment environment. Proper fit is dependent on the clinician’s working distance and neutral position. Clinicians need to research the differences to select best option.

IV. Handpieces Technology has provided handpieces that are ergonomically compatible with procedures clinicians provide. The best designs are small, light, and well-suited for the size of

dental hygienist’s hand.12 Ergonomically designed handpieces are lightweight, decreasing stress on hand and wrist. Fit in the contours of the clinician’s hand and allow functional light grasp. Reduce fatigue and strain. Allow maneuverability. Provide power assist without strain. Produce less heat buildup. Are available in a cordless option.

V.

Cords

A. Management Managing cords is a significant aspect of ergonomic practice. Cords are part of most dental units and are an integral part of delivery of care for every patient. Ultrasonics, air/water syringes, slow-speed handpieces, and all power-driven equipment require cords connected to a power source. Improper management and inefficient design of the cords can increase drag on hand, wrist, and arm, increasing risk of repetitive injury. Cord design must allow for disinfection; cords should not interfere with functionality of other equipment.

B. Curly Cords Can cause excessive stretching and pulling by clinician. Associated with bending, reaching, and awkward postures to position for treatment. Increase the strain on hand, wrist, arm, and shoulder of clinician. Provide an ergonomic risk by increasing fatigue level and creating muscle imbalances.

Straight cords may be generally easier to manage.

ERGONOMIC PRACTICE I. Scope of Ergonomic Dental Hygiene Includes all practices that make work safe, decrease strain and fatigue, eliminate hazards, and improve work process affecting health and well-being of clinician and patient. Box 8-1 lists items of the equipment, work layout, and work process organization that need attention during practice if physical occupational disorders are to be prevented.

BOX 8-1 Factors to Consider for Ergonomic Practice Equipment • PPE (Personal Protective Equipment) • Lighting (Figure 8-6) • Magnification, coaxial headlight • Properly fitted gloves • Instruments balanced, sharp, of varied diameters, with knurling on handles • Power instruments • Handpiece lightweight and ergonomically designed • Cords and cord management • Foot pedals • Suction • Air/water syringe Work Layout • Uncluttered, easy access to patient, patient records, computer, radiographs • Counters clear with designated area for documentation • Instrument tray within arm’s reach • Light fixture within arm’s length, easy to move and adjust • Orderly tray setup with complete armamentarium for services to be delivered • Convenient treatment room setup and design for patient chair, air/water syringe, suction, cords, foot pedals Work Process Organization

• • • • • •

Clinician neutral working position (NWP) Use of magnification system supporting NWP CPP (Clinician–Patient Positioning) Light within easy arm’s reach with clear illumination of treatment area Access and management of suction and air/water syringe Cords and cord maintenance

Instrumentation • Reach of tray • Order of instruments on tray • Consistent instrumentation sequence for all surfaces of sextants • Proper grasp and fulcrum technique for dominant hand • Proper grasp and fulcrum technique for nondominant hand • Sharp instruments • Correct working stroke for location and type of deposit • Inclusion of power instrumentation • Placement and access of foot pedals • Selective polishing • Placement and access to overgloves • Documentation procedure

II.

Related Occupational Problems The physical challenges inherent in dental hygiene practice place the clinicians at risk for developing work-related musculoskeletal disorders.13 Table 8-1 lists a variety of disorders that can occur among clinicians. TABLE 8-1 • Musculoskeletal Disorders Affecting Dental Hygienists With any symptoms or any ongoing discomfort, take action to find the source of the problem and how to relieve the symptom. Prevention is the best course of action. Early intervention will decrease the risk of a more involved condition or a more costly injury. If not addressed in a timely manner, any of these conditions could lead to a limited ability to practice or total disability. CONDITION Carpal Tunnel Syndrome

CAUSES

SYMPTOMS

A symptomatic compression of the median nerve within the carpal tunnel (Figure 87)

Deviations of wrist from neutral Pinch grasp with insufficient rest

Numbness; tingling in the thumb, index, and middle fingers

Tilting head forward Hunched and/or rounded forward shoulders Continuously reaching overhead

Numbness, tingling, and/or pain in the hand or wrist

FIGURE 8-7 • Anatomy of the Wrist (Palmar View). Left, the median nerve passes through the transverse carpal tunnel of the wrist and branches to innervate the thumb, the index and middle fingers, and the medial aspect of the ring finger. Right, cross section of wrist shows the median nerve passing through the carpal tunnel. The tunnel is formed by the concave arch of the carpal (wrist) bones and roofed over by the transverse carpal ligament.

Thoracic Outlet Syndrome Painful disorder of the fingers, hand, and/or wrist from compression of the brachial nerve plexus and vessels between the neck and shoulder

Bursitis Inflammation of the bursa

Areas of friction or impingement anywhere in the body, usually the shoulder

Decreased range of motion. Aching

Repeated wrist extension or palmar flexion

Pain in the wrist, especially along the outer edges of the hand rather than through the center of the wrist

Prolonged, static postures of forward flexion, hyperextension, lateral bending, or rotation of the spine Can present on cervical, thoracic, or lumbar areas of the spine

Pain, numbness, tingling of the arm, fingers, lower back, hip, or leg

Tendonitis Painful inflammation of the wrist resulting in strain

Disk Herniation Displacement of the nucleus of the disk with resultant pressure on the spinal cord or peripheral nerves

Prevention of the slow developing conditions is a daily responsibility.

III. Ergonomic Risk Factors Prevention begins with the recognition of the risk factors that can point to potential body injury and more serious permanent musculoskeletal disorders.14 Table 8-2 lists and defines significant risk factors and provides examples of various practices that can lead to musculoskeletal disorders. TABLE 8-2 • Ergonomic Risk Factors

Intensity (strength or concentration of exposure), frequency (how often is the exposure), and duration (length of time of exposure) are related to the detrimental effects of the risk factor. A combination of risk factors intensifies risk and increases potential for injury. RISK FACTOR

DEFINITION

EXAMPLE

Prolonged awkward position

Body postures that deviate from the normal resting or neutral positions

Twisting the torso during instrumentation Arm raised when scaling

Static positions long-term static load

Assuming and holding any position for a long period; stresses the body, accelerates fatigue and discomfort

Bending neck for long periods Retracting cheek with nondominant hand without stable fulcrum Prolonged seated posture

Repetition

Performing the same motion or series of motions continually or frequently

Scaling and root planing Probing Exposing radiographs Using computer keyboard Writing

Force/grasp

Physical effort needed to lift, push, pull, Manual grasp, and pinch items in the work instrumentation environment Exposing radiographs Often required to handle and control equipment and tools Force increases as contact area decreases

Environmental Can directly influence comfort and risk of injury

Cold Heat Poor lighting Noise

Vibration

Tools such as jackhammers Additional research is needed to

The physical exposure to rapidly oscillating tools or machinery

demonstrate the effect power scaling and handpieces have on dental personnel Insufficient rest

Performing the same motion or series of motions continually or frequently without sufficient recovery time for muscles

Scaling procedures Probing Exposing radiographs Unreasonable patient scheduling Insufficient breaks

Stress

A physical, chemical, or emotional factor that causes bodily or mental tension and may be a factor in disease causation or fatigue Involves clinician perception of control of work environment and psychosocial factors

Having no control over scheduling Delivering care when patient arrives late Poor team communication Insufficient input concerning workload at work

Poor physical fitness

Decreased capacity for body to resist the negative consequences of physical demands of dental hygiene practice

Demands of long periods of sitting Demands of repeated instrumentation

SELF-CARE FOR THE DENTAL HYGIENIST Responsible self-care and attention to the risk factors of musculoskeletal disorders are central to ergonomic practice. Self-care is built on but not limited to all safe work practices that incorporate ergonomic principles for health and well-being. Selfcare includes but is not limited to: Physical fitness: immunizations, healthy diet, adequate sleep, exercise. Standard precautions: personal protective equipment. Clinical practice: clinician–patient positioning (CPP), instrument selection and use, prevention of sharps injuries. NWP: in all activities, not only clinical practice. Stress management: reasonable patient scheduling; adequate breaks.

I.

Daily Functional Movement Exercises In dental hygiene practice, it is necessary to give constant attention to maintaining a healthy spine. Achieving neutral work posture throughout the work day. Performing effective CPP, and practicing daily functional movement exercises will protect and encourage a healthy spine. A healthy spine requires that it be flexible. To accomplish a flexible spine, encourage movement in all directions so that no one area of the spine becomes overused, limiting its movement potential and affecting other areas of the spine. With impingement of an area of the spine for any length of time, blood flow and oxygenation to the area are affected. Chronic poor postural habits can lead to nerve impingement, resulting in chronic pain and possible injury. Practicing daily functional movement exercises for the spine and other joints in the practice setting and at home is a preventive strategy for all dental personnel.

DOCUMENTATION Documentation for a patient with requirements for a personalized dental chair positioning during instrumentation would include: Medical history notations indicating health history and current problem causing physical limitations or breathing difficulties. Potential emergency that could occur if patient is overstressed; need for preparation at future appointments. Notation for reference to length of appointment and time of day if needed. Example documentation using the SOAP format can be reviewed in Box 8-2.

BOX 8-2 Example Documentation: The Patient Who Is Unable to Tolerate the Supine Position S—Patient presents for routine 3-mo periodontal maintenance appointment; however, she came in on crutches due to a broken hip in a recent car accident. The patient provided a letter from her orthopedic surgeon clearing her for dental treatment. She is undergoing physical therapy twice a week for the next month or longer. The patient reports moderate soreness of back, arms, legs, and neck. Chief complaint is having a “dirty mouth” due to time spent in hospital and rehab, combined with inability to keep arms raised to clean teeth. She requests that the chair remain in the upright position during treatment. O—Examination showed limited opening of mouth, plaque index (PI) score 72%, compared with PI of 12% from last visit. Noted: moderate biofilm on maxillary and mandibular posterior teeth, supragingival calculus in the mandibular anterior region; probing mostly within 3 mm range with a few bleeding spots. A—The patient’s current medical condition is preventing her from providing adequate self-care. Pain in arms and shoulders may be from use of crutches. P—Adjusted chair per patient’s request for most comfortable position. Limited opening and patient position caused difficulty in accessing dentition. Completed assessments only; patient requested appointment be stopped due to pain in back and legs. Advised patient to alert physician and physical therapist if increase in level, duration, or frequency of pain. Next Step: Reappoint patient in 1 mo for periodontal maintenance completion

pending improved physical condition. Signed: _____________________________, RDH Date: ___________________________________

EVERYDAY ETHICS After practicing for a few years as a dental hygienist, Delia has developed chronic pain in her neck, back, and hands. As a result, she knows that her instrumentation is affected and patients are not receiving definitive scaling at their appointments. Questions for Consideration 1. What is Delia’s ethical responsibility to herself in this situation? (Note: the ADHA Code of Ethics for Dental Hygienists, Section 7, Standards of Professional Responsibility.) 2. Explain which core values (Chapter 1, Box 1-6) apply to Delia’s ethical responsibility to her patients if her ability to perform dental hygiene treatment is compromised? 3. Explain which of the questions (included in Chapter 1, Box 1-6) for making ethical decisions might help direct Delia in determining actions she can take now to assure that her patients continue to receive the best possible dental hygiene care.

Factors to Teach the Patient How certain positions of the clinician are necessary for safe ergonomic practice and patient care. How patient cooperation makes it possible for the dental hygienist to practice with less stress and strain to prevent musculoskeletal discomfort and pain and deliver better patient care.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary

Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Prasad KD, Hegde C, Alva H, Shetty M. Medical and dental emergencies and complications in dental practice and its management. J Educ Ethics Dent. 2012;2(1):13. 2. Hemalatha VT, Manigandan T, Sarumathi T, Aarthi Nisha V, Amudhan A. Dental considerations in pregnancy—a critical review on the oral care. J Clin Diagn Res. 2013;7(5):948. 3. Branson BG, Williams KB, Bray KK, McIlnay SL, Dickey D. Validity and reliability of a dental operator posture assessment instrument (PAI). J Dent Hyg. 2002;76(4):255. 4. Sanders MJ, Turcotte CM. Posture makes perfect. Dimens Dent Hyg. 2011;9(11):30-32, 35. 5. Brame JL. Seating, positioning, and lighting. Dimens Dent Hyg. 2008;6(9):3637. 6. Jordre BD, Bly J. Prevent pain with the right operator stool. Dimens Dent Hyg. 2014;12(1):16-18. 7. Valachi B. Practice Dentistry Pain-free: Evidence-based Strategies to Prevent Pain and Extend Your Career. Portland, OR: Posturedontics Press; 2008. 8. Shah MA, Pellegrini JM. Magnification basics. Dimens Dent Hyg. 2010;8(11):36-38. 9. Maillet JP, Millar AM, Burke JM, et al. Effect of magnification loupes on dental hygiene student posture. J Dent Educ. 2008;72(1):33-44. 10. Sunell S, Rucker L. Surgical magnification in dental hygiene practice. Int J Dental Hyg. 2004;2(1):26-35. 11. Chang BJ. Ergonomic benefits of surgical telescope systems: selection guidelines. J Calif Dent Assoc. 2002;30(2):161-169. 12. Dong H, Loomer P, Barr A, Laroche C, Young E, Rempel D. The effect of tool handle shape on hand muscle load and pinch force in a simulated dental scaling task. Appl Ergon. 2007;38(5):525-531. 13. Hayes MJ, Smith DR, Cockrell D. An international review of musculoskeletal disorders in the dental hygiene profession. Int Dent J. 2010;60(5):343-352. 14. Sanders MJ, Turcotte CM. Occupational stress in dental hygienists. Work. 2010;35(4):455-465.

9 Emergency Care Wendy Male, MBA, BDSc, RDH

CHAPTER OUTLINE EMERGENCY PREPAREDNESS PREVENTION OF EMERGENCIES I. II.

Attention to Prevention Factors Contributing to Emergencies

PATIENT ASSESSMENT I. II. III. IV. V.

Assessment for Routine Treatment The Patient’s Medical History Vital Signs Extraoral and Intraoral Examinations Recognition of Increased Risk Factors

STRESS MINIMIZATION I. II. III.

Recognize the Patient with Stress Problems Suggestions for Effective Communication Reduction of Stress

EMERGENCY MATERIALS AND PREPARATION I. II. III. IV. V.

Communication: Telephone Numbers for Medical Aid Equipment for Use in an Emergency Care of Drugs Medical Emergency Report Form Practice and Drill

BLS CERTIFICATION OXYGEN ADMINISTRATION I. II. III.

Equipment Patient Breathing: Use Supplemental Oxygen Patient Not Breathing: Use Positive Pressure

SPECIFIC EMERGENCIES DOCUMENTATION I. II. III.

Comprehensive Record Keeping Consults New Entries

EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Develop a plan to prevent and prepare for medical emergencies. 2. Identify signs and symptoms related to a possible emergency. 3. Define key words related to emergencies. 4. Describe stress minimization techniques. 5. Identify procedures for specific emergencies. 6. Incorporate documentation into the emergency plan.

EMERGENCY PREPAREDNESS The public expects competence in emergency situations. This chapter is designed to help prevent emergencies from escalating into more serious conditions. Emergency drills can reveal weaknesses in team responses that may identify a need for further training or education for dental office personnel.1,2 Emergencies in the dental office were reported by more than half of those surveyed,3-5 but the following measures may increase emergency preparedness: Periodic review of the literature to update drills is necessary for evidence-based response to emergencies. Well-maintained emergency equipment stored in a convenient location. Post a Quick Reference with emergency equipment so it is readily available. Quick Reference must include symptoms, equipment needed, and management of common emergencies. Box 9-1 contains abbreviations.

BOX 9-1 Emergency Care Abbreviations • • • • • • • • • • • • • •

ACLS: advanced cardiac life support AED: automated external defibrillator AHA: American Heart Association ALS: advanced life support BCLS: basic cardiac life support BLS: basic life support CAD: coronary artery disease CPR: cardiopulmonary resuscitation ECC: emergency cardiac care ECG: electrocardiogram EMD: emergency medical dispatcher EMS: emergency medical service EMT: emergency medical technician EMT-P: emergency medical technician paramedic

PREVENTION OF EMERGENCIES I. Attention to Prevention Prevention of emergencies requires preparedness, alertness, and anticipation. The following patient assessment procedures may reduce the occurrence of a medical emergency: Thorough medical history questionnaires updated at every appointment.6-8 Documentation of baseline vital signs, updated at each appointment.9 Documentation of findings on Medical Alert Tags; wrist or ankle bracelet or necklace that provides information on patient’s medical condition. Physical assessment beginning with the first interaction with a patient.10 Incorporation of proper risk management and stress reduction protocols into the patient care plan.3,8 Implementation of preparatory steps when a careful review and update of the patient record identifies potential risks. Box 9-2 suggests a basic five-point plan for emergency prevention.

BOX 9-2 Five-Point Plan to Prevent Emergencies • • • • •

II.

Use careful, routine patient assessment procedures. Document and update accurate, comprehensive patient records. Implement stress reduction protocols. Recognize early signs of emergency distress. Organize team management plan for emergency preparedness.

Factors Contributing to Emergencies Increased number of older and medically compromised patients in

society with natural teeth and dental diseases that require invasive procedures.6,11-13 Many patients, especially older adults, are taking medications that may interact adversely with drugs used in dentistry.11,14 More complex dental procedures require longer appointments.15 Increased use of drugs in dentistry.15 Anesthesia: local, general, conscious sedation. Tranquilizers. Pain medications (central nervous system depressants). Antibiotics.

PATIENT ASSESSMENT I. Assessment for Routine Treatment A. First Contact Start with the first interaction with the patient. Note abnormalities of patient’s voice on the telephone during appointment scheduling. Handwriting on medical history can indicate steadiness, ability to communicate, and education. Assess overall appearance and gait when patient enters the dental office or clinic. Document findings in the patient’s record.

B. Parts of the Assessment Physical assessment (signs and symptoms). Comprehensive patient history to include medical, dental, and psychosocial history. Vital signs. Extraoral and intraoral examination. Comprehensive documentation of findings.

C. Emergency Indicators Changes in a patient’s appearance on the day of an appointment may suggest indicators that encourage preparation for emergencies.

II.

The Patient’s Medical History

A. Update and Document Changes Review at each appointment.11 Discuss changes with dental team members who are providing

treatment for the patient. A comprehensive medical history includes all the items found in Chapter 11.

B. Use of Medical Alert Box Many dental offices utilize computerized patient records but some are limited to paper records. If paper records are utilized, charts or folder are required for confidentiality and Health Insurance Portability and Accountability Act. Only the patient’s name and/or record number may be included on the folder or chart. The “Medical Alert Box” is usually located on the front page of the medical history to alert the dental team of information that may predispose a patient to a medical emergency before, during, or postdental treatment. Significant items include: Physical conditions that may lead to an emergency. Diseases the patient has or previously had. Previous surgeries. Medical emergencies the patient experienced previously. Medications the patient has taken within the past 2 years. Allergies and adverse drug reactions. Previous adverse reactions to dental treatment.

III. Vital Signs Vital signs are essential to assess a patient’s overall health status and to evaluate the severity of a medical emergency by comparison with baseline findings. A well-prepared dental team takes vital signs routinely to record baseline findings, not only during the earliest sign of emergency distress.9

A. The Vital Signs

Pulse, blood pressure, respirations, temperature, height, weight, and the information from the patient’s personal Medical Alert Tag (bracelet, necklace, or anklet) provide essential information.

B. Baseline Vital Signs The vital signs taken at the first appointment are considered baseline.16 The ranges of vital signs are described in Chapter 12.

C. During Emergency Compare vital signs to baseline findings during a medical emergency. Compensating: In most medical emergencies, patients will experience a “fight or flight” reaction, during which time they are said to be compensating. The vital signs are elevated above the baseline findings.17 Decompensating: When vital signs have fallen below baseline, the patient could be going into a state of shock.18 Shock: A state of lack of perfusion (saturation) of oxygenated blood to all cells of the brain and body. When brain cells are deprived of oxygenated blood, they cease to provide respiratory and circulatory function.

IV. Extraoral and Intraoral Examinations Extraoral and intraoral examinations can provide significant clues to underlying disease processes that predispose a patient to a medical emergency. Thorough examinations are an integral part of the prevention of medical emergencies.19,20

A. Extraoral Blood disorders, cancers, and endocrine disorders may be suspected or discovered from extraoral palpation, skin color changes, abnormalities of the eyes, and asymmetry of the face or neck.

B. Intraoral Oral manifestations and lesions can be indications of many disease states, such as diabetes, anemia, leukemia, lupus erythematosus, or human immunodeficiency virus/acquired immune deficiency syndrome.

V.

Recognition of Increased Risk Factors

The carefully prepared and regularly updated medical and personal history, with adequate follow-up consultation with the patient’s physician for integration of dental and medical care, can prevent many emergencies by alerting dental personnel to the individual patient’s needs and idiosyncrasies. Special needs may include: Specific physical conditions that may lead to an emergency, for example, genetic predispositions, seizures, diabetes. Diseases for which the patient is (or has been) under the care of a physician and the type of treatment, including medications. Allergies or drug reactions or interactions.19

STRESS MINIMIZATION Stress and anxiety are the basis for many of the common emergencies that occur in a dental office or clinic. The clinic atmosphere and the warmth and sincerity of the personnel can help a patient feel accepted and secure. The apprehension and anxiety associated with dental treatment compounds the risk factors for medical emergencies.8,19

I.

Recognize the Patient with Stress Problems Apprehension or anxiety-related disorders related to dental procedure. Elderly patients are prone to medical emergencies, as they may have cardiovascular diseases or other undiagnosed conditions.6,11 Essential medications: ensure certain prescriptions are taken on schedule to avoid risk of an emergency. The medications may cause adverse reactions that can lead to a medical emergency such as orthostatic hypotension.

II.

Suggestions for Effective Communication

Provide a stress reduction plan to any patient who is apprehensive or medically predisposed to emergencies. Reduction of stress includes the development of patient rapport through effective communication between the dental team and the patient.

A. Actively Listen to a Patient’s Fears Develop rapport so the patient senses the listener is empathetic and interested in alleviating the apprehension. Communicate with the patient about their fear of treatment. When a patient confides in a caregiver, trust is established and the patient is calmer.

Patient trust in the care provider can be beneficial for emergency prevention.

B. Effects of Fear Patients who try to repress their fears are more likely to hyperventilate or experience syncopal episodes.

III. Reduction of Stress A. Appointment Scheduling New patient: Initial appointment for consultation and assessment provides an opportunity to build rapport and to evaluate the patient’s level of anxiety. Stress reduction can be built into treatment appointments.9 Time of appointment: Plan in accordance with personal health requirements.8,9,19 Waiting time minimized: First appointment in the morning prevents building of anxiety by waiting all day for the appointment. In addition, anxiety can be decreased by taking the patient into the treatment room immediately and starting treatment promptly.8,9 Eating requirements: Identify usual mealtime and ask about previous meal eaten to prevent hypoglycemia.9,20 Length of appointment: Limited to the patient’s tolerance.9,19

B. Medication Premedication when indicated and prescribed by the physician or dentist.19 Pain control during treatment.19 Patient’s own prescriptions. Patients subject to emergencies are instructed to bring their own prescribed medicines, for example, the patient with asthma or one who is subject to attacks of angina pectoris.

C. Posttreatment Care Postcare instructions for prevention and/or relief of discomfort. Postcare pain control as needed. Analgesics may be prescribed.8 Place a follow-up telephone call to an anxious patient to make certain there were no postoperative complications.

EMERGENCY MATERIALS AND PREPARATION Organization is a key concept in emergency preparedness.21 The first steps in preparing for managing emergencies include setting up the emergency equipment and a systematic protocol.21,22 Group planning and individual acceptance of responsibility can provide the team with efficiency, composure, and freedom from fear at the time of crisis.23

I.

Communication: Telephone Numbers for Medical Aid

Postemergency telephone numbers near each extension that permits outside calls. Rescue squads with paramedics (fire, police, flying squad, or 911 in many cities in the United States and Canada). Ambulance service. Nearest hospital emergency department. Poison information center: 1-800-222-1222 in the United States. In Canada, visit SafeMedicationUse.ca for poison center telephone listings by province. Physicians Patient’s physician is listed in the permanent record in a standard, convenient place. Physicians available for emergency calls.

II.

Equipment for Use in an Emergency Every dental office or clinic should have an emergency kit or cart,9,24 and everyone in the office must become familiar with its contents. Kits can be purchased commercially (Figure 9-1).

FIGURE 9-1 • Emergency Medical Kit for the Dental Office.

The kit is kept in order, its contents replenished, and outdated materials replaced as needed. The emergency equipment is portable, well-maintained, and kept in a place readily accessible to all treatment rooms. Materials are plainly marked and kept separate from other office supplies. Materials included are selected to accomplish emergency treatment by current methods. The items included in the kit imply proper training in their use. Members of a team can add new items for the list in keeping with their training and abilities. Table 9-1 provides a typical list of essential emergency equipment items.

TABLE 9-1 • Equipment in an Emergency Kit or Cart CATEGORY

ESSENTIAL ITEMS

Required equipment

Series E portable oxygen tank Low-flow oxygen regulator Nasal cannula Simple face mask Nonrebreather mask Bag-valve masks (adult and pediatric) Demand valve resuscitator Automated external defibrillator (AED) Oro- and nasopharyngeal airways Sizes: pediatric to large adult Water-soluble lubricant Sphygmomanometer Blood pressure cuffs: pediatric, adult regular, and large adult Magill forceps Syringes: 2–3 mL Luer-Lok tip 21-gauge needles Medical Emergency Report Forms Cricothyrotomy equipmenta Intravenous equipmenta

Injectable drugs

Epinephrine via autoinjector (EpiPen®) Diphenhydramine (injectable antihistamine) Cortisonea Glucagona Midazolama Atropinea

Noninjectable drugs

Antiplatelet: aspirin Respiratory stimulant: ammonia vaporole or ammonia inhalant capsule Bronchodilator: albuterol inhaler Antihypoglycemic: glucose gel, glucagon paste Vasodilator: nitroglycerin tablets, nitrolingual spray Diphenhydramine tablets Naloxone (Narcan): nasal spray

Supplementary equipment

Thermometer Blood glucose meter, lancets, and test strips Pen flashlight Stopwatch Razor (for hair removal for AED pads)

Scissors Cotton pliers Emesis basin Blanket Pillow Inflatable splints Backboard (12 × 249 for patients who cannot be moved for cardiopulmonary resuscitation) Quick-activated cold packs Betadine wipes (Povidone-Iodine antiseptic wipes) Sterile packages of gauze and adhesive tape 2 × 2 inches 4 × 4 inches Rolled gauze (2 × 5 inches) aAdministered

only by personnel with advanced medical training.

III. Care of Drugs All dental personnel become familiar with the emergency drugs maintained in the particular office or clinic.15 Only specially trained, experienced persons will administer injectable medications.21 The only drugs kept in the dental office are those that the dentist or emergency team is trained to use.15,21

A. Identification The purpose and method of administration of each drug is clearly identified on the container.15 A compartmentalized clear plastic cabinet or box can be useful for this purpose because the labels and instructions can be seen from the outside and efficient selection can be made.15,25 The expiration date appears clearly on each item that has a limited shelf life.15,25 When narcotics are included in the list of drugs available for emergencies, they are stored in a secured location other than the emergency kit, and typically purchased in predosed amounts for

specific emergency situations.

B. Record of Drugs Label each with information about shelf life and due date for replacement. Example: Nitroglycerin is replaced at 6 months.15 Check weekly to maintain emergency kit in workable order.15 A complete record of each available drug is kept. The following are recorded: Name of drug. Dosage. Date purchased. Address of source if different from the usual local pharmacy. Itemized record, signed by the staff member responsible. Specific entry as each drug is used. Expiration dates checked at routine intervals. Instructions for disposal.

C. Disposal of Drugs Follow specific disposal instructions on the drug label or patient information sheet. Do not flush prescription drugs down the toilet. Take advantage of community drug take-back programs that allow the public to bring unused drugs to a central location for disposal.

IV. Medical Emergency Report Form Figure 9-2 shows an example of a form that can be used to record the essential information during an emergency.

FIGURE 9-2 • Sample Medical Emergency Report. The form is prepared in duplicate. One copy accompanies the patient to the emergency clinic, and the second copy is retained in the patient’s dental record file.

Such a form can be filed or scanned and stored in the computerized patient record control system to include in the patient’s permanent record. The forms can be placed on a clipboard on the emergency cart. A copy of the emergency report is given to the emergency medical service (EMS) personnel to present to those in the emergency room at the hospital or other medical facility when the patient is admitted.26

A. Purposes Organize data collected during the emergency. Serve as a time reference during the monitoring of vital signs. Prepare a record from which the medical personnel can interpret the patient’s condition at the time of transfer from the dental facility.26

B. Uses Evaluation for planning dental and dental hygiene appointments to avoid future emergencies for the patient. Provide a reference in the event legal questions arise. A well-kept record can be vital, and each emergency, however insignificant the incident may seem, is recorded.15

V.

Practice and Drill

A. Staff Instruction In an emergency situation, seconds count and there is no time for fumbling or discussion.23 Each member of the clinic and office staff is thoroughly familiar with the location, purpose, effect, and application of each item of equipment and its source.25 Each staff member also knows the order of procedures in all types

of emergencies (Figure 9-3) and can assume any role when needed.15,25

FIGURE 9-3 • Flowchart: In Every Emergency. BLS, basic life support; EMS, emergency medical service.

B. Assignments Preparation: The assignment of specific responsibilities during an emergency is the result of planning by the whole team.3,4,23 Substitutions: Because a staff member may be absent from the scene at the time of an emergency, each person learns and practices the duties for all positions so substitutions can be made with a minimum of discussion and no confusion.3,4,23 Figure 9-4 shows an example of a possible distribution of duties when three people are available to attend to the patient.

FIGURE 9-4 • Division of Duties for Three-Person Emergency Team. Suggested distribution of responsibilities to be memorized and practiced by the dental personnel who form the emergency team. AED, automated external defibrillator; CPR, cardiopulmonary resuscitation.

Advantages of assignments Organization efficiently uses personnel. Sharing responsibility relieves pressure. Duties can be carried out quietly, without excess discussion or attention from others in the clinic.

Necessary work gets done without duplication and without omissions.

C. Drills Regular reviews and rehearsals for each type of emergency are conducted, preferably on a “surprise” basis, at least once a month.23 A specific emergency code call can be used when an intercom or other message system is available. Mentioning “code” in front of a number or phrase may panic the other patients; therefore, it is best to use only a number like “17.” For each type of emergency, practice in the use of procedures, including oxygen administration, resuscitation, and airway maneuvers, as well as specific positioning of a patient for all emergencies is indicated.23 Equipment and materials can be checked at the time of the drill to ensure their availability and that each is in working order. Outdated supplies are replaced. One staff member is designated to be in charge of the emergency supplies.25 A record of drills is kept with a diary of dates, procedures practiced, and names of those present.

D. New Staff Member Assignment of duties and practice for new members are a part of the first working day’s orientation. New members are expected to renew basic life support (BLS)/cardiopulmonary resuscitation (CPR) certification by taking necessary refresher courses within a specified time. Most states and/or provinces require a renewal certificate for annual licensure. The Commission on Dental Accreditation has established standards requiring all clinic personnel to be healthcare provider BLS/CPR certified.

E. Procedures Manual A paper manual is a valuable reference, but an electronic format is a currently accepted method of storing procedure manuals. They need to be accessible from a computer or mobile device readily available in the clinic. Reviewed and updated three or four times each year. Useful during the orientation of a new member. Contains work assignments and checklists for equipment and resources. Provides reference information concerning specific emergencies organized in color-coded sections and alphabetical order to outline signs, symptoms, and initial treatment. Members of the team are given assignments to update the manual by conducting a critical review of the scientific literature for quality assurance and evidence-based, patient-centered care. All updates are referenced in the index of the manual.

BLS CERTIFICATION Licensed dental hygienists are required to maintain a current BLS/CPR certification in most states for licensure. The American Heart Association (AHA) provides guidelines and training for healthcare professionals. The AHA BLS for Healthcare Providers Manual is updated regularly to reflect the most current information and procedures to follow when responding to an emergency situation.

OXYGEN ADMINISTRATION High concentration of oxygen is contraindicated for chronic obstructive lung diseases, especially emphysema. Oxygen is also not indicated in the presence of hyperventilation because the patient is receiving increased amounts of oxygen in air inhaled and is in need of carbon dioxide.15,24 The use of oxygen is beneficial in all other emergencies.15 When the patient is not breathing, positive pressure oxygen (also known as demand valve resuscitator) delivery is needed.24

I.

Equipment

Oxygen delivery systems with indications, flow rate, and percentage of oxygen delivered are listed in Table 9-2. A portable oxygen delivery system is shown in Figure 9-5.

FIGURE 9-5 • Portable Oxygen Delivery System. The portable unit is stored in an area immediately accessible to all treatment areas in the dental clinic. If a fixed oxygen delivery system is available in the treatment area, it can be used in an emergency situation.

TABLE 9-2 • Oxygen Delivery Systems

Description

A. Parts Oxygen resuscitation equipment consists of the following: An oxygen tank. A reducing valve. A flow meter. Tubing. Mask. A positive pressure bag. The E cylinder, which can provide oxygen for 30 minutes, is the minimum size recommended. Smaller tanks provide little oxygen for short periods only, and larger tanks are less portable.24

B. Directions Box 9-3 outlines the steps for operation of an oxygen tank. Clear, readable directions are permanently attached to the tank’s portable carriage. Practice is a definite part of team drills.

BOX 9-3

Operation of Oxygen Tank

Operation of Oxygen Tank To turn on: • Attach oxygen delivery system to tank. • Turn key on top of tank in counterclockwise direction to open flow of oxygen. • Adjust low-flow regulator knob and turn in the direction the arrow indicates to increase or open; many regulators are opposite of sink faucets and open clockwise instead of counterclockwise. • Attach oxygen delivery system to patient. To turn off: • Remove oxygen delivery system from patient. • Turn key on top of tank in clockwise direction to shut off flow of oxygen. • Turn the low-flow regulator knob to the open position to bleed oxygen from the system. • After bleeding, gently close the low-flow regulator knob. Laminate and Affix to the Oxygen Tank To turn on: • Attach oxygen delivery system to tank. • Turn key on top of tank in counterclockwise direction to open flow of oxygen. • Adjust the low-flow regulator knob. • To increase O2 flow: turn the knob in the direction the arrow indicates. (Many regulators are the opposite of sink faucets and open clockwise instead of counterclockwise.) • Attach oxygen delivery system from patient. To turn off: • Remove oxygen delivery system from patient. • Turn key on top of tank in clockwise direction to shut off flow of oxygen. • Turn the low-flow regulator knob to open position to bleed oxygen from the system. • After bleeding, gently close the low-flow regulator knob.

II.

Patient Breathing: Use Supplemental Oxygen Apply a full-face clear mask or a nasal cannula.24

Supplemental oxygen is started at 6–10 L/min.24 Monitor breathing; if breathing stops, proceed with positive pressure oxygen.

III. Patient Not Breathing: Use Positive Pressure For persons not trained in the use of the bag-valve mask or positive pressure delivery, a mouth-to-mask procedure is used.27,28 Apply full-face clear mask so a tight seal is formed. One dental team member may need to apply pressure to the face mask to maintain a complete seal. Adjust oxygen flow so the positive pressure bag remains filled. Compress the bag manually, one ventilation every 5–6 seconds to provide 10–12 respirations/min for an adult. For a child, 1 ventilation every 3 seconds. Watch chest rise. When the chest does not rise, recheck airway for obstruction. Proceed with airway obstruction management. Call EMS.

SPECIFIC EMERGENCIES Certain systemic disease conditions and physical injuries require specific treatment during an emergency. In Tables 9-3 and 9-4, the Emergency Reference Charts, several conditions are listed with their symptoms and treatment procedures. TABLE 9-3 • Emergency Reference Chart: Medical Emergencies EMERGENCY All Cases Call Emergency Medical Service (EMS) immediately if problem with: Breathing Unconsciousness Anaphylaxis Bleeding Poisoning Chest pain

SIGNS/SYMPTOMS

PROCEDURE i. Determine consciousness (tap and shout): yell for help If patient is unconscious: Call EMS and get automated external defibrillator (AED) i. Conduct primary assessment: C—Circulation: check for pulse for 10 sec, if none: start compressions A—Airway: open with head tiltchin lift B—Breathing: (look, listen, feel) if none: give 2 (1-sec) breaths D—Defibrillate: 1 shock: then 5 cycles of cardiopulmonary resuscitation (CPR) If patient is conscious and breathing: i. Conduct secondary assessment: a. Evaluate level of consciousness 1. Does patient know own name, location, date? 2. Use penlight to see if pupils react equally to light 3. If conscious: check for equal hand strength by asking patient to squeeze your hands 4. Position according to

signs/symptoms 5. If face is red, raise the head 6. If face is pale, raise the tail 7. Evaluate heart rate, blood pressure, respirations b. Findings in patient record or medical alert bracelet 1. Disabilities, diseases, drugs, baseline vital signs: Call EMS Respiratory failure

Labored or weak respirations or cessation of breathing Cyanosis or ashenwhite with blood loss Pupils dilated Loss of consciousness

Position: semisupine if not breathing; upright if breathing Check for and remove foreign material from mouth Establish airway. Begin CPR. If patient does not spontaneously breathe: Call EMS Monitor vital signs: blood pressure, pulse, respirations Administer oxygen by nonrebreather mask if patient is already breathing

Mild airway obstruction

Good air exchange, coughing, wheezing (patient can speak)

Sit patient up Loosen tight collar, belt No treatment; let patient cough

Severe airway obstruction

Poor air exchange; noisy breathing; weak, ineffective cough; difficult respirations; gasping. Unable to speak, breathe, cough. Cyanosis, dilated pupils

Reassure patient Treat for complete obstruction Conscious patient: Perform Heimlich maneuver Patient becomes unconscious: Begin CPR Unconscious patient: Call EMS

Hyperventilation syndrome

Light-headedness, giddiness Anxiety, confusion Dizziness Overbreathing (25–30 respirations/min) Feelings of suffocation Deep respirations

Terminate oral procedure Remove rubber dam and objects from mouth Position upright Immediately tell patient: “There will be no more dental treatment today” Loosen tight collar Reassure patient Explain overbreathing; request that

Palpitations (heart pounds) Tingling or numbness in the extremities

each breath be held to a count of 10. Ask patient to breathe deeply (7–10/min) into a paper bag adapted closely over nose and mouth Never use a bag for a patient with diabetes or patients exhibiting signs of diabetic coma, e.g., fruity breath odor, Kussmaul breathing, lethargy, dry skin

Heart failure

Difficult or labored breathing Pulmonary congestion with cough and difficulty breathing May cough up pink sputum Rapid, weak pulse Dilated pupils May have chest pain

Place patient in upright position. Call EMS. Make patient comfortable: cover with blanket Administer oxygen by nonrebreather mask Reassure patient. Provide basic life support (BLS)

Cardiac arrest

Skin: ashen gray, cold, clammy No pulse No heart sounds No respirations Eyes fixed, with dilated pupils; no constriction with light Unconscious

Call EMS. Check oral cavity for debris or vomitus; leave dentures in place for a seal. Begin CPR27

Asthma attack

Difficulty breathing, wheezing (extreme cases—silence, indicating little to no air exchange) Cyanosis Dilated pupils Confusion due to lack of oxygen Chest pressure Sweating

Position patient upright with arms up and supported forward Assist with patient’s own bronchodilator Administer supplemental oxygen by nasal cannula Epinephrine if patient decompensates Supplemental cortisone to patients on corticosteroid therapy BLS—may need demand valve resuscitator if patient experiences respiratory depression. Call EMS

Syncope (fainting)

Pale gray face, anxiety Dilated pupils Weakness, giddiness, dizziness, faintness, nausea Profuse cold perspiration Rapid pulse at first, followed by slow pulse Shallow breathing Drop in blood pressure Loss of consciousness

Position: Trendelenburg Open airway Loosen tight collar, belt Place cold, damp towel on forehead Crush ammonia vaporole and place under patient’s nose Keep warm (blanket) Monitor vital signs: blood pressure, pulse, respirations Keep airway open Administer oxygen by nasal cannula Keep in supine position 10 min after recovery to prevent nausea and dizziness Reassure patient, especially during recovery

Shock

Skin: pale, moist, clammy Rapid, shallow breathing Low blood pressure Weakness and/or restlessness Nausea, vomiting Thirst, if shock is from bleeding Eventual unconsciousness if untreated

Position: Trendelenburg Open airway Keep quiet and warm Monitor vital signs: blood pressure, respirations, pulse Keep airway open Administer oxygen by nonrebreather bag If patient does not recover fully and/or vital signs not at baseline: Call EMS

Stroke (cerebrovascular accident)

Premonitory dizziness, vertigo Transient paresthesia or weakness Transient speech defects Serious headache (with cerebral hemorrhage) Breathing labored, deep, slow Chills Paralysis on one side

Conscious patient: Call EMS. Turn patient on paralyzed side; semiupright Loosen clothing about the throat Reassure patient; keep calm, quiet Monitor vital signs: blood pressure, pulse, respirations Administer oxygen by nasal cannula Clear airway; suction vomitus because the throat muscles may be paralyzed Unconscious patient: Position: supine BLS

of body Nausea, vomiting Convulsions Loss of consciousness (slow or sudden onset)

CPR if indicated

Cardiovascular diseases

Symptoms vary depending on cause

For all patients: Call EMS Be calm and reassure patient Keep patient warm and quiet; restrict effort Always administer oxygen when there is chest pain

Angina pectoris

Sudden crushing, paroxysmal pain in substernal area Pain may radiate to shoulder, neck, arms Pallor, faintness Shallow breathing Anxiety, fear

Position: upright, as patient requests, for comfortable breathing If patient has been diagnosed with angina and has own nitroglycerin: Place nitroglycerin sublingually only when the blood pressure is at or above baseline Administer oxygen by nasal cannula Reassure patient Without prompt relief from nitroglycerin: Call EMS. Treat as a myocardial infarction

Myocardial infarction (heart attack)

Sudden pain similar to angina pectoris, which may radiate, but of longer duration Pallor; cold, clammy skin Cyanosis Nausea Breathing difficulty Marked weakness Anxiety, fear Possible loss of consciousness

Call EMS. Position: with head up for comfortable breathing Symptoms are not relieved with nitroglycerin Encourage to chew 1 adult (not enteric coated) or 2 low-dose “baby” aspirin if the patient has no allergy to aspirin29 Monitor vital signs: blood pressure, pulse, respirations Administer oxygen by nonrebreather bag Alleviate anxiety; reassure

Adrenal crisis (cortisol mental deficiency)

Anxious, stressed Confusion Pain in abdomen,

Conscious patient: Terminate oral procedure Call EMS

back, legs Muscle weakness Extreme fatigue Nausea, vomiting Lowered blood pressure Elevated pulse Loss of consciousness Coma

Request telephone call for medical assistance Administer oxygen by nonrebreather mask Monitor blood pressure and pulse Place patient on stable side with legs slightly raised Unconscious patient: Call EMS BLS Try ammonia vaporole when cause is undecided Administer oxygen

Insulin reaction (hyperinsulinism, hypoglycemia)

Sudden onset Skin: moist, cold, pale Confused, nervous, anxious Bounding pulse Salivation Normal to shallow respirations Convulsions (late)

Conscious patient: Administer glucose gel Observe patient for 1 hr before dismissal Determine time since previous meal, and arrange next appointment following food intake Unconscious patient: Call EMS BLS Position: supine Maintain airway Administer oxygen by nonrebreather bag Monitor vital signs Administer intramuscular glucagon or intravenous glucose

Diabetic coma (ketoacidosis) (hyperglycemia)

Slow onset Skin: flushed and dry Breath: fruity odor Dry mouth, thirst Low blood pressure Weak, rapid pulse Exaggerated respirations (Kussmaul breathing)

Conscious patient: Call EMS. Keep patient warm Administer oxygen by nasal cannula Unconscious patient: BLS Position: supine

Seizure Generalized tonic-clonic

Coma Anxiety or depression Pale, may become

Call EMS. Position supine: Do not attempt to move from dental chair Make safe by placing movable

Generalized absence

cyanotic Muscular contractions Loss of consciousness Brief loss of consciousness Fixed posture Rhythmic twitching of eyelids, eyebrows, or head May be pale

equipment out of reach Do not force anything between the teeth; a soft towel or large sponges may be placed while mouth is open Open airway; monitor vital signs Administer oxygen by nasal cannula or face mask Allow patient to sleep during postconvulsive stage EMS to determine need for transport to hospital Take objects from patient’s hands to prevent their being dropped

Allergic reaction Delayed (anaphylactic shock)

Skin Erythema (rash) Urticaria (wheals, itching) Angioedema (localized swelling of mucous membranes, lips, larynx, pharynx) Respiration Distress, dyspnea Wheezing Extension of angioedema to larynx: may have obstruction from swelling of vocal apparatus

Skin Administer antihistamine Respiration Position: upright Administer oxygen by nasal cannula Epinephrine may be needed if breathing difficulty If airway obstruction: Position: supine Airway maintenance Epinephrine (EpiPen®)

Immediate anaphylaxis

Skin Urticaria (wheals, itching) Flushing Nausea, abdominal cramps, vomiting, diarrhea Angioedema Swelling of lips, membranes, eyelids Laryngeal edema with difficulty swallowing Respiration distress

Rapid treatment needed. Administer epinephrine via autoinjector (EpiPen®) Call EMS Position: supine (except when dyspnea predominates) Administer oxygen by nonrebreather mask BLS Monitor vital signs CPR if airway obstructed

Cough, wheezing Dyspnea, airway obstruction Cyanosis Cardiovascular collapse Profound drop in blood pressure Rapid, weak pulse Palpitations Dilation of pupils Loss of consciousness (sudden) Cardiac arrest Local anesthesia reactions Psychogenic Allergic (very rare) Toxic overdose

Reaction to injection, not the anesthetic Syncope Hyperventilation syndrome Anaphylactic shock Allergic skin and mucous membrane reactions Bronchial asthma attack Effects of intravascular injection rather than increased quantity of drug more common Stimulation phase Anxious, restless, apprehensive, confused Rapid pulse and respirations Elevated blood pressure Tremors Convulsions Depressive phase follows stimulation phase

Syncope Hyperventilation See earlier in this table Mild reaction Stop injection Position: supine Loosen tight clothing Reassure patient Monitor blood pressure, heart rate, respirations Administer oxygen by nasal cannula Severe reaction: Call EMS BLS: maintain airway Administer oxygen by nonrebreather mask Continue to monitor vital signs CPR Administration of anticonvulsant

Drowsiness, lethargy Shocklike symptoms: pallor, sweating Rapid, weak pulse and respirations Drop in blood pressure Respiratory depression or respiratory arrest Unconsciousness Opioid overdose Fentanyl overdose

Trouble breathing, very slow breathing, or not breathing Unresponsive Limp, immobile Snoring, gurgling sounds Cold, clammy skin Blue lips, fingernails Drowsiness, lethargy Tiny pupils30

Assess for unresponsiveness: Call EMS Observe breathing vs. no breathing or only gasping BLS: if unresponsive with no breathing or only gasping, begin CPR Administer Naloxone 2 mg intranasal (may repeat after 4 min) Assess response: if move purposefully, breathe regularly, moan, or otherwise respond— stimulate and reassess Continue to monitor responsiveness and breathing until EMS arrives. If person stops responding, begin CPR and repeat Naloxone Assess response: if no response, continue CPR and use AED if available28

TABLE 9-4 • Emergency Reference Chart: Traumatic Injuries EMERGENCY SIGNS/SYMPTOMS

PROCEDURE

Hemorrhage

Compression over bleeding area 1. Apply gauze pack with direct pressure 2. Bandage pack into place firmly where possible 3. Elevate injury above the heart if possible

Prolonged bleeding Spurting blood: artery Oozing blood: vein

Severe bleeding: digital pressure on pressure point of supplying vessel If shock symptoms: Call EMS Bleeding from tooth socket

Pack with folded gauze; do not dab Have patient bite down firmly If bleeding does not stop, instruct patient to gently bite down on a damp tea bag and hold in place for 10 min

Nosebleed

Seat patient upright, head elevated Tell patient to breathe through mouth Apply cold application to nose Press nostril on bleeding side for a few minutes Advise patient not to blow the nose for an hour or more If bleeding does not stop, wet cotton rolls with water and lubricate with water-soluble lubricant Pack nostril Instruct patient to breathe through the mouth Leave packing in place until patient sees a physician

Chemical burn Reddened, discolored

Immediate: copious irrigation with water for 1/2 hr Check directions on chemical container for antidote or other advice Burn caused by acid: rinse with bicarbonate of soda; burn caused by alkali: rinse in weak acid (e.g., vinegar)

Internal poisoning

Call Poison Control Center: 1-800-2221222 in the United States. In Canada, visit SafeMedicationUse.ca for poison center telephone listings by province. Be calm and supportive Basic life support (BLS): airway maintenance Artificial ventilation (inhaled poison) Record vital signs Do not give water or milk or Ipecac unless instructed to do so by Poison

Signs of corrosive burn around or in oral cavity Evidence of empty container or information from patient Nausea, vomiting, cramps

Control Center Avoid nonspecific and questionably effective antidotes, stimulants, sedatives, or other agents, which may do more harm Call EMS Foreign body in eye

Tears Blinking

Wash hands Ask patient to look down Bring upper lid down over lower lid for a moment; move it upward Turn down lower lid and examine: if particle is visible, remove with moistened cotton applicator Use eye cup: wash out eye with plain water When unsuccessful, seek medical attention: prevent patient from rubbing eye by placing gauze pack over eye and stabilizing with adhesive tape

Chemical solution in eye

Tears Stinging

Irrigate promptly with copious amounts of water Turn head so water flows away from inner aspect of the eye; continue for 15–20 min

Dislocated jaw Mouth is open: patient Stand in front of seated patient is unable to close Wrap thumbs in towels and place on occlusal surfaces of mandibular posterior teeth Curve fingers and place under body of the mandible Press down and back with thumbs, and at the same time pull up and forward with fingers (Figure 9-6)

FIGURE 9-6 • Treatment for a Dislocated Mandible. With thumbs wrapped in toweling and placed on the buccal cusps of the mandibular teeth, the fingers are curved under the body of the mandible. The jaw is pressed down and back with the thumbs while pulling up and forward with the fingers to permit the condyle to pass over the articular eminence into its normal position in the glenoid fossa. As the jaw slips into place, the thumbs are moved quickly aside.

As joint slips into place, quickly move thumbs outward Place bandage around head to support under chin Facial fracture

Pain, swelling Ecchymoses Deformity, limitation of movement Crepitation on manipulation Zygoma fracture: depression of cheek Mandibular fracture: abnormal occlusion

Place patient on side BLS Support with bandage around face, under chin, and tied on the top of the head Call EMS

Tooth forcibly displaced

Swelling, bruises, or other signs of trauma

Instruct patient or parent to hold the tooth by the crown, and avoid touching

(avulsed tooth)

depending on the type of accident

the root(s) If the tooth is dirty, rinse it gently in cool water, but do not scrub it or remove tissue fragments from its root surface Keep the tooth moist by placing it in milk to transport to dentist Bring the tooth and the patient to dental office or clinic immediately The longer the time lapse between avulsion and replantation, the poorer the prognosis

Broken dental instrument during treatment

Instrument tip missing after use in patient’s mouth

Examine carefully for broken piece A radiograph may assist in locating the broken segment of the instrument Gently sweep through the sulcus/pocket with a curet or periodontal probe to try to remove broken piece of the instrument Patient may need to be referred to an oral surgeon or periodontist for further evaluation

Some of the same conditions have been described in detail in Section IX of this book.

DOCUMENTATION All details about the patient, the treatments, reactions, healing, and comments by the patient provide crucial information in a medical emergency or posttreatment complication.

I.

Comprehensive Record Keeping All medical findings and changes. Treatments provided, including types and amounts of local anesthesia, general anesthesia, nitrous oxide, or other types of sedation.15 Regimens of medications prescribed for patients are crucial information should a medical emergency or a posttreatment complication occur.

II.

Consults

In the patient’s record, document telephone and written responses of consultations with physicians or other healthcare providers.15

III. New Entries Response to treatment: Document a patient’s reactions and responses to treatments, whether they are unremarkable or remarkable. Previous appointment review: Complete a comprehensive review of previous appointment documentation before providing additional treatment at sequential appointments. Current information: Update information about the patient’s health status including vital signs as an integral part of the prevention of medical emergencies.8 Emergency documentation: Include a copy of the Medical Emergency Report Form (Figure 9-2) in the patient’s permanent

record.26 Progress notes: Box 9-4 contains an example progress note for an emergency that happens during an appointment.

BOX 9-4 Example Documentation: Emergency during Patient Treatment S—Patient experienced blatant signs of anaphylaxis after exposure to latex gloves during a routine scaling appointment. O—Patient presented with urticaria and pruritus on the arms, neck, and chest. Signs of lip, tongue, and laryngeal edema were exhibited with difficulty swallowing and breathing. Quickly informed the patient that he was experiencing an allergic reaction and needed an injection of epinephrine. A—Findings indicate need for nonlatex gloves and caution during dental appointments especially when using new materials. At 8 minutes, the patient’s vital signs were near baseline. Patient was released to emergency medical service (EMS) after 15 min to determine the extent of anaphylaxis. Patient was in stable condition. P—Epinephrine was administered via EpiPen® and EMS was summoned. About 50 mg of Benadryl and 100 mg of Solu-Cortef were also administered intramuscularly. Oxygen was delivered by nonrebreather mask at 15 L/min. A Medical Emergency Report Form (Figure 9-2) was completed and given to EMS with one copy included in the patient’s chart and the other sent to the patient’s physician. Signed: _________, DDS or DMD Date: ________ Signed: _________, RDH Date: _______________

EVERYDAY ETHICS A 12-year-old patient, Jonathan, had just received local anesthesia in Dr. Spar’s treatment room in preparation for a restorative procedure. Suddenly Jonathan started to have a rhythmic twitching of the eyelids and appeared pale. Dr. Spar’s assistant, Loraine, called the usual emergency alarm, and Elisa, the dental hygienist, joined in the team protocol for medical emergencies. In a few minutes, the generalized absence (petit mal) seizure was over and the patient was conscious with no other symptoms evident. Dr. Spar went about the dental procedure as if nothing had happened. Neither Loraine nor Dr. Spar

made an entry in the record at the time. Elisa glanced over the patient’s record and nothing she could find in the history showed that Jonathan had a susceptibility to seizures. As Elisa went back to her own treatment room, she wondered if she needed to record the emergency or ask Dr. Spar about it. Questions for Consideration 1. Which of the dental hygiene core values (Chapter 1, Box 1-6) apply in this situation? Explain the relationship. 2. Who needs to be informed of the event, and what potential ethical responsibilities are related to the patient? 3. What considerations for future treatment appointments are needed? From an ethical point of view, in what way were the patient’s best interests compromised?

Factors to Teach the Patient Stress minimization to prevent emergencies. If medications are prescribed by the dentist, review the instructions with the patient to ensure an understanding. Schedule appointments when there is no waiting, first appointment of the morning or afternoon. Eat breakfast before morning appointment, or lunch before afternoon appointment, unless instructed by the patient’s physician not to eat before the appointment. If patient has prescription medications for emergency episodes, bring those medications to the appointment. Examples: nitroglycerin tablets for angina, asthma inhaler, glucagon for hypoglycemia.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW

Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Brooks-Buza H, Fernandez R, Stenger JP. The use of in situ simulation to evaluate teamwork and system organization during a pediatric dental clinic emergency. Simul Healthc. 2011;6(2):101-108. 2. Skryabina E, Reedy G, Amlot R, et al. What is the value of health emergency preparedness exercises? A scoping review study. Int J Disaster Risk Reduct. 2017;21:274-283. 3. Jevon P. Updated guidance on medical emergencies and resuscitation in the dental practice. Br Dent J. 2012;212(1):41-43. 4. Malamed SF. Medical emergencies in the dental surgery. Part 1: preparation of the office and basic management. J Irish Dent Assoc. 2015;61(6):302-308. 5. Muller MP, Hansel M, Stehr SN, et al. A state-wide survey of medical emergency management in dental practices: incidence of emergencies and training experience. Emerg Med J. 2008;25:296-300. 6. Abraham-Inpijn L, Russell G, Abraham DA, et al. A patient-administered Medical Risk Related History questionnaire (EMRRH) for use in 10 European countries (multicenter trial). Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105(5):597-605. 7. de Jong KJM, Borgmeijer-Hoelen A, Abraham-Inpign L. Validity of a riskrelated patient-administered medical questionnaire for dental patients. Oral Surg Oral Med Oral Pathol. 1991:527-533. 8. Malamed SF. Knowing your patients. JADA. 2010:3S-7S. 9. Meiller TF, Wynn RL, McMullin AM, et al. Dental Office Medical Emergencies. 5th ed. Hudson, OH: Lexi-Comp; 2012:9, 89. 10. Reed KL. Basic management of medical emergencies: recognizing a patient’s distress. JADA. 2010;141:S20-S24. 11. Smeets EC, de Jong KJM, Abraham-Inpijn L. Detecting the medically compromised patient in dentistry by means of the medical risk-related history. Prev Med. 1998;27:530-535. 12. Anders PL, Comeau RL, Hatton M, et al. The nature and frequency of medical emergencies among patients in a dental school setting. J Dent Educ. 2010;74(4):392-396. 13. Tanzawa T, Futaki K, Kurabayashi H, et al. Medical emergency education using a robot patient in a dental setting. Eur J Dent Educ. 2013;17:e114-e119. 14. Dawoud BE, Roberts A, Yates JM. Drug interactions in general dental practice —considerations for the dental practitioner. Br Dent J. 2014;216(1):15-23. 15. Malamed SF. Medical Emergencies in the Dental Office. 7th ed. St. Louis, MO: Mosby; 2014:3. 16. Baseline. The free dictionary: medical dictionary. 2003-2017. http://medicaldictionary.thefreedictionary.com/baseline. Accessed August 24, 2017. 17. Compensation. The free dictionary: medical dictionary. 2003-2017. http://medical-dictionary.thefreedictionary.com/compensation. Accessed

August 30, 2017. 18. Decompensation. The free dictionary: medical dictionary. 2003-2017. http://medical-dictionary.thefreedictionary.com/decompensation. Accessed August 30, 2017. 19. Patton LL. Medical history, physical evaluation, and risk assessment. In: The ADA Practical Guide to Patients with Medical Conditions. 2nd ed. Hoboken, NJ: John Wiley & Sons, Inc; 2016:1-24. 20. Little JW, Falace DA, Miller CS, et al. Patient evaluation and risk assessment. In: Little JW, Falace DA, eds. Little and Falace’s Dental Management of the Medically Compromised Patient. 8th ed. St. Louis, MO: Elsevier Mosby; 2013:2-19. 21. Rosenberg M. Preparing for medical emergencies. The essential drugs and equipment for the dental office. JADA. 2010;141:S14-S19. 22. Chapman PJ. Medical emergencies in dental practice and choice of emergency drugs and equipment: a survey of Australian dentists. Aust Dent J. 1997;42(2):103-108. 23. Haas DA. Preparing dental office staff members for emergencies. Developing a basic action plan. JADA. 2010; 141:S8-S13. 24. Haas DA. Management of medical emergencies in the dental office: conditions in each country, the extent of treatment by the dentist. Anesth Prog. 2006;53:20-24. 25. Dym H, Barzani G, Mohan N. Emergency drugs for the dental office. Dent Clin N Am. 2016;60:287-294. 26. Bost N, Crilly J, Patterson E, et al. Clinical handover of patients arriving by ambulance to a hospital emergency department: a qualitative study. Int Emerg Nurs. 2012;20:133-141. 27. Berg RA, Hemphill R, Abella BS, et al. Adult basic life support: 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(suppl 3):S685-S705. 28. Hazinski MF, Shuster M, Donnino MW, et al. Highlights of the 2015 American Heart Association. Guidelines update for CPR and ECC. Professional.heart.org. https://eccguidelines.heart.org/wpcontent/themes/eccstaging/dompdf-master/pdffiles/part-5-adult-basic-lifesupport-and-cardiopulmonary-resuscitation-quality.pdf. Published October, 2015. Accessed August 31, 2017. 29. Markenson D, Ferguson JD, Chameides L, et al. Part 17: first aid: 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(suppl 3):2685-2705. 30. Kingston, Frontenac and Lennox & Addington Public Health. Fentanyl. KFL & A Public Health. https://www.kflaph.ca/en/healthy-living/fentanyl.aspx. Published 2016. Accessed May 25, 2017.

SECTION

III Documentation INTRODUCTION FOR SECTION III Maintenance of complete records for every aspect of care provided for each patient is a key aspect of dental hygiene practice. Patient records may be kept in many different formats, both handwritten and electronic, in different dental practices. Essential factors for legal documentation of all aspects of dental hygiene care include record-keeping that is: Chronological (each entry dated). Systematic. Comprehensive. Accurate. Unaltered. Signed by the dental hygienist.

THE DENTAL HYGIENE PROCESS OF CARE Documenting patient care is an integral component of each step in the Dental Hygiene Process of Care, as illustrated in Figure III-1.

FIGURE III-1 • The Dental Hygiene Process of Care.

Description Every step in the process is documented in each patient record at the initial appointment and at every continuing care or treatment appointment.

Comprehensive, accurate, and concise documentation of each step forms a complete and chronologic record of the patient’s oral health status and treatment over time.

ETHICAL APPLICATIONS A dental hygienist may be involved in a variety of moral, ethical, and legal situations related to documentation of patient information during practice. Understanding the patient record can be subpoenaed in the event of litigation is a basic tenant of ethical and legal risk management for professional practice. Knowledge of and adherence to Health Insurance Portability and Accountability Act (HIPAA) requirements for privacy and security of patient records is imperative. An overview of the key concepts in patient record-keeping, with explanations and examples of ethical applications is found in Table III-1. TABLE III-1 • Essentials of Ethical Record-Keeping CONCEPT

EXPLANATION

ETHICAL APPLICATION

Privacy

Patient’s right to control access to identifiable personal health information.

Unless permission is given, a family member cannot receive information about the patient.

Confidentiality

The responsibility of the healthcare provider to protect patient’s information.

HIPAA training is provided for new employees.

Security

Protection against unsecured patient data.

A secure computer network is used or paper records are kept in locked files.

Accuracy

Recorded information is not A new entry (dated and altered after the fact. signed) is made in the patient’s record to correct

an error or omission in documentation during the patient appointment. Authenticity

Only data actually obtained during the patient visit are recorded.

Impersonal/Objective Personal opinion or negative social observations not pertinent to the patient’s treatment are never placed in the patient record.

Completely document only what actually happened during a patient visit. Uncooperative behavior or noncompliance are documented using subjective, factual statements.

10 Documentation for Dental Hygiene Care Christine A. Fambely, DH, BA, MEd, and Charlotte J. Wyche, BSDH, MS

CHAPTER OUTLINE THE PATIENT RECORD I. II. III. IV.

Purposes and Characteristics Components of a Patient Record The Handwritten Record The Electronic Record

THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT I. II.

The HIPAA Privacy Rule The HIPAA Security Rule

DOCUMENTING THE EXTRA- AND INTRAORAL

EXAMINATION TOOTH NUMBERING SYSTEMS I. II. III.

Universal System Fédération Dentaire Internationale Two Digit Palmer Notation System

CHARTING OF HARD AND SOFT TISSUES I. II. III.

Purpose Forms Used for Charting Sequence for Charting

PERIODONTAL RECORDS I. II. III. IV. V. VI.

Clinical Observations of the Gingiva Items to Be Charted Deposits Factors Related to Occlusion Radiographic Findings Severity of Periodontal Disease

DENTAL RECORDS I. II.

The Anatomic Tooth Chart Form Items to Be Charted

CARE PLAN RECORDS INFORMED CONSENT DOCUMENTATION OF PATIENT VISITS I. II. III. IV.

Purpose Essentials of Good Progress Notes Systematic Documentation: The SOAP Approach Risk Reduction and Legal Considerations

EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Identify and define key terms and concepts related to written and computerized dental records and charting.

2. Describe concepts related to ensuring confidentiality and privacy of patient information. 3. Compare three tooth numbering systems. 4. Discuss the various components of a patient’s permanent, comprehensive dental record. 5. Recognize and explain a systematic method for documenting patient visits.

THE PATIENT RECORD I. Purposes and Characteristics Accurate record keeping is essential to a safe, thorough, and caring dental hygiene practice as well as clinical and ethical risk management.1 Complete and accurate documentation of patient information and treatment provided facilitates communication, coordinated planning, and continuity of care. Patient records serve as a basis for the evaluation of the quality of care and aid when a review is made of the effectiveness of patient care practices. Data from health records are utilized in research and education. Documentation in the patient’s record is considered legal evidence in any legal or forensic situation.2,3 Documentation in a patient record is2: Authentic: genuine and undisputed reality. Accurate and comprehensive. Legible. Objective. Patient record entries are: Recorded promptly during or following treatment. Recorded using clear, concise, objective statements. Subjective information is written using objective statements. Dated. Signed by the clinician.

II.

Components of a Patient Record

The format of a patient record will vary among private dental practices and clinics; however, essential elements remain consistent regardless of the clinical environment. All information collected during the initial examination and during

continuing patient appointments is an official part of the permanent records.2,4,5 To meet the dental hygiene standard of care, all components of the dental hygiene process of care are addressed, including the dental hygiene care plan.6 Required components of a complete and regularly updated patient record include2: Medical history and vital signs. Dental history. Clinical assessment and diagnosis. Treatment recommendations and written treatment plan. Progress notes for each patient visit. Signed acknowledgment of confidentiality measures (see HIPAA section in this chapter). Additional components, required when applicable, include2: Informed consent forms.7 Radiographs and radiographic assessment. Periodontal risk assessment. Caries risk assessment. Trauma and/or surgery anesthesia records. Study models. Oral photographs.8 Orthodontic records, if available. Laboratory orders and test results. Referral records and copies of consultation correspondence with dental specialists or medical practitioners. Each component of the patient record is marked with patient identification and/or demographic information.

III. The Handwritten Record Historically, dental healthcare personnel have maintained handwritten documentation of patient records. Handwritten records are recorded legibly and written in ink. Records have also been dictated into a machine to be typewritten

into the permanent record later. Mistakes are corrected by placing a single line through the error, writing the correct information immediately after, and signing the entry. If a late entry is necessary, the new information: Follows the most recent entry in the patient record. Is noted as a late entry. Includes the date and time that the late entry was made. Systems may involve the completion of forms with topics and spaces to check off and spaces for writing descriptive information and/or prose-style summary. Strict infection control protocols are required to prevent contamination of paper records during patient care. For written records, a filing system is needed that provides accessibility to the health records by authorized personnel only.

IV. The Electronic Record Computerized records have provided a faster, more convenient, and better organized mode of information gathering, preserving, and sharing patient information with other healthcare professionals or providers.

A. Characteristics9 Data can be accessed from anywhere within the system by authorized personnel. A variety of custom software programs are available to include complete patient information, appointment schedules, medical alerts, and financial aspects of patient care. Systems may provide methods for documenting dental and periodontal assessments with automated, voice-activated recordings. Other systems permit printing hard copies for the patient when indicated.

Computerized records require computer terminals where only authorized personnel can access required information. Computer monitors are directed away from the view of unauthorized persons. Infection control protocols include providing plastic barriers for computer keyboard and mouse, as well as disinfection of chairside monitors.

B. Features Specially designed software and record storage systems can: Standardize terminology used for data entry. Improve efficiency and accountability; speed up entry of information and encourage entry of more comprehensive information.10 Increase the legibility of information. Provide easier, faster access to clinical information. Enhance communication with patients and with consulting dental specialists or other multidisciplinary team members who may not be together at one clinical site.10 Provide new ways of analyzing clinical information and outcomes of various clinical treatment approaches or treatment procedures. Maintain digital radiographs and photographs within the patient record.

THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT The Health Insurance Portability and Accountability Act (HIPAA) of 1996 took effect for dental practices in the United States on April 14, 2003. The law provides federal privacy standards that protect patient records and other health-related information in an emerging electronic information environment.11 The law applies to: Healthcare facilities. Healthcare insurance companies. Healthcare providers. Some states may have stricter laws that take priority over the federal standards. The current law is divided into two separate components that address: Privacy and the patient’s ability to access their health information. Security of patient information in healthcare settings. Legislation is in place in Canada and some European countries to protect the privacy of personal information.12,13 In Canada, healthcare privacy legislation is largely a provincial responsibility. The Personal Information Protection and Electronic Documents Act exists at the federal level. There are also specific health privacy acts in most provinces. Dental hygiene colleges/regulatory bodies have their own professional guidelines, which reinforce the jurisdictional acts.14

I.

The HIPAA Privacy Rule

Establishes a national standard to protect individual’s privacy and access to medical records and other health information.15

Patients have the right to: Receive a copy of personal health records. Ask to change incorrect or incomplete information. Receive reports on when, why, and with whom their health information is shared. Decide, in some cases (such as marketing), whether health information can be shared. Ask to be contacted regarding health information in a specific location or by a specific method such as telephone or mail. File a complaint with the provider, health insurer, or the U.S. government regarding concerns about use of their health information. Healthcare facilities are responsible to: Develop required privacy and confidentiality forms. Adopt written privacy policies and educate staff about confidentiality of patient information. Appoint staff privacy officers and privacy contact persons. Provide patients with a Notice of Privacy Practices document at the beginning of their care and receive signed acknowledgment of receipt. Implement security measures, policies, and formal protocols that protect patient information. Conduct analysis of security risks and vulnerabilities. Establish sanctions for workforce members who fail to comply with policies. Healthcare providers are responsible to: Comply with protocols and practices that protect patient information and avoid inappropriate disclosure.

II.

The HIPAA Security Rule

Updated in 2013 by establishing a national set of standards to strengthen digital security standards and enhance enforcement for protection of health information that is held or transferred in electronic form.5,15

Comprises three separate standards5: Administrative safeguards: limitation of access to appropriate members in the workforce. Physical safeguards: use of storage systems and procedures that prevent access for unauthorized individuals. Technical safeguards: use of technology, such as coding and encryption, to control access to patient information.

DOCUMENTING THE EXTRA- AND INTRAORAL EXAMINATION A specific objective of the extra- and intraoral examination as a part of the total patient assessment is the recognition of deviations from normal that may be signs and symptoms of disease (see Chapter 13). The need for careful, thorough documentation of hard and soft examination findings cannot be overemphasized. Concentration and attention to detail are necessary in order that each slight deviation from normal may be entered on the record.

TOOTH NUMBERING SYSTEMS Different systems are used in the various dental offices and clinics worldwide. The three most commonly used tooth designation systems are described here:

I.

Universal System

This tooth numbering method is referred to as the Continuous Numbers 1–32 or American Dental Association (ADA) system.16 Figure 10-1 shows the crowns of the teeth with the corresponding numbers.

FIGURE 10-1 • Universal Tooth Numbering (American Dental Association). Above, permanent dentition designated by numbers 1–32, starting at the maxillary right with 1 and following around to the maxillary left third molar (number 16) to the left mandibular third molar (number 17) and around to the right mandibular third molar (number 32). Below, primary teeth are designated by letters in the same sequence.

A. Permanent Teeth Start with the patient’s right maxillary third molar (number 1). Follow around the arch to the left maxillary third molar (16). Descend to the left mandibular third molar (17). Follow around to the right mandibular third molar (32).

B. Primary or Deciduous Teeth Use continuous upper case letters A–T in the same order as described for the permanent teeth. Right maxillary second molar (A) around to left maxillary second molar (J). Descend to left mandibular second molar (K) and around to the right mandibular second molar (T).

II.

Fédération Dentaire Internationale Two Digit

The Fédération Dentaire Internationale system (Figure 10-2) is also called the International system.17,18

FIGURE 10-2 • International Tooth Numbering—Fédération Dentaire Internationale. It is a two-digit system. The first digit indicates the quadrant; the second digit identifies the specific tooth. Each quadrant is numbered 1–4, with number 1 on the patient’s maxillary right, number 2 on the maxillary left, number 3 on the mandibular left, and number 4 on the mandibular right. Each tooth in a quadrant is numbered 1–8 from the central incisor. Quadrants of the primary dentition are numbered from 5 through 8.

A. Permanent Teeth Each tooth is identified by the quadrant (1 through 4) represented by the first digit. The second digit will then identify the tooth within the quadrant (1 through 8). Quadrant numbers—FIRST digit 1 = Patient’s maxillary right 2 = Maxillary left 3 = Mandibular left 4 = Mandibular right Tooth numbers within each quadrant: Start with number 1 at the midline (central incisor) to number 8, third molar. Figure 10-2 shows each tooth number in the four quadrants. Designation: The digits are pronounced separately. For example, “two-five” (25) is the permanent maxillary left second premolar, and “four-two” (42) is the permanent mandibular right lateral incisor.

B. Primary or Deciduous Teeth Each tooth is numbered by quadrant (5 through 8) to continue with the permanent quadrant numbers. The teeth are numbered within each quadrant (1 through 5). Quadrant numbers—FIRST digit 5 = Maxillary right 6 = Maxillary left 7 = Mandibular left 8 = Mandibular right

Tooth numbers within each quadrant: Number 1 is the central incisor, and number 5 is the second primary molar. Designation: The digits are pronounced separately. For example, “eight-three” (83) is the primary mandibular right canine, and “sixfive” (65) is the primary maxillary left second molar.

III. Palmer Notation System Names to identify this method are the Palmer System or Set-square.19

A. Permanent Teeth Each tooth is designated using the numbers 1 (central incisor) through 8 (third molar) in each quadrant. The patient’s right and left quadrants for each tooth are designated using a specific pattern of vertical and horizontal lines as shown in Figure 10-3.

FIGURE 10-3 • Palmer System Tooth Numbering. Each permanent tooth is designated by numbers 1–8, starting at the central incisor of each quadrant.

Quadrants are designated by horizontal and vertical lines. Primary teeth are identified by the letters A–E, starting at the central incisor.

B. Primary or Deciduous Teeth Upper case letters A–E are used instead of the numbers.

CHARTING OF HARD AND SOFT TISSUES I. Purpose The purpose of each type of charting is defined by its title. Dental chart (hard tissue) includes diagrammatic representation of existing conditions of the teeth. Periodontal chart (soft tissue) indicates clinical features of the periodontium. The use of separate chart forms to record the special features of periodontal and dental findings is preferable. Dental and periodontal charts are updated routinely on new forms with current dates to record changes in the patient’s oral features over time. Neatness in the markings of symbols, drawings, and labels goes hand-in-hand with the accuracy of the examination itself. An accurate, detailed, and carefully recorded charting is used for: Care planning: The charting is a graphic representation of the existing condition of the patient’s teeth and periodontium from which needed treatment procedures can be organized into a treatment plan. Treatment: During dental and dental hygiene appointments, the charting is useful for guiding specific procedures. Evaluation: The outcome and degree of treatment effects are determined by comparing the findings of the initially recorded examination with periodic follow-up examinations. Protection: In the event of misunderstanding by a patient, or if legal questions should arise, the records and chartings are evidence. Identification: In the event of emergency, accident, or disaster, a patient may be identified by the teeth for which a record has been maintained.

II.

Forms Used for Charting

Many variations of chart forms are in current use: some available

commercially, and some designed by the individual practitioner to meet particular needs. Specifications for an adequate form include ample space to: Chart neatly, accurately, and completely. Label as needed for clarity. Record in a manner that can be interpreted by all who use it. Anatomic drawings of the complete teeth: Figure 10-4 provides a typical example of a form that may be used for periodontal and/or dental charting.

FIGURE 10-4 • Periodontal and Dental Charting. A: Example of dental charting notations. B: Example of computerized periodontal charting with key.

Geometric: A diagrammatic representation that provides space to record findings for each tooth. Examples of geometric charting forms used to record a patient’s disclosed biofilm for teaching personal disease control are shown in Figures 21-1 and 21-2 in Chapter 21.

FIGURE 21-1 • Biofilm Control Record. Diagrammatic representation of the teeth includes spaces to record biofilm on six areas of each tooth. The facial surfaces are on the outer portion and the lingual and palatal surfaces are on the inner portion of the arches. Teeth are numbered by the American Dental Association system on the inside and by the Fédération Dentaire Internationale system on the outside. (Adapted with permission from Ramfjord SP, Ash MM. Periodontology and Periodontics. Philadelphia, PA: WB Saunders Co; 1979:273; from O’Leary TJ, Drake RB, Naylor JE. The plaque control record. J Periodontol. 1972;43:38.)

FIGURE 21-2 • Biofilm-Free Score. A: Diagrammatic representation of the teeth used to record biofilm and papillary bleeding. B: Enlargement of one section of the diagram shows tooth surfaces. Teeth are numbered by the American Dental Association system inside each block and by the Fédération Dentaire Internationale system outside each block. (Adapted with permission from Grant DA, Stern IB, Listgarten MA. Periodontics. 6th ed. St. Louis, MO: Mosby; 1988:613.)

III. Sequence for Charting A. Basic Entries Name, birth date. Date of examination: Every entry is dated. Missing teeth: When radiographs are available in advance, missing teeth can be charted before the clinic appointment. Whether dental

or periodontal charting is completed first, marking the missing teeth will be necessary.

B. Systematic Procedure An accurate odontogram is a systematic representation of both intraoral clinical findings and radiographic findings. The use of a set routine is essential to accomplishing a complete and accurate charting, not only for the tooth surface-to-surface pattern but also for the parts of the charting itself. Charting all of one item for the entire mouth, rather than complete charting of one tooth, helps to ensure accuracy. For example, in the dental charting, record all the restorations first. Then start again at the first tooth and chart all the deviations from normal. Missing teeth. Location of crowns, bridges, and implants. Charting all restorations and deviations for each tooth separately is less efficient. The patient’s permanent records include the itemized findings of all the clinical and radiographic examinations. Prepare entries that are clear and easily understood by all who read them and use them in continuing treatment. Additions to the records are made to show the progress of treatment and comparative observations throughout the series of appointments. After the periodontium has been brought to a state of health, a continuing care plan is outlined. At each succeeding appointment, new and comparative records and chartings are made.

C. Radiographic Charting The following may be charted from radiographs without the

presence of the patient: Missing or impacted teeth. Endodontic treatment. Overhanging margins of existing restorations. Proximal surface carious lesions. Other deviations from normal evident from the radiographs. Supplemental and confirmational observations and checks are made during the clinical examination with the patient. For example, when a carious lesion is suspected but not visible on the radiograph, clinical examination is required.

D. Study Models Study models are useful to record details related to occlusion (see Chapter 16).

PERIODONTAL RECORDS I. Clinical Observations of the Gingiva Clinical observations are recorded either on the chart form or in the patient progress notes during each patient visit. Examine gingiva and record findings before disclosing agent is used for biofilm score.

A. Describe Gingiva Color, size, position, shape, consistency, and surface texture; extent of bleeding when probed; and areas where there is minimal attached gingiva (Table 18-1 in Chapter 18).

B. Describe Distribution of Gingival Changes Localized or generalized; specify the areas with disease involvement as mild, moderate, or severe. Use tooth numbers to identify adjacent gingival tissue.

II.

Items to Be Charted Gingival line (margin) and mucogingival lines (junctions). Probing depths (except around dental implants). Recession. Areas of suspected mucogingival involvement. Furcation involvement. Abnormal frenal attachments. Mobility and fremitus of teeth.

III. Deposits Deposits can be recorded on forms such as the one illustrated in Figure 10-4 or on dental index forms, which are illustrated in Chapter

21.

A. Stains Extrinsic: Record type of stain, color, distribution; specific location by tooth number; whether slight, moderate, or heavy. Intrinsic: Record separately from extrinsic and identify by type when known.

B. Soft Deposits Food debris: Distribution and amount. Record location by teeth when the biofilm control instruction requires special emphasis on a particular area. Dental biofilm: Record direct observations with or without disclosing agent; include distribution and degree or amount. Record biofilm index or score as described in Chapter 21.

C. Calculus Record distribution and amount of supragingival and subgingival calculus separately for treatment planning purposes. Record subgingival calculus in periodontal pockets on the probing chart.

IV. Factors Related to Occlusion Clinical signs of trauma from occlusion are described in Chapter 16. The following list is for consideration with other records for the treatment planning.

A. Mobility of Teeth Record degree of mobility for each tooth (see Chapter 20). An

example of a method for recording mobility is shown in Figure 10-4.

B. Fremitus Fremitus determination is described in Chapter 20. Record the significance in relation to mobility.

C. Possible Food Impaction Areas Ask the patient where fibrous foods usually catch between the teeth. Use dental floss to identify inadequate contact areas that may contribute to food impaction. An example of one method for recording an open contact is shown by the vertical parallel lines between teeth numbered 21 and 22 in Figure 10-4.

D. Occlusion-Related Habits Observe for evidence of, and question patient concerning, such parafunctional habits as bruxism or clenching. Note wear patterns and facets on study cast. Note attrition.

V.

Radiographic Findings

Specific notes are made to correlate the radiographic findings with the clinical observations just listed. Details of radiographic findings in periodontal disease are described in Chapter 20. The following are recorded in relation to the specific teeth involved: Height of bone as related to the cementoenamel junction. Horizontal or angular shape of remaining interdental bone. Intact, broken, or missing crestal lamina dura. Furcation involvement. Widening of periodontal ligament space.

Overhanging fillings, large carious lesions, and other dental biofilm–retention factors.

VI. Severity of Periodontal Disease Determination of the severity of periodontal disease is based on analysis of gingival changes. Clinical assessment procedures include periodontal probing recordings, sites of bleeding on probing, clinical attachment level, tooth mobility and fremitus, and the radiographic findings. A dental or dental hygiene diagnosis statement can be developed using the disease classifications outlined in Chapter 19.

DENTAL RECORDS The patient’s permanent records include the itemized clinical and radiographic findings related to the teeth, periodontal descriptors along with subjective symptoms reported by the patient. Information about conditions related to the teeth is included in Chapter 16. Occlusion and mobility of teeth are documented during the periodontal examination because the causes of mobility are related to the patient’s periodontal status. After initial entries are recorded, new and comparative records and chartings are prepared at each periodic maintenance visit to show the progress of treatment. The need for meticulous examination and recording cannot be overemphasized. Finding and recording a carious lesion may mean saving a tooth for the patient’s lifetime. Inadvertent neglect of a tooth may lead eventually to a need for endodontic therapy or even extraction.

I.

The Anatomic Tooth Chart Form

Figure 10-4 is an example of a quadrant of dental charting using anatomic tooth drawings. When charting, clinical and radiographic findings are coordinated.

II.

Items to Be Charted

A list of basic items to be charted includes: Missing teeth. Existing restorations. Note restorative materials so that the care plan can designate selective polishing agents that will not harm the surfaces of restorations. Fixed and removable prostheses.

Dental sealants. Abrasion and erosion. Overhangs, open contacts, open margins, and other irregularities. Cavitated carious lesions and questionable demineralized noncavitated lesions. Inadequate contact areas and observed proximal surface roughness. Use dental floss. Fraying of dental floss as it is passed over a rough proximal surface may mean the defective margin of a restoration, a sharp cavity margin, or dental calculus. Pulp vitality. Record numbers in the permanent record. Chart forms sometimes include a specific place for the recording of such data. Tooth sensitivity. The patient may report hypersensitive areas. Record the tooth number and surface for reference during the treatment phase.

CARE PLAN RECORDS Along with a comprehensive dental treatment plan, a formal dental hygiene care plan that includes dental hygiene diagnostic statements and addresses the patient’s risk factors is included in the patient’s record. Chapter 23 provides more information about developing a written dental hygiene care plan. The initial care plan developed during an initial examination and copies of updated plans are included as part of the comprehensive, permanent patient record.

INFORMED CONSENT Documentation of informed consent obtained before initiating treatment is an essential component of each patient’s record. Information about obtaining and documenting informed consent is found in Chapter 23.

DOCUMENTATION OF PATIENT VISITS I. Purpose Documentation completed during or immediately following a patient visit, sometimes referred to as a progress note, is a chronologic history of treatment received by the patient during each appointment.

II.

Essentials of Good Progress Notes Dental hygiene progress notes document all aspects of the dental hygiene process of care and record all interactions between the patient and the practice.4 In addition to documentation about treatment rendered, essential components of a patient progress note are listed in Box 10-1.

BOX 10-1 Essential Components of a Patient Progress Note • • • • • • • • • • •

Purpose of the visit History review Assessment findings Description of treatment provided Drugs (including topical or local anesthetic) administered during treatment or prescribed by the dentist Self-care and other instructions provided Referrals, consultations with physician or dental specialist Laboratory tests ordered; results of laboratory tests Next visit appointments scheduled or recommended; appointment cancellations Details related to patient conversations, including telephone and e-mail Signature of clinician and date

Each entry in the patient record is dated and signed by the clinician. The use of unique abbreviations that are not easily understood by

others can cause clinical or legal problems. A selected list of standard abbreviations and symbols developed by the ADA is found in Appendix VII. Information that is never in the patient record includes: Speculation. Derogatory statements. Financial matters, professional disputes, legal actions, or riskmanagement protocol.

III. Systematic Documentation: The SOAP Approach A systematic, standardized approach to writing patient progress notes assures that no details are missing from the patient’s record. Many clinicians and most electronic patient record systems have developed their own systematic approach to recording patient information. Several formalized documentation systems have been developed to make sure documentation is comprehensive. One approach, which uses the acronym SOAP as a guide, is well accepted for use in the medical and dental professions and is recommended for use by the American Pediatric Dentistry Association.2,5,20 S = Subjective. O = Objective. A = Assessment (or analysis). P = Procedures (provided or planned). Table 10-1 further defines the components of the SOAP acronym and provides examples of factors that are included in patient progress notes. TABLE 10-1 • Components of SOAP Documentation and Examples of Factors to Include in Progress Notes DESCRIPTION

EXAMPLES

S

Subjective Characteristics stated by the patient or perceived by the clinician

Age and gender as stated by the patient Type of appointment scheduled Medical history findings provided by the patient Patient’s chief complaint Patient’s self-care regimen Social history

O

Objective Characteristics observed during examination

Head and neck examination findings Periodontal examination findings, bleeding, soft tissue condition Hard tissue examination findings; current cavitated carious lesions and demineralized noncavitated lesions Radiographic findings Comparison of current findings with previous findings

A

Assessment/Analysis Identification of problems or patient needs

Risk factors for oral disease Caries risk level Calculus level Current periodontal diagnosis/case type and status Periodontal disease risk level

P

Procedures Interventions performed or planned

Dental hygiene interventions performed Medicaments or local anesthesia applied and to which teeth Consult with dentist or other health providers Self-care instructions Goals for patient improvement Pending/planned dental hygiene interventions

Source: Jacks ME, Blue C, Murphy D. Short- and long-term effects of training on dental hygiene faculty members’ capacity to write SOAP notes. J Dent Educ. 2008;72(6):719-724.

Box 10-2 provides an example of documentation for a patient visit

written using the SOAP format.

BOX 10-2 Example of Patient Care Documentation: Using the SOAP Format S—Patient presents for reassessment of oral self-care 2 weeks following oral hygiene instruction. Patient states that he notices a reduction in biofilm following oral self-care instructions provided at the previous appointment. O—Today’s “Plaque-Free Score” = 89%; sulcus bleeding index (SBI) score = 2. A—“Plaque-Free Score” compared with previous score of 22%; SBI score compared with previous score of 5. Significant improvement in biofilm control noted in all areas except buccal surfaces of maxillary molars. P—Patient congratulated on areas of success. Additional instruction provided specifically related to biofilm removal on posterior buccal and proximal tooth surfaces. Patient observed while brushing and flossing maxillary molar areas using a mirror. Next visit: 3 months reevaluation. Signed: _____________________________, RDH Date: ___________________________________

Additional documentation examples, each related to a clinical situation and formatted using the SOAP approach, can be reviewed near the end of each chapter of this book.

IV. Risk Reduction and Legal Considerations Malpractice allegations can, unfortunately, occur against even a dental hygienist who routinely meets every standard when providing dental hygiene care. Because litigation can occur years after the patient visit when the details and even the patient may have been forgotten, excellent comprehensive documentation in each patient record entry is the best protection for the clinician against allegations of wrongdoing.

EVERYDAY ETHICS Mrs. Belvedere, the office manager in Dr. Grain’s office, has online access to all electronic patient records from her computer at home. With Dr. Grain’s permission, she often uses her home e-mail to contact patients and insurance companies regarding treatment plans, insurance coverage, or financial records. Patients receive HIPAA information about confidentiality and security of their information, but are not told that Mrs. Belvedere has access to their records at her home. Hanna, who is a new dental hygienist in the office, inadvertently finds out that sensitive patient information is being sent out from the same home email account that is used by both Mrs. Belvedere’s husband and her adult son. When Hanna approaches Dr. Grain about the potential breach in security of patient information, he seems unconcerned. Questions for Consideration 1. What dental hygiene core values (Chapter 1, Box 1-6) are being compromised if Hanna decides not to follow through to try to change the situation? 2. What standards of professional responsibility, identified in the American Dental Hygienists’ Association code of ethics, apply in this situation? 3. Which essential record keeping concepts, as described in Table III-1 (Section III Introduction), can support Hanna as she decides how to approach Mrs. Belvedere and Dr. Grain to make changes in the way patient records and information are handled?

Factors to Teach the Patient Interpretation of all recordings; meaning of all numbers used, such as for probing depths. The importance of making a complete study of the patient’s oral problems before beginning treatment. Advantages of cooperation and patience in furnishing information that will help dental personnel to interpret observations accurately so that the correct diagnosis and appropriate treatment plan can be made. Assurance that all information received is completely confidential.

ENHANCE YOUR UNDERSTANDING

ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Collier A. The management of risk, Part 3: recording your way out of trouble. Dent Update. 2014;41(4):338-340. 2. American Academy of Pediatric Dentistry, Council on Clinical Affairs. RecordKeeping. Chicago, IL: American Academy of Pediatric Dentistry; 2017. https://www.aapd.org/globalassets/media/policies_guidelines/bp_recordkeeping.pdf Accessed June 2, 2019. 3. Dym H. Risk management techniques for the general dentist and specialist. Dent Clin North Am. 2008;52(3):563-577, ix. 4. American Association of Dental Boards. Guidelines on the Dental Patient Record. Chicago, IL: American Association of Dental Boards; 2009:4-12. 5. Leeuw W. Maintaining proper dental records. Dent Assist. 2014;83(2):22-23, 26-30, 32-34. 6. American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene Practice. Chicago, IL: American Dental Hygienists’ Association; 2008:9. 7. Collier A. The management of risk. Part 2: good consent and communication. Dent Update. 2014;41(3):236-238, 241. 8. Wander P, Ireland RS. Dental photography in record keeping and litigation. Br Dent J. 2014;217(3):133-137. 9. Emmott L. Electronic dental records in dentistry. J Am Coll Dent. 2010;77(1):10-12. 10. Hudis S. Converting to electronic dental records. J Am Coll Dent. 2010;77(1):13-15. 11. U.S. Department of Health and Human Services. Health information privacy. http://www.hhs.gov/ocr/privacy/hipaa/administrative/index.html. Accessed September 16, 2014. 12. Office of the Privacy Commissioner of Canada. Privacy legislation in Canada. https://www.priv.gc.ca/resource/fs-fi/02_05_d_15_e.asp. Accessed September 16, 2014. 13. European Commission. Data Protection in the EU. http://ec.europa.eu/health/data_collection/data_protection/in_eu/index_en.htm. Accessed September 16, 2014. 14. Genge A. Responsibility without power: the dilemma of privacy compliance for Canadian dental hygienists. Oh Canada. 2016, 35-37. 15. U.S. Department of Health and Human Services. Health information privacy: summary of the HIPAA security rule. http://www.hhs.gov/ocr/privacy/hipaa/understanding/srsummary.html. Accessed September 16, 2014. 16. American Dental Association. System of Tooth Numbering and Radiograph Mounting. Chicago, IL: American Dental Association; 1968. 17. Fédération Dentaire Internationale. Two-digit system of designating teeth. Int

Dent J. 1971;21(1):104. 18. Türp JC, Alt KW. Designating teeth: the advantages of the FDI’s two-digit system. Quintessence Int. 1995;26(7):501-504. 19. Palmer C. Palmer’s dental notation. Dent Cosmos. 1891;33:194. 20. Rethman J. Clean up your records with SOAP. S (subjective findings), O (objective findings), A (assessment), P (plan). Dent Today. 1995;14(8):80.

SECTION

IV Assessment INTRODUCTION FOR SECTION IV Assessment in dental hygiene practice is the collection of pertinent facts, clinical data, and dental materials, such as radiographs and study models related to the patient’s oral health and overall health status. Initial assessment data are used: In planning care. As a guide during all treatment. After care has been provided, assessment data must be gathered again to evaluate the outcomes of the dental hygiene interventions. An efficiently conducted assessment and critical analysis of assessment findings: Provide a permanent, continuing, accurate, and complete record of the patient’s oral and general health. Help formulate dental hygiene diagnostic statements from which

a patient-oriented dental hygiene care plan can be prepared to include individualized preventive and treatment interventions. Guide instrumentation during dental hygiene treatment. Provide the basis to correlate dental hygiene care with the comprehensive dental treatment plan.

THE DENTAL HYGIENE PROCESS OF CARE Assessment is the first step in the dental hygiene process of care, as illustrated in Figure IV-1.

FIGURE IV-1 • The Dental Hygiene Process of Care.

Description

Critical analysis of the data identifies patient’s problems used to formulate the dental hygiene diagnosis and develop an individualized care plan. Comprehensive and accurate assessment data aid the dental hygienist in identifying: Health-related factors affecting the management of dental hygiene care. Risk factors for oral or systemic disease. Description of personal and culturally related habits affecting oral status. Health-related attitudes of the patient and the value placed on maintenance of oral health and the prevention of disease. Oral hygiene methods and communication strategies that meet the patient’s needs. Built into the sequence of clinical procedures is the initiation of steps for arresting oral disease processes and controlling etiologic factors, and prevent episodes of recurrence of oral disease.

ETHICAL APPLICATIONS An ethical theory, often based on norms or rules that ask which type of action is morally correct, offers a general approach to an ethical problem. A dental professional may consider the most favorable outcome of a particular situation, what guidelines to follow, or whether to rely on personal and professional virtues when making a judgment. A few of the many philosophical theories that apply to the delivery of dental care, with corresponding definitions, are described in Table IV-1. TABLE IV-1 • Some Ethical Theories THEORY

DEFINITION

APPLICATION EXAMPLES

Deontology

A study of rules by following The dental hygienist must the proper duties or obligations complete accurate and pertaining to one’s role. detailed documentation of the

services rendered for every patient. Rights theory

Focusing on what is rightfully due to both patients and providers.

A patient has the right to be informed of what treatment the dental hygienist will perform.

Teleology

Concerned with the consequences or usefulness of one’s actions, goal-driven.

A dental hygienist provides chairside education that meets the individual needs of the patient.

Utilitarianism

A form of teleology that says an action is good if it brings about the greatest pleasure for the greatest number of people.

Dental insurance companies set limits of reimbursement based on how a procedure is coded.

Virtue ethics

A moral theory that is concerned with the virtuous qualities of a professional’s character (compassion, empathy, honesty, respect, wisdom, patience).

Always being honest and offering the best care to every patient.

11 Medical, Dental, and Psychosocial Histories Lisa Welch, RDH, BS, MSDH, and Linda D. Boyd, RDH, RD, EdD

CHAPTER OUTLINE INTRODUCTION I. II.

Significance Purpose of the History

HISTORY PREPARATION I. II. III. IV.

Methods Record Forms Introduction to the Patient Limitations of a History

THE QUESTIONNAIRE I.

Types of Questions

II. III.

Advantages of a Questionnaire Disadvantages of a Questionnaire (If Used Alone without a Follow-up Interview)

THE INTERVIEW I. II. III. IV. V. VI.

Participants Setting Pointers for the Interview Interview Form Advantages of the Interview Disadvantages of the Interview

ITEMS INCLUDED IN THE HISTORY I. II. III.

Dental History Medical History Psychosocial History

APPLICATION OF PATIENT HISTORIES I. II. III.

Medical Consultation Radiation Prophylactic Premedication

PRETREATMENT ANTIBIOTIC PROPHYLAXIS I. II. III.

American Heart Association Guidelines Recommendations Based on Principles Medical Conditions That Require Antibiotic Premedication before Invasive Dental and Dental Hygiene Procedures IV. Recommended Antibiotic Protocol

AMERICAN SOCIETY OF ANESTHESIOLOGISTS DETERMINATION REVIEW AND UPDATE OF HISTORY DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to:

1. Relate and define key terms and concepts utilized in the creation of patient histories. 2. Explain the significance and purpose of accurate and complete patient medical, dental, and psychosocial histories. 3. Compare and contrast the different methods available for the compilation of patient histories and the advantages and disadvantages of each. 4. Discuss how the components of patient histories relate directly to the application of patient care.

INTRODUCTION For safe, evidence-based dental and dental hygiene care, a thorough patient health history is an essential part of the complete assessment. The history directs and guides steps to be taken in preparation for, during, and following appointments. Some important points about the patient history are listed here. The history is needed before oral examination procedures with periodontal probe and explorer are carried out. The use of instruments that would manipulate the soft tissue around the teeth is contraindicated until it has been determined that antibiotic premedication is not indicated. When a question exists about the medical history as described by the patient, or when an unusual or abnormal condition is observed, consultation with the patient’s primary care provider or referral for examination of the patient who does not have a primary care provider is required. Even emergency treatment must be postponed or kept to a minimum until the patient’s medical status is determined.

I.

Significance

The significance of taking a complete and accurate patient history cannot be overemphasized for the following reasons: Oral conditions reflect the general health of the patient; dental procedures may complicate or be complicated by existing pathologic or physiologic conditions elsewhere in the body. General health factors influence response to treatment, such as tissue healing, and thereby influence the outcomes that may be expected from oral care. The state of the patient’s health is constantly changing. Therefore, the history must be updated continually.

II.

Purpose of the History

Carefully prepared medical, dental, and psychosocial histories are used in comprehensive patient care to: Provide information pertinent to the etiology and diagnosis of oral conditions and the total patient care plan. Reveal conditions that necessitate precautions, modifications, or adaptations during appointments to ensure dental and dental hygiene procedures will not harm the patient and to prevent emergency situations. Aid in the identification of possible unrecognized conditions for which the patient will be referred for further diagnosis and treatment. Permit appraisal of the general health and nutritional status, which, in turn, contributes to the prognosis of success in patient care and instruction. Give insight into emotional and psychological factors, attitudes, and prejudices that may affect present appointments as well as continuing care. Document records for reference and comparison over a series of appointments for periodic follow-up. Furnish evidence in legal matters if questions arise.1 Identify cultural beliefs and practices that affect risk for oral disease. Determine ethnic/racial influences on risk factors for oral disease.

HISTORY PREPARATION The general methods in current use for obtaining a health history are the interview, the questionnaire (which may be paper or electronic), or a combination of the two. There are several methods for obtaining the history.

I.

Methods Preappointment information Basic information obtained before the initial assessment appointment can save time and facilitate the process. A brief telephone screening interview or downloadable questionnaire can help determine potential medical problems, need for premedication or consultation with the patient’s primary care provider, and identification of medically compromised or physically challenged patients for whom modifications in routine care may be needed. Self-history Because a self-history can be prepared at home, the history form can be provided online for the patient to download and complete, sent via e-mail, or mailed to the patient in advance of the first appointment. This kind of form might include some items that can be checked or circled, with space to allow the patient to provide additional information. Complete history A complete patient history is gathered at the initial visit and is a combination of interview and questionnaire. At successive appointments, the complete history is reviewed with the patient and changes are considered when planning patient care.

II.

Record Forms

Basic history forms Forms are available commercially or from the American Dental Association (ADA) for a fee, but many dentists and dental hygienists prefer to develop their own and have a form printed to their specifications. ADA and other organizations have basic history forms translated into a variety of languages. Many are available on the Internet. An adequate basic history form will: Enable the recording of important details in a logical sequence. Permit quick identification of special needs of a patient when the history is reviewed before each appointment. Allow ample space whenever possible to record the patient’s own words in the interview method or for self-expression by the patient on a questionnaire. Have space for notes concerning attitudes and knowledge as stated or displayed by the patient during the history-taking or other later appointments. Be provided, when possible, in the patient’s primary or dominant language. Supplementary forms A secondary, more detailed questionnaire can be used to determine additional information for specialized topics. The basic questionnaire reveals whether a topic applies to an individual. If the answer is positive, additional information is requested. Example: Simple questions on the basic questionnaire indicate the use of tobacco products. Completion of another questionnaire provides details about the type of tobacco used and frequency of use. Chapter 32 illustrates a tobacco use assessment form.

III. Introduction to the Patient Patient education about why the information requested in the history is essential before treatment can be undertaken.

Convey the idea that oral health and general health are interrelated, without creating undue alarm concerning potential ill effects or harmful sequelae from required treatment. To build rapport, allow children to participate in their history preparation, but most of the information will need to be supplied by a parent or legal guardian. The signature of the responsible adult is required on the record.

IV. Limitations of a History Many patients cannot or will not provide complete or, in certain cases, correct information when answering medical or dental history questions. Reasons for inaccuracy or incompleteness of information can include: Problems related to the method of obtaining the histories, how the questions are worded, or an inadvertent lack of neutrality in the attitude of the person gathering the history. Difficulty in comprehending a self-administered test because the patient cannot read or has a language barrier. The location in which the questionnaire is completed, such as a crowded reception area without sufficient privacy. The patient’s limited knowledge and inability to understand the relationship between certain diseases or conditions and dental treatment. Information may seem irrelevant, so it is withheld. Reluctance to discuss a health condition that may be embarrassing, such as history of infectious or communicable disease. The patient may fear refusal of treatment.

THE QUESTIONNAIRE Positive findings on a questionnaire are explained further in a personal interview. A questionnaire by itself cannot be expected to satisfy the overall purposes of the history, but it can provide some basic personal history, dental history, and factual information in the medical history.

I.

Types of Questions

Figures 11-1 and 11-2 provide useful examples of questions necessary for a thorough patient evaluation.

FIGURE 11-1 • Medical History: General Medical/Dental History.

FIGURE 11-2 • Medical History: Medical Conditions.

System oriented Direct questions to determine if the patient has had a disease. Often the questions are organized as a review of systems, for example, the digestive system, respiratory system, or urinary

system. The questions may contain references to specific organs, for example, the stomach, lungs, or kidneys. Disease oriented A typical set of questions may start with “Do you have, or have you had, any of the following diseases or problems?” A listing under that question contains items such as diabetes, asthma, or hypertension arranged alphabetically or grouped by systems or body organs. Follow-up questions can determine dates of illness, severity, and outcome. Symptom oriented In the absence of previous or current disease states, questions may lead to a suspicion of a condition, which, in turn, can provide an opportunity to recommend and encourage the patient to schedule an examination by a primary care provider. Examples of the symptom-oriented questions are “Are you thirsty much of the time?” “Does your mouth frequently become dry?” or “Do you have to urinate more than six times a day?” Positive answers could lead to tests for diabetes detection. Culture oriented Identify ethnic or gender-related increase in risk for systematic or oral disease. Determine traditional, culturally related health beliefs that may influence dental hygiene interventions or recommendations. Identify herbal preparations or other traditional medications used by the patient that may affect oral care or risk for disease.

II.

Advantages of a Questionnaire Broad in scope; useful during the interview to identify positive answers needing additional clarification. Time saving. Consistent; all selected questions are included, and none is omitted because of time or other factors.

Patient has time to think over the answers—not under pressure from the interviewer. Patient may write information that might not be expressed directly in an interview. Legal aspects of a written or an electronic record with the patient’s signature.

III. Disadvantages of a Questionnaire (If Used Alone without a Follow-Up Interview) Impersonal; no opportunity to develop rapport. Inflexible; no provision for additional questioning in areas of specific importance to an individual patient.

THE INTERVIEW In long-range planning for a patient’s health, much more is involved than asking questions and receiving answers. The rapport established during the interview contributes to the continued cooperation of the patient.

I.

Participants The interviewer is alone with the patient or parent of the child patient and, if necessary, a qualified professional translator/interpreter. The history is never to be taken in a reception area when other patients are present.

II.

Setting A consultation room or office is preferred; if possible, move the patient away from the atmosphere of the treatment room, where thoughts may be on the services to be provided. The treatment room may be the only available place with privacy. If the treatment room is used for a patient interview: Seat patient comfortably in upright position. Turn off running water and dental light, and close the door (if possible). Sit on clinician’s stool to be at eye level and face-to-face with the patient.

III. Pointers for the Interview Interviewing involves communication between individuals. Communication implies the transmission or interchange of facts, attitudes, opinions, or thoughts through words, gestures, or other means.

Communication through tactful but direct questioning can elicit necessary information from the patient. Frequently, the patient is unaware of a health problem. The most effective attitude for the clinician to portray is one of friendly understanding, reassurance, and acceptance. Genuine interest and willingness to listen when a patient wishes to describe symptoms, complaints, or current health practices not only aids in establishing the rapport needed but also frequently provides insight into the patient’s real attitudes and prejudices. By asking simple questions at first and more personal questions later after rapport has developed, the patient will be more relaxed and truthful in answering. Skill is required because tact, ingenuity, judgment, and cultural sensitivity are taxed to the fullest in the attempt to obtain accurate and complete information from the patient. The culturally sensitive dental hygienist will be aware of nonverbal communication issues when interviewing a patient from a different culture (see in Chapter 3).

IV. Interview Form The interviewer may use a structured form with places to check and fill in. Another method is to record on blank sheets from questions created from a guide or list of topics. Either type of form can involve reference to the positive or negative answers on a previously completed questionnaire. Familiarity with the items on the history permits the interviewer to be direct and informal without reading from a fixed list of topics, a method that may lack the personal touch necessary to gain the patient’s confidence. When appropriate, the patient’s own words are recorded.

V.

Advantages of the Interview

Personal contact contributes to development of rapport for future appointments. Flexibility for individual needs; details obtained can be adapted for supplementary questioning.

VI. Disadvantages of the Interview Time-consuming when not prefaced with questionnaire. Unless a list is consulted, items of importance may be omitted. Patient may be embarrassed to talk about personal conditions and may hold back significant information.

ITEMS INCLUDED IN THE HISTORY Information obtained by means of the history is directly related to how the goals for patient care are established and will be accomplished. In Tables 11-1 through 11-3, items are listed with possible medications and other treatments the patient may have or has had, along with suggested considerations for appointment procedures. TABLE 11-1 • Items for the Dental History ITEMS TO RECORD IN THE HISTORY

RECORD NOTES

CONSIDERATIONS FOR APPOINTMENT PROCEDURES

Reason for present appointment

Chief complaint in patient’s own words Pain or discomfort Onset, symptoms, duration of an acute condition

Need for immediate treatment Attitude toward dentistry and preventive care

Previous dental appointments

Date of last treatment Services performed Regularity

Patient knowledge concerning regular dental care Cooperation anticipated

Anesthetics used

Local, general Adverse reactions

Choice of anesthetic

Radiation history

Type, number, dates of dental and medical radiographs Therapeutic radiation Availability of dental radiographs from previous dentist Amount of exposure considered with exposure for medical purposes

Amount of exposure; limitations Educate patient about value of radiographs in diagnosis

Family dental history

Parental tooth loss or maintenance

Attitude toward saving teeth and preventive

dentistry Culturally related oral health beliefs and practices Previous dental treatment

Type of treatment; frequency of maintenance appointments

Value for dental care Previous familiarity with role of dental hygienist

Periodontal

History of periodontal disease and treatment

Attitude toward oral selfcare and disease control

Orthodontic

Age during treatment; completion date Previous problem Habit correction Compliance with wearing appliances

For current treatment, consultation with orthodontist

Endodontic

Dates, etiology

Determine if monitoring continues

Prosthodontic

Types of prostheses

Care of prostheses and abutment teeth

Other dental treatment

Extent of restorations Tooth loss Implants

Understanding prevention

Injuries to face or teeth

Causes and extent Fractured teeth or jaws

Limitation of opening Special care during healing

Temporomandibular joint

History of injury, discomfort, disease, dislocation Previous treatment

Effect on opening; accessibility during instrumentation

Oral habits

Clenching, bruxism Mouth breathing Biting objects; fingernails, pipe stem, thread, other Cheek or lip biting Patient awareness of habits

Stress level of patient Instruction relative to effects of habits

Piercing

Types and locations of

Evaluate for oral health

piercings Date for piercing History of infection related to piercing

changes related to piercing Educate patient on any risks the piercings may pose

Fluorides

Systemic, topical, dates Residence during tooth development years Amount of fluoride in drinking water

Current preventive procedures and need for reevaluation

Biofilm control procedures

Toothbrushing: current procedures, type of brush (manual or powered), texture of filaments, frequency of use, age of brush; frequency of having a new brush Dentifrice name how selected; reason Additional cleansing devices and frequency of use Mouthrinse or other agents: frequency, purpose Source of instruction in care of oral cavity

Ask about patient oral selfcare routine Explore challenges encountered in changing habits Adapt education to patient needs, abilities, preferences, and disease state Educate about risk factors for oral disease For parents/caregivers of young children, educate on need to perform and supervise oral care

TABLE 11-3 • Items for the Psychosocial History

In specialized practices, objectives may require increased emphasis on certain aspects of the history. The age group most frequently served will influence the focus of the history. Example: parental history and prenatal and postnatal information may take on particular significance for the treatment of a small child; in a pediatric dentistry practice, a special form could be developed to include all essential items. The American Academy of Pediatric Dentistry (www.aapd.org) also has a form that can be used, which includes medical conditions, medications, dental history, supplemental questions for infants/toddlers related to dietary habits, and supplemental questions for adolescents.

Insight and awareness shown while preparing the patient history depend on background knowledge of the manifestations of systemic diseases and the medications for various conditions. Objectives for the items to include in the various parts of the history are listed here.

I.

Dental History

The dental history (Table 11-1; sample form Figure 11-1) contributes to the care provider’s knowledge of: The immediate problem, chief complaint, cause of present pain, or discomfort in the oral cavity. Risk assessment forms, such as the American Academy of Pediatric Dentistry Caries Risk Assessment Tool and the ADA Caries Risk Assessment forms, provide the information needed for planning individualized dental hygiene interventions based on the patient’s risk factors. Previous dental hygiene and dental care, including preventive care, periodontal treatments, and the extent of restorative and prosthetic replacement, as well as any adverse effects. Personal daily oral self-care habits.

II.

Medical History

Objectives of the medical history (Table 11-2) are to determine whether the patient has or has had any conditions. Samples of forms for the medical conditions and medications in Figures 11-2 and 11-3. The following are categories to be assessed in a medical history:

FIGURE 11-3 • Medical History: Medications.

TABLE 11-2 • Items for the Medical History

Description Personal information (Figure 11-1)

Examples: age; address and contact information; dental insurance; physician’s name and contact information; height/weight. Conditions that may complicate certain kinds of dental and dental hygiene treatment Examples: Lowered resistance to infection; uncontrolled hypertension; uncontrolled diabetes; or systemic disease that requires treatment before stressful dental procedures, particularly surgery, can be carried out. Conditions or diseases that may require special precautions or premedication before treatment Examples: Increased osteonecrosis risk related to previous treatment with bisphosphonates; or antibiotic coverage for the patient at risk for infective endocarditis (IE). Conditions under treatment by a physician that require medicating drugs that may influence or contraindicate certain procedures Examples: Anticoagulant therapy requires consultation with physician; antihypertensive drugs may alter the amount and/or choice of local anesthetic used. Gender or ethnic/racial influences that increase risk for systemic and oral disease Example: American Indians and African Americans have increased risk for diabetes and a related increased risk for periodontal disease. Allergic or adverse reactions Examples: Latex hypersensitivity; medication or material for which there was a previous adverse reaction. Diseases and drugs with manifestations in the mouth Examples: Hematologic disorders; phenytoin-induced gingival overgrowth; infectious diseases such as herpesvirus. Communicable diseases Examples: Active tuberculosis; viral hepatitis; herpes. Physiologic state of the patient Examples: Pregnancy and birth control pills.

III. Psychosocial History

The psychosocial history (Table 11-3) gathers information about many aspect of the patient’s life that may impact their oral and overall health in the following ways2: Alter health behaviors such as smoking, drug use, and dietary intake. These factors may also impact resistance to disease, that is, stress. Areas to be assessed include (sample in Figure 11-4), but are not limited to:

FIGURE 11-4 • Medical History: Psychosocial.

Living situation and social support. Education. Employment situation. Health literacy levels that may impact communication. Beliefs and attitudes about health, illness, and oral health. Culturally related health practices that may impact the patient’s

oral health.

APPLICATION OF PATIENT HISTORIES Information from the histories influences all aspects of total patient care and dental hygiene care planning. Immediate evaluation of the histories is necessary before proceeding to complete the assessment. Together with information from all other parts of the diagnostic workup, the patient histories are essential for the preparation of the dental hygiene care plan.

I.

Medical Consultation

Dentist and primary care provider need to consult relative to the patient’s current therapy and medications or to elements of the patient’s past health status that could influence dental treatment needs.3 Telephone or personal contact Immediate consultation may be needed so that urgent treatment may proceed. Follow-up in writing by electronic communication, fax, or mailed hard copy to provide a legal record of the advice or decision to avoid a misunderstanding. Written request A formal letter is the preferred procedure for medical consultation. This may be e-mailed or faxed to the physician. A prepared form can be developed with spaces for filling in the specific questions and with space in the lower half for the primary care provider to complete confidential information from the patient’s medical record or to provide the necessary recommendations. Referrals Referral for medical examination when signs of a possible disease condition are present. Referral for laboratory tests may be necessary when recent test

results are not available or follow-up tests are needed.

II.

Radiation When a patient is receiving radiation therapy or has had recent radiation for other purposes, a conference with the primary care provider or oncologist is recommended regarding the need for dental radiographs. It is the dental practitioner’s responsibility to utilize all available clinical, assessment, and health history information when contemplating the necessity of diagnostic radiographs in order to optimize care while minimizing radiation exposure.4

III. Prophylactic Premedication Selected patients at risk for IE receive antibiotic premedication before any oral tissue manipulation that could create a bacteremia. The patient history and the information in Box 11-1 are reviewed to identify a patient needing premedication in accordance with the recommendations of the American Heart Association (AHA) guidelines.

BOX 11-1 Medical Conditions That Require Antibiotic Premedication before Dental and Dental Hygiene Treatment Antibiotic prophylaxis with dental procedures is recommended only for patients with cardiac conditions associated with the highest risk of adverse outcomes from endocarditis, including: • Prosthetic cardiac valve. • Previous endocarditis. • Congenital heart disease only in the following categories: ♦ Unrepaired cyanotic congenital heart disease, including those with palliative shunts and conduits. ♦ Completely repaired congenital heart disease with prosthetic material or

device, whether placed by surgery or catheter intervention, during the first 6 months after the procedure. (Prophylaxis is recommended because endothelialization of prosthetic material occurs within 6 months of the procedure.) ♦ Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization). • Cardiac transplantation recipients with cardiac valvular disease. Source: Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736-1754.

Routine use of antibiotic premedication is never indicated. Overuse of antibiotics can induce microbial resistance and, rarely, allergy or toxicity to the drug used.5 The subgingival use of instruments (e.g., periodontal probe or curet) is avoided until the level of risk has been assessed, the condition has been discussed with the patient’s primary care provider, and the prescription has been obtained, and taken as directed. The oral antibiotic prescription is required 1 hour before instrumentation begins to assure adequate blood concentration during and immediately following instrumentation. At-risk patients already taking an antibiotic for other health conditions may require additional antibiotic prophylaxis before dental and dental hygiene instrumentation. A different class of antibiotic is prescribed rather than to increase the dose of the current drug being taken.5

PRETREATMENT ANTIBIOTIC PROPHYLAXIS I. AHA Guidelines A. Brief Historical Review The AHA has made recommendations for the prevention of IE for many years. The first document was published in 1955. There have been nine revisions since then including the latest one published in Circulation 2007 reviewed and updated on the AHA website in 2014.6,7

B. Rationale for 2007 Revision and 2014 Review6,7 Former guidelines were based more on expert opinion or individual case studies; the 2007 guidelines, 2014 review, attempted to be more evidence based. Frequent exposure to random bacteremias resulting from daily activities are more likely to cause IE than are treatment procedures performed at dental and dental hygiene appointments. Antibiotic prophylaxis may prevent a very small number of cases of IE, if any, in patients receiving a dental or dental hygiene treatment procedure. There are risks of antibiotic-associated adverse events that may exceed the benefit, if any, of antibiotic therapy. Maintenance of optimal oral health with daily biofilm removal may reduce the incidence of IE due to bacteremias caused by daily activities. Such prevention can be more significant than prophylactic antibiotics given occasionally for a dental or dental hygiene invasive treatment procedure. Literature reviews found no evidence-based method to decide exactly which procedures require prophylactic antibiotic premedication and which do not need it. Other factors limiting conduct of controlled research trials are: Low incidence of IE.

Wide variety of types of cardiac diseases. Wide variety of invasive dental procedures. Incidents when antibiotic premedication did not prevent IE following a dental invasive procedure.

II.

Recommendations Based on Principles5-7 Only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective. IE prophylaxis for dental procedures is recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcomes from IE. For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue, the periapical region of teeth, or perforation of the oral mucosa. Patients requiring antibiotic prophylaxis may carry a wallet card documenting their need for premedication. Antibiotic prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of IE.

III. Medical Conditions That Require Antibiotic Premedication before Invasive Dental and Dental Hygiene Procedures Box 11-2 lists the cardiac conditions for which antibiotic prophylaxis is recommended.

BOX 11-2 Dental and Dental Hygiene Procedures for Which Endocarditis Prophylaxis Is Recommended for Patients in Box 11-1

All dental and dental hygiene procedures that involve: • Manipulation of gingival tissue. • The periapical region of teeth. • Perforation of the oral mucosa need antibiotic premedication (Table 11-4). TABLE 11-4 • Prophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures

aTotal

child dose never exceeds adult dose. are not prescribed for individuals with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins or ampicillin. IM, intramuscularly; IV, intravenously. Source: Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O’Gara PT, American College of Cardiology/American Heart Association Task Force, et al. ACC/AHA 2008 guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008 Aug 19;118(8):887-896. bCephalosporins

The following procedures and events do not need prophylaxis: • Routine anesthetic injections through noninfected tissue. • Taking dental radiographs. • Placement of removable prosthodontic or orthodontic appliances. • Adjustment of orthodontic appliances. • Placement of orthodontic brackets. • Shedding of primary teeth. • Bleeding from trauma to the lips or oral mucosa. Source: Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective

endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736-1754.

Box 11-2 lists the following: Dental and dental hygiene procedures for which endocarditis prophylaxis is recommended. Procedures for which prophylaxis is not needed. A codeveloped evidence-based guideline for the prevention of orthopedic implant infection in patients undergoing dental procedures was released in 2012 by the ADA and the American Academy of Orthopaedic Surgeons.8 A 2014 systematic review found no direct evidence that dental procedures cause prosthetic joint implant infections.9 Evidencebased clinical practice guidelines for dental practitioners recommend against the routine use of antibiotics prior to dental procedures to prevent prosthetic joint infection9; however, premedication may be considered in the case of the high-risk medically complex or immunocompromised patient.10 Consultation with the patient’s primary care provider regarding the need for antibiotic prophylaxis for patients with prosthetic joints is recommended.9,10

IV. Recommended Antibiotic Protocol Table 11-4 provides the recommended antibiotic prescriptions for prevention of cardiac endocarditis.

AMERICAN SOCIETY OF ANESTHESIOLOGISTS DETERMINATION With the completion of the patient histories, an overall estimate of medical risk of a patient can be made. American Society of Anesthesiologists (ASA) Physical Status Classification System11 describes six categories of physical status and provides examples of adaptations necessary for providing dental hygiene care for a patient in each category. ASA I: a patient without apparent systemic disease: a normal healthy patient. ASA II: a patient with mild systemic disease. ASA III: a patient with severe systemic disease that limits activity but is not incapacitating. ASA IV: a patient with an incapacitating systemic disease that is a constant threat to life. ASA V: a moribund patient not expected to survive 24 hours with or without care.

REVIEW AND UPDATE OF HISTORY Updating the patient’s health history at each appointment is essential. Changes in health status revealed by interim medical examinations or evidenced by reported illness or hospitalizations are recorded and considered during continuing treatment. Post a wall plaque that states Please Advise Us of Any Change in Your Medical History Since Your Last Visit in an appropriate place in a dental office or clinic to remind patients about the importance of updating information at each appointment. Following a review of the previously recorded history, questions can be directed to the patient to compare the present condition with the previous one and to determine at least the following: Interim illnesses; changes in health. Visits to physician; reasons and results. Laboratory tests performed and the results; blood, urine, or other analyses. Current medications. Changes in the oral soft tissues and the teeth observed by the patient.

DOCUMENTATION Date all records. All hard copy permanent records are written in ink. Electronic patient records are stored on a secure server on password-protected computers, with only office staff having access to the computers and passwords. All electronic charting documentation are signed electronically and saved in such a way that falsifications to patient records cannot be made. The patient signature must be recorded upon completion of the health history to verify the information.1,3 The completed history for a minor is signed by a parent or guardian. A signature is also needed on the informed consent form. Signatures may be recorded or electronically dependent on the method in which the information is collected. All information obtained for a patient history should be maintained with the strictest privacy. For patients with special health problems that require premedication, coded tab systems on paper charts or pop-up alerts in electronic records should be used to notify all dental personnel to check the medical history before each appointment. Evaluate the usefulness of items on the patient history form periodically, and plan for revision as scientific evidence reveals new information. Progress notes document regular update of forms completed and changes in personal, dental, or health history since last appointment. Box 11-3 provides an example of a progress note related to completion of personal, dental, and medical histories.

BOX 11-3 Example Documentation: Updating a Patient’s Medical History S—Forty-five-year-old patient presents for routine 6-month maintenance

appointment. She is new to the office and reports she has always taken penicillin prior to her “cleaning” appointments. She completed and signed a new health history form. Her medical history indicates she has a heart murmur, and she reports this is why she has been told to take penicillin before appointments. She became quite concerned about not premedicating with antibiotics. O—The recommendations for antibiotic prophylaxis were reviewed with the patient and a consult with the primary care provider determined she was not a candidate for premedication. A full series of radiographs was taken and the clinical examination was completed. No dental caries noted. Pocket depths in the maxillary molar area range from 5 to 6 mm with bleeding on probing. No suppuration present. No mobility. Furcation involvement Grade II on ML and DL of #2, 3, 14, and 15. Plaque score 15%, primarily in maxillary molar areas. A—Caries risk: low; periodontal risk: high; oral cancer risk: low. On the basis of the comprehensive periodontal examination and radiographic findings, she has localized Stage II, Grade A periodontitis. P—Oral self-care review of interdental brush for maxillary molar areas. Fullmouth debridement with localized scaling and periodontal debridement on #2, 3, 14, and 15. One carpule: 2% lidocaine with 1:100,000 epinephrine for a posterior superior alveolar upper right and upper left. Selective polishing: 5% sodium fluoride varnish was applied. A 3-month periodontal maintenance interval was recommended. Signed: ______________________________, RDH Date: _____________________________________

EVERYDAY ETHICS Chris, the dental hygienist, was waiting for her new patient at 1:00 PM. All she knew was that Irina was 70 years old, from Russia, and could speak and understand English fairly well. Chris heard the front door to the office open and went out to greet her patient. The woman was on the arm of a teenage boy who quickly helped Irina to a chair and turned to leave after saying to Chris (pointing to the patient) “Just back from hospital. They fixed her heart and told her to get her teeth cleaned to keep her healthy. Car not parked.” Then to his grandmother, “Back in an hour,” before he rushed out. Chris ushered Irina into the treatment room and helped her into the chair, then started the history questions with “What were you in the hospital for?” Irina grabs Chris’s arm and firmly requests, “Want teeth cleaned.” Chris attempts to explain why she is asking the questions about her health. Then she asks for her physician’s name and permission to call the physician to obtain the information.

Irina points to her heart, but just becomes more agitated and keeps repeating “Want teeth cleaned” and refuses to give approval to call her doctor. Chris is alarmed at the thought of providing care for this patient without complete information about her health history, but hates to waste the scheduled appointment time, given how difficult it is for patients to get an appointment. Questions for Consideration 1. Professionally and ethically, what are a dental hygienist’s responsibilities to take time to help a patient understand the seriousness of an illness and the need for a complete personal, dental, and medical history before receiving dental treatment? 2. Provide an example of how each of the ethical theories (Table IV-1, Section IV Introduction) might apply as Chris determines how to resolve this issue? 3. Which of the dental hygiene core values (Chapter 1, Box 1-6) apply as Chris determines what action to take?

Factors to Teach the Patient The need for obtaining the personal, medical, and dental history before performance of dental and dental hygiene procedures and the need for keeping the histories up to date. The assurance that recorded histories are kept in strict professional confidence. The relationship between oral health and general physical health. The interrelationship of medical and dental care. All patients who require antibiotic premedication need special attention paid to (1) the importance of preventive dentistry, (2) the imperative need for regular dental care, and (3) the necessity for taking the prescribed prescription 1 hour before the appointment starts.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition

INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References

1. Collier A. The management of risk. Part 3: recording your way out of trouble. Dent Update. 2014;41(4):338-340. 2. Kye SY, Park K. Psychosocial factors and health behavior among Korean adults: a cross-sectional study. Asian Pac J Cancer Prev. 2012;13(1):49-56. 3. Chiodo GT, Rosenstein DI. Consultation between dentists and physicians. Gen Dent. 1984;32(1):19-22. 4. U.S. Department of Health and Human Services, U.S. Food and Drug Administration. ADA/FDA Guide to patient selection for dental radiographs. https://www.fda.gov/RadiationEmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalXRays/ucm116503.htm. Accessed August 30, 2017. 5. American Academy of Pediatric Dentistry. Guideline on antibiotic prophylaxis for dental patients at risk for infection (Originating Committee Clinical Affairs, Committee Review Council, Council on Clinical Affairs Adopted 1990 Revised 1991, 1997, 1999, 2002, 2005, 2007, 2008, 2011, 2014). http://www.aapd.org/media/Policies_Guidelines/G_AntibioticProphylaxis.pdf. Accessed August 30, 2017. 6. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736-1754. 7. American Heart Association. Infective endocarditis. http://www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/TheImpactofCongenita Accessed August 30, 2017. 8. American Academy of Orthopaedic Surgeons, American Dental Association Clinical Practice Guideline Unit. Prevention of orthopaedic implant infection in patients undergoing dental procedures evidence-based guideline and evidence report. http://www.ada.org/~/media/ADA/Member%20Center/FIles/PUDP_guideline.ashx Accessed August 30, 2017. 9. Sollecito T, Abt E, Lockhart P, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: evidence-based clinical practice guideline for dental practitioners—a report of the American Dental Association Council on Scientific Affairs. JADA. 2015;146(1):11-16. 10. Elliot A, Hellstein JW, Lockhart PB, et al. American Dental Association guidance for utilizing appropriate use criteria in the management of the care of patients with orthopedic implants undergoing dental procedures. JADA. 2017;148(2):57-59.

American Society of Anesthesiologists. New classification of physical status. 11. Anesthesiology. 1963;24(1):111.

12 Vital Signs Lisa B. Johnson, RDH, MSDH

CHAPTER OUTLINE INTRODUCTION I. II.

Patient Preparation and Instruction Dental Hygiene Care Planning

BODY TEMPERATURE I. II. III. IV.

Indications for Taking the Temperature Maintenance of Body Temperature Methods of Determining Temperature Care of Patient with Temperature Elevation

PULSE I. II.

Maintenance of Normal Pulse Procedure for Determining Pulse Rate

RESPIRATION I. II.

Maintenance of Normal Respirations Procedures for Observing Respirations

BLOOD PRESSURE I. II. III. IV. V. VI.

Components of Blood Pressure Factors That Influence Blood Pressure Equipment for Determining Blood Pressure Procedure for Determining Blood Pressure Hypertension (High Blood Pressure) Blood Pressure Follow-up Criteria

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. List and explain the vital signs and why proper assessment is key to identifying the patient’s health status. 2. Demonstrate and explain the correct procedures for assessing the vital signs: temperature, respiration, radial pulse, and blood pressure. 3. Recognize and explain factors that may affect temperature, respiration, pulse, and blood pressure. 4. Describe and evaluate equipment used for assessing temperature and blood pressure. 5. Recognize normal vital signs across varied age groups.

INTRODUCTION Determination of four vital signs—body temperature, pulse, respiratory rates, and blood pressure—is considered standard procedure in patient care. Table 12-1 summarizes the normal values of the four basic vital signs for infant through older adults. TABLE 12-1 • Resting Vital Sign Ranges Infant through Older Adult10,14,15

Description Children and adolescent blood pressure recommendations are based on recently revised guidelines from the USDHHS 4th Report on Diagnosis, Evaluation, and Treatment of Blood Pressure in Children and Adolescents.

I.

Patient Preparation and Instruction Seat patient in upright position, at eye level for instruction. Explain the vital signs and obtain consent. Explain how vital signs can affect dental hygiene and dental treatment. During the process, explain each step as needed by the individual patient (Box 12-1).

BOX 12-1 Example Documentation: Vital Signs

S—Mrs. Patel apologized for arriving 5 minutes late and stated she had no concerns at the start of her dental appointment. O—Vital signs at 9:00 AM; pulse 64; respirations 12; blood pressure (right arm) 190/88 seated. A—Hypertension stage 3 range. P—Advised Mrs. Patel her blood pressure is measuring at a high and an unsafe level for treatment. Blood pressure remained elevated when reassessed 10 minutes later. Discussed hypertension range with dentist and referred patient to primary care provider for urgent follow-up. Delay maintenance appointment until hypertension under control. Follow-up later today by phone. Signed: _____________________________, RDH Date: ___________________________________

II.

Dental Hygiene Care Planning Recording vital signs contributes to the proper systemic evaluation of a patient in conjunction with the complete medical history. Dental hygiene care planning and appointment sequencing are directly influenced by the findings. When vital signs are not within normal, advise the patient check with the primary care provider. Referral for medical evaluation and treatment is indicated.

BODY TEMPERATURE While preparing the patient history and making the extraoral and intraoral examinations, the need for taking the temperature may become apparent, or the dentist may have requested the procedure in conjunction with current oral disease.

I.

Indications for Taking the Temperature For the new patient’s initial permanent record along with all vital signs. For complete examination during a continuing care appointment. When oral infection is known to be present. Necrotizing ulcerative gingivitis or periodontitis. Apical or periodontal abscess. Acute pericoronitis. With other vital signs, prior to administration of local anesthetic. At any appointment when the patient reports illness or there is a suspected infection. Protection of the health of the healthcare personnel and patients or families who may be exposed secondarily. Special significance during epidemics when community exposures are at risk. For patient’s referral for medical care when indicated.

II.

Maintenance of Body Temperature Normal Adults: The normal average temperature is 98.6°F (37°C). The normal range is from 97 to 99°F (36.1–37.2°C). Older adults: Over 70 years of age, the average temperature is slightly lower (96.8°F, 36°C). Children: There is no appreciable difference between boys and girls. Average temperatures are as follows:

First year—99.1°F (37.3°C). Fourth year—99.4°F (37.5°C). Fifth year—98.6°F (37°C). Twelfth year—98°F (36.7°C). Temperature variations Fever (pyrexia): values over 99.5°F (37.5°C). Hyperthermia: values over 104°F (40°C). Hypothermia: values below 96°F (35.5°C). Factors that alter body temperature Time of day: highest in late afternoon and early evening; lowest during sleep and early morning. Temporary increase: exercise, hot drinks, smoking, or application of external heat. Pathologic states: infection, dehydration, hyperthyroidism, myocardial infarction, or tissue injury from trauma. Decrease: starvation, hemorrhage, or physiologic shock.

III. Methods of Determining Temperature A. Locations for Measurement Oral: most common site due to ease of access. Drinking hot or cold liquids just prior can affect results; wait at least 15 minutes before oral measurement is taken. Not recommended for infants, young children, and unconscious or highly behavioral patients. Temporal artery (forehead): measurements taken with electronic device; easily tolerated and results comparable to oral thermometers. Ear: with a tympanic device. Medical/hospital applications: also use axilla or rectum for assessment.

B. Types of Thermometers

Electronic thermometer (Figure 12-1A)

FIGURE 12-1 • Types of Thermometers. A: Electronic thermometer. B: Tympanic membrane thermometer. C: Temporal artery thermometer. (A, Reprinted from Springhouse. Nursing Procedures. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006; B, C, Reprinted from Lynn P. Taylor’s Clinical Nursing Skills. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins;

2010.)

Cover with disposable protective sheath. Place under tongue; short time required. Read on the digital display. Tympanic thermometer (Figure 12-1B) Cover with protective sheath. Insert gently into ear canal. Short exposure (2–5 seconds) before reading appears on digital unit. Temporal artery thermometer (Figure 12-1C) Measures the temperature of the skin over the temporal artery on the head. Place the scanner on the center of the forehead, midway between the eyebrow and hairline. Slide the thermometer across the forehead until the hairline is reached. Read the temperature on the display. Replace the protective cap. More accurate in infants than the tympanic thermometer.

IV. Care of Patient with Temperature Elevation Temperature over 104°F (40°C)1,2 Treat as a medical emergency. Transport to a hospital for medical care. Temperature 99.6–104°F (37.6–40°C)1 Check possible temporary causes of pyrexia, such as hot beverage or smoking; observe patient while repeating the determination. Review the dental and medical history. Postpone elective oral care when there are signs of respiratory infection or other possible communicable disease.

PULSE The pulse is the intermittent throbbing sensation felt when the fingers are pressed against an artery. It is the result of the alternate expansion and contraction of an artery as a wave of blood is forced out from the heart. The pulse rate or heart rate is the count of the heartbeats. Irregularities of strength, rhythm, and quality of the pulse are noted while counting the pulse rate.

I.

Maintenance of Normal Pulse

A. Normal Pulse Rates Adults: There is no absolute normal. The adult range is 60–100 beats per minute (BPM), slightly higher for women than for men. Children: The pulse or heart rate falls steadily during childhood.

B. Factors That Influence Pulse Rate An unusually fast heartbeat (over 100 BPM in an adult) is called tachycardia; an unusually slow heartbeat (below 50 BPM) is bradycardia. Increased pulse: caused by exercise, stimulants, eating, strong emotions, extremes of heat and cold, and some forms of heart disease. Decreased pulse: caused by sleep, depressants, fasting, quiet emotions, and low vitality from prolonged illness. Emergency situations: listed in Tables 9-3 and 9-4 in Chapter 9.

II.

Procedure for Determining Pulse Rate Sequence The pulse rate is obtained following the body temperature.

Sites The pulse may be felt at several points over the body. Radial pulse: at the wrist (Figure 12-2).

FIGURE 12-2 • Arteries of the Arm. Note the location of the radial pulse. The brachial pulse may be felt just before the brachial artery branches into the radial and ulnar arteries.

Other sites convenient for use in a dental office or clinic are the temporal artery on the side of the head in front of the ear, or the facial artery at the border of the mandible.

Carotid pulse: used during cardiopulmonary resuscitation for an adult. Brachial pulse: used for an infant (Figure 12-2). Prepare the patient 1. Tell the patient what is to be done. 2. Have the patient in a comfortable position with arm and hand supported, palm down. 3. Locate the radial pulse on the thumb side of the wrist with the tips of the first three fingers (Figure 12-3). Do not use the thumb because it contains a pulse that may be confused with the patient’s pulse.

FIGURE 12-3 • Determination of Pulse Rate. A: Correct position of hands. B: The tips of the clinician’s first three fingers are placed over the radial pulse located on the thumb side of the ventral surface of the wrist.

Count and record 1. When the pulse is felt, exert light pressure and count for 1 clocked minute. Use the second hand of a watch or clock. Check

with a repeat count when there is a question about rate or quality of pulse. 2. While taking the pulse, observe the following: Rhythm: regular, regularly irregular, irregularly irregular. Volume and strength: full, strong, poor, weak, thready. 3. Record the date, pulse rate as BPM, with other characteristics in patient’s record. Document BPM reading prior to administering local anesthesia (see Chapter 36) when included in the care plan. A pulse rate over 100 is considered abnormal for an adult and requires further investigation before proceeding with dental treatment.

RESPIRATION The function of respiration is to supply oxygen to the tissues and to eliminate carbon dioxide. Variations in normal respirations may be shown by such characteristics as the rate, rhythm, depth, and quality and may be symptomatic of disease or emergency states.

I.

Maintenance of Normal Respirations

A respiration is one breath taken in and let out. Normal respiratory rate Children: The respiratory rate decreases steadily during childhood.3 Adults: The adult range is from 12 to 20/min, slightly higher for women. Older Adults: Respiratory rate has been shown to have a higher predictive value for serious adverse events and should be considered an important component of vital sign assessment.4 Factors that influence respirations. Many of the same factors that influence pulse rate also influence the number of respirations. A rate below 12/min (bradypnea) is considered subnormal for an adult, rate over 28 is accelerated (tachypnea), and rates over 60 are extremely rapid and dangerous. Increased respiration: caused by work and exercise, excitement, nervousness, strong emotions, pain, hemorrhage, and shock. Decreased respiration: caused by sleep, certain drugs, pulmonary insufficiency, apnea. Emergency situations: such as anoxia are included in Chapter 9.

II.

Procedures for Observing Respirations

Determine rate 1. Make the count of respirations immediately after counting the

pulse. 2. Maintain the fingers over the radial pulse. 3. Respirations must be counted so that the patient is not aware, as the rate may be voluntarily altered. 4. Count the number of times the chest rises in 1 clocked minute. It is not necessary to count both inspirations and expirations. Factors to observe Depth: Describe as shallow, normal, or deep. Rhythm: Describe as regular (evenly spaced) or irregular (with pauses of irregular lengths between). Quality: Describe as strong, easy, weak, or labored (noisy). Poor quality may have an effect on body color; for example, a bluish tinge of the face or nail beds may mean an insufficiency of oxygen. Sounds: Describe deviant sounds made during inspiration, expiration, or both. Position of patient: When the patient assumes an unusual position to secure comfort during breathing or prefers to remain seated upright, mark records accordingly. Record Record all findings in the patient’s record.

BLOOD PRESSURE I. Components of Blood Pressure Blood pressure is the force exerted by the blood on the blood vessel walls. When the left ventricle of the heart contracts, blood is forced out into the aorta and travels through the large arteries to the smaller arteries, arterioles, and capillaries. The vessels of the heart are shown in Chapter 61. The pulsations extend from the heart through the arteries and disappear in the arterioles. During the course of the cardiac cycle, the blood pressure is changing constantly. Systole Phase The systole phase occurs during ventricular contraction. It is measured as systolic pressure. It is the peak or the highest pressure exerted by the heart during contraction. The normal systolic pressure for an adult is less than 120 mm Hg. Diastole Phase Diastolic pressure is the lowest pressure. It is the effect of ventricular relaxation. The normal diastolic pressure for an adult is less than 80 mm Hg. Pulse Pressure The pulse pressure is the difference between the systolic and diastolic pressures.

II.

Factors That Influence Blood Pressure Blood pressure depends on the following: Force of the heartbeat (energy of the heart). Peripheral resistance; condition of the arteries; changes in elasticity of vessels, which may occur with age and disease.

Volume of blood in the circulatory system. Factors that increase blood pressure Exercise, eating, stimulants, and emotional disturbance.5 Use of oral contraceptives; blood pressure increases with age and length of use.6,7 Factors that decrease blood pressure Fasting, rest, depressants, and quiet emotions. Such emergencies as fainting, blood loss, shock (Tables 9-3 and 9-4, Chapter 9).

III. Equipment for Determining Blood Pressure A sphygmomanometer is made up of a pressure-measuring device (manometer) and an inflatable cuff to wrap around the arm or under certain circumstances, the leg. Mercury sphygmomanometer (analog) Traditional system, but mercury is a potential health hazard because of mercury spillage and is less commonly used.8,9 Has shown to be more accurate and consistent than other types. Aneroid sphygmomanometer (analog) Compact, portable glass-enclosed gauge with needle for registration of blood pressure. Requires regular calibration to keep accurate. Electronic sphygmomanometer (digital) Automatic determination of blood pressure without use of stethoscope. Size: Choosing the correct size cuff (see Figure 12-4) is critical to accurate blood pressure results.

FIGURE 12-4 • Selection of Cuff Size. The correct width (W) is 20% greater than the diameter of the arm where applied. A: Too wide. B: Correct width. C: Too narrow.

The cuff needs to be long enough to encircle 80% of the arm and wide enough to encircle 40% of the arm at its midpoint.10 A longer, wider cuff is required for obese or muscular individuals and children require pediatric-sized cuffs.11 Always refer to the recommended cuff sizes for accuracy of readings (Figure 12-5).

FIGURE 12-5 • Three Sizes of Blood Pressure Cuff. Extra-large, regular, and pediatric cuff.

Wrist or finger devices Considered to be less accurate.8 Stethoscope Consists of an endpiece that has a flat diaphragm on one side and (may or may not have) a smaller, concave-shaped bell side. Both sides transmit and send sound through tubes to the earpieces.

IV. Procedure for Determining Blood Pressure Prepare patient 1. Tell patient briefly what is to be done. Detailed explanations need to be avoided because they may excite the patient and change the blood pressure. 2. Seat patient comfortably, with the arm slightly flexed, with palm up, and with the whole forearm supported on a level surface at the level of the heart.10 Arm above heart will result in a false low reading.8 Arm below heart level will result in false high reading.8 Improper cuff selection will result in false high or low depending on size.8,10,12 3. Use either arm unless otherwise indicated, for example,

handicap, history of vascular surgery or mastectomy would indicate arm on opposite side be used. Repeat blood pressure determinations need to be made on the same arm because a variation in pressure may exist between arms.8,10,12 4. Take pressure on bare arm, not over clothing.8,12 Loosen a tight sleeve. 5. Select cuff size as described in Figure 12-5. Apply cuff 1. Apply the completely deflated cuff to the patient’s arm, supported at the level of the heart. If the arm rests on the arm of a dental chair, lower than the heart, the diastolic pressure may show a small but significant increase.8 2. Place the portion of the cuff that contains the inflatable bladder directly over the brachial artery. The cuff may have an arrow to show the point that is placed over the artery. The lower edge of the cuff is placed 1 inch above the antecubital fossa (Figure 126). Fasten the cuff evenly and snugly.8

FIGURE 12-6 • Blood Pressure Cuff in Position. The lower edge of the cuff is placed approximately 1 inch above the antecubital fossa. The stethoscope endpiece is placed over the palpated brachial artery pulse point

approximately 1 inch below the antecubital fossa and slightly toward the inner side of the arm.

3. Adjust the position of the gauge/dial so that it is clearly visible and facing you. Locate the radial pulse (Figures 12-2 and 12-3). 1. Palpate 1 inch below the antecubital fossa to locate the brachial artery pulse (Figure 12-6). 2. Hold the fingers on the pulse. Determine maximum inflation level (MIL) or estimated systolic blood pressure. 1. Close the needle valve (air lock) attached to the hand control bulb firmly but so it may be released readily. 2. Pump to inflate the cuff until the radial pulse stops. Monitor the gauge to note the level at which the pulse disappears. This is the estimated systolic pressure. 3. Continue to pump until the gauge reads 30 points beyond where the radial pulse was no longer felt. This is the MIL. It means that the brachial artery is collapsed by the pressure of the cuff and no blood is flowing through. Unless the MIL is determined, the level to which the cuff is inflated will be arbitrary. Excess pressure can be very uncomfortable for the patient.8 Position the stethoscope. Place the endpiece over the palpated brachial artery, 1 inch below the antecubital fossa, and slightly toward the inner side of the arm (Figures 12-6 and 12-7). Hold lightly in place.

FIGURE 12-7 • Forearm Properly Supported during Blood Pressure Assessment.

Earpieces should be angled forward into the ear canal for proper auscultation (Figure 12-8A and B).

FIGURE 12-8 • Placement of the Earpieces for the Stethoscope. A: Proper placement of the earpieces for the stethoscope. B: Improper placement.

Manual stethoscopes can be turned on/off by rotating the

endpiece. Power stethoscopes can be turned on/off by the push of a button or tap of the diaphragm. Tap gently and listen to confirm it is on (in active mode). Diaphragm or bell side of endpiece should be placed with light, steady, and complete contact with skin. Either side of the endpiece can be used for reliable measurement13 (Figure 12-7). Avoid contact with cuff to prevent extraneous sounds that may distract from Korotkoff sounds. Support patient’s arm at heart level (see Figure 12-9). The position of the arm is critical to accuracy and can greatly influence readings. The upper arm raised above the heart can produce a false low reading and when placed below heart level will result in a false high reading.8,10

FIGURE 12-9 • Correct Stethoscope Endpiece Placement, Away from Cuff and in Contact with Skin.

Deflate the cuff gradually 1. Release the air lock slowly so that the dial drops very gradually and steadily, approximately two to three lines.

2. Listen for the first Karotkoff sound (“tap tap”). This is the beginning of the flow of blood past the cuff. Note the number on the dial as the systolic pressure. 3. Continue to release the pressure slowly. The sound will continue, first becoming louder, then diminishing and becoming muffled, until finally disappearing. Note the number on the dial where the last distinct tap was heard. That number is the diastolic pressure. 4. Release further (about 10 points) until all sounds cease. That is the second diastolic point. In some clinics and hospitals, the last sound is taken as the diastolic pressure. 5. Let the rest of the air out rapidly. Repeat for confirmation Wait 30 seconds before inflating the cuff again. More than one reading is needed within a few minutes to determine an average and ensure a correct reading. Record Write date, arm used, and seated or standing. Record blood pressure as a fraction, for example, 120/80.

V.

Hypertension (High Blood Pressure)

Hypertension (HTN) or high blood pressure (HBP) is a serious condition that affects nearly one out of every three individuals in the United States and is the leading cause of death in the United States.5,8 HTN of above 140/90 is associated with cardiovascular diseases, stroke, kidney failure, and premature death.8,10 Contributing factors to hypertension include smoking, stress, obesity, alcohol and drug abuse, and life style.5 Information about the patient’s blood pressure is essential during dental and dental hygiene appointments because special adaptations may be needed. Blood pressure readings are recorded with the medical history and other assessment data. White-coat hypertension is more common in older adults and

reported as frequent among centenarians.4,6,8 Readings taken at the start of an appointment can be significantly higher than at the end of treatment.12 To establish a baseline reading and determine the need for patient referral for medical attention, more than one reading is advised. A comparison of the reading at the beginning of the appointment with one at the close of appointment when the patient is relaxed may be helpful. Screening for blood pressure in dental practices has been shown to be an effective health service for all ages since many patients are unaware that they have hypertension (see Table 12-2). TABLE 12-2 • Adult Blood Pressure Classifications10,15-17

Description Growing evidence indicates that primary hypertension is commonly asymptomatic and often unrecognized in young children and adolescents.14 Children above 3 years old who are seen in medical settings should have their blood pressure measured annually. Blood pressure should be measured at each dental encounter for children with obesity, renal disease, diabetes, aortic arch obstruction or coarctation or taking medications known to elevate

blood pressure.14 Children and adolescent blood pressure should be matched to Guidelines in the updated (2017) U.S. Department of Health and Human Services (USDHHS) 4th Report on Diagnosis, Evaluation, and Treatment of Blood Pressure in Children and Adolescents.14 The USDHHS guidelines use age, sex, and height percentile data to more accurately determine the presence or absence of hypertension in children and adolescents. Updated guidelines of 2017 reflect normal blood pressure tables based on children with normal weight.14 Cardiovascular diseases are described in Chapter 61. That information can be a helpful introduction and is recommended for reading in conjunction with this section on the techniques for obtaining blood pressure.

VI. Blood Pressure Follow-up Criteria Dental personnel have an obligation to advise and refer for further evaluation. Diagnosis of hypertension would never be made or treatment initiated based on an isolated reading. Vital signs should be recorded for all new patients, and pre- and postoperatively if medically compromised. Rechecking within 1 year is recommended for persons at increased risk for hypertension, such as family history, weight gain, obesity, African American, use of oral contraceptives, smoking, and excessive alcohol consumption (see Tables 12-1 and 12-2).7,10,14 Lifestyle modifications are indicated for all levels of blood pressure classification5,15 and HBP management should follow current evidence-based management guidelines through collaborative efforts with the patients primary care provider.14,16 Immediate consultation with a patient’s primary care provider is indicated prior to dental or dental hygiene treatment when either reading is more than or equal to 180/110 (Tables 12-2 and 12-3).

TABLE 12-3 • Lifestyle Modifications for Hypertension Management10

MODIFICATION RECOMMENDATION

APPROXIMATE REDUCTION IN SYSTOLIC BLOOD PRESSURE RANGE

Weight loss

Normal body weight maintenance based on average body mass index

5–20 mm Hg/10 kg weight loss

Dietary approaches to stop hypertension

A diet rich in fruits, vegetables, and low-fat dairy products with reduced saturated and total fat

8–14 mm Hg

Dietary sodium intake

Reduce Na intake to ≤100 mmol/d (2.4 g Na or 6 g NaCl)

2–8 mm Hg

Physical activity

Aerobic activity at least 30 min/d

4–9 mm Hg

Moderate alcohol consumption

Limit to no more than 2 drinks/d for most men and no more than 1 drink/d for women or lighter-weight individualsa

2–4 mm Hg

a1

oz or 20 mL ethanol, that is, 24 oz beer, 10 oz wine, or 2 oz 80 proof whiskey.

DOCUMENTATION15 Documentation in the permanent record of a patient with HBP would include the following: Carefully document medical history with regular updates at each maintenance appointment. Reminder to help patient realize the importance of regularly taking prescribed medication. Prepared and documented blood pressure reading at each appointment especially when anesthesia is included in the care plan. Box 12-1 contains a sample progress note.

EVERYDAY ETHICS Gracie was having a very busy day and at 10:15 AM was already late for the 10:00 AM patient, Mr. McElroy, who had arrived early and was waiting in the reception area. While completing his history, to save time, she copied over the blood pressure recording from his previous appointment just 2 weeks ago. It had been 130/83, only slightly into the prehypertension level. The appointment was planned for the maxillary left quadrant with anesthesia. After the scaling was complete and Mr. McElroy was climbing out of the dental chair, looking a bit unsteady as he stood up, he casually remarked: “I just remembered while you were working that my Doc gave me a new prescription— I suppose I should have told you before. But it is only one pill a day—for keeping the blood pressure down. I don’t have any trouble anyway, he just wanted to be sure.” Questions for Consideration 1. Explain how the principles of beneficence and maleficence apply to Gracie’s actions with Mr. McElroy’s examination and charting procedures. 2. How has Gracie placed the office at risk for a possible medical emergency given Mr. McElroy’s physical status? Answer by describing the rights and duties of both the hygienist and the patient. 3. Who is responsible for ensuring that accurate documentation has been completed on all patients, from an ethical and a quality assurance perspective?

Factors to Teach the Patient How vital signs can influence dental and dental hygiene appointments. The importance of having a blood pressure determination at regular intervals. For the patient diagnosed as hypertensive, encourage regular continuing use of prescription drugs for control of HBP. Encourage healthy lifestyle changes such as tobacco cessation, drug and/or alcohol counseling, exercise, and healthy dietary habits (see Table 12-3).

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. MayoClinic. Thermometers: understand the options. 2017. https://www.mayoclinic.org/diseases-conditions/fever/indepth/thermometers/art-20046737. Accessed April 23, 2019. 2. MedlinePlus. Temperature measurement. 2017. https://medlineplus.gov/ency/article/003400.htm. Accessed April 23, 2019. 3. Fleming S, Thompson M, Stevens R, et al. Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies. Lancet. 2011;377:1011. 4. Chester JG, Rudolph JL. Vital signs in older patients: age-related changes. J Am Med Dir Assoc. 2011;12:337-343. 5. U.S. Preventive Services Task Force; Grossman DC, Bibbins-Domingo K, Curry SJ, et al. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults without cardiovascular risk factors: U.S. Preventive Services Task Force recommendation statement. JAMA. 2017;318:167-174. 6. Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents Developed in Collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology. J Am Soc Hypertens. 2011;5:259. 7. American Heart Association. High blood pressure and women. 2016. https://www.heart.org/en/health-topics/high-blood-pressure/why-high-bloodpressure-is-a-silent-killer/high-blood-pressure-and-women. Accessed April 23, 2019. 8. Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension. 2005;45:142. 9. Herman WW, Konzelman JL Jr, Prisant LM. New national guidelines on hypertension: a summary for dentistry. J Am Dent Assoc. 2004;135:576. 10. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206. 11. U.S. Department of Health and Human Services. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. 2013:60. https://www.nhlbi.nih.gov/files/docs/resources/heart/hbp_ped.pdf. Accessed April 23, 2019.

Kallioinen N, Hill A, Horswill MS, Ward HE, Watson MO. Sources of inaccuracy 12. in the measurement of adult patients’ resting blood pressure in clinical settings: a systematic review. J Hypertens. 2017;35:421-441. 13. Kantola I, Vesalainen R, Kangassalo K, Kariluoto A. Bell or diaphragm in the measurement of blood pressure? J Hypertens. 2005;23:499-503. 14. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140. 15. Centers for Disease Control and Prevention. High blood pressure fact sheet|Data & statistics|DHDSP|CDC. 2014. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm. Accessed April 23, 2019. 16. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the eighth joint national committee (jnc 8). JAMA. 2014;311:507520. 17. Bader JD, Bonito AJ, Shugars DA. A systematic review of cardiovascular effects of epinephrine on hypertensive dental patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93:647.

13 Extraoral and Intraoral Examination Lisa B. Johnson, RDH, MSDH

CHAPTER OUTLINE RATIONALE FOR THE EXTRAORAL AND INTRAORAL EXAMINATION COMPONENTS OF EXAMINATION I. II. III. IV.

Types of Examinations Methods for Examination Signs and Symptoms Preparation for Examination

ANATOMIC LANDMARKS OF THE ORAL CAVITY I.

Oral Mucosa

SEQUENCE OF EXAMINATION I.

Extraoral Examination

II. III.

Intraoral Examination Documentation of Findings

MORPHOLOGIC CATEGORIES I. II. III. IV.

Elevated Lesions Depressed Lesions Flat Lesions Other Descriptive Terms

ORAL CANCER I. II.

Location Appearance of Early Cancer

CLINICAL RECOMMENDATIONS FOR EVALUATION OF ORAL LESIONS I.

Biopsy

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Explain the rationale for a comprehensive extra- and intraoral examination. 2. Explain the systematic sequence of the extra- and intraoral examination. 3. Identify normal hard and soft tissue anatomy of the head, neck, and oral cavity. 4. Describe and document physical characteristics (size, shape, color, texture, and consistency) and morphologic categories (elevated, flat, and depressed lesions) for notable findings. 5. Identify suspected conditions that require follow-up and referral for medical evaluation.

RATIONALE FOR THE EXTRAORAL AND INTRAORAL EXAMINATION The extra- and intraoral examination is performed for early identification of abnormalities and pathologies, especially oral cancer. Although an essential goal of the examination is to detect cancer of the mouth at the earliest possible stage, a thorough examination may also reveal signs of thyroid disorders, eating disorders, nutritional deficiencies, sexually transmitted diseases, and a host of systemic conditions.

COMPONENTS OF EXAMINATION The standard of patient care is that the total patient is being treated, not only the oral cavity, and particularly not just the teeth and immediate surrounding tissues. The examination is all-inclusive to detect possible physical or psychological influences on the patient’s oral health. Thorough examination is essential for each continuing care appointment so that the treatment for the control and prevention of oral diseases will be effective. Assessment of health-related risk factors such as1: History of previous cancer Family history of squamous cell carcinoma (SCC) Tobacco. Alcohol use. Cultural and genetic susceptibility. Sun exposure and lack of use of sun protection. Diet. Certain surgeries such as organ or bone marrow transplant and subsequent long-term immunosuppressive medications. Sexual behaviors involving orogenital contact may increase the risk of human papillomavirus (HPV) transmission.2

I.

Types of Examinations Complete A complete examination includes a thorough summary of all the components of the assessment. The extra- and intraoral examination is a component of a patient’s complete assessment and is performed for all new patients and at each routine continuing care visit. Screening Screening implies a brief, preliminary examination, usually for a particular purpose such as pain relief or for initial patient

assessment and triage to determine priorities for treatment. Limited examination A type of brief examination made for an emergency situation. It may be used in the management of an acute condition. Follow-up Brief follow-up examination to check healing following a treatment. Continuing care/reevaluation After a specific period of time following the completion of the care plan and the anticipated restoration to health. A continuing care examination is a complete reassessment from which a new dental hygiene diagnosis and care plan are derived.

II.

Methods for Examination

The extra- and intraoral examination is accomplished by various visual and tactile, manual, and instrumental methods. Patient position, optimum lighting, and effective retraction for accessibility and visibility contribute to the accuracy and completeness of the examination. Visual examination Direct observation: Visual observation is carried out in a systematic sequence to note surface appearance (color, contour, size) and to observe movement and other evidence of function. Radiographic examination: The use of radiographs can reveal deviations from normal not observable by direct vision. Transillumination: A strong light directed through a soft tissue or a tooth to enhance examination is useful for detecting irregularities of the teeth and locating calculus. Hold the mouth mirror to view from the lingual to see the translucency. Palpation Palpation is examination using the sense of touch through tissue manipulation or pressure on an area with the gloved fingers of one hand or both. Digital: The use of a single finger. Example: index finger applied to the lingual side of the mandible beneath the canine and

premolar area to determine presence of a torus mandibularis. Bidigital: The use of finger and thumb of same hand. Example: palpation of the lips (Figure 13-1).

FIGURE 13-1 • Palpation of the Lip to Illustrate the Use of a Finger and Thumb of the Same Hand.

Bimanual: The use of finger or fingers and thumb from each hand applied simultaneously in coordination. Example: index finger of one hand palpates on the floor of the mouth inside, while a finger or fingers from the other hand press on the same area from under the chin externally (Figure 13-2A and B).

FIGURE 13-2 • Bimanual Palpation. A: Examination of the buccal mucosa by simultaneous palpation extraorally and intraorally. B: Examination of the floor of the mouth by simultaneous palpation with fingers of each hand in apposition.

Bilateral: Two hands are used at the same time to examine corresponding structures on opposite sides of the body. Comparisons can be made. Example: fingers placed beneath the chin to palpate the submandibular lymph nodes (Figure 13-3).

FIGURE 13-3 • Bilateral Palpation. Bilateral palpation is used to examine

corresponding structures on opposite sides of the body.

Instrumentation Examination instruments, such as a periodontal probe and an explorer, are used for specific examination of the teeth and periodontal tissues. Percussion Percussion is the act of tapping a surface or tooth with the fingers or an instrument. Information about the status of health is determined either by the response of the patient or by the sound. When a tooth is known to be sensitive in any way, percussion needs to be avoided. Electrical test An electric pulp tester may be used to detect the presence or absence of vital pulp tissue. Methods for use of a pulp tester are described in Chapter 16. Auscultation Auscultation is the use of sound. Example: The sound of clicking of the temporomandibular joint when the jaw is opened and closed. Figure 13-4 shows examination of the temporomandibular joint.

FIGURE 13-4 • Assessment of the Temporomandibular Joint. The joint is palpated as the patient opens and closes the mouth.

III. Signs and Symptoms A specific objective for patient examination as a part of the complete assessment is the recognition of deviations from normal that may be signs or symptoms of disease. General signs and symptoms may occur in various disease conditions. Example: Fever, or increase in body temperature accompanies most infections. A pathognomonic sign or symptom is unique to a disease and may be used to distinguish that condition from other diseases or conditions.

A. Signs A sign is any abnormality identified by a healthcare professional while examining a patient. A sign is an objective symptom. Examples of signs include

observable changes such as color, shape, consistency, or abnormal findings revealed using a probe, explorer, radiograph, or other instrument for disease detection.

B. Symptoms A symptom is any departure from normal that may be indicative of disease. It is a subjective abnormality that can be observed by the patient. Examples are pain, tenderness, and bleeding when toothbrushing as described by the patient.

IV. Preparation for Examination Review the patient’s health histories and dental/medical record, including risk factors, radiographs, dental caries, periodontal, and oral cancer risk assessments. Examine dental radiographs. Explain the procedures to be performed and relevance of the procedures. Example: “I am going to perform an extra-/intraoral examination to look for abnormalities that can affect your oral and overall health.” Patients understanding the rationale for an extra- and intraoral examination is critical to acceptance and education. When a patient is wearing a scarf or other head/neck covering for cultural or religious purposes, the dental hygienist uses culturally sensitive communication skills (Chapter 3).

ANATOMIC LANDMARKS OF THE ORAL CAVITY Familiarization with structures (Figures 13-5 through 13-7) and normal anatomy is a prerequisite to understanding abnormal presentations in the head and neck region.1-3

FIGURE 13-5 • Papillae of the Tongue.

FIGURE 13-7 • Anatomic Landmarks of the Oral Cavity—Ventral Tongue View.

I.

Oral Mucosa

The lining of the oral cavity, the oral mucosa, is a mucous membrane composed of connective tissue covered with stratified squamous epithelium. There are three divisions or categories of oral mucosa.

A. Masticatory Mucosa Covers the gingiva and hard palate, the areas most used during the mastication of food. Except for the free margin of the gingiva, the masticatory mucosa is firmly attached to underlying tissues. The normal epithelial covering is keratinized.

B. Lining Mucosa Covers the inner surfaces of the lips and cheeks, floor of the mouth, underside of the tongue, soft palate, and alveolar mucosa. These tissues are not firmly attached to underlying tissue. The epithelial covering is not keratinized.

C. Specialized Mucosa Covers the dorsum (upper surface) of the tongue. Composed of many papillae; some contain taste buds. The distribution of the four types of papillae is shown in Figure 13-5. Filiform: threadlike keratinized elevations that cover the dorsal surface of the tongue; they are the most numerous of the papillae. Fungiform: mushroom-shaped papillae interspersed among the filiform papillae on the tip and sides of the tongue, appear redder than the filiform papillae and contain variable numbers of taste buds. The inset enlargement in Figure 13-5 shows the comparative shape and size of the filiform and fungiform papillae. Circumvallate (vallate): the 10–14 large round papillae arranged in a “V” between the body of the tongue and the base. Taste buds line the walls. Foliate: vertical grooves on the lateral posterior sides of the tongue; also contain taste buds.

SEQUENCE OF EXAMINATION Conducting an examination with routine order will minimize the possibility of excluding areas and overlooking details of importance. A systematic sequence improves efficiency, promotes professionalism, and inspires patient confidence. A recommended sequence for examination is outlined in Box 13-1 in which factors to consider during appointments are related to the actual observations made and recorded.

BOX 13-1 Anatomic Landmarks of the Oral Cavity Lips Vermillion border Labial commissure Labial mucosa Buccal mucosa Philtrum Nasolabial groove Fauces Oral pharynx Vestibule Buccal vestibule Buccinator muscle Labial Buccal Mucobuccal fold Buccal frenum Labial frenum Exostosis Wharton’s duct Lingual vein Sublingual fold Plica fimbriata Sublingual caruncle

Median sulcus Lingual tonsils Lingual frenum Ankyloglossia Marginal gingiva Attached gingiva Free gingival groove Canine eminence Pterygomandibular raphe Parotid papilla Midpalatine raphe Palatine rugae Fovea palatine Torus palatinus Incisive papilla Uvula Palatine tonsils Pharyngeal adenoid tonsils Tonsillar pillars Tongue: Dorsal Ventral Lateral border Filiform papilla Fungiform papilla Folate papillae Circumvallate papilla Lingual tonsils Stensen’s duct Maxillary tuberosity Retromolar pad Ramus of mandible Zygomatic arch Mandibular tori (prevalence varies) Alveolar mucosa Mylohyoid muscle Refer to Figures 13-6 and 13-7

FIGURE 13-6 • Anatomic Landmarks of the Oral Cavity—Dorsal Tongue View. A: View of hard and soft palate. B: View of uvula and oropharynx.

This sequence is adapted from Detecting Oral Cancer, available from the National Institutes of Health and the National Cancer Institute.3,4 In addition to proper sequence, familiarization of anatomic structures common to normal anatomy is critical to understanding abnormal findings (Table 13-1).5 TABLE 13-1 • Extraoral and Intraoral Examination SEQUENCE OF EXAMINATION

OBSERVE

INDICATION AND INFLUENCES ON APPOINTMENTS

1. Overall appraisal of patient

Posture, gait General health status; size Hair; scalp Breathing; state of fatigue Voice, cough, hoarseness

Response, cooperation, attitude toward treatment Length of appointment

2. Face

Expression: evidence of fear or apprehension Shape: twitching; paralysis Jaw movements during speech Injuries; signs of abuse

Need for alleviation of fears Evidence of upper respiratory or other infections Enlarged masseter muscle (related to bruxism)

3. Skin

Color, texture, blemishes Traumatic lesions Eruptions, swellings Growths, scars,

Relation to possible systemic conditions Need for supplementary history Biopsy or other treatment to recommend Influences on instruction in diet

moles 4. Eyes

Size of pupils Color of sclera Eyeglasses (corrective) Protruding eyeballs

5. Nodes (palpate) (Figure 13-8)

Adenopathy; Need for referral lymphadenopathy Medical consultation Induration or pain Ear infection Coordinate with intraoral examination

FIGURE 13-8 • Lymph Nodes. The locations of the major lymph nodes into which the vessels of the facial and oral regions drain.

a. Pre- and postauricular b. Occipital c. Submental; submandibular d. Cervical chain (Figure 13-9)

FIGURE 13-9 • Cervical Node Palpation. Left anterior cervical lymph node chain is

Dilated pupils or pinpoint may result from drugs, emergency state Eyeglasses essential during instruction Hyperthyroidism

examined. Finger tips gently press and roll nodes along the length of the sternocleidomastoid muscle.

e. Supraclavicular 6. Glands (palpate) a. Parotid b. Submental c. Submandibular (Figure 13-3)

Enlargement or pain Induration longer than 2 wk

Referral for medical consult

7. Temporomandibular Limitations or joint (palpate) deviations of (Figure 13-4) movement Trismus Tenderness; sensitivity Noises: clicking, popping, grating

Disorder of joint; limitation of opening Discomfort during appointment and during personal biofilm control

8. Lips a. Observe closed, then open b. Palpate (Figure 13-1)

Color, texture, size Cracks, angular cheilosis Blisters, ulcers Traumatic lesions Irritation from lipbiting Limitation of opening; muscle elasticity; muscle tone Evidences of mouth breathing Induration

Need for further examination: referral Immediate need for postponement of appointment when a lesion may be communicable or could interfere with procedures Care during retraction Accessibility during intraoral procedures Patient instruction: dietary, special biofilm control for mouth breather

9. Breath odor

Severity Relation to oral hygiene, gingival health

Possible relation to systemic condition Alcohol use history; special needs

10. Labial and buccal

Color, size,

Need for referral, biopsy,

mucosa, left and right examined systematically a. Vestibule b. Mucobuccal folds c. Frena d. Opening of Stensen duct e. Palpate cheeks (Figure 13-2A)

11. Tongue a. Vestibule b. Dorsal (Figure 13-6A) c. Lateral borders d. Base of tongue (Figure 13-10)

FIGURE 13-10 • Examination of the Tongue. To observe the posterior third of the tongue and the attachment to the floor of the mouth, hold the tongue with a gauze sponge, retract the cheek, and move the tongue out, first to one side and then the other, as each section of the mucosa is carefully examined.

texture, contour Abrasions, traumatic lesions, cheek bite Effects of tobacco use Ulcers, growths Moistness of surfaces Relation of frena to free gingiva Induration

cytology Frena and other anatomic parts that need special adaptation for radiography or impression tray Avoid sensitive areas during retraction

Shape: normal asymmetric Color, size, texture, consistency Fissures; papillae Coating Lesions: elevated, depressed, flat Induration

Need for referral, biopsy, cytology Need for instruction in tongue cleaning

e. Deviation on extension 12. Floor of mouth a. Ventral surface of tongue (Figure 13-7) b. Palpate (Figure 13-2B) c. Duct openings d. Mucosa, frena e. Tongue action

Varicosities Lesions: elevated, flat, depressed, traumatic Induration Limitation or freedom of movement of tongue Frena; tongue-tie

Large muscular tongue influences retraction, gag reflex, accessibility for instrumentation Film placement problems

13. Saliva

Quantity; quality (thick, ropy) Evidence of dry mouth; lip wetting Tongue coating

Reduced in certain diseases, by certain drugs Special dental caries control program Influence on instrumentation Need for saliva substitute

14. Hard palate (Figure 13-6A)

Height, contour, color Appearance of rugae Tori, growths, ulcers

Need for referral, biopsy, cytology Signs of tongue thrust, deviate swallow Influence on radiographic film placement

15. Soft palate, uvula (Figure 13-6B)

Color, size, shape Petechiae Ulcers, growths

Referral, biopsy, cytology Large uvula influences gag reflex

16. Tonsillar region, throat (Figure 136B)

Tonsils: size and shape Color, size, surface characteristics Lesions, trauma

Referral, biopsy, cytology Enlarged tonsils encourage gag reflex Throat infection, a sign for appointment postponement

I.

Extraoral Examination

1. Observe patient during reception and seating to note physical characteristics and abnormalities, and make an overall appraisal. 2. Observe head, face, eyes, and neck and evaluate the skin of the

face and neck. 3. Request the patient to remove prosthesis prior to performing the intraoral examination. Explain how this will improve the ability to inspect all areas of the mouth adequately. 4. Palpate the salivary glands and lymph nodes. Figure 13-8 shows the location of the major lymph nodes of the face, oral regions, and neck. Palpation is a significant component of the extra-/intraoral examination (Figure 13-9). Note any of the following symptoms or experiences: Pain or discomfort upon palpation and/or upon swallowing. Persistent difficulty swallowing in the absence of pain. Any recent noticeable lumps the patient may have experienced without pain. Persistent earache or hoarseness of voice.6 5. Observe mandibular movement and palpate the temporomandibular joint (Figure 13-4). Relate to items from questions in the medical/dental history.7,8

II.

Intraoral Examination

1. Make a preliminary examination of the lips and intraoral mucosa by using a mouth mirror or a tongue depressor. 2. View and palpate lips, labial and buccal mucosa, and mucobuccal folds (Figures 13-1 and 13-2A). 3. Examine and palpate the tongue, including the dorsal and ventral surfaces, lateral borders, and base. Retract to observe posterior third, first to one side and then the other (Figure 13-10). 4. Observe mucosa of the floor of the mouth. Palpate the floor of the mouth (Figure 13-2B). 5. Examine the hard and soft palates, tonsillar areas, and pharynx (Figure 13-6A and B). Use a mirror to observe the oropharynx, nasopharynx, and larynx. 6. Note amount and consistency of the saliva and evidence of dry mouth (xerostomia).

III. Documentation of Findings A. History Questions directed to the patient provide necessary information in the management of an oral lesion. Because alarming the patient must be avoided, judgment is needed for selecting the appropriate time to obtain the history of a lesion. Whether the lesion is known or not known to the patient; previous evaluation. If known, when first noticed; if recurrence, previous date when lesion was first noticed. Duration, symptoms, changes in size and appearance.

B. Location and Extent When a lesion is first seen, its location is noted in relation to adjacent structures. Document a complete description of each finding including the location, extent, size, color, surface texture or configurations, consistency, morphology, and history. Intraoral photography can be of value to record images of anatomical deviations, location, and proportions.9 Descriptive words to define the location and extent include the following: Localized: Lesion limited to a small focal area. Generalized: Involves most of an area or segment. Single lesion: One lesion of a particular type with a distinct margin. Multiple lesions: More than one lesion of a particular type. Lesions may be: Separate: discrete, not running together; may be arranged in clusters. Coalescing: close to each other with margins that merge.

C. Physical Characteristics Size and shape Record length and width in millimeters. The height of an elevated lesion may be significant. Use a probe to measure, as shown in Figure 13-11.

FIGURE 13-11 • Use of a Probe to Measure a Lesion. In addition to the exact location, the width and length of a lesion is recorded. Using the probe provides a convenient method.

Color Red, pink, white, and red and white are the most commonly seen. Other more rare lesions may be blue, purple, gray, yellow, black,

or brown. Surface texture A lesion may have a smooth or an irregular surface. The texture may be papillary, verrucous or wart-like, fissured, corrugated, or crusted. Consistency Lesions may be soft, spongy, resilient, hard, or indurated.

MORPHOLOGIC CATEGORIES Most lesions can be classified readily as elevated, depressed, or flat as they relate to the normal level of the skin or mucosa. Flowcharts of elevated lesions (Figure 13-12A), depressed lesions (Figure 13-12B), and flat lesions (Figure 13-12C) break down the terms used for describing lesions in each category.10

FIGURE 13-12 • Flowcharts. A: Description of elevated soft tissue lesions. Elevated lesions are blisterform or nonblisterform. B: Description of depressed soft tissue lesions. Depressed lesions are below the normal plane of the mucosa, usually an ulcer where there is a loss of continuity of epithelium. C: Description of flat soft tissue lesions. Flat lesions are on the level of normal plane of the mucosa. (A–C reprinted with permission from McCann A. Describing soft tissue lesions of the oral cavity. Dent Hyg News. 1992;5:9.)

I.

Elevated Lesions

An elevated lesion (Figure 13-12A) is above the plane of the skin or

mucosa. Elevated lesions are considered blisterform or nonblisterform. Blisterform Blisterform lesions contain fluid and are usually soft and translucent. They may be vesicles, pustules, or bullae. Vesicle: A vesicle is a small (1 cm or less in diameter), circumscribed lesion with a thin surface covering. It may contain serum or mucin and appear white. Pustule: A pustule may be more than or less than 5 mm in diameter and contain pus giving it a yellowish color. Bulla: A bulla is large (>1 cm). It is filled with fluid, usually mucin or serum, but may contain blood. The color depends on the fluid content. Nonblisterform Nonblisterform lesions are solid and do not contain fluid. They may be papules, nodules, tumors, or plaques. Papules, nodules, and tumors are also characterized by the base or attachment. As shown in Figure 13-13, the pedunculated lesion is attached by a narrow stalk or pedicle, whereas the sessile lesion has a base as wide as the lesion itself.

FIGURE 13-13 • Attachment of Nonblisterform Lesions. The sessile lesion has a base as wide as the lesion itself; the pedunculated lesion is attached by a narrow stalk or pedicle.

Papule: A papule is a small (pinhead to 5 mm in diameter), solid lesion that may be pointed, rounded, or flat topped.

Nodule: A nodule is larger than a papule (>5 mm but 30 grams/day or >2 standard drinks) consumption.22

F. Diet Macronutrient and micronutrient intake may be modifying factors in periodontal disease.3,23 Macronutrient intake such as high carbohydrate intake impacts glycemic control and may be involved in initiation of the inflammatory state in periodontal disease.23 Micronutrient deficiencies, such as vitamin C, vitamin D or vitamin B12, may impact onset, healing, and progression of periodontal disease.23

G. Psychosocial Factors Some research suggests individuals under psychological stress, anxiety, or depression are more likely to have periodontal disease.3,24 The association may be related to the impact on the immune response as well as behavior changes.

H. Medications Medications for specific systemic conditions can lead to gingival enlargement.10 The enlarged tissue encourages dental biofilm retention and complicate removal, thus increasing the potential for periodontal infections. These medications may or may not be modifiable in discussion with the medical provider. Phenytoin-induced gingival enlargement: Phenytoin is a drug used to control seizures (see Figure 19-3).

FIGURE 19-3 • Gingival Hyperplasia in Patient Treated with Phenytoin. (From Science Source, New York, NY.)

Cyclosporine-induced gingival enlargement: Cyclosporine is an immunosuppressant drug used for patients with organ transplants to prevent rejection. Nifedipine-induced gingival enlargement: Nifedipine is a calciumchannel blocker used in the treatment of angina and ventricular arrhythmias. Oral contraceptives with high doses of estrogen, progestin, or both.10

II.

Nonmodifiable Risk Factors

A. Genetic Predisposition From 33 to 39% of the risk for periodontal disease is related to genetic factors.10 Genetic testing is likely to become more cost effective and will benefit patients and dental providers in targeting those at risk for enhanced prevention.

B. Host Response Host response refers to the way an individual’s immune response interacts with bacteria to resolve inflammation. Bacteria initiate an inflammatory response in periodontal disease and in susceptible individuals the body’s immune response becomes chronic resulting in tissue destruction.25 In addition to chronic diseases that impair the immune response, such as diabetes, genetic disorders associated with deficiencies in the immune system, such as Down syndrome, also result in a higher prevalence and severity of periodontal disease.2,14

C. Osteoporosis Research suggests an association between osteoporosis and periodontal disease with three times the risk of greater than 4 mm of CAL.2,26 There was a five times greater risk of CAL greater than or equal to 6 mm.26 In osteopenia, there was nearly a two times greater risk of greater than 4 mm of CAL.26

D. Age Age also is factored into the 2017 Periodontal grading system to

take into consideration more severe periodontal disease at an earlier age.14 The grading of periodontitis is related to the potential for disease progression and will be described later in this chapter.

III. Local Factors Although dental biofilm is the primary etiologic factor in the development of inflammatory gingival and periodontal diseases, a variety of other factors predispose some patients to the retention of bacterial deposits and to the development of periodontal disease.27 Retentive areas may be associated with rough surfaces of teeth and restorations; tooth contour and position; and gingival size, shape, and position. Iatrogenic causes, that is, factors created by professionals during patient treatment or neglect of proper treatment and can impact development and progression of periodontal disease. Factors, such as mastication (chewing), saliva, the tongue, cheeks, lips, oral habits, and personal biofilm control procedures, contribute to retention.

A. Dental Factors Tooth surface irregularities: Pellicle and biofilm microorganisms attach to defective or rough surfaces include the following: Pits, grooves, cracks. Calculus. Exposed altered cementum with irregularities. Demineralization and cavitated dental caries. Iatrogenic factors such as rough or grooved surfaces left after scaling or inadequately contoured and polished dental restorations (Figure 19-4B).

FIGURE 19-4 • Effect of Tooth Position. A: Food impaction area, shown by plunger cusp (with arrow) directing pressure between lower teeth with open contact area. B: Inadequate restoration without proximal contact and with overhang. C: Tipped tooth leaving irregular marginal ridge relation. D: Natural open contact (diastema) with saddle-shaped gingival margin.

Tooth contour: Altered shape may interfere with oral self-cleansing mechanisms (see Chapters 16 and 27). Congenital abnormalities: extra or missing cusps or bell-shaped crown with prominent facial and lingual contours that tend to provide deeper retentive areas in the cervical third. Teeth with flattened proximal surfaces have faulty contact with adjacent teeth, thus permitting debris to wedge between the teeth. Occlusal and incisal surfaces altered by attrition interrupt normal excursion of food during chewing. Marginal ridges have worn down. Areas of erosion and abrasion. Carious lesions. Heavy calculus deposits; biofilm retained on rough surface. Overcontoured, undercontoured, or overhanging restorations (see Figure 19-5).

FIGURE 19-5 • Restoration with an Overhang. The distal surface of the mandibular first molar in this radiograph has a faulty restoration that creates a food trap and harbors biofilm.

Tooth position 1. Malocclusion: Irregular alignment of a single tooth or groups of teeth leaves areas prone to collection of biofilm formation. Crowded or overlapped. Rotated. Deep anterior overbite (Chapter 16). Mandibular teeth force food particles against maxillary lingual surface. Lingual inclination of mandibular teeth allows maxillary teeth to force food particles against mandibular facial gingiva. 2. Tooth adjacent to edentulous area may be inclined or migrated; contact missing. 3. When an opposing tooth is missing, the tooth may extrude beyond the line of occlusion. 4. Related to eruption Incomplete eruption: the teeth do not erupt into the line of

occlusion. Partially erupted impacted third molar. 5. Lack of function or the use of teeth eliminates or decreases effectiveness of natural cleansing: Lack of opposing teeth. Open bite (Figure 19-6).

FIGURE 19-6 • Anterior Open Bite.

Marked maxillary anterior protrusion. Crossbite with limited lateral excursion. Unilateral chewing. 6. Food impaction Created by the combined effect of tooth contour, missing proximal contact, proximal carious lesions, and irregular marginal ridge relationship. Inclination related to loss of adjacent tooth and a plunger cusp from the opposite arch (Figure 19-4A). 7. Defective contact area Restoration margin is faulty, and the contact area is missing, improperly located, or unnaturally wide (Figure 19-4B). Inclined tooth with irregular marginal ridge relation (Figure 19-

4C). Dental appliances and prostheses Orthodontic appliances provide retentive areas (see Figure 197).

FIGURE 19-7 • Orthodontic Appliances as a Predisposing Factor for Periodontal Disease. Infrequent oral self-care and biofilm accumulation resulted in periodontitis in this individual with orthodontic appliances. (Courtesy of Dr. Richard Foster, Guilford Technical Community College, Jamestown, NC.)

Fixed partial denture with deficient margin on an abutment tooth or an unusually shaped pontic. Removable partial denture with poorly fitting clasps.

B. Gingival Factors Position Deviations from normal provide retentive areas for biofilm. Gingival recession: may expose root irregularities that serve as areas for biofilm retention.

Enlarged gingival margin or papillae: extended to or over the height of contour. Reduced height of interdental papilla creating an open interdental area. Operculum: Tissue flap over occlusal surface of an erupting tooth (Figure 19-8).

FIGURE 19-8 • Operculum Is a Flap of Tissue over a Partially Erupted Third Mandibular Molar. This flap makes removal of biofilm difficult and may lead to inflammation and infection. (Courtesy of Dr. Carl Allen.)

Periodontal pocket: Depth and shape can make biofilm removal difficult. Calculus creating a rough retentive surface. Size and contour Deviation of shape of enlarged gingiva: rolled, bulbous, and

cratered. Combination with presence of irregular restorations or dental prosthesis can result in marked biofilm retention. Effect of Mouth Breathing Dehydration of oral tissues in the anterior region leads to changes in size, shape, surface texture, and consistency.

C. Other Factors A variety of factors may predispose or contribute to the progression of periodontal infections. Some of the items listed here may have an indirect effect, whereas others have a direct effect on the oral tissues. Personal oral self-care28 Neglect: This can lead to generalized dental biofilm accumulation and disease promotion. Inadequate biofilm control techniques: Incorrect use of brush and interdental cleaning aids. Awareness of oral cleanliness: Cleansing habits, including both self-cleansing mechanisms and mechanical biofilm removal, depend in part on an individual’s perception and feeling of debris through taste and tongue activity. This can become impaired in individuals with some conditions like poststroke. Diet and eating habits.29 Soft foods tend to be less nutrient dense and more retentive than fibrous, firm foods. Masticatory deficiencies limit diet selection. Missing teeth, illfitting partial dentures, and various occlusal deficiencies alter diet selection and eating habits.

PATHOGENESIS OF PERIODONTAL DISEASES Pathogenesis refers to the process by which a disease develops and progresses. The primary etiology of periodontal disease is bacteria that initiate an inflammatory process. The inflammatory process is very complex and influenced by patient and environmental factors and progression of disease is impacted by the individual’s response to the bacterial challenge.30–32

I.

Acute Inflammatory Response When the immune response is working effectively with no disease modifiers, that is, diabetes or smoking, the presence of biofilm results in gingival inflammation with no breakdown of tissue.30–32 Activation of the local acute inflammatory response begins the process of lesion development.

II.

Development of Gingival and Periodontal Infection

The stages of development of gingivitis and periodontitis are divided into the initial lesion, early lesion, established lesion, and advanced lesion.30,32 With an accumulation of dental biofilm on the cervical tooth surface adjacent to the gingival margin, an inflammatory reaction is initiated, and the immune system responds.

A. The Initial Lesion Inflammatory response to dental biofilm30,32 Occurs within 2–4 days in response to bacterial accumulation. Migration and infiltration of white blood cells (neutrophils) into the junctional epithelium and gingival sulcus result from the natural body response to infectious agents.

Increased flow of gingival crevicular fluid. Early breakdown of collagen of the supporting gingival fiber groups (Chapter 18). Fluid fills the spaces in the connective tissue. Clinical appearance No clinical evidence of change may appear in the earliest phases. Marginal redness with enlargement due to the fluid collection follows as the infection develops.

B. The Early Lesion Increased inflammatory response30,32 Dental biofilm becomes older and thicker (7–14 days; time reflects individual differences). Infiltration of fluid, macrophages, T-cells, and neutrophils with a few plasma cells migrating into the connective tissue. Breakdown of collagen fiber support to the gingival margin. Epithelium proliferates: Epithelial extensions and rete ridges are formed. Clinical appearance Early signs of gingivitis become apparent with slight gingival enlargement; will become an established lesion if undisturbed. Early gingivitis is reversible when biofilm is controlled and inflammation is reduced. Healthy tissue may be restored. Susceptibility of individuals varies; time before lesion becomes established varies.

C. The Established Lesion Progression from the early lesion Migration of B-lymphocytes and plasma cells within connective tissue are characteristics of the established lesion.30,32 Formation of pocket epithelium. 1. Proliferation of the junctional and sulcular epithelium

continues in an attempt to wall out the inflammation. 2. Pocket epithelium is more permeable; areas of ulceration of the lining epithelium develop. 3. Early pocket formation with bleeding on probing. Collagen destruction continues; connective tissue fiber support is lost. Progression to early periodontal lesion may occur or the established lesion may remain stable for extended periods of time. Clinical appearance Clear evidence of inflammation is present with marginal redness, bleeding on probing, and spongy marginal gingiva. This is followed by chronic fibrosis development.

D. The Advanced Lesion Extension of inflammation The two hallmarks of the advanced lesion include: alveolar bone resorption and collagen breakdown.30,32 B-lymphocytes and plasma cells are thought to influence both these processes due to the cytokines released.32 Progressive destruction of connective tissue Connective tissue fibers below the junctional epithelium are destroyed; the epithelium migrates along the root surface. Coronal portion of junctional epithelium becomes detached. Exposed cementum where Sharpey’s fibers were attached becomes altered by the host response to the bacterial challenge. Diseased cementum contains a thin superficial layer of endotoxins from the bacterial breakdown. Without treatment, loss of attachment results with an increase in pocket depth. Characteristics of the advanced lesion Pocket formation, bleeding, inflammation, and bone loss are all signs of periodontitis. Persistence of the chronic inflammatory process; plasma cells

predominate. Junctional epithelium continues to migrate; lesion extends through connective tissue. Periods of disease inactivity alternating with periods of activity.

GINGIVAL AND PERIODONTAL POCKETS The presence or absence of infection distinguishes a pocket from a sulcus and the level of attachment on the tooth distinguishes a gingival pocket from a periodontal pocket. A pocket has an inner wall (the tooth surface) and an outer wall (the sulcular epithelium or pocket epithelium) of the free gingiva. The two walls meet at the base of the pocket. The base of the pocket is the coronal margin of the attached periodontal tissues. Histologically, the base of a healthy sulcus is the coronal border of the junctional epithelium, whereas the base of a pocket (diseased sulcus) may be at the coronal border of the connective tissue attachment. Substances found in a pocket Communication of the opening of the pocket with the oral cavity provides an opportunity for dental biofilm to collect. The deeper the pocket, the more difficult it is to clean by toothbrushing or other biofilm control devices. The following may be found in a pocket: Microorganisms and their products: enzymes, endotoxins, and other metabolic products. Gingival crevicular fluid. Desquamated epithelial cells. Leukocytes, the numbers of which increase with increased inflammation in the tissues. Purulent exudate made up of living and broken down leukocytes, living and dead microorganisms, and serum. Pockets are divided into gingival and periodontal types to clarify the degree of anatomic involvement. Periodontal pockets are further categorized by their position in relation to the alveolar bone, that is, whether their pocket base is suprabony or intrabony (Figure 19-9).

FIGURE 19-9 • Types of Periodontal Pockets. A: Normal relationship of the gingival tissue and the cementoenamel junction in a fully erupted tooth. B: Gingival pocket showing attachment at the cementoenamel junction and the pocket formed by enlarged gingival tissue. There is no bone loss. C: Periodontal pocket showing attachment on cementum with root surface exposed. Gingival tissue has enlarged. D: Periodontal intrabony pocket with the bottom of the pocket within the bone. See the text for further description of each type of pocket.

I.

Gingival Pocket or Pseudopocket Definition: A pocket formed by gingival enlargement without apical migration of the junctional epithelium (Figure 19-9B). The margin of the gingiva has moved toward the incisal or occlusal without the deeper periodontal structures becoming involved. The tooth wall of the pocket is enamel. During eruption, the base of the sulcus is at various levels along the enamel. The base of the sulcus of a fully erupted tooth is near the cementoenamel junction. All gingival pockets are suprabony, that is, the base of the pocket is coronal to the crest of the alveolar bone.

II.

Periodontal Pocket Definition: A pocket formed as a result of disease or degeneration causing apical migration of the junctional epithelium along the cementum. The periodontal deeper structures (attachment apparatus) are involved, that is, the cementum, periodontal ligament, and bone. The tooth wall of the pocket is cementum or partly cementum and partly enamel. The base of the pocket is on cementum at the level of attached periodontal tissue. Periodontal pockets may be suprabony or intrabony. Suprabony: Pocket in which the base of the pocket is coronal to the crest of the alveolar bone (Figure 19-9A–C). Intrabony: Pocket in which the base of the pocket is below or apical to the crest of the alveolar bone (Figure 19-9D). “Intra” means located within the bone. The term “infrabony” is used in some texts. “Infra” means under or beneath.

III. Tooth Surface Irregularities Supragingival tooth surface irregularities are detected by drying the surface and observing under adequate direct or indirect light; limited use of the sharp tip of an explorer is recommended. Subgingival examination is dependent, for the most part, on tactile and auditory sensitivity transmitted by a probe or an explorer. Causes of surface roughness on the enamel surface include the following: Structural defects: cracks and grooves. Demineralization; cavitated dental caries. Calculus deposits and heavy stain deposits. Erosion, abrasion. Pits and irregularities from hypoplasia. Root surface irregularities Diseased cementum.

Cemental resorption. Root caries. Abrasion. Calculus. Deficient or overhanging filling (see Figure 19-5). Grooves from improper instrumentation. Irregularities at the cementoenamel junction The relationships of enamel and cementum at the cementoenamel junction are shown in Chapter 18.

COMPLICATIONS RESULTING FROM PERIODONTAL DISEASE PROGRESSION I. Furcation Involvement Furcation involvement means the clinical attachment level and bone loss have extended into the furcation area between the roots of a multirooted tooth (see the Glickman furcation grades in Chapter 20 and Figure 19-10).

FIGURE 19-10 • Classification of Furcations. I: Early, beginning involvement. II: Moderate involvement, in which the furcation can be probed but not through and through. III: Severe involvement, when the bone between the roots is destroyed and a probe can be passed through. IV: Same as III, with clinical exposure resulting from gingival recession.

Presence of furcation involvement increases the risk of tooth loss.33 It is difficult to adequately remove biofilm and calculus from the furcation area (see Figure 19-11) for both the dental hygienist and the patient who makes it challenging to manage the inflammation and infection in this area.

FIGURE 19-11 • Calculus in the Furcation Area and Root Depressions. This extracted molar has mineralized deposits (calculus) in the furcation. Once disease progresses into the furcation area, access for removal becomes difficult.

A. Clinical Observations When the gingiva over the furcation has not receded, the following may be seen: The furcation is covered by the periodontal pocket wall. No differences in color, size, or other tissue changes may exist to differentiate the area from adjacent gingiva, but when color changes do exist, they provide clues to guide further examination.

A radiolucency in the furcation area (sometimes called a furcation arrow) may be noted on the radiographs (Figure 19-12).

FIGURE 19-12 • Furcation Involvement. A: Note radiolucency in the furcation area on the distolingual of the maxillary first molar. B: The red triangle outlines the radiolucency in the furcation area.

When the gingiva over a molar furcation is receded, the root division may be seen directly (Figure 19-10).

B. Detection A suggested procedure for probing furcation areas is described in Chapter 20.

II.

Mucogingival Involvement

A pocket that extends to or beyond the mucogingival junction and into the alveolar mucosa is described as mucogingival involvement (Figure 19-13). There is no attached gingiva in the area, and a probe can pass through the pocket and beyond the mucogingival junction into the alveolar mucosa.

FIGURE 19-13 • Mucogingival Defect. A mucogingival defect is suspected at tooth #24, which has a very narrow zone of keratinized gingiva. (From Scheid RC. Woelfel’s Dental Anatomy: Its Relevance to Dentistry. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.)

A. Significance of Attached Gingiva Functions of attached gingiva Give support to the marginal gingiva. Withstand the frictional stresses of mastication and toothbrushing. Provide attachment or a solid base for the movable alveolar mucosa for the action of the cheeks, lips, and tongue. Barrier to passage of inflammation The junctional epithelium (epithelial attachment) acts as a barrier to keep infection outside the body. With destruction of the connective tissue and periodontal ligament fibers under the junctional epithelium, the epithelium migrates along the root. In a patient with poor oral hygiene, lack of attached gingiva or keratinized tissue is a predisposing factor for inflammation and possible further gingival recession.34,35

B. Clinical Observations Color changes, tension test, and probe measurements are used during assessment of the mucogingival areas (see Chapter 20). Thickness of attached gingiva: In patients with a thin type of gingiva, the periodontal probe will be visible through the gingiva when probing and these individuals are at greater risk for gingival recession.35 Width of keratinized or attached gingiva: current evidence suggests 1–2 mm of attached gingiva is desirable, although a minimal amount is not needed if the patient can execute optimal biofilm control at the site(s).35 When the attached gingiva measures 1–2 mm and there is no bleeding on probing or marginal inflammation, it is recorded and reevaluated at each continuing care or periodontal maintenance appointment (see Figure 19-14A and B).

FIGURE 19-14 • Measuring for a Mucogingival Defect. A: The width of keratinized gingival is measured at 2 mm. B: The probe depth is measured at less than 2 mm (only 1 mm), indicating no mucogingival defect. If the probe depth reached or exceeded the mucogingival junction (exceeded the width of keratinized gingiva), there would be no attached gingiva, and a mucogingival defect would be present. (From Scheid RC. Woelfel’s Dental Anatomy: Its Relevance to Dentistry. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.)

Long-term, longitudinal studies have shown that in the absence

of inflammation and good biofilm control, areas with a narrow band of attached gingiva can be maintained for long periods.34 A patient with such an area needs specific instruction in biofilm control procedures for preventive maintenance.

C. Mucogingival Deformities and Conditions Classification The 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions proposed a new classification for mucogingival conditions based more on treatment and potential for root coverage. It is quite complex and includes the following components35: Periodontal biotype related to the thickness of the gingiva, width of keratinized tissue, tooth dimension, and bone thickness. Gingival recession related to interdental CAL, facial/lingual attachment loss, severity, gingival thickness and width, cervical carious or non-carious lesions, hypersensitivity, and esthetic concerns. Lack of keratinized gingiva. Frenum position. Gingival excess. Abnormal color.

THE RECOGNITION OF GINGIVAL AND PERIODONTAL INFECTIONS I. The Clinical Examination The recognition of normal gingiva, gingival infections, and deeper periodontal involvement depends on a systematic, step-by-step examination. It is necessary to know the extent of the disease: Gingival infections are confined to the gingiva. Periodontal infections include all parts of the periodontium, namely, the gingiva, periodontal ligament, bone, and cementum. A comprehensive periodontal examination to gather assessment information and identify the signs of inflammation include the following: Gingival tissue changes (color, size, shape, surface texture, position). Mucogingival involvement (width of attached gingiva). Probing depths. Clinical attachment levels. Bleeding on probing. Exudate or suppuration. Furcation involvement. Dental biofilm and calculus distribution. Tooth mobility. Fremitus. Radiographic evaluation.

II.

Signs and Symptoms Patients may or may not have specific symptoms to report because periodontal infections may be painless. Symptoms the patient reports may include: Bleeding gingiva while brushing or flossing.

On occasion, spontaneous bleeding of the gingiva. Other possible symptoms the patient may notice include: Sensitivity to hot and cold. Tenderness or discomfort while eating or pain after eating. Food retained between the teeth. Unpleasant mouth odors. Chronic bad taste. A feeling that the teeth are loose.

III. Causes of Tissue Changes Disease changes produce alterations in color, size, position, shape, consistency, surface texture, bleeding readiness, and exudate production. To understand the changes that take place in the gingival tissues during the transition from health to disease, the clinician must understand: The role of biofilm in the development of disease. The inflammatory response initiated by the body. When the products of the biofilm microorganisms cause breakdown of the intercellular substances of the sulcular epithelium, injurious agents can pass into the connective tissue, where an inflammatory response is initiated. An inflammatory response means there is increased blood flow, increased permeability of capillaries, and increased collection of defense cells and tissue fluid. The changes produce tissue alterations, such as in color, size, shape, and consistency.

CLASSIFICATION OF PERIODONTAL HEALTH Before reviewing the classification of gingival and periodontal conditions, it is important to first define the classifications of periodontal health.28

I.

Pristine Periodontal Health Signs associated with pristine periodontal health28: No attachment loss. No bleeding on probing. No pocket depths greater than 3 mm. No gingival redness, swelling, edema, or suppuration.

II.

Clinical Periodontal Health (Intact Periodontium) Signs of clinical periodontal health classification28: Absence or minimal levels of clinical inflammation. No or minimal bleeding on probing. No attachment loss. No pocket depths greater than 3 mm.

III. Periodontal Disease Stability (Reduced Periodontium) Signs of periodontal disease stability28: No or minimal bleeding on probing. Optimal reduction in pocket depths. Control of modifying factors such as optimal control of diabetes and reduction or cessation of smoking.

IV. Periodontal Disease Remission/Control

(Reduced Periodontium) The periodontal disease remission/control classification is characterized by28: Reduction in inflammation, bleeding on probing, and pocket depth. May not have optimal control of modifying factors, that is, diabetes.

CLASSIFICATION OF GINGIVITIS Gingivitis continues to be designated into plaque-induced and nonplaque-induced gingivitis classifications. An overview is shared here, but there are many complexities to the classifications so the original 2017 World Workshop articles should be reviewed or a current periodontology textbook.

I.

Plaque (Biofilm)-Induced Gingivitis

Common clinical signs of gingivitis include inflammation, erythema, bleeding, swelling (enlargement), and possible tenderness.27

A. Dental Biofilm–Associated Gingivitis Dental biofilm is the primary etiology, but the severity may be impacted by tooth and root anatomy, restorative factors, and other tooth-related factors.27 No loss of attachment; however, gingivitis can also occur on a reduced periodontium and appears as inflammation of the gingival margin with no progression of attachment loss.27

B. Modifying Factors for Plaque-Induced Gingivitis Sex steroid hormones occur at various points in the life cycle can exacerbate gingivitis and include27: Puberty. Menstruation. Pregnancy. Oral contraceptives. Systemic conditions may also modify plaque-induced gingivitis and include27: Hyperglycemia is often seen in poorly controlled diabetes. Leukemia: enlarged, glazed, spongy gingiva that is red to deep

purple in color. Smoking. Malnutrition. Local risk factors (predisposing factors) include27: Poorly contoured restorations. Hyposalivation or xerostomia: Sjogren’s syndrome, medicationinduced, anxiety, etc. may result in xerostomia.

C. Drug-Induced Gingival Enlargement A number of drugs such as antiepileptic drugs (e.g., dilantin and valproate), calcium-channel blockers (e.g., nifedipine, verapamil, diltiazem), and immunosuppressants (e.g., cyclosporine), and highdose oral contraceptives.27 Occurs most commonly in the anterior areas and usually seen earliest in the papilla.

II.

Non-Plaque (Biofilm)-Induced Gingivitis

Plaque-induced gingivitis is one of the most common inflammatory diseases and although less common, non-plaque-induced gingivitis may be of importance for some patients.36

A. Genetic/Developmental Disorders Genetic causes of gingivitis are rare, an example is hereditary gingival fibromatosis.36

B. Specific Infections Bacterial origin36 Necrotizing gingivitis and stomatitis are due to underlying risk factors such as poor oral hygiene, stress, and compromised immunity with no loss of attachment. Sexually transmitted disease such as gonorrhea and syphilis.

Tuberculosis. Viral origin36 Herpes simplex, that is, primary herpetic infection or gingivostomatitis resulting in many vesicles that rupture leaving irregular mucosal ulcers. Human papilloma virus. Varicella-zoster virus. Fungal infections such as candidosis.36

C. Inflammatory and Immune Conditions Autoimmune diseases, that is, lupus erythematosus, lichen planus. Hypersensitivity reactions that is, contact allergies. Granulomatous inflammatory conditions, that is, Crohn’s disease.

D. Reactive Processes Lesions are thought to be due to a response to local irritation or trauma and may include pyogenic granuloma (pregnancy), fibrous epulis, etc.36

E. Neoplasms Premalignant lesions such as leukoplakia and erythroplakia. Malignant conditions such as leukemia and lymphoma.

F. Endocrine, Nutritional, and Metabolic Diseases Vitamin deficiencies like scurvy (vitamin C).36

G. Traumatic Lesions Physical/mechanical insults, that is, toothbrush abrasion, habits causing self-injury. Chemical insults, that is, etching, cocaine, dentifrice ingredients.

Thermal insults, that is, mucosal burns.

H. Gingival Pigmentation Gingival pigmentation may be the result of smoker’s melanosis, amalgam tattoo, or drug induced (minocycline), etc.36

CLASSIFICATION OF PERIODONTITIS The classification of periodontitis focuses on detectable interdental CAL.14

I.

Periodontitis Classifications

A. Necrotizing Periodontitis Necrotizing periodontal disease (NPD) begins as an acute condition with rapid tissue destruction, but NPD may also become chronic. Characterized by a history of pain, ulceration of the gingival margin, and punched out papillae.14 A major predisposing factor is a compromised host immune response. Factors associated with host response include37: HIV/AIDS: CD4 counts less than 200 and detectable viral load. Immunosuppression. Severe malnutrition. Psychological stress and insufficient sleep. History of NPD and poor oral self-care.

B. Periodontitis as a Manifestation of Systemic Disease Genetic disorders are rare, but may be significantly impact periodontal status. These include immunologic, metabolic, and endocrine disorders; and connective tissue, oral mucosa, and gingival tissue diseases.38 Systemic diseases have a variable effect on the course of periodontitis, but can influence the occurrence and severity. These include38: Diabetes mellitus. Obesity. Osteoporosis.

Arthritis (rheumatoid and osteoarthritis). Emotional stress and depression. Smoking. Medications. Systemic disorders associated with loss of periodontal tissue independent of periodontitis include: Neoplasms, that is, odontogenic tumors and squamous cell carcinoma. Other disorders such as hyperparathyroidism and scleroderma.

C. Periodontitis The periodontitis case definition or classification system aids in identification of disease, risk factors for progression of disease, and aid in identifying individualized approaches to management and treatment of the disease. The 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions system for classification of periodontitis takes into account the following elements14: Severity relates to the periodontal attachment loss at diagnosis and affects the complexity of management and treatment. Complexity of management includes factors such as probing depths, type of bone loss (vertical vs. horizontal), furcation involvement, occlusal issues. Extent refers to the number of teeth and distribution of the periodontitis and uses the terminology localized (30% of teeth affected), and molar–incisor involvement only. Rate of progression is primarily dependent on radiographic evidence over time of attachment loss, but other methods to assess progression are under investigation. Risk factors.

II.

Terminology for Staging Periodontitis

As previously noted, the staging of periodontitis includes: severity, complexity, and extent and distribution (Figure 19-15).14

FIGURE 19-15 • Periodontitis Stage Flow chart. (Credit: Lori J. Giblin-Scanlon, RDH, DHSc, Forsyth School of Dental Hygiene.)

Stage I is mild periodontitis. Stage II is moderate periodontitis. Stage III is severe periodontitis. Stage IV is very severe or advanced periodontitis.

A. Severity 1. Interdental CAL at site of greatest loss14: Slight or mild = 1–2 mm CAL. Moderate = 3–4 mm CAL. Severe or advanced = >5 mm CAL. 2. Radiographic bone loss (RBL)14 Coronal third (250 kHz).

Rotation oscillation. Counter oscillation. Sonic or ultrasonic motion. Side to side. Circular.

B. Speeds Vary from low to high. Generally, power brushes with replaceable batteries move slower than those with rechargeable batteries and have been shown to be

less effective in plaque biofilm removal.22 Movement per minute varies from 3,800 to over 48,000 depending on the manufacturer and type (battery, sonic, or ultrasonic).

C. Brush Head Design Adult: The variety of shapes continues to evolve, but a few examples are illustrated in Figure 26-4. They may be small and round, or like traditional manual heads. Trim profiles include flat, bilevel, rippled, or angled.

FIGURE 26-4 • Power Brush Trim Profiles. Power brushes are made in a variety of brush head shapes, such as oval, teardrop, rectangular, and round. Some power brushes have two different-shaped heads on the same brush. In addition, there are a variety of brush head trims on power brushes, including flat, bi-level, and multilevel.

Child: A child’s power brush head should be specially designed to accommodate a smaller mouth, as shown in Figure 26-5.

FIGURE 26-5 • Child Power Brush Profile. Power brushes for children could necessitate smaller head sizes and shorter filaments to allow for distal reach in tight posterior areas. Raised blue filaments allow for better access to occlusal pits and fissures.

D. Filaments or Bristles Made of soft, end-rounded nylon. Diameters: from extra soft, 0.075 mm (0.003 inch), to soft, 0.15 mm (0.006 inch).

E. Types of Power Source Direct

Utilize an electrical outlet. Replaceable batteries Relatively inexpensive and convenient. As most batteries lose their power, brush speed is reduced. Advise patients to select a brush that has a water-tight handle to avoid corrosion of batteries. Rechargeable Rechargeable, non-replaceable battery. Recharges via a stand connected to an electrical outlet. Disposable Batteries cannot be replaced or recharged.

TOOTHBRUSH SELECTION FOR THE PATIENT Overarching factors in toothbrush selection include the quality of clinical research supporting the efficacy and safety of the brush and the ADA Seal of Approval along with the clinical decision making of the clinician regarding what is best for an individual patient.

I.

Influencing Factors

Factors influencing the selection of a proper manual or power toothbrush for an individual patient include the following:

A. Patient Ability of the patient to use the brush and remove dental biofilm from tooth surfaces without damage to the soft tissue or tooth structure. Manual dexterity of the patient. The age of the patient and the differences in dentition and dexterity.

B. Gingiva Status of gingival and periodontal health. Anatomic configurations of the gingiva.

C. Position of Teeth Crowded teeth. Open contacts.

D. Compliance Patient preference may dictate which brush is recommended. Patient may have preferences and may resist change.

Patient may lack motivation, ability, or willingness to follow the prescribed procedure.

E. Specific Factors to Consider for Selection of Power Toothbrush Replaceable brush head. Features that include a timer and pressure sensor. Patient affordability. Battery-operated models are often less expensive and may be a good way for the patient to try out a power toothbrush before investing in a more expensive rechargeable model.

II.

Toothbrush Characteristics Brush head selection is dependent on the patient’s ability to maneuver and adapt the brush correctly to all facial, lingual, palatal, and occlusal surfaces for dental biofilm removal. Some research suggests angled tufted designs of manual toothbrush heads and rotating, oscillating round power brush heads are most effective.14,19

III. Stiffness of Filaments or Bristles Toothbrush bristles are typically classified as hard, medium, soft, or extra soft. The same classification for stiffness, that is, soft, may vary between manufacturers.24 Filaments must have adequate stiffness to remove plaque biofilm and do no harm to oral soft and hard tissues. Despite beliefs that a soft toothbrush is more effective, more recent research suggests plaque biofilm removal may be significantly better with a medium toothbrush.25 However, the ADA recommends a soft bristle toothbrush.12

Tooth abrasion and/or gingival abrasion and gingival recession are multifactorial even though they are often attributed solely to the failure to use a soft toothbrush.11 Factors include anatomical features (e.g., tooth position and crowding), toothbrushing technique, frequency, duration, force (pressure), and self-inflicted gingival trauma, which points to the need to individualize recommendations.26 An extra soft toothbrush may be indicated in conditions such as necrotizing ulcerative or following periodontal surgery.

METHODS FOR MANUAL TOOTHBRUSHING The ideal toothbrushing technique is one that the patient can perform effectively to remove plaque biofilm while avoiding any damage to hard and soft oral tissues. Research on which method is better remains limited (see Box 26-1 for a historical perspective on proper toothbrushing instruction). However, hands-on instruction with the patient leads to improvement in their brushing methods.27,28

BOX 26-1 Historical Perspective on Proper Toothbrushing Instruction Koecker, in 1842, wrote that after the dentist has scaled off the tartar, the patient will clean the teeth every morning and after every meal with a hard brush and an astringent powder. For the inner surfaces, he recommended a conical-shaped brush of fine hog’s bristles. For the outer surfaces, he believed in an oblong brush made of the “best white horse-hair.” He instructed the patient to press hard against the gums so the bristles go between the teeth and “between the edges of the gums and the roots of the teeth. The pressure of the brush is to be applied in the direction from the crowns of the teeth toward the roots, so that the mucus, which adheres to the roots under the edges of the gums, may be completely detached, and after that removed by friction in a direction toward the grinding surfaces.” Koecker L. Exhibiting a new method of treating the diseases of the teeth and gums. In: Principles of Dental Surgery. Baltimore, MD: American Society of Dental Surgeons; 1842:155-156.

Without instruction, normal brushing may consist of vigorous horizontal, vertical, and/or circular strokes.28 Manual toothbrushing methods include the following: Sulcular: modified Bass. Roll: rolling stroke, modified Stillman. Vibratory: Stillman, Charters, Bass. Horizontal (or scrub). Circular: Fones.

Vertical: Leonard.

THE BASS AND MODIFIED BASS METHODS The Bass and modified Bass methods are widely accepted as an effective method for dental biofilm removal adjacent to and directly beneath the gingival margin (sulcus) despite conflicting evidence.11,28,29 It is considered to be a type of sulcular brushing. The areas at the gingival margin and in the col are the most significant in the control of gingival and periodontal infections.

I.

Purposes and Indications Dental biofilm removal adjacent to and directly beneath the gingival margin. Open embrasures, cervical areas beneath the height of contour of the enamel, and exposed root surfaces. Adaptation to abutment teeth or implants, under the gingival border of a fixed partial denture.

II.

Procedure

A. Position the Brush30 Direct the filaments apically (up for maxillary, down for mandibular teeth). First, position the sides of the filaments parallel with the long axis of the tooth (Figure 26-6A).

FIGURE 26-6 • Bass/Modified Bass Method of Brushing. A: Filament tips are directed into the gingival sulcus at approximately 45° to the long axis of the tooth. B: Brushes designed with tapered filaments reach below the gingival margin with ease. C: Brush in position for lingual surfaces of mandibular posterior teeth. D: Position for palatal surface of maxillary anterior teeth.

From that position, turn the brush head toward the gingival margin to make approximately a 45° angle to the long axis of the tooth (Figure 26-6B). Direct the filament tips into the gingival sulcus (Figure 26-6A and B).

B. Strokes24,30 Press lightly so the filament tips enter the gingival sulci and embrasures and cover the gingival margin. Do not bend the filaments with excess pressure. Vibrate the brush back and forth with very short strokes without disengaging the tips of the filaments from the sulci. Count at least 10 vibrations. In the modified Bass method, the vibratory, sulcular brush stroke is followed by rolling the toothbrush down over the crown of the tooth to clean the rest of the tooth surface.

C. Reposition the Brush Apply the brush to the next group of two or three teeth. Take care to overlap placement, as shown in Figure 26-7.

FIGURE 26-7 • Brushing Positions. Each brush position, as represented by a black line, will overlap the previous position. Note placement at canines, where the distal aspect of the canine is brushed with the premolars and the mesial aspect is brushed with the incisors. Short lines on the lingual anterior aspect indicate a brush placed vertically. The maxillary teeth require a similar number of brushing positions.

D. Repeat Stroke The entire stroke (steps A–C) is repeated at each position around the maxillary and mandibular arches, on both facial and lingual tooth surfaces.

E. Position Brush for Lingual and Palatal Anterior Surfaces Tilt the brush handle somewhat vertically for the anterior components (Figure 26-6D).12 The bristles are directed into the sulci.

III. Limitations The toothbrush bristles extend only 0.9 mm below the gingival margin so plaque removal in the sulcus is limited.31 An individual who is an aggressive brusher may interpret “very short strokes” into a vigorous horizontal scrubbing motion causing injury to the gingival margin. Dexterity requirement for the vibratory stroke may be difficult for certain patients.

THE STILLMAN AND MODIFIED STILLMAN METHODS The modified Stillman method is considered a sulcular brushing technique along with the modified Bass method.

I.

Purposes and Indications As originally described by Stillman,32 the method is designed for massage and stimulation, as well as for cleaning the cervical areas. The modified Stillman method adds a rolling stroke to the vibratory stroke to clean the crown of the tooth.33 Dental biofilm removal from cervical areas below the height of contour of the crown and from exposed proximal surfaces. General application for cleaning tooth surfaces and massage of the gingiva.

II.

Procedure32

A. Position the Brush Place side of brush on the attached gingiva: The filaments are directed apically (up for maxillary, down for mandibular teeth) in Figure 26-8A. When the plastic portion of the brush head is in level with the occlusal or incisal plane, generally the brush is at the proper height, as shown in Figure 26-7A.

FIGURE 26-8 • Modified Stillman Method of Brushing. A: Initial brush placement with sides of bristles or filaments against the attached gingiva. B: The brush is pressed and angled, then vibrated. C: Vibrating is continued as the brush is rolled slowly over the crown. D: Using the toe of the brush, place the bristles into the gingival sulcus of the maxillary anterior teeth, press lightly, vibrate the bristles, and use a rolling stroke to clean the remainder of the lingual surface. Repeat for each anterior tooth and for the mandibular teeth.

The brush ends are placed partly on the gingiva and partly on the cervical areas of the tooth and directed slightly apically.

B. Strokes Press to flex the filaments: The sides of the filaments are pressed lightly against the gingiva, blanching of the tissue occurs (Figure 26-8B). Angle the filaments: Turn the handle by rotating the wrist so that the filaments are directed at an angle of approximately 45° with the long axis of the tooth. Activate the brush: Use a slight rotary motion. Maintain light pressure on the filaments, and keep the tips of the filaments in position on the tooth surface. Count to 10 slowly as the brush is vibrated by a rotary motion of the handle. Roll and vibrate the brush: Turn the wrist and work the vibrating brush slowly down over the gingiva and tooth. Make some of the filaments reach interdentally (Figure 26-8C).

C. Replace Brush for Repeat Stroke Reposition the brush by rotating the wrist. Avoid dragging the filaments back over the free gingival margin by holding the brush out, slightly away from the tooth.

D. Repeat Stroke Five Times or More

The entire stroke (steps A–C) is repeated at least five times for each tooth or group of teeth. When moving the brush to an adjacent position, overlap the brush position.

Position Brush for Anterior Lingual and Palatal E. Surfaces Position the brush somewhat vertically using the toe of the brush head for the anterior components (Figure 26-8D). Press and vibrate, roll, and repeat.

III. Limitations Careful placement of a brush with end-rounded filaments is necessary to prevent tissue laceration. Light pressure is needed. Patient may try to move the brush into the rolling stroke too quickly, and the vibratory aspect may be ineffective for biofilm removal at the gingival margin.

THE ROLL OR ROLLING STROKE METHOD I. Purposes and Indications Removing biofilm, materia alba, and food debris from the teeth without emphasis on gingival sulcus. Used in conjunction with a vibratory technique such as modified Bass, Charters, and Stillman methods. Can be particularly helpful when there is a question about the patient’s ability to master and practice a more complex method.

II.

Procedure34

A. Position the Brush Filaments: Direct filaments apically (up for maxillary, down for mandibular teeth). Place side of brush parallel to and against the attached gingiva: The filaments are directed apically. When the plastic portion of the brush head is in level with the occlusal or incisal plane, generally the brush is at the proper height, as shown in Figure 26-8A.

B. Strokes Press to flex the filaments: The sides of the filaments are pressed lightly against the gingiva. The gingiva will blanch. Roll the brush slowly over the teeth: As the brush is rolled, the wrist is turned slightly. The filaments remain flexed and follow the contours of the teeth, thereby permitting cleaning of the cervical areas. Some filaments may reach interdentally.

C. Replace and Repeat Five Times or More Repeat the entire stroke: The entire stroke (steps A and B) is repeated at least five times for each tooth or group of teeth.

Rotate the wrist: When the brush is removed and repositioned, the wrist is rotated. Stretch the cheek: The brush is moved away from the teeth, and the cheek is stretched facially with the back of the brush head. Be careful not to drag the filament tips over the gingival margin when the brush is returned to the initial position.

D. Overlap Strokes When moving the brush to an adjacent position, overlap the brush position, as shown in Figure 26-8.

E. Position Brush for Anterior Lingual or Palatal Surfaces Tilt the brush slightly vertically and use the toe of the brush head to access the lingual surfaces of the anterior teeth. Press (down for maxillary, up for mandibular) until the filaments lie flat against the teeth and gingiva. Press and roll (curve up for mandibular, down for maxillary teeth). Replace and repeat five times for each brush width.

III. Limitations Brushing too high during initial placement can lacerate the alveolar mucosa. Minimal plaque removal interproximally or in sulcular areas. Tendency to use quick, sweeping strokes results in failure to adequately remove plaque biofilm from the cervical third of the tooth because the brush tips pass over rather than into the area; likewise for the interproximal areas.

CHARTERS METHOD Charters strongly believed in prevention and felt dentists were not doing their “full duty” if they were not taking the time to teach patients a system of home care.35 He advocated for personal demonstration of techniques by the patient. Charters felt particularly strongly about teaching children proper home care and even went so far as to recommend it to be a part of the curriculum in schools.35

I.

Purposes and Indications Loosen debris and dental biofilm.35 Stimulate marginal and interdental gingiva.35 Aid in biofilm removal from proximal tooth surfaces when interproximal tissue is missing creating open embrasures, for example, following periodontal surgery.35 Remove dental biofilm from abutment teeth and under the gingival border of a fixed partial denture (bridge) or implant-supported bridge or partial denture.

II.

Procedure35

A. Position the Brush Filaments: Direct bristles at 90° angle to the teeth. Place side of brush at right angles (90°) to the long axis of the teeth (Figure 26-9B).

FIGURE 26-9 • Stillman and Charters Methods Compared. A: Stillman: The brush is angled at approximately 45° to the long axis of the tooth. B: Charters: The brush is angled at approximately 45° to the occlusal plane, with brush tips directed toward the occlusal or incisal surfaces.

Note the contrast with position for the Stillman method (Figure 269A).

B. Strokes Press the bristles gently between the teeth being careful not to injure the gingiva. With the bristles between the teeth, use as little pressure as possible and make three to four small rotary movements with the bristles. The sides of the bristles should come into contact with the gingival margin to massage or stimulate them. Remove the brush from the interproximal area and move to the next area.

C. Reposition the Brush and Repeat Repeat steps A and B, as described, three to four times in each area on the maxillary and mandibular arches.

D. Overlap Strokes Move the distance of one embrasure and repeat the process to overlap strokes.

III. Limitations Brush ends do not engage the gingival sulcus to disturb subgingival bacterial accumulations. In some areas, the correct brush placement is limited or impossible; modifications become necessary, consequently adding to the complexity of the procedure.

THE HORIZONTAL (OR SCRUB) METHOD I. Purposes and Indications A systematic review suggested the most effective method for toothbrushing in children is the horizontal method up to the age of 6 or 7 years.36 Once the child reaches the late mixed dentition stage, modification to another technique can be initiated as the horizontal method has limitations in terms of thorough plaque biofilm removal.

II.

Procedure

A. Position the Toothbrush Filaments: Direct bristles at right angle to the tooth. Place toothbrush head at a 90° angle to the long axis of the teeth on both buccal and lingual posterior surfaces. For anterior teeth, the head of the toothbrush is held parallel to the long axis of the tooth and the toe of the brush is used.

B. Stroke Bristles are moved in gentle back and forth motion on the posterior surfaces, buccal, lingual, and occlusal. Bristles are moved in an up and down motion on the anterior teeth using the toe of the toothbrush.

III. Limitations Although this method can remove plaque biofilm on buccal and lingual surfaces, it does not reach interproximal areas.29 There are also concerns about this method resulting in cervical abrasion if excessive pressure along with an abrasive toothpaste is

used in adults.11

THE FONES (OR CIRCULAR) METHOD I. Purpose and Indications This method is easy for children to learn.

II.

Procedure Place toothbrush at 90° to the long axis of the teeth, buccal and lingual, and press bristles gently against the teeth.

A. Stroke Bristles are moved in a circular motion several times in each area and then the brush is moved to a new area (Figure 26-10).

FIGURE 26-10 • Fones Method of Brushing. With the teeth closed, a circular motion extends from the maxillary gingiva to the mandibular gingiva using light pressure.

III. Limitations Efficiency of plaque removal was the lowest as compared to sulcular and horizontal brushing methods.37

LEONARD’S (OR VERTICAL) METHOD I. Purpose and Indication May work well for small children.

II.

Procedure Place toothbrush at 90° to the long axis of the teeth, buccal and lingual, and press bristles gently against the teeth. The teeth are edge to edge.

A. Stroke Bristles move in an up and down motion with light pressure on the tooth surfaces. Move systematically from area to area around the mouth.

III. Limitations Much like the rolling stroke, there is minimal plaque removal interproximally and in the sulcular areas.38

METHOD FOR POWER TOOTHBRUSHING As previously noted, a systematic review found powered toothbrushes reduced plaque biofilm and gingivitis better than a manual toothbrush and may be of benefit for some individuals.18 However, the type of power supply, mode of action of the powered toothbrush, brushing duration, and method of instruction are factors impacting the effectiveness of biofilm removal.22

I.

Procedure

Although no clearly defined brushing method has been evaluated, the following was developed by the Swiss Dental Society24: Place bristles at a 45° to 90° angle to the long axis of the tooth, then turn the brush on. Move the brush over the buccal (or lingual) and interproximal surfaces of each tooth (or area depending on the size of the brush head) for about 5 seconds. Reposition the brush on the next tooth and repeat both on the buccal and lingual surfaces in a systematic approach. Many powered toothbrushes have a built-in 2 minute timer which can signal to the patient the minimum brushing time.

II.

Limitations Cost for the rechargeable models can be an economic hardship for some patients. Some people may not like the sound or vibration of the powered toothbrushes, especially those with oral hyposensitivity. However, desensitization may allow for power toothbrushes to be used and they have been shown to be effective in those with autism.39

SUPPLEMENTAL BRUSHING METHODS I. Occlusal Brushing A. Purpose Loosen food debris and biofilm microorganisms in pits and fissures. Remove biofilm from the margins of occlusal restorations. Clean pits and fissures to prepare for sealants.

B. Procedure Place brush head on the occlusal surfaces of molar teeth with filament tips pointed into the occlusal pits at a right angle. Position the handle parallel with the occlusal surface. Extend the toe of the brush to cover the distal grooves of the most posterior tooth (Figure 26-11A).

FIGURE 26-11 • Occlusal Brushing. Small circular or vibrating strokes with light pressure while maintaining filament tips on the occlusal surface permit tips to work their way into pits and fissures.

Strokes: The two acceptable strokes include: Vibrate the brush in a slight circular movement while maintaining the filament tips on the occlusal surface throughout a count of

10. Press moderately so filaments do not bend but go straight into the pits and fissures. Force the filaments against the occlusal surface with sharp, quick strokes; lift the brush off each time to dislodge debris; repeat 10 times. Overlap previous stroke by moving the brush to the premolar area. Gradually progress around each maxillary and mandibular arch until all occlusal surfaces have been thoroughly debrided.

II.

Brushing Difficult-to-Reach Areas

A. Adaptations Hands-on demonstration by the patient is essential so the clinician can assess dexterity and ability of the patient to reach difficult areas. This also allows the clinician to determine if a different oral hygiene aid may be more effective. Use of disclosing solution to provide the patient and clinician with visibility of difficult-to-reach areas may be useful in order to work with the patient to modify the technique for effective plaque biofilm removal. At successive appointments, the difficult-to-reach areas should be monitored with continued refinement of oral self-care techniques.

B. Areas for Special Attention Distal surfaces of most posterior teeth (Figure 26-12). At best, the brush may reach only the distal line angles and a single- or endtufted brush may be necessary (see Chapter 27).

FIGURE 26-12 • Brushing Problems. Brush placement to remove biofilm from the distal surfaces of the most posterior teeth. The distobuccal surface is approached by stretching the cheek; the distolingual surface is approached by directing the brush across from the canine of the opposite side.

Facially displaced teeth, especially canines and premolars, where the zone of attached gingiva and buccal alveolar bone on the facial surface may be minimal. These areas are at risk for gingival recession and toothbrush abrasion. Lingually inclined teeth such as the maxillary anterior teeth. Exposed root surfaces: cemental and dentinal surfaces. Overlapped teeth or wide embrasures, which may require use of vertical brush position (Figure 26-13).

FIGURE 26-13 • Brush in Vertical Position. For overlapped teeth, open embrasures, and selected areas of recession, the dental biofilm on proximal tooth surfaces can be removed with the brush held in a vertical position.

Surfaces of teeth next to edentulous areas.

III. Tongue Cleaning The dorsum of the tongue is an ideal environment for harboring bacteria and is a key component of the overall oral self-care process.40

A. Anatomic Features of the Tongue Conducive to Debris Retention40 Surface papillae: Numerous filiform papillae extend as minute projections, whereas fungiform papillae are not as high and create

elevations and depressions that entrap debris and microorganisms. These papillae provide a large surface area for the microflora of the tongue. Fissures may be several millimeters deep and also provide a surface for bacterial growth.

B. Microorganisms of the Tongue Anaerobic bacteria involved in the production of volatile sulfur compounds related to oral malodor (bad breath) or halitosis reside on the tongue.40 Periodontal pathogens such as Porphyromonas gingivalis, Prevotella intermedia, and Aggregatibacter actinomycetemcomitans are also found on the dorsum of the tongue.40,41 Microorganisms in saliva are typically the same as those found on the tongue.

C. Purposes and Indications Remove or reduce tongue coating. Tongue coating is a white-brownish layer on the dorsum of the tongue and is made up of desquamated epithelial cells, blood cells and metabolites, food debris, and bacteria.40 The composition of the coating is affected by factors including periodontal status, salivary flow, age, tobacco use, and oral hygiene.40 The tongue coating is implicated in halitosis. Reduces bacterial load. However, research has not indicated that this reduces the periodontal pathogens on the dorsum of the tongue or in the saliva so the effect may be primarily on the bacteria producing halitosis.41 Reduces potential for halitosis.42 Tongue brushing and scraping can be effective in reducing halitosis. According to some research findings, the effect is unclear or may only provide short-term benefit.3,40

D. Brushing Procedure Hold the brush handle at a right angle to the midline of the tongue and direct the brush tips toward the throat. With the tongue extruded, the sides of the filaments are placed on the posterior part of the tongue surface. With light pressure, draw the brush forward and over the tip of the tongue. Repeat three or four times. A power brush can only be used for tongue cleaning when the switch is in the “off” position.

E. Types of Tongue Cleaners and Scrapers As an alternative to brushing the tongue, a tongue cleaner or scraper can be used. Tongue cleaners or scrapers are typically made of plastic or a flexible metal strip. A variety of tongue cleaners and scrapers are available and may include the following: Loop with a single handle (Figure 26-14).

FIGURE 26-14 • Tongue Cleaners or Scrapers. A variety of plastic or

flexible metal cleaners are available to clean the dorsal surface of the tongue.

Curved with two ends to hold. Raised, textured rubber pad on the back side of the toothbrush head. Procedure Place the cleaner toward the most posterior area of the dorsal surface (Figure 26-14). Press with a light but firm stroke, and pull forward. Repeat several times, covering the entire surface of the tongue. Wash the tongue cleaner under running water to remove debris.

GUIDELINES FOR TOOTHBRUSHING INSTRUCTIONS Comprehensive toothbrushing instruction for a patient involves teaching what, when, where, and how (see Chapter 24 for guidance effectively educating the patient). Hands-on demonstration by the patient is essential. In addition to a description of specific toothbrushing methods, the following sections address the grasp, sequence, frequency, duration, and force for toothbrushing. Possible detrimental effects from improper toothbrushing and variations for special conditions are described.

I.

Toothbrush Grasp

A. Objectives of Instruction on Grasp Ability to manipulate the brush for successful removal of dental biofilm. A light, but controlled grasp also accomplishes the following: Control of the brush during all movements. Effective positioning at the beginning of each brushing stroke, follow-through during the complete stroke, and repositioning for the next stroke. Sensitivity to the amount of pressure applied.

B. Procedure Grasp the toothbrush handle in the palm of the hand with the thumb against the shank. Grasp the brush near the head so it can be controlled effectively. Do not grasp so close to the head of the brush that manipulation of the brush is hindered or fingers touch the anterior teeth when moving the brush head to molar regions.

Position according to the brushing method to be used. Adapt grasp for the various positions of the brush head on the teeth throughout the procedure; adjust to permit unrestricted movement of the wrist and arm. Apply appropriate pressure for removal of the dental biofilm avoiding excessive pressure that results in soft tissue trauma.

II.

Brushing Sequence There is no one recommended sequence for brushing. Research suggests similar results irrespective of whether patients begin on the buccal or lingual surfaces.43 The brushing process should be approached in a systematic way to ensure complete coverage for each tooth surface. Divide the mouth into sextants or quadrants. Start brushing from a molar region of one arch around to the midline facial then lingual followed by brushing the occlusal surfaces. Repeat in the opposing arch. Each brush placement should overlap the previous one for thorough coverage as shown in Figure 26-7. Approaches to address areas where patients may have more difficulty removing plaque biofilm may include: Changing the sequence and starting with areas where the patient misses plaque biofilm such as the lingual of the mandibular right for a right-handed patient and mandibular left for a left-handed patient. Specific areas with active periodontal disease.

III. Frequency of Brushing Brushing a minimum of 2 times/day has been shown to reduce caries incidence and severity of periodontal disease.44,45 Regular daily oral self-care is most effective at reducing risk and severity of oral disease. Infrequent brushing results in higher odds

for dental caries and more severe periodontal disease.44,45 Failure to adequate disturb plaque biofilm allows for continued maturation which increases the pathogenic potential of the biofilm (see Chapter 17). Quality of brushing technique for plaque biofilm removal is equally important as the frequency.

IV. Duration of Brushing The average times for brushing range from 60 to 80 minutes in the literature.46 Several factors impact the time required for each individual including tendency to accumulate plaque, psychomotor skills, position of the teeth, orthodontics, etc. Research suggests an increase in plaque removal with increased brushing time.47 However, more recent research with power toothbrushes suggests that there is no additional benefit beyond 120 seconds or 2 minutes for brushing duration.48

A. The Count System To ensure thorough coverage with an even distribution of effort in all areas, a system of counting can be useful. Count the number of strokes in each area (or 5 or 10, whichever is most appropriate for the particular patient) for modified Stillman or other methods in which a stroke is used. Count slowly to 10 for each brush position while the brush is vibrated and filament ends are held in position for the Bass, Charters, or other vibratory method.

B. The Clock System Some patients brush thoroughly while watching a clock or an egg timer for 3 or 4 minutes. Timed procedures cannot guarantee thorough coverage, because

the easily accessible areas may get more brushing time.

C. Combination For many patients, the use of the “count” system in combination with the “clock” system may be most effective.

D. Built-in Timers Many power toothbrushes have built-in timers that signal lapsed time. Signals may be set for 30 seconds, 1 or 2 minutes. Timers can motivate patients to increase the total time spent brushing.

E. Oral Hygiene Mobile Applications There are a variety of mobile toothbrushing applications (also known as apps) available for download on a variety of electronic devices including cell phones and tablets which provide an interactive brushing experience and reminders, thus enhancing patient oral hygiene.49–51 These applications may include the following features51: Educational videos and texts. Goal setting with reminders such as “Time to brush!” set to times designated by the patient. Monitoring of oral hygiene behaviors through reports and graphs of how often a patient brushes or flosses and the duration. Feedback on progress toward goals such as badges for children. Peer support through sharing of progress with friends. Research suggests these mobile applications hold promise in terms of improving oral hygiene. In adolescents, use of a mobile app resulted in reductions in gingivitis and plaque compared to verbal oral hygiene instructions.50 In another study, the majority (>90%) of participants said the app

motivated them to brush their teeth longer.49

V.

Toothbrushing Force

Toothbrushing force has been evaluated in terms of the impact on gingival recession and tooth abrasion as well as on effectiveness of plaque removal.48,52,53 Most research suggests that plaque removal is improved with force up to a point beyond which there is no benefit and potential harm.53 Suggested optimal brushing force for plaque removal: Manual toothbrushing: 400 g.53 Power toothbrushing: 150 g.48 Although force alone does not cause soft and hard tissue injury, that is, gingival recession and tooth abrasion, it is important to provide patient education to avoid aggressive brushing techniques while effectively removing plaque biofilm.54 Many power toothbrushes have a mechanism to alert the user to excessive force which may help them to adjust the force applied in those who brush aggressively and are unable to modify their manual toothbrushing technique.55,56

VI. General Toothbrushing Instruction A. Preparation for Instructing Patient The dental hygienist must become familiar with an oral self-care product before providing patient education. For power toothbrushes, review manufacturer instructions and practice with a toothbrush model, if available, prior to instructing the patient on using it effectively.

B. Patient Education Research suggests the most effective teaching strategies for

patient education include computer technology, audio and videotapes, written materials, and demonstrations.57 Verbal instructions alone had only a small effect on patient outcomes, that is, plaque biofilm removal, and should not be used as a stand-alone educational strategy. Demonstrations had the largest effect on patient outcomes and are an essential component of educating the patient. Multiple educational strategies lead to further improvement in patient outcomes. When initially introducing a new power toothbrush or oral self-care aid, a demonstration model and/or video can be helpful to introduce the new product to the patient. Adult learning theory suggests patients come to us with experience so it is important to understand what the patient already knows prior to beginning patient education.58 Like motivational interviewing (see Chapter 24), adult learning theory stresses the importance of the adult patient establishing the learning goals. If a patient is familiar with an oral self-care tool such as a toothbrush, allow the patient to demonstrate their technique and help refine it as needed to be effective. Disclosing the plaque biofilm in the patient’s mouth can be very useful to provide the patient with a way to visualize the biofilm and its removal when practicing brushing and other oral self-care aid techniques. Do not forget to provide the patient with a hand mirror. Disclosing plaque biofilm makes it easy for the patient and clinician to assess whether the techniques have been effective in biofilm removal. In subsequent follow-up appointments, disclosing the plaque biofilm is also a way for the patient and clinical to assess progress toward plaque biofilm removal goals and to identify problem areas requiring further modification of techniques or a different oral self-care aid. Observe the patient’s technique and refine as needed to show the patient how to adapt the brush head to reach difficult areas.

C. Toothbrushing Procedure Select a brush size and shape appropriate for the individual patient. Select a dentifrice with minimum abrasivity. Place a small amount of fluoride dentifrice on the brush and spread the dentifrice over the teeth. For a manual toothbrush: Place the brush on the most posterior maxillary molar and begin moving around each arch on the buccal and then lingual surfaces using the chosen toothbrushing method until all surfaces are completed. Move the brush to the mandibular teeth and repeat. This sequence may vary depending on the preferences of the patient. Brush the occlusal surfaces of first the maxillary and then the mandibular teeth. For a power toothbrush, place the brush in the mouth before turning the power on to prevent splatter. Place the brush on the most posterior maxillary molar and move the brush around all surfaces including angling into interproximal areas of each tooth if using a small circular brush. If using a more typical rectangular brush head, start in the posterior and work on each area individually before moving to the next. Carefully angle the brush head to access rotated, crowded, or otherwise displaced teeth.

TOOTHBRUSHING FOR SPECIAL CONDITIONS Prolonged omission of biofilm removal is not indicated because of the association between oral infection and inflammation and many systemic diseases/conditions.59 Examples of conditions that may require a temporary modification of oral self-care routines may include, but are not limited, to the following conditions.

I.

Acute Oral Inflammatory or Traumatic Lesions

When an acute oral condition precludes normal oral self-care, instruct the patient to: Brush all areas of the mouth not affected and if tolerable clean the affected area with an extra soft toothbrush. Reducing the bacterial load is essential to aid in healing. Rinse with a warm, mild saline solution to encourage healing and debris removal. Consider prescribing an antimicrobial rinse like chlorhexidine to aid in the reduction of bacterial load until normal oral self-care can resume. Resume regular biofilm control measures on the affected area as soon as possible.

II.

Following Periodontal Surgery

Provide specific instructions concerning brushing while sutures and/or a dressing are in place. Perform oral self-care in the areas not involved in the surgery as usual. Follow directions provided by the periodontal office for care of the surgical area. Rinsing and brushing the surgical area may not be recommended until at least 24 hours after surgery at which time care should be taken to avoid the gingival areas when brushing.

If gingival grafting was done, no brushing may be allowed until the postoperative follow-up appointment. An antimicrobial rinse like chlorhexidine may be prescribed to aid with reducing the bacterial load and to aid in healing while the oral self-care process is modified.

III. Following Dental Extraction Clean the teeth adjacent to the extraction site the day following surgery. Brush areas not involved in the surgery as usual to reduce biofilm and promote healing. Beginning 24 hours after surgery, rinse the mouth with a warm, mild saline solution after each meal or snack to help remove food debris from the extraction site. Detailed instructions for pre- and post-surgery are found in Chapter 56.

IV. Oral Self-Care of the Neutropenic Patient Neutropenia or a low white blood cell count (14 weeks) nicotine patch + nicotine gum or spray

Nicotine patch + nicotine inhaler Nicotine patch + bupropion SR.

IV. Second-Line Medications Second-line medications are pharmacotherapies for which there is evidence of efficacy for treating tobacco dependence, but they have a more limited role because of the following reasons2: The FDA has not approved them for a tobacco dependence treatment indication. Second-line treatments, clonidine and nortriptyline, can be considered for use on a case-by-case basis after first-line treatments have been used or considered and while under a primary care provider’s supervision.

V.

Alternative Cessation Therapies

Research suggests alternative aids such as acupuncture and hypnotherapy may help with smoking cessation.75 It is unclear whether these alternative smoking aids are as effective as pharmocotherapies.75

DENTAL HYGIENE CARE FOR THE PATIENT WHO USES TOBACCO The majority of people who smoke state they would like to quit, and almost half say they have tried to quit in the past 12 months.59 The tobacco-using patient presents a unique challenge to the oral health team. Specific treatment modifications are indicated. Helping the patient to quit using tobacco becomes an integral part of the dental hygiene care plan.

ASSESSMENT I. Patient History Tobacco use status is assessed at each appointment. The basic history form in Chapter 11 used by all patients includes questions to determine whether the patient currently uses tobacco and, if so, the types of tobacco (cigarette, ATPs, and/or smokeless). A sample of a tobacco use assessment form is shown in Figure 323.

FIGURE 32-3 • Sample Tobacco Use Assessment Form.

Concomitant use of alcohol and other psychoactive drugs (substances that can alter mood, behavior, cognitive processes, or mention tension) with tobacco may necessitate modifications of clinical procedures.56 Healthcare providers should consider tobacco use status as a vital sign along with temperature, pulse, respiratory rate, and blood

pressure.65,67

II.

Extraoral Examination Breath and body odor Halitosis.76 Smoke from tobacco products clings to skin, hair, and clothes and results in body odor.30 Fingers Smokers of nonfiltered cigarettes have a yellowish-brown discoloration of the fingers and fingernails. Skin Smokers experience premature and more extensive facial wrinkling.1 Lips Cigar smokers are at risk for development of precancerous and cancerous lip lesions.4

III. Intraoral Examination An excellent outline for conducting a thorough intraoral examination for the patient who uses tobacco is provided in Chapter 13. Oral consequences of tobacco use are listed in Table 32-3.

CLINICAL TREATMENT PROCEDURES Patients who use tobacco may require longer and more frequent appointments due to the presence of increased risk for the following1,52,77,78: Dental stain Calculus Dental caries Gingival inflammation Periodontal problems

I.

Dental Biofilm Control Self-care for daily dental biofilm control is the first priority in the care plan. Meticulous oral self-care is required by this group of high-risk patients owing to their susceptibility to dental caries, periodontal infections, and other soft-tissue alterations.

II.

Nonsurgical Periodontal Therapy Inform the patient healing will be jeopardized by continued tobacco use, and users cannot expect the same treatment results as nonusers.52,54 Inform the patient tobacco cessation would improve the results of treatment.79 When using power-driven instruments: Take precautions to protect the patient from aerosols-containing bacteria and debris (smokers often have pulmonary and cardiovascular complications).1

III. Other Patient Instruction Diet and nutrition

Tobacco users may be poorly nourished because tobacco use suppresses appetite.80 Conversely, the desire to control body weight through tobacco use may impede a patient’s willingness to quit.2 Suggestions about diet and exercise are included as a part of the cessation program.2

TOBACCO CESSATION PROGRAM A program for tobacco cessation is an essential component of the oral healthcare plan for all tobacco-using patients.2,64,81 The treatment of tobacco use and dependence will often require multiple appointments, repeated interventions, and multiple attempts to quit.2,81 The dental setting provides an excellent opportunity to assist tobacco users in tobacco cessation.2,64,81 Interventions and their outcomes will vary depending on the motivation and experience of the clinician and the patient’s acceptance of, and adherence to, the regimen.2,81 Even a minimal intervention conducted by a clinician may help a patient become tobacco free.67

MOTIVATIONAL INTERVIEWING The use of brief motivational interviewing is an effective method of tobacco cessation. Motivation and improving self-confidence increase likelihood of tobacco cessation.78,79 Motivational interviewing techniques are described in Chapter 24, which can be useful in conversing with patients concerning behavior change.

THE “5 A’s” The “5 A’s”—ask, advise, assess, assist, arrange—provide the basis for a brief, simple, but effective tobacco dependence intervention for clinicians.2,82,83 A cessation program flowchart is presented in Figure 32-4.

FIGURE 32-4 • Tobacco Cessation Flowchart. Flowchart to show how the 5 A’s can be incorporated into the clinical setting. (Adapted from Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. In: Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service; 2009.)

I.

Ask Health history Ask all patients about tobacco use.2,81 Include questions about tobacco use on the health history (Chapter 11) and document tobacco use at every appointment. Present questions carefully2 During review of the health history, present questions related to tobacco use nonjudgmentally. Address tobacco use as a health issue, not as a moral and/or social issue. Obtain facts without placing the patient on the defensive. Obtain patient’s confidence2 Express empathy and support patient’s decision to choose or reject change. Social disapproval of tobacco use is increasing, and patients may hesitate to disclose their habit. Children and adolescents E-cigarettes are the most common tobacco product used among adolescents.84 In the United States, 6.6% of adolescents reported smoking a whole cigarette before 13 years of age.85 The two greatest factors effecting a child or adolescent smoking are parents who smoke and parental nicotine dependence.86 Brief counseling, including risk assessment, needs to be implemented to prevent initiation of tobacco use. Assessment should include parent’s history of smoking, product access, smoking among peers, and tobacco advertisement exposure.86 Most smokers try their first cigarette at approximately 11 years of age.85 Children need to hear negative impact messages to counter messages produced by the tobacco industry.38 Discuss with the parents about the effects of ETS on health, developmental risks, and how tobacco use sets a bad example for children.1

Group-based behavioral interventions may be helpful in adolescent tobacco cessation.74

II.

Advise2,81

A. Never Users/Former Users Advise every patient about tobacco use. Praise “never users” and “former users” for their tobacco-free behavior. Reinforcement counters the tobacco industry’s message and other enticements to begin tobacco use and can help prevent relapse.

B. Current Users: Stop–Look–Listen Approach 1. Stop now: Clearly advise the patient about the importance of stopping now. Present the advice in a caring, compassionate manner so patients realize clinicians are interested in their health and well-being. 2. Show: Have patients look in their mouths during the initial oral examination to observe the clinical effects of tobacco use. Patients may or may not be impressed by a discussion of possible future health problems or of the effect of tobacco use on others. Advice needs to be relevant to existing conditions. Existing oral conditions that may serve as strong motivators to quit. 3. Listen2: Ask patients whether they want to quit and their reasons. Most users want to quit. Their reasons may have little to do with health, but verbalizing the reasons force patients to focus and strengthen their reasons. Listening to the patient allows the clinician to support the patient’s thoughts and provide appropriate reinforcement.

III. Assess2,81 1. Ask the patient: “Are you ready to quit?” 2. If the patient is ready: Determine whether the patient could best be treated in your practice. (A patient may have multiple problems necessitating referral.) If treatment is provided in your office, go to the assist step. 3. If the patient is not ready to quit, use the “5 R’s”: Relevance: Patient indicates personal importance of quitting. Risks: Patient identifies negative consequences of continued use. Rewards: Patient identifies personal benefits of quitting. Roadblocks: Patient identifies barriers to quitting, and clinician helps address barriers. Repetition: Reinforce the motivational message at every visit.

IV. Assist A. Establish a Quit Plan Set a quit date, preferably within 2 weeks.2,81 Have the patient tell family, friends, and coworkers about quitting and request their understanding and support.2,81 Warn the patient to anticipate challenges to the planned quit attempt, particularly during the first few weeks. This includes nicotine withdrawal symptoms. Ask the patient to remove all tobacco-related products from home and work sites.2

B. Provide Practical Counseling Total abstinence is essential: “not even a single puff or dip after the quit date.” Review past quit attempts and identify what helped and what

factors contributed to relapse. Discuss challenges/triggers and how the patient will overcome them successfully. Because alcohol can cause relapse, the patient needs to limit/abstain from alcohol use. Quitting is more difficult when there is another smoker in the household. Tobacco-using housemates are encouraged to avoid use in the presence of the patient attempting to quit. Prolonged use of varenicline may assist in relapse prevention.87

C. Pharmacotherapy The combination of smoking cessation counseling and medication is more effective than either counseling or medication alone.69 Suggest the use of approved OTC or prescription pharmacotherapy. Refer to Table 32-5.

D. Provide Educational Information Agencies publishing motivational materials are listed in Table 32-6. TABLE 32-6 • Sources for Tobacco Cessation Patient Educational Materials NAME OF SOURCE

QUIT LINES

LINKS

American Cancer Society

1–877—yes quit 1–877—937– 7848

www.yesquit.com https://www.cancer.org/treatment.html

American Lung Association

1-800LUNGUSA

http://www.lung.org/support-andcommunity/

National Cancer Institute

www.cancer.gov

CDC Tobacco Information and

www.cdc.gov/tobacco/

Prevention Tips Nicotine Anonymous

www.nicotine-anonymous.org

QuitNet

www.quitnet.com

National Alliance for Tobacco Cessation

www.becomeanex.org

You Can Quit Smoking— Agency for Healthcare Research and Quality

www.ahrq.gov/consumer/tobacco

Smokefree.gov

National Quit Line 1–800—QuitNow (1–800-784– 8669)

www.smokefree.gov

Web-based tobacco interventions have demonstrated promising evidence over the past few years. An e-referral program www.decide2quit.org is funded by the National Institutes of Health and is free service.88,89 Specific educational materials are available for: Various cultures and ethnic groups. Different levels of education and literacy. Readers of all ages. Keep a supply of these materials in the office for distribution to patients. Online communities can be supportive, providing motivation and reinforcing cessation.90

V.

Arrange

A. Follow-up Essential for successful quit rates.2,81 Provide written documentation as a reminder, listing their quit date. Suggest posting quit-date reminders in visible locations, such as refrigerator door or bathroom mirror or placing index card, with the quit date between cellophane and paper of the cigarette package.2,81

B. Contact the Patient before the Quit Date Assure patient of care provider’s sincere interest in their tobacco cessation attempt via telephone call, e-mail, or text message.2 Inquire: If information provided at initial contact has been helpful. If the patient has any questions regarding the information received. Follow-up contact2,81 Follow-up, either in person or via telephone or e-mail. Timely intervals would be once within the first week after the quit date when the patient’s physical withdrawal symptoms are most intense, and again at the end of the first, second, and third months of their tobacco cessation. More than four contacts with patient help to increase long-term abstinence. Follow-up at regularly scheduled continuing care appointments. Actions during follow-up contact2,81 Congratulate and praise patients who have remained tobacco free. Provide the opportunity for patients to ask questions. If they have none, encourage the patient to contact you if questions arise. If relapse has occurred, ask the patient to recall and record the circumstances that led to reuse.2,81 Encourage the patient to set another quit date, reminding the patient that a lapse can be a learning experience.2,81

Review the use of pharmacotherapy.2,81 Provide agencies and local contact numbers for the patient who requests a more intensive cessation program.

THE TEAM APPROACH Evidence concludes that oral health professionals are more effective than other healthcare professionals in providing tobacco cessation interventions.2,64

I.

Organize the Clinic Team2 Select a team coordinator The coordinator does not do everything, but sees that everything is done. Responsibilities Identify tobacco use status at patient’s first visit. Record appropriate documentation in patient’s records. Ensure all tobacco-using patients are offered the opportunity to enter a cessation program. Contact patients for follow-up. Act as a coach for patients who relapse. Maintain a supply of literature for patients.

II.

Organize a Tobacco-Free Environment2 Display tobacco use prevention and cessation materials prominently. Eliminate magazines that contain tobacco advertising from reception area.

III. Organize a Tobacco User Tracking System Tobacco use assessment form: Figure 32-3. Patient permanent progress report: Records include dated case notes for all advice to quit, responses and interest in quitting, and progress.2 Tobacco status on records: Clearly mark records (paper or

electronic) so status can be immediately seen by any clinic staff.

ADVOCACY1 I. Public Health Policy The Surgeon General’s Report on Oral Health was the first report of a Surgeon General focused on oral health, and the report specifically identified tobacco use as a risk factor for oral cavity and pharyngeal cancer.91 Healthcare providers can help tobacco users quit and can become partners with one another and with community programs to prevent diseases and promote good health habits. The Centers for Disease Control and Prevention has been supporting state-based tobacco control coalitions in all 50 states. Many local communities and municipalities are considering or have adopted smoke-free workplace ordinances.92 Oral health professionals can be valuable and collaborative partners in these programs.64

II.

Community Oral Health Educational Programs

No community oral health program can be considered complete without inclusion of tobacco prevention, control, and cessation education. Excellent materials are available from many nonprofit and professional organizations.

DOCUMENTATION2 Careful and complete documentation of tobacco use is a component of each patient assessment. It is part of the health history for new patients and part of the clinical (progress) notes for maintenance patients. Include tobacco history and/or current use, type of tobacco, and amount typically used. Age, ethnicity, gender, periodontal, and overall dental status as well as oral cancer screening findings. Patient interest/confidence motivation/readiness to quit and previous quit attempts and techniques used. Options for cessation presented to patient and referrals to primary care provider for examination/treatment. Box 32-4 contains an example for tobacco use assessment and cessation treatment.

BOX 32-4 Example Documentation: Tobacco Use Assessment and Cessation Treatment S— A 45-year-old African American male presents for second quadrant scaling, upper left (UL) with local anesthesia, and postscaling evaluation of first quadrant, upper right (UR). Cigarette smoker for 15 years; 1–2 packs a day. Patient states his oral self-care has improved since the initial quadrant scaling. Patient’s chief complaint: Gums still sore from previous scaling appointment. O—Intraoral assessment reveals slow healing for first quadrant scaling with localized inflammation and erythematous areas, evidence of nicotine stomatitis, other oral cancer finding negative, and no cavitated carious lesions. Periodontal examination findings: UL quadrant with generalized 5–6 mm pocket depths, and 7 mm pocket on #15 MB, bleeding on probing #14 and 15 buccal. A—Patient presents with a high risk for oral and systemic disease due to tobacco dependence. Provided patient with smoking cessation basics, and explanation of oral and systemic effects of tobacco use. Brief discussion indicated patient is motivated to quit because he and his wife are expecting their first baby, but reports previous attempts to quit “Cold Turkey” were

unsuccessful due to weight gain, mood swings, and increased stress. P—Patient congratulated on wanting to quit and reminded previous attempts at quitting should not be looked upon as failures. Introduced various options for cessation support. Patient agreed to Internet option www.smokefree.gov, with quitting apps; walked patient through the website. Additionally, patient agreed to 21 mg nicotine transdermal patch, transitioning to 14 mg, then 7 mg patch over 8–10 weeks, combining patch therapy with nicotine gum to help prevent weight gain and provide relief for additional withdrawal symptoms and cravings. Follow-up by telephone in 1 week and re-evaluate at next visit scheduled in 2 weeks. Next visit: Scale lower right quadrant with local anesthesia, reassess UL quadrant, and continue tobacco cessation counseling. Signed: _____________________________, RDH Date: ___________________________________

EVERYDAY ETHICS Fifteen-year-old Jason comes with his mother for a regular maintenance appointment. During the oral examination, Edith, the dental hygienist who has been providing dental hygiene treatment for Jason and his family for many years, notices small red and white patches in the vestibular areas of the mandible adjacent to the molar teeth. She also records moderate brownish staining on the teeth and plans to use the air-powder polisher after scaling. She questions Jason about smoking and the use of smokeless tobacco, but he states he has tried cigarettes only once or twice. Questions for Consideration 1. What approach can Edith use to further assess and enhance Jason’s understanding of the oral effects of tobacco use if she suspects he is not telling the truth? 2. What alternatives does Edith have in reporting her assessment findings to maintain Jason’s right to confidentiality but still inform his mother of the potentially serious oral tissue changes she has observed? 3. Which legal and ethical concepts apply to this situation?

Factors to Teach the Patient The most effective method to stop using tobacco or nicotine use is never to

start. How to perform a regular self-examination of the oral cavity. Pregnant women who use tobacco products can harm the developing fetus and the newborn infant. Young children may experiment with or use tobacco products. Parents can be educated so that they are prepared to provide guidance. All forms of social tobacco use can lead to addiction. Nonsmokers who breathe ETS can incur the same serious health problems as smokers; children are especially susceptible. Smokeless tobacco use is not a safe alternative to smoking. Oral health team members can help patients become tobacco free. Learn about local or state tobacco legislation and public health policy to make informed choices related to a tobacco smoke-free society.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention (US); 2014. 2. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service; 2009. 3. Hu S, Neff L, Agaku I, et al. Tobacco product use among adults—United States, 2013-2014. MMWR Morb Mortal Wkly Rep. 2016;65:685-691. doi:10.15585/mmwr.mm6527a1. 4. Sung H, Wang Y, Yao T, Lightwood J, Max W. Polytobacco use of cigarettes, cigars, chewing tobacco, and snuff among U.S. adults. Nicotine Tob Res. 2016;18:817-826. 5. Ko T, Tsai L, Chu L, et al. Parental smoking during pregnancy and its association with low birth weight, small for gestational age, and preterm birth offspring: a birth cohort study. Pediatr Neonatol. 2014;55(1):20-27. 6. Singh T, Arrazola RA, Corey CG, et al. Tobacco use among middle and high school students—United States, 2011-2015. MMWR Morb Mortal Wkly Rep. 2016;65(14):361-367. doi:10.15585/mmwr.mm6514a1. 7. American Cancer Society. Cancer facts and figures 2017. 2017. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-andstatistics/annual-cancer-facts-and-figures/2017/cancer-facts-and-figures2017.pdf. Accessed November 28, 2017. 8. Benowitz NL, Hukkanen J, Jacob P. Nicotine chemistry, metabolism, kinetics, and biomarkers. Handb Exp Pharmacol. 2009;192:29-60. doi:10.1007/978-3540-69248-5_2. 9. Maisto SA, Galizio M, Connors GJ. Drug Use and Abuse. 8th ed. Boston, MA: Cengage Learning, Inc.; 2019. 10. Office on Smoking and Health. Centers for Disease Control and Prevention (CDC). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services; 2006. 11. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. 2010. http://www.cdc.gov/tobacco/data_statistics/sgr/2010/index.htm. 12. Food and Drug Administration. Harmful and Potentially Harmful Constituents in Tobacco Products and Tobacco Smoke; Established List. Atlanta, GA: U.S. Department of Health and Human Services; 2012. 13. Djordjevic MV, Doran KA. Nicotine content and delivery across tobacco products. Handb Exp Pharmacol. 2009;192:61-82. doi:10.1007/978-3-54069248-5_3.

McMillen R, Maduka J, Winickoff J. Use of emerging tobacco products in the 14. United States. J Environ Public Health. 2012;2012:989474. doi:10.1155/2012/989474. 15. U.S. Department of Health and Human Services. E-Cigarette Use among Youth and Young Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2016. 16. U.S. Food and Drug Administration. Deeming Tobacco Products to Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products. Federal Register. https://www.federalregister.gov/documents/2016/05/10/2016-10685/deemingtobacco-products-to-be-subject-to-the-federal-food-drug-and-cosmetic-act-asamended-by-the. Published May 10, 2016. Accessed November 28, 2017. 17. Centers for Disease Control and Prevention, Office on Smoking and Health. Smokeless tobacco: products and marketing. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/products_marketing/inde Accessed November 19, 2017. 18. World Health Organization. Smokeless tobacco and some tobacco-specific NNitrosamines. 2007. https://www.cabdirect.org/cabdirect/abstract/20083307001. Accessed January 20, 2018. 19. Munshi T, Heckman CJ, Darlow S. Association between tobacco waterpipe smoking and head and neck conditions: a systematic review. J Am Dent Assoc 1939. 2015;146(10):760-766. doi:10.1016/j.adaj.2015.04.014. 20. Maziak W, Ben Taleb Z, Jawad M, et al. Consensus statement on assessment of waterpipe smoking in epidemiological studies. Tob Control. 2017;26(3):338343. doi:10.1136/tobaccocontrol-2016-052958. 21. U.S. Food and Drug Administration. Hookah Tobacco (Shisha or Waterpipe Tobacco). https://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm482575 Accessed November 28, 2017. 22. Waziry R, Jawad M, Ballout RA, Al Akel M, Akl EA. The effects of waterpipe tobacco smoking on health outcomes: an updated systematic review and metaanalysis. Int J Epidemiol. 2017;46(1):32-43. doi:10.1093/ije/dyw021. 23. U.S. Food and Drug Administration. Vapes, E-Cigs, Hookah Pens, and other Electronic Nicotine Delivery Systems (ENDS). https://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm456610 Accessed November 28, 2017. 24. U.S. Food and Drug Administration. Electronic cigarettes (e-cigarettes). 2014. http://www.fda.gov/newsevents/publichealthfocus/ucm172906.htm. 25. Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev.

2016;(9):CD010216. doi:10.1002/14651858.CD010216.pub3. 26. Glasser AM, Collins L, Pearson JL, et al. Overview of electronic nicotine delivery systems: a systematic review. Am J Prev Med. 2017;52(2):e33-e66. doi:10.1016/j.amepre.2016.10.036. 27. U.S. Cancer Statistics. https://nccd.cdc.gov/uscs/. Accessed January 21, 2018. 28. National Institute of Dental and Craniofacial Research. Oral cancer. https://www.nidcr.nih.gov/oralhealth/Topics/OralCancer/. Accessed November 28, 2017. 29. National Cancer Institute at the National Institutes of Health. What You Need to Know about Oral Cancer. U.S. Department of Health and Human Service. NIH Publication No. 09-1574. http://www.nidcd.nih.gov. 30. National Cancer Institute at the National Institutes of Health. Health Effects of Exposure to Environmental Tobacco Smoke: The Report of the California Environmental Protection Agency. Smoking and Tobacco Control Monograph no. 10.. Bethesda, MD. U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; 1999. 31. Centers for Disease Control and Prevention. Secondhand smoke: an unequal danger. Vital Signs. 2015. https://www.cdc.gov/vitalsigns/pdf/2015-02vitalsigns.pdf. 32. Sleiman M, Gundel LA, Pankow JF, Jacob P, Singer BC, Destaillats H. Formation of carcinogens indoors by surface-mediated reactions of nicotine with nitrous acid, leading to potential thirdhand smoke hazards. Proc Natl Acad Sci USA. 2010;107(15):6576-6581. doi:10.1073/pnas.0912820107. 33. Schick SF, Farraro KF, Perrino C, et al. Thirdhand cigarette smoke in an experimental chamber: evidence of surface deposition of nicotine, nitrosamines and polycyclic aromatic hydrocarbons and de novo formation of NNK. Tob Control. 2014;23(2):152-159. doi:10.1136/tobaccocontrol-2012-050915. 34. Leonardi-Bee J, Jere ML, Britton J. Exposure to parental and sibling smoking and the risk of smoking uptake in childhood and adolescence: a systematic review and meta-analysis. Thorax. 2011;66(10):847-855. doi:10.1136/thx.2010.153379. 35. Hackshaw A, Rodeck C, Boniface S. Maternal smoking in pregnancy and birth defects: a systematic review based on 173 687 malformed cases and 11.7 million controls. Hum Reprod Update. 2011;17(5):589-604. doi:10.1093/humupd/dmr022. 36. Homa DM, Neff LJ, King BA, et al. Vital signs: disparities in nonsmokers’ exposure to secondhand smoke—United States, 1999-2012. MMWR Morb Mortal Wkly Rep. 2015;64(4):103-108. 37. Burke H, Leonardi-Bee J, Hashim A, et al. Prenatal and passive smoke exposure and incidence of asthma and wheeze: systematic review and metaanalysis. Pediatrics. 2012;129(4):735-744. doi:10.1542/peds.2011-2196. 38. U.S. Department of Health and Human Services. Preventing Tobacco Use among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and

Health Promotion, Office on Smoking and Health; 2012. http://www.surgeongeneral.gov/library. 39. Ji EH, Sun B, Zhao T, et al. Correction: characterization of electronic cigarette aerosol and its induction of oxidative stress response in oral keratinocytes. PLoS One. 2016;11(12):e0169380. doi:10.1371/journal.pone.0169380. 40. Eke PI, Wei L, Thornton-Evans GO, et al. Risk indicators for periodontitis in U.S. adults: NHANES 2009 to 2012. J Periodontol. 2016;87(10):1174-1185. doi:10.1902/jop.2016.160013. 41. The American Academy of Periodontology. The parameters of care. J Periodontol. 2000;71(5 suppl):847-848. 42. Akinkugbe AA, Slade GD, Divaris K, Poole C. Systematic review and metaanalysis of the association between exposure to environmental tobacco smoke and periodontitis endpoints among nonsmokers. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2016;18(11):2047-2056. doi:10.1093/ntr/ntw105. 43. Johannsen A, Susin C, Gustafsson A. Smoking and inflammation: evidence for a synergistic role in chronic disease. Periodontol 2000. 2014;64:111-126. 44. Mavropoulos A, Brodin P, Rosing KC, Aass AM, Aars H. Gingival blood flow in periodontitis patients before and after periodontal surgery assessed in smokers and non-smokers. J Periodontol. 2007;78(9):1774-1782. 45. Bahrami G, Vaeth M, Kirkevang L-L, Wenzel A, Isidor F. The impact of smoking on marginal bone loss in a 10-year prospective longitudinal study. Community Dent Oral Epidemiol. 2017;45(1):59-65. doi:10.1111/cdoe.12260. 46. Patel RA, Wilson RF, Palmer RM. The effect of smoking on periodontal bone regeneration: a systematic review and meta-analysis. J Periodontol. 2012;83(2):143-155. 47. Visvanathan R, Mahendra J, Ambalavanan N, Pandisuba, Chalini. Effect of smoking on periodontal health. J Clin Diagn Res. 2014;8(7):ZC46-ZC49. doi:10.7860/JCDR/2014/8359.4597. 48. Hanioka T, Ojima M, Tanaka K, Matsuo K, Sato F, Tanaka H. Causal assessment of smoking and tooth loss: a systematic review of observational studies. BMC Public Health. 2011;11:221. doi:10.1186/1471-2458-11-221. 49. Karasneh JA, Al Habashneh RA, Marzouka NAS, Thornhill MH. Effect of cigarette smoking on subgingival bacteria in healthy subjects and patients with chronic periodontitis. BMC Oral Health. 2017;17(1):64. doi:10.1186/s12903017-0359-4. 50. Ramôa CP, Eissenberg T, Sahingur SE. Increasing popularity of waterpipe tobacco smoking and electronic cigarette use: implications for oral healthcare. J Periodontal Res. 2017;52(5):813-823. doi:10.1111/jre.12458. 51. Heasman L, Stacey F, Preshaw PM, McCracken GI, Hepburn S, Heasman PA. The effect of smoking on periodontal treatment response: a review of clinical evidence. J Clin Periodontol. 2006;33(4):241-253. 52. Research, Science and Therapy Committee of the American Academy of Periodontology. Position paper: tobacco use and the periodontal patient. J Periodontol. 1999;70(11):1419-1427. doi:10.1902/jop.1999.70.11.1419. 53. Chrcanovic BR, Albrektsson T, Wennerberg A. Smoking and dental implants: a

systematic review and meta-analysis. J Dent. 2015;43(5):487-498. doi:10.1016/j.jdent.2015.03.003. 54. Chambrone L, Preshaw PM, Rosa EF, et al. Effects of smoking cessation on the outcomes of non-surgical periodontal therapy: a systematic review and individual patient data meta-analysis. J Clin Periodontol. 2013;40(6):607-615. doi:10.1111/jcpe.12106. 55. Rosa EF, Corraini P, de Carvalho VF, et al. A prospective 12-month study of the effect of smoking cessation on periodontal clinical parameters. J Clin Periodontol. 2011;38(6):562-571. 56. American Psychiatric Association. Tobacco-related disorders. In: Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Arlington, VA: American Psychiatric Association; 2013:571-576. 57. Picciotto MR, Mineur YS. Molecules and circuits involved in nicotine addiction: the many faces of smoking. Neuropharmacology. 2014;76:545-553. 58. Tobacco Control Legal Consortium. Addiction. In: The Verdict Is In: Findings From United States v. Philip Morris. St. Paul, MN: Tobacco Control Legal Consortium; 2006. 59. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting smoking among adults—United States, 2000-2015. MMWR Morb Mortal Wkly Rep. 2017;65(52):1457-1464. doi:10.15585/mmwr.mm6552a1. 60. Wellman RJ, O’Loughlin EK, Dugas EN, Montreuil A, Dutczak H, O’Loughlin J. Reasons for quitting smoking in young adult cigarette smokers. Addict Behav. 2018;77:28-33. doi:10.1016/j.addbeh.2017.09.010. 61. Rodu B, Plurphanswat N. Quit methods used by American smokers, 2013– 2014. Int J Environ Res Public Health. 2017;14(11):1403. doi:10.3390/ijerph14111403. 62. Hartmann-Boyce J, Lancaster T, Stead LF. Print-based self-help interventions for smoking cessation. Cochrane Database Syst Rev. 2014;3(6):CD001118. 63. Lindson-Hawley N, Hartmann-Boyce J, Fanshawe TR, Begh R, Farley A, Lancaster T. Interventions to reduce harm from continued tobacco use. Cochrane Database Syst Rev. 2016;10:CD005231. doi:10.1002/14651858.CD005231.pub3. 64. Carr AB, Ebbert J. Interventions for tobacco cessation in the dental setting. Cochrane Database Syst Rev. 2012;13(6). doi:10.1002/14651858.CD005084.pub3. 65. Fiore MC. The new vital sign: assessing and documenting smoking status. JAMA. 1991;266(22):3183-3184. 66. Aveyard P, Begh R, Parsons A, West R. Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance. Addiction. 2010;107(6):1066-1073. doi:10.1111/j.13600443.2011.03770.x. 67. Van Schayck OCP, Williams S, Barchilon V, et al. Treating tobacco dependence: guidance for primary care on life-saving interventions. Position statement of the IPCRG. NPJ Prim Care Respir Med. 2017;27(1):38. doi:10.1038/s41533-017-0039-5.

68. Taylor GMJ, Dalili MN, Semwal M, Civljak M, Sheikh A, Car J. Internet-based interventions for smoking cessation. Cochrane Database Syst Rev. 2017; (9):CD007078. doi:10.1002/14651858.CD007078.pub5. 69. Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev. 2016;(3):CD008286. doi:10.1002/14651858.CD008286.pub3. 70. Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2012;(11). doi:10.1002/14651858.CD000146.pub4. 71. Agency for Healthcare Research and Quality. Clinical Guidelines for Prescribing Pharmacotherapy for Smoking Cessation. Rockville, MD: Agency for Healthcare Research and Quality; 2012. https://www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/tobacco/prescrib.html. Accessed November 30, 2017. 72. Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev. 2013;(5):CD009329. doi:10.1002/14651858.CD009329.pub2. 73. Chamberlain C, O’Mara-Eves A, Porter J, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev. 2017;(2):CD001055. doi:10.1002/14651858.CD001055.pub5. 74. Fanshawe TR, Halliwell W, Lindson N, Aveyard P, Livingstone-Banks J, Hartmann-Boyce J. Tobacco cessation interventions for young people. Cochrane Database Syst Rev. 2017;(11):CD003289. doi:10.1002/14651858.CD003289.pub6. 75. Tahiri M, Mottillo S, Joseph L, Pilote L, Eisenberg MJ. Alternative smoking cessation aids: a meta-analysis of randomized controlled trials. Am J Med. 2012;125(6):576-584. doi:10.1016/j.amjmed.2011.09.028. 76. Mark AM. Knocking tobacco out. J Am Dent Assoc 1939. 2017;148(12):948. doi:10.1016/j.adaj.2017.09.028. 77. Kumar PS, Matthews CR, Joshi V, de Jager M, Aspiras M. Tobacco smoking affects bacterial acquisition and colonization in oral biofilms. Infect Immun. 2011;79(11):4730-4738. doi:10.1128/IAI.05371-11. 78. Shah SA, Ganesan SM, Varadharaj S, Dabdoub SM, Walters JD, Kumar PS. The making of a miscreant: tobacco smoke and the creation of pathogen-rich biofilms. NPJ Biofilms Microbiomes. 2017;3:26. doi:10.1038/s41522-017-00332. 79. Fiorini T, Musskopf ML, Oppermann RV, Susin C. Is there a positive effect of smoking cessation on periodontal health? A systematic review. J Periodontol. 2014;85(1):83-91. doi:10.1902/jop.2013.130047. 80. Audrain-McGovern J, Benowitz N. Cigarette smoking, nicotine, and body weight. Clin Pharmacol Ther. 2011;90(1):164-168. doi:10.1038/clpt.2011.105. 81. Ramseier CA, Warnakulasuriya S, Needleman IG, et al. Consensus report: 2nd European workshop on tobacco use prevention and cessation for oral health professionals. Int Dent J. 2010;60(1):3-6.

82. Siu AL, U.S. Preventive Services Task Force. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163(8):622-634. doi:10.7326/M15-2023. 83. Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Five Major Steps to Intervention (The “5A’s”). https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/cliniciansproviders/guidelines-recommendations/tobacco/5steps.pdf. Accessed January 27, 2018. 84. Jamal A, King BA, Neff LJ, Whitmill J, Babb SD, Graffunder CM. Current cigarette smoking among adults—United States, 2005-2015. MMWR Morb Mortal Wkly Rep. 2016;65(44):1205-1211. doi:10.15585/mmwr.mm6544a2. 85. Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance— United States, 2015. Morb Mortal Wkly Rep Surveill Summ. 2016;65(6):1-174. doi:10.15585/mmwr.ss6506a1. 86. Moyer VA, U.S. Preventive Services Task Force. Primary care interventions to prevent tobacco use in children and adolescents: U.S. preventive services taskforce recommendation statement. Pediatrics. 2013;132(3):560-565. doi:10.1542/peds.2013-2079. 87. Hajek P, Stead LF, West R, Jarvis M, Hartmann-Boyce J, Lancaster T. Relapse prevention interventions for smoking cessation. Cochrane Database Syst Rev. 2013;(8):CD003999. doi:10.1002/14651858.CD003999.pub4. 88. Ray MN, Funkhouser E, Williams JH, et al. Smoking-cessation e-referrals: a national dental practice-based research network randomized controlled trial. Am J Prev Med. 2014;46(2):158-165. doi:10.1016/j.amepre.2013.10.018. 89. Sadasivam RS, Kinney RL, Delaughter K, et al. Who participates in Webassisted tobacco interventions? The QUIT-PRIMO and National Dental Practice-Based Research Network Hi-Quit studies. J Med Internet Res. 2013;15(5). doi:10.2196/jmir.2385. 90. Cutrona SL, Sadasivam RS, DeLaughter K, et al. Online tobacco websites and online communities-who uses them and do users quit smoking? The quit-primo and national dental practice-based research network Hi-Quit studies. Transl Behav Med. 2016;6(4):546-557. doi:10.1007/s13142-015-0373-5. 91. U.S. Department of Health and Human Services PHS National Institutes of Health, National Institute of Dental and Craniofacial Research. National Call to Action to Promote Oral Health. Rockville, MD: National Institute of Dental and Craniofacial Research (US); 2003. 92. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Best Practices for Comprehensive Tobacco Control Programs-2014. Atlanta, GA: Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/stateandcommunity/best_practices/pdfs/2014/comprehensive.p Accessed January 28, 2018. 93. World Health Organization. Waterpipe Tobacco Smoking: Health Effects,

Research Needs, and Recommended Actions by Regulators. 2005. http://www.who.int/tobacco/global_interaction/tobreg/Waterpipe%20recommendation_Final.p

33 Diet and Dietary Analysis Lisa F. Mallonee, RDH, RD, LD, MPH

CHAPTER OUTLINE NUTRIENT STANDARDS FOR DIET ADEQUACY IN HEALTH PROMOTION I. II. III. IV. V.

Government Standards Dietary Standards Dietary Guidelines for Americans MyPlate Food Guidelines Recommended Food Intake Patterns

ORAL HEALTH RELATIONSHIPS I. II. III. IV.

Skin and Mucous Membrane Periodontal Tissues Tooth Structure and Integrity Dental Caries

COUNSELING FOR DENTAL CARIES CONTROL THE DIETARY ASSESSMENT

I. II. III. IV. V. VI.

Purposes of a Dietary Assessment Preliminary Preparation for Dietary Assessment Forms Used for Assessment Presentation of the Food Diary to the Patient Receiving the Completed Food Diary Analysis of Dietary Intake

PREPARATION FOR ADDITIONAL COUNSELING I. II. III.

Define Objectives Planning Factors Appropriate Teaching Materials

COUNSELING PROCEDURES I. II. III. IV.

Setting Setting the Stage for a Successful Counseling Session Presentation of Findings Specific Dietary Recommendations

EVALUATION OF PROGRESS I. II. III. IV.

Immediate Evaluation Three-Month Follow-up Six-Month Follow-up Overall Evaluation

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Recognize oral manifestations of vitamin and mineral deficiencies. 2. Explain the function of nutrients in maintaining oral and overall health. 3. Identify good food sources for each micronutrient relevant to oral health. 4. Determine the caries risk potential of a patient’s food record.

5. Access and utilize the MyPlate website for diet analysis and as a tool for patient education. Nutrition is an integral part of an individual’s general health as well as the health status of the oral cavity. The health of oral tissues can be affected by nutrition, diet, and food habits. The interrelationship between nutritional status, systemic diseases, and oral conditions supports the need for timely and effective diet intervention. Within the scope of practice, the dental hygienist has a responsibility to assess, screen, and deliver nutritional information and instruction as part of comprehensive education in health promotion and disease prevention and intervention. Dietary and nutritional counseling, as part of a dental caries control program and periodontal maintenance, is an essential part of the dental hygiene care plan.

NUTRIENT STANDARDS FOR DIET ADEQUACY IN HEALTH PROMOTION Patient education centers on helping patients learn about selection of foods that make up a healthy diet.

I.

Government Standards

A. Purposes of Standards Facilitate education for individuals about dietary needs and goals to achieve and maintain health. Prevent deficiency diseases and help achieve diet adequacy for the public. Make recommendations relative to poor food habits, such as missed meals, omission of essential foods and nutrients, and fad dieting. Make specific recommendations for oral health. Motivate for behavioral modification.

B. Guidelines Provide guidelines through printed and web-based educational materials. Guidelines reflect public health concerns as they relate to nutrition.

II.

Dietary Standards

A. Dietary Reference Intakes (DRI) Dietary reference intakes (DRI) is a comprehensive term for categories of reference values to meet the general nutrient needs for the healthy population to prevent deficiencies, toxicities, and chronic disease.

Encompasses the current nutrient recommendations made by the Institute of Medicine (IOM), National Academy of Sciences, and Food and Nutrition Board.1 The categories include: Recommended Dietary Allowance (RDA). Adequate Intake (AI). Estimated Average Requirement (EAR). Tolerable Upper Intake Level (UL). Established for vitamins and minerals.

B. Estimated Average Requirements Estimates the nutritional requirements of the average individual.1 Categorized by age and gender. Provide the foundation for the RDAs.

C. Recommended Dietary Allowances Recommended amounts of macronutrients and micronutrients needed to consume daily to maintain good health and prevent deficiency.2 Categorized by age and gender; do not include special needs such as illness. Based on gender and age; do not include special needs such as in illness.

D. Adequate Intakes The AI is the recommended nutrient intake utilized when there is not enough information to establish an EAR.2,3 AIs have been established for calcium, vitamin D, and fluoride for all age groups.

E. Tolerable Upper Intake Levels

The UL is the maximum intake by an individual that is unlikely to create risks of adverse health effects in almost all healthy individuals. ULs were established to avoid toxicity due to excess intake of specific nutrients from food, fortified food, water, and nutrient supplements.2,3

III. Dietary Guidelines for Americans Established by U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services as the basis for a federal nutrition policy based on the most recent scientific evidence review. Provides information and advice for choosing healthy eating patterns that focus on consuming nutrient-dense foods to promote a healthy weight and reduce risk of chronic disease. Includes food safety principles to avoid foodborne illness. Used as the basis for developing nutrition-related programs, educational materials, and consumer health messages to promote healthy eating patterns at home, school, work, community, and food retail. Box 33-1 lists key recommendations in the 2015–2020 Dietary Guidelines for Americans.

BOX 33-1 Key Recommendations: Dietary Guidelines for Americans, 2015–2020 • Follow a healthy eating pattern across the life span to maintain healthy weight and reduce risk of chronic disease. • Choose a variety of nutrient-dense foods from each food group in recommended amounts. • Consume an eating pattern low in added sugars, saturated fats, and sodium. • Choose nutrient-dense food and beverages in place of less healthy choices. • Support healthy eating patterns for all—locally and nationwide. Source: U.S. Department of Health and Human Services and U.S. Department

of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/. Accessed January 21, 2019.

IV. MyPlate Food Guidelines Originally developed as a “Food Pyramid” by the USDA in 1991.4 Newest version established in June 2011 using the graphic representation of a “dinner-plate” icon as illustrated in Figure 33-1.

FIGURE 33-1 • ChooseMyPlate Guidelines Icon. (From U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. ChooseMyPlate guidelines. 2011. http://www.choosemyplate.gov. Accessed January 18, 2019.)

Colorful graphic provides a visual reminder of the approximate proportions of five food groups necessary for a healthy diet. Educational materials accompanying the MyPlate food guidance

system encourage consumers to build a healthy plate: Make half the plate vegetables and fruits. Switch to fat-free or low-fat milk. Choose whole grains. Vary protein choices to include seafood and legumes and keep meat portions small. Cut back on foods high in solid fat, added sugars, and salt. Eat the right amount of calories to maintain a healthy weight. Enjoy food, but eat less and keep track of what is consumed. Cook more often at home and choose lower calorie options when eating out. Limit alcoholic beverages. Be physically active.

V.

Recommended Food Intake Patterns

Including estimated calorie needs and recommended amounts of food from each food group accompany the MyPlate food guidelines. Individual plans based on age, gender, weight, height, and activity levels can be created. Provide option to create a plan to maintain current weight or achieve a healthy weight. Estimated calorie needs based on gender, age, and activity level are presented in Table 33-1. TABLE 33-1 • Estimated Calorie Needs Per Day by Age, Gender, and Physical Activity Level

aSedentary

means a lifestyle that includes only the light physical activity associated with typical day-to-day life. Moderately active means a lifestyle that includes physical activity equivalent to walking about 1.5–3 miles/d at 3– 4 miles/hr, in addition to the light physical activity associated with typical dayto-day life. Active means a lifestyle that includes physical activity equivalent to walking more than 3 miles/d at 3–4 miles/hr, in addition to the light physical activity associated with typical day-to-day life. bEstimates for females do not include women who are pregnant or

breastfeeding. cBased on estimated energy requirements (EER) equations, using reference heights (average) and reference weights (healthy) for each age-gender group. For children and adolescents, reference height and weight vary. For adults, the reference man is 5 feet 10 inches tall and weighs 154 pounds. The reference woman is 5 feet 4 inches tall and weighs 126 pounds. EER equations are from the Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: The National Academies Press; 2002. USDA, U.S. Department of Agriculture. Source: U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. Mission. 2015. www.cnpp.usda.gov.

Twelve-calorie patterns ranging from 1,000 to 3,200 kilocalories provide specific amounts of food consumption from each of the food groups, subgroups, oils, and limits on calories from solid fats and added sugars, as presented in Table 33-2. TABLE 33-2 • USDA Food Patterns-Healthy U.S.-Style Pattern

aFood

intake patterns at 1,000, 1,200, and 1,400 calories are designed to meet the nutritional needs of 2- to 8-year-old children. Patterns from 1,600 to 3,200 calories are designed to meet the nutritional needs of children aged 9 years and older and adults. If a child aged 4 to 8 years needs more calories and, therefore, is following a pattern at 1,600 calories or more, his or her recommended amount from the dairy group should be 2.5 cups/d. Children aged 9 years and older and adults should not use the 1,000-, 1,200-, or 1,400-calorie patterns. bFoods in each group and subgroup are: Vegetables Dark green vegetables: All fresh, frozen, and canned dark green leafy vegetables and broccoli, cooked or raw: for example, broccoli, spinach, romaine, kale, and collard, turnip, and mustard greens. Red and orange vegetables: All fresh, frozen, and canned red and orange vegetables or juice, cooked or raw: for example, tomatoes, tomato juice, red peppers, carrots, sweet potatoes, winter squash, and pumpkin. Legumes (beans and peas): All cooked from dry or canned beans and peas: for example, kidney beans, white beans, black beans, lentils, chickpeas, pinto beans, split peas, and edamame (green soybeans). Does not include green

beans or green peas. Starchy vegetables: All fresh, frozen, and canned starchy vegetables: for example, white potatoes, corn, green peas, green lima beans, plantains, and cassava. Other vegetables: All other fresh, frozen, and canned vegetables, cooked or raw: for example, iceberg lettuce, green beans, onions, cucumbers, cabbage, celery, zucchini, mushrooms, and green peppers. Fruits All fresh, frozen, canned, and dried fruits and fruit juices: for example, oranges and orange juice, apples and apple juice, bananas, grapes, melons, berries, and raisins. Grains Whole grains: All whole-grain products and whole grains used as ingredients: for example, whole-wheat bread, whole-grain cereals and crackers, oatmeal, quinoa, popcorn, and brown rice. Refined grains: All refined grain products and refined grains used as ingredients: for example, white breads, refined grain cereals and crackers, pasta, and white rice. Refined grain choices should be enriched. Protein foods. All seafood, meats, poultry, eggs, soy products, nuts, and seeds. Meats and poultry should be lean or low fat, and nuts should be unsalted. Legumes (beans and peas) can be considered part of this group as well as the vegetable group, but should be counted in one group only. Dairy All milk, including lactose-free and lactose-reduced products and fortified soy beverages (soymilk), yogurt, frozen yogurt, dairy desserts, and cheeses. Most choices should be fat free or low fat. Cream, sour cream, and cream cheese are not included due to their low calcium content. cFood group amounts shown in cup-(c) or ounce-equivalents (oz-eq). Oils are shown in grams (g). Quantity equivalents for each food group are: Fruits and vegetables, 1 cup-equivalent is: 1 cup raw or cooked fruit or vegetable, 1 cup fruit or vegetable juice, 2 cups leafy salad greens, ½ cup dried fruit or vegetable. Grains, 1 ounce-equivalent is: ½ cup cooked rice, pasta, or cereal; 1 ounce dry pasta or rice; 1 medium (1 ounce) slice bread; 1 ounce of ready-to-eat cereal (about 1 cup of flaked cereal). Protein foods, 1 ounce-equivalent is: 1 ounce lean meat, poultry, or seafood; 1 egg; ¼ cup cooked beans or tofu; 1 tablespoon peanut butter; ½ ounce nuts or seeds. Dairy, 1 cup-equivalent is: 1 cup milk, yogurt, or fortified soymilk; 1½ ounces natural cheese such as cheddar cheese or 2 ounces of processed cheese. dAmounts of whole grains in the patterns for children are less than the minimum of 3 oz-eq in all patterns recommended for adults. eAll foods are assumed to be in nutrient-dense forms, lean, or low fat and prepared without added fats, sugars, refined starches, or salt. If all food choices

to meet food group recommendations are in nutrient-dense forms, a small number of calories remain within the overall calorie limit of the pattern (i.e., limit on calories for other uses). The number of these calories depends on the overall calorie limit in the pattern and the amounts of food from each food group required to meet nutritional goals. Nutritional goals are higher for the 1,200- to 1,600-calorie patterns than for the 1,000-calorie pattern, so the limit on calories for other uses is lower in the 1,200- to 1,600-calorie patterns. Calories up to the specified limit can be used for added sugars, added refined starches, solid fats, alcohol, or to eat more than the recommended amount of food in a food group. The overall eating pattern also should not exceed the limits of less than 10% of calories from added sugars and less than 10% of calories from saturated fats. At most calorie levels, amounts that can be accommodated are less than these limits. For adults of legal drinking age who choose to drink alcohol, a limit of up to 1 drink/d for women and up to 2 drinks/d for men within limits on calories for other uses applies (see Appendix 9. Alcohol in the 2015–2020 Dietary Guidelines for Americans for additional guidance); and calories from protein, carbohydrate, and total fats should be within the acceptable macronutrient distribution ranges. f Values are rounded. USDA, U.S. Department of Agriculture. Source: www.cnpp.usda.gov/USDAFoodPatterns

ORAL HEALTH RELATIONSHIPS Nutrition, diet, and oral health are closely interrelated. The oral cavity is the gateway to the body. Healthy masticatory function of the dentition contributes to proper dietary selection for maintenance of the nutritional status of the entire body. Healthy diet selection provides essential nutrients for optimum health of oral tissues and prevention of nutrient deficiency. Table 33-3 outlines micronutrients relevant to oral health, their function, associated deficiency state(s), and food sources. TABLE 33-3 • Nutrients Relevant to Oral Health

RBC, red blood cell; UV, ultraviolet. Source: Palmer CA, ed. Diet and Nutrition in Oral Health. 3rd ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2017. Adapted from Palmer CA, Papas A. Chapter 8: The minerals and mineralization. In: Diet and Nutrition in Oral Health. Upper Saddle River, NJ: Pearson Prentice Hall; 2003; Palmer CA. Chapter 9: Vitamins today. In: Diet and Nutrition in Oral Health. Upper Saddle River, NJ: Pearson Prentice Hall; 2017.

I.

Skin and Mucous Membrane Relevant vitamins: vitamin A, vitamin B complex, and ascorbic acid (vitamin C). Relevant minerals: zinc and iron.

II.

Periodontal Tissues

Periodontal diseases are not caused by nutritional deficiencies, but malnutrition may contribute to the progression of periodontal disease symptoms and influence healing following treatment. Nutritional deficiencies do not cause periodontal diseases. Without local factors, including the periodontal pathogens in biofilm, biofilmretentive factors (such as calculus and defective restorations), and lack of the oral self-care to remove biofilm, periodontal infections cannot occur. Severe deficiencies are rare in developed countries. Symptoms of deficiencies such as those listed in Table 33-4 may be seen in

cases of severe deprivation, starvation, and patients with long-term alcoholism or other drug addictions. TABLE 33-4 • Oral Manifestations of Nutrient Deficiencies ORAL SYMPTOMS ASSOCIATED WITH THE TONGUE

NUTRIENT DEFICIENCY

Altered taste sensations

Riboflavin, thiamin, zinc, vitamin A, vitamin B12

Glossitis

Folate, niacin, riboflavin, vitamin B6, vitamin B12

Glossodynia

Niacin, vitamin B6, vitamin B12

Sore or burning tongue

Iron, niacin, riboflavin, thiamin, vitamin B6, vitamin B12

ORAL SYMPTOMS ASSOCIATED WITH MUCOSAL TISSUE Angular cheilosis

Folate, iron, riboflavin, vitamin B6, vitamin B12

Candidiasis

Folate, iron, zinc, vitamin A, vitamin C

Delayed wound healing

Riboflavin, zinc, vitamin A, vitamin C

Mucositis/stomatitis

Folate, niacin, thiamin, vitamin B12

Source: Palmer CA, ed. Diet and Nutrition in Oral Health. 3rd ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2017. Adapted from Palmer CA, Papas A. Chapter 8: The minerals and mineralization. In: Diet and Nutrition in Oral Health. Upper Saddle River, NJ: Pearson Prentice Hall; 2003; Palmer CA. Chapter 9: Vitamins today. In: Diet and Nutrition in Oral Health. Upper Saddle River, NJ: Pearson Prentice Hall; 2017.

RDAs are essential to the health of the periodontal tissues. As part of total body health, the daily diet nourishes the oral tissues. The physical characteristic of the diet contributes. A soft, sticky diet that stays on the tooth surfaces, especially cervical third and

proximal areas, encourages biofilm buildup and proliferation of bacteria, including the periodontal pathogens. Malnutrition suppresses the immune system and impairs the host’s reaction to infections. Increased activity of pathogenic microorganisms may result in increased periodontal disease. Nutrients contribute to healing and tissue repair.5 The elements strongly associated with wound healing include vitamin B complex, vitamin C (ascorbic acid), and dietary calcium. B complex refers to all the water-soluble vitamins, except vitamin C. They are thiamin (vitamin B1), riboflavin (vitamin B2), niacin (vitamin B3), pyridoxine (vitamin B6), cobalamin (vitamin B12), biotin, folic acid, and pantothenic acid. Each member of the B complex has individual functions. Vitamin C is needed for collagen formation and intercellular material, and healing tissues after procedures including periodontal debridement. Dietary calcium. About 99% of the calcium in the body is in the bones and teeth; 1% is in the body tissues and fluids; essential for cell metabolism, muscle contraction, and nerve impulse transmission. Vitamin D is necessary for the continuous exchange of calcium between the blood, skeletal bones, and other cells. Low dietary intake of calcium and vitamin D can impact alveolar bone integrity in periodontal disease. Loss of alveolar bone and soft-tissue attachment are typical of periodontal disease progression.6 Current and former smokers with low dietary vitamin C intake are at risk for more severe periodontal disease.7 The IOM suggests smokers need 35 mg more vitamin C per day than nonsmokers.8 Obesity and periodontal disease Obesity and periodontal disease have an association with each other, and inflammation is the proposed mechanism for this relationship.9,10 Higher body mass index and waist circumference have been correlated with increased incidence of periodontal disease.9,10

As with all chronic diseases, it is the dental professional’s role to promote healthy lifestyle choices, including, but not limited to, oral self-care, tobacco cessation, healthy nutrition, adequate physical exercise, and weight control to manage and/or prevent progression of disease. Dietary assessment for periodontal conditions Following surgical intervention, patients may need to alter diet consistency during the healing period. A soft diet of high-quality protein is indicated for adequate wound healing. Puddings, scrambled eggs, milkshakes, yogurt, and cottage cheese have high-quality protein to promote healing. Chewing firm foods increases salivary flow. Saliva acts as a buffer, and increased saliva aids in oral clearance.

III. Tooth Structure and Integrity Nutrients and health of tooth structure Adequate nutrition during tooth development is essential for mineralization. Relevant minerals: calcium, phosphorus, magnesium, and fluoride. Relevant vitamin: vitamin A. Dietary assessment Diet assessment during early tooth development is essential to assist parents in caries prevention. Anticipatory guidance for the parents of infants, children, and adolescents can be found in Chapters 46 and 47.

IV. Dental Caries Prevention11 Fluoride is an essential mineral for dental caries prevention. The complexity of dental caries formation is illustrated in Figure 33-2.

FIGURE 33-2 • Dental Caries Process. Four overlapping circles illustrate the factors involved in the development of dental caries. All four act together, and as shown by the center, dental caries results. (Adapted from U.S. Department of Health and Human Services, Public Health Service, National Institute of Dental Research. Broadening the Scope. Long-Range Research Plan for the 1990s. Washington, DC: U.S. Government Printing Office; 1990. NIH Publication No. 90-1188.)

Role of cariogenic foods12 Dental caries is a result of biofilm and excess cariogenic foods, not a nutrient deficiency. Streptococcus mutans, Lactobacilli, and other acid-forming organisms use fermentable carbohydrate from the diet to produce acids. Consistency of food12 Soft, sticky foods cling to the teeth and gingiva and encourage biofilm accumulation.

Microorganisms are protected and nourished in dental biofilm on the tooth, leading to increased acid formation. Dietary assessment and counseling Use of dietary assessment and patient instruction relative to dental caries control. Personal recommendations foster behavioral modification in disease prevention.

COUNSELING FOR DENTAL CARIES CONTROL Risk factors (see Chapter 25) Inadequate biofilm removal. Inadequately mineralized tooth enamel, such as in enamel hypoplasia, or demineralization. Frequent snacks with fermentable carbohydrates and acidic beverages between meals. Altered salivary flow such as in drug-induced xerostomia. Figure 33-2 illustrates the intricate relationship of all four factors in the development of dental caries. Preventive measures that support dietary control Adequate plaque biofilm removal. Modification of intake of cariogenic foods and beverages. Strengthening the tooth surface to resist caries activity with appropriate office and home fluorides. Pit-and-fissure sealants. Restoration of existing carious lesions.

THE DIETARY ASSESSMENT The dietary assessment is an integral part of disease prevention and health promotion in the scope of dental hygiene care.13 The patient and dental hygienist have the opportunity to collaborate in the evaluation of diet adequacy and in diet intervention.

I.

Purposes of a Dietary Assessment Identify the patient who may be at nutritional and oral health risk. Refer to a registered dietitian or registered dietitian nutritionist (RD or RDN) when intervention beyond the scope of dental hygiene practice is indicated. Provide an opportunity for a patient to study personal dietary habits objectively. Obtain an overall picture of the types of food in the patient’s diet, food preferences, and quantity of food eaten. Study the food habits and snacking patterns. Record frequency of use and consumption of cariogenic food. Determine the overall consistency of the diet. Identify fibrous foods regularly consumed. Identify soft, sticky foods regularly consumed. Identify the nutritional status of an individual with regard to overall requirements and then collaborate with the patient to make suggestions for modification in nutritional adequacy of the diet in health promotion. Plan with the patient for necessary changes to improve the health of the oral mucosa and periodontium and to prevent dental caries.

II.

Preliminary Preparation for Dietary Assessment

A. Patient History

Information obtained from medical, dental, and social histories is essential in assessing oral health and nutritional status: Disease states Medications Disabilities Learning limitations Significant unintentional change in body weight Factors influencing food use and food intake. Dietary influences can be identified by intraoral and extraoral examination, which may reveal oral tissue changes suggestive of nutritional deficiencies.

B. Clinical Evaluation High-risk patients can be identified by noting factors suggestive of a dietary problem. Clinical examination and charting of cavitated carious lesions and demineralizing areas. Identification of any abnormalities in the patient’s overall appearance: weight, skin, nails, and hair. Table 33-4 lists oral manifestations of severe deficiencies.

III. Forms Used for Assessment A. Twenty-Four Hour Recall A detailed account of the patient’s dietary intake over the previous 24 hours (Table 33-5). TABLE 33-5 • Dietary Intake Form Type of Foods/Beverages BREAKFAST SNACK

Quantity Eaten (cup, oz, tbsp, tsp, etc.)

Preparation Method

Lunch SNACK Dinner SNACK Sample of a form for patients to use to record the daily intake of foods. Can be used for the 24-hour recall or multiple forms used in the 3- to 7-day food diary. NAME_____________________________TEL_______________ AGE______SEX______Height______Weight_______BMI_________ 7:30 AM Orange juice Bagel Cream cheese Coffee Milk Sugar

1/ 2

cup Whole 2 tablespoons 2 cups 1/ cup 2 2 packets

Bagel shop

10:00 AM Chocolate chip cookies Orange soda

2 12 oz can

1:00 PM Mushroom pizza Orange soda Cheese cake

2 slices 12 oz can 1 slice

School cafeteria

1 bag

Vending machine

6 oz 1 medium 2 tablespoons 1 cup 2 tablespoons 1/ cup 2

Roasted Baked Sautéed Canned

3 cups

Microwave

4:00 PM Whole-wheat pretzels 7:00 PM Turkey Potato Sour cream Broccoli Oil Gravy 9:30 PM Popcorn

Obtained during face-to-face interview with patient. Assesses nutrients, food groups, diet adequacy, form and frequency of the carbohydrate intake, and snacking patterns. Results are reviewed and appropriate instruction given at appointment or a follow-up appointment. It is quick and easy to administer and can be done chairside in one visit. Is limited to 1-day intake; therefore, it is not necessarily representative of a patient’s normal diet.

B. Dietary Analysis Recording Form 3–7 Days A more accurate account of a patient’s intake (Table 33-6). TABLE 33-6 Dietary Analysis Recording Form

a

eq is the abbreviation for the word equivalents. See MyPyramid Food Intake Patterns (Figure 33-2) for more details on equivalents. bk 4.2 grams =1 tsp.

Patient completes food diary for 3, 5, or 7 days, inclusive of oneweekend day.

Affords the patient a more active role in the dietary assessment and a chance to observe areas that require modification. Provide patient with three to seven copies of the Dietary Intake Form (Table 33-6). Request patient to return the forms at follow-up visit. At follow-up visit, the patient’s diary is evaluated for: Eating patterns. Consumption and frequency of fermentable carbohydrates. Nutritional adequacy.

IV. Presentation of the Food Diary to the Patient Explain the purpose Briefly describe how diet relates to oral health. Provide a foundation for the education to follow. Avoid mention of specific foods to prevent patient bias. Explain the form Provide written and oral instructions for use of the food diary. Provide suggestions for listing various foods and use of household measurements for indicating quantity (see examples in Box 33-2).

BOX 33-2 Food Diary Instructions • • • • •

Write down all foods consumed on the Dietary Intake Form (Table 33-5). Record each meal as soon after eating as possible to avoid forgetting. Record all fluids; include water and alcoholic beverages. Do not choose days when dieting, fasting, or ill. Be accurate in determining the amounts eaten, using household measurements (e.g., 1/2 cup cereal, 1 tsp margarine, 3 oz fish). A 3-oz serving size can be compared to the size of a deck of cards. • Use brand names whenever possible. • Record added sauces, gravies, condiments, and all extras (e.g., sugar or cream in coffee, mayonnaise, chewing gum, cough drops). • Record food preparation methods (e.g., baked, fried, boiled, grilled).

Instruction for completing the food diary encourages the patient to provide a more accurate portrayal of eating behaviors. Complete the current day’s food diary with the patient Helps to illustrate how to itemize and list foods eaten. Provides an example while completing the patient’s own daily diary. General directions Emphasize the importance of completing the diary for each meal as soon after eating as possible to avoid forgetting. Encourage use of typical days, uncomplicated by illness, dieting, holidays, or other unusual events. Review details of recording the component parts of a combination dish, such as a sandwich: 2 slices of whole-wheat bread, 4 oz of turkey, 1 teaspoon of mayonnaise, 2 slices tomato with lettuce, and 1 slice of cheddar cheese. Indicate need for recording nutritional supplements and all fluids consumed, including water and alcoholic beverages. The patient needs to indicate where the meal was eaten, such as at home, restaurant, or friend’s house. Instruct patient to select consecutive days and at least oneweekend day for a realistic representation of diet pattern. Encourage patient to include oral hygiene methods performed before or after meals.

V.

Receiving the Completed Food Diary

Obtain supplemental data Receive the food diary soon after its completion. Question the patient to clarify presented information. Does food diary represent a typical day or week? Identify influences on appetite such as illness or stress. Identify food likes and dislikes, food preferences, intolerances, and food allergies. Frequency of dining out. Identify special diets being followed at home.

Average alcohol intake. Which family member is doing the cooking and food shopping? Ask about common food habits, such as snacking at night. Review patient’s food diary Common omissions include: Garnishes: frosting, whipped cream, butter or margarine on vegetables, salad dressings, and oil. Beverages: quantity and sweetened. Snacks: type, brand, and quantity. Chewing gum or mints: sugarless, noncariogenic sweetener such as xylitol, and quantity. Canned fruit: packed in water, heavy or light syrup, own juices, or sweetened with sugar substitute, and quantity. Fruit and vegetables: canned, fresh, or frozen. Cereal: sugar-coated or low sugar brand, type of milk and/or sugar added, and quantity. Potato: baked, mashed, or fried. Seasonings or sauces: quantity and type.

VI. Analysis of Dietary Intake Three principal parts of the food diary to analyze are the number of servings in each food group, frequency of cariogenic foods, and consistency of the diet.

A. Nutritional Analysis for Adequacy of 24-Hour Recall Intake When time is a factor, a 24-hour analysis is appropriate. Compare intake of food groups recorded in the patient’s 24-hour food diary with individual needs identified using MyPlate. Determine nutritional adequacy. Calculate the patient’s “sweet score,” as outlined in Table 33-7. TABLE 33-7 • Scoring the Sweets

Form to be used to determine patient’s caries risk when doing a 24-hour recall at chairside. (Adapted with permission from Carole A. Palmer EdD, RD. Division of Nutrition and Oral Health Promotion, Department of General Dentistry, Tufts University School of Dental Medicine.)

Cariogenic foods are listed and categorized as solid, liquid, or slowly dissolving. Totals for the 1 day are multiplied by respective time factors and a score determines patient’s caries risk.

B. Nutritional Analysis for Adequacy of Food Intake from the Food Diary Use the Dietary Analysis Recording Form to summarize adequacy

of daily portions of each food group (Table 33-6). Each food eaten is entered into a food group with number of servings. Comparison of intake reported on patient’s food diary with individual caloric needs for age, gender, height, weight, and activity level identified using MyPlate food guidance system (Figure 33-1; Tables 33-1 and 33-2). Totals for the week are added, and the average per day calculated. The average is compared to the recommended servings for each food group. Assist patient when inadequacies or deficiencies are identified. Analysis of cariogenic foods. Identify physical form of carbohydrate. Liquids: sweetened or unsweetened soft drinks; fruit juice with added sugars. Soft solid/sticky and retentive: retentive cakes, cookies, chips, pretzels, jellybeans, and chewy, sticky candies. Hard solid/slowly dissolving: hard candies, mints, and cough drops. Identify frequency of meals and snacks. When snacks are consumed. Number of between-meal snacks consumed daily. Circle in red and tally the number of cariogenic foods, both solid and liquids. Frequency more relevant than quantity in caries incidence. High frequency of eating events decreases the ability of calcium and phosphate to remineralize teeth between episodes. During counseling appointment, show the patient how to: Select and circle in red the cariogenic foods on the Scoring the Sweets form (Table 33-6). Select liquid, soft solid, hard solid, and time of eating. Total the number of sweets for both liquid and solids and multiply total by 20 minutes (liquids) and 40 minutes (solids). Divide by number of days (3-, 5-, or 7-day diary). Add both liquid and solid scores to determine total minutes teeth are exposed to sweets and acid attack (Table 33-6).

C. Analysis of Diet Consistency Help patient to identify the types of firm and fibrous foods from the food diary such as: Uncooked fruits and vegetables. Cooked; crisp–tender vegetables. Help patient to identify the frequency of cariogenic food patterns: Daily or occasionally. During meal, end of meal, or between meals.

D. Benefits of Food Diary Analysis Patient can identify appropriate and inappropriate practices for dental caries control. Corroborate findings with clinical findings and patient’s oral health problems in preparation for counseling session.

PREPARATION FOR ADDITIONAL COUNSELING I. Define Objectives To help patient understand the individual oral problems and appreciate the need for changing habits. To explain specific alterations in the diet necessary for improved general and oral health. For dental caries control. Promote minimal consumption of cariogenic foods, particularly between meals. Substitute noncariogenic foods or include anticariogenic foods, when possible, into the diet.

II.

Planning Factors

A. Patient Attitude Consider patient’s willingness and ability to cooperate as evidenced by keeping appointments and following personal oral care procedures. Consider patient’s healthcare beliefs and nutrition and dental knowledge.

B. Possible Barriers Difficulty and resistance to change of normal habits. Patient dissatisfaction with loss of usual or customary foods. Patient may not attempt to make modifications if recommendations are numerous or overwhelming. Lack of appreciation of need for change due to limited knowledge of diet, nutrition, and oral health relationship. Common misconception about concentrated sugar as an indispensable energy source. Cultural and religious patterns significant to food selection and

preparation. Financial considerations in food purchasing. Emotional eating patterns and cravings for sweets. Parental attitude toward sweets in the diet. Elimination of all sugars would deprive a child of normal childhood pleasures. All sugars may be viewed as “bad” foods for children. Foods are not “good” and “bad,” rather it is the frequency and amount that may be a concern for oral and overall health.

III. Appropriate Teaching Materials Patient’s radiographs, dental charting, and food diary. Diagrams, food models, food labels, or charts of dietary standards and requirements. Educational leaflets or pamphlets to illustrate patient’s special dietary or oral health needs. An outline of a realistic diet plan with specific suggestions for food substitutes that is created based on patient preferences. A list of snack suggestions.

COUNSELING PROCEDURES I. Setting An environment free from interruptions and distracting background sounds. Apart from the clinical treatment room. Patient comfort promotes environment conducive to learning. Provide limited but pertinent educational information. Posters and pamphlets. Food labels and food models of portion sizes. Avoid overloading with too much new information to minimize confusion. Persons involved in promoting change: For a younger patient, the primary caregiver is present since this individual supervises the child’s eating and oral care. Person preparing meals and grocery shopping needs to be present to learn about appropriate food choices.

II.

Setting the Stage for a Successful Counseling Session Be prepared and on time. Plan for only a few simple visual aids. Concentrate on the factors related to the patient’s diet-based dental problem. Encourage parents to exclude small children (other than the patient) from the conference; they may create distractions. Develop a friendly atmosphere; establish eye contact with a warm, nonthreatening environment. Adequately discuss all questions from patient or parent using a conversational tone without lecturing. Keep session brief, informative, and engaging for the patient without taking notes.

III. Presentation of Findings A. Review Purpose of the Meeting Provide explanation of the relevance between diet and patient’s oral disease. Emphasize health promotion and disease prevention.

B. Clarification of “Cariogenic” Foods Calculate the sugar score from the Scoring the Sweets or Dietary Analysis Recording Form to emphasize caries risk. Clarify confusion of hidden sugars, added sugars, and natural sugars. Clarify the moderation of sugar intake and help patient identify substitutions.

C. Review of Dental Caries Initiation The sucrose from cariogenic food on the tooth surface can be changed to acid in minutes. The pH drops to below 5.5, which is the critical level for demineralization of enamel. Acid left undisturbed will be cleared from the mouth from 20 minutes to up to 2 hours, depending primarily on salivary flow. For a patient with xerostomia, clearance takes much longer. Figure 33-3 illustrates how the frequent intake of sucrose lowers the pH for several hours in the course of the day.

FIGURE 33-3 • Cariogenic Foods and Biofilm pH. The range of pH in dental biofilm from 5 to 7 is shown on the left. Time intervals are shown across the bottom of each graph. The double-line curve represents the variations in biofilm pH throughout a day. Each time sugar or a cariogenic food is taken in, the pH of the dental biofilm drops to or below the critical pH (5.2–5.5). As shown in the lower graph, frequent eating keeps the pH at the critical level below which enamel demineralization can occur. On the right, (A) shows that bacterial counts are lower, whereas in (B), aciduric microorganisms are greatly increased in numbers. The critical pH for the root surfaces is 6.0–6.7. (Adapted with permission from Larmas M. Simple test for caries susceptibility. Int Dent J. 1985;35 (2):109–117.)

D. Frequency and Time of Exposure Each exposure of the tooth surface to sucrose or other cariogenic food in a meal or snack increases the amount of acid on the tooth. The quantity of a cariogenic food is not as significant as when and how often the tooth is exposed to a cariogenic food.14 Prolonged intake of a cariogenic liquid or solid, such as continuous sipping of a sucrose-containing beverage while working at a desk, does not allow for a remineralization period to occur in which the pH

can rise above the critical level.

E. Retention Cariogenic foods consumed after brushing and flossing before bedtime are not cleared readily because salivary flow decreases during sleep. Cariogenic liquids are cleared from the mouth faster than solids. Oral retentiveness of cariogenic foods is related to length of time food debris with fermentable carbohydrate remains on the teeth and exposure to decreased biofilm pH.15–17 Highly retentive fermentable carbohydrates have a delayed rate of oral clearance, increasing exposure of teeth to a decreased pH and higher potential for demineralization.15,16,18 Sequence of food consumption within a meal pattern is related to caries incidence.17–20 Eating fermentable carbohydrates at the beginning of a meal or between other noncariogenic foods (protein and fat) is less cumulative in cariogenic potential. Protein and fat are not metabolized by oral bacteria or broken down by salivary amylase and are recommended to be eaten at the end of a meal. Cheese eaten after sweets or at the end of a meal prevents the decrease in pH and production of acids in the oral cavity.20 Noncariogenic sweeteners may be incorporated for caries prevention and management of a healthy weight in patients at risk for obesity.11,21 Sugar-free gums decrease lactic acid production and increase salivary flow, potentially buffering acids. Chewing a gum with xylitol immediately after each meal reduces the levels of S. mutans and promotes remineralization. Xylitol is the sugar substitute of choice because it is not fermentable by caries-promoting bacteria. Sorbitol can be fermented by S. mutans at a very slow rate.11,22

IV. Specific Dietary Recommendations A. Examination of the Patient’s Food Diary After analyzing the diet, assist the patient in identifying the deficiencies and excesses in intake. Consult Chapter 24 for guidance on working collaboratively with the patient to develop a plan. Try to retain as many as possible of the patient’s present food habits. Make recommendations that can be adapted to the patient’s lifestyle. Discuss foods from each food group that the patient likes and can be added to the diet. Limit the use of cariogenic foods to mealtimes. Evaluate the final food in a meal because it may remain on the teeth if rinsing is not possible. Recommend chewing a gum containing xylitol at the end of each meal, especially for a caries-susceptible person. Recommend specific stores in the area where patients can purchase gum containing xylitol. Assist patient in finding acceptable substitutions for the cariogenic food choices. Unflavored milk. Cheese. Peanut butter (check the label of the peanut butter to choose one without added sugar) on sliced apples. Sugar-free gelatin or pudding. Crunchy vegetables. Explore ways to decrease sugar in food preparation and when purchasing ready-made food. Decrease the amount of granulated or brown sugar by half when baking. Consider substituting alternative sweeteners, such as xylitol. Carefully read nutrition labels of prepared foods and choose foods with no added sugar when possible.

Natural sugars are just as detrimental as refined sugars (e.g., honey, maple syrup). To enhance compliance, help patients create their own meal plans for 1 day. Incorporate the principles discussed during the counseling. Collaborate on modifications the patient can achieve realistically and is willing to try. Avoid too many changes that may be overwhelming. Determine patient comprehension of information presented and patient’s motivational level. Include morning, afternoon, and evening snacks as well as breakfast, lunch, and dinner in a meal plan for a day. Encourage daily use of fluoride in water, foods, dentifrices, and rinses. When toothbrushing and flossing are not possible, encourage rinsing with water.

EVALUATION OF PROGRESS I. Immediate Evaluation The patient’s verbal and nonverbal interest, comprehension, and participation in the dietary analysis and counseling session.

II.

Three-Month Follow-Up Request patient to keep a 3-, 5-, or 7-day food diary for assessment and evaluation. Review personal oral care procedures and provide suggestions as needed. Scaling as needed; fluoride varnish application. Collaborate on ideas for further modifications when indicated. Smaller goals may need to be established for greater compliance. Document progress, additional material reviewed, and plan for continued behavior modification.

III. Six-Month Follow-Up Perform examination and clinical procedures. Charting of carious lesions and demineralized areas. Disclose and evaluate biofilm score and reteach as needed with new biofilm removal brush, interdental, and tongue-cleaning devices. Scaling as needed; fluoride varnish application. Compare dental caries incidence with previous chartings and completed restorative dentistry. Make collaborative dietary recommendations with patient in accord with new assessment. Document progress, education provided, and plan.

IV. Overall Evaluation

Consistent reduction in dental caries rate in the years following the initial counseling shows sustained change in habits. Patient’s and parents’ attitudes toward maintaining adequate oral health habits. Attempts to maintain a diet containing minimum cariogenic foods. Compliance with keeping regular appointments for professional dental care.

DOCUMENTATION The following factors are included when documenting patient care that includes diet analysis and patient counseling: Rationale for dietary analysis. The type of dietary intake utilized for dietary assessment. The results of the dietary analysis. The results of the sugar score and the level of caries risk. Instructions given on completing the food diary. Box 33-3 contains an example progress note for a patient receiving dietary analysis and counseling.

BOX 33-3 Example Documentation: Patient Receiving a Dietary Analysis and Counseling S— A 24-year-old, Hispanic female arrived for her annual examination and preventive care appointment. Her medical and dental history were unremarkable. O—Caries, periodontal, and oral cancer risk assessments were performed. A comprehensive periodontal examination reveals biofilm-induced gingivitis with localized bleeding on probing. Dental examination reveals three new carious lesions. A—Risk assessment indicates the patient is at high risk for dental caries because of the frequency of snacks. A 24-hour recall was performed chairside. Dietary analysis revealed a sweet score of 9, indicating a moderate caries risk. Evaluation of diet for nutritional adequacy revealed an inadequate representation of fruits and vegetables. P—Preventive education included review of toothbrushing, flossing, and dietary changes to reduce the risk for caries. Reducing the frequency of snacks between meals was discussed. Recommendations include having desserts or sodas during meals. Rinsing with water or chewing xylitol gum were provided as options following desserts or sodas consumed between meals to reduce the caries risk. The patient was also provided with a prescription for a home fluoride for daily application prior to bedtime. A follow-up appointment was made in 2 weeks. Signed: _____________________________, RDH Date: ___________________________________

EVERYDAY ETHICS Ms. Carlson presents with type 1 diabetes and several significant changes in her oral cavity since her last dental hygiene appointment, including angular cheilosis, glossitis, and several proximal carious lesions. The hygienist, Bettina, believes that Ms. Carlson has advanced dietary needs beyond the scope of practice of a dental hygienist and, therefore, avoids any chairside dietary assessment with the patient. Routine oral self-care instructions are given. On completion of the examination, Bettina mentions her concerns about Ms. Carlson’s dietary status to the dentist but does not record any recommendations in the patient’s permanent record. Questions for Consideration 1. What professional protocol for referrals can be followed by the dental hygienist since she believes giving dietary advice to a patient with diabetes is beyond the scope of practice for a dental hygienist? 2. By eliminating the chairside dietary assessment for dental caries prevention, did Bettina act nonmaleficently toward the patient? Explain your response. 3. Which ethical principles would be ignored if Bettina does not educate the patient about the preventive measures for her dental caries or document this information in the patient’s record?

Factors to Teach the Patient Medications with Sucrose The need to avoid liquid or chewable forms containing sucrose. Reasons to avoid frequent daily use of medications with sucrose. Reasons for rinsing with water after a medication contained in a sucrose mixture. Medications with Side Effect of Xerostomia Drugs the patient is using that cause xerostomia (dry mouth). How xerostomia increases the risk of dental caries development. Why it is necessary to use saliva substitutes, chew gum containing xylitol, and avoid slowly dissolving in the mouth candies containing sucrose. Effect of xerostomia on chewing and swallowing and how it compromises nutrient intake. Facts about Dental Caries

How dental caries on the tooth surface starts and progresses. How the interaction of cariogenic foods, tooth surface, saliva, and microorganisms act together, contributing as factors in the dental caries process (Figure 33-2). How repeated, frequent acid production and the pH in the dental biofilm adversely affect the teeth. Why there is a need to avoid frequent episodes of eating or drinking food or beverages that contain sucrose (Figure 33-3).

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. National Research Council. Dietary Reference Intakes: Applications in Dietary Planning. Washington, DC: The National Academies Press; 2003. 2. National Research Council. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC: The National Academies Press; 2006. 3. Institute of Medicine. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: The National Academies Press; 1998. 4. Department of Agriculture, Center for Nutrition Policy and Promotion. ChooseMyPlate guidelines. 2011. http://www.choosemyplate.gov. Accessed January 21, 2019. 5. Varela-López A, Navarro-Hortal MD, Giampieri F, Bullón P, Battino M, Quiles JL. Nutraceuticals in periodontal health: a systematic review on the role of vitamins in periodontal health maintenance. Molecules. 2018;23(5):pii: E1226. doi:10.3390/molecules23051226. 6. Miley DD, Garcia MN, Hildebolt CF, et al. Cross-sectional study of vitamin D and calcium supplementation effects on chronic periodontitis. J Periodontol. 2009;80(9):1433-1439. 7. Aziz AS, Kalekar MG, Suryakar AN et al. Assessment of some biochemical oxidative stress markers in male smokers with chronic periodontitis. Indian J Clin Biochem. 2013;28(4):374-380. 8. Institute of Medicine. Food and nutrition board. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington, DC: National Academy Press; 2000. 9. Martinez-Herrera M, Silvestre-Rangil J, Silvestre FJ. Association between obesity and periodontal disease. A systematic review of epidemiological studies and controlled clinical trials. Med Oral Patol Oral Cir Bucal. 2017;22(6):e708-e715. doi:10.4317/medoral.21786. 10. Keller A, Rohde Jf, Raymond K, Hetiman BL. Association between periodontal disease and overweight and obesity: a systematic review. J Periodontol. 2015;86(6):766-776. 11. Horst JA, Tanzer JM, Milgrom PM. Fluorides and other preventive strategies for tooth decay. Dent Clin North Am. 2018;62(2):207-234. 12. Sheiham A, James WP. Diet and dental caries: the pivotal role of free sugars reemphasized. J Dent Res. 2015;94(10):1341-1347. 13. Marshall TA. Chairside diet assessment of caries risk. J Am Dent Assoc. 2009;140(6):670-674. 14. Head D, A Devine D, Marsh PD. In silico modelling to differentiate the contribution of sugar frequency versus total amount in driving biofilm dysbiosis in dental caries. Sci Rep. 2017;7(1):17413. doi:10.1038/s41598-017-17660-z. 15. Bradshaw DJ, Lynch RJ. Diet and the microbial aetiology of dental caries: new

paradigms. Int Dent J. 2013;63(suppl 2):64-72. 16. Chankanka O, Marshall TA, Levy SM, et al. Mixed dentition cavitated caries incidence and dietary intake frequencies. Pediatr Dent. 2011;33(3):233-240. 17. Botelho JN, Villegas-Salinas M, Troncoso-Gajardo P, Giacaman RA, Cury JA. Enamel and dentine demineralization by a combination of starch and sucrose in a biofilm—caries model. Braz Oral Res. 2016;30(1). doi:10.1590/18073107BOR-2016.vol30.0052. 18. Halvorsrud K, Lewney J, Craig D, Moynihan PJ. Effects of starch on oral health: systematic review to inform WHO guideline. J Dent Res. 2019;98(1):4653. doi:10.1177/0022034518788283 19. Rugg-Gunn AJ, Edgar WM, Geddes DA, Jenkins GN. The effect of different meal patterns upon plaque pH in human subjects. Br Dent J. 1975;139(9):351356. 20. Linke HA, Riba HK. Oral clearance and acid production of dairy products during interaction with sweet foods. Ann Nutr Metab. 2001;45(5):202-208. 21. Roberts MW, Wright JT. Nonnutritive, low caloric substitutes for food sugars: clinical implications for addressing the incidence of dental caries and overweight/obesity. Int J Dent. 2012;2012:625701. doi:10.1155/2012/625701. 22. Janakiram C, Deepan Kumar CV, Joseph J. 2017. Xylitol in preventing dental caries: a systematic review and meta-analyses. J Nat Sci Biol Med. 2017;8(1):16-21.

34 Fluorides Erin E. Relich, RDH, BSDH, MSA

CHAPTER OUTLINE FLUORIDE METABOLISM I. II. III. IV.

Fluoride Intake Absorption Distribution and Retention Excretion

FLUORIDE AND TOOTH DEVELOPMENT I. II. III.

Pre-eruptive: Mineralization Stage Pre-eruptive: Maturation Stage Posteruptive

TOOTH SURFACE FLUORIDE I. II. III.

Fluoride in Enamel Fluoride in Dentin Fluoride in Cementum

DEMINERALIZATION–REMINERALIZATION

I. II.

Fluoride in Biofilm and Saliva Summary of Fluoride Action

FLUORIDATION I. II.

Historical Aspects Water Supply Adjustment

EFFECTS AND BENEFITS OF FLUORIDATION I. II. III. IV. V. VI. VII.

Appearance of Teeth Dental Caries: Permanent Teeth Root Caries Dental Caries: Primary Teeth Tooth Loss Adults Periodontal Health

PARTIAL DEFLUORIDATION SCHOOL FLUORIDATION DISCONTINUED FLUORIDATION FLUORIDES IN FOODS I. II. III. IV. V. VI.

Foods Salt Halo/Diffusion Effect Bottled Water Water Filters Infant Formula

DIETARY FLUORIDE SUPPLEMENTS I. II. III. IV.

Assess Possible Need Available Forms of Supplements Prescription Guidelines Benefits and Limitations

PROFESSIONAL TOPICAL FLUORIDE APPLICATIONS I. II. III.

Historical Perspective Indications Compounds

CLINICAL PROCEDURES: PROFESSIONAL TOPICAL FLUORIDE I. II. III. IV. V. VI.

Objectives Preparation of the Teeth for Topical Application Patient and/or Parent Counseling Tray Technique: Gel or Foam Varnish Technique After Application

VII. Silver Diamine Fluoride

SELF-APPLIED FLUORIDES I. II.

Indications Methods

TRAY TECHNIQUE: HOME APPLICATION I. II.

Indications for Use Gels Used (Available by Prescription)

FLUORIDE MOUTHRINSES I. II. III. IV.

Indications Limitations Preparations Benefits

BRUSH-ON GEL I. II.

Preparations Procedure

FLUORIDE DENTIFRICES I. II. III. IV. V.

Development Indications Preparations Patient Instruction: Recommended Procedures Benefits

COMBINED FLUORIDE PROGRAM FLUORIDE SAFETY I. II. III. IV. V. VI.

Summary of Fluoride Risk Management Toxicity Signs and Symptoms of Acute Toxic Dose Emergency Treatment Chronic Toxicity How to Calculate Amounts of Fluoride

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES

After studying this chapter, the student will be able to: 1. Describe the mechanisms of action of fluoride in the prevention of dental caries. 2. Explain the role of community water fluoridation on the decline of dental caries incidence in a community. 3. Recommend appropriate over-the-counter (OTC) and professionally applied fluoride therapies based on each patient’s caries risk assessment. 4. Compare use of fluoride home products (OTC and prescription). 5. Incorporate fluoride into individualized prevention plans for patients of various ages and risk levels. The use of fluorides provides the most effective method for dental caries prevention and control. Fluoride is necessary for optimum oral health at all ages and is made available at the tooth surface by two general means: Systemically, by way of the circulation to developing teeth (preeruptive exposure). Topically, directly to the exposed surfaces of teeth erupted into the oral cavity1 (posteruptive exposure). Maximum caries inhibiting effect occurs when there is systemic exposure before tooth eruption and frequent topical fluoride exposure throughout life.2

FLUORIDE METABOLISM1,3 I. Fluoride Intake Sources Drinking water that contains fluoride naturally or has been fluoridated. Prescribed dietary supplements. Foods, in small amounts. Foods and beverages prepared at home or processed commercially using water that contains fluoride. Varying small amounts ingested from dentifrices, mouthrinses, supplements, and other fluoride products used by the individual.

II.

Absorption

A. Gastrointestinal Tract Fluoride is rapidly absorbed as hydrogen fluoride through passive diffusion in the stomach: Rate and amount of absorption depend on the solubility of the fluoride compound and gastric acidity. Most is absorbed within 60 minutes. Fluoride that is not absorbed in the stomach will be absorbed by the small intestine. There is less absorption when the fluoride is taken with milk and other food.

B. Blood Stream Plasma carries the fluoride for its distribution throughout the body and to the kidneys for elimination. Maximum blood levels are reached within 30 minutes of intake. Normal plasma levels are low and rise and fall according to intake.

III. Distribution and Retention Fluoride is distributed by the plasma to all tissues and organs. There is a strong affinity for mineralized tissues. Approximately 99% of fluoride in the body is located in the mineralized tissues. Concentrations of fluoride are highest at the surfaces next to the tissue fluid supplying the fluoride. The fluoride ion (F) is stored as an integral part of the crystal lattice of teeth and bones. Amount stored varies with the intake, the time of exposure, and the age and stage of the development of the individual. The teeth store small amounts, with highest levels on the tooth surface. Fluoride that accumulates in bone can be mobilized slowly from the skeleton due to the constant resorption and remodeling of bone. Once tooth enamel is fully matured, the fluoride deposited during development can be altered by cavitated dental caries, erosion, or mechanical abrasion.1

IV. Excretion Most fluoride is excreted through the kidneys in the urine, with a small amount excreted by the sweat glands and the feces. There is limited transfer from plasma to breast milk for excretion by that route.1

FLUORIDE AND TOOTH DEVELOPMENT Fluoride is a nutrient essential to the formation of sound teeth and bones, as are calcium, phosphorus, and other elements obtained from food and water. A comprehensive review of the histology of tooth development and mineralization is recommended to supplement the information included here.4,5

I.

Pre-eruptive: Mineralization Stage Fluoride is deposited during the formation of the enamel, starting at the dentinoenamel junction, after the enamel matrix has been laid down by the ameloblasts. Figure 34-1A shows the distribution of fluoride in all parts of the teeth during mineralization.

FIGURE 34-1 • Systemic Fluoride. Green dots represent fluoride ions in the tissues and distributed throughout the tooth. A: Developing tooth during mineralization shows fluoride from water and other systemic sources deposited in the enamel and dentin. B: Maturation stage before eruption, when fluoride is taken up from tissue fluids around the crown. C: Erupted tooth continues to take up fluoride on the surface from external sources. Note concentrated fluoride deposition on the enamel surface and on the pulpal surface of the dentin.

The hydroxyapatite crystalline structure becomes fluorapatite, which is a less soluble apatite crystal.2 Pre-eruptive fluoride may contribute to shallower occlusal grooves and reduce the risk of fissure caries.2 Chapter 47 lists the weeks in utero when the hard-tissue formation begins for the primary teeth. The first permanent molars begin to mineralize at birth as listed in Chapter 16. Effect of excess fluoride (fluorosis)6,7 Dental fluorosis is a form of hypomineralization that results from systemic ingestion of an excess amount of fluoride during tooth development. During mineralization, the enamel is highly receptive to free fluoride ions. The normal activity of the ameloblasts may be inhibited, and the defective enamel matrix that can form results in discontinuity of crystal growth. Dental fluorosis can appear clinically in varying degrees from white flecks or striations to cosmetically objectionable stained pitting, as listed in Chapter 21.

II.

Pre-eruptive: Maturation Stage After mineralization is complete and before eruption, fluoride deposition continues in the surface of the enamel.

Figure 34-1B shows fluoride around the crown during maturation. Fluoride is taken up from the nutrient tissue fluids surrounding the tooth crown.

III. Posteruptive After eruption and throughout the life span of the teeth, the concentration of fluoride on the outermost surface of the enamel is dependent on: Daily topical sources of fluoride to prevent demineralization and encourage remineralization for prevention of dental caries. Sources for daily topical fluoride include fluoridated drinking water, dentifrices, mouthrinses, and other fluoride preparations used by the patient. The fluoride on the outermost surface is available to inhibit demineralization and enhance remineralization as needed. Figure 34-2A depicts the areas on the tooth that acquire fluoride after eruption.

FIGURE 34-2 • Fluoride Acquisition after Eruption. A: Fluoride

represented by green dots on the enamel surface is taken up from external sources, including dentifrice, rinse, topical application, and fluoridated drinking water passing over the teeth. B: Gingival recession exposes the cementum to external sources of fluoride for the prevention of root caries and the alleviation of sensitivity.

The continuous daily presence of fluoride provided for the tooth surfaces can inhibit the initiation and progression of dental caries. Uptake is most rapid on the enamel surface during the first years after eruption. Repeated daily intake of drinking water with fluoride provides a topical source as it washes over the teeth throughout life.

TOOTH SURFACE FLUORIDE Fluoride concentration is greatest on the surface next to the source of fluoride. For the enamel of the erupted tooth, highest concentration is at the outer surface exposed to the oral cavity. For the dentin, the highest concentration is at the pulpal surface. Periodontal attachment loss (gingival recession) can often cause the root surface and cementum to become exposed to the oral cavity and external fluoride sources.

I.

Fluoride in Enamel

A. Uptake Uptake of fluoride depends on the level of fluoride in the oral environment and the length of time of exposure. Hypomineralized enamel absorbs fluoride in greater quantities than sound enamel; it incorporates into the hydroxyapatite crystalline structure to become fluorapatite.6 Demineralized enamel that has been remineralized in the presence of fluoride will have a greater concentration of fluoride than sound enamel.

B. Fluoride in the Enamel Surface Fluoride is a natural constituent of enamel. The intact outer surface has the highest concentration that falls sharply toward the interior of the tooth.8

II.

Fluoride in Dentin9 The fluoride level may be greater in dentin than that in enamel. A higher concentration is at the pulpal or inner surface, where

exchanges take place. Newly formed dentin absorbs fluoride rapidly.

III. Fluoride in Cementum9 The level of fluoride in cementum is high and increases with exposure. With recession of the clinical attachment level, the root surface is exposed to the fluids of the oral cavity. Figure 34-2B shows fluoride acquisition to exposed cementum. Fluoride is then available to the cementum from the saliva and all the sources used by the patient, including drinking water, dentifrice, and mouthrinse.

DEMINERALIZATION–REMINERALIZATION8 Figure 34-3 illustrates the comparative levels of fluoride that may be found in the tooth surface and the sublevel lesion in early dental caries.

FIGURE 34-3 • Examples of Enamel Fluoride Content. A: Early stage of dental caries with an intact surface enamel and subsurface demineralized area. B: A demineralized area readily takes up available fluoride. As shown, the fluoride

content (1,000 ppm) of the relatively intact surface over a subsurface demineralized white spot is higher than that of the sound surface enamel (500 ppm). The body of the advancing lesion has a higher fluoride content (150 ppm) than does the sound inner enamel (75 ppm). (From Melberg JR, Ripa LW, Leske GS. Fluoride in Preventive Dentistry: Theory and Clinical Applications. Chicago, IL: Quintessence; 1983:31.)

I.

Fluoride in Biofilm and Saliva Saliva and biofilm are reservoirs for fluoride; saliva carries minerals available for remineralization when needed. Fluoride helps to inhibit demineralization when it is present at the crystal surface during an acid challenge. Fluoride enhances remineralization, forming a condensed layer on the crystal surface, which attracts calcium and phosphate ions. High concentrations of fluoride can interfere with the growth and metabolism of bacteria. Dental biofilm may contain 5–50 ppm fluoride. The content varies greatly and is constantly changing. Fluoride may be acquired directly from fluoridated water, dentifrice, and other topical sources and brought by the saliva or by an exchange of fluoride in the biofilm to the demineralizing tooth surface under the biofilm.

II.

Summary of Fluoride Action

Having fluoride available topically to the tooth posteruptively is key to its effectiveness. Frequent exposure to fluoride, such as from fluoridated water, dentifrice, and mouthrinse, is recommended. There are three basic topical effects of fluoride to prevent dental caries:8 Inhibit demineralization. Enhance remineralization of incipient lesions. Inhibit bacterial activity by inhibiting enolase, an enzyme needed

by bacteria to metabolize carbohydrates.

FLUORIDATION Fluoridation is the adjustment of the natural fluoride ion content in a municipal water supply to the optimum physiologic concentration that will maximize caries prevention and limit enamel fluorosis.10 Fluoridation has been established as the most efficient, effective, reliable, and inexpensive means for improving and maintaining oral health for all who use it. Fluoridation was named by the U.S. Centers for Disease Control and Prevention (CDC) as one of the 10 most significant public health measures of the 20th century.10 The estimated annual cost per person per year is low, with lower cost per person for communities of more than 20,000 people.11 In 2014, 66.3% of the total U.S. population received fluoridated water, whereas 74.4% of the population served by public (municipal) water systems received fluoridated water. These percentages vary greatly from state to state.12

I.

Historical Aspects13

A. Mottled Enamel and Dental Caries Dr. Frederick S. McKay Early in the 20th century, Dr. McKay began his extensive studies to find the cause of “brown stain,” which later was called mottled enamel and now is known as dental fluorosis. He observed that people in Colorado Springs, Colorado, with mottled enamel had significantly less dental caries.14 He associated the condition with the drinking water, but tests were inconclusive. H.V. Churchill In 1931, H.V. Churchill, a chemist, pinpointed fluorine as the specific element related to the tooth changes that Dr. McKay had been observing clinically.15

B. Background for Fluoridation Dr. H. Trendley Dean Epidemiologic studies of the 1930s, sponsored by the U.S. Public Health Service (USPHS) and directed by Dr. Dean, led to the conclusion that the level of fluoride in the water optimum for dental caries prevention averages 1 ppm in moderate climates. Clinically objectionable dental fluorosis is associated with levels well over 2 ppm.16 From this knowledge and the fact many healthy people had lived long lives in communities where the fluoride content of the water was much greater than 1 ppm, the concept of adding fluoride to the water developed. It was still necessary to show the benefits from controlled fluoridation could parallel those of natural fluoride.

C. Fluoridation—1945 The first communities were fluoridated in 1945. Research in the communities began before fluoridation was started to obtain baseline information.

D. Control Cities Aurora, Illinois, where the natural fluoride level is optimum (1.2 ppm), was used to compare the benefits of natural fluoride in the water supply with those of fluoridation, as well as with a fluoridefree city, Rockford, Illinois. Original cities with fluoridation and their control cities in the research are shown in Box 34-1.

BOX 34-1 First Fluoridation Research Cities

RESEARCH CITY

CONTROL CITY

Grand Rapids, Michigan (January 1945)

Muskegon, Michigan

Newburgh, New York (May 1945)

Kingston, New York

Brantford, Ontario (June 1945)

Sarnia, Ontario

Evanston, Illinois (February 1947)

Oak Park, Illinois

The research conducted in those cities, as well as throughout the world, has documented the influence of fluoride on oral health.

II.

Water Supply Adjustment

A. Fluoride Level In 2015, the U.S. Department of Health and Human Services updated the recommendation for the optimal concentration of water fluoridation to 0.7 ppm for all communities, regardless of climate. The decision is based on the fact that Americans have access to many more sources of fluoride today than they did when water fluoridation was introduced in the United States.17 The change still provides an effective level of fluoride to reduce the incidence of dental caries while minimizing the rate of fluorosis.

B. Chemicals Used All fluoride chemicals must conform to the appropriate American Water Works Association standards to ensure that the drinking water will be safe.18 Sources Compounds from which the fluoride ion is derived are naturally

occurring and are mined in various parts of the world. Examples of common sources are fluorspar, cryolite, and apatite. Criteria for acceptance of a fluoride compound for fluoridation include: Solubility to permit regular use in a water plant. Relatively inexpensive. Readily available to prevent interruptions in maintaining the proper fluoride level. Compounds used: Dry compounds: sodium fluoride (NaF) and sodium silicofluoride. Liquid solution: hydrofluorosilicic acid.

EFFECTS AND BENEFITS OF FLUORIDATION Fluoridated water is a systemic source of fluoride for developing teeth and a topical source of fluoride on the surfaces of erupted teeth throughout life.19

I.

Appearance of Teeth Teeth exposed to an optimum or slightly higher level of fluoride appear white, shining, opaque, and without blemishes. When the level is slightly more than optimum, teeth may exhibit mild enamel fluorosis seen as white areas in bands or flecks. Without close scrutiny, such spots blend with the overall appearance. Today, the majority of fluorosis is mild and not considered an esthetic problem.10,20

II.

Dental Caries: Permanent Teeth

A. Overall Benefits Maximum benefit is seen with continuous use of fluoridated water from birth. Estimates have shown the reduction in caries due to water fluoridation alone (factoring out other sources of topical fluoride) among adults of all ages is 27%.19 The effects are similar to communities with optimum levels of natural fluoride in the water. Many more individuals are completely caries free when fluoride is in the water.

B. Distribution Anterior teeth, particularly maxillary, receive more protection from

fluoride than do posterior teeth.16 Anterior teeth are contacted by the drinking water as it passes into the mouth.

C. Progression Not only are the numbers of carious lesions reduced, but the caries rate is slowed. Caries progression is also reduced in the surfaces that receive fluoride for the first time after eruption.21

III. Root Caries Root caries experience in lifelong residents of a naturally fluoridated community is in direct proportion to the fluoride concentration in the water compared with the experience of residents of a fluoride-free community.22 The incidence of root caries is approximately 50% less for lifelong residents of a fluoridated community.23

IV. Dental Caries: Primary Teeth With fluoridation from birth, the caries incidence is reduced up to 40% in the primary teeth.10 The introduction of fluoridation into a community significantly increases the proportion of caries-free children and reduces the decayed, missing, and filled teeth (dmft/DMFT) scores compared to areas that are nonfluoridated over the same time period.20

V.

Tooth Loss

Tooth loss due to dental caries is much greater in both primary and permanent teeth without fluoride24 because of increased dental caries, which progresses more rapidly.

VI. Adults When a person resides in a community with fluoride in the drinking water throughout life, benefits continue.25,26

VII. Periodontal Health Indirect favorable effects of fluoride on periodontal health can be shown. Fluoride works to decrease dental caries. The presence of carious lesions favors biofilm retention, which can lead to periodontal infection, particularly adjacent to the gingival margin.

PARTIAL DEFLUORIDATION Water with an excess of natural fluoride does not meet the requirements of the USPHS. Several hundred communities in the United States had water supplies that naturally contained more than twice the optimal level of fluoride. Defluoridation can be accomplished by one of several chemical systems.27 The efficacy of the methods has been shown. Examples: The water supply in Britton, South Dakota, has been reduced from almost 7 to 1.5 ppm since 1948, and in Bartlett, Texas, from 8 to 1.8 ppm since 1952. Examinations have shown a significant reduction in the incidence of objectionable fluorosis in children born since defluoridation.27,28

SCHOOL FLUORIDATION To bring the benefits of fluoridation to children living in rural areas without the possibility for community fluoridation, adding fluoride to a school water supply has been an alternative. Because of the intermittent use of the school water (only 5 days each week during the 9-month school year), the amount of fluoride added was increased over the usual 1 ppm. Example: In the schools of Elk Lake, Pennsylvania, after 12 years with the fluoride level at 5 ppm in the school drinking water, the children experienced a 39% decrease in DMF surfaces compared with those in the control group.29 Example: In the schools of Seagrove, North Carolina, after 12 years with the fluoride level at 6.3 ppm in the school drinking water, the children experienced a 47.5% decrease in DMF surfaces compared with those in the control group.29 Such systems have significance in the long history of efforts for fluoridation for all people in the United States. School fluoridation has been phased out in several states, and the current extent of this practice is unknown. Operations and maintenance of small fluoridation systems are problematic.10

DISCONTINUED FLUORIDATION When fluoride is removed from a community water supply that had dental caries control by fluoridation, the effects can be clearly shown. Example: In Antigo, Wisconsin, the action of antifluoridationists in 1960 brought about the discontinuance of fluoridation, which had been installed in 1949. Examinations in the years following 1960 revealed the marked drop in the number of children who were caries free and the steep increases in caries rates. From 1960 to 1966, the number of caries-free children in the second grade decreased by 67%.30 Fluoridation was reinstated in 1966 by popular demand.

FLUORIDES IN FOODS I. Foods31 Certain foods contain fluoride, but not enough to constitute a significant part of the day’s need for caries prevention. Examples: Meat, eggs, vegetables, cereals, and fruit have small but measurable amounts, whereas tea and fish have larger amounts. Foods cooked in fluoridated water retain fluoride from the cooking water.

II.

Salt32-34 Fluoridated salt has not been promoted in the United States, but is widely available and used in Germany, France, and Switzerland along with other European countries where 30%–80% of the domestic marketed salt is fluoridated. Another 30 countries or more use fluoridated salt worldwide for its effectiveness as a community health program. Fluoridated salt results in a reduced incidence of dental caries, but there is insufficient evidence for its overall effectiveness. Fluoridated salts currently available supply about one-third to onehalf of the amount of fluoride ingested daily from 1 ppm fluoridated water. Fluoridated salt is recommended by the World Health Organization as an alternative to fluoridated water to target underprivileged groups.

III. Halo/Diffusion Effect Foods and beverages that are commercially processed (cooked or reconstituted) in optimally fluoridated cities can be distributed and consumed in nonfluoridated communities. The halo or diffusion effect can result in increased fluoride intake

by individuals living in nonfluoridated communities, providing them some protection against dental caries.31

IV. Bottled Water Bottled water usually does not contain optimal fluoride unless it has a label indicating that it is fluoridated. Patients need to be advised to fill their drinking water bottles from a fluoridated water supply.

V.

Water Filters35

Reverse osmosis and water distillation systems remove fluoride from the water, but water softeners do not. Carbon filters (for the end of a faucet or in pitchers) vary in their removal of fluoride. Carbon filters with activated alumina remove fluoride. Patients need to be warned that water filters may remove fluoride from the drinking water and need to be checked with the manufacturer before purchase.

VI. Infant Formula36-38 There has been an increase in breastfeeding in the United States, but infant formula remains a major source of nutrition for many infants. Ready-to-feed formulas do not need to be reconstituted, but water is added to powdered and liquid concentrate formulas. Breast milk may contain 0.02 ppm fluoride, and all types of infant formula themselves contain a low amount of fluoride (0.11–0.57 ppm).37 The level of fluoride in the water supply used to reconstitute powdered or liquid concentrate formulas determines the total fluoride intake. The American Dental Association (ADA) recommends continuing to

use optimally fluoridated water to reconstitute infant formula while being aware of the possible risk of mild enamel fluorosis in the primary teeth.38

DIETARY FLUORIDE SUPPLEMENTS10,39,40 Prescribed dietary supplements were introduced in the late 1940s and are intended to compensate for fluoride-deficient drinking water. The current supplementation dosage schedule developed by the ADA and the American Association of Pediatric Dentistry (AAPD) and revised in 2010 includes children aged 6 months through 16 years. Table 34-1 contains the daily dosage amounts based on the age of the child and the amount of fluoride in the primary water supply. TABLE 34-1 • Fluoride Supplements Dose Schedule (Mg Naf/D)a

aAbout

2.2 mg of sodium fluoride provides 1 mg of fluoride ion. Source: Rozier, Adair S, Graham F, et al. Evidence-based clinical recommendations on the prescription of dietary fluoride supplements for caries prevention: a report of the ADA Council on Scientific Affairs. J Am Dent Assoc. 2010;141:1480-1489. http://www.aapd.org/media/Policies_Guidelines/G_FluorideTherapy.pdf (2014)

Clinical recommendations from the ADA Council on Scientific

Affairs include the use of fluoride supplements for children: At high risk of developing dental caries Those whose primary source of drinking water is deficient in fluoride.41

I.

Assess Possible Need Review the patient’s history to be certain the child is not receiving other fluoride in such preparations as vitamin–fluoride supplements. Determine the fluoride level of all sources of drinking water is below 0.6 ppm. Refer to the list of fluoridated communities available from state or local health departments. Request water analysis when the fluoride level has not been determined, for example, in private well water. Determine the child’s risk for dental caries is high or moderately high before considering the use of fluoride supplements.39 Reassess the caries risk at frequent intervals as the status may be affected by the child’s development, personal and family situations, and behavioral factors such as changes in oral hygiene practices.33,41

II.

Available Forms of Supplements NaF supplements are available as tablets, lozenges, and drops in 0.25, 0.50, and 1.0 mg dosages. Prescribed on an individual patient basis for daily use at home.

A. Tablets and Lozenges Tablets are chewed thoroughly, swished/rinsed around in the oral cavity, and forced between the teeth before swallowing. Lozenges are dissolved for 1–2 minutes in the mouth to provide both pre-eruptive and posteruptive benefits.41 Best taken at bedtime after teeth are brushed.

Avoid drinking, eating, or rinsing before going to sleep to gain maximum benefit.

B. Drops A liquid concentrate with directions that specify the number of drops for the prescription dose daily. Primary use for child aged 6 months to 3 years, and patient of any age unable to use other forms that require chewing and swallowing.

III. Prescription Guidelines No more than 264 mg NaF (120 mg fluoride ion) to be dispensed per household at one time. Take supplements with juice or water. Avoid taking with dairy products because fluoride can combine with calcium and be poorly absorbed. Storage Keep products out of reach of children. Keep tablets in the original container, away from heat and direct light, and away from damp places such as a bathroom or kitchen sink area. Missed dose Take as soon as remembered. If near next dose time, skip that dose and go to the next regular time.

IV. Benefits and Limitations Prenatal use by pregnant women Administration of prenatal dietary fluoride supplements is not recommended. Some evidence has shown that fluoride crosses the placenta during the fifth and sixth months of pregnancy and may enter the prenatal deciduous enamel.42

Overall, there is weak evidence to support the use of fluoride supplements to prevent dental caries in primary teeth. Daily fluoride supplements offer caries preventive benefits in permanent teeth. School-aged children who chewed, swished, and swallowed 1 mg fluoride tablets daily on school days had significantly lower caries experience than those who did not use fluoride supplements. The use of fluoride supplements in children over 6 years of age shows a 24% decrease in DMF tooth surfaces in permanent teeth compared to no fluoride supplements.43 Consider the child’s age, caries risk, and all sources of fluoride exposure before recommending the use of fluoride supplements.33,41

PROFESSIONAL TOPICAL FLUORIDE APPLICATIONS Topical fluorides are an essential part of a total preventive program for patients of all ages. Fluoridated water and fluoride toothpaste are the primary sources of topical fluoride for patients of all ages and levels of caries risk. Additional topical fluoride sources may be professionally applied and/or self-applied by the patient, primarily for those at an elevated caries risk.

I.

Historical Perspectives Professionally applied fluoride has been instrumental in the reduction of dental caries in the United States and other industrialized countries since the early 1940s. Dr. Basil G. Bibby conducted the initial topical NaF study using Brockton, Massachusetts, schoolchildren.44 More than one-third of the fewer new carious lesions resulted from a 0.1% aqueous solution applied at 4-month intervals for 2 years applied by a dental hygienist. The research led to extensive studies by Dr. John W. Knutson and others sponsored by the USPHS. The aim was to determine the most effective concentration of NaF, the minimum time required for application, and procedural details.45,46

II.

Indications The professional application of a high-concentration fluoride preventive agent is based on caries risk assessment for the individual patient. See Chapter 25 for the criteria to determine low, moderate, and high caries risk.

Indications for a professional fluoride application are outlined in Box 34-2.47

BOX 34-2 Indications for Professional Topical Fluoride Application47 • Patients at an elevated (moderate or high) risk of developing caries • See Table 25-1 for the criteria to determine low, moderate, and high caries risk. • 5% NaF varnish at least every 3–6 months (for all ages and adult root caries) Or • 1.23% APF gel 4-minute trays at least every 3–6 months (for 6 years and older and adult root caries) • Patients at a low risk of developing caries may not benefit from additional topical fluoride other than OTC-fluoridated toothpaste and fluoridated water daily. Source: American Dental Association Council on Scientific Affairs. Topical fluoride for caries prevention: executive summary of updated clinical recommendations and supporting systematic review. J Am Dent Assoc. 2013;144(11):1279-1291.

III. Compounds Table 34-2 provides a summary of the available professional fluoride applications. TABLE 34-2 • Professionally Applied Topical Fluorides

a

There is limited published clinical evidence supporting the effectiveness of

foam.47 NAF, sodium fluoride; SDF, silver diamine fluoride.

2.0% NaF as gel or foam delivered in trays. 1.23% acidulated phosphate fluoride (APF) as a gel or foam delivered in trays. 5% NaF as a varnish brushed on the teeth. 2.0% NaF gel NaF, also called “neutral sodium fluoride” due to its neutral pH of 7.0, contains 9,050 ppm fluoride ion. Clinical trials demonstrating the efficacy of neutral NaF are based on a series of four or five applications on a weekly basis.48 Quarterly or semiannual applications are most common in clinical practice. 2.0% NaF foam There is limited clinical evidence to demonstrate foam’s effectiveness in caries prevention. 1.23% APF gel Contains 12,300 ppm fluoride ion. A 4-minute tray application is recommended at least every 3–6 months per year for individuals aged 6 years and older at an elevated risk for dental caries.47 Widely used because of its storage stability, acceptable taste, and tissue compatibility. Low pH of 3.5 enhances fluoride uptake, which is greatest during the first 4 minutes.49 APF may etch porcelain and composite restorative materials, so it is not indicated for patients with porcelain, composite restorations, and sealants.50 The hydrofluoride component of APF can dissolve the filler particles of the composite resin restorations. Macroinorganic filler particles of composite materials demonstrate noticeable etched patterns generated by APF, whereas many of the more recently available microfilled

composites/resins are not as sensitive to the APF.50 The prevented fraction of dental caries ranged from 18% to 41% with the use of APF or NaF gels.51 1.23% APF foam There is limited clinical evidence to show the effectiveness of foam in caries prevention. 5% NaF varnish Fluoride varnishes (FVs) were developed during the late 1960s and early 1970s to prolong contact time of the fluoride with the tooth surface.52 Varnishes are safe and effective, fast and easy to apply, and patient acceptance is good. The use of FV 2–4 times per year is associated with a 43% decrease in DMFT surfaces in permanent teeth and 37% in primary teeth.53 Varnish has a higher concentration of fluoride than gel or foam (22,600 ppm fluoride ion), but an overall less amount of fluoride is used per application (4 mm. Signed: ______________________________, RDH Date: ____________________________________

EVERYDAY ETHICS Leslie is eager to begin a new position in her first year of clinical practice as a dental hygienist. Dr. Shepherd has been in practice for 15 years and most staff members have been with him at least the past 10 years, including Ann, the dental hygienist with whom she will be practicing. Leslie is glad to have someone with experience take her under her wing. A dental assistant takes care of instrument sterilization and tray setups for the dental hygienists. As she sat down to her first patient, she noticed the instruments on her instrument cassette were all sickle scalers and she wanted curets. On closer inspection, however, she discovered that all but one instrument were indeed curets; they had just

been sharpened incorrectly, leaving them with no contour (curvature) at the toe. She excused herself to go into the instrument supply room only to find that all of the curets had sharp, pointed toes. Going back to the clinical area, she peeked in to ask Ann if the assistant did the sharpening for her (as she glanced at Ann’s tray she noted the curets were equally sharpened to a distinct point). Ann answered, “No, I do all the sharpening myself because I am very picky.” Leslie suddenly realizes nothing has ever been said in a work description about who orders new dental hygiene instruments. She had learned in school that dental hygiene practitioners took care of their own instruments. Leslie pondered what she would do to address this situation—especially how to approach it without alienating her new coworkers. Questions for Consideration 1. Given Leslie’s novice status as a clinician, how will she approach her new colleague—an experienced practitioner—with her concerns? Which core values of dental hygiene are involved in this scenario? 2. What harm, if any, is affecting Dr. Shepherd’s patients? Discuss whether the dentist needs to be notified about the condition of the instruments. 3. Utilizing an ethical decision framework (see Chapter 1), describe realistic alternatives for Leslie’s course of action in this situation.

Factors to Teach the Patient Benefits of using a finely sharpened instrument for calculus removal. Harmful effects of using dull instruments.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Wiebe CB, Hoath BJ, Owen G, Bi J, Giannelis G, Larjava HS. Sterilization of ceramic sharpening stones. J Can Dent Assoc. 2017 September;83:h11. 2. Balevi B. Engineering specifics of the periodontal curet’s cutting edge. J Periodontol. 1996 Apr;67(4):374–378. 3. Nahass HE, Madkour GG. Evaluation of different resharpening techniques on the working edge of periodontal scalers: a scanning electron microscopic study. Life Sci J. 2013;10(1):589–593. 4. Andrade Acevedo RA, Cézar Sampaio JE, Shibli JA. Scanning electron microscope assessment of several resharpening techniques on the cutting edges of Gracey curettes. J Contemp Dent Pract. 2007 November 1;8(7):70– 77. 5. Silva MV, Gomes DA, Leite FR, et al. Sharpening of periodontal instruments with different sharpening stones and its influence upon root debridement— scanning electronic microscopy assessment. J Int Acad Periodontol. 2006;8(1):17–22. 6. Hessheimer HM, Payne JB, Shaw LE, Spanyers EM, Beatty MW. A comparison of efficiency and material wear of diamond-plated versus ceramic sharpening stones. J Dent Hyg. 2017 October;91(5):64–67.

39 Nonsurgical Periodontal Therapy and Adjunctive Therapy Linda D. Boyd, RDH, RD, EdD, Uhlee (Yuri) Oh, RDH, BS, MSDH, and Esther M. Wilkins, BS, RDH, DMD

CHAPTER OUTLINE NONSURGICAL PERIODONTAL THERAPY I. II.

Introduction to Components of Initial Periodontal Therapy Overview of Nonsurgical Periodontal Therapy Outcomes

AIMS AND EXPECTED OUTCOMES I. II.

Interrupt or Arrest the Progress of Disease Create an Environment to Encourage Healing and Resolution of Inflammation III. Induce Positive Changes in the Quality and Quantity of Subgingival Bacterial Flora IV. Provide Initial Preparation (Tissue Conditioning) for Surgical Periodontal Therapy in Advanced Disease

V. Educate and Motivate the Patient

NONSURGICAL PERIODONTAL THERAPY TREATMENT GOALS I. II. III.

Patient with Plaque (or Biofilm)-Induced Gingivitis Patient with Mild-to-Moderate Periodontitis (Stage I or II) Patients with Moderate-to-Severe Periodontitis (Stage III or IV), or Poor Response to Initial or Maintenance Therapy IV. Patients Who Require Surgical or Other Advanced Periodontal Therapy

COMPONENTS OF NONSURGICAL PERIODONTAL THERAPY I. II. III. IV.

Preventive Services Dental Biofilm Removal Calculus Removal Restorative Biofilm-Retentive Factors

DENTAL HYGIENE TREATMENT CARE PLAN FOR PERIODONTAL DEBRIDEMENT APPOINTMENT PLANNING I. II. III. IV.

Single Appointment Multiple Appointments Full-Mouth Disinfection Definitive Nonsurgical Periodontal Therapy

PREPARATION FOR PERIODONTAL DEBRIDEMENT I. II. III. IV. V. VI. VII.

Review the Patient’s Assessment Record Review Radiographic Findings Review Care Plan and Treatment Records Patient Preparation Supragingival Examination Subgingival Examination Formulate Strategy for Instrumentation

ADVANCED INSTRUMENTATION I. II. III.

Definitions Subgingival Anatomical Considerations Instrumentation Technique

SPECIALIZED DEBRIDEMENT INSTRUMENTS I. II. III. IV. V.

Furcation Debridement Advanced Ultrasonic Tips Microultrasonics Endoscope-Assisted Periodontal Debridement Subgingival Air Polishing

VI. Laser Therapy

POST-OP INSTRUCTION FOR PERIODONTAL DEBRIDEMENT APPOINTMENTS I. II. III. IV. V.

Management of Discomfort Oral Self-Care Diet Emergency Management Instruction Format

RE-EVALUATION OF NONSURGICAL PERIODONTAL THERAPY I. II. III.

Clinical Endpoints Re-evaluation Time Frame Re-evaluation Procedure

ADJUNCTIVE THERAPY ANTIMICROBIAL THERAPY I. II. III.

Systemic Delivery of Antibiotics Systemic Subantimicrobial Dose Antibiotics Local Delivery Antimicrobials Agents

INDICATIONS FOR USE OF LOCAL DELIVERY AGENTS I. II. III. IV.

Nonsurgical Periodontal Therapy Adjunctive Treatment: At Re-Evaluation Recurrent Disease Peri-Implantitis

TYPES OF LOCAL DELIVERY AGENTS I. II. III.

Minocycline Hydrochloride Doxycycline Hyclate Chlorhexidine Gluconate

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to:

1. Explain the goals and desirable clinical endpoints or outcomes for nonsurgical periodontal therapy. 2. Devise a care plan for a patient with slight-to-moderate chronic periodontitis. 3. Describe the changes in the subgingival bacteria after periodontal debridement. 4. Describe current evidence related to laser therapy for initial therapy. 5. Develop postoperative instructions for a patient following a nonsurgical periodontal therapy appointment. 6. List the steps in re-evaluation of nonsurgical periodontal therapy and the decisions that must be made based on the clinical outcomes. 7. Compare and contrast the risks and benefits of systemic antibiotics and local delivery antimicrobials. 8. Critically evaluate the benefit of local delivery antimicrobials on changes in pocket depth and clinical attachment level (CAL).

NONSURGICAL PERIODONTAL THERAPY I. Introduction to Components of Initial Periodontal Therapy Periodontal debridement remains the “gold standard” for initial therapy in inflammatory gingival and periodontal infections and includes the following therapeutic interventions1–4: Management or elimination of modifiable risk factors for periodontal disease. Patient education for preventive strategies including control of biofilm, tobacco cessation, and nutritional counseling with ongoing evaluation and reinforcement. Nonsurgical periodontal therapy (NSPT) to remove dental biofilm, endotoxins, other bacterial products, and calculus. Administration of antimicrobial or antibiotic agents as appropriate to enhance periodontal treatment outcomes. Elimination of local factors contributing to periodontal disease, including: Overhanging margins of restorations. Unfinished, poorly contoured, or unpolished restorations. Carious lesions. Ill-fitting prosthetic devices. Occlusal trauma. Re-evaluation of initial therapy to identify the need for surgical periodontal therapy or ongoing periodontal maintenance.

II.

Overview of Nonsurgical Periodontal Therapy Outcomes The therapeutic goals of periodontal therapy are to manage or eliminate plaque biofilm and risk factors for periodontitis in order to stop progression of disease and maintain oral health. NSPT consisting of periodontal debridement can provide the

definitive or complete treatment for many patients with mild-tomoderate periodontitis. Research shows the following outcomes1–4: Reduction in inflammation and infection. Reductions in pocket depth. Gains in clinical attachment. Research suggests NSPT plus certain adjunctive therapies may have an additive effect on improvements in clinical attachment level (CAL). The adjunctive therapies with moderate evidence of efficacy include3: Systemic subantimicrobial dose doxycycline (SSD). Systemic antimicrobials. Chlorhexidine gluconate (CHX) chips. Photodynamic therapy with a diode laser. The long-term success of treatment depends on the following4: Control of the dental biofilm by the patient on a daily basis. Management of modifiable periodontal risk factors. Regular periodontal maintenance based on risk factors and disease control.5 A skilled clinician to provide definitive debridement initially and on an ongoing basis.

AIMS AND EXPECTED OUTCOMES The effects and benefits of complete, carefully performed NSPT are summarized here.

I.

Interrupt or Arrest the Progress of Disease Reduce formation of dental biofilm. Delay repopulation of pathogenic microorganisms. Change behavioral and lifestyle habits of the patient to reduce risk factors for periodontal infections.

II.

Create an Environment to Encourage Healing and Resolution of Inflammation Facilitate resolution of disease to restore health. Reduce pocket depths.1 Eliminate bleeding on probing (BOP). Restore the gingival tissues to normal texture, color, size, and contour. Increase attachment level.1,3 Remove calculus and restorative dentistry irregularities to reduce biofilm retention.4

III. Induce Positive Changes in Quality and Quantity of Subgingival Bacterial Flora Before instrumentation, the predominant microorganisms are anaerobic, gram-negative, motile forms with many spirochetes and rods, high counts of all types of microorganisms, and many leukocytes. After instrumentation, the composition of the bacterial flora tends to shift to a predominance of aerobic, gram-positive, nonmotile,

coccoid forms with lower bacterial load (Table 39-1). TABLE 39-1 • Effect of Instrumentation on Pocket Microflora PERIODONTAL INFECTION BEFORE TREATMENT

PERIODONTAL HEALTH AFTER TREATMENT

Predominant flora is: Anaerobic Gram negative Motile Spirochetes, motile rods; pathogenic

Predominant flora is: Aerobic Gram positive Nonmotile Coccoid forms; nonpathogenic

Total microbial count: Very high total count of all types of microorganisms

Total microbial count: Much lower total counts of all types of microorganisms

Leukocyte count: Many leukocytes

Leukocyte count: Lower leukocyte counts

However, in some individuals, periodontal pathogens may persist after NSPT, and further treatment may be necessary to manage periodontal disease progression.6

IV. Provide Initial Preparation (Tissue Conditioning) for Surgical Periodontal Therapy in Advanced Disease Reduce or eliminate etiologic and predisposing factors.7 Re-evaluation following initial NSPT allows for identification of those areas requiring surgical intervention.7

V.

Educate and Motivate the Patient

To assume a co-therapist role in maintaining periodontal health following nonsurgical and/or surgical periodontal treatment. To make a commitment to perform daily personal biofilm control measures.

To continue with periodontal maintenance appointments at intervals consistent with patient’s individual risk factors to monitor and manage periodontal disease.5,8

NONSURGICAL PERIODONTAL THERAPY TREATMENT GOALS I. Patient with Plaque (or Biofilm)-Induced Gingivitis Complete scaling. Patient compliance in personal daily biofilm removal. Therapeutic goal: Reversal of inflammation to establish gingival health through elimination of etiologic factors.9

II.

Patient with Mild-to-Moderate Periodontitis (Stage I or II) Control of infection may be attained through NSPT. Maintaining the healthy state requires continuing routine appointments for professional scaling and supervision of the patient’s biofilm removal methods. Therapeutic goals4: Reduction in gingival inflammation and BOP. Reduction in pocket depths. CALs are stabilized or improved. Decrease in detectable dental biofilm to a level consistent with health.

III. Patients with Moderate-to-Severe Periodontitis (Stage III or IV) or Patients with Poor Response to Initial or Maintenance Therapy Supplemental therapeutic measures, such as adjunctive chemotherapeutics, may be needed. Specialized instruments may be required for deep pockets,

furcations, and complex anatomical features of involved diseased root surfaces. Therapeutic goals7: Same goals as mild-to-moderate periodontal conditions. Radiographic improvement in osseous lesions. Occlusal stabilization.

IV. Patients Who Require Surgical or Other Advanced Periodontal Therapy Certain periodontal conditions will require surgical or other advanced therapeutic procedures. Examples of surgical periodontal procedures include7: Gingival augmentation therapy: periodontal plastic surgeries, gingival grafts. Regenerative procedures: bone grafting, guided tissue regeneration. Resective therapy: gingival flaps with or without osseous surgery, root resective therapy, gingivectomy. For these patients, thorough NSPT prepares the tissues for the surgical phase of treatment by reducing the bacterial load and reducing inflammation.

COMPONENTS OF NONSURGICAL PERIODONTAL THERAPY I. Preventive Services Education for patients and collaboration with primary care providers for patients with systemic conditions for which periodontal infection is a risk factor (e.g., pregnancy, cardiovascular disease, diabetes).4,7,9 Fluoride applications and other preventive measures, especially for root caries prevention in the patient with recession. At-home rinsing, irrigation, other selective use of antimicrobials, and fluorides (dentifrice, chlorhexidine, water fluoridation). Smoking cessation support and referral to services as appropriate. Dietary assessment and counseling. Desensitization of teeth. Care for dental implants and prostheses.

II.

Dental Biofilm Removal Gingival inflammation and periodontal destruction result from the action of pathogenic microorganisms in dental biofilm and the host response. Endotoxin Lipopolysaccharides or endotoxins, derived from the cell walls of gram-negative pathogenic microorganisms, trigger an inflammatory host response, leading to periodontitis and destruction of the periodontal attachment.8 Endotoxins exist in biofilm and can be removed with scaling. Calculus removal results in endotoxin levels consistent with health.10,11 Cementum The cementum is thin at the cervical third of the root, and some removal of the cementum during instrumentation for calculus

removal is inevitable. However, the cementum should be preserved as much as possible as it serves as a source of growth factors for new attachment.12

III. Calculus Removal Calculus is not directly a cause of gingival inflammation, but it provides an environment for biofilm retention.13 Although historically a smooth root surface was the endpoint for scaling, the current evidence suggests disruption of biofilm and removal of calculus along with preservation of the cementum is the ideal endpoint of root debridement.12

IV. Restorative Biofilm-Retentive Factors Overhanging margins and rough surfaces of restorations create a niche for biofilm development. Personal oral self-care efforts by the patient are impeded by overhanging margins, irregular margins that are breaking down, and poorly contoured restorations. Removal of an overhanging margin or replacement is a critical component of facilitating returning the periodontium to health.

DENTAL HYGIENE TREATMENT CARE PLAN FOR PERIODONTAL DEBRIDEMENT The needs of the individual patient are identified through patient assessment (refer to Chapter 20). The course of treatment is defined by the dental hygiene diagnosis and care plan (refer to Chapters 22 and 23). Included in the care plan are the following: Management of individual modifiable risk factors such as tobacco cessation. Periodontal diagnosis, including the distribution and severity of the periodontal infection. Treatment sequence needed for the individual. Length and number of appointments required to complete treatment. Plan for re-evaluation and continuing care (described in Chapters 44 and 45).

APPOINTMENT PLANNING Whether a single or multiple appointment plan is required, the initial step is patient education. The overall care plan should be reviewed and discussed to obtain informed consent of the patient, parent, or guardian obtained. Treatment begins with the patient taking responsibility for daily removal of biofilm.

I.

Single Appointment The diagnosis may be gingivitis (Chapter 19) with minimal inflammation and small deposits near gingival margin; local anesthesia may not be needed. If only a few teeth are periodontally involved and require localized NSPT, limited areas of local anesthesia may be required. Patient presents with an acceptable biofilm score, and evidence of reasonable oral self-care without need for time to provide extended follow-up instruction. Patient acts responsibly in keeping appointments for periodontal maintenance and continued monitoring for disease control.

II.

Multiple Appointments

Factors that determine the number of appointments needed include the extent of periodontal involvement as shown by probing measurements, distribution and extent of calculus deposits, and adequate biofilm removal.

A. Management of Modifiable Risk Factors At the initial appointment, education should begin to manage modifiable risk factors, such as tobacco cessation and biofilm removal. Chapter 24 provides guidance on motivational interviewing

to assist with this component of treatment. Patient education to assess and refine daily oral self-care techniques for dental biofilm removal is initiated at the first NSPT appointment. Interdental devices to complement the use of a toothbrush can be added as the patient demonstrates readiness. It is important not to overwhelm the patient at the first appointment. At each successive appointment, disclose the biofilm and review with the patient. Add new oral hygiene aids as needed based on patient’s preferences and dexterity. Typically, inflammation and bleeding will gradually improve at each appointment as a result of improvement in biofilm removal and periodontal debridement.

B. Quadrant Scaling Appointments One system for appointment planning is by quadrants or sextants with local anesthesia for moderate-to-severe disease, such as stages III and IV periodontitis, at 1-week intervals. This allows for review of oral self-care and healing of the area(s) previously treated. With less severe periodontitis, such as stage I or II, and a compliant patient, two quadrants on the same side (maxillary and mandibular arches) may be completed at an appointment. After periodontal debridement is completed, the need for reevaluation should be reinforced to assess the need for additional care. The periodontal maintenance interval should be determined based on the patient risk for disease progression.

C. Evaluation At each appointment, the healing of the quadrants previously treated should be assessed.

Any residual calculus remaining can be removed. Best done 4–8 weeks following completion of NSPT to allow for connective tissue healing.14 Re-evaluation is important to determine the periodontal maintenance interval and the need for referral and/or surgical therapy.

III. Full-Mouth Disinfection A. Definition System of performing NSPT in two long appointments completed within a 24-hour period with adjunctive chlorhexidine mouthrinse.15 The procedures are best accomplished under local anesthesia with a chairside dental assistant. Systematic review of the research on full-mouth disinfection versus traditional NSPT found no clear evidence of a benefit for one approach over another.15 The approach of NSPT selected needs to be based on patient preference and scheduling options.

B. Rationale The rationale is completing the procedure in one session or multiple sessions within 24 hours reduces likelihood of re-infection of previously treated sites.15

C. Limitations Case selection: Many patients would not be able to withstand such intense treatment. Patient instruction: Eliminates opportunities for review and repeated instruction at the patient’s learning pace without a series of appointments with time in between for patient practice of oral selfcare.

The ability to re-evaluate immediate healing of each quadrant is also not possible.

IV. Definitive Nonsurgical Periodontal Therapy A. Quadrant or Sextant Approach Quadrant or sextant treatment to completion is recommended. The decision between a quadrant and sextant approach is made according to what can reasonably be completed by the clinician and tolerated by the patient during an appointment. Treatment appointments are scheduled accordingly.

B. Factors to Consider in Care Planning Access: the relative ease of instrument insertion to the base of the soft-tissue pocket. Tissue tone, such as fibrosity of the free gingiva. Probing depths: attachment pattern around the full circumference of each tooth. Deposit on tooth surfaces Extent and distribution of calculus. Age of calculus/degree of mineralization. Strength of attachment of calculus to the tooth. Root anatomy Multirooted teeth with furcation involvement. Deep concavities. Patient factors Behavioral factors, such as apprehension. Need for local anesthetic or nitrous oxide/oxygen sedation. Limited capacity for opening mouth.

PREPARATION FOR PERIODONTAL THERAPY I. Review the Patient’s Assessment Record Document individual needs: from medical, dental, and psychosocial history along with previous appointment experiences. Identify systemic or physical problems with potential for emergency.

II.

Review Radiographic Findings

A. Findings Applicable During Instrumentation Anatomic features of roots, furcations, and bone level, which may impact selection and adaptation of instruments. Overhanging restorations to be removed or scheduled for replacement.

B. Use Radiographs as Guide Keep radiographs on lighted viewbox or computer screen throughout the treatment for reference to observe bone level, root anatomy, and contour of restorations for each area.

III. Review Care Plan and Treatment Records Document flow and sequence of planned appointments. Document findings related to the instrumentation process. Assess periodontal chart to review attachment topography and access limitations. Assemble procedure tray setup or cassette to include appropriate instruments. Review previous appointment progress notes. Read details of prior treatment, noting quadrants or sextants completed, which will be reassessed for healing.

Ascertain how previous treatment appointments have been tolerated by the patient. Plan appropriate local anesthesia for pain management. Keep periodontal probing chart within view of the clinician throughout the treatment for reference.

IV. Patient Preparation A. Premedication Requirements for High-Risk Patient Transient bacteremia can occur during and immediately after scaling procedures. Flossing and a single quadrant of scaling and root debridement result in the same incidence and magnitude of bacteremia, so only high-risk patients are in need of antibiotic premedication.16 Consult with the primary care provider to determine whether premedication is required (see Chapter 11 to identify patients who may be at risk for bacterial endocarditis and be in need of prophylactic premedication).

B. Provide Preprocedural Antimicrobial Rinse Preprocedural rinsing with chlorhexidine gluconate lowers bacterial aerosols and contamination produced by ultrasonic instrumentation.17,18 Preprocedural rinsing with chlorhexidine rinse has not been shown to reduce bacteremia, or bacteria in the bloodstream following NSPT.19

C. Prepare for Local Anesthesia Adequate pain control tends to facilitate better patient outcomes and higher levels of patient satisfaction with treatment. Patients who refuse local anesthesia experience more discomfort,

dental anxiety, longer treatment times, greater residual gingival inflammation, and more pocket depths greater than or equal to 5 mm.20 Rather than asking patients if they “want” local anesthesia, the clinician should state the best treatment option and discuss the impact of pain control on improved outcomes to aid the patient in decision-making.

V.

Supragingival Examination

A. Visual Gross deposits and tooth surface irregularities can be seen by direct vision. Fine, unstained, white, or yellowish calculus is frequently invisible when wet with saliva. Observe tooth surfaces closely while applying a gentle stream of compressed air. Dry calculus is more visible than wet calculus.

B. Tactile An enamel surface without deposits or anatomical irregularities is smooth. An explorer tip passed over the surface slides freely, smoothly, and quietly. When rough calculus deposits are present, the explorer tip does not slide freely, but meets with resistance over varying textures. Deposits can produce a surface that feels like sand paper or a click as the explorer passes over them.

VI. Subgingival Examination A. Visual Gingiva: The clinical appearance suggestive of underlying calculus may be the following:

Soft, spongy, bluish-red gingiva, with enlargement of the interdental papillae over proximal surface calculus. Dark-colored area beneath relatively translucent marginal gingiva. Calculus A loose, edematous pocket wall can be deflected from the tooth surface with a gentle stream of compressed air. Dark, subgingival calculus can be seen within the pocket on the root.

B. Tactile Periodontal charting Use probing depth recordings as a basic guide for the depth of insertion of the curet. Study the soft-tissue attachment pattern for instrument selection to provide access to the base of the pocket. Identify shallow pockets (sulci) Scaling in shallow pockets of fewer than 3 mm can lead to loss of periodontal attachment due to detachment of periodontal ligament fibers, so it should be done with care.1 Root surfaces free of calculus require minimal lateral pressure for comprehensive biofilm removal. Determine distribution and extent of deposits Use an explorer, such as an ODU 11/12, for detection of calculus deposits. The novice dental hygiene student will benefit from recording the location of calculus. The periodontal probe may also detect the presence of calculus deposits, as shown in Figure 39-1.

FIGURE 39-1 • Subgingival Examination Using a Probe. A: Probe inserted into the bottom of a pocket for complete examination prior to subgingival scaling. B: As the probe passes over the root surface, it may be intercepted by a hard mass of calculus. C: Using a horizontal probe stroke to examine the topography of a furcation area. Keep the side of the tip of the probe on the tooth surface and slide over one root, into the furcation, and across to the other root.

Evaluate tooth topography Detect grooves and furcations using a horizontal stroke (Figure 39-1C). Use a Nabers furcation probe to examine furcations (see Chapter 20). Note anatomic root and furcation variations (Figure 39-2).

FIGURE 39-2 • Anatomic Variations of Furcations. A: Divergent roots with the furcation in the coronal one-third of the root with a short root trunk. B: Convergent roots with the furcation in the middle one half of the root with a longer root trunk. C: Very convergent roots. D: Fused roots with the furcation in the coronal one-third of the root. (Reprinted from Scheid R, Weiss G. Woelfel’s Dental Anatomy. Philadelphia, PA: Lippincott Williams & Wilkins; 2016.)

Evaluate restorative margins Detect overhanging restorations that need to be evaluated by the dentist for possible replacement or margination. Detect marginal irregularities that retain biofilm.

VII. Formulate Strategy for Instrumentation Combine clinical findings with information documented in the patient’s record. Review overall treatment objectives for the patient. Determine a strategy for instrumentation.

ADVANCED INSTRUMENTATION I. Definitions Scaling and root planing (SRP): entails removal of calculus and “diseased” cementum. It was previously considered the desired endpoint necessary in order to achieve periodontal health. Evidence now demonstrates removal of cementum is not necessary to reduce endotoxin levels and cementum needs to be preserved to facilitate new attachment.10,11,21 SRP is common terminology used in private practice and by insurance companies. Periodontal debridement or root surface debridement: involves disruption and removal of dental biofilm and associated endotoxins along with calculus from the root. Use of ultrasonic instrumentation, along with avoidance of excessive instrumentation time and pressure, helps to preserve cementum and dentin.21

II.

Subgingival Anatomical Considerations Tooth morphology Level of clinical attachment (normal or clinical attachment loss) varies; more attachment loss, resulting in deeper pocket depths exposing additional root concavities and possible furcations, complicates instrumentation. The cementum is thin (0.03–0.06 mm), and care must be taken to minimize removal during instrumentation.11 Soft-tissue pocket wall The pocket is an extremely small area for manipulation of instruments. The pocket narrows in the deeper area next to the clinical attachment. Bleeding during instrumentation can impact visibility. Variations in probing depths

The periodontal charting is a guide to subgingival instrumentation and will serve as a road map to guide instrument depth of insertion. Nature of subgingival calculus Location: Calculus may be located on the enamel or the root or both (Figure 39-3).

FIGURE 39-3 • Location of Instrumentation. The location of calculus deposits, level of periodontal attachment, depth of pocket, and position of the gingival margin determine the site of instrumentation. A: Supragingival calculus on the enamel. B: Gingival pocket with both supragingival and subgingival calculus on enamel. C: Periodontal pocket with both supragingival and subgingival calculus. D: Periodontal pocket with subgingival calculus only on the root surface. E: Periodontal pocket with subgingival calculus on both the enamel and the root surface. F: Calculus on the root surface exposed by gingival recession.

Morphology of calculus: Subgingival calculus is irregularly deposited. It can present as a spicule, ledge, smooth veneer, and other forms (Chapter 17). Burnished calculus: Subgingival calculus that has been partially scaled and left after incomplete instrumentation may be smooth and may not be detected when an explorer is used to check the

area.

III. Instrumentation Technique Types of instruments and the basic principles for their use are included in Chapter 37. This chapter focuses on the components of advanced instrumentation for deposit removal. Box 39-1 summarizes the steps.

BOX 39-1 Steps for Calculus Removal Using Manual Instruments Assessment • Probe to determine pocket/sulcus characteristics and confirm soft-tissue attachment topography. • Explore to determine location and extent of deposits and tooth surface irregularities. • Select correct instruments that will adapt and conform to concavities and other root morphology characteristics for areas being treated. Preparation: Instrument Control • Hold instrument with a modified pen grasp. • Identify correct cutting edge of blade for surface being scaled. ♦ For area-specific curets: terminal shank parallel with surface being scaled. ♦ For universal curets: terminal shank less than parallel with surface being scaled (~20°). • Establish a light finger rest for instrument placement to allow for adjustment and repositioning. • Insert: use placement or exploratory stroke to locate apical edge of deposit. • Adjust working angulation (average at 70°). Action: Strokes • Secure a stable, functional extraoral finger rest or intraoral fulcrum that can support instrument placement and activation at the correct working stroke angulation. ♦ Pressure into the fulcrum equals the pressure against the tooth. ♦ Balance fulcrum pressure with lateral pressure of the strokes. • Activate for working stroke.

♦ ♦ ♦ ♦ ♦

Apply firm lateral pressure for calculus removal. Apply moderate lateral pressure to smooth the surface. Apply light lateral pressure for biofilm debridement. Control length and direction of stroke: respect to the instrumentation zone. Maintain continuous adaptation throughout the stroke.

Channels: Overlap to Completion • Continue channel scaling with overlapping multidirectional strokes. ♦ Use an exploratory stroke to reposition blade for next stroke. ♦ Activate instrument circumferentially around tooth. ♦ Keep toe adapted around line angles by rolling handle. ♦ Cover all surfaces comprehensively to remove all traces of calculus and biofilm. Evaluation • Use explorer to determine endpoint of treatment.

A. Instrument Selection and Sequence The order in which instruments are selected and used can impact the efficiency and quality of biofilm and calculus removal. Instrument selection sequence is recommended as follows (the order may vary depending on the depth of the periodontal pocket and tenacity of the calculus): For stages I and II periodontitis, the following instruments are used in this order: 1. Straight/universal and triple bend-type ultrasonic tips/inserts used on moderate-to-high power. 2. Sickle scalers and/or periodontal files. 3. Universal curets. 4. Gracey curets. 5. Precision-thin ultrasonic tips/inserts for final finishing. For stages III and IV periodontitis where greater clinical attachment loss is involved, the following instruments may also be needed to access the base of pockets and furcation areas for debridement: 1. Thin left/right ultrasonic tips/inserts used on low-to-moderate

2. 3. 4. 5.

power. Mini-bladed area-specific Gracey curets. Micro-mini–bladed Gracey curets. Diamond files—used with light pressure only. Periodontal files.

B. Finger Rest Various factors such as tooth position and calculus tenacity may impact the fulcrum chosen. Review Chapter 37 for basics on fulcrums, which may include intraoral, extraoral, and alternative fulcrums such as supplementary, substitute, and reinforced.

C. Adaptation Keep working-end closely aligned with the surface of the tooth throughout the stroke. Convex surfaces, concavities, and furcations all require precise adaptation (Figure 39-4).

FIGURE 39-4 • Instrument Adaptation. A: Maxillary first premolar shows cross section of root drawn for (B) and (C). B: Diagram of three positions of a curet shows correct adaptation at a line angle and on the concave mesial surface with toe third of the instrument maintained on the tooth as the instrument is adapted. C: Diagram shows incorrect adaptation with toe of curet extended away from the tooth surface.

D. Lateral Pressure Light pressure is needed for exploration to position blade below the calculus deposit and to debride biofilm while preserving cementum. Moderate-to-heavy pressure is needed for manual working strokes depending on the degree of mineralization or tenacity of the calculus attachment. Factors affecting lateral pressure are as follows: Sharp instrument A minimum degree of pressure allows the cutting edge to

“grab” the calculus. Less time, with fewer strokes, is required. Fatigue is kept to a minimum. Dull instrument When dull, the blade cannot engage the deposit and will slide over it, burnishing it on the surface, making it difficult to detect and remove. Stroke control is reduced with the heavier pressure needed to activate a dull blade; this can lead to instrument slippage and trauma to the patient’s gingival tissues. Grasp and lateral pressures increase to compensate for the sliding effect. More strokes are needed, causing increased fatigue. Inefficiency increases treatment time.

E. Activation/Stroke Confine the strokes to the pocket to minimize the need for repeated reinsertion of the curet to prevent trauma to the gingival margin. Make strokes in channels (Figure 39-5).

FIGURE 39-5 • Channel Scaling. A: Curet adapted in position for channel 1 stroke from the base of the pocket under the calculus deposit. B: Completion of stroke for channel 1. C: Using an exploratory stroke, the curet is lowered into the pocket and is positioned for calculus removal in channel 2. D: Curet positioned for channel 3. Several strokes in each channel may be needed to ensure complete calculus removal. E: Strokes of each channel overlap strokes of the previous channel. (Adapted from Parr RW, Green E, Madsen L, et al. Subgingival Scaling and Root Planing. Berkeley, CA: Praxis; 1976.)

At the completion of each stroke, move the instrument laterally a very short distance to assure overlap. Maintain the same finger rest.

Overlap strokes in channels to ensure complete coverage of subgingival surface for thorough removal of deposits. Repeat strokes until surface has been completely debrided.

F. Channeling Overlap strokes in channels to ensure complete coverage of subgingival surface for thorough removal of deposits (Figure 39-5). Maintain the same finger rest. At the completion of each stroke, move the instrument laterally a very short distance to assure overlap. Repeat strokes until surface has been completely debrided. As a surface area becomes smooth, a gradual change in the sound of the instrument stroke may occur as the calculus is removed.

SPECIALIZED DEBRIDEMENT INSTRUMENTS I. Furcation Debridement Specialized instruments for furcation debridement include: Precision-thin left/right ultrasonic tips/inserts used at low power may be used alone or in combination with hand instrumentation. Mini-bladed Gracey numbers 5–6, 11–12, 13–14. Micro-mini–bladed Gracey numbers 1–2, 11–12, 13–14. Diamond files: use only with light pressure. Close adaptation of precision ultrasonic insert or blade to the contour of the furcation area. Use explorer such as regular or extended ODU 11/12 with light lateral pressure to assess root debridement.

II.

Advanced Ultrasonic Tips Straight/universal and triple bend-type tips are used for moderateto-heavy deposit removal on most surfaces; however, periodontal involvement may call for use of more specialized and area-specific tips, such as those listed in the subsequent section.

A. Thin/Periodontal Tip Thinner and longer tips provide better access to subgingival surfaces. Allow superior coverage of deep pockets and furcations. The limitation for magnetostrictive thin tips is they can only be used on low-to-medium power to prevent breakage and may burnish and/or not remove moderate-to-heavy calculus deposits. This limits their use to light calculus and biofilm debridement.22 Piezoelectric thin tips may be used on high power.

B. Diamond-Coated Tip

Limited evidence is available for diamond-coated tips. A small study suggests the diamond-coated tips appear to remove calculus efficiently.23 It is not clear if cementum is preserved.24

C. Plastic, Silicone, or Carbon Composite Tip An insert with a plastic, silicone, or carbon composite tip may be used to protect vulnerable restorative surfaces, such as titanium abutments of implants or esthetic materials surfaces.25,26 A low power, light pressure is all that is needed to remove biofilm and mineralizing deposits.

III. Microultrasonics Microultrasonics is a term used to describe the use of slimmer ultrasonic tips in conjunction with a dental endoscope to visualize subgingival calculus for debridement (Figure 39-6).27

FIGURE 39-6 • Endoscope-Assisted Calculus Detection and Removal. A: The calculus is a cream white color because of the mineralization. The explorer for the endoscope is to at the bottom of the picture. B: In this image, the

precision or slimline ultrasonic tip (left) is being used with the endoscope to the right. (Courtesy of Judy Carroll, RDH.)

Advantages of microultrasonics include: Reduce overinstrumentation. Minimize excessive removal of cementum. Improves outcomes and minimizes the need for periodontal surgery. Quality of end product: Enhance the quality of instrumentation by providing an objective means of evaluating root surface. Patient education: Create a new means of engaging, motivating, and educating the patient in the treatment. Provide opportunity for noninvasive, definitive root debridement: When access is limited during routine instrumentation. For sites unresponsive to traditional nonsurgical therapy. In anterior regions where preservation of soft tissue is necessary for optimum esthetics. When surgical therapy may be contraindicated for the patient. Provide confirmation of clinical findings that might otherwise go undiagnosed or require surgical intervention. Root fractures. Restorative following perforations. Open margins. Subgingival caries. Residual cement. Anatomical anomalies. Disadvantages Learning curve: Using the endoscope to visualize root accretions is of significant benefit, but learning to utilize the endoscope is challenging and takes regular use to become proficient. Some of the challenges include: The clinician must work two-handed and hold the endoscope in the nondominant hand while adapting instruments and ultrasonic to the root surface with the dominant hand. The clinician has to watch the monitor in order to assess the

presence of calculus and adaptation for removal, which may impact ability to adapt to the root surface. The cost of the endoscope system and fiberoptic sheaths for each patient could be a disadvantage.

IV. Endoscope-Assisted Periodontal Debridement The dental endoscope is a device developed to visualize below the gingival margin for use during diagnosis and instrumentation for treatment of periodontally diseased root surfaces. Objectives Visualization of the root surface during instrumentation. Explore, instrument, and evaluate the root surface using indirect visual observation on the device monitor. Increase the effectiveness and thoroughness of root debridement.28,29 Augment subjective data collection with objective confirmation. Dental Endoscope Components (Figure 39-7A and B):

FIGURE 39-7 • A: Dental endoscopic system. B: The clinician holds the endoscopic instrument in her nondominant hand. In this photo to visualize

calculus and the root surface. The clinician uses microultrasonics in her dominant hand. (Courtesy of John Y. Kwan, DDS. Reprinted from Nield-Gehrig J. Fundamentals of Periodontal Instrumentation and Advanced Root Instrumentation. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.)

Subgingival probe: adapted to provide fiberoptic imaging with magnification. Sheath to provide a sterile barrier between the patient and the endoscope. Peristaltic pump to provide irrigation to the working field. LED lamp to provide illumination to the working field. Video camera to capture images of the working field for display. Video monitor for live viewing of the working field. Specialized probes, curets, and retracting instruments to maximize tissue visualization. Indications for Use During maintenance to detect and remove remaining deep burnished calculus deposits, which are the cause of continued BOP (Figure 39-6A and B). Advanced root debridement for patients unable or unwilling to have recommended surgical procedures.

V.

Subgingival Air Polishing

Over the years, subgingival air polishing has become a popular alternative to hand and ultrasonic instrumentation for subgingival biofilm management.30 Subgingival air polishers deliver a stream of compressed air, water, and a nonabrasive powder (e.g., glycine or erythritol powder) through a nozzle to debride biofilm from shallow sulci, periodontal pockets, and around implants (Figure 39-8A).

FIGURE 39-8 • Air Polisher. A: A handheld air polisher that connects to the dental until. Can be filled with appropriate powder and used supragingivally and subgingivally. B: Air polisher with a disposable periodontal nozzle that is inserted subgingivally into a deeper pocket to flush out biofilm.

Subgingival air polishing has been shown to be equally effective as ultrasonic instrumentation in reducing BOP, periodontal probing depths, and attachment loss.31 Advantages More effective than hand instrumentation at lowering bacterial counts in deep periodontal pockets.32 Nonabrasive and safe to use on soft tissues, round restorations, and titanium implants.33 Faster and more time-efficient than hand instrumentation.34,35 Greater comfort for patients and less perceived pain than hand and ultrasonic instrumentation.31,34,35

A. Contraindications Due to the production of water and aerosols, contraindications remain

similar to those for the use of an ultrasonic scaler: Communicable diseases. Immunosuppression. Respiratory risk. Difficulty swallowing. Allergies to powder used.

B. Use Infection control protocol is also similar to that used for ultrasonic instrumentation, including the use of: Antimicrobial preprocedural mouth rinse. High-volume evacuator. Face mask with a high bacterial filtration efficiency (e.g., American Society for Testing and Materials level 3 mask). Technique for debriding shallow sulci: Keeping a distance of 3–5 mm away from the tooth surface, direct the nozzle toward the gingival margin anywhere from 30 to 60°. Press the device pedal for no longer than 5 seconds per site. Make small horizontal or circular strokes. Technique for debriding periodontal pockets up to 5 mm using a disposable periodontal nozzle (Figure 39-8B): Gently insert nozzle into the periodontal pocket. Once inserted, press the device pedal for 5 seconds per site. Use short vertical strokes.

VI. Laser Therapy Use of lasers in periodontal treatment is controversial, but continues to increase despite conflicting research findings.36,37 The American Academy of Periodontology’s best evidence consensus summary suggests the evidence to support use of lasers for treatment of chronic periodontitis is weak.36,37 Evidence suggests that as an adjunct to conventional NSPT,

laser therapy has modest additional benefit of less than 1 mm of improvement in pocket depth and CAL.36,37 Significantly more well-designed research is needed to further explore the benefit of laser-assisted periodontal therapy.37

A. Types of Lasers Lasers emit light through a process called stimulated emission. When the light reaches the tissue, it is reflected, scattered, absorbed, or transmitted to surrounding tissues. The wavelength of the light influences how the light interacts with the tissue. The wavelength of lasers most often used in periodontal treatment is 635–10,600 nm and includes36: Semiconductor diode lasers. Solid-state lasers: neodymium-doped yttrium, aluminum, and garnet (Nd:YAG); neodymium-doped yttrium, aluminum, and perovskite (Nd:YAP); erbium-doped yttrium, aluminum, and garnet (Er:YAG); and erbium, chromium-doped yttrium scandium, gallium, and garnet (Er,Cr:YSGG). Gas lasers (CO2). The equipment for laser therapy is expensive, and cost–benefit over traditional periodontal debridement has not been evaluated. Each manufacturer requires the purchaser to contract with them for training to use the equipment, which further impacts the cost and standardization of therapy.

B. Purported Benefits of Lasers in Nonsurgical Periodontal Therapy Enhances pocket disinfection by reduction of subgingival bacterial load. Promotes wound healing. Hemostasis. Root debridement.

Erbium lasers (Er:YAG) show the most potential as an adjunct in root debridement of deep periodontal pockets (≥7 mm).37 There is potential for damage to the root surface because the Er:YAG is a hard-tissue laser.

C. Technique For calculus removal: Insert laser fiber into the pocket parallel to the long axis of the tooth. Angulation is 45°. A horizontal and vertical stroke is used as the fiber is advanced around the root surface. Water spray along with high-volume evacuation is used to keep the area clear of debris. For reduction of bacterial load (a.k.a. pocket sterilization) and curettage of granulation tissue (a.k.a. laser curettage) as an adjunct to traditional root debridement38,39: Insert laser fiber into the pocket parallel to the long axis of the tooth. The fiber is directed toward the soft-tissue wall of the pocket. Move fiber in a horizontal and apical direction in a sweeping motion at a slow-to-moderate speed. Use moistened gauze to remove debris from the fiber periodically. Use high-volume evacuation for debris and to aspirate fumes.

POST-OP INSTRUCTION FOR PERIODONTAL DEBRIDEMENT APPOINTMENTS Instructions following NSPT should include information on: Management of discomfort. Oral self-care. Diet. Where to call in case of a problem or question.

I.

Management of Discomfort There may be some soft-tissue discomfort when the local anesthesia wears off. Any discomfort can usually be managed with over-the-counter analgesics, including acetaminophen (Tylenol®), aspirin, or ibuprofen (Advil®). A nonsteroidal anti-inflammatory drug such as ibuprofen can also help reduce inflammation and swelling. On occasion, a cold compress or ice pack may help with discomfort. If the patient experiences dentin hypersensitivity, a toothpaste for sensitivity, such as a 5% potassium nitrate dentifrice, may be recommended. The patient should understand that it may take several weeks of repeated used for the dentin hypersensitivity for improvement of sensitivity.

II.

Oral Self-Care

A. Rinsing A warm solution may be soothing to the tissues helping healing. Possible solutions for rinsing may include: Hypertonic salt solution: 1/2 teaspoonful of salt in 1/2 cup (4 oz)

of warm water. Sodium bicarbonate solution: 1/2 teaspoonful of baking soda in 1 cup (8 oz) of warm water. Rinsing directions: Every 2 hours; after eating; after toothbrushing; before retiring. Chlorhexidine gluconate 0.12% has been shown to provide a small reduction in pocket depths when used in conjunction with periodontal debridement.40 It may be especially helpful in the presence of significant gingival inflammation. Directions: twice daily, after breakfast and before going to bed, without eating after rinsing to take advantage of the substantivity property of chlorhexidine. Rinsing is not a substitute for personal biofilm removal with toothbrush and interdental aids. Limit use to 2 weeks following the final periodontal debridement appointment to minimize tooth staining or other adverse effects of chlorhexidine.

B. Biofilm Management The patient needs to understand the significance of daily biofilm disruption/removal, particularly in the quadrant or sextant receiving treatment to support optimal healing. A soft toothbrush should be used. The patient may find that moistening the toothbrush with warm water and brushing without toothpaste initially may be more comfortable for the tissues. The fluoride toothpaste can then be added at the end of brushing. There may be slight bleeding during oral self-care, but this should stop as the tissues heal. The patient should continue to use the interdental cleaning aid recommended. If an interdental brush will fit interproximally, this can be very helpful for tissue healing.

III. Diet

The patient should be instructed to avoid chewing solid food or drinking hot liquids until the anesthetic has worn off to avoid trauma to the tongue, cheek, and lips. If the tissues are tender during healing, consume bland foods without strong, spicy seasonings, as well as use of nutrient-dense, high-protein foods to promote healing.

IV. Emergency Management The patient should be given information about who to call in the following situations: Bleeding that does not stop within a few hours. Pain not stopped by use of ibuprofen or Tylenol, particularly pain that wakes the patient during the night. Swelling that increases after the first 1-2 days.

V.

Instruction Format

The instructions may be handed out in paper form at the appointment with notes specific to the patient. Some offices may choose to provide instructions via email or may have general instructions on their office website. Patients particularly appreciate a call the evening or day after the appointment to check on how they are doing.

RE-EVALUATION OF NONSURGICAL PERIODONTAL THERAPY I. Clinical Endpoints BOP: eliminated. Probing depths: reduced. Attachment levels: same or improved. Inflammation: resolved. Gingival appearance: size reduced, color normal. Subgingival microflora: lowered in numbers, delay in repopulation. Dental biofilm control record: improvement in scores approaching 100% biofilm free. Tooth surfaces: smooth; no biofilm-retentive irregularities. Quality-of-life factors: oral comfort with freedom from pain.

II.

Re-evaluation Timeframe Recommendations are for the initial therapy re-evaluation to occur 4–8 weeks after NSPT.14 At least 2 weeks after instrumentation is complete for the reestablishment of the junctional epithelium.14 Four to 8 weeks are needed for the connective tissue to heal following NSPT.14 Waiting longer than 2 months may allow the pathogenic bacteria to repopulate the periodontal pockets. In addition, it is necessary to identify and remediate any residual subgingival calculus at the re-evaluation appointment to facilitate continued healing.14

III. Re-evaluation Procedure A. Periodontal Examination A comprehensive periodontal examination is performed and

documented to compare pre- and post-treatment findings.41 Changes in BOP, CAL, biofilm, and inflammation in particular are evaluated and discussed with the patient. Assessment for subgingival calculus is also needed. According to the literature, 17%–69% of surfaces may have residual calculus.14 Re-instrument as needed. Review oral self-care techniques with the patient and offer assistance in continued refinement is essential to aid in continued healing and disease management.

B. Establish Continuing Care Interval The patient may have reached the point of being able to be managed under the care of the dental hygienist, and a maintenance interval should be determined based on the following: Soft-tissue response to instrumentation and degree of healing. Changes and/or stabilization in probing depth. Patient factors: use of tobacco; systemic influences such as control of diabetes. Currently demonstrated biofilm control efforts; level of skill. Motivation and responsibility assumed for daily oral self-care. Psychosocial factors; stress, mental health issues impacting oral self-care. There may be localized activity, and adjunctive therapy may be considered. In case of advanced disease that has not responded adequately to NSPT, a referral to a periodontist is necessary, as described in Chapter 45.

ADJUNCTIVE THERAPY Pharmacologic agents are used as adjuncts to mechanical therapy.

ANTIMICROBIAL TREATMENT Objectives of antimicrobial therapy include: Arresting of infection using antimicrobial drugs to slow or arrest loss of periodontal attachment and other periodontal tissue destruction caused by microorganisms. Suppression and elimination of pathogenic microorganisms to allow the recolonization of the microbiota compatible with health.

I.

Systemic Delivery of Antibiotics Systemic administration of antibiotics is well known and highly successful in the world of medical care. Antibiotics have saved the lives of many people with generalized infectious diseases. A significant disadvantage to use of systemic antibiotics over the past 50 years is an increase in antibiotic resistance, so they need to be used with caution after a careful risk–benefit analysis.39

A. Action of Systemically Administered Antibiotic In contrast to locally applied agents placed directly into a pocket, antibiotics administered systemically reach the pathogenic organisms in the pocket through blood circulation via the cardiovascular system. The antibiotic is absorbed into the circulation from the intestine. From the bloodstream, the drug is passed into the body tissues. The antibiotic enters the periodontal tissues and passes into the pocket by way of the gingival crevicular fluid.

B. Selection of Antibiotic Systemic antibiotics may be prescribed as an adjunct to NSPT for a patient who does not respond to traditional periodontal therapy and experience continued loss of attachment; however, evidence is

inconsistent on the benefit of their use.40–44 Ideally, the specific microorganism causing a certain periodontal disease needs to be determined, and the antibiotic selected needs to be specific for the organism.7,40 Microbiologic testing is available and can be used to guide clinical decisions. Periodontal diseases are caused by mixed infections of microorganisms. The pathogens tend to work in clusters, that is, in combination with other organisms so microbiological testing has limitations in mixed infections. Antibiotics regimens used with periodontal debridement include the following: Metronidazole is effective against Porphyromonas gingivalis and Prevotella intermedia and a meta-analysis found reductions in pocket depths and clinical attachment gain.45 Tetracycline, specifically doxycycline or minocycline, to treat Aggregatibacter actinomycetemcomitans in more aggressive periodontitis. Azithromycin with NSPT has shown reductions in pocket depths and gain in clinical attachment.46

C. Limitations The precautions and adverse effects, as well as the acquisition of antibiotic resistance by the organisms, preclude the widespread use of systemic antibiotics for periodontal problems.40 Limitations include the following40: Side effects of certain antibiotics. Potential for the development of resistant strains. Local concentration diluted by the time the drug reaches the pathogens; drug is “wasted” in that it covers a large area not needing the treatment. Superimposed opportunistic infection can develop, such as candidiasis. Low compliance of the patient in following the prescription for the

required number of days.

D. Use of Systemic Therapy Most periodontal infection responds well to NSPT, meticulous biofilm control, and antimicrobial mouthrinses/dentifrices. However, there are groups of people who do not respond to initial therapy who would benefit from systemic antibiotics, including those with40–44: Continued loss of attachment despite initial therapy and thorough biofilm control. Recurrent or refractory periodontitis. Acute periodontal infection, such as necrotizing ulcerative gingivitis or periodontitis, periodontal abscess. Aggressive types of periodontitis. Medical conditions predisposing to periodontal disease, such a poorly controlled diabetes.

II.

Systemic Subantimicrobial Dose Antibiotics A subantimicrobial dose (SSD) does not have antimicrobial or antibiotic effects, and to date, antibiotic resistance has not been identified.47 Doxycycline in a low dose modulates the host inflammatory response and inhibits the continued breakdown of collagen.47,48 The only approved systemic SDD is Periostat®. SDD (20 mg/twice a day) has been used for moderate-to-severe periodontitis as an adjunct to NSPT for 3–9 months.47 Evidence shows small gains in clinical attachment and reductions in pocket depths.48

III. Local Delivery Antimicrobial Agents The concept of a controlled local delivery system for treatment of periodontal pathogens in a pocket infection was developed over

many years by Goodson et al. with the introduction of a tetracycline fiber placed subgingivally.49 Improvements in probing depth, CAL, BOP, and reduction of sites with periodontal pathogenic microorganisms laid the groundwork for continuing research and development in local delivery agents.49 Local delivery means the medication is concentrated at the site of the infection to reduce the bacterial load and inflammation to enhance healing. Local drug antimicrobial agents (LDAs) can be divided into two classes50: Sustained-release formulations release a drug for a period less than 24 hours and are used in a variety of ways. The nicotine patch, used to assist a person trying to break a smoking addiction, is an example. Controlled delivery refers to providing the medication over an extended period of time that exceeds 1 day.

A. Requirements A local delivery method can place high concentrations of the antimicrobial in an infected pocket. To be successful, the medication must: Provide adequate bactericidal drug concentration. Reach site of disease activity, such as the bottom of the pocket and furcation. Stay in contact long enough in the effective concentration for the antimicrobial action to take place. Be easy to apply. Be biocompatible and biodegradable. Cost and the benefit for the patient must be carefully evaluated, given the average reduction in pocket depth ranges from 0.25 to 0.50 mm and the gains in clinical attachment of approximately 0.20 mm.50,51

B. Advantages of Local Delivery Agents Local delivery agents have the potential to enhance therapy at localized sites unresponsive to NSPT. Advantages include51: Direct placement at site of infection. Reliable drug delivery without reliance on patient compliance. Safer with fewer side effects. Noninvasive and typically painless.

C. Limitations to Local Delivery Agents Therapies other than LDAs should be considered in the following situations52: Multiple sites with pocket depths greater than or equal to 5 mm in a quadrant. LDAs have been attempted and did not control the localized infection. Intrabony defects are present, which require surgical intervention.

INDICATIONS FOR USE OF LOCAL DELIVERY AGENTS I. Nonsurgical Periodontal Therapy NSPT is considered the “gold” standard and results in reduction in inflammation and gain in clinical attachment gains of 0.49 mm.44 The adjunctive use of local antimicrobials may enhance the effect of the mechanical instrumentation. Use of an LDA in addition to NSPT may result in an additional 0.24–0.64 mm gain in clinical attachment.44

II.

Adjunctive Treatment: At Re-Evaluation At the completion of initial periodontal therapy, a re-evaluation is completed 4–6 weeks later. Residual calculus is removed. Control of dental biofilm is assessed, and reinforcement is provided for the patient. For areas of residual pocket depth and/or BOP, adjunctive therapy may be considered, such as systemic antibiotics or a local delivery antimicrobial agent.

III. Recurrent Disease Periodontal disease tends to be cyclical with periods of stability and progression. Recurrence or progression of periodontal disease may be due to: Noncompliance with periodontal maintenance schedule. Inadequate daily control of dental biofilm. Inadequate periodontal debridement. Continued tobacco use. Unknown. Recurrence of periodontal infection may be localized, particularly in

pockets associated with root concavities, furcations, and areas of complex root morphology, where definitive debridement is most challenging. Burnished calculus is difficult to detect with an explorer and becomes recolonized with pathogenic microbes soon after debridement, which interferes with healing. Bleeding may indicate residual burnished calculus from insufficient instrumentation. Localized areas of recurrence of disease are candidates for application of an antimicrobial agent.

IV. Peri-Implantitis Peri-implantitis may respond to a local delivery antimicrobial.53

TYPES OF LOCAL DELIVERY AGENTS Average improvement in clinical attachment with use of adjunctive agents versus periodontal debridement alone ranges from 0.18 to 0.64 mm (Table 39-2).44 TABLE 39-2 Local Delivery Antimicrobials

I.

Minocycline Hydrochloride Bioresorbable minocycline hydrochloride (HCl) is a sustainedrelease agent delivered in microsphere form and placed in periodontal pockets after periodontal debridement. Research indicates the following benefits to use of the minocycline HCl microspheres with NSPT: Overall pocket depth reduction was an additional 0.47 mm over SRP alone.54 Gain in clinical attachment was an average of 0.24 mm.44

A. Description

Unit-dose cartridge contains 1 mg minocycline. Once the minocycline microspheres come in contact with gingival crevicular fluid, they hydrolyze allowing them to adhere to the surrounding surfaces. Sustained release for 14 days. Does not block the flow of subgingival fluid. Contraindications54: Patients sensitive to tetracycline. Women who are pregnant or breastfeeding. Do not use in children less than 8 years of age due to possible enamel hypoplasia or permanent tooth discoloration. Gastrointestinal issues. Photosensitivity may occur, so protect the skin from prolonged sun exposure. Prolonged use can result in fungal or bacterial superinfection.

B. Administration Site selection: Use as an adjunct to periodontal debridement. Probing depth of at least 5 mm. Cartridge loading: Insert unit-dose cartridge into dispenser handle. Exert slight pressure. Twist cartridge until it locks securely into place. Tip preparation 1. Cartridge tip can be manipulated to reposition the angle for difficult-to-reach areas. 2. Leave cap covering the cartridge in place prior to manipulating the angle to prevent agent from being inadvertently expelled. 3. Remove cap. Delivery of agent: 1. Place cartridge tip into the site selected for treatment.55 2. Keep tip parallel to the long axis of the tooth as it enters the periodontal pocket (Figure 39-9).

FIGURE 39-9 • Minocycline HCl. A: Minocycline microspheres intact within cannula, prior to application. B: Deposition: cannula is withdrawn from periodontal pocket as plunger is depressed. C: Once deposited, microspheres dissipate, releasing activated minocycline HCl into the subgingival space.

3. Do not force the tip to the base of the pocket. 4. Gently press thumb ring of handle to express the agent while withdrawing cartridge tip coronally from the base of the pocket.54 5. With delivery complete, retract thumb ring and remove cartridge with free hand. 6. Discard contaminated cartridge. 7. Sterilize handle prior to reuse.54

C. Post-treatment Instructions Instruct patient on proper care of treated areas. Give written guidelines to prevent misunderstanding. Avoid touching treated area(s). Do not use interdental cleaners or floss between teeth that have been treated for at least 10 days. Avoid eating hard, crunchy, or sticky foods that could disturb retention of the product for 1 week. Avoid brushing for 12 hours. Some mild-to-moderate sensitivity may be present the first week after scaling and root debridement and placement of minocycline HCl, but the patient needs to contact the dentist if pain or swelling occurs. Schedule a follow-up appointment for continuing maintenance care.

II.

Doxycycline Hyclate

A. Description Biodegradable doxycycline polymer in liquid form is controlledrelease agent delivered by cannula into a pocket and solidifies on contact with the sulcular fluid. Research indicates the following benefits to use of the minocycline doxycycline hyclate with NSPT: Overall pocket depth reduction was an additional 0.57 mm over periodontal debridement alone.55

Gain in clinical attachment with periodontal debridement was an average of 0.64 mm.44

B. Equipment Syringe: Two syringe mixing system consisting of the following55: Syringe A contains 450 mg of the bioabsorbable polymeric formulation. Syringe B contains 50 mg of doxycycline hyclate. Once combined the solution contains 10% of doxycycline hyclate. Cannula: Blunt ended, 23-gauge, narrow diameter. Controlled release of drug for 7 days.55 Contraindications55: Patients sensitive to tetracycline. Women who are pregnant or breastfeeding. Do not use in children less than 8 years of age due to possible enamel hypoplasia or permanent tooth discoloration. Photosensitivity may occur, so protect the skin from prolonged sun exposure. Prolonged use can result in fungal or bacterial superinfection.

C. Administration Site selection Probing depth of at least 5 mm. Preparation of agent If refrigerated, take pouches with product out of refrigerator at least 15 minutes before mixing. Mixing: Two syringes are coupled, and the substances are passed back and forth, which is one mixing cycle. Mixing continues for 100 mixing cycles (Figure 39-10A). Follow the manufacturer’s instructions.55

FIGURE 39-10 • Doxycycline Polymer Gel. A: Syringes are coupled, and the contents passed back and forth until mixed. B: The cannula is attached to the syringe with the agent; as the cap is removed, the cannula is pressed against the side to bend it to an angle appropriate for accessing the pocket to be treated. C: The cannula is inserted into the base of the pocket, and the agent is released to fill the pocket.

Adapt cannula: Attach 23-gauge blunt cannula to syringe. As the cap is removed, the cannula is held part way and bent against the wall of the cover to provide an angle appropriately similar to a periodontal probe for insertion into the periodontal pocket (Figure 39-10B). Delivery of agent56

1. Place cartridge tip into the site selected for treatment. 2. Keep tip parallel to the long axis of the tooth as it enters the periodontal pocket. 3. Do not force the tip to the base of the pocket. 4. Express the agent as the cannula is withdrawn to the gingival margin (Figure 39-10C). 5. Use a blunt instrument to pack the agent down. 6. Placing a periodontal dressing or adhesive over the area to aid retention.

D. Post-treatment Instructions Instruct patient on proper care of treated areas including the following: Prevent accidental removal. Routine brushing and other oral self-care on all other areas, but avoid toothbrushing or flossing the treated areas for 7 days.55 Schedule a follow-up appointment to remove periodontal dressing and evaluate tissue response. Schedule periodontal maintenance.

III. Chlorhexidine Gluconate The chlorhexidine gluconate chip is biodegradable and intended for use as an adjunctive therapy with periodontal debridement.44,54,56 Research indicates the following benefits to use of the chlorhexidine chip with periodontal debridement: Overall pocket depth reduction was an additional 0.40 mm over periodontal debridement alone.54 Gain in clinical attachment with periodontal debridement was an average of 0.40 mm.44

A. Description Size: 4 mm × 5 mm and 0.35-mm thick (Figure 39-11).

FIGURE 39-11 • Chlorhexidine Gluconate Chip. The gelatin chip is inserted into periodontal pockets greater than or equal to 5 mm. The gelatin chip adheres to the tooth surface and dissolves slowly—releasing the chlorhexidine antimicrobial agent trapped in the gelatin.

Shape: orange-brown, rectangular, rounded at one end. Contents: matrix of hydrolyzed gelatin with 2.5 mg chlorhexidine gluconate. Controlled delivery with 40% of dose in first 24 hours and remaining dose is delivered over a period up to 10 days.56 Store product at controlled room temperature 15°C–25°C (59°F– 77°F). Contraindications: Do not use in acute periodontal abscess. Exercise caution in pregnant or breastfeeding women.

B. Administration Site selection Pocket depth: pockets greater than or equal to 5 mm.56 Chips placed: up to eight chips can be inserted at one

appointment. Steps in placement56 Isolate with cotton rolls and dry area prior to chip placement. Chip may start to soften and become more difficult to place if it gets wet before placement in the pocket. Insert by grasping the chip with cotton pliers position chip with round side away from the cotton pliers. Insert the chip to the bottom of the pocket. The chip can be maneuvered with the tips of the cotton pliers or a flat instrument.

C. Post-treatment Instructions Instruct patient on proper care of treated areas, including the following: Prevent accidental removal. Avoid flossing the treated areas for 10 days.56 Schedule periodontal maintenance.

DOCUMENTATION Documentation for the second in a series of appointments for a quadrant of scaling and root debridement with local anesthesia: Complete health history and assessment examination findings. Record new blood pressure. Oral preliminary examination to evaluate progress of healing for the previously treated quadrant(s). Note patient’s biofilm successes: provide instructions for care of newly treated area. Treatment completed during the appointment, including description of the amount of bleeding, necrotic tissue, and tenacity of subgingival calculus. Also note any areas that will need reevaluation at the next appointment. A sample progress note may be reviewed in Box 39-2.

BOX 39-2 Example Documentation: Special Attention to Instrument Adaptation on a Compromised Tooth Surface S—Female patient, 26 years old, presents for routine continuing care after being away for 2 years in the Peace Corps in Africa. Patient states she had tried hard to care for her teeth daily, but safe water was never assured, and she ran out of floss without a place to shop for more. She pointed to the upper left quadrant and said it was sore and bleeding up there. No basic changes in health history O—Vital signs normal (BP 121/70). Generalized moderate calculus, with generalized 4 mm probing depths. Tooth #12 mesial has 6 mm pocket, BOP, and calculus (visible on the BW radiograph). A—Tooth #13 may have a mesial concavity that requires careful adaptation of both hand and ultrasonic instrument tips. P—Careful adaptation of the ultrasonic tip and a mini curet on the mesial surface of #13 to assure the base of a mesial concavity has been reached to remove calculus and root plane the root surface, followed by careful evaluation with an explorer. Next Steps: Appointment made in 2 weeks for re-evaluation of #13 mesial. Signed: _____________________________, RDH

Date: ____________________________________

EVERYDAY ETHICS Lorna and Caroline practice as dental hygienists in the same office approximately 21/2 days per week. Lorna graduated from dental hygiene school about 15 years ago, while Caroline was licensed just 3 years ago. The front desk tries to schedule patients with the same hygienist. One day, Mrs. Border, a patient routinely scheduled with Lorna, showed up in Caroline’s appointment book because she wanted to fit in her regular maintenance appointment before going to live with her daughter for several months. The receptionist scheduled her with the first available hygienist. Caroline reviewed the patient’s medical history and recorded the blood pressure. During the periodontal examination, she found many areas of pocket depth increases with BOP in molar areas. Upon review of the radiograph taken that day, subgingival calculus was noted in many areas. Caroline raised Lorna’s chair to an upright position to discuss the findings. She showed Mrs. Border the radiographs with the calculus and then reviewed the periodontal charting comparing today’s numbers with her previous examination. Caroline then went to get Dr. Bennett to discuss the need for NSPT with Ms. Border. The patient was outraged at the recommendation for quadrant NSPT with local anesthesia and complained that Caroline “should have used the sprayer-machine like Lorna usually does.” Questions for Consideration 1. Is this an ethical dilemma or an issue for Caroline? For Lorna? For Dr. Bennett? Why? 2. Caroline realizes the deep calculus could not all have formed since the previous appointment. How should Caroline have addressed this problem with the patient? With Lorna? With Dr. Bennett? 3. Outline three or four possible avenues for Caroline to consider in resolving this difficult situation.

Factors to Teach the Patient The significance of dental biofilm in periodontal infection. The nature, occurrence, and etiology of calculus; its role as a biofilm reservoir. The importance and necessity for thorough daily removal of biofilm by the patient to prevent and manage periodontal infection. It is essential for the

patient to understand their role in success of treatment. Reasons for multiple appointments to complete the scaling and root debridement or periodontal debridement. The rationale for re-evaluation following the completion of scaling and root debridement. The importance of the patient’s role in maintenance of therapeutic gains. The limits of what can be accomplished nonsurgically and the rationale for referral to a periodontist so the patient understands all their treatment options. The rationale for adjunctive therapy to aid in healing following periodontal debridement.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Drisko CL. Periodontal debridement: still the treatment of choice. J Evid Based Dent Pract. 2014;14(suppl):33.e1-41.e1. 2. Suvan JE. Effectiveness of mechanical nonsurgical pocket therapy. Periodontol 2000. 2005;37:48-71. 3. Smiley CJ, Tracy SL, Abt E, et al. Systematic review and meta-analysis on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts. J Am Dent Assoc. 2015;146(7):508.e5524.e5. 4. American Academy of Periodontology. Parameter on chronic periodontitis with slight to moderate loss of periodontal support. J Periodontol. 2000;71(suppl 5):853-855. 5. Farooqi OA, Wehler CJ, Gibson G, Jurasic MM, Jones JA. Appropriate recall interval for periodontal maintenance: a systematic review. J Evid Based Dent Pract. 2015;15(4):171-181. 6. Charalampakis G, Dahlén G, Carlén A, Leonhardt A. Bacterial markers vs. clinical markers to predict progression of chronic periodontitis: a 2-yr prospective observational study. Eur J Oral Sci. 2013;121(5):394-402. 7. American Academy of Periodontology. Parameter on chronic periodontitis with advanced loss of periodontal support. J Periodontol. 2000;71(suppl 5):856-858. 8. Lee CT, Huang HY, Sun TC, Karimbux N. Impact of patient compliance on tooth loss during supportive periodontal therapy: a systematic review and meta-analysis. J Dent Res. 2015;94(6):777-786. 9. American Academy of Periodontology. Parameter on plaque-induced gingivitis. J Periodontol. 2000;71(suppl 5S):851-852. 10. Strachan A, Harrington Z, McIlwaine C, et al. Subgingival lipid A profile and endotoxin activity in periodontal health and disease. Clin Oral Investig. 2018; [Epub ahead of print]. 11. Cadosch J, Zimmermann U, Ruppert M, Guindy J, Case D, Zappa U. Root surface debridement and endotoxin removal. J Periodontal Res. 2003;38(3):229-236. 12. Bozbay E, Dominici F, Gokbuget AY, et al. Preservation of root cementum: a comparative evaluation of power-driven versus hand instruments. Int J Dent Hyg. 2018;16(2):202-209. 13. Akcalı A, Lang NP. Dental calculus: the calcified biofilm and its role in disease development. Periodontol 2000. 2018;76(1):109-115. 14. Segelnick SL, Weinberg MA. Reevaluation of initial therapy: when is the appropriate time? J Periodontol. 2006;77(9):1598-1601. 15. Eberhard J, Jepsen S, Jervøe-Storm PM, Needleman I, Worthington HV. Fullmouth treatment modalities (within 24 hours) for chronic periodontitis in adults. Cochrane Database Syst Rev. 2015;(4):CD004622. 16. Zhang W, Daly CG, Mitchell D, et al. Incidence and magnitude of bacteraemia

caused by flossing and by scaling and root planing. J Clin Periodontol. 2013;40(1):41-52. 17. Shetty SK, Sharath K, Shenoy S, et al. Compare the efficacy of two commercially available mouthrinses in reducing viable bacterial count in dental aerosol produced during ultrasonic scaling when used as a preprocedural rinse. J Contemp Dent Pract. 2013;14(5):848-851. 18. Gupta G, Mitra D, Ashok KP, et al. Efficacy of preprocedural mouth rinsing in reducing aerosol contamination produced by ultrasonic scaler: a pilot study. J Periodontol. 2014;85(4):562-568. 19. Balejo RDP, Cortelli JR, Costa FO, et al. Effects of chlorhexidine preprocedural rinse on bacteremia in periodontal patients: a randomized clinical trial. J Appl Oral Sci. 2017;25(6):586-595. 20. Leung WK, Duan YR, Dong XX, et al. Perception of non-surgical periodontal treatment in individuals receiving or not receiving local anaesthesia. Oral Health Prev Dent. 2016;14(2):165-175. 21. Ciantar M. Time to shift: from scaling and root planing to root surface debridement. Prim Dent J. 2014;3(3):38-42. 22. Walmsley AD, Lea SC, Landini G, Moses AJ. Advances in power driven pocket/root instrumentation. J Clin Periodontol. 2008;35(suppl 8):22-28. 23. Yukna RA, Vastardis S, Mayer ET. Calculus removal with diamond-coated ultrasonic inserts in vitro. J Periodontol. 2007;78(1):122-126. 24. Ioannou I, Dimitriadis N, Papadimitriou K, Sakellari D, Vouros I, Konstantinidis A. Hand instrumentation versus ultrasonic debridement in the treatment of chronic periodontitis: a randomized clinical and microbiological trial. J Clin Periodontol. 2009;36(2):132-141. 25. Park JB, Kim N, Ko Y. Effects of ultrasonic scaler tips and toothbrush on titanium disc surfaces evaluated with confocal microscopy. J Craniofac Surg. 2012;23(5):1552-1558. 26. Kawashima H, Sato S, Kishida M, Yagi H, Matsumoto K, Ito K. Treatment of titanium dental implants with three piezoelectric ultrasonic scalers: an in vivo study. J Periodontol. 2007;78(9):1689-1694. 27. Kwan JY. Enhanced periodontal debridement with the use of micro ultrasonic, periodontal endoscopy. J Calif Dent Assoc. 2005;33(3):241-248. 28. Geisinger ML, Mealey BL, Schoolfield J, Mellonig JT. The effectiveness of subgingival scaling and root planing: an evaluation of therapy with and without the use of the periodontal endoscope. J Periodontol. 2007;78(1):22-28. 29. Wilson TG Jr, Carnio J, Schenk R, Myers G. Absence of histologic signs of chronic inflammation following closed subgingival scaling and root planing using the dental endoscope: human biopsies—a pilot study. J Periodontol. 2008;79(11):2036-2041. 30. Bastendorf KD, Becker C, Bush B, et al. A paradigm shift in mechanical biofilm management? Subgingival air polishing: a new way to improve mechanical biofilm management in the dental practice. Quintessence Int. 2013:44(7):475477. 31. Wennström JL, Dahlén G, Ramberg P. Subgingival debridement of periodontal

pockets by air polishing in comparison with ultrasonic instrumentation during maintenance therapy. J Clin Periodontol. 2011;38(9):820-827. 32. Flemmig TF, Arushanov D, Daubert D, Rothen M, Mueller G, Leroux BG. Randomized controlled trial assessing efficacy and safety of glycine powder air polishing in moderate-to-deep periodontal pockets. J Periodontol. 2012;83(4):444-452. 33. Schwarz F, Ferrari D, Popovski K, Hartig B, Becker J. Influence of different airabrasive powders on cell viability at biologically contaminated titanium dental implants surfaces. J Biomed Mater Res B Appl Biomater. 2009;88(1):83-91. 34. Moëne R, Décaillet F, Andersen E, Mombelli A. Subgingival plaque removal using a new air-polishing device. J Periodontol. 2010(1);81:79-88. 35. Crispino A, Figliuzzi MM, Iovane C, et al. Effectiveness of a diode laser in addition to non-surgical periodontal therapy: study of intervention. Ann Stomatol. 2015;6(1):15-20. 36. Mizutani K, Aoki A, Coluzzi D, et al. Lasers in minimally invasive periodontal and peri-implant therapy. Periodontol 2000. 2016;71(1):185-212. 37. da Costa LFNP, Amaral CDSF, Barbirato DDS, Leão ATT, Fogacci MF. Chlorhexidine mouthwash as an adjunct to mechanical therapy in chronic periodontitis: a meta-analysis. J Am Dent Assoc. 2017;148(5):308-318. 38. American Academy of Periodontology. Parameter on comprehensive periodontal examination. J Periodontol. 2000;71(suppl 5):847-848. 39. Frieri M, Kumar K, Boutin A. Antibiotic resistance. J Infect Public Health. 2017;10(4):369-378. 40. Slots J; Research, Science and Therapy Committee. Systemic antibiotics in periodontics. J Periodontol. 2004;75(11):1553-1565. 41. Santos RS, Macedo RF, Souza EA, Soares RS, Feitosa DS, Sarmento CF. The use of systemic antibiotics in the treatment of refractory periodontitis: a systematic review. J Am Dent Assoc. 2016;147(7):577-585. 42. Keestra JA, Grosjean I, Coucke W, Quirynen M, Teughels W. Non-surgical periodontal therapy with systemic antibiotics in patients with untreated chronic periodontitis: a systematic review and meta-analysis. J Periodontal Res. 2015;50(3):294-314. 43. Garcia Canas P, Khouly I, Sanz J, Loomer PM. Effectiveness of systemic antimicrobial therapy in combination with scaling and root planing in the treatment of periodontitis: a systematic review. J Am Dent Assoc. 2015;146(3):150-163. 44. Smiley CJ, Tracy SL, Abt E, et al. Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts. J Am Dent Assoc. 2015;146(7):525-535. 45. Sgolastra F, Severino M, Petrucci A, Gatto R, Monaco A. Effectiveness of metronidazole as an adjunct to scaling and root planing in the treatment of chronic periodontitis: a systematic review and meta-analysis. J Periodontal Res. 2014;49(1):10-19. 46. Zhang Z, Zheng Y, Bian X. Clinical effect of azithromycin as an adjunct to nonsurgical treatment of chronic periodontitis: a meta-analysis of randomized

controlled clinical trials. J Periodontal Res. 2016;51(3):275-283. 47. Preshaw PM. Host modulation therapy with anti-inflammatory agents. Periodontol 2000. 2018;76(1):131-149. 48. Sgolastra F, Petrucci A, Gatto R, Giannoni M, Monaco A. Long-term efficacy of subantimicrobial-dose doxycycline as an adjunctive treatment to scaling and root planing: a systematic review and meta-analysis. J Periodontol. 2011;82(11):1570-1581. 49. Goodson JM, Haffajee A, Socransky SS. Periodontal therapy by local delivery of tetracycline. J Clin Periodontol. 1979;6(2):83-92. 50. American Academy of Periodontology. Statement on local delivery of sustained or controlled release antimicrobials as adjunctive therapy in the treatment of periodontitis. J Periodontol. 2006;77(8):1457-1458. 51. Joshi D, Garg T, Goyal AK, Rath G. Advanced drug delivery approaches against periodontitis. Drug Deliv. 2016;23(2):363-377. 52. Jepsen K, Jepsen S. Antibiotics/antimicrobials: systemic and local administration in the therapy of mild to moderately advanced periodontitis. Periodontol 2000. 2016;71(1):82-112. 53. Esposito M, Grusovin MG, Worthington HV. Treatment of peri-implantitis: what interventions are effective? A Cochrane systematic review. Eur J Oral Implantol. 2012;5(suppl):S21-S41. 54. Lexicomp for Dentistry. Minocycline Hydrochloride. Updated December 14, 2018. Hudson, OH: Wolters Kluwer Clinical Drug Information. 55. Lexicomp for Dentistry. Doxycycline Hyclate Periodontal Extended-Release Liquid. Updated January 15, 2019. Hudson, OH: Wolters Kluwer Clinical Drug Information. 56. Lexicomp for Dentistry. Chlorhexidine Gluconate (Oral). Updated March 20, 2019. Hudson, OH: Wolters Kluwer Clinical Drug Information.

40 Sutures and Dressings Susan J. Jenkins, RDH, PhD

CHAPTER OUTLINE SUTURES I. II. III. IV. V.

The Ideal Suture Material Functions of Sutures Characteristics of Suture Materials Classification of Suture Materials Selection of Suture Materials

NEEDLES I. II.

Needle Components Needle Characteristics

KNOTS I. II.

Knot Characteristics Knot Management

SUTURING PROCEDURES I.

Blanket (Continuous Lock)

II. III. IV. V. VI.

Interrupted Continuous Uninterrupted Circumferential Interdental Sling or Suspension

PROCEDURE FOR SUTURE REMOVAL I. II. III. IV. V.

Review Previous Documentation Sterile Clinic Tray Setup Preparation of Patient Steps for Removal Safety Measures

PERIODONTAL DRESSINGS I. II.

Purposes and Uses Characteristics of Acceptable Dressing Material

TYPES OF DRESSINGS I. II. III. IV.

Zinc Oxide with Eugenol Dressing Chemical-Cured Dressing Visible Light–Cured Dressing Collagen Dressing

CLINICAL APPLICATION I. II. III.

Dressing Placement Characteristics of a Well-Placed Dressing Patient Dismissal and Instructions

DRESSING REMOVAL AND REPLACEMENT I. II. III. IV. V.

Patient Examination Procedure for Removal Dressing Replacement Procedure Patient Oral Self-care Instruction Follow-up

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES

After studying this chapter, the student will be able to: 1. State the functions and purposes of sutures and periodontal dressings. 2. Describe the differences between absorbable and nonabsorbable sutures. 3. Describe the procedure for suture removal. 4. Describe the procedure for periodontal dressing placement and periodontal dressing removal. 5. Explain approaches for managing biofilm with the periodontal dressing in place and upon removal. Many periodontal surgical procedures require sutures and dressings. The dental hygienist will often participate in the patient’s oral self-care instruction at initial placement and during postoperative care.

SUTURES I. The Ideal Suture Material A suture is a strand of material used to control bleeding, stabilize the wound edges in the proper position, protects the wound, and aids in patient comfort.1 Sutures are necessary in many oral surgical procedures when a surgical wound must be closed, a flap positioned, or tissue grafted. Historically a wide range of suture materials has been used including silk, cotton, linen, and animal tendons and intestines. The ideal suture material is nonallergic, easy to handle, has adequate tensile strength, sterile, does not interfere with healing, causes minimal inflammatory reaction, and has some capacity to stretch to allow for wound edema.1,2 Ultimately, the ideal suture does not exist and each surgeon must select the best suture material based on the surgical procedure to be performed, patient, and wound characteristics.2

II.

Functions of Sutures Close periodontal wounds and secure grafts in position. Assist in maintaining hemostasis. Reduce posttreatment discomfort. Promote primary intention healing. Prevent underlying bone exposure. Protect a healing surgical wound from foreign debris and trauma.

III. Characteristics of Suture Materials A. Biological Characteristics1 Sterility.

Reabsorption ability. Tolerability: creates minimal inflammatory reaction in the tissue.

B. Physical Characteristics1 Tensile strength. Flexibility: ability to twist and tie know without breaking. Plasticity: ability to maintain new shape. Elasticity: ability of material to stretch and return to original shape. Maneuverability: easy to handle and able to create a small knot. Fluency: passes through tissue with minimal trauma. Length and diameter: various lengths and diameters are available.

IV. Classification of Suture Materials A. Type of Material Used1 Natural: classified into animal origin (i.e., catgut and silk) and vegetal origin (i.e., cotton and linen). Synthetic: developed to reduce tissue reactions and unpredictable rates of absorption commonly found in natural sutures.

B. Absorption Properties Absorbable sutures: Natural absorbable sutures: digested by body enzymes. Plain gut: monofilamentous, derived from purified collagen of sheep or cattle and lasts about 8 days before beginning to degrade.1 Chromatic gut: chromatic salts to delay enzyme resorption for 18 days.1 Synthetic resorbable sutures: broken down by hydrolysis, a process in which water slowly penetrates the suture filaments to cause a breakdown of the suture’s polymer chain. Example: polyglactin (Vicryl), poliglecaprone (Monocryl), and

polydioxanone (PDS II). Nonabsorbable sutures: not digested by body enzymes or hydrolyzation; patient returns for removal usually after 1 week. Natural nonabsorbable Braided silk. Synthetic nonabsorbable Nylon (Ethilon). Polyester (Ethibond). Polypropylene (Prolene). Polytetrafluoroethylene (PTFE) (Gore-Tex®). Coated sutures: Suture material coated with the antibacterial agents triclosan and chlorhexidine may provide antibacterial efficacy and oral biofilm inhibition.1,3

C. Number of Strands Monofilament suture: single strand of material; typical of gut, nylon, PTFE, and other synthetic sutures.1 Multifilament suture: several strands twisted or braided together: typical of silk, nylon, polyglycolic acid, polyester, and other synthetic sutures.1

D. Diameter of Suture Material Diameters range from 1–0 to 11–0. More zeros = smaller the diameter. Fewer zeros = larger the diameter. Example: 3–0 is larger than 5–0; size 4.0 and 3.0 are the most common intraoral sutures.

V.

Selection of Suture Materials

Choosing the appropriate suture material for a specific procedure is critical both for patient comfort and tissue health. Suture selection is based on the following2:

Preference and experience of the surgeon. Characteristics of the patient such as age. Characteristics of the wound such as length and tissue type (mucosa vs. attached gingiva). Cosmetic implications. Examples of suture types surgeons may use for specific procedures are listed in Table 40-1. TABLE 40-1 • Selection of Suture Material SUTURE TYPES

SPECIFIC DENTAL PROCEDURES

Silk, nonresorbable, braided

Periodontal flaps and closure

Nylon, monofilament

Periodontal flaps and closure

Polyester, braided

Periodontal flaps and closure

Gut, resorbable

Extraction socket, bone grafting, free-gingival grafting

Resorbable preferred: nonresorbable used when pain and swelling may be anticipated

Implant flap closure

NEEDLES Many types of suturing needles are available. Their use and selection are primarily based on specific procedures, location for use, and clinician’s preference.

I.

Needle Components Swaged end (eyeless) Swaged allows suture material and needle to act as one unit (Figure 40-1).

FIGURE 40-1 • Suture Needle Components. (Courtesy of Susan Jenkins, MCPHS University Forsyth School of Dental Hygiene.)

Body Shape/curvature Straight. Half-curved. Curved 1/4, 3/8, 1/2, 5/8 (Figure 40-2).

FIGURE 40-2 • Suture Needles. A curved needle is manipulated with a needleholder. The 3/8 curve is most effective for closure of skin and mucous membranes and is a needle of choice in many dental and periodontal surgeries.

Diameter Gauge or size; finer for delicate surgeries. Body is the strongest part of the needle that is grasped with the needleholder during the surgical procedure. Swaged end is the weakest part of the body. Point Point of the needle extends from the extreme tip of the needle to the widest part of the body. Each needle point is designed and manufactured to penetrate tissue with the highest degree of sharpness.

II.

Needle Characteristics Material Most needles are made of stainless steel formulated and sterilized for surgical use.

Attachment Majority of needles are permanently attached to suture material. Eliminates need for threading and unnecessary handling. Cutting edge (Figure 40-3)

FIGURE 40-3 • Suture Needles. Shapes of Points. Triangle shows cross section of needle point. A: Conventional cutting with third cutting edge on the inside of the needle curvature. B: Reverse cutting with third cutting edge on the outer curvature of the needle, used for difficult-to-penetrate tissue, such as skin. (Courtesy of Susan Jenkins, MCPHS University Forsyth School of Dental Hygiene.)

Reverse cut: the sharpest needle3; has two opposing cutting edges, with a third located on outer convex curve of needle. Conventional cut: consists of two opposing cutting edges and a

third within the concave curvature of the needle. Requirements Needle point: designed to meet the needs of specific surgical procedures. Sharp enough to penetrate tissues with minimal resistance. Rigid enough to resist bending, yet are flexible. Sterile and corrosion resistant. Surgical needles: intended to carry suture material through tissues with minimal trauma.

KNOTS The book Surgical Knots and Suturing Techniques4 describes a variety of surgical knots. Only a few are used in dentistry. Type of knot used will depend on the specific procedure. Location of the incision. Amount of stress the wound will endure. Square knots are most frequently used in dentistry because they are the easiest and most reliable.

I.

Knot Characteristics The knot is tied as small as possible. Completed knot needs to be firm to reduce slipping. Excessive tension should be avoided to prevent breakage or trauma to the tissue.

II.

Knot Management The knot is tied on the facial aspect for easier access for removal. A 2- to 3-mm suture “tail” is left to assist in locating the suture for removal.

SUTURING PROCEDURES Many different patterns of suturing are used. Assisting and observing during the surgical procedure can be an educational experience for the dental hygienist. General types of sutures used in the oral cavity are described in Figure 40-4.

FIGURE 40-4 • Types of Sutures. A: Blanket stitch. B: Interrupted, individual sutures. C: Interdental individual sutures. D: Sling or suspension suture tied on the lingual (dotted line) E: Interrupted silk sutures in place 1-week postsurgery. (Courtesy of Dr. Robert Lewando, Boston, MA.)

I.

Blanket (Continuous Lock) Each stitch is brought over a loop of the preceding one, thus forming a series of loops on one side of the incision and a series of stitches over the incision (Figure 40-4A). Uses: to approximate the gingival margins after alveolectomy.

II.

Interrupted Figure 40-4B shows a series of interrupted sutures.

III. Continuous Uninterrupted A series of stitches tied at one or both ends. Examples of sutures that may be applied in a series are the sling or suspension and the blanket.

IV. Circumferential Suture that encircles a tooth for suspension and retention of a flap.

V.

Interdental

Flaps are on both the lingual and facial sides; interdental ligation joins the two by passing the suture through each interdental area (Figure 40-4C). Coverage for the interdental area can be accomplished by coapting the edges of the papillae.

VI. Sling or Suspension

When a flap is only on one side, facial or lingual, the sutures are passed through the interdental papilla, around the tooth, and into the adjacent papilla (Figure 40-4D). The suture is adjusted so that the flap can be positioned for correct healing.

PROCEDURE FOR SUTURE REMOVAL Removal schedule: 7 days after the surgery and no longer than 14 days to prevent tissue infection and promote healing.

I.

Review Previous Documentation Medical history. Surgical procedures. Patient reactions to healing. Current surgery: number and type of sutures placed.

II.

Sterile Clinic Tray Setup Sterile mouth mirror. Sterile cotton pliers. Sterile curved sharp scissors with pointed tip (suture scissors). Gauze, that is, 2 × 2. Topical anesthetic: type that can be applied safely on an abraded or incompletely healed area. Cotton pellets. Saliva ejector tip.

III. Preparation of Patient Patient history check Patients with valvular heart disease require consultation with the cardiologist.5 Sutures are colonized by bacteria and should be removed as soon as possible once adequate wound healing has occurred.1,2,6 Suture removal can cause bacteremia.7–9 Patient examination Observe healing tissue around the suture(s) (Figure 40-4E).

Record any deviations in color, size, shape of the tissue, adaptation of a flap, or coaptation of an incision healing by first intention. Preparation of the sutured area Sutures placed without a dressing may have debris lodged in them at the time of removal. Irrigate and/or swab with a cotton tip applicator or cotton pellet. 0.12% chlorhexidine mouthrinse or 3% peroxide can be used to dip the cotton tip applicator to aid in debris removal. Follow with another rinse or wipe gently with a gauze sponge. Place and adjust saliva ejector.

IV. Steps for Removal The suture removal procedure described here and illustrated in Figure 40-5 is for a single interrupted suture.

FIGURE 40-5 • Suture Removal. A: Suture grasped by pliers near the entrance into tissue. B: Suture pulled gently up while scissor is inserted close to the tissue. Suture is cut in the part previously buried in the tissue. C: Suture is held up for vertical removal. D: Suture is pulled gently to bring it out on the side opposite from where it was cut. The object is to prevent the external part of the suture from passing through the tissue and introducing infectious material. (Courtesy of Dr. Robert Lewando, Boston, MA.)

The same principles apply for the ends and each segment of a continuous suture, wherever suture material can pass through the soft tissue. Steps 1. Review the surgeon’s chart notes to determine the number of sutures placed and visually locate them prior to beginning suture removal.

2. Use caution when removing a periodontal dressing to prevent tearing a suture that may have become embedded in the dressing causing the patient significant discomfort. 3. Once the sutures are exposed, carefully remove debris by irrigating with water and/or use antiseptic/antimicrobial like 0.12% chlorhexidine mouthrinse on a cotton tip applicator or cotton pellet. 4. Gently grasp the ends of the suture above the knot with the cotton plier held in the nondominant hand. Gently draw the suture up several millimeters if possible and hold with slight tension (Figure 40-5A). A finger rest is needed for control. 5. With the scissors in the dominant hand, insert one blade of the scissors just under the suture knot on one thread of the suture material (Figure 40-5B). 6. Hold knot end up with the cotton plier and pull gently to allow suture to exit through the side opposite where it was cut (Figure 40-5C). 7. Place each suture on a piece of gauze and proceed to remove the next suture. 8. Count the total number of sutures removed to ensure they were all removed. During healing, sutures can become loosened, misplaced, or occasionally covered by tissue. The effect of a remaining suture can lead to infection and possible abscess around the suture left behind. 9. Irrigate with water or antiseptic. Apply gauze with slight pressure on any bleeding spots. 10. Provide proper postsuture removal instructions both verbally and in writing. 11. Observe all tissue and record observations, noting any adverse reactions or bleeding.

PERIODONTAL DRESSINGS Historically, periodontal dressing were thought to prevent wound infection and enhance healing; however, current evidence does not support this.10,11 The use of a periodontal dressing is the personal preference and judgment of the clinician.

I.

Purposes and Uses10–12 Reduce pain following surgery. Provide a physical barrier to external irritation, trauma, and may reduce bacterial colonization of the suture material. Help prevent posttreatment bleeding by securing initial clot formation. Support mobile teeth during healing. Minimize tooth hypersensitivity. Assist in shaping or molding newly formed tissue, in securing a flap, or in immobilizing a graft. Possible use after nonsurgical periodontal therapy has also been proposed to enhance periodontal outcomes, but more research is needed.13

II.

Characteristics of Acceptable Dressing Material

An acceptable dressing material has the following characteristics: Preparation, placement, and removal will take place with minimal discomfort to the patient. Material adheres to itself, teeth, and adjacent tissues and maintains retention within interdental areas. Provides stability and flexibility to withstand distortion and displacement without fracturing. Is nontoxic and nonirritating to oral tissues. Possesses a smooth surface that will resist accumulation of dental

biofilm. Will not traumatize tissue or stain teeth and restorative materials. Possesses an aesthetically acceptable appearance.

TYPES OF DRESSINGS Traditionally, dressings were classified into two groups: those that contained eugenol and those that did not. With the development of new products, “noneugenol-containing” dressings have been reclassified into chemical-cure and visible light–cure (VIC) materials. They are available as ready-mix, paste–paste, or paste–gel preparations.

I.

Zinc Oxide with Eugenol Dressing Example: Kirkland periodontal pack.

B. Advantages Consistency: firm and heavy—provides support for tissues and flaps. Slow setting: extended working time. Preparation and storage: can be prepared in quantity and stored (frozen) in work-size pieces.

C. Disadvantages Taste: sharp, unpleasant taste. Tissue reaction: irritating; hypersensitivity reactions can occur. Consistency: the dressing is rough, hard and brittle, breaks easily, and encourages dental biofilm retention.

II.

Chemical-Cured Dressing Two examples of chemical-cured dressings are PerioCare® and Coe-Pak™.

A. Basic Ingredients Coe-Pak™: Most commonly used two-paste system.12 Base paste: zinc oxide with added oils and gums. Catalyst paste: resins, fatty acids, and chlorothymol as an antibacterial agent. Coe-Pak™ is available in regular and fast set; hand mix or cartridge delivery. PerioCare®: two-paste system.12 One paste contains metal oxides and oil. The other paste contains a gel rosin and fatty acids.

B. Advantages Consistency: pliable, easy to place with light pressure. Smooth surface: comfortable to patient; resists biofilm and debris deposits. Taste: acceptable. Removal: easy, often comes off in one piece.

III. VIC Dressing VIC dressing (Barricaid®) is available in a syringe for direct application. The same light-curing unit used for composite restorations and sealants is used.

A. Advantages Color: more like gingiva than other dressings and often preferred in anterior areas. Setting: cured in increments with a light-curing unit. Removal: easy, often comes off in one piece.

IV. Collagen Dressing

Absorbable collagen dressings used to promote wound healing.12 Special use in periodontal surgery for a collagen patch dressing: for protection of graft sites of the palate during healing. One form prepared in a bullet shape to use for deep biopsy sites.12 Available in individual unit sterile packages. Collagen dressing may be placed on clean moist or bleeding wounds.

CLINICAL APPLICATION I. Dressing Placement General procedure For all types of dressing, follow the manufacturer’s instructions. Each product has unique properties that require special handling. Retention Mold the dressing by pressing at each interproximal site to cover interdental tissue (Figure 40-6A). Do not extend over the height of contour of each tooth.

FIGURE 40-6 • Periodontal Dressing. A: Gently pressing the facial periodontal dressing into the interproximal space. B: Gently pushing the lingual periodontal dressing into the interproximal space. C: Gently pressing the dressing from the buccal and lingual to help “lock” the dressing in place. D: Correct placement of the periodontal dressing. A dressing must cover the surgical wound without unnecessary overextension and fill interdental areas to lock the dressing between the teeth. It is molded in the vestibule and

around frena to allow movement of the lips, cheeks, and tongue with no displacement of the dressing. E: Reso-Pac™-(Hager Worldwide), a hydrophilic, more esthetically pleasing periodontal dressing. (Courtesy of Susan Jenkins, MCPHS University Forsyth School of Dental Hygiene.)

Border mold to prevent displacement by the tongue, cheeks, lips, or frena (Figure 40-6 B and C). Check the occlusion and remove areas of contact.

II.

Characteristics of a Well-Placed Dressing Dressings placed in keeping with biologic principles contribute to healing and are tolerated more comfortably by the patient. A satisfactory dressing (Figure 40-6D) has the following characteristics: Is secure and rigid. A movable dressing is an irritant and can promote bleeding. Has as little bulk as possible, yet is bulky enough to give strength. Locks mechanically interdentally and cannot be displaced by action of tongue, cheek, or lips. Covers the entire surgical wound without unnecessary overextension. Fills interdental area and adequately covers the treated area to discourage retention of debris and dental biofilm. Possesses a smooth surface to prevent irritation to cheeks and lips while resisting debris and biofilm retention.

III. Patient Dismissal and Instructions Patient is not dismissed until bleeding or oozing from under a dressing has stopped. Written instructions are necessary to reinforce those that are provided verbally. Table 40-2 lists items to discuss with the patient before discharge.

TABLE 40-2 • Instructions for Posttreatment Care FACTOR

INSTRUCTIONS TO PATIENT

PURPOSE OF INSTRUCTION

Information for the patient about the dressing

Dressing will protect the surgical wound. Do not disturb the dressing. Allow it to remain until the next appointment.

An informed patient is more likely to be more compliant.

Care during the first few hours

Do not eat anything that requires chewing. Use only cool liquids. Stay quiet and rest. If a periodontal dressing was placed, it will not set for a few hours.

Do not touch or disturb the surgical area. Dressing will become set or become hard.

Local anesthesia

Be careful not to bite lip, cheek, or tongue. Avoid foods that require chewing, hot liquids, and spicy foods until anesthesia has worn off.

Prevent trauma to lips, cheeks, and tongue. Rest and be quiet.

Discomfort after local anesthesia wears off

Fill any prescriptions provided by the dentist or periodontist and follow directions. Do not take more than directed. Avoid aspirin. Call the dental office if pain persists.

Pain control. Aspirin can interfere with blood-clotting mechanism. The patient will be more prepared to manage any postoperative discomfort when appropriately informed.

Ice pack or cold compress

Apply every 30 min for 15 min; or 15 min on, then 15 min off. Use as directed only.

Prevent swelling from edema.

Bleeding

Slight bleeding within the first few hours is not unusual. Blood clot must not be disturbed.

When bleeding seems persistent or excessive, please call the dental office immediately.

Do not suck on the area or use straws. Dressing care and retention

Avoid disturbing the dressing with the tongue or trying to clean under it. Small particles may chip off, which is not a problem unless sharp edges irritate the tongue or the dressing becomes loose. Call the dentist if the entire dressing or a large portion falls off before the fifth day. Rinse with a saline solution; rinse with chlorhexidine 0.12% morning and evening after brushing teeth.

Dressing is needed for wound protection. Epithelium covers wound by fifth or sixth day in normal healing.

Use of tobacco and tobacco products

Do not smoke; avoid all tobacco products. A heavy smoker must make every effort to decrease quantity of tobacco used. The dental hygienist may suggest a nicotine patch to aid in preventing withdrawal symptoms and aid the patient in abstaining from tobacco use.

Heat and smoke irritate the gingiva and delay healing.

Rinsing

Do not rinse on the day of treatment. Second day: Use saline solution made with 1/2 teaspoon (measured) in 1/2 cup of warm water every 2– 3 hr. Begin chlorhexidine 0.12% b.i.d. (twice a day).

Might disturb blood clot. Saline cleanses and aids healing.

FACTOR Toothbrushing and flossing

INSTRUCTIONS TO PATIENT Continue to maintain optimal personal oral self-care in

PURPOSE OF INSTRUCTION Dental biofilm control essential to reduce the

untreated areas. Lightly brush occlusal surface over dressing material. Use extra soft or soft brush dampened with warm water, and carefully clean film from dressing. Clean the tongue.

number of oral microorganisms. Odor and taste control. Oral sanitation.

Diet

Use highly nutritious foods for healing. Follow the MyPlate guide (Chapter 33). Use soft-textured diet. Avoid highly seasoned, spicy, hot, sticky, crunchy, and coarse foods.

Healing tissue requires a healthy diet and specific comfort foods. Use soft foods to protect the dressing from breakage or displacement.

Mastication

Avoid foods that require excessive chewing such as hard, crunchy, or sticky foods. Chew only on the untreated side. Use ground meat or cut meat into small, bite-sized pieces.

To protect the dressing while it protects the surgical site.

DRESSING REMOVAL AND REPLACEMENT During healing, epithelium begins to cover a wound in 5–6 days and complete epithelial healing in 7–14 days.14 The dressing may be left in place for 7 to 10 days, as determined by the surgeon. Keep the following factors relative to dressings in mind: If the dressing becomes dislodged before the removal appointment, the healing tissue needs to be evaluated. When the dressing remains intact for 4 or 5 days, replacement may not be necessary. When replacement is indicated, the dressing is replaced in its entirety rather than patched. Instruct the patient to proceed with daily biofilm removal and rinsing using an antimicrobial agent. Schedule patient’s follow-up appointment.

I.

Patient Examination Question patient about and record posttreatment effects or discomfort. Record length of time the dressing remained in place. Examine the mucosa around the dressing and record its appearance.

II.

Procedure for Removal Insert a smooth instrument such as a plastic instrument under the border of the dressing and gently apply lateral pressure. Watch for sutures lodged in the dressing. If present, cut before removing the dressing. Remove fragments of dressing gently with cotton pliers to avoid scratching the thin epithelial covering of the healing tissue. Observe tissue and record its appearance. Note any deviations from normal healing that is expected within the number of days. Use a scaler for removal of fragments adhering to tooth surfaces

and near the gingival margin. Use an air–water syringe with a gentle stream of warm water. Warm diluted mouthrinse may soothe the healing area.

III. Dressing Replacement Procedure Topical anesthetic may be necessary to prevent patient discomfort. Use a soft dressing with minimal pressure during application.

IV. Patient Oral Self-Care Instruction Biofilm control follow-up is essential after final dressing removal. Use an extra soft or soft toothbrush on the treated area, paying careful attention to biofilm removal at the gingival margin. Increase intensity of care on the treated area each day, with a return to normal oral self-care procedures by day 3 or 4. Rinse with 0.12% chlorhexidine gluconate twice daily during the healing period. Gently force liquid between the teeth when swishing. Recommend a dentifrice with sodium fluoride for caries prevention and a prescription fluoride may be indicated depending on the patient’s caries risk. If the patient experiences postsurgical sensitivity, recommend a dentifrice containing a desensitizing agent. Suggestions for coping with sensitivity are found in Chapter 41.

V.

Follow-Up

The return for observation of the surgical areas can be scheduled in 1–2 weeks, depending on the patient’s progress and treatment planning.

DOCUMENTATION Detailed documentation is required at each patient visit. The appointment is dated and signed by the attending clinician. At the time of surgical treatment include in the patient’s permanent record at least the following: Vital signs. Anesthesia: type, location, number and size of carpules, and patient response to anesthesia. Sutures: type, location, and number placed. Dressing: specific type and area placed. Provide instructions to patient prior to dismissal. Date and signature by attending dentist or periodontist and surgical assistant. Dressing and suture removal Tissue examination: tissue response. Patient comments of posttreatment effects, discomfort. Number of sutures removed: compare with number placed. Patient instruction for continued care. Date and signature by attending dental hygienist. Sample documentation may be reviewed in Box 40-1.

BOX 40-1 Example Documentation: Sutures and Dressings S—Patient presents for postsurgical dressing removal between teeth 11 and 15. Patient states no postsurgical problems. O—Tissue bled slightly during dressing removal. Removed four sutures; confirmed four sutures were placed during surgery. Patient responded well. A—Dr. examined area; no additional dressing needed; patient discharged with posttreatment instructions. P—Patient instructed to call if any problems; patient to return for 3-month maintenance appointment. Signed: ______________________________, RDH Date: ____________________________________

EVERYDAY ETHICS Ms. Jean arrived for a suture removal appointment with Susan, the dental hygienist, and immediately explains the discomfort she is feeling. When asked why she didn’t come in sooner to have the area observed, she said it was so close to the removal appointment she might as well wait. Susan notes from the chart notes that no dressing was placed. The area appeared inflamed, with a slight cyanotic appearance circumscribing the suture area. The patient prerinsed with a 0.12% chlorhexidine, and Susan began removing the sutures. Moderate bleeding and discomfort were present. Upon removal, Susan noted that only three sutures could be found, but four silk sutures had been placed. When she conferred with Dr. Wynn, the periodontist, Susan was told to dismiss the patient and “prepare a prescription for an antibiotic to prevent an infection. Eventually the suture will be absorbed by body tissues.” Questions for Consideration 1. Given the sequence of events, what issues of ethical principles may be applied? 2. Does it seem clear that the patient understood the postoperative instructions? What suggestions do you have to improve communication? 3. Was the treatment provided within an acceptable standard of care for this patient? Which of the core values have application here? 4. You know the periodontist reviews all chart notes at the end of the day, prepare a progress note that you suggest Susan could write in the permanent record for Ms. Jean’s appointment. Do you feel the note covers all the important information? Why or why not?

Factors to Teach the Patient Provide the posttreatment instructions as outlined in Table 40-2. Care of the mouth during the period after treatment while wearing a periodontal dressing. Reasons for not using aspirin for pain relief. Inform and explain why tobacco use is detrimental and delays healing. Encourage cessation of use of all forms of tobacco. Discuss the importance of regular periodontal maintenance after treatment is complete.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Minozzi F, Bollero P, Unfer V, Dolci A, Galli M. The sutures in dentistry. Eur Rev Med Pharmacol Sci. 2009 May–June;13(3):217–226. 2. Selvi F, Cakarer S, Can T, et al. Effects of different suture materials on tissue healing. J Istanb Univ Fac Dent. 2016;50(1):35–42. 3. Burkhardt R, Lang NP. Influence of suturing on wound healing. Periodontol 2000. 2015 June;68(1):270–281. 4. Giddings FD. Book of Surgical Knots and Suturing Techniques. 3rd ed. Fort Collins, CO: Giddings Studio Publishing; 2009. 5. Nishimura RA, Otto CM, Bonow RO,et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol. 2017 July 11;70(2):252–289. 6. Giglio JA, Rowland RW, Dalton HP, et al. Suture removal-induced bacteremia: a possible endocarditis risk. J Am Dent Assoc. 1992;123(1):65–70. 7. Banche G, Roana J, Mandras N, et al. Microbial adherence on various intraoral suture materials in patients undergoing dental surgery. J Oral Maxillofac Surg. 2007 August;65(8):1503–1507. 8. Otten JE, Wiedmann-Al-Ahmad M, Jahnke H, Pelz K. Bacterial colonization on different suture materials: a potential risk for intraoral dentoalveolar surgery. J Biomed Mater Res B Appl Biomater. 2005 July;74(1):627–635. 9. King RC, Crawford JJ, Small EW. Bacteremia following intraoral suture removal. Oral Surg Oral Med Oral Pathol. 1988;65(1):23–27. 10. Soheilifar S, Bidgoli M, Faradmal J, Soheilifar S. Effect of periodontal dressing on wound healing and patient satisfaction following periodontal flap surgery. J Dent. 2015 February;12(2):151–156. 11. Dumville JC, Gray TA, Walter CJ, et al. Dressings for the prevention of surgical site infection. Cochrane Database Syst Rev. 2016 December 20;12:CD003091. 12. Kathariya R, Jain H, Jadhav T. To pack or not to pack: the current status of periodontal dressings. J Appl Biomater Funct Mater. 2015 July 4;13(2):e73– e86. 13. Monje A, Kramp AR, Criado E, et al. Effect of periodontal dressing on nonsurgical periodontal treatment outcomes: a systematic review. Int J Dent Hyg. 2016 August;14(3):161–167. 14. Hämmerle CH, Giannobile WV; Working Group 1 of the European Workshop on Periodontology. Biology of soft tissue wound healing and regeneration: consensus report of Group 1 of the 10th European Workshop on Periodontology. J Clin Periodontol. 2014 April;41(suppl 15):S1–S5.

41 Dentinal Hypersensitivity Amy N. Smith, RDH, MS, MPH

CHAPTER OUTLINE HYPERSENSITIVITY DEFINED I. II.

Stimuli that Elicit Pain Reaction Characteristics of Pain from Hypersensitivity

ETIOLOGY OF DENTINAL HYPERSENSITIVITY I. II. III.

Anatomy of Tooth Structures Mechanisms of Dentin Exposure Hydrodynamic Theory

NATURAL DESENSITIZATION I. II. III. IV.

Sclerosis of Dentin Secondary Dentin Smear Layer Calculus

THE PAIN OF DENTINAL HYPERSENSITIVITY I.

Patient Profile

II.

Pain Experience

DIFFERENTIAL DIAGNOSIS I. II. III.

Differentiation of Pain Data Collection by Interview Diagnostic Techniques and Tests

HYPERSENSITIVITY MANAGEMENT I. II. III. IV.

Assessment Components Educational Considerations Treatment Hierarchy Reassessment

ORAL HYGIENE CARE AND TREATMENT INTERVENTIONS I. II. III. IV. V. VI.

Mechanisms of Desensitization Behavioral Changes Desensitizing Agents Self-Applied Measures Professionally Applied Measures Additional Considerations

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Describe stimuli and pain characteristics specific to hypersensitivity and explain how this relates to differential diagnosis. 2. Describe the factors that contribute to dentin exposure and behavioral changes that could decrease hypersensitivity. 3. Explain the steps in the hydrodynamic theory. 4. Describe two mechanisms of desensitization and their associated treatment interventions for managing dentin hypersensitivity.

The dental hygienist is often the first oral health professional to become aware of the presence of hypersensitive teeth when a patient presents for care. Individuals who suffer from hypersensitivity may be uncomfortable during dental hygiene treatment, since exposure to stimuli such as a cold water spray or contact with metal instruments can elicit the pain of hypersensitive teeth. Patients often report activities of daily living such as eating or drinking cold foods or beverages cause pain and request information about causes and treatment for their discomfort. Hypersensitivity is often difficult to diagnose because the presenting symptoms can be confused with other types of dental pain with a different etiology. Management of hypersensitivity can be a challenge because there are numerous treatment approaches with varying degrees of efficacy. Knowledge of the predisposing factors that lead to gingival recession and loss of enamel or cementum and dentin can assist patients in preventing conditions that cause or exacerbate hypersensitivity.

HYPERSENSITIVITY DEFINED A definitive characteristic associated with dentinal hypersensitivity is pain elicited by a stimulus and alleviated upon its removal. Numerous types of stimuli can lead to pain response in individuals with exposed dentin surfaces.

I.

Stimuli That Elicit Pain Reaction Tactile: contact with toothbrush and other oral hygiene devices, eating utensils, dental instruments, and friction from prosthetic devices such as denture clasps. Thermal: temperature change caused by hot and/or cold foods and beverages, and cold air as it contacts the teeth. Cold is the most common stimulus for pain. Evaporative: dehydration of oral fluids as from high-volume evacuation or application of air to dry teeth during intraoral procedures. Osmotic: alteration of pressure in dentinal tubules through a selective membrane. Chemical: acids in foods and beverages such as citrus fruits, condiments, spices, wine, and carbonated beverages; acids produced by acidogenic bacteria following carbohydrate exposure; acids from gastric regurgitation; acidic formulation of whitening agents.

II.

Characteristics of Pain from Hypersensitivity Sharp, short, or transient pain with rapid onset. Cessation of pain upon removal of stimulus. Presents as a chronic condition with acute episodes. Pain in response to a non-noxious stimulus, one that would not normally cause pain or discomfort. Discomfort that cannot be ascribed to any other dental defect or

pathology.1

ETIOLOGY OF DENTINAL HYPERSENSITIVITY A review of tooth anatomy facilitates an understanding of the mechanism of hypersensitivity.

I.

Anatomy of Tooth Structures

A. Dentin The portion of the tooth covered by enamel on the crown and cementum on the root. Composed of fluid-filled dentinal tubules that narrow and branch as they extend from the pulp to the dentinoenamel junction or from the pulp to the dentinocementum junction (Figure 41-1).

FIGURE 41-1 • Relationship of Dentinal Tubules and Pulpal Nerve Endings. Nerve endings from the pulp wrap themselves around the odontoblasts that extend only a short distance into the tubule. Fluid-filled dentinal tubules transmit fluid disturbances through the mechanism known as hydraulic conductance. CEJ, cementoenamel junction.

Only the portions of the dentinal tubules closest to the pulp are

potentially innervated with nerve fiber endings from the pulp chamber. Tubules are wider and more numerous in sensitive areas.2

B. Pulp Highly innervated with nerve cell fiber endings that extend just beyond the dentinopulpal interface of the dentinal tubules.3 Body portions of odontoblasts (dentin-producing cells) located adjacent to the pulp extend their processes from the dentinopulpal junction a short way into each dentinal tubule (Figure 41-1).

C. Nerves Nerve fiber endings extend just beyond the dentinopulpal junction4 and wind around the odontoblastic processes as shown in Figure 41-1. However, not all dentinal tubules contain nerve fiber endings. Nerves react via the same neural depolarization mechanism (sodium–potassium pump), which characterizes the response of any nerve to a stimulus.

II.

Mechanisms of Dentin Exposure The sequential events of gingival recession, loss of cementum or enamel, and subsequent dentin exposure, as seen in Figure 41-2, can result in hypersensitivity.

FIGURE 41-2 • Gingival Recession. Note recession from the mandibular right central incisor to the second premolar. If the thin cemental layer of the exposed root surface is lost, dentin hypersensitivity can develop.

Loss of enamel or cementum can expose dentin gradually or suddenly as in tooth fracture. As a result of the lower mineral content of cementum and dentin compared with enamel, demineralization occurs more rapidly and at a lower critical pH. Acute hypersensitivity may occur with sudden dentin exposure since gradual exposure allows for the development of natural desensitization mechanisms such as smear layer or sclerosis. After many years, secondary or tertiary/reparative dentin may form, which also protects the pulp.

A. Factors Contributing to Gingival Recession and Subsequent Root Exposure The occurrence of gingival recession has a multifactorial etiology. Potential causes include:

Effects of improper oral self-care: Use of a medium- or hard-bristle toothbrush. Frequent, long-term aggressive use of the toothbrush and/or other oral hygiene devices. An anatomically narrow zone of attached gingiva is more susceptible to abrasion. Facial orientation of one or more teeth. A tight and short labial or buccal frenum attachment that pulls on gingival tissues during oral movement. Scaling and root debridement procedures that result in gingival tissue shrinkage. Subgingival instrumentation involving excessive scaling and debridement in shallow sulci.5 Tissue alteration due to apical migration of junctional epithelium from periodontal diseases. Periodontal surgical procedures can alter the architecture of gingival tissues resulting in recession. Surgical procedures such as crown lengthening, repositioning of gingival tissues, or tooth extractions can affect gingival coverage of adjacent teeth. Orthodontic tooth movement may result in loss of periodontal attachment. Restorative procedures, such as crown preparation, that abrade marginal gingival tissues. Metal jewelry used in an oral piercing of the lip or tongue that repeatedly traumatizes the adjacent facial or lingual gingival tissue.

B. Factors Contributing to Loss of Enamel and Cementum Loss of tooth structure rarely develops from a single cause but rather from a combination of contributing factors. Cementum at the cervical area is thin and easily abrades when exposed. Enamel and cementum do not meet at the cementoenamel

junction in about 5–10% of teeth, leaving an area of exposed dentin.

C. Attrition, Abrasion, and Erosion Attrition can occur due to parafunctional habits such as bruxing. Effects of attrition and abrasion are exacerbated when acid erodes the tooth surface or when the tooth is brushed immediately after consumption of acidic foods and beverages. Hypersensitivity may be a clinical outcome of erosion.6 Erosion can occur from dietary acids, such as citrus fruits/juices, wine, and carbonated drinks.7 Dietary acid intake results in an immediate drop in oral pH; after normal salivary neutralization, a physiologic pH of 7 reestablishes within minutes. Frequent acid consumption is a critical factor; holding or “swilling” of acidic agents, holding low pH foods such as citrus fruits against teeth, or continual snacking increases erosion risk. Gastric acids from conditions such as gastric reflux, morning sickness, or self-induced vomiting (bulimia) repeatedly expose teeth to a highly acidic environment.

D. Abfraction Abfraction, a wedge-shaped cervical lesion, has a questionable etiology.8–11 A cervical lesion caused by lateral/occlusal stresses or tooth flexure from bruxing. Microscopic portions of the enamel rods chip away from the cervical area of the tooth resulting in loss of tooth structure (Figure 41-3).

FIGURE 41-3 • Process of Abfraction. Lateral occlusal forces stress the enamel rods at the cervical area, resulting in enamel rod fracture over time. In an advanced stage, a wedge- or V-shaped cervical lesion is visible. Although minute cracks in the enamel rods may not be clinically evident, the tooth can exhibit hypersensitivity.

Lesion appears as a wedge- or V-shaped cervical notch. A cofactor with abrasion for loss of tooth structure and potential sensitivity.

E. Other Factors Crown preparation procedures that remove enamel or cementum can expose dentin at the cervical area. Instrumentation during scaling or root debridement procedures on thinning cementum. Frequent or improper stain-removal techniques, in which abrasive particles wear away the cementum and dentin. Root surface carious lesions. Removal of proximal enamel using a sandpaper disk or strip to create additional space for orthodontic movement of crowded teeth, also known as “enamel stripping.”

III. Hydrodynamic Theory Hydrodynamic theory is a currently accepted explanation for transmission of stimuli from the outer surface of the dentin to the pulp. Described by Brännström in the 1960s,12 who theorized that a stimulus at the outer aspect of dentin will cause fluid movement within the dentinal tubules. Fluid movement creates pressure on the nerve endings within the dentinal tubule, which transmits the pain impulse by stimulating the nerves in the pulp. Credibility for this theory is supported by the greater number of widened dentin tubules seen in hypersensitive teeth compared with

nonsensitive teeth.2 Figure 41-4 depicts open dentinal tubules at the microscopic level. Figure 41-5 depicts partially occluded dentinal tubules.

FIGURE 41-4 • Open Dentin Tubules. Note cross-section and transverse views of tubules. (Courtesy of Dr. Sheldon Newman.)

FIGURE 41-5 • Partially Occluded Dentin Tubules. These dentin tubules are nearly filled. (Courtesy of Anthony Giuseppetti.)

NATURAL DESENSITIZATION Hypersensitivity can decrease naturally over time, even without treatment interventions. These mechanisms include the following:

I.

Sclerosis of Dentin Occurs by mineral deposition within tubules as a result of traumatic stimuli, such as attrition or dental caries. Creates a thicker, highly mineralized layer of intratubular or peritubular dentin (deposited within the periphery of the tubules). Results in a smaller-diameter tubule that is less able to transmit stimuli through the dentinal fluid to the nerve fibers at the dentinopulpal interface.

II.

Secondary Dentin Deposited gradually on the floor and roof of the pulp chamber after the apical foramen is completed. Formed more slowly than primary dentin; both types of dentin are created by odontoblasts. Creates a “walling off” effect between the dentinal tubules and the pulp to insulate the pulp from dentin fluid disturbances caused by a stimulus such as dental caries. With aging, secondary dentin accumulates, resulting in a smaller pulp chamber with fewer nerve endings and less sensitivity.

III. Smear Layer Consists of organic and inorganic debris that covers the dentinal surface and the tubules.13 Accumulates following scaling and root instrumentation, use of toothpaste (abrasive particles), cutting with a bur, attrition, or

abrasion. Occludes the dentinal tubule orifices, forming a “smear plug” or a natural “bandage” that blocks stimuli. The nature of the smear layer changes constantly since it is subject to effects such as mechanical disruption from ultrasonic debridement, or dissolution from acid exposure.

IV. Calculus Provides a protective coating to shield exposed dentin from stimuli. Postdebridement sensitivity can occur after removal of heavy calculus deposits; dentinal tubules may become exposed as calculus is removed.

THE PAIN OF DENTIN HYPERSENSITIVITY Individuals react differently to pain based on factors such as age, gender, situation and context, previous experiences, pain expectations, and other psychological and physiological parameters.

I.

Patient Profile

The prevalence of reported hypersensitivity varies due to differences in the stimulus, and whether data are gathered by patient report or standardized clinical examination. Patient accounts may not represent true hypersensitivity since the pain can be confused with other conditions.

A. Prevalence of Hypersensitivity Current systematic review articles reveal a global prevalence of dental hypersensitivity to be between 3% and 65% with most populations ranging from 10% to 30%.14–16 Most commonly found among 30- to 40-year-olds.14,15 Higher prevalence has been reported in periodontally involved populations.14,16 Incidence and severity decline with advancing age due to the effects of sclerosis and secondary dentin.14 Gingival recession is more prevalent with aging.18 However, dentinal hypersensitivity is not more prevalent with aging. Hypersensitivity, when measured objectively, occurs more often in women.14,17

B. Teeth Affected Hypersensitivity has been reported to occur primarily at the cervical one-third of the facial surfaces of premolars and mandibular anterior teeth,19 or on premolars and molars.14

Can occur on any tooth exhibiting predisposing factors.

II.

Pain Experience

A. Neural Activity Stimuli that affect the fluid flow within the dentinal tubules can activate the terminal nerve endings near to or surrounding the dentinal tubules; activation of these nerve fibers elicits the pain response. Occurs via the depolarization/neural discharge mechanism that characterizes all nerve activity. The sodium–potassium pump depolarizes the nerve as potassium leaves the nerve cell and sodium enters it.

B. Pain Perception The degree of pain is not always proportional to the amount of recession, the percentage of tooth structure loss, or to the quality or quantity of stimulus. Individuals experience the subjective phenomenon of pain differently. Many diverse variables such as stress, fatigue, and health beliefs can impact pain perception.

C. Impact of Pain Hypersensitivity can manifest as acute or chronic pain; acute pain may result in anxiety, whereas chronic pain may contribute to depression. Stress may exacerbate the pain response. Persistent discomfort from dentin hypersensitivity may affect quality of life.

DIFFERENTIAL DIAGNOSIS Etiology of pain can be systemic, pulpal, periapical, restorative, degenerative, or neoplastic. A differential diagnosis can rule out other causes of pain before treating for hypersensitivity. Skilled interviewing and diagnostics contribute to the differential diagnosis. Components to consider in the differential diagnosis of tooth pain are detailed in Table 41-1 TABLE 41-1 • Differential Diagnosis of Tooth Pain CONDITION

SIGNS AND SYMPTOMS

CLINICAL ASSESSMENT

Dentinal Thermal, mechanical, hypersensitivity evaporative, osmotic, chemical sensitivity Sharp, sudden, transient pain

Clinical examination: gingival recession and loss of tooth structure

Caries extending into dentin

Thermal sensitivity Pain on pressure Pain with sweets

Clinical examination Radiographic examination

Pulpal caries

Thermal sensitivity Severe, intermittent, or throbbing pain Pain on chewing

Clinical examination Radiographic examination

Fractured restoration

Thermal sensitivity Pain on pressure

Clinical examination

Fractured tooth

Thermal sensitivity Pain on pressure

Occlusal examination Transillumination

Recently placed restoration

Thermal sensitivity Pain on pressure

Dental history Clinical examination Occlusal examination

Occlusal trauma

Chemical sensitivity Thermal sensitivity Pain on pressure

Occlusal examination

Mobility Pulpitis

Severe, intermittent, throbbing pain

Thermal and electric pulp tests Percussion

Sinus infection

“Nondescript” tooth pain Nasal congestion (drainage) Sinus pressure Headache

Clinical examination, including extraoral sinus palpation Radiographic examination

Galvanic pain

Sudden, sharp stabbing pain on tooth-to-tooth contact

Examination for contact between restoration of dissimilar nonprecious metals

Periodontal ligament inflammation

Pain on chewing Clinical examination, including palpation for apical tenderness

Percussion

Abfraction

“Cratered” areas of enamel or dentin at cementoenamel junction in the shape of a wedge- or V-shaped notch

Clinical examination Occlusal examination

I.

Differentiation of Pain Hypersensitivity pain elicited by a non-noxious stimulus, such as cold water, can mimic pain elicited by a noxious agent, such as cavitated dental caries. The pain of hypersensitivity subsides when the stimulus is removed. It is difficult to distinguish between the pain of hypersensitivity and other causes of dental pain when both are in the mild-to-moderate range. Many types of dental pain can be intensified by thermal, sweet, and sour stimuli. Chewing pain (occlusal pressure) can be indicative of pulpal pathology. Pulpal pain is severe, intermittent, and throbbing. The pain results from deep dental caries, pulpal inflammation, vertical tooth fracture, or infection, and may occur without provocation and persist after

stimulus is removed.

II.

Data Collection by Interview Utilize direct, open-ended, and nonleading questions. Establish the location, degree of pain, onset/duration, source of stimulus, intensity, and alleviating factors related to the painful response; patients may have difficulty characterizing the pain. Ask trigger questions as suggested in Box 41-1 to elicit detailed information to characterize the pain and assist in the dental hygiene diagnosis.

BOX 41-1 Trigger Questions for Data Collection • Which tooth or teeth surfaces is/are sensitive? • On a scale from 1 to 10, with 10 being the most painful, what is your pain intensity? • How long does the pain last? • Which words best describe the pain: sharp, dull, shooting, throbbing, persistent, constant, pressure, burning, intermittent? • Does it hurt when you bite down (pressure)? • On a scale from 1 to 10, with 10 being a major impact, how much does the pain impact your daily life? • Is the pain stimulated by certain foods? Sweet? Sour? Acidic? • Does sensitivity occur with hot or cold food or beverages? • Does discomfort stop immediately upon removal of the painful stimulus, such as cold food or beverage, or does it linger? • Have you used whitening products lately?

Establish rapport, combined with effective listening and counseling skills, to develop collaborative treatment/management strategies. Record a thorough dental history, including pain chronology, nature, location, aggravating and alleviating factors, and history of dental treatment/restorations.

III. Diagnostic Techniques and Tests When patients have difficulty describing and localizing their pain, the following diagnostic techniques and tests can aid in differentiating among the numerous causes of tooth pain. Visual assessment of tooth integrity and surrounding tissues. Palpation of extra- and intraoral soft tissues. Evaluation of nasal congestion, drainage, or sinus expressed as tooth pain. Occlusal examination with use of marking paper to detect a premature contact or hyperfunction following placement of a new restoration. Radiographic assessment to determine signs of pulpal pathology, vertical tooth fracture, or other irregularities of the teeth or surrounding structures. Percussion with use of an instrument handle to lightly tap on each tooth. A pain response may indicate pulpitis. Mobility testing may detect trauma or periodontal pathology. Pain from biting pressure with use of a bite stick to assess pain indicative of tooth fracture. Transillumination with a high-intensity, focused light to enhance visualization of a cracked tooth; dye may also indicate a fracture line. Pulpal pathology assessment with thermal or electric pulp tests.

HYPERSENSITIVITY MANAGEMENT When the differential diagnosis indicates dentinal hypersensitivity, the dental hygiene care plan includes further assessment and patient counseling combined with treatment interventions.

I.

Assessment Components Determine extent and severity of pain. Solicit a self-report of symptoms, including the eliciting stimuli. Quantify and record the baseline pain intensity using objective measures such as the visual analog scale (VAS) and/or the verbal rating scale (VRS), as described in Box 41-2.

BOX 41-2 Subjective Pain Assessment Form Name: ______________ Date: _______________ Teeth: _______________ VAS—Visual Analog Scale Please place an “X” on the line at a position between the two extremes to represent the level of pain that you experience.

VRS—Verbal Rating Scale 0 = No discomfort/pain, but aware of stimulus 1 = Slight discomfort/pain 2 = Significant discomfort/pain 3 = Significant discomfort/pain that lasted more than 10 seconds

Determine if oral self-care procedures contribute to loss of gingiva

or tooth structure. Use a diet analysis to assess the frequency of acidic food and beverage intake; correlate intake with timing of toothbrushing. Explore parafunctional habits, such as bruxing, that may contribute to abfraction and attrition.

II.

Educational Considerations Provide education regarding etiology and contributing factors. Explain the natural mechanisms for resolution of hypersensitivity over time. Discuss realistic oral self-care measures that the patient is likely to maintain and include technique demonstrations. Utilize effective communication and motivational interviewing skills to promote compliance and to decrease patient anxiety (see Chapter 24).

III. Treatment Hierarchy There are two basic treatment goals: Pain relief. Modification or elimination of contributing factors. Address mild-to-moderate pain with conservative approaches or agents; more severe pain may require an aggressive approach. Sequence treatment approaches from the most conservative and least invasive measures to more aggressive modalities. Prognosis of pain resolution is difficult to predict due to variable success with different treatment options among individuals. Historically, a vast array of treatment approaches have been utilized with varying degrees of success; no one best method has been identified due to lack of quality randomized controlled trial data, difficulties inherent in dentin hypersensitivity research design, and a significant placebo effect. A trial-and-error approach may be necessary to determine the most effective treatment option.

Characteristics of an ideal desensitizing agent are listed in Box 41-3 and can be useful evaluation criteria when selecting a desensitizing agent.

BOX 41-3 The Ideal Desensitizing Agent • • • • • • • • • •

Minimal application time. Easy application procedure. Does not endanger the soft tissues. Acceptable cost. Requires few dental appointments. Does not cause pulpal irritation or pain. Rapid and lasting effect. Causes no staining. Consistently effective. Acceptable taste.

Treatment options that include both oral self-care measures and professional interventions with the same objective of reducing hypersensitivity have a synergistic effect.

IV. Reassessment Evaluate treatment interventions. Allow sufficient time to elapse (2–4 weeks) to evaluate effectiveness of treatment recommendations; assess and reinforce behavioral changes. Repeat the VAS and/or the VRS to compare changes in pain perceptions from baseline. If pain persists, a different option may provide relief.

ORAL HYGIENE CARE AND TREATMENT INTERVENTIONS I. Mechanisms of Desensitization Desensitization agents and oral self-care measures disrupt the pain transmission as described by the hydrodynamic theory in one of two ways15: Prevent nerve depolarization that interrupts the neural transmission to the pulp. This physiologic process is the mechanism of action for potassium-based products.20 Prevent a stimulus from moving the tubule fluid by occlusion of dentin tubule orifices or reduction in tubule lumen diameter.

II.

Behavioral Changes Encourage habits that allow tubules to remain occluded or that occlude patent tubules. Use a motivational interviewing approach (Chapter 24) to help the patient commit to appropriate oral hygiene self-care and dietary habits before or in conjunction with self-applied or professionally applied desensitizing agents. Educate the patient that some products may take 2–4 weeks to decrease sensitivity.

A. Dietary Modifications Have patient analyze acidic food and beverage habits that incite pain from dissolution of the smear layer, which covered open dentinal tubules.21 Examples include citrus fruits and juices, acidic carbonated beverages, sharp flavors and spices, pickled foods, wines, and ciders. Counsel patient regarding change in dietary habits. Help patient determine if brushing is sequenced immediately after

consuming acidic foods and beverages. Advise altering sequence to eliminate combined effects of erosion and abrasion, which can accelerate tooth structure loss.22 Guide patient toward mouthrinses with a nonacidic formulation. Provide professional treatment referrals for patients with eating disorders such as bulimia or systemic conditions such as acid reflux that repeatedly create an acidic oral environment. The acidic environment created by bulimia and acid reflux can be neutralized by rinsing with water (particularly fluoridated water) or an alkaline rinse such as bicarbonate of soda in water. Counsel patient to eliminate or reduce extremes of hot and cold foods and beverages to avoid discomfort.

B. Dental Biofilm Control In the presence of dental biofilm, the dentinal tubule orifices increase to three times the original size; with reestablishment of biofilm control measures, there is a 20% decrease in size.23 The presence/amount of dental biofilm on exposed root surfaces does not directly correlate with the degree of dentin sensitivity,17 suggesting biofilm composition may be a factor.

C. Eliminate Parafunctional Habits Help patient assess bruxing and clenching behaviors and whether additional treatment is indicated. Determine need for occlusal adjustments to eliminate abfractive forces. Coach patient to monitor occurrence of subconscious parafunctional behaviors and levels of stress. Identify whether stress reduction protocols are needed. Introduce behavior modification techniques and refer when needed.

D. Toothbrush Type and Technique

Brush one or two teeth at a time with a soft or ultrasoft toothbrush, rather than using long, horizontal strokes over several teeth to prevent further recession and loss of tooth structure. Identify brushing sequence and adjust by beginning in least sensitive areas and ending with more sensitive areas. In the initial phases of brushing, toothbrush filaments are stiffer and brushing is more aggressive. Explore option of brushing with the nondominant hand, if dexterity permits; nondominant hand exerts less pressure than the dominant hand. Help patient investigate current toothbrush grip. Adjust to a modified pen grasp rather than a traditional palm grasp to reduce the amount of pressure applied. Explore receptivity to use of a power toothbrush because it removes dental biofilm effectively with less than half the pressure of a manual toothbrush; an individual using a manual toothbrush typically exerts 200–400 g of pressure; 70–150 g of pressure is usually exerted with a power toothbrush.24 Some power toothbrushes have a self-limiting mechanism to reduce filament action if too much pressure is applied. Recommend and demonstrate dental biofilm control measures that are meticulous, yet gentle, and do not contribute to abrasion of hard or soft tissues.

III. Desensitizing Agents There are study design challenges when researching desensitization due to subjectivity of the pain response, the strong placebo effect, and the process of natural desensitization. Despite widespread professional recommendation and use, there is little in vivo scientific evidence validating the efficacy and mechanisms of action of desensitizing agents. Randomized controlled trials (RCTs) are needed to support professional recommendation and treatment. The exception is fluoride, with a substantial body of knowledge validating its

usefulness as a desensitizing agent. Desensitizing agents can be categorized according to their mechanisms of action, either depolarization of the nerve or occlusion of the dentinal tubule. Potassium salts are the only agents that are theorized to work by depolarization.

A. Potassium Salts Formulations containing potassium chloride, potassium nitrate, potassium citrate, or potassium oxalate reduce depolarization of the nerve cell membrane and transmission of the nerve impulse.22 Potassium nitrate dentifrices containing fluoride are widely used20 and readily available over the counter.

B. Fluorides Precipitate calcium fluoride (CaF2) crystals within the dentinal tubule to decrease the lumen diameter.22 Create a barrier by precipitating CaF2 at the exposed dentin surface to block open dental tubules.25 Fluoride varnishes are Food and Drug Administration (FDA)approved for tooth desensitization and a cavity liner, although they are frequently used “off-label” for dental caries prevention. Fluoride gels and varnishes are most commonly used and are a successful treatment modalilty.26,27

C. Oxalates Block open dental tubules.28 Oxalate salts such as potassium oxalate and ferric oxalate precipitate calcium oxalate crystals to decrease the lumen diameter.28

D. Glutaraldehyde

Coagulates proteins and amino acids within the dentinal tubule to decrease the dentinal tubule lumen diameter.28 Can be combined with hydroxyethylmethacrylate, a hydrophilic resin, which seals tubules.28 Creates calcium crystals within the dentinal tubule to decrease the lumen diameter.29

E. Calcium Phosphate Technology Advocated for use as a caries control agent to reduce demineralization and increase remineralization by releasing calcium and phosphate ions into saliva for deposition of new tooth mineral (hydroxyapatite).30 Calcium phosphates can compromise the bioavailability of fluorides since calcium and fluoride react to form calcium fluoride.31 May be effective for patients with poor salivary flow and consequent deficient calcium phosphate levels.32 Agents that support remineralization may lessen dentinal hypersensitivity by occluding dentinal tubule openings. Most studies in support of calcium phosphate technology are animal, in vitro, or in situ models designed to analyze remineralization rather than hypersensitivity. One in vivo study found a reduction in bleaching-induced sensitivity at days 5 and 14 when amorphous calcium phosphate (ACP) was added to a bleaching gel.33 Additional research related to calcium phosphate technologies is needed.34 ACP Theorized to plug dentinal tubules with calcium and phosphate precipitate; promotes an ACP reservoir within the saliva. Enhances fluoride delivery in calcium- and phosphate-deficient saliva.32 May remineralize areas of acid erosion and abrasion and reduce hypersensitivity.32

Calcium sodium phosphosilicate (CSP) Contains sodium and silica in addition to calcium and phosphorus. Delivered in solid bioactive glass particles that react in the presence of saliva and water to release calcium and phosphate ions and create a calcium phosphate layer that crystallizes to hydroxyapatite. Reacts with saliva; sodium buffers the acid, and calcium and phosphate saturate saliva to fill demineralized areas with new hydroxyapatite. Claims include remineralizing enamel and dentin, positive impact on acid erosion and abrasion, a bactericidal effect, and reduction in hypersensitivity. RCT comparing a CSP and a potassium nitrate toothpaste found, using a VAS, that CSP paste was significantly better at reducing dentin hypersensitivity.35 Casein phosphopeptide (CPP)–ACP CPP is a milk-derived protein that stabilizes ACP and allows it to be released during acidic challenges. Researchers are exploring benefits such as remineralization of acid erosion, caries inhibition, and reduction of dentinal hypersensitivity. Tricalcium phosphate (TCP) Developed in an effort to create a calcium material that can coexist with fluoride to provide greater efficacy than fluoride alone.32 Additional components are added to β-TCP to “functionalize” it. Increased remineralization has been demonstrated in vitro36; in vivo evidence is needed.

IV. Self-Applied Measures A. Dentifrices In many OTC sensitivity-reducing dentifrices, 5% potassium nitrate, sodium fluoride, or stannous fluoride separately or in combination

are the active desensitizing agents. Studies have suggested that some of the desensitizing effects of dentifrices may be due to the blocking action of the abrasive particles.22 Tartar control dentifrices may contribute to increased tooth sensitivity for some individuals, although the mechanism is unclear. Dentifrices containing highly concentrated fluoride (5,000 ppm fluoride) combined with an abrasive to facilitate extrinsic stain control are available by prescription. This formulation is also available with the addition of potassium nitrate.

B. Gels Gels containing 5,000 ppm fluoride are a prescription product brushed on for generalized hypersensitivity or burnished into localized areas of sensitivity. Contain no abrasive agents for biofilm and stain control. Can be self-applied with custom or commercially available fluoride or whitening trays.

C. Mouthrinses Mouthrinse containing 0.63% stannous fluoride mouthrinse can be prescribed for daily use to treat hypersensitivity. Short-term use (2–4 weeks) will limit staining concerns.

V.

Professionally Applied Measures

A. Tray-Delivered Fluoride Agents A tray delivery system can be used to apply a 2% neutral sodium fluoride solution. Select trays of adequate height and fill with sufficient fluoride agent to cover the cervical areas of each tooth.

B. Fluoride Varnish

A 5% sodium fluoride varnish maintains prolonged contact with the tooth surface by serving as a reservoir to release fluoride ions in response to pH changes in saliva and biofilm.37 Does not require a dry tooth surface, which is advantageous since drying the tooth can be a painful procedure for a patient with dentin hypersensitivity. Use a microbrush to apply the varnish to the exposed dentin surface. Instruct the patient to avoid oral hygiene self-care for several hours to allow the fluoride to stay in contact with the tooth surface for as long as possible, preferably overnight.

C. 5% Glutaraldehyde Use a microbrush to apply to the affected tooth surface. Prevent excess flow into soft tissues with cotton roll isolation since contact with soft tissues may cause gingival irritation.

D. Oxalates Oxalate preparations are applied (burnished) to a dried tooth surface. May provide immediate and short-term relief, rather than long-term relief.

E. Unfilled or Partially Filled Resins Used to cover patent dentinal tubules. Resins are applied following an acid etch step that may remove the smear layer and cause discomfort. The tooth surface must be dehydrated before resin application, which can create discomfort. Use of local anesthetic may facilitate patient comfort during this procedure.

F. Dentin-Bonding Agents Obturates the tubule opening and does not require use of acid etch or dehydration; a single application may protect against further erosion for 3–6 months. Methylmethacrylate polymer is a common dentin sealer.

G. Glass Ionomer Sealants/Restorative materials Glass ionomer may be placed in the presence of moisture, which eliminates the need for drying the tooth. In addition to the glass ionomer restoration physically blocking the dentinal tubule, there is an added benefit of slow fluoride release.

H. Soft-Tissue Grafts Surgical placement of soft-tissue grafts to cover a sensitive dentinal surface.

I. Lasers Nd:YAG laser treatment can obliterate dentinal tubules through a process called “melting and resolidification.” When used with an appropriate protocol, there is no resulting damage to the pulp or dentin surface cracking.38,39 Low-level diode laser treatments have shown a reduction in dentinal hypersensitivity, but the exact mechanism of action is unclear.40 Diode laser treatments combined with sodium fluoride varnish application have shown an immediate decrease in sensitivity.41 Long-term, in vivo studies are needed to establish safety and efficacy of laser treatment for dentin hypersensitivity. The FDA has not approved these devices for this therapeutic modality.

VI. Additional Considerations A. Periodontal Debridement Considerations Preprocedure Explain potential for sensitivity resulting from calculus removal and/or instrumentation of teeth with areas of exposed cementum or dentin. Patients are likely to respond more favorably to treatment when prepared for what might occur. When multiple teeth in the same treatment area are hypersensitive during scaling and root planing procedures, local anesthetics and/or nitrous oxide analgesia can be utilized. Desensitizing agents that are marketed for immediate relief from severe hypersensitivity can be used. Postprocedure Professionally applied desensitization agents can be used. Patient is instructed in daily oral health behavior changes and use of self-applied desensitizing agents.

B. Tooth Whitening–Induced Sensitivity Tooth whitening agents, such as hydrogen peroxide and carbamide peroxide, may contribute to increased dentinal hypersensitivity. Thought to result from by-products of 10% carbamide peroxide (3% hydrogen peroxide and 7% urea) readily passing through the enamel and dentin into the pulp; the reversible pulpitis is caused from the dentin fluid flow and pulpal contact of the hydrogen peroxide without apparent harm to the pulp.42 Hypersensitivity may dissipate over time, lasting from a few days to several months. Exposed dentin and preexisting dentin hypersensitivity increase hypersensitivity risk secondary to whitening. Some whitening products contain fluoride or potassium nitrate to eliminate or minimize the effects of sensitivity. Recommendations outlined in Chapter 43 to prevent or reduce

tooth whitening–induced sensitivity include: Use of a potassium nitrate, fluoride, or other desensitization product before or concurrently with whitening. Some take home whitening gels incorporate, 5% potassium nitrate, fluoride, and ACP. Home-use whitening products are usually less concentrated than professionally applied in-office treatment options, with less hypersensitivity risk. Allow for a “recovery period” between whitening sessions during which desensitizing agents are used. Decrease frequency of use by whitening every second or third day.

C. Research Developments The search for the ideal desensitizing agent is ongoing. Evidence-based scientific research indicated as new products are developed; in vivo research protocols are needed to support clinical application.

DOCUMENTATION The permanent record for a patient with a history of tooth sensitivity needs to include at least the following information: Medical and dental history, vital signs, extra- and intraoral examinations, consultations, and individual progress notes for each appointment and maintenance appointments. For dentin hypersensitivity: identify teeth involved (including measurements of recession, attached gingiva, abfractions, and attrition), differential diagnosis, and all treatments, along with patient instruction for ideal oral self-care, diet, and other for preventive recommendations. Outcomes and posttreatment directions. A progress note example for the patient with hypersensitive dentin may be reviewed in Box 41-4.

BOX 41-4 Example Documentation: Patient with Dentinal Hypersensitivity S—Patient complains of pain when eating/drinking cold foods/beverages that disappears immediately after. O—Generalized facial gingival recession of 1–2 mm on all teeth in the mandibular arch. A—Based on patient symptoms, exposed roots, and no other evidence of dental disease, the working diagnosis is dentinal hypersensitivity. P—Applied fluoride varnish and gave postoperative instructions; advised patient to avoid acidic beverages; or not to brush immediately after ingestion of citrus fruits or beverages; also advised to rinse with fluoridated water to buffer acidic conditions (to raise pH). Recommended purchase and use of an OTC potassium nitrate–containing dentifrice. Explained that relief from the dentifrice can take between 2 and 4 weeks. Advised to contact the office if pain persists or worsens. Next Steps: Follow-up at next visit. Signed: ______________________________, RDH Date: ____________________________________

EVERYDAY ETHICS Marcy, the dental hygienist, practices with Dr. Goldman, who only schedules time to examine a patient at alternate dental hygiene visits unless requested for special needs. Mrs. Stuart arrives for her dental hygiene appointment but is not scheduled to see Dr. Goldman until her next visit. She is complaining of discomfort “on the lower back teeth” when she chews and when she eats or drinks something cold. The pain may last up to an hour. When she completes the scaling and debridement, Marcy determines that Dr. Goldman is running behind schedule. She knows it will be difficult to get him to come to her treatment room to examine her patient in a timely manner. Marcy gives Mrs. Stuart a sample of desensitizing toothpaste and suggests they will see how it is at the next appointment. Marcy then advises Mrs. Stuart to “Call if it gives you more trouble.” The patient is not classified as having a periodontal condition, but is considered low-to-medium risk for dental caries. Her next visit will be in 4 months. Questions for Consideration 1. How do each of the core values (Table II-1, Section II Introduction) apply in this event? Does the issue of informed consent enter this discussion? Explain why or why not. 2. What ethical issues can arise if Marcy and Dr. Goldman do not take time during this appointment to thoroughly assess Mrs. Stuart’s situation to establish a differential diagnosis? 3. Answer the questions provided in the “Questions to Ask” column of Table VI-1 (Section VI Introduction) to determine at least two ethical alternative actions Marcy could have taken.

Factors to Teach the Patient Etiology and prevention of gingival recession. Factors contributing to dentin hypersensitivity. Mechanisms of dentin tubule exposure, which can allow various stimuli to trigger pain response. Natural desensitization mechanisms that may lessen sensitivity over time. Appropriate oral hygiene self-care techniques, such as using a soft toothbrush and avoiding a vigorous brushing technique that may contribute to gingival recession and subsequent abrasion of root surfaces. Connection between an acidic diet and dentin sensitivity; need to eliminate specific foods and beverages that can trigger sensitivity.

Toothbrushing is not recommended immediately after consumption of acidic foods or beverages. Behavior modifications or treatments for eliminating parafunctional habits. The challenges of managing hypersensitivity, hierarchy of treatment measures, and variable effect of treatment options.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Addy M. Etiology and clinical implications of dentine hypersensitivity. Dent Clin North Am. 1990;34(3):503-514. 2. Absi EG, Addy M, Adams D. Dentine hypersensitivity: the development and evaluation of a replica technique to study sensitive and non-sensitive cervical dentine. J Clin Periodontol. 1989;16(3):190-195. 3. Frank RM. Attachment sites between the odontoblast process and the intradental nerve fibre. Arch Oral Biol. 1968;13(7):833-834. 4. Thomas HF, Carella P. Correlation of scanning and transmission electron microscopy of human dentinal tubules. Arch Oral Biol. 1984;29(8):641-646. 5. Dufour LA, Bissell HS. Periodontal attachment loss induced by mechanical subgingival instrumentation in shallow sulci. J Dent Hyg. 2002;76(3):207-212. 6. Absi EG, Addy M, Adams D. Dentine hypersensitivity: the effect of toothbrushing and dietary compounds on dentine in vitro. J Oral Rehabil. 1992;19(2):101-110. 7. Prati C, Montebugnoli L, Supp P, et al. Permeability and morphology of dentin after erosion induced by acidic drinks. J Periodontol. 2002;74(4):428-436. 8. Staninec M, Nalla RK, Hilton JF, et al. Dentin erosion simulation by cantilever beam fatigue and pH change. J Dent Res. 2005;84(4):371-375. 9. Litonjua LA, Andreana S, Bush OJ, et al. Wedged cervical lesions produced by toothbrushing. Am J Dent. 2004;17(4):237-240. 10. Estafan A, Furnari PC, Goldstein G, et al. In vivo correlation of noncarious cervical lesions and occlusal wear. J Prosthet Dent. 2005;93(3):221-226. 11. Sarode GS, Sarode CS. Abfraction: a review. J Oral Maxillofac Pathol. 2013;17(2):222-227. 12. Brännström M, Linden LA, Astrom A. The hydrodynamics of the dental tubule and of pulp fluid: a discussion of its significance in relation to dentinal sensitivity. Caries Res. 1967;1(4):310-317. 13. Eldarrat AH, High AS, Kale GM. In vitro analysis of “smear layer” on human dentine using ac-impedance spectroscopy. J Dent. 2004;32(7):547-554. 14. Splieth CH, Tachou A. Epidemiology of dentin hypersensitivity. Clin Oral Invest. 2013;17(suppl 1):S3-S8. 15. Shiau HJ. Dentin hypersensitivity. J Evid Base Pract. 2012;12(suppl 1):220228. 16. Kim JW, Park JC. Dentin hypersensitivity and emerging concepts for treatments. J Oral Bio. 2017;59(4):211-217. 17. Mantzourani M, Sharma D. Dentine sensitivity: Past, present, and future. J Dent. 2013;41(suppl 4):S3-S17. 18. Kassaba MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent Assoc. 2003;134(2):220-225. 19. Gillam DG, Aris A, Bulman JS, et al. Dentine hypersensitivity in subjects recruited for clinical trials: clinical evaluation, prevalence and intraoral

distribution. J Oral Rehabil. 2002;29(3):226-231. 20. Orchardson R, Gillam DG. The efficacy of potassium salts as agents for treating dentin hypersensitivity. J Orofac Pain. 2000;14(1):9-19. 21. Correa FO, Sampaio JE, Rossa C, et al. Influence of natural fruit juices in removing the smear layer from root surfaces—an in vitro study. J Can Dent Assoc. 2004;70(10):697-702. 22. Orchardson R, Gilla DC. Managing dentin hypersensitivity. J Am Dent Assoc. 2006;137(7):990-998. 23. Kawasaki A, Ishikawa K, Sug T, et al. Effects of plaque control on the patency and occlusion of dentine tubules in situ. J Oral Rehabil. 2001;28(5):439-449. 24. Van Der Weijden GA, Timmerman MF, Reijerse E, et al. Toothbrushing force in relation to plaque removal. J Clin Periodontol. 1996;23(8):724-729. 25. Suge T, Ishikowa K, Kawasaki A, et al. Effects of fluoride on the calcium phosphate precipitation method for dentinal tubule occlusion. J Dent Res. 1995;74(4):1079-1085. 26. Ritter AV, de L Dias W, Miguez P, et al. Treating cervical dentin hypersensitivity with fluoride varnish: a randomized clinical study. J Am Dent Assoc. 2006;137(7):1013-1020. 27. Cunha-Cruz J, Wataha JC, Zhou L, et al. Treating dentin hypersensitivity, therapeutic choices made by dentists of the Northwest PRECEDENT network. J Am Dent Assoc. 2010;141(9):1097-1105. 28. Haywood VB. Dentine hypersensitivity: bleaching and restorative considerations for successful management. Int Dent J. 2002;52(suppl 1):376. 29. Pashley DH, Kalathoor S, Burnham D. The effects of calcium hydroxide on dentin permeability. J Dent Res. 1986;65(3):417-420. 30. Featherstone JD. The continuum of dental caries-evidence for a dynamic disease process. J Dent Res. 2004;83(Spec No C):C39-C42. Karlinsey RL, Mackey AC, Walker ER, et al. Surfactant-modified B-TCP: 31. structure, properties, and in vitro remineralization of subsurface enamel lesions. J Mater Sci Mater Med. 2010;21(4):2009-2020. 32. Chow L, Wefel JS. The dynamics of de-and remineralization. Dimensions Dent Hyg. 2009;7(2):42-46. 33. Giniger M, MacDonald J, Ziemba S, et al. The clinical performance of professionally dispensed bleaching gel with added amorphous calcium phosphate. J Am Dent Assoc. 2005;136(3):383-392. 34. Yengopal V, Mickenautsch S. Caries-preventive effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP): a meta-analysis. Acta Odontol Scand. 2009;21:1-12. 35. Pradeep AR, Sharma A. Comparison of clinical efficacy of a dentifrice containing calcium sodium phosphosilicate to a dentifrice containing potassium nitrate and to a placebo on dentinal hypersensitivity: a randomized clinical trial. J Periodontol. 2010;81(8):1167-1173. 36. Karlinsey RL, Mackey AC, Walker ER, et al. Preparation, characterization and in vitro efficacy of an acid-modified β-TCP material for dental hard-tissue remineralization. Acta Biomater. 2010;6(3):969-978.

37. Shen C, Autio-Gold J. Assessing fluoride concentration uniformity and fluoride release from 3 varnishes. J Am Dent Assoc. 2002;133(2):176-182. 38. Kara C, Orbak R. Comparative evaluation of Nd:YAG laser and fluoride varnish for the treatment of dentinal hypersensitivity. J Endod. 2009;35(7):971-974. 39. Lopes AO, Aranha ACC. Comparative evaluation of the effects of Nd:YAG laser and a desensitizer agent on the treatment of dentin hypersensitivity: a clinical study. Photomed Laser Surg. 2013;31(3):132-138. 40. Yilmaz H, Kurtulmus-Yilmaz S, Cengiz E. Long-term effect of diode laser irradiation compared to sodium fluoride varnish in the treatment of dentine hypersensitivity in periodontal maintenance patients: a randomized controlled clinical study. Photomed Laser Surg. 2011;29(11):721-725. 41. Corona S, Nascimento T, Catirse A, Lizarelli R, Dinelli W, Palma-Dibb R. Clinical evaluation of low-level laser therapy and fluoride varnish for treating cervical dentinal hypersensitivity. J Oral Rehabil. 2003;30(12):1183–1189. 42. Li Y, Greenwall L. Safety issues of tooth whitening using peroxide-based materials. Br Dent J. 2013;215(1):29-34.

42 Extrinsic Stain Removal Heather Doucette, DipDH, BSc, MEd

CHAPTER OUTLINE INTRODUCTION PURPOSES FOR STAIN REMOVAL SCIENCE OF POLISHING EFFECTS OF CLEANING AND POLISHING I. II. III. IV.

Precautions Environmental Factors Effect on Teeth Effect on Gingiva

INDICATIONS FOR STAIN REMOVAL I. II. III.

Removal of Extrinsic Stains To Prepare the Teeth for Caries-Preventive Procedures To Contribute to Patient Motivation

CLINICAL APPLICATION OF SELECTIVE STAIN REMOVAL

I. II.

Summary of Contraindications for Polishing Suggestions for Clinic Procedure

CLEANING AND POLISHING AGENTS I. II. III. IV. V.

Cleaning Agents Polishing Agents Factors Affecting Abrasive Action with Polishing Agents Abrasive Agents Cleaning Ingredients

PROCEDURES FOR STAIN REMOVAL (CORONAL POLISHING) I. II.

Patient Preparation for Stain Removal Environmental Preparation

THE POWER-DRIVEN INSTRUMENTS I. II. III. IV.

Handpiece Types of Prophylaxis Angles Prophylaxis Angle Attachments Uses for Attachments

USE OF THE PROPHYLAXIS ANGLE I. II.

Effects on Tissues: Clinical Considerations Prophylaxis Angle Procedure

AIR-POWDER POLISHING I. II. III. IV. V. VI.

Principles of Application Specially Formulated Powders for Use in Air-Powder Polishing Uses and Advantages of Air-Powder Polishing Technique Recommendations and Precautions Risk Patients: Air-Powder Polishing Contraindicated

POLISHING PROXIMAL SURFACES I. II.

Dental Tape and Floss Finishing Strips

THE PORTE POLISHER DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Describe the difference between a cleaning agent and a polishing agent. 2. Explain the basis for selection of the grit of polishing paste for each individual patient. 3. Discuss the rationale for avoiding polishing procedures on areas of demineralization. 4. Explain the effect abrasive particle shape, size, and hardness have on the abrasive qualities of a polishing paste. 5. Explain the types of powdered polishing agents available and their use in the removal of tooth stains. 6. Explain patient conditions that contraindicate the use of airpowder polishing.

INTRODUCTION After treatment by scaling, root debridement, and other dental hygiene care, the teeth are assessed for the presence of remaining dental stains. The cleaning or polishing agents used must be selected based on the patient’s individual needs such as the type, location, and amount of stain present. Preliminary examination of each tooth will reveal the surfaces to be treated may be tooth structure (enamel, or with recession, cementum or dentin) or when restored, a variety of dental materials (metal or esthetic, tooth-color restorations). Preservation of the surfaces of both the teeth and the restorations is of primary importance during all cleaning and polishing procedures. Stain removal requires the use of polishing agents with various abrasive grits. The smallest, least abrasive grit is used. Some patients will not consider their teeth “cleaned” unless they have been polished. This situation is ideal for a cleaning agent that will not abrade the dental hard tissues, but will remove dental biofilm and the patient’s teeth will have the same clean feeling as they would if an abrasive prophylaxis paste were used. Incorrect selection of a prophylaxis paste can worsen hypersensitivity and cause significant damage to esthetic restorations. The longevity, esthetic appearance, and smooth surfaces of dental restorations depend on appropriate care by the dental hygienist and the daily personal care by the patient. It is the responsibility of the dental hygienist to be current in knowledge of the procedures to prevent damage to the restorations during professional healthcare appointments.

PURPOSES FOR STAIN REMOVAL Stains on the teeth are not etiologic factors for oral disease. The removal of stains is for esthetic, not for therapeutic or health, reasons. The American Dental Hygienists’ Association and the Academy of Periodontology include tooth polishing in their definitions of the term “oral prophylaxis.”1,2

SCIENCE OF POLISHING Polishing is intended to produce intentional, selective and controlled wear. Within the science of tribiology, polishing is considered to be two-body abrasive polishing or three-body abrasive polishing.3 Two-body abrasive polishing involves the abrasive particles attached to a medium, such as a rubber cup impregnated with abrasive particles that does not require a prophylaxis polishing paste. Three-body abrasive polishing is the type most commonly used by dental hygienists, in which loose abrasive particles (the abrasive particles in prophylaxis polishing paste) move in the interface space between the surface being polished and the polishing application device (rubber cup or brush).4–6

EFFECTS OF CLEANING AND POLISHING Attention must be given to the positive and negative effects of polishing so evidence-based decisions can be made for the treatment of each patient.

I.

Precautions As with all gingival manipulation with instruments, including a toothbrush,7,8 bacteremia can be created during the use of powerdriven stain removal instruments. Rotation of the rubber cup can force microorganisms into the tissues. An inflammatory response can be expected, and bacteria may gain access to the bloodstream to create a bacteremia. This is a concern for an immunocompromised patient and for a patient who requires prophylactic antibiotic coverage before dental treatment. A thorough medical history is essential before all treatments and must be reviewed and updated at each succeeding appointment. Patients at risk, particularly those with damaged or abnormal heart valves, prosthetic valves, and other conditions listed in Chapter 11, may require antibiotic prophylaxis as specified by the patient’s cardiologist.

II.

Environmental Factors

A. Aerosol Production Aerosols are created during the use of all rotary instruments, including a prophylaxis handpiece with a rubber cup to hold polishing paste, the air and water sprays used during rinsing, and air polishing.9 The biologic contaminants of aerosols stay suspended for long periods and provide a means for disease transmission to dental

personnel, as well as to other patients. Use of power-driven instruments is limited when a patient is known to have a communicable disease, a serious or chronic respiratory disease, or is immunocompromised. Standard personal protective procedures are used.

B. Spatter Protective eyewear is needed for all dental team members and for the patient. Serious eye damage has occurred because of spatter from polishing paste or from instruments.10

III. Effect on Teeth A. Removal of Tooth Structure Polishing with coarse abrasive prophylaxis pastes may remove a few micrometer of the outer enamel. This is justification for using the least abrasive prophylaxis paste necessary to meet the patient’s needs. The fluoride-rich outer surface of the enamel is necessary for protection against dental caries11 and care must be taken to preserve it. The use of a cleaning agent in place of an abrasive prophylaxis polishing agent will not remove the outermost layer of enamel.

B. Areas of Demineralization Demineralization: Polishing demineralized white spots of enamel is contraindicated. More surface enamel is lost from abrasive polishing over demineralized white spots than over intact enamel.12 Remineralization: Demineralized areas of enamel can remineralize as these areas are exposed to fluoride from saliva, water, dentifrices, and professional fluoride applications. Polishing

procedures can interrupt enamel surface remineralization.

C. Areas of Thin Enamel, Cementum, or Dentin Areas of thin enamel are contraindicated for polishing. Amelogenesis imperfecta is an example of thin enamel resulting from imperfect tooth development (see Chapter 16). Exposure of dentinal tubules: Cementum and dentin are softer and more porous than enamel, so greater amounts of their surfaces can be removed during polishing than from enamel. Polishing of exposed cementum and dentin is contraindicated. Smear layer could be removed and dentinal tubules exposed13 resulting in tooth sensitivity.14

D. Care of Restorations and Implants Use of coarse abrasives may create deep, irregular scratches in restorative materials. Figure 42-1 shows a scanning electron photomicrograph of the damaged surface of a composite restoration polished with a rubber cup and coarse prophylaxis paste.

FIGURE 42-1 • Scanning Electron Photomicrograph of a Composite Restoration Polished with Coarse Prophylaxis Paste.

It is imperative that prophylaxis polishing agents are not used on restorative materials. Polishing pastes not intended for use on restorative materials can destroy the surface integrity of the dental material.15 Select a cleaning agent or a polishing agent recommended by the manufacturer of the restorative materials.15,16

E. Heat Production Steady pressure with a rapidly revolving rubber cup or bristle brush and a minimum of wet abrasive agent can create sufficient heat to cause pain and discomfort for the patient. The pulp chamber in the teeth of children are large and may be more susceptible to heat. The rules for the use of cleaning or polishing agents include: Use light pressure, slow speed of the rubber cup. Use a moist agent.

Cleaning or polishing agents are never to be used as dry powders applied directly on teeth.

IV. Effect on Gingiva Trauma to the gingival tissue can result, especially when the prophylaxis angle is operated at a high speed with heavy pressure and the rubber cup is applied for an extended period of time adjacent to gingival tissues. It may be best to delay stain removal after nonsurgical periodontal treatments (NSPTs) to allow for healing of the sulcular tissue. If selective polishing is required, it can be done at the reevaluation appointment following initial NSPT therapy.

INDICATIONS FOR STAIN REMOVAL I. Removal of Extrinsic Stains A. Patient Instruction Discuss source of stain and how it can be prevented. Encourage patient to make necessary habit changes, especially to seek counseling for smoking cessation if that is the cause of the patient’s stain. Tobacco cessation is described in Chapter 32. Practice toothbrushing to remove stains incorporated in dental biofilm. For example, educate the patient that careful dental biofilm removal when using chlorhexidine rinse can prevent and/or minimize stain accumulations. The less dental biofilm, the less chlorhexidine may stain the teeth.

B. Scaling and Root Debridement In addition to the use of cleaning or polishing agents during polishing procedures, stains can also be removed during scaling and root debridement instrumentation. Example: Black line stain has been compared to calculus because it may be elevated from the tooth surface and may need to be removed by instrumentation. It is described in Chapter 17.17

II.

To Prepare the Teeth for Caries-Preventive Procedures

A. Placement of Pit and Fissure Sealant Follow manufacturer’s directions. Sealants vary in their requirements.

Avoid commercial oral prophylaxis pastes containing glycerin, oils, flavoring substances, or other agents. Glycerin and oils can prevent an optimum acid-etch and interfere with the adherence of the sealant to the tooth surface, causing the sealant to fail. Air-powder polishing is one method of choice for preparing tooth surfaces for sealants (see Chapter 35).18,19 An alternative is the use of a plain, fine pumice mixed with water when precleaning is necessary. After the use of pumice, the tooth surface(s) needs to be rinse thoroughly to remove the particles.

III. To Contribute to Patient Motivation Removal of biofilm is a daily procedure to be carried out by the patient. When accomplished thoroughly at least twice daily and for some patients three times daily, infection can be controlled, the sanitation of the mouth maintained, and staining can be minimized or prevented. Motivation Smooth, polished tooth surfaces may contribute in part to the following effects: Help the patient to obtain more satisfactory results from oral selfcare procedures. A smooth surface can be easier to achieve once the patient understands what a biofilm and debris-free mouth feels like after having the teeth professionally polished with a cleaning or polishing agent. Show the patient the appearance and feeling of a clean mouth for motivational purposes. The change in behavior, or the true learning, can be obtained through patient participation in the use of a disclosing agent and personal visualization of the biofilm followed by removal of the biofilm with floss and toothbrush.

CLINICAL APPLICATION OF STAIN REMOVAL The decision to polish teeth is based on the individual patient’s needs.

I.

Summary of Contraindications for Polishing

The following list suggests some of the specific instances in which polishing either can be performed with a cleaning agent or is contraindicated.

A. No Unsightly Stain If no stain is present, polishing with an abrasive polishing agent is not necessary; however, this is an ideal situation for using a cleaning agent.

B. Patients with Respiratory Problems Polishing procedures typically require rinsing of the patient’s mouth several times throughout the procedure. Care is taken to minimize the spray from the air–water syringe as much as possible as the aerosols are contraindicated for such conditions as asthma, emphysema, cystic fibrosis, lung cancer, patients requiring oxygen, or when breathing is a problem. This caution also applies to the use of air-powder polishers and spatter from prophylaxis polishing pastes.

C. Tooth Sensitivity Abrasive agents can uncover ends of dentinal tubules in areas of thin cementum or dentin. The polishing of dentin and cementum is contrain-dicated.

D. Restorations

Restorations and titanium implants may be scratched by abrasive prophylaxis polishing pastes. Tooth-colored restorations need to be polished with a cleaning agent, a polishing paste specifically formulated for use on esthetic restorations, or the paste recommended by the manufacturer of the restorative material.15

E. Conditions That Require Postponement for Later Evaluation When instruction for personal biofilm removal (daily care) has not yet been given or when the patient has not demonstrated adequate biofilm control. Soft, spongy tissue that bleeds on brushing or gentle instrumentation. Communicable disease potentially disseminated by aerosol.

II.

Suggestions for Clinic Procedure

A. Provide Initial Education Daily dental biofilm removal to assist in dental stain control. Explain to the patient that drinking coffee, tea, red wine, and coloradded soft drinks and/or use of tobacco is responsible for most dental stains. Provide patients with information about the types of dentifrices that are safe for stain control and those contraindicated due to excessive abrasiveness or chemical harshness. Tobacco cessation introduction when stain is primarily from tobacco use (see Chapter 32).

B. Remove Stain by Scaling Whenever possible, stains can be removed during scaling and root debridement.

C. Stain Removal Techniques Cleaning agent or low-abrasion oral prophylaxis paste. Use the lightest pressure necessary for stain removal. Low-speed handpiece. Minimal heat production. Soft rubber cup at 90° to tooth surface with intermittent light applications.

CLEANING AND POLISHING AGENTS There are two distinct types of agents used for “polishing” teeth: one is a cleaning agent and the other is a polishing agent.20,21

I.

Cleaning Agents Unlike polishing agents, cleaning agents are round, flat, nonabrasive particles and do not scratch surface material but produce a higher luster than polishing agents. The most readily available cleaning agent (ProCare, Young Dental Mfg., Earth City, MO) is made of a combination of feldspar, alkali (sodium and potassium), and aluminum silicates. This feldspar, sodium–aluminum silicate cleaning agent is formulated into a powder and can be mixed with water or sodium fluoride to make a paste for cleaning.22,23 Because of the extremely low level of abrasion, cleaning agents can be used on any tooth surface, restorative surface, or implant surface without fear of creating deep scratches. Cleaning agents will not harm restorative surfaces, and any other polishing agent selected for restorative surfaces should be selected based on the formulation and appropriateness for the restorative material.24

II.

Polishing Agents Traditionally, abrasive agents have been applied with polishing instruments to remove extrinsic dental stains and leave the enamel surface smooth and shiny. Polishing agents act by producing scratches in the surface of the tooth or restoration created by the friction between the abrasive particle and the softer tooth or restorative surface. The cleaning and polishing process progresses from coarse abrasion to fine abrasion until the scratches are smaller than the

wavelength of visible light, which is 0.05 μm.24 When scratches of this size are created, the surface appears smooth and shiny—the smaller the scratches, the shinier the surface. Unless the abrasive agent has been specially formulated for esthetic restorative surfaces, the use of prophylaxis polishing pastes is contraindicated for application to any esthetic restorative surfaces.16,25

III. Factors Affecting Abrasive Action with Polishing Agents During polishing, sharp edges of abrasive particles are moved along the surface of a material, abrading it by producing microscopic scratches or grooves. The rate of abrasion, or speed with which structural material is removed from the surface being polished, is governed by hardness and shape of the abrasive particles, as well as by the manner in which they are applied.

A. Characteristics of Abrasive Particles Shape: Irregularly shaped particles with sharp edges produce deeper grooves and thus abrade faster than do rounded particles with dull edges. Hardness: Particles must be harder than the surface to be abraded; harder particles abrade faster. Many of the abrasives used in prophylaxis polishing pastes are 10 times harder than the tooth structure to which they are applied.24 Table 42-1 provides a comparison of the Mohs hardness value of dental tissues compared to agents commonly used in prophylaxis polishing pastes and substances used in cleaning agents.

TABLE 42-1 • Mohs Hardness Value of Dental Tissues Compared to Commonly Used Polishing Abrasive Particles MOHS HARDNESS VALUE Dental Tissues Enamel

5

Dentin

3.0–4.0

Cementum

2.5–3.0

Abrasive Agents in Polishing Pastes Zirconium silicate

7.5–8.0

Pumice

6.0–7.0

Silicone carbine

9.5

Boron

9.3

Aluminum oxide

9

Garnet

8.0–9.0

Emery

7.0–9.0

Zirconium oxide

7

Perlite

5.5

Calcium carbonate

3

Aluminum silicates

2

Sodium

0.5

Potassium

0.4

The Mohs hardness value of enamel, cementum, and dentin compared to the Mohs hardness value of abrasive materials commonly used in prophylaxis polishing pastes. The Mohs hardness value is indicative of a material’s resistance to scratching. Diamonds have a maximum Mohs value of 10; talc has a minimum of Mohs hardness of 1.

Body strength: Particles that fracture into smaller sharp-edged particles during use are more abrasive than those that wear down during use and become dull. Particle size (grit) The larger the particles, the more abrasive they are and the less polishing ability they have. Finer abrasive particles achieve a glossier finish. Abrasive and polishing agents are graded from coarse to fine based on the size of the holes in a standard sieve through which the particles will pass.

B. Principles for Application of Abrasives Quantity applied: The more particles applied per unit of time, the faster the rate of abrasion. Particles are suspended in water or other vehicles for frictional heat reduction. Frictional heat produced is proportional to the rate of abrasion; therefore, the use of dry agents is contraindicated for polishing natural teeth because of the potential danger of thermal injury to the dental pulp. Speed of application: The greater the speed of application, the faster the rate of abrasion. With increased speed of application, pressure must be reduced. Rapid abrasion is contraindicated because it increases frictional heat. Pressure of application: The heavier the pressure applied, the faster the rate of abrasion. Heavy pressure is contraindicated because it increases frictional heat. Summary: When cleaning and polishing are indicated after patient evaluation, the following are observed: Use wet agents. Apply a rubber polishing cup, using low speed. Use a light, intermittent touch.

IV. Abrasive Agents The abrasives listed here are examples of commonly used agents. Some are available in several grades, and the specific use varies with the grade. For example, while a superfine grade might be used for polishing enamel surfaces and metallic restorations, a coarser grade would be used only for laboratory purposes. Abrasives for use daily in a dentifrice necessarily are of a finer grade than those used for professional polishing accomplished a few times each year.

A. Silex (Silicon Dioxide) XXX Silex: fairly abrasive. Superfine Silex: can be used for heavy stain removal from enamel.

B. Pumice Powdered pumice is of volcanic origin and consists chiefly of complex silicates of aluminum, potassium, and sodium. Pumice is the primary ingredient in commercially prepared prophylaxis pastes. The specifications for particle size are listed in the National Formulary26 as follows: Pumice flour or superfine pumice: least abrasive, and may be used to remove heavy stains from enamel. Fine pumice: mildly abrasive. Coarse pumice: not for use on natural teeth.

C. Calcium Carbonate (Whiting, Calcite, Chalk) Various grades are used for different polishing techniques.

D. Tin Oxide (Putty Powder, Stannic Oxide)

Polishing agent for teeth and metallic restorations.

E. Emery (Corundum) Not used directly on the enamel. Aluminum oxide (alumina): the pure form of emery. Used for composite restorations and margins of porcelain restorations. Levigated alumina: consists of extremely fine particles of aluminum oxide, which may be used for polishing metals but are destructive to tooth surfaces.

F. Rouge (Jeweler’s Rouge) Iron oxide is a fine red powder sometimes impregnated on paper discs. It is useful for polishing gold and precious metal alloys in the laboratory.

G. Diamond Particles Constituent of diamond polishing paste for porcelain surfaces.

V.

Cleaning Ingredients

Particles for cleaning agents differ from abrasive agents in shape and hardness. Particles used for cleaning agents include feldspar, alkali, and aluminum silicate.

A. Clinical Applications Numerous commercial preparations for dental prophylactic cleaning and polishing preparations are available. Clinicians need more than one type available to meet the requirements of individual restorative materials.

B. Packaging Commercial preparations are in the form of pastes or powders. Some are available in measured amounts contained in small plastic or other individual packets that contribute to the cleanliness and sterility of the procedure. Selection of a preparation is based on qualities of abrasiveness, consistency for convenient use, or flavor for patient pleasure.

C. Enhanced Prophylaxis Polishing Pastes Additives are included in prophylaxis polishing pastes to provide a specific function, such as enhancing the mineral surface of enamel, diminishing dentin hypersensitivity, or tooth whitening. Fluoride prophylaxis pastes Application of fluoride by use of fluoride-containing prophylaxis polishing pastes cannot be considered a substitute for or the equivalent of a conventional topical fluoride treatment. Enamel surface: The greatest benefit of fluoride as a prophylaxis polishing paste additive occurs when the fluoride ions in the prophylaxis paste are released into the saliva. The fluoride ions that become mixed in the saliva may become incorporated into the hydroxyapatite structure of the tooth, thus aiding in the remineralizing of the tooth and improving enamel hardness. Clinical application: Use only an amount sufficient to accomplish stain removal to prevent a child patient from swallowing unnecessary fluoride. The paste may contain 4,000–20,000 ppm fluoride ion.27 Amorphous calcium phosphate and other forms of calcium and phosphate Amorphous calcium phosphate and other formulations of calcium and phosphate, as an additive to prophylaxis polishing pastes, have been shown to hydrolyze the tooth mineral to form apatite. When prophylaxis polishing pastes containing calcium and

phosphate become mixed with saliva, the mineral ions may become incorporated into the hydroxyapatite structure of the tooth, thus aiding in remineralizing the tooth and improving enamel hardness. Polishing agents containing amorphous calcium phosphate have the potential to enhance tooth smoothness and the luster of the enamel surface.28,29 Fluoride, calcium, and phosphate Fluoride, calcium, and phosphate prophylaxis pastes have the potential to have all three minerals incorporated into the hydroxyapatite structure of the tooth, thus aiding in remineralization to improve enamel hardness. Tooth whitening In addition to removing extrinsic stains, there are commercially available prophylaxis polishing pastes that contain 35% hydrogen peroxide to provide a whitening benefit. A hydrogen peroxide gel is applied to the tooth and then “polished” into the tooth surface with a rubber cup and prophylaxis polishing paste. Dentin hypersensitivity The purpose of prophylaxis polishing pastes containing arginine, calcium, and bicarbonate/carbonate is to minimize dentin hypersensitivity. Mixing these ingredients produces arginine bicarbonate and calcium carbonate. When applied with a rubber cup, these adjunctive ingredients can aid in temporarily occluding the dentinal tubules.30

PROCEDURES FOR STAIN REMOVAL (CORONAL POLISHING) I. Patient Preparation for Stain Removal A. Instruction and Clinical Procedures Review medical history to determine premedication requirements. Review intraoral charting and radiographs to locate all restorations. Provide education and hands-on practice with biofilm control techniques. Complete scaling, root debridement, and overhang removal. After scaling and other periodontal treatment, an evaluation is made to determine the need for coronal polishing for stain removal, polishing restorations, and dental prostheses. Inform the patient that polishing is a cosmetic procedure, not a therapeutic one. Explain the difference between cleaning and polishing agents. Check all restorations to ensure that the correct polishing agent has been selected.

B. Explain the Procedure Describe the noise, vibration, and grit of the polishing paste. Explain the frequent use of rinsing and evacuation with the saliva ejector.

C. Provide Protection for Patient Safety glasses worn for scaling should be kept in place to prevent eye injury or infection from the prophylaxis paste. Fluid-resistant drape over patient to keep moisture from skin and clothing.

D. Patient Position The patient is positioned for maximum visibility.

E. Patient Breathing Encourage the patient to breath only through the nose. Reduced potential for aspiration of oral pathogens into the lungs. Allows water to pool for evacuation with saliva ejector. Less fogging of mouth mirror. Enhanced patient comfort.

II.

Environmental Preparation

Environmental factors are described in Chapter 7.

A. Procedures to Lessen the Extent of Contaminated Aerosols Flush water through the tubing for 2 minutes at the beginning of each work period and for 30 seconds after each appointment. Request the patient rinse with an antimicrobial mouthrinse to reduce the numbers of oral microorganisms before starting instrumentation. Use high-velocity evacuation.

B. Protective Barriers Protective eyewear and bib are necessary for the patient. The clinician should wear the standard barrier protection, namely, eyewear, mask, gloves, and clinic gown to cover clothing.

THE POWER-DRIVEN INSTRUMENTS I. Handpiece A handpiece is used to hold rotary instruments. The three basic designs are straight, contra-angle, and right-angle. Instruments have been classified according to their rotational speeds, designated by revolutions per minute (rpm) as high speed and low (or slow) speed. Handpiece must be maintained and sterilized according to manufacturer’s directions.

A. Low Speed Low-speed handpieces are used for cleaning or polishing the teeth with a prophylaxis angle and rubber cup. Speed: Typical range is up to 5,000 rpm for low-speed handpieces manufactured for dental hygienists. Other low-speed handpieces may have a higher range of rpms; air-driven.

II.

Types of Prophylaxis Angles Types of prophylaxis angles are described in Table 42-2. TABLE 42-2 • Types of Prophylaxis Polishing Angles

a

A comparison of the features of a disposable prophylaxis angle to a disposable prophylaxis angle with abrasive-impregnated rubber cup and a sterilizable stainless steel prophylaxis angle.

Contra- or right-angle attachments to the handpiece for which polishing devices (rubber cup, bristle brush) are available. Contra-angle prophylaxis angles may have a longer shank and a wider angle between the rubber cup and shank to allow for greater reach when polishing posterior teeth and surfaces. Disposable with rubber cup impregnated with polishing agent (abrasive particles) embedded in the rubber cup.20,21 Stainless steel with hard chrome, carbon, steel, or brass bearings. Figure 42-2 shows examples of disposable for one-time use31 contra-angle and right-angle prophylaxis angles and a stainless steel prophylaxis angle.

FIGURE 42-2 • Prophylaxis Angles. A: Disposable right-angled prophylaxis angle with rubber cup attached. B: Disposable contra-angled prophylaxis angle with an attached rubber cup impregnated with a polishing agent (abrasive particles). C: Sterilizable stainless steel prophylaxis angle holding a cleaning or polishing brush on a mandrel.

Stainless steel prophylaxis angles that are sealed will not allow saliva and debris into the head of the angle nor will they allow grease and debris to leak out of the head of the angle.32,33 Stainless steel or any other type of metal autoclavable prophylaxis angle must be sterilized after every use and the manufacturer’s instructions followed for the proper maintenance and care as well as the correct sterilization procedures. Unless they are disposable, only instruments that can be sterilized should be used.

III. Prophylaxis Angle Attachments A. Rubber Polishing Cups Types: Figure 42-3 shows several types of rubber polishing cups from which to choose. The internal designs and sizes have the same purpose, which is to aid in holding the prophylaxis polishing paste in the rubber cup while polishing. The ideal rubber cup design

retains the prophylaxis polishing paste in the cup and will release the paste at a steady rate.

FIGURE 42-3 • Rubber Cup Attachments. A: Slip-on or snap-on for buttonended prophylaxis angle. B: Threaded for direct insertion in right-angle. C: Mandrel stem for latch-type prophylaxis angle.

Slip-on (snap-on): with ribbed cup to aid in holding polishing agent. Threaded (screw type): with plain ribbed cup or flange (webbed) type. Mandrel mounted. Materials Natural rubber: more resilient; adapts readily to fit the contours of the teeth. Synthetic: stiffer than natural rubber.

B. Bristle Brushes Types For prophylaxis angle: slip-on or screw type. For handpiece: mandrel mounted. Materials: synthetic.

C. Rubber Polishing Points Figure 42-4 shows an example of a rubber point that screws into a prophylaxis angle.

FIGURE 42-4 • Flexible Rubber Point Has Screw Connection for a Prophylaxis Angle. Made with ribs or grooves to carry cleaning or polishing agent to difficult-to-reach areas.

Material Natural rubber: flexible so that tip adapts to proximal surfaces, embrasures, and around orthodontic bands and brackets. Use: Because the ribs for holding the prophylaxis polishing paste onto the rubber polishing point are on the external surface, the polishing paste will have to be reapplied frequently.

IV. Uses for Attachments A. Handpiece with Straight Mandrel Dixon bristle brush (type C, soft) for polishing removable dentures.

Rubber cup on mandrel for polishing facial surfaces of anterior teeth.

B. Prophylaxis Angle with Rubber Cup, Brush, or Rubber Point Rubber cup: for removal of stains from the tooth surfaces and polishing restorations. Brush: for removing stains from deep pits and fissures and enamel surfaces away from the gingival margin. A brush is contraindicated for use on exposed cementum or dentin. Rubber polishing point: for removing stains and biofilm from proximal surfaces, embrasures, and around orthodontic bands and brackets.

USE OF THE PROPHYLAXIS ANGLE I. Effects on Tissues: Clinical Considerations Can cause discomfort for the patient if care and consideration for the oral tissues are not exercised to prevent unnecessary trauma. Tactile sensitivity of the clinician while using a thick, bulky handpiece is diminished and unnecessary pressure may be applied inadvertently. The greater the speed of application of a polishing agent, the faster the rate of abrasion. Therefore, the handpiece is applied at a low rpm. Trauma to the gingival tissue can result from too high a speed, extended application of the rubber cup, or use of an abrasive polishing agent. Tissue damage and the need for antibiotic premedication for risk patients are described in Chapter 11.

II.

Prophylaxis Angle Procedure Apply the polishing agent only where it is needed. See section Contraindications.

A. Instrument Grasp Modified pen grasp (see Chapter 37).

B. Finger Rest Establish a fulcrum firmly on tooth structure or use an exterior rest. Use a wide rest area when practical to aid in the balance of the large instrument. For example, place cushion of rest finger across occlusal surfaces of premolars while polishing the molars. Avoid use of mobile teeth as finger rests.

C. Speed of Handpiece Use lowest available speed to minimize frictional heat. Adjust rpm as necessary.

D. Use of Rheostat Apply steady pressure with foot to produce an even, low speed.

E. Rubber Cup: Stroke and Procedure Observe where stain removal is needed to prevent unnecessary rubber cup application. Fill rubber cup with polishing agent, and distribute agent over tooth surfaces to be polished before activating the power. Establish finger rest and bring rubber cup almost in contact with tooth surface before activating power source. Using slowest rpm, apply revolving cup at a 90° angle lightly to tooth surfaces for 1 or 2 seconds. Use a light pressure so that the edges of the rubber cup flare slightly. The rubber cup needs to flare slightly underneath the gingival margin and onto the proximal surfaces. Move cup to adjacent area on tooth surface; use a patting or brushing motion. Replenish supply of polishing agent frequently. Turn handpiece to adapt rubber cup to fit each surface of the tooth, including proximal surfaces and gingival surfaces of fixed partial dentures. Start with the distal surface of the most posterior tooth of a quadrant and move forward toward the anterior; polish only the teeth that require stain removal. For each tooth, work from the gingival third toward the incisal third of the tooth. When two polishing agents of different abrasiveness are to be applied, use a separate rubber cup for each. Rubber cups, polishing points, and polishing brushes cannot be

sterilized and are used only for one patient and then discarded.

F. Rubber Polishing Points Rubber polishing points can be used around orthodontic bands and brackets, on fixed bridges, and in wide interproximal spaces or embrasures.

FIGURE 42-5 • Air-Powder Polishing. Direct the aerosolized spray for (A) the anterior teeth at a 60° angle. B: The posterior teeth facial and lingual or palatal at an 80° angle. C: The occlusal surfaces at a 90° angle to the occlusal plane.

Rubber points are loaded with the cleaning or polishing agent in the grooves around the sides. The rubber points will need to be replenished frequently with paste after use on every 1–2 teeth.

G. Bristle Brush Bristle brushes are used selectively and limited to occlusal surfaces. Lacerations of the gingiva and grooves and scratches in the tooth surface, particularly the roots and restorations, can result when the brush is not used with caution. Soak stiff brush in hot water to soften bristles.

Distribute mild abrasive polishing agent over occlusal surfaces of teeth to be polished. Place fingers of nondominant hand in a position to retract and protect cheek and tongue from the revolving brush. Establish a firm finger rest and bring brush almost in contact with the tooth before activating power source. Use slowest rpm as the revolving brush is applied lightly to the occlusal surfaces only. Avoid contact of the bristles with the soft tissues. Use a short stroke in a brushing motion; follow the inclined planes of the cusps. Move from tooth to tooth to prevent generation of excessive frictional heat. Avoid overuse of the brush. Replenish supply of polishing agent frequently.

H. Irrigation Irrigate teeth and interdental areas thoroughly several times with water from the syringe to remove abrasive particles. Avoid heavy water pressure to prevent forcing particles into the tissue. The rotary movement of the rubber cup or bristle brush tends to force the abrasive into the gingival sulci, thereby creating a potential source of irritation to the soft tissues.

AIR-POWDER POLISHING Principles of selective stain removal are applied to the use of the air-powder polishing system (Figure 42-5). After biofilm control instruction, instrumentation, and periodontal debridement are completed, follow with an evaluation of need for stain removal.

I.

Principles of Application Air-powder systems manufactured by several companies are efficient and effective methods for mechanical removal of stain and biofilm.34–36 Air-powder polishing systems use air, water, and specially formulated powders to deliver a controlled spray that propels the particles to the tooth surface. Only powders approved by each air-powder polishing manufacturer are used in each brand of air-powder polishing unit. The use of an unapproved powder in an air-powder polishing unit could void the warranty on the unit.34,36 The handpiece nozzle is moved in a constant circular motion, with the nozzle tip 4–5 mm away from the enamel surface. The spray is angled away from the gingival margin. The periphery of the spray may be near the gingival margin, but the center is directed at an angle less than 90° away from the margin. Complete directions for care of equipment and preparation for use of the device are provided by the individual manufacturer.

II.

Specially Formulated Powders for Use in AirPowder Polishing

Several manufacturers make and sell air-powder polishing powders. The abrasiveness of one brand of powder may differ from another brand, even though it is the same type of powder.37,38

A. Sodium Bicarbonate38 Sodium bicarbonate was the original powder used in air-powder polishing. It is specially formulated with scant amounts of calcium phosphate and silica to keep it free flowing. The Mohs hardness number for sodium bicarbonate is 2.5 and the particles average 74 μm in size. The only type of sodium bicarbonate that can be used in air-powder polishing units is the type specially formulated for air-powder polishing. Sodium bicarbonate air-powder is available with flavorings. However, the patient will taste the salt and smell the flavor.

B. Aluminum Trihydroxide Aluminum trihydroxide was the first air-powder developed as an alternative to sodium bicarbonate for patients who are sodium bicarbonate intolerant.37 Aluminum trihydroxide has a Mohs hardness value of 4 and the particles range in size from 80 to 325 μm.

C. Glycine Glycine is an amino acid. For use in powders, glycine crystals are grown using a solvent of water and sodium salt. Glycine particles for use in air polishing have a Mohs hardness number of 2 and are 20 μm in size.38 Glycine has been shown to be safe and effective for subgingival plaque removal in pockets up to 5mm.34

D. Calcium Carbonate Calcium carbonate is a naturally occurring substance that can be found in rocks.

It is a main ingredient in antacids, and is also used as filler for pharmaceutical drugs. Calcium carbonate has a Mohs number of 3.38

E. Calcium Sodium Phosphosilicate (Novamin) Calcium sodium phosphosilicate (Novamin) is a bioactive glass and has a Mohs hardness number of 6, making it the hardest airpolishing particle used in air-powder polishing powders.38 The particles vary from 25 to 120 μm in size. This powder should not be used on any tooth structure or restorative material.38

III. Uses and Advantages of Air-Powder Polishing Requires less time, is ergonomically favorable to the clinician, and generates no heat.35,37,39 Sodium bicarbonate is less abrasive than traditional prophylaxis pastes, which makes the air-powder polisher ideal for stain and biofilm removal. However, some air-polishing powders are much more abrasive than sodium bicarbonate and should only be used on surfaces that they will not damage.38 Removal of heavy, tenacious tobacco stain and chlorhexidineinduced staining.35,37,40 Stain and biofilm removal from orthodontically banded and bracketed teeth40,41 and dental implants.42,43 Before sealant placement or other bonding procedures.18,19 Root detoxification for periodontally diseased roots by the periodontist during open periodontal surgery.44,45

IV. Technique Proper angulation of the air-powder polishing handpiece is essential to reduce the amount of inherent aerosols created46–48 and to remove stain and biofilm without iatrogenic soft-tissue trauma.

A. For Anterior Teeth Place the handpiece nozzle at a 60° angle to the facial and lingual surfaces of anterior teeth (Figure 42-5A).

B. For Posterior Teeth Place the handpiece nozzle at an 80° angle to the facial and lingual surfaces (Figure 42-5B).

C. For Occlusal Surfaces Place the handpiece nozzle at a 90° angle to the occlusal plane (Figure 42-5C).

D. Incorrect Angulation Incorrect angulation of the handpiece is probably the single most common cause of excess aerosol production. The handpiece nozzle is never directed into the gingival sulcus or into a periodontal pocket with little bony support remaining, as this could result in facial emphysema36 (also known as a subcutaneous emphysema). Facial emphysemas occur due to the abnormal introduction of air into subcutaneous tissues or interstitial spaces.36 Facial emphysemas can be prevented by avoiding the use of highspeed handpieces during third molar extractions,49 air/water syringes near extraction or surgical sites or lacerations,50–54 and airpolishing55 spray in these areas. Facial emphysemas exhibit symptoms such as facial swelling, a “crackling” sensation of the face and neck area when touched, tenderness, and pain. If detected early, patients with facial emphysemas usually require observation, antibiotics, and analgesia.36 Box 42-1 contains a list of the sequelae that can develop as a

result of compressed air forced into soft tissues of the head and neck.

BOX 42-1 Sequelae That Can Develop as a Result of Compressed Air Forced into Soft Tissues of the Head and Neck Bilateral pneumothorax Cerebral air embolism Cervicofacial emphysema Facial emphysema Mediastinal emphysema Pneumediastinum Pneumothorax Retropharyngeal emphysema

Box 42-2 contains a list of sequelae that can develop as a result of a facial emphysema.

BOX 42-2 Sequelae That Can Develop as a Result of Facial Emphysema Bilateral pneumothorax Cerebral air embolism Embolism Pneumediastinum Pneumothorax Thrombosis

The closer the nozzle is held to the enamel, the more spray will deflect back into the direction of the clinician. When a clinician directs the handpiece at a 90° angle toward a facial, buccal, and some lingual surfaces, the result is an immediate

reflux of the aerosolized spray back onto the clinician. Changing the angle of incidence to the proper angulations of 60° and 80° will result in a change in the angle of the reflection, thus reducing the amount of reflux of aerosolized spray.

V.

Recommendations and Precautions

A. Aerosol Production A copious spray containing oral debris and microorganisms is produced. As with all contaminated aerosols, a health hazard can exist. Suggestions for minimizing contamination and the effects of the aerosols include the following: Patient uses a preprocedural antibacterial mouthrinse.56 High-volume evacuation is needed, using a wide tip held near the tooth where the spray is released from the nozzle or using a highvolume scavenger attachment for a high-volume evacuation suction tip or saliva ejector.46–48

B. Protective Patient and Clinician Procedures Use protective eyewear, protective gown, and hair cover. Lubricate patient’s lips to prevent drying effect of the sodium bicarbonate using a nonpetroleum lip lubricant. Do not direct the spray on the gingiva, or other soft tissues, which can create patient discomfort, undue tissue trauma. Avoid directing the spray into periodontal pockets with bone loss or into extraction sites as a facial emphysema can be induced.

VI. Risk Patients: Air-Powder Polishing Contraindicated The information from the patient’s medical history is used and appropriate applications made. Antibiotic premedication is indicated for all the same patients who are at risk for any dental hygiene

procedure (see Chapter 11).

A. Contraindications36 Physician-directed sodium-restricted diet (only for sodium bicarbonate powder). Respiratory disease or other condition that limits swallowing or breathing, such as chronic obstructive pulmonary disease. Patients with end-stage renal disease, Addison’s disease, or Cushing’s disease. Communicable infection that can contaminate the aerosols produced. Immunocompromised patients. Patients taking potassium, antidiuretics, or steroid therapy. Patients who have open oral wounds, such as tooth sockets, from oral surgery procedures.

B. Other Contraindications Root surfaces: Avoid routine polishing of cementum and dentin. There is some evidence they can be removed readily during airpowder polishing.57 However, research indicates that glycine powder is safe for use subgingivally.57 Soft, spongy gingiva: The air-powder can irritate the free gingival tissue, especially if not used with the recommended technique. When heavy stain calls for the use of an air-powder polisher, instruct the patient in daily bacterial biofilm removal. Following scaling and periodontal debridement, postpone the stain removal until soft tissue has healed. Restorative materials: The use of air-powder polishing on composite resins, cements, and other nonmetallic materials can cause removal or pitting.15,16,22 Table 42-3 provides a guide as to which restorative materials can be safely treated with air-powder polishing agents, the

sodium bicarbonate powder, and the aluminum trihydroxide powder.33 TABLE 42-3 • Recommendations for Use of Air Polishing on Restorative Materials POLISHING POWDER CONTAINING RESTORATIVE MATERIAL

SODIUM BICARBONATE

ALUMINUM TRIHYDROXIDE

Amalgam

Yes

No

Gold

Yesa

No

Porcelain

Yesa

No

Hybrid composite

No

No

Microfilled composite

No

No

Glass ionomer

No

No

Compomer

No

No

Luting agents

No

No

aOnly

if margin is avoided.

Significant damage to margins of dental castings has been shown.32

POLISHING PROXIMAL SURFACES Care must be exercised in the use of floss, tape, and finishing strips. Understanding the anatomy of the interdental papillae and relationship to the contact areas and proximal surfaces of the teeth is prerequisite to the prevention of tissue damage. As much polishing as possible of accessible proximal surfaces is accomplished during the use of the rubber cup in the prophylaxis angle. This can be followed by the use of dental tape with polishing agent when indicated. Finishing strips are used only in selected instances, when all other techniques fail to remove a stain.

I.

Dental Tape and Floss

A. Uses During Cleaning and Polishing Techniques for tape and floss application are described in Chapter 27. The same principles apply whether the patient or the clinician is using the floss. Finger rests are used to prevent snapping through contact areas. Stain removal with dental tape: Polishing agent is applied to the tooth, and the tape is moved gently back and forth and up and down curved over the area where stain was observed. Cleaning gingival surface of a fixed partial denture: A floss threader is used to position the floss or tape over the gingival surface. Floss threaders are described and illustrated in Chapter 30. The agent is applied under the pontic, and the floss or tape is moved back and forth with contact on the bridge surface. Flossing: Particles of abrasive agent can be removed by rinsing and by using a clean length of floss applied in the usual manner. Rinsing and irrigation: Irrigate with water-spray syringe to clean out

all abrasive agent.

II.

Finishing Strips

A. Description Finishing strips are thin, flexible, and tape-shaped. Available in four widths: extra narrow, narrow, medium, and wide. Available in extra fine, fine, medium, and coarse grit. Only extra narrow or narrow strips with extra fine or fine grit are suggested for stain removal, and then only with discretion. Most finishing strips are now made of plastic; however, linen abrasive strips are available. Finishing strips have one side that is smooth and the other side serves as a carrier for abrasive agents bonded to that side. “Gapped” strips are available with an abrasive-free portion to permit sliding the strip through a contact area without abrading the enamel. Finishing strips are available with two different grits on one strip. One-half of the strip may have fine abrasives and the other one-half will have medium-grit abrasives. These strips are available in several different combinations.

B. Use For stain removal on proximal surfaces of anterior teeth; when other techniques are unsuccessful. Precautions for use Edge of strip is sharp and may cut gingival tissue or the lip. Use of a finishing strip is limited to enamel surfaces and some restorative materials, such as composite. It is of upmost importance to ensure the finishing strip selected has an appropriate grit abrasive for the surface to be polished. Manufacturers make finishing strips intended for use solely on composites or porcelain; other types of finishing strips are

available for use on enamel.

C. Technique for Finishing Strip Grasp and finger rest A strip no longer than 6 inches is most convenient to apply. Grasp and finger rest must be well controlled. Protection of the lip by retraction with the thumb and index finger holding the strip is a helpful safety measure. Positioning Direct the abrasive side of the strip toward the proximal surface to be treated as the strip is worked slowly and gently between the teeth with a slight sawing motion. Bring strip just through the contact area. If the strip breaks, immediately use floss to remove abrasive particles separated from the finishing strip. When a space is clearly visible through an embrasure and the interdental papilla is missing, a narrow finishing strip may be threaded through. Prepare strip by cutting the end on a diagonal to facilitate threading. Stain removal Press abrasive side of strip against tooth. Draw back and forth in a 1/8-inch arc two or three times, rocking on the established fulcrum. Remove strip. Do not attempt to turn the strip while it is in the interdental area. Dental floss: Follow each application of a finishing strip with dental floss to remove abrasive particles.

HISTORIAL PERSPECTIVE: THE PORTE POLISHER Design The porte polisher is a manual instrument designed especially for extrinsic stain removal or application of treatment agents such as for hypersensitive areas. It is constructed to hold a wood point at a contra-angle. The wood points may be cone or wedge-shaped and made of various kinds of wood, preferably orangewood. Figure 42-6 illustrates a typical porte polisher.

FIGURE 42-6 • Porte Polisher. A: Assembled instrument shows position of wood point ready for instrumentation. B: Working end shows wedge-shaped wood point inserted. C: Disassembled, ready for autoclave.

Grasp: The instrument is held in a modified pen grasp or palm grasp. Application: The wood point is applied to the tooth surface using firm, carefully directed, massaging, circular or linear strokes to accommodate the anatomy of each tooth.

A firm finger rest and a moderate amount of pressure of the wood point provide protection for the gingival margin and efficiency in technique. Features The porte polisher is useful for instrumentation of difficult-toaccess surfaces of the teeth, especially malpositioned teeth. No heat generation, no noise compared with powered handpieces, and minimal production of aerosols. The porte polisher is readily portable and therefore is useful in any location, for example, for a bed bound patient.

DOCUMENTATION Documentation for a patient receiving tooth stain removal as part of the dental hygiene care plan for a maintenance appointment would include a minimum of the following: Review patient medical history with questions to determine health problems, recent medical examinations and treatments, and changes in medications. Current clinical examination findings: intraoral, extraoral, periodontal, and dental. With dental charting: identification of dental materials used in restorations that can influence choice of polishing agents. Identification would require use of radiographs and the intraoral dental charting. Dental hygiene examination for state of patient’s personal daily selfcare, calculus and biofilm deposits, sources for dental stains, products used for oral care, and dietary factors influencing the dentition and all oral tissues: questions answered about best choices for various products. A sample progress note may be reviewed in Box 42-3.

BOX 42-3 Example Documentation: Selection of Polishing Agent for a Patient with Esthetic Restorations S–A 36-year-old male patient presents for regular maintenance appointment, grinning to show that his new implant crown and other esthetic restorations are not distinguishable from the color of his teeth. Updated medical history, medications, no changes. O–Blood pressure (115/75); extra-intraoral examinations: no findings; comprehensive periodontal examination: localized 3–4 mm, with bleeding on probing in 4 mm pockets in molar areas; supragingival calculus mand ant.; minimal biofilm with isolated areas of yellowish staining. A–Checked his dental records for the material used for the various restorations and found that the patient has porcelain crowns on teeth numbers #2, 14, and anterior microhybrid composite restorations in teeth numbers #6, 7, 8, 10, and 11. Patient has an implant and porcelain crown on #9. Note: Microhybrid

composite restorations and implant crown match the patient’s natural teeth to the extent that it is difficult to identify the restorations. P–Gave patient new toothbrush with tongue cleaner on back, and demonstrated the tongue cleaner. Went over places he had been missing on his teeth and gingiva. Calculus removal. Avoided use of air polishing with sodium bicarbonate (the only powder I have available) and also avoided prophy paste. Selected a cleaning agent to remove biofilm and isolated areas of yellowish staining. Next regular appointment 4 months made at front desk. Signed: ______________________________, RDH Date: ____________________________________

EVERYDAY ETHICS Mr. Jackson, the 62-year-old chief executive officer of a major oil company, presents for his routine 3-month maintenance with Carol, his dental hygienist of several years. Mr. Jackson is meticulous about his appearance and is always handsomely dressed. He is well-known internationally and frequently seen in the news media being interviewed and having pictures taken for news articles. Mr. Jackson had a complete cosmetic restoration of his teeth a year ago. Previously his teeth had been stained by the numerous cups of tea he drank every day. He has had porcelain veneers placed on his maxillary anterior teeth, and all restorations are now tooth-colored. Unfortunately, Mr. Jackson has not reduced intake of tea and during her assessment, Carol notes that generalized stain is starting to discolor most of the new restorations. Before the cosmetic restorations were placed, Carol used a coarse prophy paste to eliminate the tea stains and now Mr. Jackson asks her to “just use that gritty stuff again.” He states that he absolutely does not want his teeth to appear stained. QUESTIONS FOR CONSIDERATION 1. What role does each of the dental hygiene core values play as Carol contemplates a course of action to take in this situation? 2. What alternative actions are available that would respect Mr. Jackson’s rights as well as allow Carol to provide treatment that meets standards of care? 3. What financial or legal considerations will Carol need to consider as she determines her course of action?

Factors to Teach the Patient

How dental biofilm and stains form on the natural teeth and their replacements. The meaning of selective polishing and why it is not necessary to polish all teeth at every appointment when daily care is effective. Stains and biofilm removed by polishing can return promptly if biofilm is not removed faithfully on a schedule of two or three times each day. Polishing agents used during professional coronal polishing are too abrasive for daily home use.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. American Academy of Periodontology. Glossary of Periodontal Terms. 4th ed. Chicago, IL: American Academy of Periodontology; 2001:42. https://members.perio.org/libraries/glossary. 2. American Dental Hygienists’ Association. Position Paper on the Oral Prophylaxis. Chicago, IL: ADHA; 1998. www.adha.org/profissues/prophylaxis.htm. 3. Jeffries SR. Abrasive finishing and polishing in restorative dentistry: a state-ofthe-art review. Dent Clin North Am. 2007;51(2):379-397. 4. Hutchings IM. Abrasion process in wear and manufacturing. Proc Inst Mech Eng Part J: J Eng Tribol. 2002;216(2):55-62. 5. Rémond G, Nockolds C, Phillips M, et al. Implications of polishing techniques in quantitative x-ray microanalysis. J Res Natl Inst Stand Technol. 2002;107(6):639-662. 6. Williams JA. Wear and wear particles: some fundamentals. Tribiol Int. 2005;38(10):863-870. 7. Fine DH, Furgang D, McKiernan M, et al. An investigation of the effect of an essential oil mouthrinse on induced bacteraemia: a pilot study. J Clin Periodontol. 2010;37(9):840-847. 8. Hatzell JD, Torres D, Kim P, Wortmann G. Incidence of bacteremia after routine tooth brushing. Am J Med Sci. 2005,Apr;329(4):178-180. 9. Cristina ML, Spagnolo AM, Sartini M, et al. Investigation of organizational and hygiene features in dentistry: a pilot study. J Prev Med Hyg. 2009;50(3):175180. 10. Farrier SL, Farrier JN, Gilmour AS. Eye safety in operative dentistry: a study in dental practice. Br Dent J. 2006;200(4):218-223. 11. Buzalaf MAR, Pessan JP, Honório HM, Ten Cate JM. Mechanisms of action of fluoride for caries control. Monogr Oral Sci. 2011;22:97-114. 12. Honório HM, Rios D, Abdo RC, et al. Effect of different prophylaxis methods on sound and demineralized enamel. J Appl Oral Sci. 2006;14(2):117-123. 13. Kubinek R, Zapletalova Z, Vujtek M, et al. Examination of dentin surface using AFM and SEM. In: Méndez-Vilas A, Díaz J, eds. Modern Research and Educational Topics in Microscopy. Vol 2. Zurbarán: Formatex; 2007:593-598. 14. Miglani S, Aggarwal V, Ahuja B. Dentin hypersensitivity: recent trends in management. J Conserv Dent. 2010;13(4):218-224. 15. Barnes CM. Polishing esthetic restorative materials. Dimensions Dent Hyg. 2010;8(1):24, 26-28. 16. Barnes CM. Care and maintenance of esthetic restorations. J Prac Hyg. 2004;14:19-22. 17. Zyla T, Kawala B, Antoszewska-Smith J, Kawala M. Black line stain and dental caries: a review of the literature. Biomed Research International. 2015. http://dx.doi.org/10.1155/2015/469392.

Botti RH, Bossu M, Zallocco N, Vestri A, Polimeni A. Effectiveness of plaque 18. indicators and air polishing for the sealing of pits and fissures. Eur J Paediatr Dent. 2010;11(1):15-18. 19. Ahovuo-Saloranta A, Hiiri A, Nordblad A, et al. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Syst Rev. 2008;4:CD001830. Review. 20. Barnes CM. The science of polishing. Dimensions Dent Hyg. 2009;7(11):18-20, 22. 21. Covey D, Barnes C, Watanabe H, Johnson W. Effects of a paste-free prophylaxis polishing cup and various prophylaxis polishing pastes on tooth enamel and restorative materials. G Dent. November/December 2011:466-473. www.age.org. 22. Putt MS, Kleber CJ, Muhler JC. Enamel polish and abrasion by prophylaxis pastes. J Dent Hyg. 1982;56(9):38, 40-43. 23. Barnes CM. Adapting polishing procedures to maintain aesthetic restorations. J Prac Hyg. 2005;15:22. 24. Barnes CM, Covey DA, Walker MP, et al. Essential selective polishing: the maintenance of aesthetic restorations. J Prac Hyg. 2003;12(5):18-24. 25. Sawai MA, Bhardwaj A, Jafri Z, Sultan N, Daing A. Tooth polishing: the current status. J Indian Soc Periodontal. Jul-Aug 2015; 19(4):375-380. 26. Burrell KH, Chan JT. Fluorides. In: American Dental Association, ed. Council on Scientific Affairs: ADA Guide to Dental Therapeutics. 3rd ed. Chicago, IL: ADA; 2003:238. 27. Tung MS, Eichmiller FC. Amorphous calcium phosphates for tooth mineralization. Compend Contin Educ Dent. 2004;25 (9, suppl 1):9-13. 28. Tung M, Malerman R, Huang S, et al. Reactivity of prophylaxis paste containing calcium phosphate and fluoride salts. J Dent Res. 2005;84 (Special Issue A). Abstract #2156, IADR Abstracts, 2005. 29. Daniels A. Professionally applied enhanced polishing agents. J Prac Hyg. 2006;15:26. 30. Mattana D. Reducing dentin Hypersensitivity. J Prac Hyg. 2006;15:24. 31. Barnes CM, Fleming LS. An in vitro evaluation of commercially available disposable prophylaxis angles. J Dent Hyg. 1991;65(9):438-441. 32. Barnes CM, Anderson NA, Li Y, et al. Effectiveness of steam sterilization in killing spores of Bacillus stearothermophilus in prophylaxis angles. Gen Dent. 1994;42(5):456-458. 33. Barnes CM, Anderson NA, Michalek SM, et al. Effectiveness of sealed dental prophylaxis angles inoculated with Bacillus stearothermophilus in preventing leakage. J Clin Dent. 1994;5(2):35-37. 34. Graumann S, Sensat M, Stoltenberg J. Air polishing: a review of current literature. J Dent Hygi. August 2013;87(4):173-180. 35. Weaks LM, Lescher NB, Barnes CM, et al. Clinical evaluation of the Prophy-Jet as an instrument for routine removal of tooth stain and plaque. J Periodontol. 1984;55(8):486-488. 36. Barnes CM. An in-depth look at air polishing. Dimensions Dent Hyg.

2010;8(3):32, 34-36. 37. Barnes CM, Covey DA, Walker MP, et al. An in vitro evaluation of the effects of aluminum trihydroxide delivered via the Prophy Jet on dental restorative materials. J Prosthet Dent. 2004;13(3):166-172. 38. Barnes CM, Covey DA, Watanabe H, et al. An in vitro comparison of the effects of various airpolishing powders on enamel and selected esthetic restorative materials. J Clin Dent. 2014;25(4):76-87. 39. Kuar A, Gupta M, Das D, Sachdeva S, Jain S. Tooth polishing- a mouthful of history. Int J Periodontol Implantol. April-June 2018:3(2):63-67. 40. Barnes CM, Russell CM, Gerbo LR, et al. Effects of an air-powder polishing system on orthodontically bracketed and banded teeth. Am J Orthod Dentofac Orthop. 1990;97(1):74-81. 41. Shultz PH, Brockmann-Bell SL, Eick JD, et al. Effects of air-powder polishing on the bond strength of orthodontic bracket adhesive systems. J Dent Hyg. 1993;67(2):74-80. 42. Cochis A, Carassi F, Migilario M, Visai L, Rimondini L. Effect of air polishing with glycine powder on titanium abutment surfaces. Clin Oral Implants Res. 2013;24(8):904-9. 43. Barnes CM, Toothaker RW, Ross J. Polishing dental implants and dental implant restorations. J Prac Hyg. 2005;14(8):6-8. 44. Berkstein S, Reiff RL, McKinney JF, et al. Supragingival root surface removal during maintenance procedures utilizing an air-powder abrasive system or hand scaling: an in vitro study. J Periodontol. 1987;58(5):327-330. 45. Agger MS, Hörsted-Bindslev P, Hovgaard O. Abrasiveness of an air-powder polishing system on root surfaces in vitro. Quintessence Int. 2001;32(5):407411. 46. Barnes CM. The management of aerosols with airpolishing delivery systems. J Dent Hyg. 1991;65(6):280-282. 47. Harrel SK, Barnes JB, Rivera-Hidalgo F. Aerosol reduction during air polishing. Quintessence Int. 1999;30(9):623-628. 48. Worrall SF, Knibbs PJ, Glenwright HD. Methods of reducing bacterial contamination of the atmosphere arising from use of an air-polisher. Br Dent J. 1987;163(4):118, 119. 49. Davies DE. Pneumomediastinum after dental surgery. Anaesth Intensive Care. 2001;29(6):638-641. 50. Tan WK. Sudden facial swelling: subcutaneous facial emphysema secondary to use of air/water syringe during dental extraction. Singapore Dent J. 2000;23 (1, suppl):42-44. 51. Josephson GD, Wambach BA, Noordzji JP. Subcutaneous cervicofacial and mediastinal emphysema after dental instrumentation. Otolaryngol Head Neck Surg. 2001;124(2):170, 171. 52. Yang SC, Chiu TH, Lin TJ, et al. Subcutaneous emphysema and pneumomediastinum secondary to dental extraction: a case report and literature review. Kaohsiung J Med Sci. 2006;22(12):641-645. 53. Heyman SN, Babayof I. Emphysematous complications in dentistry, 1960-

1993: an illustrative case and review of the literature. Quintessence Int. 1995;26(8):535-543. 54. Arai I, Aoki T, Yamazaki H, et al. Pneumomediastinum and subcutaneous emphysema after dental extraction detected incidentally by regular medical checkup: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107(4):e33-e38. 55. Finlayson RS, Stevens FD. Subcutaneous facial emphysema secondary to use of the Cavi-Jet. J Periodontol. 1988;59(5):315-317. 56. Fine DH, Mendieta C, Barnett ML, et al. Efficacy of preprocedural rinsing with an antiseptic in reducing viable bacteria in dental aerosols. J Periodontol. 1992;63(10):821-824. 57. Buhler J, Schmidi F, Weiger R, Walter C. Analysis of the effects of air polishing powders containing sodium bicarbonate and glycine on human teeth. Clin Oral Invest. 2015;19(4):877-885.

43 Tooth Bleaching Heather Hessheimer, RDH, MS

CHAPTER OUTLINE OVERVIEW OF TOOTH BLEACHING I. II. III.

Bleaching versus Whitening Vital Tooth Bleaching versus Nonvital Tooth Bleaching History

VITAL TOOTH BLEACHING I. II. III. IV. V. VI. VII. VIII.

Mechanism of Bleaching Vital Teeth Tooth Color Change with Vital Tooth Bleaching Materials Used for Vital Tooth Bleaching Vital Tooth Bleaching Safety Factors Associated with Efficacy Reversible Side Effects of Vital Bleaching: Sensitivity Irreversible Tooth Damage Modes of Vital Tooth Bleaching

NONVITAL TOOTH BLEACHING

I. II.

Procedure for Bleaching Nonvital Teeth Factors Associated with Efficacy

DENTAL HYGIENE PROCESS OF CARE I. II. III. IV. V.

Patient Assessment Dental Hygiene Diagnosis Dental Hygiene Care Plan Implementation Evaluation and Planning for Maintenance

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Discuss the mechanism, safety, and efficacy of tooth bleaching agents. 2. Identify specific tooth conditions and staining responses to tooth bleaching. 3. Differentiate reversible and irreversible side effects associated with the tooth bleaching process. 4. Assess appropriate interventions for tooth bleaching side effects.

OVERVIEW OF TOOTH BLEACHING Patients of all ages have concerns about the appearance of their teeth and expect their dental hygienists to guide them in their esthetic choices with evidence-based information. Because there are many causes of tooth discoloration, a review of Chapter 17 is recommended. Tooth bleaching may result in significantly whiter teeth and contribute to an increase in patient’s self-confidence. A whiter smile may motivate the patient to maintain improved oral health, which is a significant benefit.

I.

Bleaching versus Whitening

The terms “bleaching” and “whitening” have been used interchangeably, but are not the same as described below1: Tooth whitening refers to use of abrasive agents and/or detergents contained in a dentifrice to remove extrinsic stain. Bleaching involves free radicals and the breakdown of pigment, which occurs in the tooth-bleaching procedures.

II.

Vital Tooth Bleaching versus Nonvital Tooth Bleaching Teeth can be stained intrinsically and extrinsically. External tooth bleaching is used for both vital and nonvital teeth. Agents for bleaching are applied to the external surfaces of the teeth. Bleaching agent breaks down chemical bonds in chromogens making them refract light and appear lighter.2 Color change can extend into the dentin to produce a whitened tooth. Nonvital teeth become intrinsically stained by blood breakdown products, or agents from root canal therapy.1

Nonvital tooth bleaching is a procedure performed by a dentist after root canal therapy using a rubber dam or other type of isolation. The bleaching agents are introduced into the pulp chamber. The color of a single tooth is lightened to help it blend with the adjacent teeth.

III. History A. Nonvital Tooth-Bleaching History Bleaching of discolored, nonvital teeth was first described as early as 1864.3,4 In 1961, the walking bleach method was introduced. The walking bleach method sealed a mixture of sodium perborate and water into the pulp chamber and retained it there between the patient’s visits.5 By 1963, the walking bleach method was modified using water and 30%–35% hydrogen peroxide instead of the sodium perborate and water. Result: improved lighter color of nonvital teeth.3

B. Vital Tooth-Bleaching History In the 1960s, tooth lightening was observed after orthodontic patients used an antiseptic containing carbamide peroxide to promote tissue healing due to gingivitis.3,6 In the 1980s, lighter tooth color was noted after advising patients to use carbamide peroxide in customized trays for antiseptic purposes following periodontal surgery.6 In 1989, the use of carbamide peroxide for the primary purpose of tooth bleaching was introduced.7 A custom tray was used to maintain the bleaching gel on the tooth surface for an extended time. The procedure was known as nightguard vital bleaching. No significant, long-term oral or systemic health risks have been associated with professional at-home tooth-bleaching materials containing 10% carbamide peroxide or 3.5% hydrogen peroxide

when professionally supervised.8,9

VITAL TOOTH BLEACHING The bleaching process is a subject of ongoing research and current theories about the mechanism of action involve a chemical change within the tooth structure.

I.

Mechanism of Bleaching Vital Teeth Bleaching products penetrate enamel and dentin reaching the pulp10 within 5–15 minutes.8,11 Bleaching products break down larger pigmented organic molecules, called chromogens, into smaller, less pigmented constituents that are locked in the enamel matrix and dentinal tubules.2,12,13 The chemical reactions from bleaching products changes the optical qualities of the tooth color.14

II.

Tooth Color Change with Vital Tooth Bleaching The color of the teeth is influenced by thickness of enamel and underlying color of dentin. Color of both dentin and enamel are changed; primarily the dentin color is changed.15 Dentin color is either yellow or gray and can be seen through the enamel due to its translucency. Darker teeth take more time to lighten. Each tooth reaches a maximum color change. Additional bleaching product or contact time will not necessarily result in a lighter color.15 Bleaching products cause teeth to become dehydrated during and after product administration. A lighter shade can result temporarily. Color will stabilize approximately 2 weeks after bleaching.15,16

III. Materials Used for Vital Tooth Bleaching Both hydrogen peroxide and carbamide peroxide are used to lighten vital teeth. Hydrogen peroxide is approximately three times stronger than carbamide peroxide.6 Hydrogen peroxide has a short working time; carbamide peroxide has an extended working time.11 Figure 43-1 compares the release or duration time of carbamide peroxide with hydrogen peroxide.

FIGURE 43-1 • Release Time of Carbamide Peroxide Compared to Hydrogen Peroxide. Hydrogen peroxide has a much shorter working time than carbamide peroxide and causes more sensitivity. Hydrogen peroxide releases all of the peroxide within 1.5 hours. Carbamide peroxide releases the peroxide over a much longer time. Hydrogen peroxide is approximately three times stronger than carbamide peroxide. (Figures courtesy of Dr. Van Haywood. Reprinted from Haywood VB. Treating sensitivity during tooth whitening. Compend Contin Educ Dent. 2005;28(9, suppl 3):11-20. © 2005, AEGIS Publications, LLC. Used with permission.)

The chemicals are used alone or in combination with each other. Bleaching materials need an appropriate viscosity to flow over the tooth surface but not so excessive as to spread onto gingival and

other oral tissues.

A. Hydrogen Peroxide Used directly or produced through a chemical reaction when carbamide peroxide breaks down (see Figure 43-2).15

FIGURE 43-2 • Hydrogen Peroxide and Carbamide Peroxide Product Breakdown. Flowchart to show breakdown of bleaching products. Hydrogen peroxide breaks down into oxygen and water; carbamide peroxide breaks down into hydrogen peroxide and urea, which further break down as shown.

Has a lower pH than carbamide peroxide, which may result in demineralization or erosion when used for longer treatment times than recommended.2,17 May result in dentin changes which never recover.18 Takes less time per day, but more days to change tooth color effectively.8 Higher concentrations of hydrogen peroxide may result in greater sensitivity and more color relapse after termination of bleaching.18

B. Carbamide Peroxide Active agent in most bleaching systems in a 10% concentration. Breaks down into hydrogen peroxide and urea. As shown in the flowchart (Figure 43-2), urea may further break down into ammonia with high pH to facilitate bleaching. Has slow release: 50% of peroxide released in 2–4 hours and remainder of peroxide in 2–6 hours resulting in less sensitivity.11 In Figure 43-1, the release time is shown for carbamide peroxide compared with hydrogen peroxide. At neutral pH, 10% solution is both safe and effective as a bleaching agent.8,19 Takes fewer days but more contact time to change tooth color effectively.1

C. Desensitizers Materials to reduce the sensitivity side effect of bleaching may be added to bleaching systems. Materials can be: Incorporated into the bleaching gel. Applied to teeth before bleaching. Given for use in trays before, during, and after treatment. Material used: Potassium nitrate: creates a calming effect on pulp by affecting the transmission of nerve impulses.20,11 Sodium fluoride: aid in remineralization.21 Calcium phosphate and amorphous calcium phosphate: aid in remineralization.20,11

D. Other Ingredients Carbopol: a water-soluble resin used as a thickening agent, which: Prolongs the release of hydrogen peroxide from carbamide peroxide.

Promotes quicker results. Glycerin: a gel to thicken and control the flow of bleaching agent to prevent overextending onto gingival tissues. Sodium hydroxide: a cleaning agent. Surfactants: help to lift and remove extrinsic stains. Flavoring: aids in patient satisfaction and compliance.

IV. Vital Tooth-Bleaching Safety A. Tooth Structure Both hydrogen peroxide 3.5% and carbamide peroxide 10% are considered safe to lighten the color of teeth when professionally monitored.8,9 Hydrogen peroxide at concentrations of 30% or higher may: Remove the enamel matrix. Create microscopic voids that scatter light. Result in increased whiteness until remineralization occurs and color partly relapses.1 Carbamide peroxide 10% will cause fewer changes in the enamel matrix.1,13,22 Pulpal necrosis was noted when material combined with excessive heat or trauma.23

B. Soft Tissue Hydrogen peroxide is caustic and may cause burning and bleaching of the gingiva and any exposed oral tissue.3 Hydrogen peroxide 10% concentration or higher has greater incidence of gingival irritation.8 Ill-fitting or overfilled tray may cause product spillage onto soft tissues resulting in tissue burning.

C. Restorative Materials

Restorative material color will not be lightened by bleaching. Complications with current restorations may include13: Increased surface roughness. Change in surface color. Increased microleakage. After bleaching, new restorative procedures need to be delayed for 2 weeks to allow for color stabilization.19 Bonding needs to be delayed for 2 weeks due to significantly reduced bonding strength associated with recently bleached tooth surface.18 Bleaching chemicals containing hydrogen peroxide may: Have a negative effect on restorations and restorative materials due to lower pH, although impact does not necessarily require the renewal of the restoration.16 Increase mercury release from amalgam restorations giving off a green hue.16 Increase solubility of some dental cements.13

D. Systemic Factors The use of tooth-bleaching products containing hydrogen peroxide or carbamide peroxide has not been shown to increase the risk of oral cancer in the general population, including those persons who are alcohol abusers and/or heavy cigarette smokers.8 Accidental ingestion of small amounts of the product may cause sore throat, nausea, vomiting, abdominal distention, and ulcerations of the oral mucosa, esophagus, and stomach.13 Medications that may be associated with photosensitivity and hyperpigmentation when light-activated bleaching agents are used are listed in Box 43-1.

BOX 43-1 Medications Associated with Potential Photosensitivity and Hyperpigmentation

• • • • • • • • • • • • • • • • • •

Acne medications Antiarrhythmic drugs Antibiotics Anticancer drugs Antidepressants Antihistamines Antiparasitics Antipsychotics Antiseizure medications Arthritis medications Birth control medications Coal tar Diuretics Hypoglycemics Nonsteroidal anti-inflammatory drugs Steroids Tranquilizers Sulfur-containing drugs

E. Cautions and Contraindications Associated with Vital Tooth Bleaching Personal factors affecting acceptance for treatment may include: Subjective determination when tooth shade is acceptable. Patients with unrealistic personal expectations. Poor patient compliance with treatment results in suboptimal results. Patients with tooth conditions that do not respond favorably to vital tooth bleaching (see Table 43-1). TABLE 43-1 • Decision Making for Tooth Bleaching TOOTH CONDITION

RESPONSE TO TOOTH BLEACHING

SPECIAL CONSIDERATIONS

Yellow color

Normally excellent.

Resistant yellow may be tetracycline stain.

Enamel white

Do not bleach well or may

Eventually background

spots

get lighter during bleaching.

color lightens resulting in less noticeable white spots. Goes through splotchy stage before background color whitens. Microabrasion may lessen white spots if less than one-third through enamel.

Brown fluorosis stains

Respond 80% of the time.

Microabrasion techniques done after bleaching and color stabilization may improve final result.

Nicotine stains

Require longer treatment.

May take 2–3 mo of nightly application.

Tetracycline stains

Multicolored band may not respond well.

Requires 2–12 mo of daily bleaching.

Gray most difficult. Dark grays only get lighter. Dark cervical has poorest prognosis. Minocycline stains

Will respond; will take longer than yellow stain.

Root exposure

Does not respond to bleaching.

Type of tetracycline stain. Gives gray hue. Better treated with periodontal coverage.

Dentinogenesis No significant imperfecta and improvement with amelogenesis bleaching. imperfecta

Inherited condition resulting in defective dentin and enamel, respectively.

Microcracks

Bright light or magnification required during assessment to view; may appear streaky during bleaching process.

Become whiter than rest of tooth.

Anterior lingual amalgams

Become more visible after bleaching.

Replacement with very light composite restoration before bleaching.

Dental caries

Not to be bleached.

Dark canines

Require longer bleaching.

Isolated canine treatment until color match.

Attrition

Incisal edges do not respond.

Composite restorations added to incisal edges after bleaching.

Aging

Excellent.

More youthful appearance; root surfaces exposure likely.

Translucent teeth

Bleaching will increase translucency at incisal.

Translucent areas will appear darker after bleaching due to contrast.

Decay removal. Temporary restoration followed by bleaching and final restoration after color stabilization. Carbamide peroxide will increase sensitivity and is bactericidal.

Children and adolescents The American Academy of Pediatric Dentistry discourages fullarch cosmetic bleaching for patients with a mixed dentition, but encourages judicious use of vital and nonvital bleaching due to the negative self-image that may arise from a discolored tooth or teeth.24 Current American Dental Association recommendations for children and adolescent use include8: Delaying treatment until after permanent teeth have erupted. Use of a custom-fabricated tray to limit amount of bleaching gel. Close supervision. Tooth bleaching is contraindicated in the following patients:

Pregnant and lactating women. Use of photosensitive medications (see Box 43-1). Recent cosmetic procedures such as skin peels, facial waxing, or use of certain essential oils. Laser light/power bleaching contraindicated for some patients as described in Box 43-2.

BOX 43-2 Issues Associated with Light-Activated Bleaching Light-activated bleaching is contraindicated for patients who are: • Light sensitive. • Taking a photosensitive medication. • Receiving photochemotherapeutic drugs or treatments such as psoralen and ultraviolet radiation. Exposure to ultraviolet radiation produced by some lights is avoided by those at increased risk for or have a history of skin cancer, including melanoma.

V.

Factors Associated with Efficacy

Some tooth conditions will not respond to tooth bleaching; other tooth conditions will respond slowly (Table 43-1).1,9 The initial color of the teeth and type of stain present will affect the final color change.1,9 Specific indications for bleaching and methods of treatments are listed in Table 43-2. TABLE 43-2 • Indications for Tooth Bleaching and Methods of Treatment INDICATION

METHOD TO TREAT

Discolored, endodontically treated tooth

Internal bleaching; in-office or walking.

Single or multiple discolored teeth

External bleaching: in-office one to three visits or custom trays worn 2–6 wk.

Surface staining

Dental prophylaxis and brushing with whitening dentifrice.

Isolated brown or white discoloration, shallow depth in enamel

Microabrasion followed by neutral sodium fluoride applications.

White discoloration on yellowish teeth Microabrasion followed by custom tray bleaching.

Attrition: occlusal wear through enamel exposes the darker underlying dentin. Concentration of bleaching agent. Ability of agent to reach the stain molecules. Duration of contact of the active bleaching agent: the longer the duration, the greater the degree of bleaching. Number of times the agent is applied to obtain desired results: darker teeth tend to require more treatment applications. Temperature of agent: heat will result in faster oxygen release, but speed of color change may not be altered.

A. Intrinsic Tetracycline and minocycline staining Tetracycline particles incorporate into dentin calcium during mineralization of unerupted teeth. Result: discolored dentin resistant to bleaching.25 Minocycline, a derivative of tetracycline, can discolor erupted teeth.26 Tetracycline and minocycline staining severity varies. A comparison of before and after bleaching of brown tetracycline staining is shown in Figure 43-3.

FIGURE 43-3 • Before and After Bleaching of Brown TetracyclineStained Teeth. A: Patient before treating. B: Patient treated with 10% carbamide peroxide for 2 months. Some tetracycline-stained teeth will require up to 12 months to achieve improved results. Those with severe gray stain or banded staining may require porcelain veneers to achieve an acceptable cosmetic result. (Images courtesy of Dr. Van Haywood. Reprinted from Haywood VB. The “bottom line” on bleaching 2008. Inside Dent. 2008;4(2):2-5. © 2008, AEGIS Publications, LLC. Used with permission.)

First-category staining: light-yellow to light-gray responds to bleaching. Second-category staining: darker and more extensive yellowgray responds to extended bleaching time. Third-category staining: intense dark gray-blue banding stains. Severe third-category staining may require porcelain veneers for satisfactory esthetic result. Some tetracycline stains will require 1–12 months to achieve a satisfactory result. Fluorosis Fluorosis results from ingesting excessive fluoride during tooth development resulting in white or brown spots on teeth. Bleaching does not change white spots, but lightens the background color, making the contrast less noticeable. White spots go through a splotchy stage during bleaching but will return to baseline. Amorphous calcium phosphate may be effective in lessening the white spots if lesion is less than one-third through enamel.27

Brown discoloration responsive to bleach 80% of the time. Resin infiltration or microabrasion may be recommended to decrease additional brown discoloration.28,29 Nicotine Nicotine stains: require 1–3 months of nightly treatment due to the tenacity of the stain.

B. Extrinsic Interactions with Bleaching Agents. Staining agents may compromise treatment.1 Advise patient to avoid: Coffee and tea. Dark sodas or soft drinks. Red wine. Soy sauce. Tobacco. Chromogenic bacteria. Biofilm accumulation. Topical medications.

C. Longevity of Results Relapse of shade occurs almost immediately as newly bleached, dehydrated teeth rehydrate. As months and years pass, teeth may discolor and darken again, especially if stain-inducing activities continue. To maintain shade, periodic bleaching procedures are performed or repeated.

VI. Reversible Side Effects of Vital Bleaching: Sensitivity The most common side effects of bleaching are tooth tingling and sensitivity. Aching sensation can occur because of insult of peroxide

on nerves: a reversible pulpitis.11,21 Up to two-thirds of patients will experience transitory mild-tomoderate tooth sensitivity.8 Primarily occur in the first 2 weeks of treatment and may last days to months after cessation of bleaching. Side effects resolve completely as teeth become accustomed to bleaching. Not correlated with increased wear time.20 Lower concentrations have been used for up to 12 months and do not exhibit greater sensitivity.11 Higher concentrations of hydrogen peroxide may result in greater sensitivity.20 Patients with prior history of tooth sensitivity may be more at risk to develop sensitivity during bleaching. Vulnerable tooth surfaces include: Exposed root surfaces and dentin appear to increase risk of developing sensitivity and need to be protected from bleaching material. Teeth with unrestored abfraction lesions (see Chapter 41) tend to have more sensitivity. Addition of desensitizing materials decreases sensitivity. Treatments to reduce tooth sensitivity are listed in Table 43-3. TABLE 43-3 • Desensitization Procedures for Bleaching Pretreatment

Brush on or use with tray a desensitizing toothpaste containing potassium nitrate, without sodium lauryl sulfate, which removes smear layer from dentin, beginning 2 wk before bleaching. Use toothpaste with prescription strength sodium fluoride. Use toothpaste that includes calcium carbonate.

During treatment

Continue to use desensitizing toothpaste, which includes sodium fluoride or potassium nitrate, daily between treatments. Amorphous calcium phosphate may be used as well.

Increase time intervals between treatments. Reduce exposure time of bleaching materials. Limit the amount in tray to prevent tissue contact. Postbleaching

Sensitivity diminishes with time. Continue daily use of desensitizing dentifrice and amorphous calcium phosphate. Have professional fluoride varnish application. Avoid foods and beverages with temperature extremes or that contain acidic elements.

VII. Irreversible Tooth Damage A. Root Resorption Can occur after bleaching, particularly after intracoronal, nonvital tooth bleaching when heat is applied during the technique.1 Internal and external resorption may become apparent several years after bleaching.1 Occurs usually in cervical third of the tooth.1 Cause may be related to a history of trauma.1 May lead to tooth loss.1 Bleaching agents should not be placed on exposed cementum to avoid complications.1

B. Tooth Fracture May be related to removal of tooth structure or reduction of the microhardness of dentin and enamel.30 More common with nonvital tooth bleaching.31 May lead to tooth loss.30

C. Demineralization Demineralization with slight surface pitting can result from H2O2 concentration above 15%.32 Patient with over-the-counter (OTC) product may not seek or follow professional advice and attempt to get the teeth whiter by using the product more often than recommended. Remineralization should be initiated early and fluoridated carbamide peroxide gels may be a good choice to aid remineralization.33 Remineralization protocols are described in Chapter 25.

D. Erosion Products containing acidic pH may result in tooth erosion over time.13 The higher the percentage of hydrogen peroxide, the lower the pH. More common with OTC bleaching products.

VIII. Modes of Vital Tooth Bleaching A comparison of the advantages and disadvantages of professionally applied and professionally dispensed/professionally monitored systems and the OTC systems is listed in Table 43-4. TABLE 43-4 • Comparisons of Modes of Tooth-Bleaching Systems METHODS Professionally applied utilizing laser/ultraviolet light system procedure

ADVANTAGES Performed as part of comprehensive care. Treatment may be combined with trays and professional grade home bleaching materials. Professional product selection. Patient education.

DISADVANTAGES Higher cost. Higher risk for sensitivity.

Follow-up, evaluation of effectiveness. Sensitivity treatment. Compliance guaranteed. Quickest result. Professionally dispensed, includes professional grade product and trays

Performed as part of comprehensive care. Appropriate patient selection. Professional product selection. Patient education. Follow-up, evaluation of effectiveness. Sensitivity treatment; patient can also use less often if sensitive. Choice of comfortable time and place for application. Potential for best result.

Cost. Longer time to whiten than professionally applied. Patient compliance.

Over-thecounter

Lowest cost. Easier access to purchase. Immediate start. Results and tissue response not monitored. Over-the-counter products have short exposure times, which limit effects. Unsupervised.

No comprehensive exam. Slowest and least effective results. Noncustomized delivery. Compliance issues. Bulky fit for patient (see Figure 43-8).

FIGURE 43-8 • Comparison of At-Home Bleaching Trays. A: Scalloped professionally dispensed bleaching trays. B: Over-the-counter (OTC) bleaching trays made by patient at home. Professionally dispensed trays are fitted to the patient using impressions, casts, and flexible plastic for custom fit.

OTC trays are more bulky and prepared by patient at home. (Photo courtesy Heather Hessheimer, RDH, MS.)

The different methods of tooth bleaching can achieve similar, effective results, although the mode of delivery, length of treatment, and ease of treatment vary.

A. Professionally Applied Professionally applied bleaching is performed with high concentrations of 30%–40% hydrogen peroxide or 35%–44% carbamide peroxide. Bleaching gels are administered by a dental professional and are not for at-home use. Some systems use activation or enhancement with a light or heat source. Local anesthesia should not be used in order to monitor heatprovoked sensitivity. Heat applied or produced by the use of light may cause an adverse effect such as necrosis of the pulp of the tooth.34 Additional issues associated with the use of a light-activated bleaching are listed in Box 43-2. Laser-safe/ultraviolet light protection of eyes for all in treatment room is required. Gingival sensitivity or irritation may occur. Rubber dam or an equivalent technique, such as a liquid lightcured resin dam, should be used to isolate the caustic agents from contact with soft tissues. Take care to assure the liquid light-cured resin dam is in the interproximal spaces to protect gingival tissue. Improvements in paint-on rubber dams, cheek, lip retractors, and lower concentrations of peroxide have made in-office bleaching safer for patient and dentist.

Treatment may take one to six applications for preferred results. Time for each application varies between different products; ranges from 30- to 60-minute treatment. Laser/power bleaching treatment plan may also involve use of bleaching trays for home use.

B. Professionally Dispensed/Professionally Monitored Also called bleaching trays, external bleaching, at-home bleaching. Study model preparation: An impression of the teeth is taken to prepare the cast for fabrication of the tray. Inspect impression to ensure all anatomy is present without bubbles or voids. Dental stone is poured into impression with little time delay to avoid distortion. Place impression on vibration plate while slowly pouring stone mixture in impression to avoid bubbles on the cast surface. After entire arch is filled with stone mixture, let solidify for one hour. Remove cast from impression and inspect for voids. An ideal cast is trimmed into a horseshoe shape with the central incisors perpendicular to the base to allow proper suction during tray formation. With a moderate grasp, place back of cast on model trimmer pushing lightly. Hold the cast with the occlusal plane parallel to wheel until vestibule is removed. Light-cured block-out resin can be placed on the surfaces of teeth to be bleached. A 1-mm border with no block-out should be maintained to allow proper fit of bleaching tray to the tooth. Tray preparation: Thin, vacuum-formed custom trays are made for each dental arch to be bleached. Place prepared cast on base of vacuum former and place sheet

of thin tray material in holder. Raise to heating element and heat tray material until sags one inch. Lower material to the vacuum base and allow machine to suction material around cast for one minute. Carefully remove from base since material may be hot. Cool completely before removing cast from material. Trays should be trimmed with small, sharp scissors in a smooth motion to produce uniform edges. As shown in Figure 43-4, trays are either scalloped at gingival margin or unscalloped and trimmed 1–2 mm from deepest portion of gingival margin, taking care to cut around the incisive papilla and frena.

FIGURE 43-4 • Scalloped and Unscalloped Bleaching Tray Designs. Either scalloped or unscalloped trays may be used. A: Scalloped trays aim to protect the gingiva and exposed root surfaces. B: Unscalloped trays are more comfortable and take less preparation time. Patients need to be warned to avoid overfilling trays.

Nonscalloped trays seal better. Trays are fitted to the patient and adjusted to ensure bleaching material will not come into contact with soft tissues. Patient instruction: Instructions and bleaching materials for use in the trays at home should be provided. Patient should practice placing correct amount of bleaching gel

to demonstrate understanding. Once or twice daily application for 1–2 weeks is usually recommended if lack of sensitivity and other side effects permit. Maximum color change obtained with consistent compliance (see Figure 43-5).

FIGURE 43-5 • Home Tray Bleaching Treatment. A: Before treatment. B: After treatment. (Photo courtesy of Gordon J. Christensen DDS MSD PhD. Used with permission.)

The enamel may become more porous during treatment13; therefore, patient should be advised to avoid staining agents. Patient retains the trays after completion of bleaching to reuse for touch-ups as needed. Professionally dispensed bleaching products are commonly recommended after professionally applied bleaching procedures to maintain and promote results.

C. OTC Products Also called at-home or self-directed products. When asked about use of the self-directed product, a dental hygienist may stress the need for professional examination and supervision; the products can cause harm if misused, may irritate tissues, or cause systemic illness if ingested. May be recommended to help maintain results of professionally applied and professionally dispensed methods of bleaching.

The dental professional must be informed of patient’s proposed use of OTC products to discuss risks and possible interaction with any proposed dental treatment. An oral evaluation is recommended before use of the at-home or OTC products, as well as appropriate dental and periodontal treatment including calculus, stain, and biofilm removal. Delivered through various packaging, viscosities, and flavors (Box 43-3).

BOX 43-3 Over-the-Counter Bleaching Preparations Strips • Hydrogen peroxide is delivered on polyethylene film strips. • Strips are placed on the teeth up to two times per day for 30 minutes for about 2 weeks. Prefabricated Trays • Thin-membrane tray loaded with bleaching agent is adapted to maxillary or mandibular arch. • Usually worn 30–60 minutes daily for 5–10 days. Paint-on • Carbamide peroxide is incorporated into a thick gel that is painted on the teeth selected to be bleached. • An advantage to this method is that individual teeth may be bleached. Dentifrice • Used to help keep teeth cleaner, and therefore look whiter. • Some have more abrasive materials to remove extrinsic stains. • Owing to short exposure time, the bleaching agent in the dentifrice has little effect on staining. • Some contain hydrogen peroxide; others contain agents that may deter further attachment of stains to the teeth. Mouthrinse • Content of alcohol is avoided in selection of mouthrinse.

NONVITAL TOOTH BLEACHING Also called walking bleach method and internal bleaching, nonvital tooth bleaching involves the bleaching of a single, endodontically treated tooth that is discolored. Alternative to more invasive correction, such as a post and core with crown. Performed by a dentist. Requirements for procedure: Healthy periodontium. Successfully obturated root canal filling. Root canal filling is sealed off with a restorative material before treatment to prevent bleaching agent from reaching periapical tissue.

I.

Procedure for Bleaching Nonvital Teeth Hydrogen peroxide and/or sodium perborate is placed in the pulp chamber, sealed, and left for 3–7 days, as outlined in Box 43-4.

BOX 43-4 Procedure for Nonvital Tooth Bleaching Periodontally healthy, endodontically treated tooth:

1. Photograph of the tooth to be bleached with shade guide. 2. Provide dental hygiene services to remove extrinsic stain and calculus. 3. Probe circumferentially to determine the outline of the cementoenamel junction. 4. Rubber dam isolation is applied to prevent contamination of root canal therapy. 5. Prepare access cavity. Remove all endodontic obturation material, sealer, cement, and necessary restorative material without removing more dentin than necessary. 6. Remove 2–3 mm of obturation material from the root canal to level below the crest of the gingival margin. 7. Irrigate access cavity with copious amount of water and dry well without

8. 9. 10. 11.

desiccating. Root canal therapy is sealed off, commonly with glass ionomer cement or other filling material. Medicament is placed in pulp chamber. Pulp chamber is sealed with a temporary restoration. Patient returns in 3–7 days for evaluation.

Aforementioned procedure is repeated several times until desired result is obtained. To finalize procedure: 1. 2. 3. 4. 5.

Rubber dam isolation. Temporary restoration on medicament is removed. Pulp chamber is irrigated thoroughly with water. Coronal restoration is placed; generally a composite material. Photograph tooth with corresponding shade guide for records.

Hydrogen peroxide and sodium perborate may be synergistic and very effective in bleaching the tooth. The process is repeated until a satisfactory result is obtained. Once a satisfactory result is obtained, the pulp chamber is sealed with glass ionomer cement. Appoint patient 2 weeks later to place permanent, bonded, composite-resin restoration in access cavity to allow dissipation of residual oxygen that would interfere with efficacy of bonding agent. If unsuccessful after repeated attempts, techniques for vital tooth bleaching can be tried or an alternative restorative procedure can be tried, such as a post and core with crown.

II.

Factors Associated with Efficacy Results usually last longer than external tooth bleaching. There is no universal standard for what is considered acceptable esthetics. Personal background, culture, and patient’s image of esthetics are factors. The dentist initially may not identify a patient’s esthetic issues in the same way that the patient identifies them.

Careful communication and agreement about the course of treatment and the expected result of treatment before the start of bleaching by the patient is essential.

DENTAL HYGIENE PROCESS OF CARE I. Patient Assessment Review of medical history; identify any contraindications for bleaching. Complete dental assessment include the following: Complete extraoral and intraoral examination including oral cancer screening. Updated radiographs. Comprehensive dental exam. The presence of cavitated dental caries is a contraindication for bleaching. A lesion is prepared and restored with a temporary restoration to be replaced with permanent matching restoration upon completion of bleaching. To identify abscesses or nonvital teeth, which would require endodontic therapy before bleaching. Comprehensive periodontal examination including areas of recession. Cementum needs to be protected from bleaching material to avoid potential internal and/or external resorption. Determine initial tooth shade either manually with a shade guide (Figure 43-6) or electronically with a spectrophotometer (Figure 437). Box 43-5 provides tips for manually selecting a tooth shade.

FIGURE 43-6 • Manual Selection of Tooth Shade. Patient’s shade taken, recorded, and photographed in natural light or color-corrected lighting after

extrinsic stain removal before bleaching. A: Several manufacturers provide color ranges with as many as 29 shades. B: Patient’s shade and photograph are recorded at each visit while in bleaching treatment. (Photo courtesy Heather Hessheimer, RDH, MS.)

FIGURE 43-7. Digital Photographic Record of Tooth Shade. Electronic digital shade guides provide objective records. (Photo courtesy of Heather Hessheimer, RDH, MS.)

BOX 43-5 Tips for Manually Selecting Tooth Shade Three concepts should be considered when determining tooth shade: hue, chroma, and value. Hue refers to the color of a tooth. Some teeth are more yellow while others are more red or gray. Chroma refers to the saturation, or intensity of the color. Value is the lightness or brightness of the color. When selecting tooth shade, it is best to start with selecting the proper value.

1. Arrange shade guide on the value scale with incisal edges oriented for maxilla. 2. Limit extra light sources in the room. Have patient face natural lighting if possible.

3. 4. 5.

6. 7.

Remove any distracting colors from view, such as wiping off lipstick or covering brightly colored clothing. Rest eyes by looking at light-gray color prior to shade matching. Hold shade guide close to patient’s teeth so shadow of the upper lip will be similar and select the value that best represents their tooth brightness. When debating between two shades, select the lighter of the two. Next select the chroma that best correlates in that value range. Finally, confirm the hue of the selected shade is appropriate for the tooth being matched.

Obtain photographic record of tooth shade without lipstick or strong clothing colors that may interfere with accurate assessment. Use the canine for base color. Color will be gray or yellow. Confirm with patient. Identify those factors that would lead to a guarded prognosis for bleaching such as: Unrealistic expectations of the patient. History of sensitive teeth. Extremely dark gingival third of tooth visible during a smile. Extensive white spots that are very visible. Temporomandibular joint dysfunction or bruxism that would make wearing bleaching trays uncomfortable and potentially aggravate condition. Inability to tolerate the taste of the product. Identify contraindications for at-home bleaching including the following: Presence of sensitive teeth. Unwillingness or inability to comply with at-home treatment routines. Excessive existing restorations not requiring replacement. Pregnancy or lactation.

II.

Dental Hygiene Diagnosis

Deficit in wholesome body image as evidenced by patient statement related to dissatisfaction of tooth color.

III. Dental Hygiene Care Plan Plan dental hygiene therapy and preventive procedures. Choose appropriate bleaching method. Discussion of procedure, risks, and realistic results. Plan with patient for anticipated needs after bleaching, such as replacement of existing tooth-colored restorations that will not match after bleaching. List procedure and risks. Encourage questions. Obtain informed consent and patient’s signature (see Chapter 23).

IV. Implementation Dental hygiene therapy: debridement of all soft and hard deposits along with extrinsic stains. Pretreatment desensitization when indicated. Recommended procedures for pretreatment, during treatment, and postbleaching are listed in Table 43-3. Premedication with anti-inflammatory pain medication when indicated for sensitivity. Preparation of trays: impression and construction. Provide patient education and instructions for use with an emphasis on the following: Tooth sensitivity treatment and sensitivity prevention. Effective daily biofilm removal before bleaching material use to prevent additional extrinsic stain accumulation. Avoidance of foods that stain teeth such as coffee, red wine, and use of tobacco to maximize results. Use of nonabrasive whitening dentifrice. Avoidance of overfilling tray to protect soft tissue and exposed cementum. Removal of excess bleaching material after use. Avoidance of swallowing bleaching material due to irritation of materials to mucosa.

V.

Evaluation and Planning for Maintenance

Monitor appointments as needed to assess patient compliance, results, and sensitivity. At continuing care appointments, compare tooth color with tooth color guide. Take follow-up photos as appropriate for records. Tooth color from bleaching relapses with time. Plan for repeat of bleaching process at appropriate intervals.

DOCUMENTATION Documentation in the patient’s permanent record when planning tooth bleaching includes a minimum of the following: Current oral conditions. Consent to treat related to tooth bleaching. Services provided including necessary records for tooth shade. Impressions and preparation of the trays. Demonstration of tray filling, positioning, timing, and cleaning. Instructions given to patient. Planned follow-up care and appointments. Patient problems or complaints expressed. An example documentation is shown in Box 43-6.

BOX 43-6 Example Documentation: Patient Receiving Vital Tooth Bleaching S–Patient states she is unhappy with the color of teeth. Patient states she has sensitive teeth. O–Tooth shade: C-1; appears to have only yellow stain. Patient’s medical and dental histories present no contraindications for tooth bleaching. Radiographs and dental examination reveal absence of cavitated caries. A–Patient presents with a deficit in wholesome body image as evidenced by her statement she is self-conscious of tooth color. P–Consent for treatment signed and copy given to patient. Completed prophylaxis with all extrinsic stain removed. Intraoral photographs obtained to document tooth color. Impressions and preparation of bleaching trays. Dispensed three syringes of carbamide peroxide 10%. Patient instructed to brush with potassium nitrate product for 2 weeks before beginning bleaching process; after beginning bleaching use of carbamide peroxide 10% every other day. Patient demonstrated dispensing correct amount of bleaching gel into tray. Patient states: tray provides comfortable fit; understanding of sensitivity treatment; and willingness to return for follow-up appointment. Next steps: Patient scheduled for follow-up appointment 2 weeks after bleaching process initiated. Signed: ______________________________, RDH

Date: ____________________________________

EVERYDAY ETHICS Sarah is a 32-year-old female who presents as a new patient with the chief complaint of “wanting whiter teeth.” Upon examination, multiple carious lesions and moderate periodontal disease is diagnosed. The dental hygienist, Sharron, educates Sarah about the need to control her diseases prior to proceeding with bleaching processes, but Sarah expresses her desire to start with bleaching and she will schedule for the other care after her results are achieved. Questions for Consideration 1. Is it ethical to perform an elective bleaching procedure prior to treating the disease? Explain. 2. Consider the steps in resolving an issue or a dilemma (see Chapter 1). What are the rights of each of the individuals involved in this situation? Are there any conflicts of interest that Sharron must identify as she works through the steps in resolving this issue? 3. What financial, legal, or cultural factors need consideration if Sharron is to identify an alternative approach that will lead to a positive outcome? Describe her possible approaches.

Factors to Teach the Patient Why a complete oral cancer screening and dental examination, including radiographs and periodontal evaluation, is performed before any form of bleaching is initiated. During bleaching, teeth and gingival tissues may become sensitive for a period of time. If sensitivity is experienced, use a desensitizing product, discontinue bleaching, or delay next treatment. Regardless of method, color relapse occurs in a relatively short period of time. Excessive use of bleaching products may be harmful. Follow manufacturer’s directions. Existing tooth-colored restorations will not change color, and therefore may not match and may need to be replaced after bleaching.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Byrne BE, McIntyre F. Chapter 12: Bleaching agents. In: ADA/PDR Guide to Dental Therapeutics. 5th ed. Chicago, IL: American Dental Association; 2009:351. 2. Carey CM. Tooth whitening: what we now know. J Evid Based Dent Pract. 2014;14:70-76. 3. Dahl JE, Pallesen U. Tooth bleaching—a critical review of the biological aspects. Crit Rev Oral Biol Med. 2003;14(4):292-304. 4. Truman J. Bleaching of non-vital discolored anterior teeth. Dent Times. 1864;1:69-72. 5. Spasser HF. A simple bleaching technique using sodium perborate. NY State Dent J. 1961;27:332. 6. Mokhlis GR, Matis BA, Cochran MA, et al. A clinical evaluation of carbamide peroxide and hydrogen peroxide whitening agents during daytime use. J Am Dent Assoc. 2000;131(9):1269-1277. 7. Haywood VB, Heymann HO. Nightguard vital bleaching. Quintessence Int. 1989;20(3):173-176. 8. ADA Council on Scientific Affairs. Tooth Whitening/Bleaching Treatment Considerations for Dentists and Their Patients. Chicago, IL: American Dental Association; 2009:12. 9. Albanai SR, Gillam DG, Taylor PD. An overview of the effects of 10% carbamide peroxide and its relationship to dentine sensitivity. Eur J Prosthodont Restor Dent. 2015;23(2):50-55. 10. Bharti R, Wadhwani KK. Spectrophotometric evaluation of peroxide penetration into the pulp chamber from whitening strips and gel: an in vitro study. J Conserv Dent. 2013;16(2):131-134. 11. Haywood VB. Treating sensitivity during tooth whitening. Compend Contin Educ Dent. 2005;26(9, suppl 3):11-20. 12. Ubaldini AL, Baesso ML, Medina Neto A, et al. Hydrogen peroxide diffusion dynamics in dental tissues. J Dent Res. 2013;92:661-665. 13. Alqahtani MQ. Tooth-bleaching procedures and their controversial effects: a literature review. Saudi Dent J. 2014;26:33-46. 14. Sanchez NP, Aleksic A, Dramicanin M, et al. Whitening-dependent changes of fluorescence of extracted human teeth. J Esthet Restor Dent. 2017;29(5):352355. 15. Haywood VB. Chapter 1: Diagnosis and treatment planning for bleaching. In: Tooth Whitening Indications and Outcomes of Nightguard Vital Bleaching. Chicago, IL: Quintessence; 2007:1–26. 16. Sweeney MR. Tooth whitening. In: Gladwin M, Bagby M, eds. Clinical Aspects of Dental Materials. Philadelphia, PA: Lippincott, Williams & Wilkins; 2009:212222. 17. Abou Neel EA, Aljabo A, Strange A, et al. Demineralization-remineralization

dynamics in teeth and bone. Int J Nano 2016;11:4743-4763. 18. Haywood VB. The “bottom line” on bleaching 2008. Inside Dent. 2008;4(2):2-5. 19. Matis BA, Wang Y, Eckert GJ, et al. Extended bleaching of tetracycline stained teeth: a 5-year study. Oper Dent. 2006;31(6):643-651. 20. Pintado-Palomino K, Filno OP, Zanoito ED, et al. A clinical, randomized, controlled study on the use of desensitizing agents on bleaching. J Dent. 2015;43:1099-1105. 21. Wang Y, Gao J, Jiang T, et al. Evaluation of the efficacy of potassium nitrate and sodium fluoride as desensitizing agents during tooth bleaching treatment— a systematic review and meta-analysis. J Dent. 2015;43(8):913-923. 22. Zanolla J, Marques ABC, da Costa DC, et al. Influence of tooth bleaching on dental enamel microhardness: a systematic review and meta-analysis. Aust Dent J. 2017;62:276-282. 23. De Moor RJ, Verheyen J, Verheyen P, et al. Laser teeth bleaching: evaluation of eventual side effects on enamel and the pulp and the efficiency in vitro and in vivo. Sci World J. 2015;2015:835405. 24. American Academy of Pediatric Dentistry Council on Clinical Affairs. Policy on the use of dental bleaching for child and adolescent patients. Oral Health Policies. 2017-2018;39(6):90-92. 25. Mello HS. The mechanism of tetracycline staining in primary and permanent teeth. J Dent Child. 1967;34(6):478-487. 26. Basting RT, Rodrigues AL Jr, Serra MC. The effect of 10% carbamide peroxide, carbopol and/or glycerin on enamel and dentin microhardness. Oper Dent. 2005;30(5):608-616. 27. Reema SD, Lahiri PK, Roy SS. Review of casein phosphopeptides-amorphous calcium phosphate. Chin J Dent Res. 2014;17(1):7-14. 28. Gugnami N, Pandit IK, Gupta MG, et al. Comparative evaluation of esthetic changes in nonpitted fluorosis stains when treated with resin infiltration, inoffice bleaching, and combination therapies. J Esthet Restor Dent. 2017;29:317-324. 29. Penumatsa NV, Sharanesha RB. Bleaching of fluorosis stains using sodium hypochlorite. J Pharm Bioallied Sci. 2015;7(suppl 2):5766-5768. 30. Elfallah HM, Bertassoni LE, Charadram N. Effect of tooth bleaching agents on protein content and mechanical properties of dental enamel. Acta Biomater. 2015;20:120-128. 31. Kazemipoor M, Shagheyegh A, Farnaz F. Concurrent effects of bleaching materials and the size of root canal preparation on cervical dentin microhardness. Iran Endod J. 2017;12(3):298-302. 32. Grazioli G, Valente LL, Isolan CP, Pinheiro HA, Duarte CG, Münchow EA. Bleaching and enamel surface interactions resulting from the use of highlyconcentrated bleaching gels. Arch Oral Biol. 2018;87:157-162. 33. Bollineni S, Janga RK, Venugopal L, Reddy IR, Babu PR, Kumar SS. Role of fluoridated carbamide peroxide whitening gel in the remineralization of demineralized enamel: an in vitro study. J Int Soc Prev Community Dent. 2014 May;4(2):117-121.

34. Mondelli RF, Soares AF, Pangrazio EG, Wang L, Ishikiriama SK, Bombonatti JF. Evaluation of temperature increase during in-office bleaching. J Appl Oral Sci. 2016;24(2):136-141. doi:10.1590/1678-775720150154.

SECTION

VIII Evaluation INTRODUCTION FOR SECTION VIII Evaluation of dental hygiene care is a determination of whether the oral health goals identified in the patient’s care plan have been met. The systematic evaluation of dental hygiene prevention and treatment interventions: Relies on the careful collection of data and comparison of posttreatment information with baseline data. Determines further treatment needs and appropriate periodontal maintenance interval. Allows comparison with both previous and future observations to determine changes in the patient’s oral health status over time.

THE DENTAL HYGIENE PROCESS OF CARE Evaluation is an essential component of every step in the dental

hygiene process of care, as illustrated by the arrows in Figure VIII1.

FIGURE VIII-1 • The Dental Hygiene Process of Care.

Description The dental hygienist who evaluates each step in the process during each patient appointment will assure that attention is paid to any

changing circumstance that affects patient care or treatment outcomes. As the process of patient care continues: A new care plan, based on evaluation data, will address further treatment or preventive needs and/or determine the proper maintenance interval to support the patient’s oral health status. During the maintenance appointment, the process will be used to determine if the patient’s needs have changed and to plan and implement interventions that meet those needs.

ETHICAL APPLICATIONS It is beneficial to evaluate an ethical situation involving treatment outcomes or self-evaluation of professional skills and abilities based on the Standards of Professional Responsibility outlined in the ADHA Code of Ethics and listed in Box VIII-1.

Box VIII-1 Standards of Professional Responsibility Professional dental hygienists acknowledge the following responsibilities: • To ourselves as individuals and professionals. • To family and friends. • To patients. • To employers and employees. • To the dental hygiene profession. • To the community and society. • To scientific investigation.

The ethical dental hygienist will: Assess how a particular decision could potentially affect each of the professional roles of a dental hygienist. Evaluate a choice of action that acknowledges each area of professional responsibility.

44 Principles of Evaluation Charlotte J. Wyche, RDH, MS

CHAPTER OUTLINE PRINCIPLES OF EVALUATION I. II. III.

Purposes of Evaluation Evaluation Design Evaluation Process

EVALUATION BASED ON GOALS AND OUTCOMES EVALUATION OF CLINICAL (TREATMENT) OUTCOMES I. II. III.

Visual Examination Periodontal Probing Tactile Evaluation

EVALUATION OF HEALTH BEHAVIOR OUTCOMES I. II.

Visual Examination Interview Evaluation

COMPARISON OF ASSESSMENT FINDINGS

STANDARD OF CARE SELF-ASSESSMENT AND REFLECTIVE PRACTICE I. II. III.

Purpose Skills and Methods A “Critical Incident” Approach

DOCUMENTATION I. II.

Patient Care Outcomes Self-assessment and Reflection

EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Identify and define key terms and concepts related to the evaluation of dental hygiene interventions. 2. Discuss standards for dental hygiene practice. 3. Identify skills related to self-assessment and reflective dental hygiene practice.

PRINCIPLES OF EVALUATION Evaluation is a systematic determination of worth, value, or significance.1 Ongoing evaluation is an important component of providing evidence-based dental hygiene care. Evaluation measures determine whether treatment and oral health education goals outlined in the dental hygiene care plan are achieved.2–4 As illustrated in the dental hygiene process of care (Figure VIII-1), ongoing evaluation at each step provides feedback to determine success or indicate the need to modify procedures throughout the process.

I.

Purposes of Evaluation Ongoing evaluation measures patient satisfaction with care provided. Assessing the outcome of both clinical and preventive interventions at the completion of a treatment cycle identifies need for further treatment and adapted self-care protocols. The evaluation process also helps to determine the appropriate continuing care interval to maintain an achieved increase in oral health status.

II.

Evaluation Design The four most common types of evaluation design (listed with dental hygiene practice examples in Table 44-1) include5: TABLE 44-1 • Four Most Common Types of Evaluation TYPES OF EVALUATION

DENTAL HYGIENE PRACTICE EXAMPLES

Formative evaluation

Information collected during dental hygiene

assessment that will allow the dental hygienist to monitor patient needs (e.g., need for pain control) and adapt care to the patient’s general health or oral health status Process evaluation

Immediate: use of explorer to check for residual calculus Ongoing: monitoring of tissue trauma during instrumentation or evaluation of patient selfcare during a multi-appointment treatment sequence

Outcome evaluation

Determination at end of treatment sequence to confirm whether oral health goals stated in the patient’s treatment plan have been met

Impact evaluation

Assessment of the impact of oral health treatment on the patient’s overall health status

Formative evaluation Process evaluation Outcome evaluation Impact evaluation. A plan for evaluation of patient care outcomes includes informal monitoring, feedback, and modifications in patient care provided during each patient appointment. Methods for evaluating the success of dental hygiene treatment have traditionally included collecting new clinical data, such as probing depths and areas of bleeding, to compare with the patient’s health status at the beginning of treatment. The evaluation process includes measures to assess the extent to which disease prevention and health promotion interventions have been effective. A comparison of pre- and posttreatment outcomes indicates areas of success or areas of need for further intervention.

III. Evaluation Process

When writing the dental hygiene care plan, indicators (evaluation measures) that will evaluate each oral health goal and outcome can be determined. Following treatment, new complete assessment data are documented. An evidence-based decision-making approach is used to determine any necessary modifications to the ongoing treatment sequence or to plan maintenance care. All assessment findings and any planned modifications for treatment or oral health education are documented in an evaluation summary.

EVALUATION BASED ON GOALS AND OUTCOMES The dental hygiene care plan establishes individualized short- and long-range patient goals for each dental hygiene intervention. The treatment, education, and self-care instruction goals listed in the patient’s care plan provide the basis for evaluating whether the expected outcomes have been achieved at each level. Outcomes that can be evaluated following the completion of dental hygiene treatment and patient education in each area of a threepart plan for care are listed in Box 44-1.

BOX 44-1 Expected Outcomes Following Dental Hygiene Interventions Gingival/Periodontal Health Outcomes • Reduced dental biofilm • Smooth tooth surfaces with calculus removed • Reduced probing depths • No bleeding on probing, exudate, or suppuration • Resolution of erythematous tissue • Reduced swelling and edema • No further loss in attachment level • Decrease or no change in mobility Dental Caries Risk Outcomes • No new cavitated lesions • Demineralized/non-cavitated areas resolved • Reduced intake of cariogenic foods/beverages • Dental sealants placed • Increased fluoride use Prevention Outcomes • Elimination of iatrogenic factors (calculus, restoration overhangs) • Increased percentage of biofilm-free areas • Patient demonstration of recommended oral care procedures

• • • •

Patient report of compliance with daily care recommendations Compliance with recommended continuing care interval Tobacco-free status achieved Modification/stabilization of systemic risk factors

Selected outcomes are used to develop goals for patient care when writing a new dental hygiene care plan.

EVALUATION OF CLINICAL (TREATMENT) OUTCOMES Final evaluation of dental hygiene treatment outcomes is performed after initial therapy has been completed, when the response of the gingival tissue to therapy is apparent. When a treatment sequence consists of multiple appointments, evaluation of the previously treated areas at each subsequent appointment allows immediate intervention in an area that shows poor response to the previous treatment. The examinations used for initial assessment as well as evaluation assessment are described more completely in Chapters 13, 16, 17, and 20.

I.

Visual Examination Obtain biofilm score after the soft tissue visual inspection has been completed so the use of disclosing solution does not interfere with soft tissue examination. Gingival examination looks for changes in tissue color, size, shape (contour), and consistency and compares them to examination findings documented prior to treatment. Visual examination can also determine whether a goal related to caries risk, such as restorative treatment or sealants, has been achieved.

II.

Periodontal Examination A comprehensive periodontal examination is performed and documented using a form that allows comparison with pretreatment assessment data. Current pocket depths, bleeding points, exudate/suppuration, changes in attached gingiva or clinical attachment level noted during the comprehensive examination are documented in the

periodontal record. See Chapter 31 for information about assessment of dental implants.

III. Tactile Evaluation All tooth surfaces, particularly in areas demonstrating bleeding points or exudate/suppuration, should be assessed for residual calculus deposits and other iatrogenic factors. Difficult-to-access areas require special attention during evaluation and include: Concavities and depressions of the root anatomy. Subgingival margins of crowns, fixed partial denture, or overhanging restoration. Furcation involvement.

EVALUATION OF HEALTH BEHAVIOR OUTCOMES Evaluation of health behavior outcomes provides evidence of: The patient’s understanding and compliance with the clinician’s counseling and education interventions. Development of oral self-care skills. The dental hygiene care plan establishes self-care and health behavior goals developed in collaboration with the patient. If the evaluation process indicates goals have not been met, the data collected during evaluation can provide a baseline from which the dental hygienist can again collaborate with the patient to develop new or next step goals. Methods for evaluating self-care and health behavior outcomes are as follows.

I.

Visual Examination Patient biofilm control is evaluated using the same dental indices used to determine original biofilm levels. Self-care skills are evaluated by observing a demonstration of each skill by the patient.

II.

Interview Evaluation Patient interviewing techniques can be used to determine whether each goal established by the patient for health behavior change and daily self-care has been met. Patient interview and discussion can be used to evaluate: Success of factors associated with patient comfort during treatment. The patient’s understanding of recommendations and self-care instructions. Effectiveness of the clinician’s communication approaches.

COMPARISON OF ASSESSMENT FINDINGS Analysis and comparison of pretreatment and outcome evaluation data determine the relative success of the therapy and can help determine whether the patient: Is able to be managed under the care of the dental hygienist, requiring development of a new dental hygiene care plan. Has not responded adequately to nonsurgical therapy and referral for specialized periodontal care may be necessary. On the basis of the findings, a recommended interval for continuing care appointments is determined. Additional factors taken into account when determining the next steps for patient care are listed in Box 44-2.

BOX 44-2 Factors Considered When Determining the Need for Retreatment, Referral, or Maintenance Interval • Soft tissue response to instrumentation and degree of healing • Changes and/or stabilization in probing depth and attachment loss • Patient health behaviors, such as use of tobacco • Systemic influences on oral health status, such as diabetes • Level of skill and effectiveness in biofilm control • Motivation and responsibility assumed for daily personal oral self-care • Psychosocial factors that can affect oral status, such as stress

STANDARD OF CARE In addition to evaluating individual patient outcomes at all points in the dental hygiene process of care, the dental hygienist is responsible for evaluating personal adherence to a professional standard of care for practice. Standards of care in dentistry evolved from early court cases that established a ruling of negligence when healthcare providers failed to possess a minimum standard of special knowledge and ability, or adhere to reasonable and recognized standards while providing patient care.6 The American Dental Hygienists’ Association Standards for Clinical Dental Hygiene Practice, based on the dental hygiene process of care, provides the standard of care for dental hygienists in the United States.2 Canada also provides documents that outline standards for delivery of dental hygiene care.3,4 Guidelines published by both dental and dental hygiene professional associations, such as the American Academy of Pediatric Dentistry Guideline on Caries Risk-Assessment,7 are additional sources used for establishing a professional standard of care. Three sources for determining standard of care in a legal dispute are listed in Box 44-3.

BOX 44-3 Three Sources for Determining Standard of Care in a Legal Dispute • Opinion of expert witnesses • Journals, guidelines, or other published documents from recognized professional associations or other authoritative sources • Federal, state, or local statutes and/or regulations Source: Curley AW. The legal standard of care. J Am Coll Dent.

2005;72(4):20-22.

Failure to provide a minimally acceptable level of patient care is considered to be professional negligence. The professional dental hygienist recognizes that standards of care change over time as new knowledge is introduced and becomes commonly accepted by the profession and the public. Knowledge of and adherence to a professional dental hygiene standard of care are enhanced through continuous evidence-based inquiry and pursuit of life-long learning.

SELF-ASSESSMENT AND REFLECTIVE PRACTICE Dental hygiene education programs recognize ongoing selfassessment of skills as an essential component of evaluating clinical practice.8,9 Although self-assessment and reflection in healthcare practice have been studied mainly in educational settings, there is evidence to suggest that development of these skills can: Be successfully taught and developed, mainly through reflective writing.9–11 Be enhanced with practice.10–12 Help assure quality and positive outcomes in the delivery of patient care.13

I.

Purpose Self-assessment of personal clinical and communication skills and knowledge can guide the dental hygiene practitioner toward an evidence-based approach to finding new information to support best-practice interventions for patient care. Reflecting on clinical experiences contributes to development of critical thinking skills that can help the practitioner determine and implement new and more successful approaches for patient care.14 Self-assessment can assist the dental hygienist to determine a need to enhance specific clinical skills and abilities, or develop a plan for continuing education that supports personal professional goals.

II.

Skills and Methods Key skills for reflective practice include: Perceptive self-awareness. Judgment and self-assessment.

Critical analysis and synthesis. Access to and application of new knowledge. Feedback and evaluation (continued reflection). Methods for informal assessment of professional practice include individual reflection (thinking about one’s own practice habits) or discussing clinical issues with colleagues. Reflective practice can also take on a more formal aspect, as in developing a professional portfolio or maintaining a written “critical incident” journal.10,15–17

III. A “Critical Incident” Approach A formal approach used to evaluate dental hygiene practice takes the form of answering questions about a specific situation, often called a critical incident, which prompts the practitioner to look for answers.17 Three steps, sometimes referred to as the “What? So What? Now What” approach, can be used to structure written reflective journal entries or can also be used to guide a less formal means of thoughtful personal self-assessment. The approach to reflective self-assessment includes a basic progression of reflective actions with questions for each step to help guide thinking about the situation from a variety of perspectives. The steps and a brief clinical practice example are provided in Table 44-2. The same steps and similar questions can be used to guide self-assessment reflection about situations involving communication skills, patient education approach, or adherence to ethical and legal standards of practice. TABLE 44-2 • Components of a “Critical Incident” Approach to Reflection and Self-Assessment

DOCUMENTATION I. Patient Care Outcomes Evaluation of factors such as patient comfort, communication efforts, and treatment safety and efficacy is ongoing and occurs at each patient appointment. Documentation in the patient record provides guidance for future patient interactions. Documentation of outcomes evaluation following clinical dental hygiene treatment is similar to the documentation of clinical data during initial assessment. Evaluation data following treatment are recorded in an identical format to the pretreatment assessment data, which facilitates comparison and analysis of outcomes. Box 44-4 has an example progress note that documents evaluation of a patient care situation.

BOX 44-4 Example Documentation: Evaluation of Patient Comfort During a Sequence of Treatment Appointments S–A 79-year-old male patient presents for the third in a series of appointments scheduled for scaling and root debridement. Patient states: “Following both of the previous appointments, my back has significantly bothered me because of laying back so far in the dental chair for such a long time. Do we need to have such long appointments?” O–Patient medical history form indicates history of osteoarthritis, but no previous problem with back pain. A–Analyzed the problem through discussion with patient about how to balance his needs with the time necessary to complete planned care at each appointment. Decided together that placing a small cushion (or his jacket) beneath his knees as well as briefly bringing the chair to an upright position every 15 minutes could help to alleviate his discomfort. P–Completed third quadrant scaling and provided flossing instruction as indicated in the patient’s care plan for this appointment while using the new “comfort protocol.” He indicated that he felt much better during this treatment session. Next steps: Reevaluate at the next appointment, scheduled in 2 weeks.

Signed: ______________________________, RDH Date: ___________________________________

II.

Self-assessment and Reflection

Self-assessment and reflective evaluation of personal professionalism and learning can be documented in several ways. Two suggestions are as follows: Regular written entries in a professional practice reflection journal that describe and critically analyze a variety of clinical, ethical, and professional situations the dental hygienist has found meaningful. Over time, this ongoing record will reflect how the practitioner’s professional skills, actions, and knowledge have been enhanced through the process of reflective practice. A clinical practice portfolio can be developed to document a variety of factors related to professional development and self-evaluation of dental hygiene practice. A portfolio may contain artifacts such as: Case presentations describing care provided for patients with special needs. A personal practice philosophy describing ethical parameters that impact how the dental hygienist provides care. Goals for future continuing education and courses taken or planned for reaching those goals.

EVERYDAY ETHICS Mrs. Midoun called in this morning and scheduled a visit during a cancelled appointment time in the afternoon. She states she is in a hurry and just wants her teeth “shined up” as her daughter is graduating this weekend. Salima, one of three dental hygienists in practice, has not provided care previously for Mrs. Midoun. She quickly scans the patient record, noticing that 3 months ago Mrs. Midoun received scaling and root debridement treatments in all four quadrants. Although she had signed a consent form outlining the entire sequence of appointments, including evaluation, Mrs. Midoun had cancelled the evaluation appointment at the last minute and never rescheduled it. Salima explains that, before providing any further dental hygiene care, it

would be necessary to complete the posttreatment evaluation. Mrs. Midoun objects strenuously to “wasting time” with evaluation of her previous treatment. She states that her oral health is much better now and she notices very little bleeding. She states emphatically that, unless Salima cleans her teeth today, she will “just leave now and find another office” where they will clean her teeth. Dr. Kim is out of the office and Salima hesitates, not knowing quite how to handle the situation without consulting him. Questions for Consideration 1. Is this an ethical issue or a dilemma? Explain. 2. What are Mrs. Midoun’s rights in this situation? What core values need to be considered during Salima’s decision-making process? 3. What alternative decisions can Salima make about interventions she will provide at Mrs. Midoun’s appointment today that will meet the standards of care for dental hygiene practice?

Factors to Teach the Patient The need for evaluation to establish the basis for “next step” treatment and maintenance decisions. Types of evaluation measures and indicators that measure outcomes for each goal. How outcomes from dental hygiene interventions are used to determine further treatment needs and maintenance interval.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Centers for Disease Control and Prevention. Program Performance and Evaluation Office (PPEO)—Program Evaluation. http://www.cdc.gov/eval/framework/. Accessed April 9, 2018. 2. American Dental Hygienists’ Association (ADHA). Standards for Clinical Dental Hygiene Practice (Revised 2016). https://www.adha.org/resources-docs/2016Revised-Standards-for-Clinical-Dental-Hygiene-Practice.pdf. Accessed April 9, 2018. 3. Canadian Dental Hygienists Association (CDHA). Dental Hygiene: Definition, Scope, and Practice Standards. https://www.cdha.ca/pdfs/Profession/Resources/DefinitionScope_public.pdf. Accessed April 9, 2018. 4. College of Dental Hygienists of Ontario. Standards of Practice. http://www.cdho.org/for-the-public/dental-hygienists/standards-of-practice. Accessed April 9, 2018. 5. Centers for Disease Control and Prevention (CDC). Types of Evaluation. https://www.cdc.gov/std/Program/pupestd/Types%20of%20Evaluation.pdf. Accessed April 9, 2018. 6. Graskemper JP. The standard of care in dentistry: where did it come from: how has it evolved? J Am Dent Assoc. 2004;135(10):1449-1455. 7. American Academy of Pediatric Dentistry (AAPD). Guideline on Caries Risk Assessment and Management for Infants, Children, and Adolescents. http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdf. Accessed April 9, 2018. 8. Commission on Dental Accreditation (CODA). Accreditation Standards for Dental Hygiene Education Programs. https://www.ada.org/~/media/CODA/Files/dental_hygiene_standards.pdf? la=en. Accessed April 9, 2018. 9. Mayes KA, Branch-Mays GL. A systematic review of the use of selfassessment in preclinical and clinical dental education. J Dent Educ. 2016; 80(8):902-913. 10. Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ Theory Pract. 2009; 14(4):595-621. 11. Tsang AK. Oral health students as reflective practitioners: changing patterns of student clinical reflections over a period of 12 months. J Dent Hyg. 2012;86(2):120-129. 12. Asadoorian J, Schönwetter DJ, Lavigne SE. Developing reflective health care practitioners: learning from experience in dental hygiene education. J Dent Educ. 2011;75(4):472-484. 13. Jackson SC, Murff EJ. Effectively teaching self-assessment: preparing the dental hygiene student to provide quality care. J Dent Educ. 2011;75(2):169-

179. 14. Mould MR, Bray KK, Gadbury-Amyot CC. Student self-assessment in dental hygiene education: a cornerstone of critical thinking and problem-solving. J Dent Educ. 2011;75(8):1061-1072. 15. Gadbury-Amyot CC, Woldt JL, Siruta-Austin KJ. Self-assessment: a review of the literature and pedagogical strategies for its promotion in dental education. J Dent Hyg. 2015;89(6):357-364. 16. Gwozdek AE, Springfield EC, Kerschbaum WE. ePortfolio: developing a catalyst for critical self-assessment and evaluation of learning outcomes. J Allied Health. 2013;42(1):e11-e17. 17. Alpers RR, Jarrell K, Wotring R. Toward a reflective practice: using critical incidents. Teach Learn Nursing. 2013;8(1):33-35.

45 Continuing Care Denise Zwicker, BDH, MEd, Linda D. Boyd, RDH, RD, EdD, and Esther M. Wilkins, BS, RDH, DMD

CHAPTER OUTLINE GOALS OF THE CONTINUING CARE PROGRAM I.

Periodontal Maintenance

CONTINUING CARE APPOINTMENT PROCEDURES I. II. III.

Assessment Continuing Care Plan Criteria for Referral to a Periodontist

APPOINTMENT INTERVALS (FREQUENCY) METHODS FOR CONTINUING CARE SYSTEMS I. II.

Prebook or Preschedule Method Monthly Reminder Method

DOCUMENTATION

EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Describe the goals of a continuing care program in dental hygiene practice. 2. Determine appointment intervals based on an individual patient’s risk factors, compliance, and oral health history. 3. Name and discuss the contributing factors in recurrence of periodontal disease. 4. List steps in a continuing care appointment including assessment, care plan, and therapy. 5. Outline methods for continuing care systems in the dental office or clinic. The overall therapeutic goals of treatment are to arrest disease and to provide optimal oral health, function, and comfort for the patient. Following active treatment, when reevaluation shows positive softtissue response and the function of the dentition has been restored, the patient enters a new phase of treatment for continuing care.

GOALS OF THE CONTINUING CARE PROGRAM Continue the healthy state attained during active therapy. Prevent recurrence of infection. The patient needs to understand that oral diseases recur, but control is possible through combined personal and professional effort. Prevent initiation of new disease. Monitor educational and behavioral changes. Monitor risk and clinical signs of health and disease including: Periodontal infection. Oral mucosal lesions. Dental caries (noncavitated and continuum to cavitated lesions). Eruption patterns and occlusion. Provide specialized instruction for implants, prostheses, orthodontic appliances, and restorations. Offer motivational encouragement for oral self-care. The success of the program depends on compliance by the patient with the daily oral self-care and regular professional maintenance.

I.

Periodontal Maintenance Patients who comply with regular periodontal maintenance (PM) intervals have less attachment and tooth loss.1,2 Evidence suggests it is optimal for patients with a history of periodontal disease to be seen four times a year to decrease the risk for disease progression.1 Therapeutic goals of PM are listed in Box 45-1 and include the following3:

BOX 45-1 Purposes and Outcomes of Periodontal Maintenance • Resolve inflammation

• • • • • • •

Eliminate BOP Preserve clinical attachment levels Arrest disease progression Provide patient comfort Encourage patient oral self-care Control periodontal reinfection Patient motivation and reinstruction

Prevent the recurrence of disease and maintain the state of periodontal health attained during surgical or nonsurgical periodontal therapy. Prevent or reduce the incidence of tooth or implant loss with careful monitoring. Increase timely identification of the need for treatment of other conditions or systemic disease manifested in the oral cavity such as poorly controlled diabetes mellitus.

CONTINUING CARE APPOINTMENT PROCEDURES The dental hygiene process of care is described in Chapter 1. As with preparation of the diagnosis and initial dental hygiene care plan, discussed in Chapters 22 and 23, the steps in the process of care apply for the dental hygiene continuing care plan.

I.

Assessment Preparation of assessment data follows the same procedure as that for a new patient. At every maintenance appointment, regardless of the interval, a patient of any age requires a complete reassessment, diagnosis, and care plan.

A. Review of Patient History Supplemental questions are asked to determine the present state of health with emphasis on changes since the previous appointment. Recent illnesses, hospitalizations, current medications including prescription, over-the-counter and herbal/supplements, and other pertinent new data. Date of last physical examination with primary care provider.

B. Vital Signs Blood pressure and other vital signs are documented (see Chapter 12).

C. Extraoral and Intraoral Examination A thorough extraoral and intraoral examination is documented, as described in Chapter 13.

D. Radiographs The frequency of radiographic surveys is in accord with the determination of an individual patient’s need and recommendations for dental radiographs from the American Dental Association and Federal and Drug Administration (see Chapter 15).

E. Periodontal Examination Observe and record: gingival color, size, shape, and texture; mucogingival changes. Complete periodontal examination: pocket depths, bleeding on probing (BOP), exudate or suppuration, attachment levels, furcation involvement, and gingival recession.4 Current findings are compared with previous periodontal assessments to assess changes since treatment was completed. Occlusion, fremitus, and mobility. Calculus: distribution and amount. Biofilm and soft deposits.

F. Examination of the Teeth Integrity of restorations and sealants. Dental caries: demineralization, white spot lesions, and cavitated lesions. Dentin hypersensitivity: location and severity.

G. Risk Assessment Evaluate the presence of systemic disease or other contributing factors such as smoking.

H. Evaluation of Oral Cleanliness and Self-Care Measures

Apply a disclosing agent to evaluate the quantity of biofilm.

I. Examination of Specific Areas Areas of special interest include endodontically treated teeth, postsurgical areas, implants, occlusal factors, and prosthetic appliances.

II.

Continuing Care Plan

A care plan is outlined on the basis of the new evaluation of the patient’s oral condition and dental hygiene diagnosis.

A. Oral Hygiene Instruction/Motivation During continuing care, the patient is considered a co-therapist. To keep etiologic factors under control, compliance with daily oral self-care is a major feature in the total program (see Chapters 26 and 27).

B. Periodontal Instrumentation and Debridement The periodontal examination findings may indicate need for active disease requiring nonsurgical periodontal therapy. Plan appropriate pain control such as local anesthesia. Plan appropriate number of appointments. Local delivery of antimicrobials in isolated periodontal pockets with active disease that fail to respond to nonsurgical therapy (see Chapter 39). For areas of continued BOP, endoscopic examination or evaluation for surgical therapy by a periodontist may be indicated.

C. Dental Caries Control Prevention needs to address modifiable caries risk factors with

attention to root caries, appropriate use of professional and home fluorides, and diet modifications. Implement or monitor previously introduced remineralization protocol (see Chapter 25).

D. Supplemental Care Procedures Smoking cessation assistance (see Chapter 32). Desensitization of dentin hypersensitivity (see Chapter 41). Special care for implants and fixed prostheses (see Chapters 30 and 31). Referral for retreatment evaluation.

III. Criteria for Referral to a Periodontist A. Referral from General Practice General practice dentists may include periodontal surgical therapy in their practice, but referral to a periodontist is recommended for care outside the scope of practice of a general dentist. Many general dentists refer severe or complicated periodontal cases to the periodontist. During patient care in a general practice, the dental hygienist should confer with the dentist to determine the need for referral to a periodontist in the following situations: Initially when a patient new to the practice is examined with the following findings: Stage III or IV periodontitis with furcation involvement. Periodontal disease classifications such as necrotizing ulcerative gingivitis or periodontitis. Drug-induced gingival enlargement (such as in dilantin hyperplasia). Areas of inadequate attached gingiva, especially when gingival margins are rolled, inflamed, and bleed easily. During the reevaluation, following nonsurgical periodontal

therapy. Referral is required for any nonresponsive or refractory type of moderate or advanced periodontal condition (or any of the conditions mentioned earlier). During PM: If there are signs of recurrence of periodontal disease including, but not limited to bleeding or suppuration on probing, increasing pocket depths, increasing mobility or migration of teeth, or recurrent periodontal abscesses.

B. Recurrence of Periodontal Disease Recurrence of signs and symptoms of periodontal infection indicates recolonization of periodontal pathogens. Recolonization of a pocket can occur in an average of 42 days.5 Without daily personal dental biofilm control combined with regular professional maintenance procedures, infection can recur. Colonization depends on the number, frequency of exposure, and virulence of the organisms. Transmission of periodontal microorganisms has been shown between family members.6–8 Upon completion of treatment, the rate at which colonization may recur will vary with each patient depending on a number of contributing factors. Contributing factors for recurrence: Inadequate biofilm control. Lack of patient compliance with PM appointments. Inadequate professional treatment. Inadequate or incomplete debridement, particularly in areas of difficult access such as furcations and deep proximal pockets. Biofilm retention: failure to remove or replace overhanging restorations and other biofilm niches that foster bacterial growth. Failure of tobacco cessation including smoking tobacco, smokeless tobacco, or waterpipe tobacco smoking.1,3,7,9–11 Systemic diseases such as diabetes mellitus,12 HIV/AIDS,13 and

certain other systemic diseases influence healing and may control factors related to bone loss and severity of infections. Genetic factors: Future testing for genetic factors may be used as a component of risk assessment.14,15

C. Criteria for Referral during PM During maintenance therapy, any of the aforementioned types of patients may still require referral. Other cases may include: Pocket depth that prohibits access for complete debridement during nonsurgical periodontal therapy. Furcation involvements and other complex anatomical areas that cannot be instrumented successfully by nonsurgical methods. Mucogingival problems; lack of attached gingiva. Periodontal disease that is refractory, or not responsive to usual treatment.16

APPOINTMENT INTERVALS (FREQUENCY) Frequency planning The frequency of continuing care or maintenance depends on the needs of each individual patient. Appointment intervals may vary from 2 to 6 months. The time interval is reevaluated periodically and modified in accordance with changing needs of the patient. Factors to consider in determining continuing care or maintenance frequency Risk for periodontal disease activity. Risk for dental carious lesions. Risk for oral cancer: frequent tobacco and alcohol users. Predisposing diseases, conditions, and behaviors for periodontal diseases, including diabetes, HIV/AIDS, host genetic factors, smoking, and stress. Compliance: keeping appointments and personal daily biofilm control. Previous treatment: Patient who has a history of disease, either dental caries or periodontal infection, is at a greater risk for recurrence. Local factors: rate of calculus formation. Restorative complications: implants and prosthetic replacements. Special appointment requirements Intervals of 2 or 3 months are required for many patients. A few examples include: History of periodontal treatment: Patients who have completed initial nonsurgical or surgical periodontal therapy. The first preventive maintenance appointment is scheduled based on the completion date of the initial nonsurgical periodontal therapy. Cognitive or physical disability: Managing the toothbrush and other oral care devices may be difficult; when the disability involves the face, opening the mouth may be challenging. Diabetes: Diabetes or other systemic disease can predispose patients to lowered resistance to infection.

Cardiovascular disease or other condition: Those who have been recently hospitalized may find oral self-care tiring and require some modifications to oral self-care routines. Appointments may need to be shorter due to patient fatigue. Patient undergoing extensive dental care: When extensive restorative, prosthetic, or other treatment is in progress, frequent tissue maintenance and reinstruction are essential. Rampant dental caries: Appointment for continuation of a caries control effort includes fluoride varnish applications, dietary supervision, and personal care factors for biofilm control. Sealants: need for regular examination for defects such as chipped or loss of a sealant to repair, replace, or extend. Orthodontic therapy: Appliances make cleaning and biofilm control difficult; frequent topical fluoride applications may be indicated; response of gingival tissue to biofilm accumulation to be monitored.

METHODS FOR CONTINUING CARE SYSTEMS The continuing care system is essential for managing the oral health of patients. Methods for administration of continuing care include prebooking or prescheduling an appointment or sending a reminder card to schedule an appointment.

I.

Prebook or Preschedule Method Make each subsequent patient appointment prior to the patient leaving the office or clinic, either electronically or in a traditional appointment book. An appointment card is given to the patient with a reminder to enter it on their calendar. If the patient uses a calendar application on their cell phone or tablet, encourage entering the new appointment before leaving the office or clinic. Appointment reminders can be done by: Preparing a postcard for mailing a month or two before the scheduled appointment. The card can be prepared by the patient before leaving the office or postcards and labels can be printed from the patient management system. Sending a reminder via e-mail, text, or other electronic media. The reminder requests the patient to confirm the appointment by calling or e-mailing. For unconfirmed appointments, a call to the patient the day before is made.

II.

Monthly Reminder Method If an appointment is not prescheduled, a monthly list of all patients due for maintenance can be generated. For a manual system, postcards can be filed alphabetically by the last name of the patient under the month when the patient is

due. Practice management systems can easily create patient-specific postcards or letters to be mailed to the patient. Many systems can be set up to automate the process.

DOCUMENTATION For the patient’s permanent record, the following information needs to be recorded for a patient who is scheduled for routine continuing care: Medical and dental histories updated with each continuing care appointment. Significant chief complaints and questions the patient may have concerning the treatment provided and of the personal self-care expected. Findings during routine examinations including vital signs, extraoral and intraoral, periodontal, dental, temporomandibular joint, occlusion, and all special examinations following individual treatments for other reasons. A sample progress note may be reviewed in Box 45-1.

BOX 45-2 Example Documentation: Continuing Care Appointment S— A patient presents for 3-month PM appointment and apologized for not being able to clean her teeth after lunch. She described her daily oral self-care regimen; a remarkable behavior change since her initial periodontal therapy and patient education 4 years ago. O—Medical, dental, and medication reviews, no changes. BP 135/60, extra- and intraoral nothing remarkable. Vertical bitewings for molar areas were exposed based on patient risk factors. Periodontal examination with probing revealed numerous proximal areas of molars had 3–4 mm areas with BOP, subgingival calculus, and moderate-to-heavy biofilm suggesting lack of flossing. A—Generalized Stage II, Grade B periodontitis. Interdental biofilm accumulation with need for more specific instruction to include interdental brushes. P— Asked patient to demonstrate current brushing method and provided additional instruction to modify her technique with emphasis on Bass brushing for interdental cleaning. Advised brushing more than once a day with a focus on every tooth. Demonstrated use of interdental brush. Gave her sample interdental brushes and explained where to purchase them. Completed calculus removal for maxillary and mandibular right quadrant. Next visit: two weeks to monitor healing and progress with improvement in oral

self-care. Complete treatment for both left quadrants with local anesthesia due to extreme sensitivity in maxillary molars. Signed: ______________________________, RDH Date: ____________________________________

EVERYDAY ETHICS There were two full-time dental hygienists in the practice. Susan had been working here for more than 15 years, and Jessica less than a year. Jessica had previously practiced with a periodontist in another city for 6 years, and she joined this practice shortly after moving here. Each hygienist had instruments of their own preference and cared for them relative to sharpening and preparation for the sterilizer. Patients usually had appointments with the same dental hygienist. Susan scheduled a maintenance appointment for 45 minutes, whereas Jessica felt she did not have enough time enough even with an hour. Occasionally, certain long-standing patients who had been with Susan for many years would be scheduled with Jessica when Susan could not be in the office. As Jessica saw more of Susan’s regular patients, she began to see a pattern of residual subgingival calculus that could not have formed since the previous 3 or 4 months’ maintenance appointment. She had decided to ask the receptionist to have Susan’s patients wait for her return for their appointments. Ms. Doubleday, a patient of Susan’s, did not want to wait, and had come in for her appointment with Jessica. After reviewing the history and updating the periodontal charting, Jessica had to tell the patient that she needed two appointments and wanted to complete her scaling with local anesthesia. The patient was confused after having only short regular appointments and wanted to know whether to reschedule with Susan to finish once she was back from her vacation. Questions for Consideration 1. Is this an ethical issue or a dilemma? Explain. How do the core values apply in this scenario? 2. Using the step procedure for solving an issue or a dilemma (see Chapter 1), suggest various possible actions for Jessica. 3. Prepare possible answers Jessica could use for her reply to Ms. Doubleday’s immediate question.

Factors to Teach the Patient Purposes of follow-up and continuing care or maintenance appointments. The importance of the role of the patient and their personal oral care habits in relation to the overall maintenance provided through professional periodontal debridement. Importance of keeping all maintenance appointments.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Lee CT, Huang HY, Sun TC, Karimbux N. Impact of patient compliance on tooth loss during supportive periodontal therapy: a systematic review and meta-analysis. J Dent Res. 2015;94(6):777-786. 2. Ng MC, Ong MM, Lim LP, Koh CG, Chan YH. Tooth loss in compliant and noncompliant periodontally treated patients: 7 years after active periodontal therapy. J Clin Periodontol. 2011;38(5):499-508. 3. Trombelli L, Franceschetti G, Farina R. Effect of professional mechanical plaque removal performed on a long-term, routine basis in the secondary prevention of periodontitis: a systematic review. J Clin Periodontol. 2015;42(suppl 16):S221-S236. 4. Preshaw PM. Detection and diagnosis of periodontal conditions amenable to prevention. BMC Oral Health. 2015; 15(suppl 1):S1-S5. 5. Mousqués T, Listgarten MA, Phillips RW. Effects of scaling and root planing on the composition of the human subgingival microbial flora. J Periodontal Res. 1980;15:144–151. 6. Al Yahfoufi Z. Prevalence of periodontal destruction and putative periodontal pathogens in the same Lebanese family. J Contemp Dent Pract. 2017;18(10):970-976. 7. Doğan B, Kipalev AS, Okte E, Sultan N, Asikainen SE. Consistent intrafamilial transmission of Actinobacillus actinomycetemcomitans despite clonal diversity. J Periodontol. 2008;79(2):307-315. 8. Monteiro MF, Casati MZ, Taiete T, et al. Salivary carriage of periodontal pathogens in generalized aggressive periodontitis families. Int J Paediatr Dent. 2014;24(2):113-121. 9. Chaffee BW, Couch ET, Ryder MI. The tobacco-using periodontal patient: role of the dental practitioner in tobacco cessation and periodontal disease management. Periodontol 2000. 2016;71(1):52-64. 10. American Academy of Periodontology, Research, Science and Therapy Committee. Position paper: tobacco use and the periodontal patient. J Periodontol. 1999;70(11):1419–1427. 11. Haddad L, Kelly DL, Weglicki LS, Barnett TE, Ferrell AV, Ghadban R. A systematic review of effects of waterpipe smoking on cardiovascular and respiratory health outcomes. Tob Use Insights. 2016;9:13-28. 12. Salvi GE, Carollo-Bittel B, Lang NP. Effects of diabetes mellitus on periodontal and peri-implant conditions: update on associations and risks. J Clin Periodontol. 2008;35(8 suppl):398-409. 13. John CN, Stephen LX, Joyce Africa CW. Is human immunodeficiency virus (HIV) stage an independent risk factor for altering the periodontal status of HIV-positive patients? A South African study. BMC Oral Health. 2013;13:69. 14. American Academy of Periodontology, Research, Science and Therapy Committee. Informational paper: implications of genetic technology for the

management of periodontal diseases. J Periodontol. 2005;76(5):850-857. 15. Schaefer AS, Bochenek G, Manke T, et al. Validation of reported genetic risk factors for periodontitis in a large-scale replication study. J Clin Periodontol. 2013;40(6): 563-572. 16. American Academy of Periodontology. Parameter on “refractory” periodontitis. J Periodontol. 2000;71(5 suppl):859-860.

SECTION

IX Patients with Special Needs INTRODUCTION FOR SECTION IX The dental hygienist’s obligation is to see that no patient needs special rehabilitative dental or periodontal services because of any condition that could have been prevented by dental hygiene care. For every patient, dental hygiene interventions are selected and patient management strategies are considered according to individualized needs. Patients with special needs that may complicate the plan for dental hygiene care are those with significant concerns related to: Their age group. Specific oral and general systemic conditions. Degree of physical or cognitive disability. Dental hygiene care for patients with special needs may require: A more skillful application of dental hygiene knowledge and ability to accomplish a comparably favorable outcome.

Pursuit of current evidence-based information about individuals with specific health concerns and successful patient management strategies. Collaboration with an interprofessional team of both healthcare and home care providers to assure the patient’s needs are met. Optimum oral health is frequently a contributing factor in maintaining or restoring optimum systemic health and enhancing quality of life. Patients with chronic disabling conditions or advanced stages of disease may not be able to perform self-care regimens independently or access dental care in traditional practice settings.

THE DENTAL HYGIENE PROCESS OF CARE The care of patients with special needs integrates learning from other areas of medical and social sciences into the dental hygiene process of care. The importance of each step in the process (Figure IX-1) is enhanced when providing care for a patient with health concerns that affect patient management or increase risk for poor treatment outcomes.

FIGURE IX-1 • The Dental Hygiene Process of Care.

Description

ETHICAL APPLICATIONS The complex medical and dental conditions of certain patients may translate into a need to identify unique treatment approaches that consider: The quality of care provided. The patient’s quality of life. Increasingly, medically compromised patients are ambulatory and

appear in a dental practice or clinic for maintenance and preventive procedures. A dental hygienist may also provide care in alternative settings such as a long-term care facility or the patient’s home. The ethical dental hygienist: Selects dental hygiene interventions consistent with the patient’s physical, mental, and personal capabilities. Instructs patients and/or caregivers about oral hygiene problems and needs related to their systemic disorders and medications. Ensures that all appropriate persons are included in all chairside discussions, if someone other than the patient is responsible for making treatment decisions. Confidently communicates with all healthcare professionals who comprise the patient’s interprofessional care team. Table IX-1 provides an overview of some ethical concerns to be considered when presenting treatment options to patients with special needs. TABLE IX-1 • Ethical Concerns for Treatment Options QUALITY OF LIFE

DEFINITION

APPLICATION EXAMPLES

Competency

The patient’s ability to make choices about dental and dental hygiene care.

Educates the patient based on intellectual capacity so autonomous consent can be given.

Surrogate

Described as a “substitute” or Acknowledges a “durable proxy with regard to healthcare power of attorney” for a decisions. patient, where applicable.

Advanced directives

Individuals may write their choices for limiting health care in the event that they are unable to make choices in the future.

Examples include a “living will,” “do not resuscitate” order, and “patient values” history.

46 The Pregnant Patient and Infant Lori Rainchuso, RDH, MS, DHSc, and Esther M. Wilkins, BS, RDH, DMD

CHAPTER OUTLINE INTRODUCTION FETAL DEVELOPMENT I. II. III.

First Trimester Second and Third Trimesters Factors That Can Harm the Fetus

ORAL FINDINGS DURING PREGNANCY I. II. III. IV. V.

Gingival Conditions Gingivitis Gingival Enlargement Periodontal Infections Enamel Erosion

ASPECTS OF PATIENT CARE

I. II. III. IV.

Assessment Radiography Overall Treatment Considerations Dental Hygiene Care

PATIENT INSTRUCTION I. II. III. IV.

Dental Biofilm Control Diet Dental Caries Control Fluoride Program

SPECIAL PROBLEMS REQUIRING REFERRAL I. II.

Depression during Pregnancy Domestic Violence

TRANSITIONING FROM PREGNANCY TO INFANCY INFANT ORAL HEALTH I. II. III. IV. V.

Anticipatory Guidance Infant Daily Oral Hygiene Care Feeding Patterns (Birth to 1 Year) Nonnutritive Sucking Components of the First Dental Visit

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Describe the oral implications of fetal development in all stages of pregnancy. 2. Identify common oral findings during pregnancy. 3. Recognize the association between periodontal infection and pregnancy. 4. Assess and develop an appropriate care plan for the pregnant patient. 5. Identify considerations that may occur during pregnancy and

6. 7. 8. 9.

need for referral. Recognize the importance of infant oral health. Describe anticipatory guidance considerations for the infant and caregiver education. Define early childhood caries and recognize methods of bacterial transmission. Describe the components and techniques for conducting an infant oral examination.

Pregnancy is a unique time during a woman’s life. Attention is focused on healthy lifestyle practices for both the mother and fetus.1 Prenatal care refers to supervised preparation for childbirth to help the mother enjoy optimum health during and after pregnancy and maximize chances for the baby to be born healthy.2 Prenatal care involves the combined efforts of the obstetrician and/or midwife, nurse practitioner, dentist, dental hygienist, dietitian, and expectant parents. There is no indication dental and dental hygiene treatment during any trimester of pregnancy can cause harm to the mother or developing fetus. However, most research indicates the second trimester is most ideal for dental treatment.3

INTRODUCTION Professional guidelines recommend medical providers (prenatal care specialists) refer patients for oral health examinations early in pregnancy.4 Referrals from medical providers may bring many women to the private dental practice or dental clinic who would not routinely access dental care. Many of these women may not have had education about the value of daily oral self-care and diet related to the health of the oral tissues.5 Numerous misconceptions can be addressed when providing information about the relationship of pregnancy and oral health.5 Women who do not receive routine oral health care may appear for emergency dental services and once the emergency situation is resolved, they may be receptive to a preventive program of care and instruction.5 The dental hygienist in public health, especially maternal and child health clinics, participates in community educational programs with public health nurses. In these programs, women not well informed about oral health may learn of the need for professional dental and dental hygiene care and education during pregnancy.

FETAL DEVELOPMENT Pregnancy is arbitrarily divided into three periods of 3 months each called the first, second, and third trimesters.6 Physiologic changes in the mother occur in nearly every body system. Early development of the embryo is greatly influenced by heredity and the general health of the mother.7 Normal pregnancy, or period of gestation, is approximately 40 weeks. Premature birth refers to a birth before 37 weeks of gestation.7

I.

First Trimester During the early stages of pregnancy, the embryo is highly susceptible to injuries, malformations, and mortality.8 Teratogenic effects can be produced by many sources, including maternal poor nutrition, infections, and drug intake. All organ systems are formed (organogenesis) during the first trimester. By 12 weeks, the fetus moves and swallows.7

A. Oral Cavity Development Includes the Teeth, Lips, and Palate Tooth buds develop between the 5th and 6th week. Initial mineralization occurs from the 4th to 5th month (see Table 47-4).9 Lips form during the 4th–7th week and the palate forms between the 8th and the 12th week.9 Cleft lip is apparent by the 8th week; cleft palate, by the 12th week (see Chapter 49).

II.

Second and Third Trimesters

The organs are completed, and growth and maturation continue.7 Rapid fetal growth and weight changes occur during the second and third trimesters. The second trimester is the ideal time for dental treatment.3

III. Factors That Can Harm the Fetus A. Infections Studies indicate a correlation between periodontitis and increased risk for adverse pregnancy outcomes.10,11 The American Academy of Periodontology recommends women who are planning to become pregnant or currently are pregnant to have a periodontal examination and receive preventive or therapeutic treatment, when needed.12 Protection from periodontal infection and infectious diseases is necessary to prevent potential damage to the developing fetus.12,13 Women of childbearing age need to take advantage of all recommended immunizations prior to conception.13 Defects, deformities, and life-threatening infections in the fetus can result from infection acquired during pregnancy or during delivery and after birth.13 Rubella (German measles), rubeola, varicella, herpes viruses, hepatitis B, human immunodeficiency virus (HIV) infection, syphilis (congenital syphilis), and gonorrhea all can have serious effects on the fetus (see Chapter 5).

B. Pharmacokinetics During pregnancy, normal physiologic changes occur; as a result, drug movement within biologic systems is unique.14 Nearly all drugs pass across the placenta to enter the circulation of the developing fetus and may have teratogenic effects based on factors such as gestational age, route of administration, absorption, dose, and maternal serum levels.14

However, the majority of medications/drugs prescribed or used by an oral health professional and dispensed during pregnancy are not associated with teratogenic effects or adverse effects of fetal development.1,15 Table 46-1 lists selected drugs with indications, contraindications, and special considerations for pregnant women. TABLE 46-1 • Pharmacological Considerations for Pregnant Womena PHARMACEUTICAL AGENT

INDICATIONS, CONTRAINDICATIONS, AND SPECIAL CONSIDERATIONS

Analgesics Acetaminophen Acetaminophen with codeine, hydrocodone, or oxycodone

May be used during pregnancy. Oral pain can often be managed with nonopioid medication. If opioids are used, prescribe the lowest dose for the shortest duration (usually 140/90 mm Hg) or taking antihypertensive medications. Women with polycystic ovarian syndrome. History of cardiovascular disease. A1c greater than 5.7%, impaired glucose tolerance, or impaired fasting glucose.

II.

Prediabetes Individuals who have blood glucose levels above normal but do not meet the criteria for diagnosis of diabetes are considered to have prediabetes. (Diagnostic criteria are provided later in this chapter.) Prediabetes means the individual is at high risk for developing diabetes and cardiovascular disease.1 The Diabetes Prevention Program (DPP) showed a 58% reduction in progression to diabetes in those with prediabetes with lifestyle changes including modest weight loss of 7% and a minimum of 150 minutes/week of physical activity.12 The most frequent medication used to manage blood glucose level is metformin.

CLASSIFICATION OF DIABETES MELLITUS Classification is based on the etiology of the disease. The type of diabetes is based on the circumstances at the time of diagnosis, such as gestational diabetes during pregnancy.1 A comparison of type 1 and 2 diabetes is found in Table 54-3. TABLE 54-3 • Comparison of Type 1 and Type 2 Diabetes Mellitus CHARACTERISTIC TYPE 1

TYPE 2

Age of onset

Young, usually before or during puberty, but may appear later

Adult, usually after 30 years, but occurring with increasing frequency in children and adolescents

Body weight

Normal or thin

Most are obese, body fat particularly in abdominal area

Ethnicity

More common in Caucasians

More common in African Americans, Asian Americans, Hispanics, Native Americans, Pacific Islanders

Hereditary

Yes, but less frequent occurrence than in type 2

Much more frequent occurrence in families

Lifestyle

Restrictions very difficult for young patients

More frequent in sedentary individuals with high-fat diets

Onset of symptoms

Rapid, abrupt symptoms of hyperglycemia

Slow, insidious progression over years, frequently goes undiagnosed for years

Symptoms

Weight loss, weakness Polyuria Frequent/recurrent infections Polydipsia, slow healing Polyphagia

Any type 1 symptom

Tingling/numb extremities Blurred vision Fatigue Mimic flu Eye/kidney/cardiovascular problems Severity

Severe, life threatening

Early mild, but progressively serious

Complications

Acute hypoglycemic/hyperglycemic emergencies and chronic long-term complications common

Acute complications rare, chronic long-term complications common

Ketoacidosis

Common

Rare

Stability

Unstable, difficult, and much effort to control

More stable, easier to manage

Insulin

No insulin production, exogenous insulin required

Insulin levels normal, elevated, or low; exogenous insulin needed by some

Prevention

None, due to multiple genetic predispositions and unclear environmental factors

May be possible to prevent or delay with lifestyle changes, increased activity, and weight loss

I.

Type 1 Diabetes Mellitus

A. Description Accounts for 5%–10% of those with diabetes. Results from the destruction of insulin-producing beta cells in the pancreas for one of the following reasons1: Autoantibodies. No known etiology. Results in an absolute insulin deficiency requiring exogenous

insulin to sustain life. Figure 54-1B illustrates the changes in pancreas function in type 1 diabetes. Patients are prone to ketoacidosis.1 Typically arises in childhood or adolescence, but may appear in adulthood depending on the rate of beta-cell destruction.1 Individuals with type 1 diabetes are also prone to other autoimmune disorders such as Graves disease or Hashimoto thyroiditis.1

B. Former Names Insulin-dependent diabetes mellitus, juvenile diabetes, or juvenileonset diabetes.

II.

Type 2 Diabetes Mellitus

A. Description Most prevalent type of diabetes, accounts for 90%–95% of all patients with diabetes.1 Pancreatic insulin secretion may be low, normal, or even higher than normal, but the patient exhibits an insulin resistance that impairs the use of insulin.1 Figure 54-1C shows changes that occur in type 2 diabetes. Onset typically occurs in adulthood, and the risk increases with age, obesity, and lack of physical activity.1 Although traditionally thought of as occurring in adults, the incidence has increased in children and adolescents due to increases in lack of physical activity, overabundance of fast food, and obesity.13 In children, the average age of onset is 13 years.

B. Screening Type 2 diabetes is usually identified after acute symptoms of

hyperglycemia prompt evaluation. Screening in asymptomatic adults is recommended for prediabetes and type 2 diabetes. Basic criteria for testing in healthcare setting are the following1: Age 45 and above, repeated a minimum of every 3 years. Screening begins earlier and more frequently if the patient is overweight or obese (BMI > 25 kg/m2) and has one or more additional risk factors. When tests are normal, they are repeated at least every 3 years. Screening should be done in children and adolescents who are overweight or obese (BMI >85th percentile for age and sex) and have other risk factors for diabetes.1

C. Former Names Noninsulin-dependent diabetes mellitus or adult-onset diabetes.

III. Gestational Diabetes Mellitus The prevalence of gestational diabetes mellitus (GDM) is as high as 9.2% of pregnancies in the United States and as high as 15% worldwide.14,15 Defined as any degree of glucose intolerance first recognized during pregnancy.1 Onset is related to genetics, obesity, and hormones causing insulin resistance. Insulin adjustment, carefully supervised prenatal care, and improved obstetric practices have lessened much of the potential danger for the mother. Infants are larger; premature births are more frequent; incidence of congenital malformations and perinatal death is high; and rates lower with improved prenatal care. More than 50% of women with GDM go on to develop type 2 diabetes within 5–10 years.1

A. Screening Pregnant women with risk factors for diabetes should be screened at the initial prenatal visit.1 Women with no history of diabetes prior to pregnancy should be screened at 24–28 weeks of gestation.1 Women with gestational diabetes should have lifelong screening for diabetes or prediabetes.1

IV. Other Specific Types of Diabetes Mellitus A. Monogenic Diabetes Syndromes Neonatal diabetes occurs before the age of 6 months and is typically of genetic origin.1 Maturity-onset diabetes of the young typically occurs before the age of 25 years and is also related to genetic abnormalities in at least 13 genes.1

B. Cystic Fibrosis–Related Diabetes Occurs in 20% of adolescents and 40%–50% of adults with cystic fibrosis.1 Insufficient production of insulin from the pancreas is the primary cause and is related to poor nutritional status, more severe inflammatory lung disease, and greater mortality.1

C. Posttransplantation Diabetes Mellitus (PTDM) Also called “new-onset diabetes after transplantation.” Immunosuppressants and glucocorticoid steroid use posttransplant are the major causes of PTDM.1

DIAGNOSIS OF DIABETES I. Diabetes Symptoms Careful review of the medical history with follow-up questions is used to identify risk factors and symptoms (Table 54-3) of diabetes. The classic symptoms of diabetes include the 3 Ps1: Polyphagia (excessive hunger). Polydipsia (excessive thirst). Polyuria (excessive urination).

II.

Diagnostic Tests

A. Glycated Hemoglobin Assay (HbA1c or A1c) A1c measures the quantity of the end product of high glucose bound to a hemoglobin molecule (glycated or glycosylated hemoglobin). An easy way to remember this is to think of the red blood cell as your “donut” and the product of high glucose as the “glaze” on your “donut.” The higher the level of end products of high glucose in the blood, the more “glazed” the “donut” (red blood cell). A1c value provides an average of glycemia (blood glucose levels) over a 3-month period. The HbA1c test is used to diagnose prediabetes and diabetes.1 Prediabetes is diagnosed with an A1c value of 5.7%–6.4%. A1c greater than or equal to 6.5% is used to diagnose diabetes. The A1c is also used to monitor diabetes control11: Testing is recommended twice a year for individuals with good glycemic control. Patients with unstable glycemic control may require testing every 3 months. A1c goal may vary slightly for an individual based on risk for hypoglycemia, but the goal for most nonpregnant adults is less than

7%.11 Individuals with a history of severe hypoglycemia may have a less stringent goal such as less than 8%.

B. Fasting Plasma Glucose Measurement for fasting plasma glucose (FPG) is taken after fasting at least 8 hours and used for diagnosis in the following ways1: FPG of 100–125 mg/dL is used to diagnose prediabetes. FPG greater than 126 mg/dL is the criterion used for diagnosis of diabetes. Repeat testing is recommended to confirm a diagnosis.

C. 2-Hour Plasma Glucose Typically measured during an oral glucose tolerance test1: A 2-hour plasma glucose (PG) of 140–199 mg/dL is also used to diagnose prediabetes. A 2-hour PG greater than 200 mg/dL is used as a criterion for the diagnosis of diabetes. Repeat testing is recommended to confirm a diagnosis.

III. Diabetes Screening in the Dental Setting Dental visits provide an opportunity to screen patients for undiagnosed diabetes (see Figure 54-2).16,17

FIGURE 54-2 • Diabetes Risk Test. “Are You at Risk for Type 2 Diabetes?” screening tool. (Copyright 2009 American Diabetes Association. From

http://www.diabetes.org. Reprinted by permission of The American Diabetes Association.)

A type 2 diabetes risk test is available on the American Diabetes Association website and could be used chairside in the dental office for screening.18 Screening may also include point-of-care (POC) A1c testing using fingersticks or gingival crevicular bleeding.16,17,19

STANDARDS OF MEDICAL CARE FOR DIABETES MELLITUS Medical management depends on the severity of the disease and on individual characteristics. Consideration is given to individualized needs related to age, activities, vocation, lifestyle, knowledge, attitudes, personality, culture, emotional and psychological needs, as well as the health and nutritional status and weight issues of the patient.

I.

Early Diagnosis Identify individuals with prediabetes and undiagnosed diabetes through regular screening and/or monitoring.1,18,20 Assess risk factors and refer for evaluation.

II.

Management of Prediabetes The DPP that demonstrated lifestyle changes including physical activity, attaining and maintaining a healthy weight, and making wise food choices is effective in preventing or delaying the onset of diabetes.20,21

III. Diabetes Self-Management Education The National Standards for Diabetes Education and Support guidelines indicate diabetes self-management education is essential for those at risk for developing diabetes as well as for those individuals who are newly diagnosed.22 Diabetes self-management education and support has been shown to reduce HbA1c by 0.6%, which is equivalent to some medications.22 Maintain tight glycemic control to reduce the complications of diabetes through regular self-monitoring of blood glucose

(SMBG) at home.11 Frequency and timing are individualized to patient needs, but are often recommended before breakfast, prior to meals, and prior to bedtime. More frequent monitoring is associated with better glycemic control and a lower A1c. Hypoglycemia is a limiting factor in setting a glycemic target. Monitoring devices for home may include the following: Glucose meter (or glucometer) is a device that requires a fingerstick to obtain a drop of blood for measurement of blood glucose. Continuous glucose monitoring (CGM) is done automatically with a device such as FreeStyle Libre throughout the day and night and may have an alarm for hypoglycemia and hyperglycemia. Depending on the device, a sensor is placed on the abdomen or back of the upper arm, and a thin filament is inserted under the skin to measure the interstitial fluid glucose level. A handheld reader is then used to scan the sensor and provide the current blood glucose, an 8-hour history, and an arrow to show the trends in the blood glucose to help the individual understand and manage his or her blood glucose. Some devices may send the information to a cell phone, and the information can be downloaded to a computer. CGM is most commonly used with an insulin pump (Figure 543).

FIGURE 54-3 • Patient Wearing Insulin Pump. Young boy with active lifestyle wearing an insulin pump. (Photo courtesy of Minimed.)

A. Interprofessional Healthcare Team

Initial and ongoing individualized education is provided by the interprofessional team. Members include physicians, registered nurses, nurse practitioners, physician assistant, registered dietitian, nutritionists, pharmacists, mental health professionals, dental professionals, and other specialists, such as endocrinologist, cardiologist, ophthalmologist, and podiatrist.

B. Educational Resources Books and journals: A number of excellent books, professional journals, and other printed materials have been prepared for the patients and for health professionals. Annually, the American Diabetes Association publishes evidence-based Clinical Practice Recommendations in the Diabetes Care journal. These can be accessed free of charge on www.diabetes.org. Internet: Access to diabetes education and support resources continues to expand rapidly (review strategies to determine the validity of information on websites in Chapter 2). In addition to static websites, the Internet provides interactive resources that include the following: Interactive behavior change programs. Peer support through social media networks such as Facebook, blogs, and chat rooms.23 Technology: Cell phone applications for tracking food intake, physical activity, weight, blood glucose, and blood pressure can be used to assist the individual with self-monitoring and can be shared with the healthcare team.24

IV. Medical Nutrition Therapy Medical nutrition therapy (MNT) is individualized to meet the needs of the patients to manage and control diabetes.25 The American Diabetes Association recommends nutrition therapy

be provided by a registered dietitian/nutritionist.25 Goals for MNT include the following25: A variety of eating patterns are acceptable and should be individualized to meet overall health goals. The Mediterranean diet and Dietary Approaches to Stop Hypertension are examples of healthy eating patterns. Energy balance for modest weight loss (5–10 pounds) and weight maintenance. Carbohydrate intake needs to be balanced throughout the day, with focus on vegetables, fruits, whole grains, beans, and low-fat dairy products and an emphasis on higher fiber and lower glycemic loads over foods with added sugars. Similar to the Dietary Guidelines for Americans, individuals with diabetes need to limit or avoid added sugar and refined carbohydrates. Limit intake of saturated fat, trans fat, and cholesterol. Include foods rich in omega-3 fatty acids such as fatty fish, nuts, and seeds. Recommendations for sodium intake of less than 2,300 mg/day are the same as for the general population (see Chapter 33). Alcohol should be in moderation with an understanding about how it may increase the risk for hypoglycemia.

V.

Physical Activity

Adults are encouraged to engage in 150 minutes/week of moderate-intensity physical activity spread over at least 3 days/week.25 Children and adolescents are encouraged to engage in 60 minutes/day of moderate- or vigorous-intensity physical activity at least 3 days/week.25 Contributes to lowering insulin requirements by increasing the muscle sensitivity to insulin.

VI. Habits A. Tobacco Patients must avoid all types of tobacco (see Chapter 32). Tobacco use increases the risk of heart disease, stroke, myocardial infarction, limb amputations, periodontal disease, and numerous other health problems.25

B. Alcohol Avoid excessive alcohol; alcohol can raise blood pressure and contribute to other health problems as well as difficulty with diabetes management.25

VII. Psychosocial Issues Screening for diabetes distress (DD) should be done routinely by the primary care provider and requires interprofessional collaboration to manage. DD refers to the psychological challenges of managing a chronic disease like diabetes.

PHARMACOLOGIC THERAPY I. Insulin Therapy All patients with type 1 diabetes require exogenous insulin for survival. Type 2 diabetic patients may need to use insulin in combination with other medications for glycemic control.26

A. Types of Insulin Insulin is classified as rapid acting, regular or short acting, intermediate acting, or long acting based on the onset, peak, and duration of action. The types of insulin and range of peak action are found in Table 54-4. TABLE 54-4 • Types and Action of Insulin

B. Dosage Objective: Attain optimum utilization of glucose throughout each 24 hours. Factors affecting the need for insulin: Food intake, illness, stress, variations in exercise, or infections. “Sick Day Rules”: Insulin dose is adjusted if there are any factors that affect the need for insulin.

C. Methods for Insulin Administration

Subcutaneous injection with syringe: A syringe is filled from vial of insulin. Injection sites are rotated usually on the abdomen, thigh, or upper arm. Insulin pen: Prefilled cartridge of single type of insulin injected with attached needle. May be disposable or a reusable type. Continuous subcutaneous insulin infusion with a battery-operated insulin pump: The insulin pump delivers a preprogrammed continuous basal rate of insulin and bolus doses when needed. Offers greater flexibility and smoother control of glycemia, but may increase the risk of hypoglycemia. The small cell phone–sized pump can be worn in a pocket or on a belt or a waistband, as shown in Figure 54-3. Inhalable insulin27: Contraindicated for those who have long-term (chronic) lung problems such as asthma or chronic obstructive pulmonary disease (COPD) Rapid-acting, “mealtime” insulin is taken through an inhaler. Side effects include lower lung function, cough, dry mouth, bronchospasm, or chest discomfort. Brand name: Afrezza®. Future modes for insulin administration include an insulin patch and implantable insulin pumps.

II.

Antihyperglycemic Therapy The medications listed in Table 54-5 may be used individually or in combinations.26 TABLE 54-5 • Antihyperglycemic Agents Used for Treatment of Type 2 Diabetes AGENT

EXAMPLE

Biguanides

Metformin (Glucophage)

ACTION/FUNCTION Prevent liver glycogen breakdown to glucose Increase tissue sensitivity

to insulin Sulfonylureas

Glyburide (Diabeta, Micronase) Glipizide (Glucotrol)

Stimulate pancreas to release more insulin after a meal May cause hypoglycemia

Meglitinides

Repaglinide (Prandin) Nateglinide (Starlix)

Stimulate pancreas to release more insulin after a meal May cause hypoglycemia

Thiazolidinediones

Pioglitazone (Actos)

Increase tissue sensitivity to insulin

Dipeptidyl peptidase4 inhibitors

Sitagliptin (Januvia)

Improve insulin level after meals and lowers glucose production

Alpha-glucosidase inhibitors

Acarbose (Precose)

Slow digestion and absorption of glucose into bloodstream after eating

Bile acid sequestrants

Colesevelam (Welchol)

Bind bile acids in intestinal tract, increasing hepatic bile production

SGLT2 inhibitors

Canagliflozin (Invokana®) Dapagliflozin (Farxiga®)

Block glucose reabsorption in kidney

GLP-1 receptor agonists

Exenatide (Byetta®) Liraglutide (Victoza®)

Increase insulin secretion Decrease glucagon secretion Slow gastric emptying Increase satiety

Dopamine-2 agonists

Bromocriptine (Cycloset®)

Increase insulin secretion

GLP: glucagon-like peptide; SGLT: sodium–glucose cotransporter. Source: Adapted from American Diabetes Association. 8. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes— 2018. Diabetes Care. 2018; 41(suppl 1):S73-S85.

The most common medication used in prediabetes is metformin. Monotherapy: lifestyle management + metformin.26 A1c less than 9%. Dual therapy: lifestyle management + metformin + additional agent.26 A1c greater than or equal to 9%. Triple therapy: lifestyle management + metformin + two additional agents.26 A1c greater than or equal to 10%. The takeaway message for dental professionals is that when a patient is on multiple medications, it means the diabetes is not well controlled.

COMPLICATIONS OF DIABETES Patients with well-controlled blood glucose levels tend to develop fewer complications later in life than those whose diabetes is less well controlled.28

I.

Infection Individuals with poorly controlled diabetes are more susceptible to infections and impaired healing, which can worsen prognosis.26,29,30 The presence of stress, trauma, and infection affects blood glucose levels. Failure to treat an infection intensifies the symptoms and increases the severity of diabetes, which can progress to life-threatening infections or precipitate DKA.1,26,29 Insulin requirements may increase with fever, infection, inflammation, trauma, bleeding, pain, or stress. When the condition is eliminated, prescribed insulin may be reduced. Numerous factors are involved including impaired immune response, alterations in metabolism of carbohydrate and protein, vascular changes and impaired circulation, and altered nutritional state.29

II.

Neuropathy Neuropathy can cause pain, numbness, or tingling of mouth, face, and extremities.

A. Peripheral Neuropathy Symptoms vary based on the sensory nerve fibers affected and may result in loss of sensation in the feet, hands, and fingers.31 Numbness in the hands and fingers may make effective oral self-

care difficult. As many as 50% of people with peripheral neuropathy may be asymptomatic and not recognize the loss of sensation, which can put them at risk for injury and resulting infection.31 Leads to increased incidence of amputations and Charcot joints.31

B. Autonomic Neuropathy Manifestations include tachycardia, orthostatic hypotension, gastroparesis, and hypoglycemic unawareness.31 Cardiovascular autonomic neuropathy can be symptomatic other than changes in the heart rate. Gastroparesis is a slowing of digestion and motility of the gastrointestinal tract. Hypoglycemic unawareness can quickly become an emergency situation because the patient is not able to recognize the usual symptoms of low blood glucose. Early management to maintain glycemic levels near normal can be effective in preventing or delaying neuropathy.31

III. Nephropathy Diabetes is a leading cause of renal disease and the most common cause of end-stage renal disease in the United States and Europe. Dialysis or kidney transplant is needed.31 Patients diagnosed with diabetes are screened at least annually for microalbuminuria (protein in the urine).31

IV. Retinopathy Diabetes is a leading cause of new cases of blindness through the progression of diabetic retinopathy.31 Patients are more likely to have glaucoma and cataracts.31

V.

Cardiovascular Disease

Individuals with diabetes are at high risk for cardiovascular disease, a major cause of morbidity and mortality. Conditions common in people with diabetes include the following32: Hypertension. Dyslipidemia (high total cholesterol and low-density lipoproteins [LDL]). Hypertriglyceridemia (high triglycerides). May lead to myocardial infarction and stroke. Owing to the excessive risk of coronary heart disease, aggressive treatment for dyslipidemia and hypertriglyceridemia is recommended.32 Low-dose aspirin therapy may be recommended for the prevention of cardiovascular disease in patients with diabetes. Daily aspirin intake may increase bleeding time.32

VI. Amputation Diabetes is a major cause of limb amputation (usually foot) from possible complications of neuropathy and vascular disease.31

VII. Pregnancy Complications Patients with diabetes are at higher risk for spontaneous miscarriages, having babies with birth defects and increased weight.33

VIII. Mental Health Due to complications of diabetes, the daily life of the patient as well as those close to the patient are significantly affected. Diabetes distress (DD) was discussed in the previous section regarding psychosocial issues. However, mental health issues common in those with diabetes include the following29: Anxiety disorders.

Depression. Disordered eating behavior characterized by omission of insulin to lose weight. Serious mental illness such as schizophrenia. Treatment regimens may be challenging to cope with and lead to emotional and social problems, including depression. A suggestion for the patient to discuss psychosocial issues with the physician may improve patient’s compliance with treatment and daily oral personal care.

DENTAL HYGIENE CARE PLAN The control of oral infection is vital. Infections can progress more quickly and can alter the management of diabetes. Frequent, thorough oral care requires the patient’s cooperation along with regular professional care. The patient with diabetes is prone to life-threatening emergencies. Emergency practice drills can help the dental team prevent an emergency, identify early indications of a developing emergency, and act swiftly and appropriately.

I.

Appointment Planning

Stress, including stress created during a dental or dental hygiene appointment, can affect blood sugar levels. Appointment planning needs to center around many factors, including stress prevention.

A. Time Treat patient after a meal, preferably containint protein and fat to slow carbohydrate absorption. Avoid peak insulin level noted in Table 54-4. Ideal time of appointment varies with individual patient’s lifestyle and method of insulin intake. Preferred time of appointment may be morning, soon after the patient’s normal breakfast and medication, during the ascending portion of the blood glucose level curve.34

B. Precautions: Prevent/Prepare for Emergency Do not keep the patient waiting. Do not interfere with the patient’s regular meal and between-meal eating schedule. Avoid long, stressful procedures; dental and dental hygiene care

can be divided into short appointments appropriate to the individual’s needs. Take additional precautions indicated for the patient with long-term diabetes with complications related to atherosclerosis and other cardiovascular diseases. Prevent and treat all infections promptly. Monitor for symptoms of hypoglycemia including dizziness, sweating (diaphoresis), mental confusion, shakiness, pallor, palpitations, and irritability. The symptoms of hypoglycemia and hyperglycemia are listed in Box 54-2. Prepare for hypoglycemic emergency. Keep glucose gel as part of the office emergency kit for the conscious patient. A glucometer should also be part of the emergency supplies to allow testing to identify hypoglycemia and monitor the effect of the glucose gel.

D. Emergency Management Recognize any change in patient behavior that signals a diabetes emergency. If in doubt, it is safer to treat for hypoglycemia since it will only cause a brief increase in blood glucose. Follow the Rule of 15s (see the flowchart in Figure 54-4 for the management of hypoglycemia).11

FIGURE 54-4 • Managing Hypoglycemia (Rule of 15s). Flowchart to show steps to take when the patient exhibits symptoms of hypoglycemia (insulin shock). Reprinted from DeLong L, Burkhart N General and Oral Pathology for the Dental Hygienist. Philadelphia: Lippincott Williams & Wilkins; 2015

II.

Patient History

A. Medical History Questions regarding signs and symptoms of diabetes are included

in a standard medical history questionnaire. Appropriate questions to ask are listed in Box 54-3.

BOX 54-3 Common Medical History Questions to Screen for Diabetes

• Have you ever been diagnosed with prediabetes, borderline diabetes, or diabetes? • Have any members of your family ever been diagnosed with diabetes? • Do you urinate frequently? How many times per day? • Are you frequently thirsty? • Does your mouth feel dry? • Have you had any unexplained weight loss? • Do you experience excessive hunger? • Did you have recent blurred vision?

Yes

No

Yes

No

Yes

No

Yes Yes Yes Yes

No No No No

Yes

No

Gather detailed information on all current prescribed and over-thecounter medications, including recommended dose. Gather information on vitamins and homeopathic or herbal supplements. Supplement the basic medical history with additional questions to obtain information about diabetes (suggested questions along with answers can be found in Box 54-4).

BOX 54-4 Questions to Ask a Patient with Diabetes to Gather Additional Information • When was your last visit to your diabetes care healthcare provider?

•

•

•

•

•

•

•

•

•

Answer: It is recommended individuals with stable glycemic control be seen twice/year and those with poor glycemic control at least quarterly. What medications and dose have you taken today? Answer: Medications need to be taken prior to the appointment, and patient knowledge about medications suggests personal responsibility for diabetes self-care. When did you eat last? What did you eat? Answer: Foods containing complex carbohydrates and protein and/or fat 1–2 hours before the appointment to prevent hypoglycemia is ideal. Do you monitor your blood sugar at home? Answer: Yes, self-monitoring of blood glucose is critical for diabetes self-care. How often do you monitor your blood glucose? Answer: Those taking multiple doses of insulin need to check the blood glucose levels three or more times daily. Once or twice daily is typical for those using oral medications. What is your usual fasting blood sugar in the morning? Answer: Glucose levels between 90 and 130 mg/dL premeal and below 180 mg/dL 2 hours postmeal (postprandial). What is your hemoglobin A1c? How often does your primary care provider check the A1c? Answer: About less than 7% and preferably less than 6.5%; A1c testing recommended twice/year in those with good glycemic control and quarterly in those with poor control. (If the patient reports poorly controlled diabetes) Are you experiencing frequent urination? Answer: Response of “yes” may indicate hyperglycemia and poor diabetes control and requires referral. The patient will not heal, and it is best to postpone treatment as healing will be suboptimal. Do you have frequent episodes of hypoglycemia (low blood sugar)? Can you tell when your blood sugar is getting low? Answer: Response of “yes” to the first question and “no” to the second identifies a patient at risk for a medical emergency. Hypoglycemic unawareness occurs as a result of neuropathy, and the patient is no longer able to identify when the blood sugar has dropped to dangerously low levels. (For those with a history of hypoglycemia, ask this question) What time of day does it usually happen and how do you treat it? Answer: If the appointment is during a critical time of day for hypoglycemia, precautions need to be taken to prevent and treat it or the appointment can be rescheduled. Mid-afternoon is typically when some types of insulin and oral medications reach their peak action and glucose from the midday meal reaches a low, resulting in a dangerous

combination putting the patient at risk for hypoglycemia. • Have you been hospitalized for hypoglycemia? Answer: Response of “yes” indicates extreme risk, and preparation needs to be made to rapidly treat hypoglycemia. Place a glucometer and glucose source near the treatment area for quick access. • Are you having problems with your eyes, feet, hands, or legs? If so, what kind of problems are you experiencing? Answer: A patient experiencing complications may be poorly controlled, and a medical consult is advised. Adapted from Boyd LD. Commentary on survey of diabetes knowledge and practices of dental hygienists. Access. 2008;22(8):40-43.

If an unexplained positive response is present suggesting symptoms of diabetes, the patient is referred to a primary care provider for evaluation. Ask about physical activity and tobacco use; review effect on health. Update medical history at each appointment. Identify health problems or complications of diabetes that may influence dental treatment.

B. Screening for Diabetes The American Diabetes Association’s diabetes risk test (Figure 542) can also be used to identify those at risk for diabetes. Using POC devices to test HbA1c and blood glucose has been shown to be a cost-effective approach to identifying undiagnosed and at-risk patients needing referral for further evaluation.16 Note: Using these devices is not similar to laboratory tests, and verification is needed by a blood sample evaluated by a certified laboratory.

III. Consultation with Primary Care Provider Consultation with the primary care provider to obtain A1c values can be initiated either prior to or at the first visit. Table 54-6 provides a conversion for the A1c values to average

blood glucose levels. TABLE 54-6 • Comparison of Average Blood Glucose and A1c MEAN PLASMA GLUCOSE A1c (%)

mg/dl

mmol/l

6

126

7.0

7

154

8.6

8

183

10.1

9

212

11.8

10

240

13.4

11

269

14.0

Source: Adapted from American Diabetes Association. 6. Glycemic targets: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(suppl 1): S55-S64.

Further consultation may be necessary in more advanced periodontal disease to obtain clearance for treatment.

IV. Dental Hygiene Assessment and Treatment A. Extraoral/Intraoral Examination Acanthosis nigricans appears as a light brown to black discoloration of the skin in the creases of the neck and can indicate risk for diabetes (Figure 54-5).35

FIGURE 54-5 • Acanthosis Nigricans. This skin condition is seen in patients at risk for diabetes and typically appears on the creases in the neck as a light brown to black discoloration. (Reprinted from DeLong L, Burkhart N. General and Oral Pathology for the Dental Hygienist. Philadelphia, PA: Lippincott Williams & Wilkins; 2015.)

B. Dental Biofilm Control Instruction

Because of the impact of diabetes on periodontal health and the effect of oral infection on diabetes status, daily meticulous oral selfcare is crucial. Disclosing the biofilm and individualized self-care measures for biofilm control should be conducted at each visit.

C. Tobacco Cessation Refer to the information on Tobacco Cessation Programs in Chapter 32.

D. Instrumentation Nonsurgical periodontal therapy: Definitive nonsurgical periodontal therapy reduces the possibility of periodontal abscess formation. Allow several short appointments if needed for stress management. Healing: Avoid undue trauma to tissues to minimize the risk for complications associated with healing.

E. Fluoride Fluoride treatments, varnishes, and home use of fluoride should be recommended based on caries risk. Methods for daily self-fluoride application are described in Chapter 34.

V.

Continuing Care

Appointment for supervision and examination on a regular 3- to 6month basis as needed. Effectiveness of daily oral self-care is evaluated. Probe carefully to detect early bleeding on probing and evidence of pocket formation. Assess soft tissue with attention to areas of irritation related to fixed and removable prostheses.

Identify any changes requiring consultation or referral to the patient’s primary care provider, dietitian, mental health professional, or other specialist. Check for dental biofilm control and review control with the patient at each appointment. Gingival health is of major importance. Keep the patient motivated.

DOCUMENTATION Record status of blood glucose control, including most recent HbA1c and other daily monitoring such as fasting blood glucose levels the patient has performed. Update current medications and doses. Confirm compliance with medication intake and food consumption. Record discussion about relationship between oral health status, oral hygiene status, risk factors, and diabetes. Box 54-5 contains an example progress note for a patient with diabetes.

BOX 54-5 Example Documentation: Patient with Diabetes Mellitus S—A 66-year-old Hispanic female who presents for a periodontal maintenance. She reports bleeding when she flosses for the last couple of weeks. She was recently diagnosed with type 2 diabetes and is taking Metformin and Glipizide. Her initial HbA1c was 8.5, and she will have a follow-up test next month. She reports checking her blood glucose when she gets up in the morning and before dinner. Her fasting blood glucose this morning was 120. Patient reports taking her medications this morning. O—Blood pressure: 131/79. Pulse: 88. Respirations: 24. Risk assessment for caries was moderate, periodontal disease was high, and oral cancer was moderate. Periodontal examination reveals localized bleeding on probing, and 1–2 mm pocket depth increases primarily in maxillary molar areas. Radiographic bone loss is 1–2 mm in maxillary posterior areas. Biofilm score: 30%. No new dental caries. A—Localized periodontitis Stage 1, Grade 3 due to poorly controlled diabetes mellitus. P—Discussed the association of periodontal infection with diabetes and need for meticulous oral self-care and regular professional periodontal maintenance appointments. Reviewed use of interdental brushes for molar areas where biofilm was located. The patient had difficulty removing biofilm on the lingual line angles of the molars, so careful wrapping of the floss was also reviewed. Complete periodontal debridement was performed. Applied 5% sodium fluoride varnish and provided a prescription for 0.12% chlorhexidine gluconate mouthrinse to use twice a day for 2 weeks to assist with healing.

Signed: ______________________________, RDH Date: ____________________________________

EVERYDAY ETHICS Ed, a 45-year-old restaurant owner, presents for an appointment with Susan, the dental hygienist. She has treated this patient before, but he has not had an appointment for more than 2 years. The review of his medical history determines he is obese, complains of a dry mouth, has excessive thirst, gets up at night multiple times to urinate, and has not seen his primary care provider in several years. An intraoral examination reveals candidiasis on his hard palate. Susan suggests that he sees his physician, but he refuses to even talk about it. He insists that he just wants “clean teeth” for his daughter’s upcoming wedding. Questions for Consideration 1. Describe how each of the dental hygiene ethical core values apply to this scenario. 2. In what ways will Susan be violating the patient’s rights if she agrees to Ed’s request that she focus only on “cleaning” his teeth at this appointment? How may she be violating his rights if she refuses to clean his teeth unless he first has an examination with his primary care provider? 3. Explain choices or alternative actions Susan can consider as she decides how to continue treatment during Ed’s appointment.

Factors to Teach Patients with Diabetes Factors to Teach Patients with Diabetes Importance of regular medical and dental care; eye examinations; blood pressure checks; blood tests for cholesterol, lipids, and kidney readings; and practicing self-examination, particularly of feet, for nerve involvement or delayed healing visits to prevent complications. Connection between oral health and diabetes and need for meticulous oral self-care. The patient’s role in self-management of diabetes with an emphasis on the need to be compliant with lifestyle modifications including healthy eating, physical activity, weight management, glucose monitoring, tobacco cessation, good oral self-care, limiting or avoiding alcohol, stress management, and use of prescribed medications.

The value of seeking immediate medical attention for any signs of complications from diabetes. Factors to Teach Patients at Risk for Diabetes Need for regular medical examinations and screening for diabetes. How to recognize the early warning signs of diabetes and seek medical consult. Factors that affect a healthy lifestyle, including healthy diet, daily exercise, no tobacco products, avoiding alcohol, and maintaining ideal weight. How to practice meticulous oral hygiene to prevent dental caries and periodontal disease. Stress reduction techniques.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. American Diabetes Association. Classification and diagnosis of diabetes mellitus: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(suppl 1):S13-S27. 2. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2017. https://www.cdc.gov/diabetes/data/statistics/statistics-report.html. Accessed November 18, 2018. 3. Ogurtsova K, da Rocha Fernandes JD, Huang Y, et al. IDF Diabetes Atlas: global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Res Clin Pract. 2017;128:40-50. 4. Sanz M, Ceriello A, Buysschaert M, et al. Scientific evidence on the links between periodontal diseases and diabetes: consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International diabetes Federation and the European Federation of Periodontology. Diabetes Res Clin Pract. 2018;137:231-241. 5. Botero JE, Rodríguez C, Agudelo-Suarez AA. Periodontal treatment and glycaemic control in patients with diabetes and periodontitis: an umbrella review. Aust Dent J. 2016;61(2):134-148. 6. Engebretson S, Kocher T. Evidence that periodontal treatment improves diabetes outcomes: a systematic review and meta-analysis. J Clin Periodontol. 2013; 40(suppl 14):S153-S163. 7. D’Aiuto F, Gable D, Syed Z, et al. Evidence summary: the relationship between oral diseases and diabetes. Br Dent J. 2017;222(12):944-948. 8. Segura-Egea JJ, Martín-González J, Cabanillas-Balsera D, Fouad AF, Velasco-Ortega E, López-López J. Association between diabetes and the prevalence of radiolucent periapical lesions in root-filled teeth: systematic review and meta-analysis. Clin Oral Investig. 2016; 20(6):1133-1141. 9. Moraschini V, Barboza ES, Peixoto GA. The impact of diabetes on dental implant failure: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2016;45(10):1237-1245. 10. Newsholme P, Cruzat V, Arfuso F, et al. Nutrient regulation of insulin secretion and action. J Endocrinol. 2014;221(3):R105-R120. 11. American Diabetes Association. 6. Glycemic targets: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(suppl 1):S55-S64. 12. Diabetes Prevention Program (DPP) Research Group. The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care. 2002;25(12):2165-2171. 13. Pulgaron ER, Delamater AM. Obesity and type 2 diabetes in children: epidemiology and treatment. Curr Diab Rep. 2014;14(8):508. 14. DeSisto CL, Kim SY, Sharma AJ. Prevalence estimates of gestational diabetes

mellitus in the United States, pregnancy risk assessment monitoring system (PRAMS), 2007–2010. Prev Chronic Dis. 2014;11:E104. 15. Linnenkamp U. IDF diabetes atlas reveals high burden of hyperglycaemia in pregnancy. Diabetes Voice. 2014; 59:55-56. 16. Glurich I, Bartkowiak B, Berg RL, Acharya A. Screening for dysglycaemia in dental primary care practice settings: systematic review of the evidence. Int Dent J. 2018; 68(6):369-377. 17. Strauss SM, Russell S, Wheeler A, et al. The dental office visit as a potential opportunity for diabetes screening: an analysis using NHANES 2003–2004 data. J Public Health Dent. 2010;70(2):156-162. 18. American Diabetes Association. Type 2 diabetes risk test. http://www.diabetes.org/are-you-at-risk/diabetes-risk-test/. Accessed November 23, 2018. 19. Strauss SM, Tuthill J, Singh G, et al. A novel intraoral diabetes screening approach in periodontal patients: results of a pilot study. J Periodontol. 2012;83(6):699-706. 20. American Diabetes Association. 5. Prevention or delay of type 2 diabetes: standards of medical care in diabetes—2018. Diabetes Care. 2018; 41(suppl 1):S51-S54. 21. The Diabetes Prevention Program Research Group. The 10-year costeffectiveness of lifestyle intervention or metformin for diabetes prevention: an intent-to-treat analysis of the DPP/DPPOS. Diabetes Care. 2012;35(4):723730. 22. Beck J, Greenwood DA, Blanton L, et al. 2017 national standards for diabetes self-management education and support. Diabetes Educ. 2018;44(1):35-50. 23. Maher CA, Lewis LK, Ferrar K, Marshall S, De Bourdeaudhuij I, Vandelanotte C. Are health behavior change interventions that use online social networks effective? A systematic review. J Med Internet Res. 2014;16(2):e40. doi:10.2196/jmir.2952. 24. Fu H, McMahon SK, Gross CR, Adam TJ, Wyman JF. Usability and clinical efficacy of diabetes mobile applications for adults with type 2 diabetes: a systematic review. Diabetes Res Clin Pract. 2017;131:70-81. 25. American Diabetes Association. 4. Lifestyle management: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(suppl 1):S38-S50. 26. American Diabetes Association. 8. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(suppl 1):S73-S85. 27. Mohanty RR, Das S. Inhaled insulin—current direction of insulin research. J Clin Diagn Res. 2017;11(4):OE01-OE02. 28. Nathan DM; DCCT/EDIC Research Group. The diabetes control and complications trial/epidemiology of diabetes interventions and complications study at 30 years: overview. Diabetes Care. 2014;37(1):9-16. 29. American Diabetes Association. 3. Comprehensive medical evaluation and assessment of comorbidities: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(suppl 1):S28-S37.

30. Baltzis D, Eleftheriadou I, Veves A. Pathogenesis and treatment of impaired wound healing in diabetes mellitus: new insights. Adv Ther. 2014;31(8):817836. 31. American Diabetes Association. 10. Microvascular complications and foot care: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(suppl 1):S105-S118. 32. American Diabetes Association. 9. Cardiovascular disease and risk management: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(suppl 1):S86-S104. 33. American Diabetes Association. 13. Management of diabetes in pregnancy: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(suppl 1):S137-S143. 34. American Dental Association. Oral health topics: diabetes key points. https://www.ada.org/en/member-center/oral-health-topics/diabetes. Updated June 6, 2018. Accessed November 25, 2018. 35. Bustan RS, Wasim D, Yderstræde KB, Bygum A. Specific skin signs as a cutaneous marker of diabetes mellitus and the prediabetic state—a systematic review. Dan Med J. 2017;64(1):pii: A5316.

55 The Patient with Cancer Dianna S. Weikel, RDH, MS, and Deborah S. Manne, RDH, RN, MSN, OCN

CHAPTER OUTLINE DESCRIPTION I. II. III. IV.

Incidence and Survival Risk Factors Types of Cancer How Cancer Is Treated

SURGERY I.

Indications for Surgery

CHEMOTHERAPY I. II. III. IV. V.

Objectives Indications Types of Chemotherapy Systemic Side Effects of Chemotherapy Oral Complications of Chemotherapy

RADIATION THERAPY I. II. III. IV. V.

Indications Types Doses Systemic Effects Oral Complications

HEMATOPOIETIC STEM CELL TRANSPLANTATION I. II. III. IV.

Types Stages of Transplantation Process Acute Complications Chronic Complications

MUCOSITIS MANAGEMENT I. II.

Prevention/Oral Health Maintenance Treatment of Established Mucositis

DENTAL HYGIENE CARE PLAN I. II. III.

Objectives Personal Factors Oral Care Protocol

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT FACTORS TO TEACH THE CAREGIVER REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Identify healthcare professionals involved in the multidisciplinary oncology team. 2. Explain several systemic medical treatment options utilized in cancer management. 3. Describe common oral complications secondary to cancer treatment. 4. Provide examples of evidence-based dental hygiene care

strategies for mucositis management. Dental hygiene care of the patient with cancer before, during, and after therapy strives to not only attain but also maintain a patient’s oral health at the highest possible level. This contributes to the patient’s general health and overall quality of life. Cancer treatment modalities (radiation therapy, chemotherapy, surgery, and hematopoietic cell transplantation) have the potential to affect the oral cavity significantly. The patient will be under the care of a team of multidisciplinary specialists. Box 55-1 lists the members of the multidisciplinary team.

BOX 55-1 Multidisciplinary Team for the Care of the Patient with Cancer Cancer Specialists • Medical oncologist: provides cancer management utilizing chemotherapeutic modalities. • Radiation oncologist: responsible for the planning, delivery, and follow-up of radiation therapy. • Surgeon (all subspecialties): biopsy and/or excision of cancer. • Oncology nurse: provides clinical support in the medical, surgical, and/or radiation management of the cancer patient. • Oncology dietitian: provides symptom management. • Oncology social worker: provides psychosocial support and is often a liaison between clinical staff and patient/family. • Oral care specialists: play a role in initial diagnosis and management of oral complications during cancer therapy. • Dental hygienist. • Dentist. • Oral maxillofacial surgeon. • Periodontist. • Endodontist. • Oral maxillofacial prosthodontist. • Oral pathologist.

Other Health Specialists • Speech pathologist. • Physical therapist. • Occupational therapist. • Psychologist/psychiatrist.

DESCRIPTION Cancer refers to: A group of neoplastic diseases in which there is transformation of normal cells into malignant ones. As cancer cells proliferate, the mass of abnormal tissue formed enlarges until it takes over the host site. It then sheds cells that spread to distant sites (metastasis). The characteristics of benign and malignant neoplasms are compared in Table 55-1. TABLE 55-1 • Characteristics of Benign and Malignant Neoplasms CHARACTERISTIC BENIGN

MALIGNANT

Cell characteristics

Well-differentiated cells of the tissue from which the tumor originated

Cells are undifferentiated. Anaplastic features (lack of differentiation)

Mode of growth

Tumor grows by expansion and does not infiltrate the surrounding tissues; encapsulated

Tumor grows at the periphery and sends out processes that infiltrate and destroy the surrounding tissues

Rate of growth

Rate of growth is usually slow

Rate of growth is usually relatively rapid and is dependent on the level of differentiation; the more anaplastic the tumor, the more rapid the rate of growth

Metastasis

Does not spread by metastasis

Gains access to the blood and lymph systems to metastasize to other organs

Destruction of tissue

Does not usually cause tissue damage unless location interferes with

Often causes extensive tissue damage as the tumor outgrows its blood

blood flow

supply or encroaches on blood flow to the area; may also produce substances that cause cell damage

Source: Adapted from Grossman SC, Porth CM. Pathophysiology: Concepts of Altered Health States. 9th ed. Philadelphia, PA: Lippincott, William & Wilkins; 2014.

Cancers are classified on the basis of the following: Origin of the tissue involved: carcinomas from epithelial tissue and sarcomas from connective tissue. Type of cell from which they arise, namely, an epithelial or connective tissue cell.1 Staging is: A succinct, standardized description of a tumor based on origin and extent. Made up of three components: T (tumor size), N (presence or absence of lymph nodes), and M (presence or absence of distant metastases). Common signs and symptoms of cancer are listed in Box 55-2.

BOX 55-2 Common Signs and Symptoms of Cancer C: A change in bowel or bladder habits (colon) A: A sore that doesn’t heal on skin or inside mouth (skin or oral) U: Unusual bleeding or discharge (uterine, lung, and colon) T: Thickening or lump in breast tissue or anywhere on the body (breast and testicle) I: Indigestion/difficulty swallowing O: Obvious change in wart or mole (skin) N: Nagging cough or hoarseness (lung or throat) Source: American Cancer Society. Signs and symptoms of cancer. http://www.cancer.org/cancer/cancerbasics/signs-and-symptoms-of-cancer. Accessed February 20, 2018.

I.

Incidence and Survival

Cancer is the second leading cause of death in the United States for adults under the age of 85 years.2 Survival depends on the following: Type of cancer. Location and size of the tumor. Presence of distant metastases. Tumor sensitivity to treatment. Physical condition: comorbidities and age.

II.

Risk Factors

Numerous factors increase a person’s risk for developing cancer, including the following3: Tobacco: both cigarette smoking and use of smokeless tobacco products are implicated in head and neck cancer, lung cancer, and bladder cancer. Alcohol: chronic, long-term use especially in combination with tobacco use implicated in head and neck cancer, bladder cancer, and liver cancer. Sunlight: especially occupations requiring work under the sun such as construction workers, farmers, as well as sunbathers. Environmental/occupational: exposure to asbestos, radon, coal dust, and chemicals, to name a few. Viruses: Epstein–Barr virus implicated in Burkett’s lymphoma. Hepatitis C implicated in liver cancer. Human papillomavirus (16 and 18) implicated in cervical cancer and cancer of the oropharynx (tonsil and base of tongue). Socioeconomic: late diagnosis with poorer prognosis seen in lower socioeconomic populations (inner city, rural, and working poor).

III. Types of Cancer The most common types of cancer are as follows2:

Men: Prostate. Lung and bronchus. Colon and rectum. Women: Breast. Lung and bronchus. Colon and rectum.

IV. How Cancer Is Treated Cancer is treated using a variety of different approaches based on the following3,4: The location and size of the tumor. Treatment objectives (cure, control, or palliation). The different approaches including: Surgery. Chemotherapy. Radiation therapy. Hematopoietic cell transplantation. Hormone therapy. Vaccine therapy. Biotherapy. Targeted therapies. A combination of two or more of the above.

SURGERY Surgery is the most common form of treatment for solid tumors, both malignant and nonmalignant.

I.

Indications for Surgery Tumors that are small in size, localized, and easy to remove.5 Debulk or remove portions of large tumors before treatment (chemotherapy or radiation therapy).5 Provide pain relief or prolong life when no chance of cure is possible (palliative/palliation).5

CHEMOTHERAPY Chemotherapy involves the use of drugs that affect the rapidly dividing cancer cells at different points in the cell cycle. The drugs are used as a single agent or in combination. Side effects can be severe and frequently involve the oral cavity.

I.

Objectives To destroy cancer cells and keep them from metastasizing. To prevent cancer from recurring. To provide an improved quality of life.

II.

Indications Eliminate a localized tumor too large for surgical removal. Treat cancer that has metastasized to other parts of the body. Prevent cancer recurrence with maintenance therapy. Use before surgery to make a tumor easier to remove completely. Palliative. Treatment of “liquid tumors” such as leukemia.

III. Types of Chemotherapy Box 55-3 lists the types of agents used for chemotherapy.

BOX 55-3 Types of Agents Used for Chemotherapy Alkylating agents Antibiotics Antimetabolites Plant alkaloids Steroids/hormones

Proteasome inhibitors, mammalian target of rapamycin inhibitors Targeted therapies

IV. Systemic Side Effects of Chemotherapy Chemotherapy affects both rapidly dividing cancer cells and rapidly dividing normal cells (hair, oral/gastrointestinal mucosa, and bone marrow). Halting cell division of normal cells may cause side effects that range from mild to life threatening. The most common include the following: Alopecia (hair loss). Myelosuppression (bone marrow suppression causing a reduction in blood counts leading to anemia, leukopenia, and thrombocytopenia). Immunosuppression (inhibition of antibody responses resulting from leukopenia). Nausea, vomiting, and diarrhea. Loss of appetite. Gastrointestinal mucositis.

V.

Oral Complications of Chemotherapy

The following are oral complications resulting from chemotherapy4,6: Oral mucositis/stomatitis: an inflammation of the oral mucosa characterized by erythema, ulceration, and pain. Xerostomia: subjective report of oral dryness. Salivary gland hypofunction: objective reduction in saliva production. Infections: Bacterial. Viral: herpes simplex, varicella zoster, and cytomegalovirus. Fungal: Candida albicans. Bleeding: anywhere in the mouth; spontaneous or induced. Neurotoxicity: mimics toothache; usually bilateral. Osteonecrosis of the jaw exposed bone of at least 8 weeks

duration in either the maxilla or mandible secondary to use of systemic bisphosphonates and/or other antiresorptive medication/therapies.7 Also referenced as medication-related osteonecrosis of the jaw and antiresorptive drug-related osteonecrosis of the jaw.

RADIATION THERAPY Radiation therapy uses ionizing radiation to treat cancer. Radiation impacts the cancer cell’s ability to replicate and survive. Not all tumors are radiosensitive (ability of the radiation therapy to kill the tumor). Head and neck radiation therapy produces acute short-term and chronic long-term effects in the oral cavity.

I.

Indications Treat a small localized tumor that is radiosensitive. Shrink a large tumor before surgery. Increase the effectiveness of chemotherapy when used concurrently. Prevent the spread of cancer or control residual tumor. Prevent a recurrence of the cancer. Provide symptom/pain relief for bone metastases or palliative therapy.

II.

Types

A. External Beam Conventional use of ionizing radiation applied outside the body. Intensity-modulated radiation therapy (IMRT) Developed in the late 1990s. Considered a high-precision delivery of radiation. Accomplished via computer-guided images of target anatomy with radiation produced by a linear accelerator. Used in treatment of head and neck cancer. Radiation dose is elevated at the site of the gross tumor while simultaneously sparing the surrounding normal tissue. Results in decreased side effects, better tumor targeting as

compared to conventional external beam radiation. Figure 55-1 illustrates the patient preparation prior to IMRT.

FIGURE 55-1 • Custom Patient Mask. This is worn by the patient at each radiation appointment. The mask, made out of firm mesh, snaps into the treatment table to assist immobilizing the patient for precise radiation delivery throughout the course of radiation therapy. A bite block is placed intraorally (arrow) to maintain the mouth in a static position. The linear accelerator (source of radiation) is seen in the background. (Used with permission from Dianna S. Wiekel.)

Proton therapy.8 New method of radiation delivery, used in some head and neck cancer patients. Technique is considered more precise than IMRT with less damage to the surrounding oral structures, thus producing less acute and chronic oral complications. Not widely available, more expensive to deliver care. Presently lack of clinical trials comparing to photon (IMRT) delivery method.

B. Internal Source Radiation source (such as radium implants or seeds) is placed within the body. Less radiation is delivered to the surrounding tissues than when an external source is utilized.

III. Doses Total dose given depends on the type of tumor, treatment goals, and patient’s ability to tolerate treatment. Total radiation dose is approximately 30–70 Gy. It is divided into equal doses (conventional) or modulated fractions (IMRT) per day. It is given once a day, 5 days a week, for 5–8 weeks.

IV. Systemic Effects Skin reactions: looks like a bad sunburn. Fatigue. Nausea, vomiting, diarrhea, and constipation.

V.

Oral Complications

Oral mucositis6 (see Figure 55-2).

FIGURE 55-2 • Mucositis Left Lateral Border of Tongue, Secondary to Radiation to the Head and Neck Tissue. Note erythema distal to the ulcerated area (arrow). This lesion is characterized by pain, complicating the patient’s ability to eat, speak, or swallow. (Used with permission from Dianna S. Wiekel.)

Xerostomia/salivary gland hypofunction.4,6,8 Radiation caries.6 Dysgeusia.4 Infection6: Bacterial. Viral: herpes simplex and varicella zoster. Fungal: C. albicans. Trismus.6,8 Osteoradionecrosis.6

HEMATOPOIETIC STEM CELL TRANSPLANTATION Hematopoietic stem cell transplantation is used to treat cancers involving the bone marrow, including leukemia. The purpose is to substitute peripheral blood stem cells from the patient or a healthy, compatible donor.9,10

I.

Types Autologous: self. Allogeneic: human leukocyte antigen–matched donor, either related or unrelated. Syngeneic: identical twin.

II.

Stages of Transplantation Process

A. Patient Selection Indications: patient not responsive to chemotherapy alone; relapse occurs after one or more remissions. Evaluation: medical and dental assessments completed to ensure the patient is free of infection and physically able to undergo the preparative regimen.

B. Donor Regimen Histocompatibility matching. Bone marrow aspirated from iliac crest, ribs, or sternum.

C. Conditioning of Patient to Receive Bone Marrow Graft Preparative high-dose immunosuppressive regimen: chemotherapy

alone or with total body irradiation. Purposes: Kill malignant cells. Suppress immune system so new stem cells/marrow will engraft.

D. Transplantation Intravenous infusion of donor’s marrow/stem cells.

E. Pancytopenia Pancytopenia is a reduction in all cellular elements of the blood, which includes white blood cells, red blood cells, and platelets. Protective isolation for the patient is required; the patient is highly susceptible to infection. Function of new marrow (to produce peripheral blood elements) begins after 10–20 days.

F. Recovery Immune recovery: 3–12 months; long-term recovery: 1–3 years.

III. Acute Complications Acute graft-versus-host disease (GVHD):6,11 Description: The donor’s T-lymphocytes see the host cell antigens as foreign and react against the host tissue. Symptoms: Present during the first 100 days posttransplant. Painful red skin rash starting on the palms of hands and soles of feet and progressing to the upper trunk. Severe, persistent diarrhea. Jaundice, elevated liver enzymes, liver tenderness. Infection: Bacterial.

Viral: herpes simplex, varicella zoster, and cytomegalovirus. Fungal: C. albicans. Gastrointestinal, hepatic, cardiac, pulmonary, hematologic, and neurologic complications. Oral complications: Oral mucositis: appears 10–14 days posttransplant. Xerostomia. Viral and fungal infections: herpes simplex virus and C. albicans.

IV. Chronic Complications Chronic GVHD11: May affect all organs of the body. Can appear up to 2 years posttransplant. Oral complications: Oral mucositis. Oral infection/periodontal infection. Xerostomia/dental caries. Poor oral hygiene. Difficulty eating/chewing.

MUCOSITIS MANAGEMENT I. Prevention/Oral Health Maintenance12–14 Basic oral care using a soft toothbrush. As dental flossing is technique sensitive, use may be precluded during cytotoxic treatment. Use of a bland mouthrinse such as normal saline, three to four times/day. Cryotherapy (ice chips): Recommended for selected patient populations such as multiple myeloma patients receiving high-dose Melphalan and head and neck cancer patients receiving bolus dosing of 5-fluorouracil. Instruct patient to hold ice chips in mouth immediately prior to and during the administration of chemotherapy agent. Palifermin (a human recombinant keratinocyte growth factor): Intravenous infusion in selected populations prior to peripheral blood stem cell transplant. Given for three consecutive days before and after myelotoxic therapy for a total of six doses. Benzydamine mouthrinse (nonsteroidal anti-inflammatory agent) in patients receiving moderate dose radiation therapy (up to 50 Gy). Note: This drug is not available in the United States.

II.

Treatment of Established Mucositis15,16 Mouthrinse containing diphenhydramine hydrochloric acid in combination with other agents (usually coating agent and topical anesthetic). Evidence does not support a direct effect of this antihistamine on the prevention or treatment of mucositis lesions. This type of rinse is often used to palliate pain topically. Systemic pain medication: Patient-controlled analgesia with morphine for the management of pain due to oral mucositis in patients undergoing hematopoietic stem cell transplant.

Transdermal fentanyl patch may be effective in the management of mucositis pain due to conventional and high-dose chemotherapy with or without total body irradiation. Morphine mouthrinse may reduce the severity and duration of mucositis pain in patients undergoing head and neck area radiation therapy. Doxepin mouthrinse (0.5%) may be effective for the management of pain due to oral mucositis.

DENTAL HYGIENE CARE PLAN I. Objectives It is recommended patients be in optimal oral health before starting any type of cancer therapy. Overall objectives include the following6: Assess the oral cavity for any signs of hard or soft tissue infection. Eliminate or minimize sources of dental/periodontal or soft tissue infection. Eliminate or minimize any areas of chronic trauma or tissue irritation. Provide preventive oral care education to the patient and/or the caregiver.

II.

Personal Factors

The very word cancer brings fear and anxiety to the patient, and many times it is viewed by the patient as cancer equals death. This will impact anything taught to the patient. Suggestions include the following: Encourage the patient to bring a friend or a family member along to take notes during teaching visits. Provide written instructions appropriate to the reading level of the patient. Make sure they are written in the patient’s native language. Provide positive reinforcement and be creative in helping the patient maintain optimal oral health. Show acceptance and empathy. Acknowledge the appropriateness of the patient’s concerns. Practice active listening skills.

III. Oral Care Protocol The following sections are adapted from the Oral Complications of

Cancer Treatment: What the Oral Health Team Can Do from the National Institute of Dental and Craniofacial Research (National Institutes of Health publication no. 09-4372). Similarities exist between the three forms of treatment (radiation therapy, chemotherapy, and hematopoietic stem cell transplantation). There are differences that dental hygienists need to know to provide appropriate oral care. Numerous grading scales have been developed to assess the severity of oral mucositis, but none for the other oral complications. Table 55-2 lists an example of one mucositis scale. Scales are useful to: TABLE 55-2 • World Health Organization’s Oral Mucositis Scale GRADE

CLINICAL FEATURES

0

No oral mucositis

1

Soreness, erythema

2

Oral ulcers, solid foods tolerated

3

Oral ulcers, liquid diet only (due to mucositis)

4

Oral ulcers, alimentation impossible (due to mucositis)

Source: Lalla R, Sonis S, Peterson D. Management of oral mucositis in patients with cancer. Dent Clin North Am. 2008;52(1):61-68.

Measure mucositis in the nursing/medical setting. Document treatment toxicity in the clinical and/or research setting. Communicate intraprofessionally.

A. Pretreatment Therapy Patients who do intensive personal oral care in preparation for and during their cancer therapy have a reduced risk for the development

of oral complications. Box 55-4 provides examples of dental hygiene/dental treatment options that may be beneficial before the start of cancer therapy.

BOX 55-4 Dental Hygiene/Dental Pretreatment Guidelines for Patients Planning to Undergo Cancer Therapy Dental • Conduct a pretreatment oral health examination. • Schedule dental treatment in consultation with the oncologist (medical or radiation). • Extract teeth with a poor or questionable prognosis at least 2 weeks before the start of cancer therapy. • Restore or repair indicated teeth before the start of cancer therapy. • Perform other necessary oral surgery procedures at least 2 weeks before the start of cancer therapy. Dental Hygiene • Conduct a pretreatment oral health assessment. • Schedule dental hygiene treatment in consultation with the oncologist (medical or radiation). • Perform dental hygiene treatment (periodontal scaling and root planing, polishing, and fluoride applications) before the start of cancer treatment. • Evaluate the patient’s oral health knowledge and provide an appropriate oral hygiene regimen based on the cancer management. • Prevent tooth demineralization and dental caries: ♦ Instruct the patient in the daily application of fluoride gel at home. ♦ If receiving head and neck radiation therapy, fabricate custom gel-applicator trays for the patient. ♦ Demonstrate application of a 1.1% neutral pH sodium fluoride gel or a 0.4% stannous, unflavored gel for use in the trays or brush-on when tray insertion may not be tolerated. ♦ Use only a neutral pH sodium fluoride gel for porcelain crowns or glass or resin ionomer restorations. ♦ The trays cover all tooth surfaces and are left in the mouth for 5 minutes. Instruct the patient to have nothing to eat or drink for 30 minutes after using the fluoride. Specific technique is located in Chapter 34.

B. Head and Neck Radiation Therapy17–19 Patients receiving radiation therapy to the head and neck are at high risk for developing severe oral complications that will affect the patient in the short and long term. Box 55-5 lists an example oral care protocol to be followed during treatment.

BOX 55-5 Oral Care Protocol during Treatment Daily Biofilm Removal • Gently brush teeth with a soft toothbrush and fluoride toothpaste after every meal and at bedtime. The tongue may be brushed with a soft toothbrush and water. • Use interdental aids gently, but thoroughly clean between teeth before brushing at least once a day. Mouthrinsing • Every 2–3 hours while awake, rinse the mouth with a baking soda, salt, and water solution, followed by a plain water rinse. (Use one-fourth teaspoon baking soda and one-eighth teaspoon salt in a cup of lukewarm water.) • Use of fluoridated water when available. Xerostomia • Sip water frequently. • Suck on ice chips or use sugar-free gum or candy. • Use saliva substitute spray or gel or a prescribed saliva stimulant. • Avoid lemon glycerin swabs. • Avoid hot, spicy, salty, sharp, or high-sucrose foods. • Moisten foods with gravy or liquids before eating. Dental Caries Prevention • Use fluoride toothpaste every day. • If prescribed, brush teeth with 1.1% neutral sodium fluoride gel for 60 seconds after usual tooth cleaning, just before going to bed. Do not eat, drink, or rinse for a minimum of 30 minutes afterward. • If using custom-made polyvinyl trays, place gel in trays, apply to teeth, close mouth, and hold in place for 4 minutes. Set timer. Remove trays, expectorate several times, and do not eat or drink for at least 30 minutes

afterward. Oral Pain Management • Swish and spit a prescribed mouthrinse containing topical anesthetic solution 30 minutes before eating.

During radiation therapy: Encourage daily oral care including biofilm removal at least twice daily. Encourage daily fluoride use (in any form, i.e., tray, brush-on, rinse). Monitor the patient for trismus; check for pain or weakness in masticating muscles in the radiation field. Instruct the patient to exercise three times a day, opening and closing the mouth as far as possible without pain; repeat 20 times. After radiation therapy: For the first 6 months after cancer treatment, recall the patient every 4–8 weeks as needed for nonsurgical periodontal therapy. Review instructions for daily oral self-care. Reinforce the importance of daily oral self-care. After mucositis subsides, consult with the radiation/medical oncologist regarding timing of denture/appliance fabrication. Observe for trismus, demineralization, and caries. Lifelong, daily applications of prescription fluoride (in any form) are recommended for patients with chronic salivary gland hypofunction. Advise against oral surgery on irradiated bone, because of the risk of osteoradionecrosis. Tooth extraction, if unavoidable, is conservative. Prophylaxis against possible osteoradionecrosis is accomplished with Pentoxifylline 400 mg pre- and postextraction.

C. Chemotherapy The extent of oral complications of chemotherapy depends on the

following6,20,21: The degree of preexistent dental and oral disease. The chemotherapy drugs used and their dosages. The use of concurrent or adjuvant radiation therapy to the head/neck. The patient’s personal daily oral hygiene. Before any dental or dental hygiene clinical procedures during chemotherapy: Consult the medical oncologist before any dental or dental hygiene clinical procedures. Ask the medical oncologist to order blood work 24 hours before oral surgery or other invasive procedures (such as periodontal scaling/root planing). Postpone when the platelet count is less than 50,000/mm3 or abnormal clotting factors are present and/or neutrophil count is less than 1,000/mm3. In patients with fever of unknown origin as determined by the medical oncologist, check for oral source of viral, bacterial, or fungal infection. Encourage thorough oral self-care. Review indications for use of antibiotic premedication for patients with central venous catheters or peripherally inserted catheters (also known as central lines). There is no evidence suggesting this is beneficial and as such varies from practitioner to practitioner. Consult the medical oncologist for preference on using the American Heart Association’s prophylactic antibiotic regimen or another antibiotic regimen. Refer to Box 55-5 for a suggested oral care protocol during treatment. After chemotherapy: Place the patient on a dental hygiene continuing care schedule when chemotherapy is completed and all side effects, including immunosuppression, have resolved.

D. Hematopoietic Stem Cell Transplantation

Some hematopoietic stem cell transplant patients develop acute oral complications, especially patients who had an allogeneic stem cell transplant and develop GVHD. After transplantation22,23 Monitor for oral infections of the soft tissues. Herpes simplex and C. albicans are common oral infections. Delay elective dental procedures (such as implants) for 1 year. Follow patients for long-term oral complications (changes in taste, xerostomia, and dental caries). Such problems are strong indicators of chronic GVHD. Continue to monitor the patient’s oral health for biofilm control, tooth demineralization, dental caries, and oral infection. Follow transplant patients carefully for second malignancies in the oral region.

E. Special Care for Children Children receiving chemotherapy and/or radiation therapy are at risk for the same oral complications as adults. Other actions to consider in managing pediatric patients include the following24,25: Extract loose primary teeth and teeth expected to exfoliate during cancer treatment. Remove orthodontic bands and brackets if myelosuppressive chemotherapy is planned or if the appliances will be in the radiation field. Continually monitor craniofacial and dental structures for abnormal growth and development. Encourage routine daily personal oral care including biofilm removal and fluoride application. Avoid cariogenic foods and drinks. If these are necessary to improve a child’s weight, then have the child rinse with fluoridated water after eating or drinking.

DOCUMENTATION Each patient appointment is carefully documented to include at least the following: Cancer diagnosis, type of treatment, treatment start and completion dates. Oncologists’ names and contact information; note any consults done with the oncologists. Oral assessment, clinical care provided, patient teaching on each visit. Any oral complications present, grade of oral mucositis indicating severity and type of symptom management prescribed. Planned follow-up visit and plan of care with proposed symptom management treatment outcomes. Box 55-6 shows an example of a documentation for a patient with oral lesions related to cancer therapy.

BOX 55-6 Example Documentation: Patient with Oral Lesions Related to Cancer Treatment S—The patient presents for 3-month periodontal maintenance appointment; medical history changes include diagnosis of stage IV floor of mouth (FOM) cancer; lesion found at previous periodontal maintenance visit and the patient evaluated by otolaryngology 3 months ago, surgery completed 10 weeks ago followed by 6 weeks of radiation therapy (total of 62 Gy) ending last week. O—Complete oral examination performed; unable to perform periodontal maintenance due to severe oral ulcerations and inflammation involving the tongue bilaterally as well as the mandibular labial mucosa and vestibule; saliva appears thick and ropey; reviewed oral hygiene; the patient is not currently using fluoride. A—Oral mucositis grade 4 and severe xerostomia following radiation to the oral cavity for squamous cell carcinoma of the FOM. Current health status precludes dental hygiene instrumentation today. P—Recommend: 1. Discuss the above findings and today’s recommendations with oncology team (primary oncologist and oncology nurse).

2. Use of extra soft toothbrush after meals and at bedtime. 3. Interproximal cleansing with appropriate aid. 4. Neutral sodium fluoride gel applied with brush 1× day following dental biofilm removal. 5. Baking soda mouthrinse—mix one-fourth teaspoon baking soda and oneeighth teaspoon salt in 8 oz of warm water; rinse with 20 mL 3× day. 6. Avoid mouthrinses containing alcohol. Will follow 1× week until oral mucositis resolves; on next visit, assess xerostomia and make treatment recommendations as needed. Signed: ________________________________, RDH Date: _____________________________________

EVERYDAY ETHICS It is the end of the day, and all of the patients, staff, and the dentist had left the office. Ashley, the dental hygienist, was reviewing the next day’s patient records at the front desk. The telephone rang, and Ashley answered it. It was Gina, the daughter of a longtime patient, Mr. Prisby. Gina, a pediatric registered nurse, lives out of state, but is visiting her 70-year-old father who is undergoing head and neck radiation therapy and chemotherapy treatments for tongue cancer. When she arrived, she was shocked to find her father having difficulty opening his mouth completely and a white coating on the inside of his cheeks. Gina also noticed multiple sores in his mouth. Her father has been unable to eat anything but the softest of foods due to the severe discomfort and dryness. Gina is concerned that her father cannot maintain a healthy weight during treatment. She asks Ashley what the white coating and the sores are in her father’s mouth and what can be done for him. Ashley puts Gina on hold and pulls Mr. Prisby’s record. She sees that he had a complete examination and all treatment performed that left him in good dental health 3 months ago, just before he started his cancer treatment. The white coating that Ashley described may be candidiasis and require medication. But she is not sure how to treat the sores Gina sees. Ashley considers whether to refer Gina back to the oncologists treating her father or phoning in the prescription in the dentist’s name to save time. Questions for Consideration 1. What advice can Ashley give to Gina, considering the stipulations of patient confidentiality? 2. Describe the ethical and legal consequences of Ashley phoning in a prescription for Mr. Prisby.

3. What decisions and/or actions are appropriate for Ashley to pursue within the scope of her legal duties at this time?

Factors to Teach Patients with Diabetes How to exercise the jaw muscles three times a day to prevent and treat jaw stiffness from head and neck radiation therapy. Why to avoid candy, gum, and soda unless they are sugar free. Why to avoid spicy or acidic foods and the use of toothpicks. Why to avoid the use of tobacco products and alcohol. Why the dental hygienist needs to conduct an oral soft tissue screening and complete oral examination at regular frequent intervals. How and when to use dental biofilm control methods, gel-tray application, use of saliva substitute, and all other details of personal oral care to reduce oral side effects caused by the disease and/or cancer treatment. Ideas for remembering to follow the instructions to keep the mouth healthier and more comfortable during cancer treatment. The reasons why a routine schedule of preventive periodontal scaling, fluoride application, and oral hygiene assessment by a dental hygienist contributes to the success of the cancer treatment.

FACTORS TO TEACH THE CAREGIVER How maintaining optimal oral health throughout the treatment will contribute to the successful outcome of cancer therapy. The need to report any changes in the oral cavity to the oncologist and/or dentist/dental hygienist. Why it is necessary for the patient to receive preventive periodontal scaling, polishing if indicated, fluoride application, and oral hygiene assessment by a dental hygienist on a regular frequent basis. Why it is important to support the patient in stopping tobacco and alcohol use.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary

Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Hanahan D, Weinberg RA. Hallmarks of cancer. Cell. 2011;144(5):646-674. 2. Siegel R, Miller K, Jemal A. Cancer statistics, 2017. CA Cancer J Clin. 2017;67(1):7-30. 3. American Cancer Society. CA Facts and Figures. Atlanta, GA: American Cancer Society; 2018. 4. American Cancer Society. Find support and treatment. http://www.cancer.org/treatment/index. Accessed February 20, 2018. 5. Scarpa R. Surgical management of head and neck carcinoma. Semin Oncol Nurs. 2009;25(3):172-182. 6. National Institutes of Health Consensus. Development Conference on oral complications of cancer therapies: diagnosis, prevention, and treatment. Bethesda, Maryland, April 17-19, 1989. NCI Monogr. 1990;9:1-184. 7. Ruggiero S, Dodson T, Fantasia J, et al. American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw—2014 update. J Oral Maxillofac Surg. 2014;72(10):1938-1956. 8. Leeman J, Romesser P, Ying Z, et al. Proton therapy for head and neck cancer patients expanding the therapeutic window. Lancet Oncol. 2017:18(5):e254e265. 9. Gooley TA, Chien JW, Pergam SA, et al. Reduced mortality after allogeneic hematopoietic-cell transplantation. N Engl J Med. 2010;363(22):2091-2101. 10. Sheppard D, Bredeson C, Allan D, Tay J. Systematic review of randomized controlled trials of hematopoietic stem cell mobilization strategies for autologous transplantation for hematologic malignancies. Biol Blood Marrow Transplant. 2012;18(8):1191-1203. 11. Elad S, Jensen S, Raber-Durlacher J, et al. Clinical approach in the management of oral chronic graft-versus-host disease (cGVHD) in a series of specialized medical centers. Support Care Cancer. 2015:23(6):1615-1622. 12. McGuire DB, Fulton JS, Park J, et al.; Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). Systematic review of basic oral care for the management of oral mucositis in cancer patients. Support Care Cancer. 2013;21(11):3165-3177. 13. Peterson DE, Ohrn K, Bowen J, et al.; Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). Systematic review of oral cryotherapy for management of oral mucositis caused by cancer therapy. Support Care Cancer. 2013;21(1):327-332. 14. Raber-Durlacher JE, von Bultzingslowen I, Logan RM, et al.; Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). Systematic review of cytokines and growth factors for the management of oral mucositis in

cancer patients. Support Care Cancer. 2013;21(1):343-355. 15. Nicolatou-Galitis O, Sarri T, Bowen J, et al; Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). Systematic review of anti-inflammatory agents for the management of oral mucositis in cancer patients. Support Care Cancer. 2013;21(11):3179-3189. 16. Saunders DP, Epstein JB, Elad S, et al.; Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). Systematic Review of antimicrobials, mucosal coating agents, anesthetics and analgesics for the management of oral mucositis in cancer patients. Support Care Cancer. 2013;21(11):3191-3207. Buglione M, Cavagnini R, Di Rosario F, et al. Oral toxicity management in head 17. and neck cancer patients treated with chemotherapy and radiation: Xerostomia and trismus (Part 2). Literature review and consensus statement. Crit Rev Oncol Hematol. 2016;102:47-54. 18. Hong CHL, Napenas JL, Hodgson BD, et al; Dental Disease Section, Oral Care Study Group, Multi-national Association of Supportive Care in Cancer (MASCC)/International Society of Oral Oncology (ISOO). A systematic review of dental disease in patients undergoing cancer therapy. Support Care Cancer. 2010;18(8):1007-1021. 19. Bueno A, Ferreira R, Barbosa F, et al. Periodontal care in patients undergoing radiotherapy for head and neck cancer. Support Care Cancer. 2013;21(11):969-975. 20. Rubenstein E, Peterson D, Schubert M, et al.; the Mucositis Study Section of the Multinational Association of Supportive Care in Cancer; and the International Society for Oral Oncology. Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and gastrointestinal mucositis. Cancer. 2004;100(suppl 9):2026-2046. 21. Jensen S, Pedersen A, Vissink A, et al. A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: prevalence, severity and impact on quality of life. Support Care Cancer. 2010;18(8):1039-1060. 22. Bos-den Braber J, Potting C, Bronkhorst E, Huysmans MC, Blijlevens NM. Oral complaints and dental care of haematopoietic stem cell transplant patients and their dentists. Support Care Cancer. 2015;23(1):13-19. 23. Meier J, Wolff D, Pavletic S, et al. Oral chronic graft-versus-host disease: report from the International Consensus Conference on clinical practice in cGVHD. Clin Oral Investig. 2011;15(2):127-139. 24. Effinger K, Migliorati C, Hudson M, et al. Oral and dental late effects in survivors of childhood cancer: a Children’s Oncology Group report. Support Care Cancer. 2014;22(7):2009-2019. 25. Cheng K, Lee V, Li C, et al. Impact of oral mucositis on short-term clinical outcomes in paediatric and adolescent patients undergoing chemotherapy. Support Care Cancer. 2013;21(8):2145-2152.

56 The Oral and Maxillofacial Surgery Patient Evie F. Jesin, RDH, BSc, Lisa F. Mallonee, RDH, RD, LD, MPH, and Esther M. Wilkins, BS, RDH, DMD

CHAPTER OUTLINE PATIENT PREPARATION I. II.

Objectives Personal Factors

DENTAL HYGIENE CARE I. II. III. IV.

Presurgery Treatment Planning Patient Instruction: Diet Selection Presurgical Instructions Postsurgical Care

PATIENT WITH INTERMAXILLARY FIXATION FRACTURED JAW

I. II. III. IV. V.

Causes of Fractured Jaws Emergency Care Recognition Types of Fractures Treatment of Fractures

MANDIBULAR FRACTURES I. II. III. IV.

Closed Reduction Intermaxillary Fixation External Skeletal Fixation (External Pin Fixation) Open Reduction

MIDFACIAL FRACTURES I. II.

Principles Description

ALVEOLAR PROCESS FRACTURE I. II.

Clinical Findings Treatment

DENTAL HYGIENE CARE I. II. III. IV.

Problems Instrumentation Diet Personal Oral Care Procedures

DENTAL HYGIENE CARE BEFORE GENERAL SURGERY I. II. III.

Patients in Whom Surgical Procedures Affect Their Risk Status Preparation of the Mouth before General Inhalation Anesthesia Patient with a Long Convalescence

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Discuss the role of the dental hygienist in the pre- and postsurgery care of the oral and maxillofacial surgery patient.

2. Discuss the pre- and postsurgical care planning for the maxillofacial surgery patient. 3. Identify the types of maxillary and mandibular fractures and discuss treatment options. 4. Describe the modifications for dental hygiene treatment, diet, and personal oral care procedures needed after maxillofacial surgery. 5. Explain the dental hygiene care needed before and after general surgery. Oral and maxillofacial surgery is the specialty of dentistry that includes diagnostic, surgical, and adjunctive treatment of diseases, injuries, and defects involving both functional and aesthetic aspects of the hard and soft tissues in the oral and maxillofacial regions.1 Box 56-1 lists the types of treatment included in this specialty.

BOX 56-1 Categories of Oral and Maxillofacial Treatments Dentoalveolar Surgery Exodontics Impacted tooth removal Alveolar bone surgery: alveoloplasty, bone grafting, ridge augmentation Infection Abscesses Osteomyelitis Traumatic Injury Treatment Fractures of jaws, zygoma Fracture of teeth, alveolar bone Neoplasm and Oral Pathology Cysts Tumors Biopsy

Incisional biopsy Excisional biopsy Exfoliative biopsy Dental Implant Placement Preprosthetic Reconstruction Maxillofacial prosthetics Immediate denture Orthognathic Surgery Prognathism correction Facial aesthetics Cleft Lip/Palate Temporomandibular Disorders Salivary Gland Obstruction

The oral surgeon may be based in a group clinical setting, in a hospital, or in a private practice with outpatient hospital facilities available. The oral surgeon is part of a team of specially trained individuals that includes surgical assistants, anesthetists, registered nurses, and dental hygienists. The oral surgeon may coordinate the surgical procedures with various dental practitioners, including general dentists, laboratory technicians, prosthodontists, orthodontists, dental implant specialists, and other specialists caring for the patient. Surgery for treatment of diseases and correction of defects of the periodontal tissues is categorized specifically as periodontal surgery. Within the scope of periodontal surgery are procedures for pocket elimination, gingivoplasty, treatment of furcation involvements, correction of mucogingival defects, treatment for bony defects about the teeth, and placing implants. Preparation for periodontal surgery is not specifically described

in this chapter. Many of the surgical instruments are used by both a periodontist and an oral surgeon (Figure 56-1).

FIGURE 56-1 • Tray Setup for Routine Extraction of Teeth. Instrument identification from left to right: dental mirror, surgical scalpel, periosteal elevator, surgical curette, elevators (three), bite-blocks, syringe with needle, Minnesota retractor, hemostat, rongeurs, retractor, forceps, bone file, surgical aspirating tip, scissors, needle holder, cups with saline solution, and bulb syringe. (Evie F. Jesin, RRDH, BSc, Professor, Toronto, ON, Canada: George Brown College.)

PATIENT PREPARATION I. Objectives Dental hygiene care and instruction before oral and maxillofacial surgery may improve a patient’s health and well-being by one or more of the following.

A. Reduce Oral Bacterial Count Aid in the preparation of an aseptic field for the surgery. The human oral cavity harbors a variety of microbes. Recent investigative data indicate more than 400 species of microorganisms exist in the microflora of the human oropharynx.2 Make postsurgical infection less likely or less severe.

B. Reduce Inflammation of the Gingiva and Improve Tissue Tone Lessen local bleeding at the time of the surgery. Promote postsurgical healing.

C. Remove Calculus Deposits Remove a source of dental biofilm retention and thus improve gingival tissue tone. Prevent interference with placement of surgical instruments. Prevent pieces of calculus from breaking away. Danger of inhalation, particularly when a general anesthetic is used. Possibility of calculus falling into a tooth socket or other surgical area and acting as a foreign body to inhibit healing.

Instruct in Presurgical Personal Oral Care D. Procedures Reduce inflammation and thus improve tissue tone. Help to prepare the patient for postsurgical care.

E. Instruct in the Use of Foods Foods that provide the elements essential to tissue building and repair during pre- and postsurgical periods. For the patient who will have teeth removed and immediate complete or partial dentures inserted, the importance of a diet containing all essential food groups is emphasized.

F. Interpret the Dentist’s Directions Explanation is needed for the immediate presurgical preparation with respect to rest and dietary limitations, particularly when a general anesthetic is to be administered.

G. Motivate the Patient Who Will Have Teeth Remaining Motivation to prevent further tooth loss through routine dental and dental hygiene professional care and personal oral care procedures.

II.

Personal Factors Extent of the surgery to be performed and previous experiences affect patient attitude. Many patients in greatest need of presurgical dental hygiene care and instruction may have neglected their mouths for many years. They may have been indifferent to or unaware of the importance of obtaining adequate oral care.

Visits to a dentist may have been to have a toothache relieved. Patient knowledge of preventive measures may be limited. A few possible patient traits are suggested here:

A. Apprehensive and Fearful Apprehensive and indifferent toward need for personal care of teeth. Fearful of all dental procedures, particularly oral surgery and anesthesia. Fearful of personal appearance after surgery.

B. Resigned Feeling the situation is unavoidable. Lack of appreciation for preserving natural teeth.

C. Discouraged Over tooth loss or development of soft-tissue lesions. Toward time lost from work. By the financial aspects of dental care. About inconvenience and discomfort.

DENTAL HYGIENE CARE I. Presurgery Treatment Planning A. Initial Oral Preparation The pending date for the surgery and the patient’s attitude may limit the time spent. Complete medical and dental history, extra- and intraoral examination, vital signs, and photographs are essential. Complete radiographs including the use of cone beam computed tomography (CBCT) are essential.3 CBCT is more accurate in predicting implant length and width and the need for bone grafting procedures. For routine unguided implant placement in sites where anatomic structures and bone grafting are not a concern, the use of a panoramic radiograph could be adequate for determining the length and width of the implant.4 Determine the need for prophylactic premedication (see Chapter 11). Antibiotics are not required as prophylaxis for third molar surgery. The standard of care after extraction of mandibular third molar surgery for all healthy patients should be a good anti-inflammatory regimen rather than an antibiotic prophylaxis.5 Proper aseptic precautions and good anti-inflammatory regimen are more important than the prophylactic antibiotics. Antibiotics use increases the risk of bacterial resistance.6 Develop rapport; explain purposes of presurgical appointments. Explain and demonstrate dental biofilm control principles. Demonstrate appropriate technique using new soft toothbrush and appropriate adjunctive interdental aids. Perform debridement to prepare for tissue healing; local anesthesia is used as needed. Provide postsurgical instruction for rinsing with basic saline or with chlorhexidine 0.12% for tissue conditioning.

Encourage participation in a tobacco cessation program if patient is currently using tobacco products.

B. Follow-up Evaluation Complete or continue the debridement. More appointments may be needed for patients who will have surgery for oral cancer or who have a cardiovascular or other condition for which all periodontal and dental treatment is completed before surgery. When radiation or chemotherapy will be used following surgery for oral cancer, or when a prosthetic heart valve or total joint replacement will be involved, complete oral care is needed before surgery. Debridement is planned for a few weeks after oral surgery. Emphasis is placed on review and demonstration of personal daily oral self-care. The patient’s oral self-care plan may require modification based on the oral surgery performed. Continue to provide support for tobacco cessation program if client uses tobacco products.

II.

Patient Instruction: Diet Selection The nutritional status can influence the resistance to infection and wound healing, as well as general recovery powers. Nutritional deficiencies can occur because of the inability to ingest adequate nutrients orally. Specific recommendations of what to include and not to include in the diet are provided. Postsurgical suggestions may differ from presurgical suggestions; for example, when difficulty in chewing is a postsurgical problem, a liquid or soft diet may be required. When major oral surgery requires hospitalization, nasogastric tube feeding may be used during the initial healing period.

A. Nutritional and Dietary Needs Diets outlined are designed to include the essential nutrients from key food groups from the current food guidance system MyPlate (see Chapter 33). Essential for promotion of healing: proteins and vitamins, particularly vitamin A, vitamin C, and riboflavin. Essential for building gingival tissue resistance: a varied diet that includes adequate portions of all essential food groups. Essential for dental caries prevention: noncariogenic foods. When a patient has not been able to masticate properly, the diet employed frequently may have included intake of the following: Soft and cariogenic foods. Frequent sugary snacks. Intake of high-sucrose calorie-dense beverages.

B. Suggestions for Instruction Provide take-home instruction sheets that recommend specific preand postsurgery food options. Foods for liquid and soft diets are listed in the “Dental Hygiene Care” section of this chapter. Express nutritional needs in terms of quantity or servings of foods so that the patient clearly understands. For the patient who will receive dentures, careful instruction is provided over a period of time. Information for the patient with new dentures is described in Chapter 30. When the patient loses the teeth because of dental caries, the diet may have been highly cariogenic. Emphasis needs to be placed on helping the patient include nutritious foods for the general health of the body and, more specifically, the health of the alveolar processes, which will support the dentures.

III. Presurgical Instructions The objective of presurgical instruction is to educate the patient on

what to expect during the oral surgery appointment and immediately afterward.7 The patient may have concerns about the anesthesia, the surgical procedure, and the outcome. For surgery in a hospital setting, the presurgical instructions are often mailed to the patient. When surgery is done in the dental office, the dental hygienist may be responsible to deliver the instructions. Verbal instructions are supplemented with printed information. Instructions may include explanation of: Food and liquid restrictions before surgery: Specify the number of hours before the time of the surgery when the patient stops further intake of food and fluids. Alcohol and medication restrictions: The patient may be instructed to discontinue use of certain medications (prescribed and over-the-counter), supplements, herbal remedies, and alcohol, which are not compatible with the anesthetic and drugs to be used during and following the surgical procedure. Smoking: The patient may be instructed to stop smoking or limit smoking well in advance of the surgery date. Clothing: The patient may be instructed to wear loose fitting clothing around the neck and upper arms for intravenous delivery and assessment of vitals throughout the surgical procedure. Makeup: The patient should not wear lipstick or excessive makeup, and nail polish color should be removed. Transport to and from the appointment: When general anesthetic or light sedation is used, the patient is instructed not to drive. Plans for someone to accompany and assist the patient are made. Ice packs: The patient may be instructed to prepare ice packs well in advance of surgery. Ice cubes may be placed in a plastic bag. Alternatively, a disposable plastic glove may be filled with cold water and the end of the glove tied in a knot and then placed in a freezer. Ice packs are beneficial for the first 36 hours following the surgical procedure.

IV. Postsurgical Care A. Immediate Instructions Printed postsurgical instructions are provided following all oral surgery procedures. The prepared material is reviewed with the patient and/or caregiver or family member after surgery. Specific details vary, but basic information for postsurgical instruction sheets includes the following: Control bleeding: Keep the gauze square in the mouth over the surgical area for half an hour and then discard it. When bleeding persists at home, place a gauze square or cold wet tea bag over the area and bite firmly for 30 minutes. Rinsing: Do not rinse for 24 hours after the surgical appointment. Then use warm saltwater (1/2 teaspoonful salt in 1/2 cup [4 ounces] of warm water) after toothbrushing and every 2 hours. Dental biofilm control: Brush the teeth and use interdental aids more carefully than usual. Avoid the surgery site. Rest: Get plenty of rest; at least 8–10 hours of sleep each night. Avoid strenuous exercise during the first 24 hours, and keep the mouth from excessive movement. Avoid sleeping on the surgical site. Diet: Use a liquid or soft diet high in protein. Drink water, warm soups (not hot), and fruit juices freely. Avoid spicy, hard, hot, or chewy foods. Smoking: The patient should avoid smoking for at least 2 weeks postsurgery to allow for initial healing of the surgical site. Pain: If needed, use a pain-relieving preparation prescribed by the oral surgeon or general dentist. Prescribed medication will vary from nonsteroidal anti-inflammatory drugs to opioid-containing compounds depending on the procedure. Adhere to directions. Pain relief medication may include ibuprofen and/or acetaminophen for atraumatic removal of teeth; acetaminophen with 30 mg of codeine or a compound using oxycodone may be

prescribed for more invasive procedures.8 Limited opening: Limited mouth opening will be present—two-finger opening is expected on the third day following surgery. Exercise: Limit strenuous exercises for the first few days after surgery. Ice pack: When swelling is possible, apply ice pack (ice cubes in a plastic bag or water frozen in a disposable glove) for 15 minutes, followed by 15 minutes off, or as directed by the oral surgeon for the first 36 hours after surgery. Heat is not used for swelling. Complications: Include the telephone number to call after office hours, should complications arise. Complications may include: Uncontrolled pain, uncontrolled bleeding. Temperature of 101°F or higher. Difficulty in opening the mouth (trismus). Unusual or excessive swelling after the surgery. Nerve damage. Infection in the surgical site or area. Possible alveolitis or dry socket, especially in lower posterior molars. Alveolitis is extremely painful and usually occurs 2–4 days after tooth extraction whereby the blood clot is dislodged from the tooth socket. The surgical site is irrigated with warm saline solution followed by the placement of iodoform gauze, which is packed into the socket. The patient returns in 1–2 days to have the iodoform gauze changed and a new one placed, and the site is reevaluated for healing. Box 56-2 identifies important habits for patients to avoid following surgery.

BOX 56-2 Five Ss for Patients to Avoid No vigorous swishing. No vigorous spitting.

No smoking. No drinking from a straw. No eating of solid food for first 24 hours.

B. Follow-up Care The dental hygienist may participate in suture removal, irrigation of sockets, and other postsurgical procedures when the patient returns. Instruction concerning biofilm control, rinsing, oral irrigation, and other personal care, as well as diet supervision, can be continued as appropriate.

PATIENT WITH INTERMAXILLARY FIXATION Limited access for personal oral care procedures and the effect of the liquid diet required for most cases define the need for special dental hygiene care for the patient with intermaxillary fixation (IMF). Attention to rehabilitation of oral tissues during the period following removal of fixation appliances takes on particular significance to prevent permanent tissue damage and inadequate oral care habits from being continued indefinitely. Descriptions in this section are related to a fractured jaw, but IMF may be required for a variety of corrective surgeries and other conditions, including temporomandibular joint treatment and reconstructive and orthognathic surgeries. Regardless of the reason for IMF, instructions for dental hygiene care are similar, and the patient’s problems are much the same.

FRACTURED JAW The patient with a fractured jaw may be hospitalized. A dental hygienist employed in a hospital would be called upon to assume part of the responsibility for patient care or to give oral hygiene instruction to direct care personnel. After dismissal from the hospital, the patient may require special attention in the private dental office for a long period. Treatment of a fractured jaw can be complex, and the patient may suffer considerably, both physically and mentally. Basic knowledge of the nature of fractures and treatment is helpful in understanding the patient’s needs.

I.

Causes of Fractured Jaws

A. Traumatic Domestic violence, gunshots, sporting injuries, falls, road traffic accidents (including motorcycles and bicycles), and industrial accidents.

B. Predisposing Pathologic conditions, such as tumors, cysts, osteoporosis, or osteomyelitis, weaken the bone; thus, slight trauma or even tooth removal can cause fracture.

II.

Emergency Care Immediate attention is paid to measures for care of the patient’s general condition. Monitor breathing, airway, and circulation, and prepare for possible basic life support measures (see Chapter 9). Hemorrhage, shock, and skull or internal head injuries are next in

the sequence of concern. Almost any category of emergency care may be required (see Chapter 9). Although treatment for the fractured jaw cannot be postponed for any great length of time, its immediate care takes second place to the vital aspects of patient care.

III. Recognition A. History Except for a pathologic fracture, a history of trauma is usually described by the patient.

B. Clinical Signs Pain, especially on movement, and tenderness on slight pressure over the area of the fracture. Teeth may be displaced, fractured, or mobile. Because of muscle pull or contraction, segments of the bones may be displaced and the occlusion of the teeth may be irregular. Muscle spasm is a common finding, particularly when the fracture is at the angle or ramus of the mandible. Crepitation can be heard if the parts of bone are moved. Soft tissue in the area of the fracture may show laceration and bleeding, discoloration (ecchymosis), and enlargement.

IV. Types of Fractures A fracture is classified by using a combination of descriptive words for its location, direction, nature (Figure 56-2), and severity. Fractures may be single or multiple, bilateral or unilateral, and complete or incomplete.

FIGURE 56-2 • Types of Fractures. (Reprinted with permission from Kruger GO. Textbook of Oral and Maxillofacial Surgery. 6th ed. St. Louis, MO: Mosby; 1984.)

A. Classification by Nature of the Fracture Simple: has no communication with outside. Compound: has communication with outside. Comminuted: shattered. Incomplete: “Greenstick” fracture has one side of a bone broken and the other side bent. It occurs in incompletely calcified bones (young children, usually). The fibers tend to bend rather than break.

B. Mandibular (Described by Location) Alveolar process. Condyle. Angle. Body. Symphysis.

C. Midfacial Alveolar process: The alveolar process fracture does not extend to the midline of the palate. Le Fort9: The Le Fort classification is used widely to identify the three general levels of maxillary fractures, as shown in Figure 56-3.

FIGURE 56-3 • Le Fort Classification of Facial Fractures. Le Fort I, horizontal fracture above the roots of the teeth, below the zygomatic process, and across the pterygoid plates. Le Fort II, midface fracture over the middle of the nose and across the intraorbital rims. Le Fort III, transversely across the bridge of the nose and across the orbits and the zygomatic bone. (Adapted with permission from Archer WH. Oral and Maxillofacial Surgery. 5th ed. Philadelphia, PA: Saunders; 1975. From American College of Surgeons, Committee on Trauma. Early Care of the Injured Patient. Philadelphia, PA: Saunders; 1972.)

Le Fort I: A horizontal fracture line extends above the roots of the teeth, above the palate, across the maxillary sinus, below the zygomatic process, and across the pterygoid plates. Le Fort II: The midface fracture extends over the middle of the nose, down the medial wall of the orbits, across the infraorbital

rims, and posteriorly across the pterygoid plates. Le Fort III: The high-level craniofacial fracture extends transversely across the bridge of the nose, across the orbits and the zygomatic arches, and across the pterygoid plates. Le Fort combination: A combination of two levels is also possible such as a right Le Fort I and a left Le Fort II.

V.

Treatment of Fractures

Each fracture differs from the next, and the methods used in treatment vary with the individual case.10,11

A. Treatment Planning Many factors are involved when the oral surgeon selects the methods to be used, particularly the location of the fracture or fractures, the presence or absence of teeth, existing injuries to the teeth, other head injuries, and the general health and condition of the patient. All fractures do not require active intervention. Examples are fractures of the condylar and coronoid processes, nondisplaced fractures of an edentulous mandible, and greenstick fractures of children.

B. Basic Treatment Reduction (open or closed) restores normal position of the bones. Fixation of the fragments. Immobilization for healing. Control of treatment complications centers around prevention of infections, misalignment of the parts, and malocclusion of the dentition.

C. Healing

Union is affected by the location and character of the fracture. Depends on the patient’s general health and resistance, as well as on cooperation. Six weeks is considered the average for the uncomplicated mandibular fracture, and 4–6 weeks for the maxillary. Major cause of complication is infection.

MANDIBULAR FRACTURES Reduction means the positioning of the parts on either side of the fracture so they are in apposition for healing and restoration of function. Open reduction refers to the use of a surgical flap procedure to expose the fracture ends and bring them together for healing. Closed reduction is accomplished by manipulation of the parts without surgery.

I.

Closed Reduction The closure of the teeth in normal occlusion for the individual is the usual guide for position of the fracture parts in the dentulous patient. To identify the customary relation of the teeth can be difficult, especially in the partially edentulous mouth.

II.

Intermaxillary Fixation

After reduction, intermaxillary fixation (IMF) is a method of fixation and immobilization used for many years. It still is indicated under certain circumstances and in certain parts of the world.

A. Description IMF is accomplished by applying wires and/or elastic bands between the maxillary and mandibular arches (Figure 56-4A and B).

FIGURE 56-4 • Intermaxillary Fracture. A: Location of fracture of the mandible. B: Segments of bone on either side of the fracture are displaced by muscle pull or contraction. C: Arch bars with hooks for metal wires or rubber bands positioned to provide a steady pull for fracture reduction. D: Note small horizontal rubber band extending from the hook at the mandibular right central incisor to the mandibular right canine to reduce the lateral displacement. (Adapted with permission from Archer WH. Oral and Maxillofacial Surgery. 5th ed. Philadelphia, PA: Saunders; 1975.)

Arch bars: Ready-made, contoured arch bars are adapted to fit accurately to each tooth and provide hooks for connecting the arches (Figure 56-4C). A small horizontal elastic may be positioned across the fracture to reduce the lateral displacement (Figure 564D).

B. Evaluation: Advantages Relative simplicity without surgical requirement: noninvasive. Lower cost; shorter hospital stay (depending on other injuries).

Resources and trained surgeons may be limited in less developed countries. Patient can return to activity and work sooner; can use outpatient facility for follow-up.

C. Evaluation: Contraindications and Disadvantages Patients with chronic airway diseases who cough and expectorate: asthma and chronic obstructive pulmonary diseases. Patients who vomit regularly; notably, during pregnancy. Patients with a mental illness. Dietary problems: Patients lose weight with the liquid, monotonous diet, often with cariogenic content. Oral hygiene and dietary limitations lead to increased dental caries and periodontal infection.

III. External Skeletal Fixation (External Pin Fixation) A. Description Precision bone screws are placed via skin incisions on either side of the fracture (Figure 56-5A). An acrylic bar is molded and, while still pliable, is pressed over the threads of the bone screws and locked into position with the screw nuts (Figure 56-5B).

FIGURE 56-5 • External Skeletal Fixation. A: Precision bone screws placed on either side of the fractures shown by heavy black lines. B: Molded acrylic bar positioned over the bone screws and locked into position with nuts.

B. Indications Management of a fracture cannot always be accomplished satisfactorily by intermaxillary wiring alone. The following are indications for external fixation: Insufficient number of teeth in good condition for IMF. As a supplement to IMF when no teeth are present in the fractured portion of the mandible. Loss of bone substance. When bone substance is lost because of an accident, a gunshot wound, or a pathologic condition, a bone graft may be indicated.12 The extraoral fixation is used first to hold the fractured parts in a normal relationship and then to immobilize the area during healing following the bone graft surgery. Some patients may be unable to have the jaws closed for a long period. Examples of these are: Patient with a vomiting problem, such as during pregnancy. Patient with a mental or physical disability, such as cerebral palsy, epilepsy, or mental retardation.

Edentulous mandible when the fracture fragments are greatly displaced, when the fracture is at the angle of the mandible, or when the mandible is atrophic or thinned.

IV. Open Reduction A. Principles for Treating Skeletal Fractures Anatomic reduction. Functionally stable fixation. Atraumatic surgical technique. Active function. Prevention of infection.

B. Description Surgical approach to bring the fracture parts together. Anesthesia: anesthesia selected in accord with patient history. Types of systems used for immobilization include: Transosseous wiring (osteosynthesis). Plates of various sizes. Titanium mesh. Bone clamps, staples, and screws. Materials: miniplates, screws, and other parts made of biodegradable or resorbable synthetic materials.

C. Clinical Example Figure 56-6 illustrates various positions for miniplate osteosynthesis to provide stability for the reduced fracture parts.

FIGURE 56-6 • Miniplates for Immobilization of Fracture. A: Tension band on the teeth to aid in maintaining correct occlusion, while miniplate holds fracture ends in apposition. B: Examples of possible positions for miniplates.

Care is needed so the screws are not placed over a fracture line or over the roots of teeth and do not infringe on the mandibular canal.

MIDFACIAL FRACTURES I. Principles Maxillary fractures are more difficult to manage because of the number of bones, the associated anatomy, and the complications of basal skull fractures. Not all midface fractures need fixation following reduction. Both function and cosmetics are involved.

II.

Description

A. Older Methods Internal wire suspension. External cranial suspension to a stable bone, such as uninvolved zygoma. Head caps.

B. Current Therapeutic Interventions Open reduction with internal fixation. Use of bone plates of various sizes. Grafts for reconstruction of midface defects. Early reconstruction before scarring and soft-tissue contracture deform the surrounding area.

ALVEOLAR PROCESS FRACTURE The most common fracture is of the alveolar process, maxillary or mandibular.

I.

Clinical Findings Face: bruising, areas of swelling. Teeth: fractures, mobility, avulsion, displacement. Lips and gingiva: bruising, bleeding lacerations from contact with teeth at the time of impact. Bone fracture: most frequently in anterior.

II.

Treatment Replantation of displaced teeth. Immobilization with interdental wiring. A temporary fixed splint of acrylic may be placed over the wires. The teeth are tested periodically for vitality. Endodontic therapy may be required later.

DENTAL HYGIENE CARE I. Problems Fixation apparatus, however carefully placed to prevent tissue irritation, interferes with normal function. Identification of possible effects of treatment provides the basis for planning dental hygiene care.

A. Development of Gingivitis or Periodontal Complications Thick biofilm formation and food debris accumulation provide sources of irritation to the gingiva, resulting in gingivitis. Lack of normal stimulation of the periodontium and of cleansing effects usually provided by the action of the tongue, lips, and facial muscles contributes to stagnation of saliva and accumulation of debris and bacteria. Tender, sensitive gingiva makes biofilm control more difficult, even on available surfaces.

B. Initiation of Demineralization An appetizing soft or liquid diet is difficult to plan using limited cariogenic foods for dental caries prevention.

C. Loss of Appetite Loss of appetite related to monotonous liquid or soft diet may lead to weight loss and lowered physical resistance. Secondary infections, including those of the oral tissues, may result.

D. Difficulty in Opening the Mouth

When there has been trauma to bony and/or soft tissues of the jaw that require fixation, there is going to be a degree of trismus following release of fixation. After removal of appliances, all patients have a degree of muscular trismus that limits personal oral self-care and mastication.

II.

Instrumentation

A. Presurgical Gross calculus is removed, as much possible, before open reduction procedures. Trauma to surrounding soft tissues of lip, tongue, and cheeks limits accessibility.

B. During Treatment Periodic debridement contributes to oral health. Although access is only from the facial aspect for a patient with intermaxillary wiring, some benefit can be obtained. An assistant provides continual suction during treatment.

C. After Removal of Appliances A few weeks after removal of appliances, when the patient can open the mouth normally and personal daily oral care has been initiated, complete debridement can be provided.

III. Diet Many patients with fractured jaws tend to lose weight, which is generally related to an inadequate nutrient and caloric intake. Objectives in planning the diet are to: Prevent new carious lesions. Help the patient maintain an adequate nutritional state. Promote healing.

Increase resistance to infection. Attention is given to the patient’s willingness and ability to follow the recommendations made. The patient may be in the hospital for a few days to a few weeks, depending on the severity of other injuries. A greater length of time is spent as an outpatient, when the diet is much more difficult to supervise. The patient’s understanding of dietary instructions and what is expected may appear more significant than the specific components of the diet recommended.

A. Nutritional Needs After a surgical fixation procedure, the diet is planned to promote tissue building and repair. All essential food elements. Emphasis on protein; vitamins, particularly A, C, and D; and minerals particularly calcium and phosphorus. Usual caloric requirements for patient’s age, taking into consideration lack of physical exercise and loss of appetite when ill.

B. Methods of Feeding Plastic straw: Liquid is sucked through the teeth or through an edentulous area. Straw can be bent to accommodate a patient who cannot sit up. Spoon feeding: When a patient’s arms are not functional, direct assistance is needed. The mouth may have injuries that prevent sucking food through a straw. Tube feeding: Tube feeding may be indicated following various types of extensive oral surgery, facial trauma, burns, immobilized fractured jaw, and other conditions that prevent ingesting sufficient calories and nutritional foods by way of the mouth. A nasogastric tube is used. Blenderized food can be prepared, or special tube formulas are available commercially. When commercial preparations are used, contents can be selected to meet the specific nutritional and caloric requirements

of an individual patient.

C. Liquid Diet A clear liquid diet to help prevent dehydration may be prescribed initially, but it can be nutritionally inadequate. A full liquid diet to provide high protein and other healing elements is of a consistency to be taken by a cup. A blenderized liquid diet can be passed through a straw. Indications All patients with jaws wired together. Patients with no appliance or single-jaw appliance who have difficulty opening the mouth because of a condition, such as temporomandibular joint involvement or tongue or lip injury, that hinders insertion of food or manipulation of food in the mouth. Examples of foods: fruit juices, milk, eggnog, smoothies, meat juices and soups, cooked thin cereals, and canned baby foods. Strained vegetables and meats (baby foods) may be added to meat juices and soups. Use of a blender: Regular table foods can be mixed in a food blender. With liquid, such as clear soup or milk, added, a fluid consistency can be obtained that will pass through a straw (Figure 56-7).

FIGURE 56-7 • Preparation of a Liquid or Soft Diet. Regular table foods can be blended with milk or other nutritious liquid.

D. Soft Diet Indications Patient with no appliance or with single-jaw appliance without complications in opening the mouth or in movement of the lips and tongue. Patient who has been maintained on liquid diet throughout treatment period. After appliances are removed, the soft diet is recommended for several days to 1 week to provide the stomach with foods that are readily digestible rather than making a drastic change to a regular diet. A soft diet can also aid by protecting tender oral tissues from the rough textures of a regular diet until the tissues have had a chance to respond to softer foods.

Examples of foods Soft-poached, scrambled, or boiled eggs; fruit and yogurt smoothies, cooked cereals; mashed soft-cooked vegetables, including potato; mashed fresh or canned fruits; soft, finely divided meats; custards; plain ice cream.

E. Suggestions for Diet Planning with the Nonhospitalized Patient Provide instruction sheets that show specific food suggestions. Express nutritional needs in quantities or servings of foods. Show methods of varying the diet. A liquid or soft diet is at best monotonous due to similarity in texture. Encourage limitation of cariogenic foods as an aid to prevention of dental caries.

IV. Personal Oral Care Procedures Every attempt is made to keep the patient’s mouth as clean as possible for comfort and sanitation, and as free of dental biofilm as possible for disease prevention. The extent of possible care depends on the appliances; the condition of the lips, tongue, and other oral tissues; and the cooperation of the patient. The patient is encouraged to begin toothbrushing as soon as possible after the surgical procedure, but until the patient is able, a plan for care is outlined for a caregiver.

A. Irrigation Indications: During the first few days after the surgical procedure, while the mouth may be too tender for brushing, frequent irrigations are required; irrigation also serves as an adjunct to toothbrushing. Method: In a hospital, irrigations with suction are possible. At home, the patient irrigates with the head lowered over a sink (see Chapter

27). Mouthrinse selection: The oral surgeon is consulted for specific instructions. Suggestions include: Physiologic saline (1 tsp [5 g] of salt to 1 cup [250 mL] of warm water). Chlorhexidine gluconate. Fluoride rinse.

B. Early Mouth Cleansing While the patient is in the hospital, a soft toothbrush with suction can be used. The toothbrush with suction is described in Chapter 4.

C. Personal Care by the Patient As soon as possible, the patient is instructed in personal care. A toothbrushing method and other aids, such as those used for orthodontic appliances, are recommended and demonstrated, as discussed in Chapter 29. Interdental and proximal tooth surface care is restricted to access only from the facial approach, making the choice of oral care devices limited.13 Some spaces permit insertion of an interdental brush. With instruction, most patients can use a toothpick in a holder (Perio Aid®) to disturb biofilm around just under the free gingival margin, as shown in Chapter 27. When the tongue is not injured, the patient can be instructed to use the tongue as an aid in cleaning the lingual surfaces of the teeth and massaging the gingiva. The ambulatory patient can use a water irrigator. A low-pressure setting is used, and the spray is directed carefully to prevent tissue injury, as illustrated in Chapter 27.

D. After Appliances Are Removed

Demineralization and dental caries can result from biofilm retention around the appliances. Except for the patient who had practiced good personal oral care before the accident, a step-by-step series of lessons is necessary. A method for daily self-applied fluoride, such as a mouthrinse or brush-on gel, can be introduced along with the use of a fluoride dentifrice.

DENTAL HYGIENE CARE BEFORE GENERAL SURGERY When emergency surgery is performed, preparation of the mouth is not possible, and postsurgical examination and care may be complicated by various limitations. When surgery is elective, or planned in advance, the patient can be encouraged to have a complete dental and periodontal treatment. Types of patients are described briefly here. Other examples are found in the various special patient chapters throughout this section of the book.

I.

Patients in Whom Surgical Procedures Affect Their Risk Status Patients who receive chemotherapeutic agents following surgery for various types of cancer, and others who use immunosuppressant drugs, require special management to prevent complications during dental and dental hygiene appointments. Antibiotic premedication to prevent infective endocarditis and other infections is mandatory for certain patients, as described in Chapter 11. Before surgery for prostheses, transplants, cancer, and other serious conditions, patients are informed of the need for completing oral care treatments and practicing preventive daily personal care.

II.

Preparation of the Mouth before General Inhalation Anesthesia Because the mouth is an entryway to the respiratory system, the possibility always exists that bacteria, debris, and fluids from the mouth may be inhaled. Inhalation could occur during the administration of an anesthetic or

when the patient coughs.

III. Patient with a Long Convalescence Patients whose surgery requires a long convalescence may be unable to keep a regular continuing care appointment. When the patient has a healthy mouth before hospitalization and convalescence, the problems of postsurgical oral care are lessened, but not eliminated. Instruction for the caregiver may be needed. A home visit by the dental hygienist may be possible depending on the state or province practice act (see Chapter 4).

DOCUMENTATION The permanent oral care record for most maxillofacial patients needs to include a summary of the hospital care when available, but may start when the patient returns to the general practice. At that time, the initial recording documentation needs a minimum of the following: Health history, radiographs interpretation, extra- and intraoral findings, and vital signs. Comprehensive periodontal examination and summary of current needs. Risk factors and dental caries review; complete examination for demineralization. Care planning for maintenance. A sample progress note is available for review in Box 56-3.

BOX 56-3 Example Documentation: Postsurgical Dental Hygiene Appointment S—A 20-year-old college student presents for first dental hygiene appointment following a mandibular fracture due to a motorcycle accident. Stabilizing interdental wiring and fixed splint were removed yesterday. Patient’s chief complaint is “My mouth feels dirty and it smells bad.” Past medical history: Patient admits to smoking a pack of cigarettes a day and an occasional beer on the weekends; otherwise unremarkable. O—Healthy looking young male in no obvious distress. Oral cavity is remarkable for heavy dental biofilm and calculus buildup; tissues are inflamed, bleeding, and edematous. No pocket depths greater than 4 mm were charted. Mandibular fracture appeared completely healed. A—A 20-year-old male status postwire removal from motorcycle accident with poor oral hygiene. P—Complete periodontal debridement × 4 quadrants, and polishing; detailed oral hygiene instructions; tobacco cessation education; 4-week follow-up to assess healing and patient compliance to oral care instructions and success with tobacco cessation. Signed: ______________________________, RDH Date: ____________________________________

EVERYDAY ETHICS Ms. Squires (age 79 years) was involved in a serious automobile accident that fractured her mandible and required fixation with intermaxillary wiring, which was recently removed. Apparently she is here because of pressure from her adult children who have been taking turns tending to her needs. The daughter who accompanied her to this appointment said her bad breath was bothering them even more than her complaining all the time. This is her first appointment with William, the dental hygienist, since the accident 10 months ago. He documented the moderate amounts of calculus and heavy dental biofilm throughout the mouth. Mrs. Squires demonstrates difficulty opening her mouth and seems fussy and apprehensive when William attempts to go over a toothbrushing procedure and continually asks her to “open wider, please.” Questions for Consideration 1. Which of the dental hygiene core values (Section II) become involved with a patient with such complications? Explain each one. 2. Review the steps for decision making in Chapter 1 to help plan and present optimal oral health services to benefit this patient. 3. Describe the role of the dental hygienist in coordinating preventive care with the posttreatment examinations Mrs. Squires has with the oral maxillofacial surgeon.

Accident Prevention Accident Prevention Always use seat belts in automobiles and other vehicles. Use mouthguards and all safety devices during contact sports. Wear motorcycle and bicycle helmets. Helmets protect against facial injuries in totality and appear to be more effective at preventing midfacial fractures when compared with mandible fractures.14 For the Patient Who Will Have General Surgery Significance of a clean mouth during general anesthesia. Postsurgery oral problems related to specific diseases.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. American Dental Association. Specialty definitions. http://www.ada.org/en/education-careers/careers-in-dentistry/dentalspecialties/specialty-definitions. Accessed April 20, 2018. 2. Ferneini EM, Goldberg MH. Management of oral and maxillofacial infections. J Oral Maxillofac Surg. 2018;76(3):469-473. 3. Carter JB, Stone JD, Clark RS, Mercer JE. Applications of cone-beam computed tomography in oral and maxillofacial surgery: an overview of published indications and clinical usage in United States Academic Centers and Oral and Maxillofacial Surgery Practices. J Oral Maxillofac Surg. 2016;74(4):668-679. 4. Deeb G, Antonos L, Tack S, Carolein C, Laskin D, Deeb JG. Is cone-beam computed tomography always necessary for dental implant placement? J Oral Maxillofac Surg. 2017;75(2):285-289. 5. Prajapati A, Prajapati A, Sathaye S. Benefits of not prescribing prophylactic antibiotics after third molar surgery. J Oral Maxillofac Oral Surg. 2016;15(2):217-220. 6. Pasupathy S, Alexander M. Antibiotic prophylaxis in third molar surgery. J Craniofac Surg. 2011;22(2):551-553. 7. Chuong R. Perioperative management of the surgical patient. In: Peterson LJ, ed. Oral and Maxillofacial Surgery. Philadelphia, PA: Lippincott; 1992:63-85. 8. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016; 315(15):1624-1645. 9. Haskell R. Applied surgical anatomy. In: Rowe NL, Williams JL, eds. Maxillofacial Injuries. London: Churchill Livingstone; 1985:21-24. 10. Bell RB. Contemporary management of mandibular fractures. In: Peterson’s Principals of Oral and Maxillofacial Surgery. Philadelphia, PA: Lippincott; 2011:407-439 11. Banks P, Brown A. Treatment of fractures of the mandible. In: Fractures of the Facial Skeleton. Oxford: Wright; 2001:81-106. 12. Boyne PJ. Bone grafts. In: Boyne and Peetz’s Osseous Reconstruction of the Maxilla and the Mandible. Chicago, IL: Quintessence; 1997:64-74. 13. Phelps-Sandall BA, Oxford SJ. Effectiveness of oral hygiene techniques on plaque and gingivitis in patients placed in intermaxillary fixation. Oral Surg Oral Med Oral Pathol. 1983; 56(5):487-490. 14. Christian JM, Thomas RF, Scarbecz M. The incidence and pattern of maxillofacial injuries in helmeted versus non helmeted motorcycle accident patients. J Oral Maxillofac Surg. 2014;72(12):2503-2506.

57 The Patient with a Seizure Disorder Sharon M. Grisanti, RDH, BA, MCOH

CHAPTER OUTLINE SEIZURES I. II. III. IV. V. VI. VII.

Seizure Definition Classification of Seizures Diagnosis of a Seizure Types of Seizures Etiology Prognosis Implications

CLINICAL MANIFESTATIONS I. II. III.

Precipitating Factors and Trigger Signs Aura Prevention of Seizure Injuries

TREATMENT I. II. III.

Medications Surgery Ketogenic Diet

ORAL FINDINGS I. II.

Effects of Accidents with Seizures Gingival Overgrowth/Gingival Hyperplasia

DENTAL HYGIENE CARE PLAN I. II. III. IV. V.

Patient History Information to Obtain Patient Approach Care Plan: Instrumentation Care Plan: Prevention

EMERGENCY CARE I. II. III. IV. V. VI.

Objectives Differential Diagnosis of Seizure Preparation for Appointment Emergency Procedure Postictal Phase Status Epilepticus

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Define each term associated with the type of seizure disorder. 2. Describe the etiology of seizure disorders. 3. Discuss clinical manifestations of seizure disorders. 4. Develop a dental hygiene care plan, including patient education prevention strategies, for working with patients with seizure disorders. 5. Prepare an emergency care protocol for a patient having a

seizure.

INTRODUCTION A seizure is a paroxysmal event resulting from abnormal brain activity. A seizure may involve loss of consciousness or awareness or impaired awareness with or without convulsive movements or spasms. Epilepsy is a term to describe a group of functional disorders of the brain characterized by recurrent seizures. Seizures are a symptom of epilepsy. The patient’s medical history may reveal susceptibility to seizures. A complete evaluation is required prior to treatment. Treatment modalities of epilepsy and a seizure itself may affect the oral tissues as well as dental and dental hygiene treatment. Dental personnel need to be aware of the issues associated with seizures, know how to evaluate the patient, and how to apply emergency measures in and out of the dental office or clinic. Care of the oral cavity is necessary due to its relationship to overall health and to oral accidents that may occur during a seizure. All patients should consult their physicians regarding exercise and lifestyle. Occupation and lifestyle may be limited for patients who have recurrent seizures. A person susceptible to seizures cannot participate in activities that may precipitate a seizure such as driving or operating machinery. Such limitations may lead to depression. According to the Center for Disease Control, there are approximately 3.4 million adults and 470,000 children in the United States who have recurrent seizures associated with epilepsy. The World Health Organization estimates more than 50 million people worldwide have epilepsy.1–4 New cases are most commonly found in children and in older adults.

SEIZURES I. Seizure Definition An epileptic seizure is a transient occurrence of signs and symptoms due to abnormal neuronal activity in the brain. Epilepsy is a disease of the brain and a seizure is a symptom of the disease. Onset defines where the seizure begins in the brain. Unknown onset seizures mean the beginning of the seizure was unknown or was not witnessed by another person. Patient may have impaired awareness or be fully aware of their surroundings. Special care must be taken with impaired awareness seizures relating to the safety of the patient. Seizures are generally unprovoked and involuntary, but triggers may precipitate an epileptic seizure. A seizure begins with an abrupt onset of symptoms that may be of a motor, sensory, cognitive, or emotional nature, depending on which cells or part of the brain is involved. Non-movement during a seizure is considered nonmotor. As a seizure progresses, it may or may not cause loss of consciousness or awareness, tonic and/or clonic movements, incontinence, saliva foaming, or tongue biting. Length of a seizure is uncontrollable. Other terms: convulsion, fit, spell, ictus.

II.

Classification of Seizures

The syndromes associated with seizures are complex. A summary of the classification of seizures is outlined in Table 57-1.5,6 TABLE 57-1 • Classifications of Seizure Types CLASSIFICATIONS

DEFINITION

SEIZURE TYPES

Focal Onset Aware Impaired awareness

Involving one side of the Motor Onset brain Spasms Aware Epileptic patient aware of Automatisms surroundings and self Atonic able to recall events Clonic of seizure Hyperkinetic Impaired awareness Myoclonic Patient is confused of Tonic surroundings Nonmotor Onset Sensory Emotional Autonomic Behavior arrest Cognitive Focal to bilateral Tonic-clonic

Generalized Onset Impaired awareness

Affecting both sides of the Motor brain Epileptic spasms Impaired awareness Clonic Patient is confused of Tonic surroundings Tonic-clonic Myoclonic Myoclonic-tonic-clonic Myoclonic-atonic Atonic Nonmotor (absence) Eyelid myoclonic Typical Atypical Myoclonic

Unknown Onset

Start of seizure is unknown Seizure not witnessed

Motor Tonic-clonic Epileptic spasms Nonmotor Behavior arrest Unclassified

Source: Adapted from Epilepsy Foundation. Types of seizures. March 20, 2017. Available from https://www.epilepsy.com/learn/types-seizures

III. Diagnosis of a Seizure

Clinical signs and symptoms: A patient with a complex seizure disorder may exhibit a trancelike state with confusion that can last for a few minutes to hours. Consciousness is impaired to varying degrees. Patient may manifest purposeless movements or actions followed by confusion, incoherent speech, ill humor, unpleasant temper; does not remember what happened during the attack. History: Medical history is the first step in the diagnosis of epilepsy seizures. Documentation of initial onset and preliminary factors that led up to the seizure should be noted. Electroencephalography (EEG): EEG shows patterns of normal and abnormal brain activity. This test can reveal slowing in rhythm due to trauma, stroke, brain tumor, or seizures. Type and symptoms: Severity. Age-related onset. Cause. Inherited and genetic. EEG patterns and part of brain involved.

IV. Types of Seizures Seizures have three basic types, generalized, focal, and those of unknown onset.5 The type depends on where and how the seizure begins in the brain. Generalized onset affects both sides of the brain. Examples are tonic-clonic, absence or atonic seizures. Focal onset begins in one area or group of cells of the brain. Examples are focal onset aware and focal onset impaired awareness.5

A. Generalized Onset Seizures

Motor Category5,6: Affecting both sides of the brain at the same time. Tonic-clonic known as convulsive or grand mal seizures. Muscles of the chest and pharynx may contract at the same time, forcing air out and a sound known as the “epileptic cry.” Loss of consciousness or awareness is sudden and complete; the patient becomes stiff and falls or may slide out of the dental chair. Musculature contraction: with tonic phase body becomes rigid, with clonic phase there is intermittent muscular contraction and relaxation. Atonic refers to weakened muscles. Skin color turns pale to bluish, breathing is shallow or stops briefly. Possible loss of bladder, and rarely, bowel control. Tongue may be bitten. Incident usually lasts 1–3 minutes. Respiration returns. Saliva, which previously could not be swallowed, may mix with air and appears foamy. Patient begins to recover, may be confused, tired, complain of muscle soreness or injury; falls into a deep sleep. Phases of seizures are aura, ictus, and postictal. Seizure may continue without recovery and progress to status epilepticus, meaning lasting more than 5 minutes or experiencing two more seizures within a 5-minute period. Nonmotor or Absence Seizure5,6: Previously known as petit mal. Loss of consciousness or awareness begins and ends abruptly in about 5–30 seconds. Most common in children, and may lead to learning difficulties if not identified. Patient has a blank stare, usually does not fall, posture becomes fixed, may drop whatever is being held. May become pale.

Myoclonus may occur: patient may have rhythmic twitching of the eyelids, eyebrows, head, or chewing movements. Attack ends as abruptly as it begins. Patient quickly returns to full awareness, resumes activities, unaware of what occurred.

B. Focal Onset Seizures Focal seizures start with one group of cells in one part of the brain. Focal onset aware means patient is aware during the seizure. Focal onset impaired awareness means the patient is confused.

C. Unknown Onset Seizures Start of seizures is unknown. Seizure has not been witnessed. Unclassified seizures may be classified once additional information has been brought to the neurologist’s attention.

V.

Etiology

In addition to epilepsy, seizures can be a symptom of many different conditions. The causes can be genetic, structural/metabolic, or unknown.7

A. Genetic Genetic predisposition to seizures or to other neurologic abnormalities for which the seizure may be a symptom.

B. Structural/Metabolic Seizures can arise during many neurologic and non-neurologic medical conditions, for example: Congenital conditions, such as maternal infection (rubella); toxemia of pregnancy.

Maternal drug use. Perinatal injuries. Brain tumor. Cerebrovascular disease (stroke). Trauma (head injury). Infection (meningitis, encephalitis, opportunistic infections of human immunodeficiency virus). Degenerative brain disease. Metabolic and toxic disorders, including lead exposure, alcoholism, and other drug addictions; seizures are common during alcohol and/or drug withdrawal. Complication of cancer.

C. Unknown Cause The onset and cause of the epileptic seizure are unknown. A neurologic examination may diagnose the reason.

VI. Prognosis Prognosis for seizure control is favorable. Epilepsy Foundation reports that 56% of adults with epilepsy have uncontrolled seizures. Of the 90% of patients taking antiepileptic (antiseizure) drug (AED), only 44% have controlled seizures. The prevalence of seizures and seizure control increases with low family income.8

VII. Implications Due to the possibility of severe injury, accidents, or embarrassment, patients who experience recurrent seizures may avoid or be legally restricted from certain activities: These may include: Vocation: occupations that involve use of machinery or require physical activity.

Licenses: certain licenses, such as driver’s license, may be restricted until the patient is seizure free. Independent living: assisted living may be advised.

CLINICAL MANIFESTATIONS I. Precipitating Factors and Trigger Signs The patient or caregiver can provide helpful information to prepare dental personnel in the management of an emergency. Triggers may occur frequently and are in response to specific stimuli. The dental hygienist should be prepared to eliminate or minimize these stimuli. Factors that may precipitate a seizure include9–11: Flashing/bright lights or noises. Stressor apprehension. Fatigue; sleep deprivation. A specific time of the day. Alcohol or drug use. Fever. Not eating resulting in low blood sugar. Noncompliance with antiseizure medications. Menstruation. Physical exercise/physical trauma.

II.

Aura An aura can be described as a sensory stimulus, a visual disturbance, numbness, tingling, twitching, or stiffness of muscles. Not all patients have warning signs, or auras, before a seizure. A patient experiencing a warning may seek a safe place to sit or lie down. In the dental environment, the patient may inform the personnel so dental procedures can be terminated and preparations made.

III. Prevention of Seizure Injuries A patient may experience more than one type of seizure. The primary method to control and prevent seizures is through antiepileptic drugs

(AEDs). The injuries associated with seizures may be prevented through modification of behaviors12: Primary prevention of seizure injuries focuses on medication compliance, avoiding brain injury through the use of protective measures such as helmets, and mouth guards. Secondary prevention includes early detection, recognition, and preparation of the seizure. Tertiary prevention comprises training and education strategies for patients, teachers, caregivers, and health care practitioners.

TREATMENT I. Medications AEDs are the primary method used to prevent and control seizures.13–15

A. Choices Patients may be placed on one or a combination of AEDs. Choice of therapy is aligned to the type of seizure and desired side effect or the elimination of an undesirable side effect. Frequently prescribed medications are listed in Table 57-2. TABLE 57-2 • Antiepileptic Medications GENERIC NAME

BRAND NAME

Carbamazepine

Tegretol, carbatrol

Clonapam

Klonopin

Clorazepate

Tranxene

Ethosuximide

Zarontin

Felbamate

Felbatol

Gabapentin

Neurontin

Lamotrigine

Lamictal

Levetiracetam

Keppra

Oxcarbazepine

Trileptal

Phenobarbital

Luminal

Phenytoin

Dilantin

Primidone

Mysoline

Tiagabine

Gabitril

Topiramate

Topamax

Valproic acid/Valproate

Depakote

Zonisamide

Zonegran

B. Side Effects Each medication has side effects a patient may experience to varying degrees. It is imperative for patients to follow directions for the use of antiseizure medications from their primary care provider. Side effects may include the following: Allergic reaction, rash. Fatigue, dizziness, drowsiness, weakness, ataxia, headache, slurred speech, blurred vision. Nausea, vomiting. Memory loss; behavioral and cognitive deficits. Damage to the pancreas, liver, interactions of medications processed in the liver. Leukopenia: delayed healing and infection. Thrombocytopenia or decreased platelet aggregation: increased bleeding, petechiae. Osteoporosis. Increased or unknown risk of birth defects. Hirsutism; hypertrichosis or excessive hair growth. Gingival hyperplasia, gingival enlargement, is most common with phenytoin. Numerous drug interactions, including other AEDs, acetaminophen, nonsteroidal anti-inflammatory drugs, erythromycins, and reduction in the efficacy of oral contraceptives. Elderly and children Both age groups are more sensitive to side effects such as weakness, unsteadiness, and cognitive alterations. Elderly are more likely to be on other medications with possible

drug interactions and may forget to take medications.

C. Precaution: Herbal Supplements Certain over-the-counter herbal supplements are used as selfmedications to help prevent seizures. These supplements may interfere with the prescribed AED. Herbal supplements have not been shown to effectively treat epileptic seizures and may make seizures worse.16,17 Patients are asked to inform their primary care provider and dental team when using alternate forms of medication. Herbal supplements such as ginkgo biloba, St. John’s wart, and some essential oils may also affect dental treatment, for example, causing increased bleeding.

II.

Surgery

A variety of surgical interventions are available and indicated when epilepsy is refractory to traditional AED therapy. Surgical intervention has become more precise through advances in identifying the epileptogenic area with magnetic resonance imaging, tomography, electroencephalographic studies, neuropsychological testing, and other analyses. Surgical options include: Lobe resection of the epileptogenic area in the brain.18,19 If total resection leads to unacceptable deficits, multiple subpial transections, which are a series of small parallel slices, are removed. Gamma-knife radiosurgery involves delivery of a focused dose of radiation to the epileptogenic area in the brain. This technique reduces the risk of infection, bleeding, and hospitalization.20 Vagus nerve stimulation utilizes a pacemaker-like device to deliver signals to the vagus nerve known to reduce seizure activity without adverse effects to the patient.21

III. Ketogenic Diet The goal of the ketogenic diet is to induce fat metabolism through ketosis by maintaining a diet high in fat and low in carbohydrates. The diet has been shown to be an effective treatment for patients with epilepsy, particularly children.22,23

ORAL FINDINGS Epilepsy in itself produces no oral changes. Specific oral changes are related to: Side effects of AEDs. Oral accidents during a seizure. Side effects of the epilepsy, such as depression leading to poor oral hygiene and neglect.24

I.

Effects of Accidents with Seizures

A. Scars of Lips and Tongue Oral tissues, particularly tongue, cheek, or lip, may be bitten. Scars may be observed during the extraoral/intraoral examination; cause may be differentiated from other types of healed wounds.

B. Fractured Teeth Clenching and bruxing may be forceful enough to fracture teeth. Fractured teeth may be sharp, lacerate tissue and need to be smoothed or restored. Fractures may extend into the pulp of the tooth, allowing bacterial infection; requiring root canal therapy or extraction.

II.

Gingival Overgrowth/Gingival Hyperplasia Gingival overgrowth occurs in 25–50% of persons using phenytoin for treatment. Phenytoin and other antiseizure drugs have been used in the treatment of other conditions besides epilepsy, including stuttering, headaches, neuromuscular disturbances, and cardiac conditions; therefore, their use should not lead to the assumption that the patient has epilepsy.

Other antiseizure drugs can induce gingival overgrowth but less frequently. Other terms for gingival enlargement in the use of phenytoin may be referred to as Dilantin hyperplasia, diphenylhydantoin-induced hyperplasia, diphenylhydantoin gingival hyperplasia, Dilantininduced gingival fibrosis, or phenytoin-induced hyperplasia.25–27

A. Mechanism Phenytoin may cause fibroblasts and osteoblasts to deposit excessive extracellular matrix, causing gingival overgrowth. Tissue color and texture are generally within normal limits with interdental papilla taking on a lobular shape. Local irritants such as biofilm, faulty restorations, or ill-fitting appliances cause a more exaggerated tissue response. Meticulous oral hygiene has been found to reduce the occurrence and severity of gingival overgrowth.

B. Occurrence Incidence is greater in younger patients just beginning drug therapy. The gingiva may start to enlarge within a few weeks or even after a few years following initial administration of drug therapy. The size of the dose and length of treatment are not necessarily factors in the incidence or nature of the gingival enlargement. The anterior gingivae are more likely affected than posterior, and the maxillary more than the mandibular arch. Facial and proximal areas are more affected than lingual or palatal areas. Although rare, an overgrowth of tissue may occur in an edentulous area. This is usually associated with trauma, irritation from a denture, the presence of retained roots, or unerupted teeth.28,29 Overgrowth of tissue surrounding dental implants may occur.30

C. Effects Control of dental biofilm may be a problem. May affect mastication. May alter tooth eruption. May interfere with speech. May cause serious esthetic concerns.31

D. Tissue Characteristics Early clinical features: Overgrowth appears as a painless enlargement of interdental papillae with signs of inflammation (Figure 57-1A).

FIGURE 57-1 • Phenytoin-Induced Gingival Enlargement. A: Papillary enlargement with cleft-like grooves. Note the effect of the pressure of the fibrotic tissue on the position of teeth. Maxillary incisors and the mandibular left canine have been wedged away from normal positions. B: Mulberry-like shape of interdental papillae.

Eventually, the tissue becomes fibrotic, pink, and stippled, with a

mulberry or cauliflower-like appearance, as in Figure 57-1B. Advanced lesion: Tissue increases in size, extends to include the marginal gingiva, and covers a large portion of the anatomic crown. Cleft-like grooves may occur between the lobules. Severe lesion: Large, bulbous gingiva may cover the enamel, tend to wedge the teeth apart, and interfere with mastication and oral self-care (Figure 57-2).

FIGURE 57-2 • Phenytoin-Induced Gingival Overgrowth. (Dr. James Cottone.)

Microscopic appearance: During therapy, phenytoin is present in the saliva, blood, gingival sulcus fluid, and dental biofilm. Number of fibroblasts and the amount of collagen in connective tissue increase. Stratified squamous epithelium is thick, with long rete ridges. Inflammatory cells are in greatest abundance near the base of pockets.

E. Complicating Factors Dental biofilm: Biofilm appears to be the most significant determinant in the severity of phenytoin-induced gingival enlargement.32 Adequate biofilm control, particularly if started prior to the administration of phenytoin, helps control the extent of gingival overgrowth. Contributing factors: Mouth breathing. Overhanging and defective restorations. Malocclusion. Large carious lesions. Calculus and biofilm retention encourages gingival overgrowth. Treatment should include removal of contributing factors by recontouring overhangs, placing or replacing restorations, effective biofilm and calculus removal.

F. Treatment There are varying ways to treat gingival enlargement based on the medication used and clinical presentation of lesions. Change in seizure medication: Collaboration with the primary care physician should be integrated into the treatment plan. Change to a different drug with a lower chance of causing gingival enlargement. Medication change should be just prior to a surgical removal procedure.33 Nonsurgical treatment: Periodontal debridement along with strict biofilm control may help early lesions regress. Where the tissue has become fibrotic, shrinkage cannot be expected. Initiate prevention of biofilm control prior to, or simultaneously

with, initial administration of the antiepileptic medication. The use of 0.12% chlorhexidine gluconate rinses is linked to positive outcomes to prevent return of gingival enlargement caused by antiseizure medication.34,35 Surgical removal: Gingivectomy: A surgical procedure used for tissue removal when a sufficient band of attached gingiva exists. A periodontal flap procedure: may be the choice for healing and esthetics. Prior to surgery, a regulated program of biofilm control is introduced and continued after surgical dressings have been removed. General health has special significance, and oral health contributes to general health. Meticulous oral hygiene is required to minimize gingival overgrowth.

G. Differential Diagnosis of Medications Causing Gingival Enlargement Numerous medications may cause gingival enlargement, including: Antiseizure medications, especially phenytoin and to a lesser extent ethosuximide, valproic acid, and primidone.36,37 Calcium channel blockers used for the treatment of hypertension such as nifedipine, verapamil, and diltiazem. Immunosuppressant cyclosporine used frequently with organ transplant patients. Tacrolimus may be a substitute with less occurrence of gingival overgrowth.

DENTAL HYGIENE CARE PLAN The majority of patients with epilepsy or a history of seizures can and need to receive the same level of dental care as the general population.38 Interprofessional collaboration plays an important role in the development of the dental hygiene care plan. The patient with a seizure disorder may be under the care of other specialists including a neurologist, social worker, and primary care physician.

I.

Patient History Most patients with epilepsy have regular, thorough medical examinations. Contact the primary care provider when the patient or caregiver is unable to provide needed information, is noncompliant, if seizure activity has increased or changed, or if treatment for epilepsy is impacting the patient’s oral health. Patients with autism may present with social, communication, and/or behavioral problems, in addition to seizure disturbances.39,40 A well-controlled patient with epilepsy may still be at risk to have a seizure. For seizure-prone patients: advise wearing medical alert jewelry.

II.

Information to Obtain

Information to obtain from a patient with a history of seizures is listed in Box 57-1.

BOX 57-1 Risk Assessment for Dental Hygiene Treatment: Information to Obtain from Patient with a History of a Seizure Disorder

Basic Information: • Thorough medical history review, including date of last physical examination, other medical conditions or risk factors present. • Physician: name and phone number. • Emergency contact person with phone number. Additional Factors: • Inquire about recent illness, stress, alcohol use, menstrual cycle, fatigue, or pain as factors that may provoke a seizure. • General well-being; refer for evaluation if patient presents with signs or symptoms of other conditions such as depression. • Ask if the patient has changed any aspect of their activities of daily living. Treatment: • Medication list, surgery, or diet. • Effectiveness of seizure control treatment. • Investigate each medication for possible interaction with the proposed dental treatment and side effects. • Nonprescription, herbal supplement use. • Medication compliance. About the Seizures: • Type of seizure(s) experienced, frequency, severity, and duration of episodes. • Age at onset. • The precipitating/trigger factors or cause of seizure if known. • Description of prodrome, aura if known. • Experience alteration or loss of consciousness. • Characteristic motor movements. • Urinary/fecal incontinence. • History of injuries, including oral injuries, broken teeth, tongue lacerations. • Postictal symptoms such as confusion. Suggestions: • Any other helpful information that the patient can provide for prevention, comfort, and management.

III. Patient Approach Provide a calm, reassuring atmosphere and treat with patience and empathy.

Use a motivational interviewing approach to patient education, enabling patients to be partners in the decision-making process (see Chapter 24). Encourage self-expression, particularly if the patient tends to be quiet and withdrawn or has a narrow range of interests. Recognize possible impairment of memory when reviewing personal oral care procedures. Help the patient develop an interest in caring for the mouth, providing positive reinforcement for patient successes. Medications used for treatment of seizures may make the patient drowsy, and chronic illness sufferers tend to have more frequent health issues that interfere with appointments. Be understanding when the patient is late or misses an appointment; confirm with telephone reminders at opportune time; do not mistake drowsiness (effect of drugs) for inattentiveness.

IV. Care Plan: Instrumentation Patients should be considered an integral part in their daily oral health maintenance. All patients need to be instructed and motivated to comply with an effective biofilm control program. Complete removal of all deposits on teeth, and thorough nonsurgical periodontal therapy is essential for patients who plan to or are taking an antiseizure medication such as phenytoin, which may cause gingival overgrowth.

A. Prior to and at the Start of Phenytoin Therapy A rigorous biofilm control program and complete periodontal debridement are needed in preparation for phenytoin therapy. The patient (and caregivers) should be guided in oral hygiene maintenance, emphasizing preventing or minimizing gingival overgrowth with effective biofilm management.

B. Initial Appointment Series for the Patient Treated with Phenytoin Weekly appointments for complete biofilm control instruction and debridement are planned with the following objectives: 1. Slight or mild gingival overgrowth. Nonsurgical treatment, including frequent thorough debridement, may lead to tissue reduction, provided the patient maintains daily biofilm control. Frequent continuing care appointments can contribute to more appealing esthetics, function, and comfort with minimum periodontal involvement. 2. Moderate gingival overgrowth. After the initial series of biofilm instruction and debridement, reevaluation of the gingival tissues will determine whether further treatment is needed. An optimal level of oral health may be attained by changing the medication to another antiseizure drug, surgical removal of excess tissue, and more frequent continuing care appointments. 3. Severe fibrotic overgrowth. Initial nonsurgical periodontal therapy and biofilm control should be provided in preparation for surgical gingival tissue removal. Consultation with the primary care provider may be indicated for modifying a drug or altering the dose to limit gingival overgrowth.

C. Continuing Care Intervals Frequent appointments on 1-, 2-, or 3-month intervals may be indicated, depending on the severity of gingival enlargement as well as the ability and motivation of the patient in maintaining their oral health. Most patients need ongoing assistance and supervision.

V.

Care Plan: Prevention

Daily biofilm removal and fluoride therapy, the use of pit and fissure sealants, and dietary control. Initiation of preventive measures as soon as possible after epilepsy has been diagnosed contributes to the overall health and wellbeing.

EMERGENCY CARE I. Objectives 1. Prevent body injury and accidents related to the oral structures, such as: Tongue bite. Broken or dislocated teeth. Dislocated or fractured jaw. Broken fixed or removable dentures.41–43 2. Ensure adequate ventilation.

II.

Differential Diagnosis of Seizure

Other diseases or conditions with similar signs or symptoms include44: Syncope. Migraine headache. Transient ischemic attack. Cerebrovascular accident, stroke. Sleep disorder such as narcolepsy. Movement disorders such as dyskinesia, common, for example, in patients with cerebral palsy or multiple sclerosis. Overdose of local anesthetic. Hypoglycemia or insulin overdose in a patient with diabetes. Hyperventilation.

III. Preparation for Appointment When the patient’s medical history indicates susceptibility to seizures, advance preparation may prevent complications should a seizure occur. Place emergency materials in a convenient location. Have the patient remove dentures for the duration of the appointment.

Provide a calm and reassuring atmosphere. Have other dental personnel available in case of an emergency.

IV. Emergency Procedure Seizures are short lived. The dental clinic team should assign responsibilities during an emergency. Initiation of procedures for seizure emergency follows preplanned routines. Make no attempt to stop the convulsion or restrain patient. Terminate the clinical procedure; call for assistance. Protect patient from injury. Position patient: lower chair and tilt to supine; raise feet. Keep patient from falling out of the dental chair. Push aside sharp objects, movable equipment, and instrument trays. Loosen tight belt, collar, and necktie. Do not place (or force) anything between the teeth. Establish airway; check for breathing obstruction; provide basic life support when indicated. Place on side recovery position. Use high-speed suction with wide tip to remove vomit. Monitor vital signs. Stay beside the patient to prevent personal injury and reassure. Check for the level of consciousness and determine if emergency medical assistance is required. When a seizure is still occurring or has recurred within 5 minutes, activate emergency medical system.

V.

Postictal Phase

Document the emergency situation as described in Chapter 9. Allow the patient to rest. Talk to the patient in a quiet, reassuring tone. Check oral cavity for trauma to teeth or tissues. Palliative care can be administered. When a tooth is broken, the piece must be located so aspiration can be prevented.

With patient’s consent, contact the patient’s family/friend to accompany the patient.

VI. Status Epilepticus Status epilepticus is when a seizure lasts longer than 5 minutes or when seizures occur close together without recovery. There are two types, convulsive and nonconvulsive. Prolonged seizure may result in brain injury and long-term morbidity or death. Emergency medical assistance is notified immediately, and the patient is transported to an emergency department. Basic life support is provided if necessary (see Chapter 9).

DOCUMENTATION The patient who is subject to seizures will need complete permanent records indicating the following: Complete health history, vital signs, radiographs, findings of extraand intraoral examination; periodontal history, charting, and tissue description; dental caries history, charting, and current demineralization and carious lesions. Progress notes for each appointment with abbreviated history and current clinical findings. Information about the type of seizure; the treatment patient is receiving; and what steps to take in the event of an emergency. A sample progress note may be reviewed in Box 57-2.

BOX 57-2 Example Documentation: Patient with a Seizure Disorder S—Steve, a healthy appearing 55-year-old man, presents for the first of four scheduled periodontal scaling appointments. He stated he recently had a seizure at work when his arms and legs stiffen and he felt confused. When pressed for more information, he stated that he had seen a physician for the seizure. He also states he will be losing his job in 1 month and has started looking for another. O—Vitals normal (see medical profile). No chief complaint, other than being upset due to impending job loss. Reassessed medical profile—added Tegretol; no other medications are taken. Noticed rash on the left side of the patient’s neck. Patient stated the rash began when antiseizure medication was added. Contacted physician for advice on patient care post-seizure; physician recommended longer appointments to account for frequent breaks during treatment and for patient to call concerning rash. Intraoral assessment reveals generalized 4–5 mm pocketing on posterior teeth. No gingival enlargement found. A—Increased risk for potential emergency situation during appointment until seizure disorder is stabilized. Need for use of stress-reduction protocols and extension of treatment time during patient visit. Potential for side effects of new medication, including current skin rash. P—Patient Education—Discussed potential side effects of medications for the

treatment of seizures. Recommended patient check with the medical provider about skin rash on the neck. Provided patient with information from the Epilepsy Foundation, also on local stress-reduction and exercise classes. Oral self-care—Discussed need for meticulous oral hygiene to avoid gingival enlargement. Showed patient how to perform an intraoral examination to check for gingival enlargement and possible areas of trauma should he experience another seizure. Treatment provided—Asked patient to verbalize any discomfort or uneasiness he may have during treatment. Completed debridement with hand and ultrasonic instruments using high-speed evacuation on quadrant one with no adverse reaction to additional sounds or light. Patient tolerated treatment well but required frequent breaks to relax and reduce stress. Next visit: Assess tissue response to quadrant one debridement; reassess plaque score and home care technique, modify as needed. Assess skin condition and determine whether the patient contacted his physician. Monitor stressreduction progress. Signed: ______________________________, RDH Date: ____________________________________

EVERYDAY ETHICS Lillian, the dental hygienist, just finished treating her last patient of the day. Diana, the patient, is a very pleasant woman with excellent oral health and a history of a car accident with concussion over a month ago. She has no other medical findings. While passing the window, Lillian notices that Diana has collapsed in the parking lot and is convulsing. She calls for assistance from the dentist and dental assistant, and they rush out to the parking lot. By the time they reach Diana, she is getting to her feet and says she just tripped and fell. Individuals with seizures may have their driver’s license revoked because of the potential for serious automobile accidents that may occur during a seizure. Diana is about to get into her car to drive home. Questions for Consideration 1. Which dental hygiene ethical core values have application in this scenario? 2. Given the patient’s medical history, will this information be documented in Diana’s dental record, remain confidential, or be otherwise handled? To evaluate one’s responsibilities toward self, one’s patients, and others, read over the Codes of Ethics professional responsibilities to help Lillian decide the correct procedure. 3. Describe the rights of the patient and professional duties of the dental

hygienist who witnessed the incident.

Factors to Teach the Patient Relationship of systemic health to oral health. Significance of daily biofilm removal. Importance of antiepileptic drug compliance. Need for providing complete medical history information for dental appointments. Antiseizure medication side effects, including gingival enlargement and how to minimize its growth. Seek immediate care if any oral change or injury is suspected.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References

1. Azanzini G, Beghi E, de Boer H, Engel J, Sander JW, Wolf P. Epilepsy. In: Neurological Disorders: Public Health Challenges. Geneva: World Health Organization; 2006:14. http://www.who.int/mental_health/neurology/chapter_3_a_neuro_disorders_public_h_challen Accessed June 13, 2018. 2. Centers for Disease Control and Prevention. National and state estimates or the number of adults and children with active epilepsy—United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(31);821-825. 3. World Health Organization. Epilepsy: key facts. Geneva: World Health Organization; 2018. https://www.who.int/news-room/fact-sheets/detail/epilepsy. Accessed June 13, 2018 4. Centers for Disease Control and Prevention. Epilepsy in adults and access to care—United States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61(45):909913. 5. Fisher RS, Cross JH, French JA, et al. Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology. Epilepsia. 2017;58:522-530. 6. Scheffer IE, Berkovic S, Capovilla G, et al. ILAE classification of epilepsies: Position paper of the ILAE Commission for Classification and Terminology. Epilepsia. 2017;58:512-521. 7. Brodie M, de Boer HM, Johannessen SI. Epidemiology. Epilepsia. 2003;44(6 suppl):17. 8. Centers for Disease Control and Prevention. Active epilepsy and seizure control in adults—United States, 2013 and 2015. MMWR Morb Mortal Wkly Rep. 2018;67(15):437-442. 9. Fattal-Valevski A, Nissan N, Kramer U, Constantini S. Seizures as the clinical presenting symptom in children with brain tumors. J Child Neurol. 2012;28(3):292-296. 10. Nakken KO, Solaas MH, Kjeldsen MJ, Friis ML, Pellock JM, Corey LA. Which seizure-precipitating factors do patients with epilepsy most frequently report? Epilepsy Behav. 2006;6(1):85-89. 11. Balamurugan E, Aggarwal M, Lamba A, Dang N, Tripathi M. Perceived trigger factors of seizures in persons with epilepsy. Seizure. 2013;22(9):743-747. 12. Dua T, Janca A, Kale R, Montero F, Muscetta A, Peden M. Public health principles and neurological disorders. In: Neurological Disorders: Public Health Challenges. Geneva: World Health Organization; 2006:20. http://www.who.int/mental_health/neurology/chapter1_neuro_disorders_public_h_challenges Accessed June 13, 2018. 13. Schoenberg MR, Frontera AT, Bozorg A, Hernandez-Frau P, Vale F, Benbadis SR. An update on epilepsy. Expert Rev Neurother. 2011;11(5):639-645. 14. Guncu G, Caglayan F, Dincel A, Bozkurt A, Saygi S, Karabulut E. Plasma and

gingival crevicular fluid phenytoin concentrations as risk factors for gingival overgrowth. J Periodontol. 2006;77(12):2005-2010. 15. Burneo JG, McLachlan RS. When should surgery be considered for the treatment of epilepsy? Can Med Assoc J. 2005;172(9):1175-1177. 16. Schachter SC. Botanicals and herbs: a traditional approach to treating epilepsy. Neurotherapeutics. 2009;6(2):415-420. doi:10.1016/j.nurt.2008.12.004. 17. Li Q, Chen X, He L, Zhou D. Traditional Chinese medicine for epilepsy. Cochrane Database Syst Rev. 2009;(3):CD006454. 18. Schmeiser B, Daniel M, Kogias E, et al. Visual field defects following different respective procedures for mesiotemporal lobe epilepsy. Epilepsy Behav. 2017;76:39-45. 19. Mohan M, Keller S, Nicolson A, et al. The long-term outcomes of epilepsy surgery. PLoS One. 2018;13(5):e0196274. 20. Bates K. Epilepsy: current evidence-based paradigms for diagnosis and treatment. Prim Care. 2015;42(2):217-232. 21. Roberts HW. The effect of electrical dental equipment on a vagus nerve stimulator’s function. J Am Dent Assoc. 2002;133(12):1657-1664. 22. Guerrini R. Epilepsy in children. Lancet. 2006;367(9509):499-524. 23. Martin K, Jackson CF, Levy RG, Cooper PN. Ketogenic diet and other dietary treatments for epilepsy. Cochrane Database Syst Rev. 2016;2:CD001903. 24. Pette GA, Siegel MA, Parker WB. Gingival enlargement. J Am Dent Assoc. 2011;142(11):1265-1268. 25. Thomason JM, Seymour RA, Rawlins MD. Incidence and severity of phenytoininduced gingival overgrowth in epileptic patients in general medical practice. Community Dent Oral Epidemiol. 1992;20(5):288-291. 26. Rees TD, Levine RA. Systematic drugs as a risk factor for periodontal disease initiation and progression. Compendium. 1995;16(1):20, 22, 26, 42. 27. Hassell TM. Epilepsy and the oral manifestations of phenytoin therapy. Monogr Oral Sci. 1981;9:1-205. 28. Bredfeldt GW. Phenytoin-induced hyperplasia found in edentulous patients. J Am Dent Assoc. 1992;123(6):61-64. 29. McCord JF, Sloan P, Hussey DJ. Phenytoin hyperplasia occurring under complete dentures: a clinical report. J Prosthet Dent. 1992;68(4):569-572. 30. Chee WW, Jansen CE. Phenytoin hyperplasia occurring in relation to titanium implants: a clinical report. Int J Oral Maxillofac Implants. 1994;9(1):107-109. 31. Camargo PM, Melnick PR, Pirih FQ, Lagos R, Takei HH. Treatment of druginduced gingival enlargement: aesthetic and functional considerations. Periodontol 2000. 2001;27:131-138. 32. Majola MP, McFadyen ML, Connolly C, Nair YP, Govender M, Laher MH. Factors influencing phenytoin-induced gingival enlargement. J Clin Periodontol. 2000;27(7):506-512. 33. Mavrogiannis M, Ellis JS, Thomason JM, Seymour RA. The management of drug-induced gingival overgrowth. J Clin Periodontol. 2006;33(6):434-439. 34. Saravia ME, Svirsky JA, Friedman R. Chlorhexidine as an oral hygiene adjunct

for cyclosporine-induced gingival hyperplasia. ASDC J Dent Child. 1990;57(5):366-370. 35. Pilatti GL, Sampaio JE. The influence of chlorhexidine on the severity of cyclosporin A—induced gingival overgrowth. J Periodontol. 1997;68(9):900904. 36. Jaiarj N. Drug-induced gingival overgrowth. J Mass Dent Soc. 2003;52(3):1620. 37. Suneja B, Chopra S, Thomas AM, Pandian J. A clinical evaluation of gingival overgrowth in children on antiepileptic drug therapy. J Clin Diagn Res. 2016;10(1):ZC32-ZC36. 38. Mehmet Y, Senem Ö, Sülün T, Hümeyra K. Management of epileptic patients in dentistry. Surg Sci. 2012;3:47-52. 39. Friedlander AH, Yagiela JA, Paterno VI, Mahler ME. The neuropathology, medical management and dental implications of autism. J Am Dent Assoc. 2006;137(11):1517-1527. 40. Rada RE. Controversial issues in treating the dental patient with autism. J Am Dent Assoc. 2010;141(8):947-953. 41. Malamed SF. Knowing your patients. J Am Dent Assoc. 2010;141(suppl 1):3S– 7S. 42. Reed KL. Basic management of medical emergencies: recognizing a patient’s distress. J Am Dent Assoc. 2010;141(suppl 1):20S–24S. 43. Panayiotis PN, Spanaki MV, Mirski MA. Status epilepticus: an update. Curr Neurol Neurosci Rep. 2013;13(7):1-9. 44. Shneker BF, Fountain NB. Epilepsy. Dis Mon. 2003;49(7): 426-478.

58 The Patient with a Mental Health Disorder Linda D. Boyd, RDH, RD, EdD, and Esther M. Wilkins, BS, RDH, DMD

CHAPTER OUTLINE OVERVIEW OF MENTAL DISORDERS I.

Prevalence of Mental Disorders

ANXIETY DISORDERS I. II. III.

Types and Symptoms of Anxiety Disorders Treatment Dental Hygiene Care

DEPRESSIVE DISORDERS I. II. III.

Types of Depressive Disorders Signs and Symptoms Treatment

IV. Dental Hygiene Care

BIPOLAR DISORDER I. II. III.

Signs and Symptoms Treatment Dental Hygiene Care

FEEDING AND EATING DISORDERS I. II. III. IV.

Types and Symptoms of Feeding and Eating Disorders Medical Complications Treatment Dental Hygiene Care

SCHIZOPHRENIA I. II. III.

Signs and Symptoms Treatment Dental Hygiene Care

MENTAL HEALTH EMERGENCY I. II. III. IV. V.

Psychiatric Emergency Patients at Risk for Emergencies Prevention of Emergencies Preparation for an Emergency Intervention

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Describe the various types of mental health disorders and major symptoms. 2. Summarize the side effects of treatment for mental health disorders that may have oral health implications. 3. Explain dental hygiene treatment considerations for each major category of mental health disorder.

OVERVIEW OF MENTAL DISORDERS A psychiatric or mental health disorder is a complex, clinically significant behavioral or psychological syndrome that may impact the individual’s ability to engage in daily activities of living. The causes may be related to behavioral, psychologic, or biologic dysfunction in the individual.1 The American Psychiatric Association has classified more than 200 types of mental disorders in the document Diagnostic and Statistical Manual of Mental Disorders (DSM-5).1 Each disorder has characteristic signs and symptoms. This chapter provides descriptions of common mental disorders including anxiety, mood, and eating disorders along with schizophrenia. Additional disorders are described in other chapters, for example, alcoholism (see Chapter 59), Alzheimer disease (see Chapter 48), autism spectrum disorder, and attention-deficit disorder (see Chapter 50). With the current policies of deinstitutionalization, more individuals with mental disorders are seeking dental and dental hygiene care in dental offices and clinics. Person-first language is used to refer to someone with a mental disorder, chronic disease, or disability.2 The person is emphasized first and not the disorder, disease, or disability. For example, refer to the patient as “an individual with schizophrenia,” not as “a schizophrenic.”

I.

Prevalence of Mental Disorders In a meta-analysis of 175 studies in 63 countries, 1 in 5 respondents met the criteria for a common mental disorder in the previous year.3 About 29% of respondents had experienced a mental disorder during their lifetime.

Women had higher rates of mood and anxiety disorders, while men had higher rates of substance abuse disorders. English-speaking countries had the highest lifetime prevalence of mental disorders with North and Southeast Asia among the lowest reported prevalence.

ANXIETY DISORDERS Anxiety disorders are the most common class of mental disorders in the general population. Anxiety disorders are common with a global prevalence of around 7%. Euro/Anglo countries having prevalence over 10%, suggesting 1 in 10 people have an anxiety disorder.4 Anxiety is a normal reaction to stress. In anxiety disorders, the anxiety is exaggerated resulting in excess worry and avoidance behavior that can impact day-to-day functioning. For formal diagnosis, the symptoms must be present for at least 6 months.1 Some individuals may have secondary problems of alcohol and other substance abuse. The abuse may be the result of an attempt at self-medication. Individuals with anxiety disorders often have comorbid conditions, including other mental health disorders, hypertension, gastrointestinal issues, thyroid disease, cardiovascular conditions, migraine headaches, allergies, and/or a respiratory disease.5

I.

Types and Symptoms of Anxiety Disorders

A. Generalized Anxiety Disorder Persistent, pervasive anxiety and excessive worry, but are not associated with life-threatening fears or “attacks.”6,7 May be complicated by depression, alcohol abuse, or anxiety related to a general medical condition. Symptoms include6,7: Feeling restless, on-edge, irritable. Difficulty falling and staying asleep. Difficulty concentrating.

Muscle tension.

B. Obsessive-Compulsive Disorder Frequent upsetting thoughts (obsessions), and when the individual tries to control them, there is an overwhelming urge (compulsion) to repeat routines or rituals over and over.8 Symptoms include8: Spend at least 1 hour a day with obsessive thoughts and rituals that cause distress and interfere with normal daily functioning. Thoughts or obsessions might include fear of germs, dirt, or intruders. Rituals might include washing hands, locking and unlocking doors, or keeping unneeded items (hoarding).

C. Panic Disorder Panic disorder is characterized by sudden and repeated episodes of extreme fear (panic attacks).9 Symptoms center on panic attacks9: A panic attack may be unexpected (uncued) or “situationally bound” (cued). A situationally bound panic attack invariably results from exposure to a specific trigger, such as the dental office. Fear of being out of control during a panic attack. Physical symptoms during an attack may include pounding or racing heart, sweating, difficulty breathing, chest pain, or dizziness (Box 58-1).

BOX 58-1 Symptoms of Panic Attack 1. Shortness of breath 2. Dizziness, unsteady feelings, or faintness 3. Palpitations or accelerated heart rate

4. 5. 6. 7. 8. 9. 10. 11. 12.

Trembling or shaking Sweating (clammy hands) Choking Nausea or abdominal stress Paresthesia (numbness or tingling sensation) Flushes (hot flashes) or chills Chest pain or discomfort Fear of dying Fear of losing control

Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Washington, DC: American Psychiatric Association; 2013:214.

D. Posttraumatic Stress Disorder All individuals experience stressful or traumatic events, yet not everyone responds in the same way. Some people will develop posttraumatic stress disorder (PTSD) and others are resilient and manage the adversity and adapt. PTSD develops after a terrifying ordeal involving physical harm or threat of physical harm.10 Onset may be triggered by destruction to the home or family or may result from a manmade disaster, such as war, imprisonment, torture, rape, physical or sexual abuse, or other exposure associated with intense fear or serious threat to life. Signs and symptoms include: Flashbacks of the traumatic experience and terror may be triggered by a stimulus that can be readily associated with the original event. Dreams or recollections may cause the individual to feel they are reliving the event. Avoidance of places, events, or objects that are reminders of the triggering event. Loss of interest in activities that were enjoyable in the past. Hyperarousal symptoms including feeling tense, difficulty sleeping, angry outbursts, and may be easily startled. In children, symptoms may be slightly different and include

bedwetting, acting out the scary event during playtime, or being unusually clingy to a parent or other adult. Risk factors for PTSD may include10: Living through a dangerous or traumatic event. A history of mental illness or substance abuse. Resilience factors for PTSD include10: Seeking out support either formal or informal from family and friends. A positive coping strategy. Ability to function despite feelings of fear.

II.

Treatment

A. Basic Therapeutic Approach Lifestyle modifications include regular physical activity, adequate sleep, and avoidance of drugs and alcohol.5,7 Diagnose and treat other medical and psychiatric problems.

B. Pharmacologic Treatment Antidepressants: antidepressants preferred as an initial treatment of anxiety disorders.7,10,11 Examples include fluoxetine (Prozac), paroxetine (Paxel), and sertraline (Zoloft). Side effects: headache, weight gain, tremor, irritability, and xerostomia. Anxiolytics: These are used only short term because of the risk of dependency.7 Examples include benzodiazepines (Valium, lorazepam). These are highly addictive and must be carefully monitored. Side effects: confusion, dizziness, muscle memory impairment, weakness, difficulty in speaking, skin rash, and xerostomia. Beta-blockers: taken on a short-term basis for anxiety, these medication help to relieve the physical symptoms of anxiety such as

trembling, shaking, and rapid heartbeat.7

B. Psychotherapy Cognitive behavioral therapy (CBT)5,7,11,12 CBT is a combination of strategies to address the cognitive, behavioral, and emotional components of the anxiety disorder. May be conducted in individual or group sessions. Support groups are also helpful. Prolonged exposure (PE) therapy7,12 PE therapy is used in treatment of PTSD and gradually exposes an individual to the traumatic event in a safe way and helps them to cope with their feelings. Cognitive processing therapy (CPT)7,12 CPT is also used to treat PTSD and helps people to make sense of the traumatic event they experienced.

III. Dental Hygiene Care A. Personal Factors Each anxiety disorder has its own characteristics. Relationships with other people can be strained. Physical complaints, such as rapid heartbeat, hyperventilation, tightness in the throat, and constant fatigue, are common.

B. Oral Implications Xerostomia related to medications put the patient at high risk for dental caries.13 Individuals with a diagnosis of an anxiety disorders are at higher risk of tooth loss.13 Individuals with mental health disorders have a 25% higher caries risk.13 The odds for periodontal disease in a patient with panic disorder is

three times that of someone without the disorder, but it was not higher in other mental health disorders.14 A patient with obsessive-compulsive disorder may perform such excessive, vigorous toothbrushing that gingival and dental abrasion may result.

C. Appointment Interventions Review medical history and medications carefully. Enhance the patient’s sense of control.15 One technique is to establish a “stop signal,” which may consist of the patient raising the left hand when they are uncomfortable or need to stop treatment. Explain each step to the patient and keep communication as open as possible. Cognitive distraction involves encouraging the patient to think about something besides the dental treatment. Headphones for music and relaxation can help to reduce stress. Environmental changes can help reduce anxiety. An example would be the smell of lavender in the waiting room to relax the patient, but this needs to be used in addition to the previously mentioned techniques. Nitrous oxide sedation may be helpful to relax the patient (see Chapter 36). Effective pain control is needed. Use local anesthesia for nonsurgical periodontal therapy (NSPT). Attention to technique to minimize discomfort is essential. Appointments are best scheduled in the morning; eliminate unnecessary waiting in the reception area; length of appointment can be minimized and planned to prevent stress. Be alert to symptoms of a panic attack (Box 58-1), such as sweating or hyperventilation. Allow the patient to sit up and take short breaks.

DEPRESSIVE DISORDERS Mood disorders that include depressive disorders are another common classification of mental disorder. The prevalence of mood disorders for adults is 7.1% in the previous 12 months with a lifetime prevalence of nearly 31% in the United States.16 Women are more likely to experience mood disorders. Onset is usually in the mid-20s, but it can occur at any age. Depression is the leading cause of disability worldwide.17

I.

Types of Depressive Disorders

A. Major Depressive Disorder Transient depressed moods occur in the lives of most people. Sadness over unforeseen tragic events, illnesses, death, or disappointments in career or other life plans can cause depressed feelings.18,19 Major depressive disorder interferes with daily life. Some individuals experience only one episode of major depression in their lifetime, but it is more common to have multiple episodes.

B. Postpartum Depression During the postpartum period, many physiologic and psychologic stresses are related to the changes taking place in the mother’s life. A moderate-to-severe depression within the first month postpartum, but postpartum depression (PPD) tends to peak at 2–6 months after delivery.20 The prevalence of PPD is estimated to be 10%–20%.20 Recent research suggests that fathers can also experience paternal PPD in the first 6 months after birth of the baby with prevalence rates of about 10%.21

It is critical to identify women with PPD because it can lead to negative mother–infant bonding and interactions that include maternal withdrawal, disengagement, and abuse.20 The mother may be less likely to engage in preventive care and is less responsive to providing care to the infant; this may include engaging in appropriate feeding practices and oral health care for the infant/children.20,21 PPD may impact developmental milestones such as cognitive scores and nonverbal communication of the infant/toddler.21 Infants may also exhibit increased dysregulation of sleep and feeding.21 Negative infant behaviors are also typical including excessive infant crying and fusiness.21

II.

Signs and Symptoms Symptoms vary between individuals, but common symptoms include18,20: Depressed mood or loss of interest or pleasure in activities present for at least 2 weeks. Feelings of hopelessness, worthlessness, or guilt. Fatigue and lack of energy. Difficulty with memory and concentration. Appetite disturbance. Insomnia, early-morning wakefulness. Thoughts of suicide.

III. Treatment In the case of depression, one of the first things assessed is suicide risk. Hospitalization may be indicated when potential danger of suicide or harm to others exists.22

A. Basic Therapeutic Approach

Lifestyle modifications include regular physical activity, adequate sleep, and avoidance of drugs and alcohol. Diagnose and treat other medical and psychiatric problems.

B. Pharmacotherapy Antidepressants are preferred as an initial treatment of depressive disorders.22 However, they take 2–4 weeks to reach therapeutic levels.22 Selective serotonin reuptake inhibitors Advantages: tolerability better than earlier drugs; better compliance; safety in overdose. Examples: fluoxetine (Prozac), paroxetine (Paxel), and sertraline (Zoloft). Serotonin and noradrenergic reuptake inhibitors Examples: duloxetine (Cymbalta) and venlafaxine (Effexor). Dopamine norepinephrine reuptake inhibitor Example: bupropion (Wellbutrin). Monoamine oxidase inhibitors Use is restricted to patients who do not respond to other medications due to drug–drug and drug–food interactions.22 Example: phenelzine and tranylcypromine. Alternative therapies St. John’s Wart may be used by some patients, but the evidence is not strong for its effectiveness and there are potential drug interactions, so patients should be encouraged to consult with their mental health provider.22

C. Psychotherapy Psychotherapy combined with pharmacotherapy is more effective than either one alone for treating depressive disorders.19,23 CBT. Problem-solving therapy. Psychodynamic therapy.

Interpersonal psychotherapy.

D. Electroconvulsive Therapy Electroconvulsive therapy is used in severe major depression disorder when pharmacologic therapy and psychotherapy have not been effective. It is also indicated in situations where an immediate response is needed, such as for someone who is suicidal.22 Patient may experience confusion and short-term memory loss.22 May have cardiovascular side effect and is contraindicated in patients with a history of cardiac arrhythmia or recent myocardial infarction.

IV. Dental Hygiene Care A. Personal Factors Self-care impairment and lack of motivation negatively impact oral health.24 Symptoms not controlled by medication, such as difficulties with memory, may need to be considered when planning dental hygiene care. Individuals with depression may have poor diet quality such as higher intakes of energy-dense foods that tend to be higher in sugar, which may increase the risk of dental caries and impact healing after periodontal therapy.24,25

B. Oral Health Implications Side effects of medications: xerostomia along with poor dietary choices encourages growth of dental biofilm and increases the risk for dental caries.13,25 Omission of general health habits and neglect of oral care make the person susceptible to oral diseases. Adults with a diagnosis of depression were at a 64% higher risk

for having six or more teeth extracted.26 Those with depression are at 37% greater risk of being edentulous.26 Taste perception changes may contribute to a diet high in cariogenic foods with high levels of sucrose.27

C. Appointment Interventions Assessment Monitor the medical and medications histories closely; note side effects and contraindications related to new drug therapies. Review consultations with medical/psychiatric specialists caring for the patient. Intraoral/extraoral examination: check for signs of xerostomia. Approach Provide positive reinforcement and reassurance. Avoid negative guilt-inducing words. Depressed patients may needlessly blame themselves. Show genuine interest in the patient to build rapport. Preventive instruction Dental biofilm control: Teach patient and caregivers the need for daily measures to preserve the teeth and periodontal tissues. Xerostomia: Manage caries risk with dietary counseling, office and home fluorides, saliva substitutes, and xylitol gum between meals. Implementation of care plan Adjust dental light carefully and provide tinted protective eyewear for the patient with photosensitivity, a side effect of certain medications. Profound local anesthesia when needed for pain control. Provide in-office fluoride treatment after instrumentation. Use care to prevent postural hypotension. Sit the patient up slowly from a reclined position and have the patient remain seated a few moments before standing.

BIPOLAR DISORDER Bipolar disorder (BD) was formerly known as manic-depressive disorder and involves mood changes from extreme highs (mania) to extreme lows (depression).28 The lifetime prevalence in the United States is approximately 4%.29 It is more prevalent in women and the average age of onset is mid-20s. In those with BD, suicide is a leading cause of death, so they need frequent monitoring by a mental health professional.30 BD is the most costly behavioral health issue in part because of high rates of comorbidities such as anxiety disorder, metabolic syndrome, substance abuse, and attention-deficit disorder.30,31

I.

Signs and Symptoms Manic episode symptoms include behaviors that are not consistent with the patient’s usual behavior including the following28: Inflated self-esteem. Decreased need for sleep. Irritable. Attention gets focused on unimportant activities. Excessive involvement in risky activities. Extreme changes in energy, activity, sleep, and behavior based on the large swings in mood. Major depressive episode symptoms are the same as those described for depressive disorders.

II.

Treatment

Both pharmacotherapy and psychotherapy are used during all phases of the disorder. Initially, hospitalization may be needed to protect the individual from harm to self or others.

A. Pharmacotherapy Mood stabilizers29 Example: lithium. Side effects: xerostomia, restlessness, joint and muscle pain, salivary gland swelling, indigestion, and bloating. Atypical antipsychotics are sometimes used in conjunction with antidepressants.29 Examples: quetiapine (Seroquel), risperidone (Risperdal), olanzapine (Zyprexa), and aripiprazole (Abilify). Side effects: dizziness, blurred vision, rapid heartbeat, skin rashes, and drowsiness. Antidepressants are usually taken with a mood stabilizer.29 Example: fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and bupropion (Wellbutrin).

B. Psychotherapy Cognitive behavioral therapy helps patients to learn to change harmful or negative thought patterns and behaviors. Family-focused therapy improves communication and coping strategies to aid in early recognition of manic or depressive episodes. Interpersonal and social rhythm therapy (IPSRT) is typically used in conjunction with other psychotherapies and is helpful in the maintenance phase of BD. IPSRT focuses on helping individuals to maintain consistent daily routines to promote stability in mood.30,32 If a patient was undergoing IPSRT, inclusion of oral hygiene procedures in the daily routines may be helpful in encouraging regular oral self-care. Psychoeducation educates the patient and family about BD and coping strategies.30

III. Dental Hygiene Care

A. Personal Factors In a manic episode: Many patients talk quickly, jump from thought to thought, and have a short attention span. A tendency to argue and become irritable may be apparent. In a depressive episode: The patient may not be interested in oral self-care and be unmotivated.

B. Oral Health Implications Oral hygiene needs are often not a priority to the patient. Gingival tissues may appear abraded and lacerated because of overzealous toothbrushing with excessive pressure. Side effects of medications with implications for oral health and dental care include33: Xerostomia. Dysgeusia and impart a metallic taste in the mouth (lithium). Stomatitis and glossitis. Loss of taste acuity. Dizziness.

C. Appointment Interventions Carefully review medical and medication history; consult with patient’s physician/psychiatrist as needed. Simplify the surroundings; provide a comfortable, calm, and uncluttered environment. Patient instruction may be difficult due to a short attention span. Use direct, simple instructions. When applicable, help the patient’s caregiver to learn procedures for dental caries prevention and periodontal health. Manage caries and periodontal risk with saliva substitutes, office and home fluoride application, dietary counseling, and sugar-free

xylitol gum or mints between meals.33 Chlorhexidine gluconate mouthrinse may be prescribed for short intervals to reduce caries risk and aid healing after NSPT. Three- to four-month continuing care appointments may be needed.

FEEDING AND EATING DISORDERS Feeding and eating disorders are serious disturbances in the amounts and types of foods consumed. The lifetime prevalence ranges from 0.9% for women and 0.3% for men for anorexia nervosa to 1% for bulimia to 2.8% for binge-eating disorder.34 Prevalence of other feeding disorders such as pica and rumination disorder is unclear. Identification and referral of a patient suspected of having an eating disorder for medical evaluation may be lifesaving because serious medical problems may exist and psychiatric therapy is indicated. An interdisciplinary team approach for successful rehabilitation of an individual with an eating disorder involves, at the least, medical, psychiatric, nutritional, dental, and dental hygiene professionals.

I.

Types and Symptoms of Feeding and Eating Disorders

A. Pica Consumption of nonfood items typically occurs in children, but it also common in adults, particularly those with mental disorders and/or intellectual disabilities.35 Diagnostic criteria include35: Persistent eating of nonfood substances such as dirt, clay, starch, gum, or ice for at least 1 month. Consumption of nonfood items may replace healthy foods and lead to nutrient deficiencies that can impact immune response and healing.

B. Anorexia Nervosa Anorexia nervosa is characterized by a refusal of the individual to

maintain body weight over the minimal normal weight for age and height. The aversion to eating results in life-threatening weight loss.35 Anorexia nervosa has the highest mortality rate of any mental disorder.36 Commonly begins in adolescence or young adulthood. Signs and symptoms (Box 58-2) include35,36:

BOX 58-2 Characteristics of Anorexia Nervosa 1. Refusal to maintain body weight over a minimally normal weight for age and height. 2. Intense fear of gaining weight or becoming fat, even though underweight. 3. Disturbance in the way in which one’s body weight or shape is experienced. 4. Denies the seriousness of the current low body weight. 5. In females, absence of menstrual cycles when otherwise expected to occur. Types Restricting type: does not regularly engage in binge-eating or purging behavior (i.e., self-induced vomiting or misuse of laxatives, diuretics, or enemas). Binge-eating/purging type: regularly engages in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Source: American Psychiatric Association. Feeding and eating disorders. In: Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington, DC: American Psychiatric Association; 2013:329-354.

Restriction of energy intake resulting in severe weight loss with emaciation; “waiflike” appearance. Intense fear of weight gain or becoming fat. Body image distortion (Figure 58-1).

FIGURE 58-1 • Anorexia Nervosa. The person with anorexia typically has a distorted body self-image. Although small and waiflike in real life, the mirror

image appears as an overweight individual. (Reprinted from Werner R. Massage Therapist’s Guide to Pathology. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.)

Purging by vomiting, laxatives, and excessive exercise. Malnutrition can have long-term impact on bone mineral density (osteopenia or osteoporosis). Vital signs: low pulse rate, hypotension, decreased respiratory rate, and low body temperature. Metabolic changes: gastrointestinal, cardiovascular, hematologic, and renal system disturbances. Amenorrhea (missed menstrual periods).

C. Bulimia Nervosa Bulimia nervosa is a mental disorder marked by recurrent episodes of uncontrollable binge eating that occurs an average of once a week for 3 months.35 Two types of compensatory behaviors are seen in individuals with bulimia nervosa known as the purging type and the nonpurging type (Box 58-3).

BOX 58-3 Characteristics of Bulimia Nervosa 1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: • Eating, within any 2-hour period, an amount of food larger than most people would eat in a similar period of time. • A sense of lack of control over eating during the episode, for example, a feeling that one cannot stop eating or control what or how much one is eating. 2. Recurrent inappropriate behavior to prevent weight gain, such as selfinduced vomiting; misuse of laxatives, diuretics, enemas; fasting; or excessive exercise. 3. Self-evaluation is unduly influenced by body shape and weight.

Types Purging type: regularly engages in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Nonpurging type: uses inappropriate compensatory behaviors such as fasting or excessive exercise, but does not engage in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Source: American Psychiatric Association. Feeding and eating disorders. In: Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington, DC: American Psychiatric Association; 2013:329-354.

Because of the fear of becoming overweight, self-induced vomiting after eating or the use of laxatives or diuretics is characteristic of the purging type (Figure 58-2).

FIGURE 58-2 • Bulimia Nervosa. The person with bulimia becomes trapped in recurring behaviors involving food and weight management. They ingest a vast number of calories at once and then take measures to purge themselves of their binge (e.g., abuse of laxatives, diet pills, and diuretics). They monitor their weight several times a day; some exercise obsessively to burn off the calories. (Reprinted from Mohr W. Psychiatric-Mental Health Nursing. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.)

The nonpurging type uses strict dieting, fasting, and/or vigorous exercise. Signs and symptoms include34–36: Normal body weight or slightly overweight is typical, in contrast

to the thin anorectic person. Comorbidity with other mental disorders is common, especially depression and BDs. Lifetime prevalence of alcohol or substance abuse is 30% for people. Chronically inflamed and sore throat. Swollen salivary glands. Enamel erosion and dentin hypersensitivity due to frequent exposure to acid gastric fluids. Severe dehydration may result from purging. Food consumed during a binge include 65% breads/pasta, 56% sweets, and 40% salty snacks, which may be more cariogenic.37

D. Binge-Eating Disorder Recurrent episodes of binge eating without compensatory behaviors seen in bulimia nervosa at least once a week for 3 months.35,36 Signs and symptoms include35,36: Occurs in normal weight, overweight, and obese individuals. Binge eating is associated with feeling embarrassed or guilty about how much one is eating. Comorbid disorders include mental health disorders such as bipolar, depressive, and anxiety disorders. Eating large amounts of food quickly in a short time. Eating alone or in secret. Frequent dieting.

E. Diabulimia Diabulimia is defined as the restriction or omission of insulin in an individual with type 1 diabetes mellitus (T1DM) in order to lose or prevent weight gain.38,39 This condition has been documented since the 1970s, but there are no recognized diagnostic criteria in the DSM-5.

Diabulimia is most often seen in adolescent and young women. These individuals are at increased risk of microvascular complications such as renal failure, neuropathy, heart attack, stroke, and death. Signs and symptoms include38: Rapid weight loss. Obsession with body size and shape and dissatisfaction with body image. Ketone or “fruity” smell. Persistent high hemoglobin A1c. Eating behaviors similar to bulimia nervosa. Frequent emergency rooms visits or admission for diabetic ketoacidosis.

F. Orthorexia Nervosa Characterized by pathologic or disordered healthy eating with a focus on the quality of food choices resulting in negative effects on health.40 This condition is not recognized by the American Psychiatric Association in the DSM-5 and did not appear in the peer-reviewed literature until 2004. Proposed diagnostic criteria include40: Compulsive behavior or preoccupation with restrictive dietary practices believed to promote health. Dietary restriction tends to escalate over time with elimination of entire food groups and may engage in “cleanses” (partial fasts) to detoxify. Violation of dietary restriction causes anxiety and shame. Malnutrition or medical complications from the restricted diet. Impairment of social, academic, and/or vocational functioning.

II.

Medical Complications

Medical complications are primarily associated with anorexia nervosa

and people with bulimia who engage in purging behaviors.35 Problems include dehydration, electrolyte imbalance, protein malnutrition, and cardiac arrhythmia. Self-medications include abuse of laxatives and diuretics, which contribute to gastrointestinal disturbances. Esophageal tears. Amenorrhea or menstrual irregularities.

III. Treatment Multidisciplinary team treatment for eating disorders is considered best practice. The primary objectives are to promote weight gain and restore the nutritional status. Treatment may require months or even years. Typically outpatient treatment is recommended, so if someone has been hospitalized for treatment, it suggests they are at high risk for medical complications and a medical consult is needed.41

A. Pharmacotherapy Antidepressants (primarily in bulimia nervosa)38,41 Example: fluoxetine (Prozac). Side effects: headache, weight gain, tremor, irritability, and xerostomia.

B. Psychotherapy The goal of therapy is to help the individual discover the underlying causes of the problems and source of the disordered eating behavior.41 Cognitive behavioral therapy is the first line of treatment in bulimia nervosa and diabulimia.38,41 Interpersonal therapy. Family-based therapy is recommended for younger patients.

C. Nutrition Therapy Registered dietitian nutritionists with advanced training in eating disorders work as part of the interprofessional team to conduct a full nutrition assessment, diagnosis, and individualize a plan for medical nutrition therapy in collaboration with the team.42 This in-depth type of nutrition counseling is beyond the scope of practice for dental professionals.

IV. Dental Hygiene Care A. Personal Factors Anorexia nervosa Individuals with anorexia are frequently engaged in excessive exercise and preoccupied with food and weight loss. Frequently the person is a high achiever and highly motivated scholastically, but may be socially isolated and withdrawn. Suicide risk is elevated in anorexia.35,36 Bulimia nervosa and binge-eating disorder The patient is well aware that the eating habits are abnormal, and as a result may suffer low self-esteem and guilt feelings.

B. Oral Implications Dental erosion (perimolysis): This is the chemical erosion of the tooth surfaces by acid from the regurgitation of stomach contents.43,44 After vomiting, acid is retained by the tongue papillae and provides longer contact with the palatal surfaces of maxillary teeth. Individuals who engage in self-induced vomiting have five times greater risk of dental erosion.44 Because of perimolysis, the earliest evidence of bulimia or bingeeating/purging type of anorexia may be on the smooth palatal surfaces of the teeth.

The lingual surfaces of the maxillary anterior teeth appear translucent and glasslike (Figure 58-3B).

FIGURE 58-3 • Oral Manifestations of Purging-Type Eating Disorders. Signs of purging include (A) irritation and inflammation of the pharynx as well as the esophagus from chronic vomiting and (B) erosion of the lingual surface of the teeth, loss of dental enamel, periodontal disease, and extensive dental caries. (Reprinted from Timby B, Smith N. Introductory Medical-Surgical Nursing. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.)

With time, the erosion extends over the occlusal and incisal surfaces and chipping may occur. Restorations in posterior teeth may appear raised because of erosion of the enamel around the margins. Dental caries: an increase in caries incidence is found,44 particularly in cervical caries. Demineralization results from pH changes in the saliva, from xerostomia, and from the large quantities of cariogenic foods ingested during binges. Mucosal lesions: Nutrient deficiencies, especially in the B vitamins, may result in angular cheilitis (Figure 58-4), glossitis, inflammation of pharynx (Figure 58-3A), and a burning sensation.43

FIGURE 58-4 • Angular Cheilitis. Angular cheilitis may occur in vitamin B deficiencies, which can occur in patients with eating disorders. (Reprinted from Schalock P, Hsu J, Arndt K. Lippincott’s Primary Care Dermatology. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.)

Periodontal manifestations: Nutritional deficiencies with inadequate control of dental biofilm due to depression may predispose the patient to gingivitis. Saliva: The decrease in quantity, quality, and pH of the saliva limits its buffering and lubricating properties.44 Dehydration of the oral soft tissues occurs. Body fluid is lost from vomiting and the use of diuretics may result in xerostomia. Xerostomia is also a side effect of antidepressant medication prescribed for patients with bulimia and anorexia. Hypersensitive teeth: The loss of enamel and the exposure of dentin results in sensitivity, which can be especially noticeable for the maxillary anterior teeth. Trauma: The soft palate can be traumatized by fingers, comb, pencils, or toothbrush used to induce vomiting. The same implement may injure the mouth at the commissures.

Pharyngeal trauma is caused by a large food bolus that is swallowed or regurgitated. Callous formation or scars on fingers or knuckles used for selfinduced vomiting may be observed. Parotid gland: Enlargement may occur for 2–6 days after a binge.43 The cause of enlargement is not known. The degree of enlargement increases with the frequency of vomiting. The gland functions normally and is not sensitive to palpation. Bruxism: Tooth wear is related to stress and tension.43 Taste: Taste perception may be impaired. Temporomandibular joint disorders (TMD): Self-induced vomiting may cause dislocation or subluxation of the mandibular condyle due to excessive opening and result in symptoms of TMD, including headaches, facial pain, and sensitivity to palpation.43

C. Appointment Interventions Present a nonthreatening, nonjudgmental demeanor. Develop rapport through mutual respect and a trusting relationship. Recognize that denial of an eating disorder is common. Be aware answers to medical and personal history questions concerning diet, medications, use of laxatives and diuretics, and weight and weight loss may provide strong suspicions of a feeding or eating disorder. Assess the nutritional status through use of a dietary assessment. Record vital signs. Perimolysis and dental caries prevention strategies include: Reduction in consumption of cariogenic foods; provide list of suggestions for substitutions. Improvement in oral self-care. Show use of appropriate brushing and flossing with additional interdental aids if required for biofilm removal. Clean the tongue (see Chapter 26). Avoidance of brushing after vomiting. Demineralization of the tooth surface by the acid from the stomach starts immediately on

contact. Brushing may remove additional enamel/dentin. Remineralization after vomiting with an alkaline rinse of sodium bicarbonate solution to neutralize the acid.43 Dental hypersensitivity is managed as follows: Office application of fluoride varnish. Use fluoride dentifrice at least twice daily. Daily application of 1.1% neutral sodium fluoride toothpaste or gel. Avoid acidic foods and beverages. Xerostomia management includes: Advise sugar-free mints or chewing gum containing xylitol to stimulate saliva flow. Recommend saliva substitutes. To reduce problems caused by hypersensitive teeth: choose sugar substitute and acid-free foods and beverages.

SCHIZOPHRENIA Schizophrenia is a complex, chronic mental disorder. Disturbances in feeling, thinking, and behavior significantly impair function to a level below normal for the individual.35,45 Prevalence of schizophrenia is 0.3%–0.7%. The onset is usually between the age of 16 and 30 years. Men tend to develop symptoms at an earlier age than women. Genetic factors are strong contributors to risk for schizophrenia.35,45 Associated medical issues such as cardiovascular disease, obesity, diabetes, and metabolic syndrome reduce life expectancy.35 About 10%–13% of people with schizophrenia attempt suicide and 4%–6% die as a result of suicide.46 However, research conducted with a large Canadian community–based sample found 39% of those with schizophrenia had a lifetime prevalence of attempted suicide and were 15 times more likely to attempt suicide than someone without schizophrenia.47

I.

Signs and Symptoms

Symptoms fall into three categories: positive symptoms, negative symptoms, and cognitive symptoms.35,45 Positive symptoms are those that reflect unusual, exaggerated behavior and include: Hallucinations that may include hearing voices. Delusions. Disorganized thinking characterized by the person having difficulty organizing thoughts or connecting them logically. Movement disorders such as agitated body movements. People with positive symptoms may “lose touch” with reality and the symptoms may come and go. Negative symptoms are associated with disruptions in normal emotions or behaviors and may be mistaken for depression. Symptoms include:

The individual may have a “flat affect” meaning the person shows no emotion. Lack of pleasure in activities once enjoyed. Inability to start and carry out tasks. Little communication even when forced to interact. These individuals have difficulty with everyday tasks such as oral self-care. Cognitive symptoms are less obvious and may be difficult to recognize. Symptoms include: Poor executive functioning, meaning difficulty with understanding information and using it to make decisions. Difficulty paying attention. Challenges with working memory or the ability to use information immediately after it is learned. Prevalence of substance-use disorder (SUD) is high among patients with schizophrenia.48 Prevalence of any SUD was approximately 42% with over 27% using illicit drugs, 26% using cannabis, 24% using alcohol, and 7% using stimulants.48 Over 60% of patients with schizophrenia use tobacco.49

II.

Treatment

The response to initial treatment can be a predictor of the long-term prognosis. The prognosis has generally been considered guarded to poor. Evidence shows that although deterioration may occur during the early years, the condition may stabilize with treatment during middle age.45–48

A. Pharmacotherapy The objectives of treatment are to reduce or alleviate the delusions, hallucinations, and other symptoms and to enable the patient to function in daily living.45 The use of antipsychotic medications has improved the outcomes

of treatment. Typical antipsychotics are used to block dopamine receptors and are effective against positive symptoms with less effect on negative symptoms.45 Examples: chlorpromazine (Thorazine), haloperidol (Haldol), and perphenazine (Etrafon, Trilafon). Side effects: xerostomia, persistent muscle spasms, tremors, and restlessness, and long-term use can lead to tardive dyskinesia (uncontrolled muscle movements), which commonly happens around the mouth. Atypical antipsychotics were developed in the 1990s and are second-generation antipsychotics: Examples: clozapine (Clozaril), quetiapine (Seroquel), risperidone (Risperdal), olanzapine (Zyprexa), and aripiprazole (Abilify). Side effects: xerostomia, dizziness, blurred vision, rapid heartbeat, skin rashes, and drowsiness. Table 58-1 lists a few of the many side effects of antipsychotic medications, with suggestions for appointment adaptations. TABLE 58-1 • Effects of Antipsychotic Medication SIDE EFFECTS

IMPLICATIONS FOR DENTAL HYGIENE CARE

Dystonia Muscle contractions

Laryngeal spasm; coughing Unable to turn head

Dysarthria Difficult speech

Communication difficulty

Parkinson-like syndrome Shuffling gait Muscular rigidity Resting tremor (pill rolling) Facial grimacing

Cooperation may be difficult Patient positioning Instrument positioning; retraction

Bradykinesia Akathisia Restlessness, pacing

Plan short appointments

Akinesia Loss of voluntary movement Lethargy, fatigue feelings

Adjust patient position

Tardive dyskinesia Involuntary mouth and jaw movements

Difficulty in instrumentation Wearing dentures difficult or impossible Muscle fatigue; may need mouth prop

Anticholinergic effects Xerostomia Blurred vision

Dental caries prevention Fluoride dentifrice; saliva substitute Difficulty seeing visual aids

Cardiovascular Postural hypotension Tachycardia, palpitations

Have patient sit up slowly and wait before standing Monitor vital signs

Sedation Drowsiness

Interfere with patient’s daily routine Patient may be late; needs reminders

Blood Reduced leukocytes Agranulocytosis

Increased susceptibility to infection Oral candidiasis may be present

B. Psychosocial Therapy Psychosocial therapy is utilized once the patient is stabilized on antipsychotic medication.45 Treatment is to help give general support in dealing with the

challenges of the illness such as self-care, work, interpersonal relationships, and communication. Rehabilitation once stabilized includes social and vocational training, so a person with schizophrenia can function in the community. Family education is also essential to help them learn coping strategies and problem-solving skills to support their loved one. CBT focuses on thinking and behavior and helps the person with schizophrenia manage symptoms that remain despite medication.

III. Dental Hygiene Care A. Oral Implications Overall degeneration of health factors may have occurred because of neglect of diet, exercise, sleep, general cleanliness, personal grooming, and oral care. Concurrent alcohol and/or other drug abuse, as well as smoking, can influence dental and periodontal health. Individuals with schizophrenia have higher rates of dental caries, more missing teeth, and fewer filled teeth, suggesting either a lack of access to dental care or a failure to seek dental care.50 Xerostomia coupled with lack of attention to self-care may lead to an increase in rampant dental caries.51 Those with schizophrenia also have higher rates of periodontal disease, which may be a result of lack of self-care coupled with lack of dental care and tobacco use.51

B. Appointment Planning Elective dental and dental hygiene treatment cannot be carried out until the schizophrenia is stabilized. If the patient decompensates, such as hallucinations or exhibits bizarre behavior, during a dental or dental hygiene appointment, immediate referral is needed.

Telephone numbers of the patient’s mental healthcare provider should be kept in an easily accessible location for quick referrals.

C. Appointment Interventions Because schizophrenia is often a lifelong disorder, planning for future oral health is essential. Review medical and medication history; analyze drugs for possible side effects that require appointment modifications (Table 58-1). Consult with the mental health provider relative to medications, alcohol or other substance use, and medico-legal competence for informed consent. Negative symptoms are associated with poor oral health and a greater need for periodontal treatment.51 Plan a simple routine. For a series of appointments and maintenance, use a familiar, organized routine that is comfortable for the patient. Decrease stimulation; create a restful atmosphere; if background music is present, keep it low and soft. Management of the risk for caries, periodontal, and oral cancer includes the following: Oral self-care instruction to improve biofilm removal on a daily basis. When applicable, evaluate the patient’s personal caregiver for attitude and knowledge and provide information and instruction. Diet assessment and counseling to assist patient in making noncariogenic food choices (see Chapter 33). Encourage use of xylitol-containing gum or mints when cariogenic snacks or beverages are consumed between meals. Office and home fluorides (see Chapter 34). Saliva substitutes may be helpful in patients with severe medication-induced xerostomia. Tobacco cessation (see Chapter 32) may be more difficult for people with schizophrenia because nicotine withdrawal may cause psychotic symptoms to worsen, so the dental professional

must collaborate with the medical treatment team to closely monitor the patient.35 Use a mouth prop to assist the patient with tardive dyskinesia. The patient who does not have control of mouth movements might appreciate the stability.

MENTAL HEALTH EMERGENCY I. Psychiatric Emergency A psychiatric emergency in a dental clinic or private dental practice would be rare. The most common causes of emergency include panic attack, atypical drug reaction, and schizophrenic or manic decompensation.

II.

Patients at Risk for Emergencies Patient with a significant psychiatric history. Patient with a known substance abuse history. Patient new to the clinic or office; not known by the practitioners.

III. Prevention of Emergencies Prepare a complete history; collect as much information as possible; consult with the patient’s physician and psychiatrist. Be alert to risks and characteristic symptoms of each disorder. Apply all the principles of stress management. Know the patient’s medications and when they are taken. Request that patient (or caregiver if accompanied) have readily available any necessary medication that may be effective during an emergency. Develop rapport with each patient; avoid confronting the patient and present a nonthreatening demeanor.

IV. Preparation for an Emergency Attend to surroundings, such as door access, objects in the room. Arrange for colleagues to be aware of the possible needs of a special patient appointment; when possible plan for an assistant to participate in clinical procedures.

Review characteristics of possible emergencies; have necessary equipment ready. Keep names and contact information of the patient’s case manager, psychiatrist, and responsible family member in the record in a prominent position for ready reference.

V.

Intervention

Stay with the patient; request colleague to contact patient’s case manager, psychiatrist, or other responsible person. Maintain a calm, serene manner; talk quietly but firmly. Move the patient to a quiet, less stimulating environment. The dental equipment and environment may have contributed to the patient’s disturbance. If you think the patient might be suicidal because the individual mentions wanting to die or kill themselves, try to remain calm and implement the five action steps of #BeThe1To52: 1. #BeThe1To ASK: Directly ask the patient “Are you thinking about suicide?” Asking in a direct manner can open the door for the individual to share their feelings. 2. #BeThe1To KEEP THEM SAFE: Showing support for someone can put time and distance between the person and their chosen suicide method. 3. #BeThe1To BE THERE: Being present shows support for the person at risk, this can be lifesaving. 4. #BeThe1To HELP THEM CONNECT: Call the Suicide Prevention Lifeline 1-800-273-TALK (8255). Your call will be routed to a local call center and they will walk you through resources available to assist and if the patient is willing have them talk to a mental health professional. 5. #BeThe1To FOLLOW-UP: Following up to see how the individual is doing has been shown to reduce the number of suicide deaths.

DOCUMENTATION The patient with a mental health disorder must complete a health history with details of the medical problem and medication history at the initial appointment. Follow-up with progress notes at each succeeding appointment to review all procedures and medications for changes. The following list suggests the minimum information to include in the permanent record: Resources for assistance in a convenient place in the event of need to contact: telephones; e-mails; and working addresses for physicians, psychiatrist, family, and emergency sources. Progress notes for each appointment and other contacts to update all personal data and treatment. Contacts and correspondence with specialists and others. A sample progress note may be reviewed in Box 58-4.

BOX 58-4 Example Documentation: Patient with a Mental Disorder S—Mary is a 23-year-old. Sporadic dental care mainly for emergency root canals and extractions. She presents for an examination and “cleaning” because her physician recommended she seek dental care for obvious dental caries. O—Medical history: She reports trouble sleeping and waking at 2 or 3 every morning and not being able to get back to sleep. Mary reports hallucination of neon people walking down the hallway. She said when she was at work she experienced high levels of anxiety. Her psychiatrist has diagnosed Mary as suffering from panic attacks. She also reported a previous history of being hospitalized for schizophrenia. She has smoked 1 pack of cigarettes/day since she was 13 years old. Medications: Risperidone (Risperdal). Dental examination: Caries noted MOD-#2, 14, 15, 18, 30; M & D #7–10 and #22– 27. Leukoplakia noted in vestibule buccal to #28–29. Generalized pocket depths 4–5 mm with bleeding on probing, indicating generalized Stage II, Grade B periodontitis. Biofilm score: 95%. Generalized moderate supra- and subgingival calculus. A—Patient education to include oral self-care along with strategies to manage risk factors for caries and periodontal disease. Consult with primary care

provider to coordinate tobacco cessation based on her history of schizophrenia. Disease control treatment phase to include restoration of carious lesions and NSPT. P—Disclosed biofilm and patient demonstrated oral self-care techniques. Mary seems to have good toothbrushing and flossing technique, but motivation seems to be her main problem. Suggested putting a sticky note on her bathroom mirror to remind her to perform oral self-care. Another suggestion was to make it a family affair and brush and floss with her children to be a role model to them. Mary was anxious at the beginning of the appointment, but seem calmer toward the end. Nutrition counseling focused on reducing the frequency of sugar-sweetened snacks and beverages with recommendations to use xylitol gum or mints when she snacks between meals and cannot brush. She was given a prescription for 1.1% sodium fluoride paste to begin using at home. There was not adequate time to begin NSPT at today’s appointment. Next visit: Review oral self-care. Follow-up on diet and tobacco cessation. NSPT maxillary and mandibular right quadrants with two carpules, 2% lidocaine with 1:100,000 epinephrine for an inferior alveolar (IA), posterior superior alveolar (PSA), middle superior alveolar (MSA), and greater palatine (GP) injections. Signed: ______________________________, RDH Date: ____________________________________

EVERYDAY ETHICS Samuel, age 28, suffers from panic disorder and generally requests short appointments because he becomes very anxious while receiving dental care. Even with a moderate amount of generalized deposits, Ginny, the dental hygienist, usually schedules two visits to complete the treatment. During his visit today, Samuel appears in an almost dream-like state. He was asked by the receptionist at the check-in about any new medications, but he stated that only a sleep aid was added to his pills, which he takes at night. Ginny suspects the patient may have taken his medication incorrectly and is concerned that Samuel is driving himself home after the appointment. Questions for Consideration 1. Without breaching confidentiality, what ethical or other responsibility does Ginny have in verifying the type and amount of medication Samuel took and how does that influence the current day’s dental hygiene appointment procedures? 2. Which of the dental hygiene core values are evidenced in this scenario?

Describe each in terms of the concern Ginny shows relative to Samuel’s “competency” at driving himself home after the appointment as well as management during the appointment. 3. Is this an ethical dilemma or issue for Ginny? Suggest several alternative procedures that Ginny can follow during this appointment.

Factors to Teach the Patient The significance of daily oral self-care of the oral cavity. How medications cause dry mouth and how it increases the risk for caries. The importance of minimizing sweets such as cake, candy, and sugarsweetened drinks to prevent dental caries. The use of saliva substitutes to make a dry mouth more comfortable. For the patient with bulimia or the binge-eating/purging type of anorexia: The causes and effects of enamel erosion; the high acidity of the vomitus from the stomach. The importance of rinsing after vomiting but not brush immediately; demineralization begins promptly after the acid from the stomach reaches the teeth. Brushing can cause abrasion of the demineralizing enamel. The need for multiple fluoride applications through office and home fluoride containing dentifrice, rinse, and brush-on gel, as well as professional application of varnish at regular dental hygiene appointments.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed., text revision. Washington, DC: American Psychiatric Association; 2013:19. 2. Centers for Disease Control and Prevention. Communicating with and about people with disabilities. 2014. http://www.cdc.gov/ncbddd/disabilityandhealth/pdf/disabilityposter_photos.pdf. Accessed September 10, 2018. 3. Steel Z, Marnane C, Iranpour C, et al. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013. Int J Epidemiol. 2014;43(2):476-493. 4. Baxter AJ, Scott KM, Vos T, Whiteford HA. Global prevalence of anxiety disorders: a systematic review and meta-regression. Psychol Med. 2013;43(5):897-910. 5. Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14(suppl 1):S1. 6. National Institute of Mental Health. Generalized anxiety disorder. Revised July 2018. http://www.nimh.nih.gov/health/topics/generalized-anxiety-disordergad/index.shtml. Accessed September 7, 2018. 7. American Psychiatric Association. Anxiety disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013:189-223. 8. National Institute of Mental Health. Obsessive-compulsive disorder. Revised January 2016. http://www.nimh.nih.gov/health/topics/obsessive-compulsivedisorder-ocd/index.shtml. Accessed September 7, 2018. 9. National Institute of Mental Health. Panic disorder. http://www.nimh.nih.gov/health/topics/panic-disorder/index.shtml. Accessed September 7, 2018. 10. National Institute of Mental Health. Post-traumatic stress disorder. http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorderptsd/index.shtml. Accessed September 10, 2018. 11. National Institute of Mental Health. Anxiety disorders. http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml. Accessed September 10, 2018. 12. American Psychological Association. Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults. February 24, 2017. Washington, DC. http://www.apa.org/ptsd-guideline/ptsd.pdf. Accessed September 10, 2018. 13. Kisely S, Sawyer E, Siskind D, Lalloo R. The oral health of people with anxiety and depressive disorders—a systematic review and meta-analysis. J Affect Disord. 2016;200:119-32.

Khambaty T, Stewart JC. Associations of depressive and anxiety disorders 14. with periodontal disease prevalence in young adults: analysis of 1999–2004 National Health and Nutrition Examination Survey (NHANES) data. Ann Behav Med. 2013;45(3):393-397. 15. Newton T, Asimakopoulou K, Daly B, Scambler S, Scott S. The management of dental anxiety: time for a sense of proportion? Br Dent J. 2012;213(6):271274. 16. Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen H-U. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012;21(3):169-184. 17. World Health Organization. Depression. March 22, 2018. http://www.who.int/mediacentre/factsheets/fs369/en/. Accessed September 7, 2018. 18. American Psychiatric Association. Depressive disorders. In: Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington, DC: American Psychiatric Association; 2013:155-188. 19. National Institute of Mental Health. Depression. February 2018. http://www.nimh.nih.gov/health/topics/depression/index.shtml. Accessed September 7, 2018. 20. Bobo WV, Yawn BP. Concise review for physicians and other clinicians: postpartum depression. Mayo Clin Proc. 2014;89(6):835-844. 21. Hoffman C, Dunn DM, Njoroge WFM. Impact of postpartum mental illness upon infant development. Curr Psychiatry Rep. 2017;19(12):100. 22. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. Reaffirmed October 31, 2015. Washington, DC: American Psychiatric Association; 2010:1-152. 23. Cuijpers P, Sijbrandij M, Koole SL, Andersson G, Beekman AT, Reynolds CF 3rd. Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis. World Psychiatry. 2014;13(1):56-67. 24. Barbosa ACDS, Pinho RCM, Vasconcelos MMVB, Magalhães BG, Dos Santos MTBR, de França Caldas Júnior A. Association between symptoms of depression and oral health conditions. Spec Care Dentist. 2018;38(2):65-72. 25. Camilleri GM, Méjean C, Kesse-Guyot E, et al. The associations between emotional eating and consumption of energy-dense snack foods are modified by sex and depressive symptomatology. J Nutr. 2014;144(8):1264-1273. 26. Wiener R, Wiener M, McNeil D. Comorbid depression/anxiety and teeth removed: Behavioral Risk Factor Surveillance System 2010. Community Dent Oral Epidemiol. 2015;43(5):433-443. 27. Platte P, Herbert C, Pauli P, Breslin PAS. Oral perceptions of fat and taste stimuli are modulated by affect and mood induction. PLoS One. 2013;8(6):e65006. 28. American Psychiatric Association. Bipolar and related disorders. In: Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington, DC: American Psychiatric Association; 2013:123-154.

29. National Institute of Health, National Institute of Mental Health. Bipolar Disorder. November 2017. https://www.nimh.nih.gov/health/statistics/bipolardisorder.shtml. Accessed September 7, 2018. 30. Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord. 2018;20(2):97-170. 31. Jin H, McCrone P. Cost-of-illness studies for bipolar disorder: systematic review of international studies. Pharmacoeconomics. 2015;33(4):341-353. 32. Haynes PL, Gengler D, Kelly M. Social rhythm therapies for mood disorders: an update. Curr Psychiatry Rep. 2016;18:75. doi:10.1007/s11920-016-0712-3. 33. Clark DB. Dental care for the patient with bipolar disorder. J Can Dent Assoc. 2003;69(1):20-24. 34. National Institute of Health, National Institute of Mental Health. Eating Disorders. November 2017. https://www.nimh.nih.gov/health/statistics/eatingdisorders.shtml. Accessed September 8, 2018. 35. American Psychiatric Association. Feeding and eating disorders. In: Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington, DC. 36. National Institute of Health, National Institute of Mental Health. Eating Disorders. https://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml. Accessed September 8, 2018. 37. Allison S, Timmerman GM. Anatomy of a binge: food environment and characteristics of nonpurge binge episodes. Eat Behav. 2007;8(1):31-38. 38. Callum AM, Lewis LM. Diabulimia among adolescents and young adults with type 1 diabetes. Clin Nurs Stud. 2014;2(4):12. 39. De Paoli T, Rogers PJ. Disordered eating and insulin restriction in type 1 diabetes: a systematic review and testable model. Eat Disord. 2018;26(4):343360. 40. Dunn TM, Bratman S. On orthorexia nervosa: a review of the literature and proposed diagnostic criteria. Eat Behav. 2016;21:11-17. 41. Hilbert A, Hoek HW, Schmidt R. Evidence-based clinical guidelines for eating disorders: international comparison. Curr Opin Psychiatry. 2017;30(6):423-437. 42. Tholking MM, Mellowspring AC, Eberle SG, et al. American Dietetic Association: standards of practice and standards of professional performance for registered dietitians (competent, proficient, and expert) in disordered eating and eating disorders (DE and ED). J Am Diet Assoc. 2011;111(8):1242-1249. 43. Romanos GE, Javed F, Romanos EB, Williams RC. Oro-facial manifestations in patients with eating disorders. Appetite. 2012;59(2):499-504. 44. Kisely S, Baghaie H, Lalloo R, Johnson N. Association between poor oral health and eating disorders: systematic review and meta-analysis. Br J Psychiatry. 2015;207(4):299-305. 45. National Institute of Health, National Institute of Mental Health. Schizophrenia. February 2016. https://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml. Accessed September 8, 2018.

46. Popovic D, Benabarre A, Crespo JM, et al. Risk factors for suicide in schizophrenia: systematic review and clinical recommendations. Acta Psychiatr Scand. 2014;130(6):418-426. 47. Fuller-Thomson E, Hollister B. Schizophrenia and suicide attempts: findings from a representative community-based Canadian sample. Schizophr Res Treatment. 2016;2016:3165243. 48. Hunt GE, Large MM, Cleary M, Lai HMX, Saunders JB. Prevalence of comorbid substance use in schizophrenia spectrum disorders in community and clinical settings, 1990-2017: systematic review and meta-analysis. Drug Alcohol Depend. 2018;191:234-258. 49. Dickerson F, Schroeder J, Katsafanas E, et al. Cigarette smoking by patients with serious mental illness, 1999-2016: an increasing disparity. Psychiatr Serv. 2018;69(2):147-153. 50. Yang M, Chen P, He MX, et al. Poor oral health in patients with schizophrenia: a systematic review and meta-analysis. Schizophr Res. 2018;201:3-9. 51. Arnaiz A, Zumβrraga M, Díez-Altuna I, Uriarte JJ, Moro J, Pérez-Ansorena MA. Oral health and the symptoms of schizophrenia. Psychiatry Res. 2011;188(1):24-28. 52. National Suicide Prevention Lifeline. #BeThe1To: Join the Movement. Rockville, MD. http://www.bethe1to.com/join/. Accessed September 9, 2018.

59 The Patient with a SubstanceRelated Disorder Karen M. Portillo, RDH, MS, and Ernestine R. Daniels, RDH, BS

CHAPTER OUTLINE INTRODUCTION ALCOHOL CONSUMPTION I. II.

Clinical Pattern of Alcohol Use Etiology

METABOLISM OF ALCOHOL I. II. III. IV.

Ingestion and Absorption Liver Metabolism Diffusion BAC

HEALTH HAZARDS OF ALCOHOL

I. II. III. IV. V. VI. VII. VIII. IX.

Brain Heart Liver Disease Digestive System Nutritional Deficiencies Cancer Risk Immunity and Infection Nervous System Reproductive System

FETAL ALCOHOL SPECTRUM DISORDERS I.

Alcohol Use during Pregnancy

ALCOHOL WITHDRAWAL SYNDROME I. II. III.

Predisposing Factors Signs and Symptoms Complications

TREATMENT FOR AUD I. II.

Types of Treatment Treatment Settings

ABUSE OF PRESCRIPTION AND STREET DRUGS RISK MANAGEMENT FOR PRESCRIPTION DRUGS OF ABUSE I.

Prevention of Opioid Addiction in the Dental Office

MOST COMMON DRUGS OF ABUSE I. II. III. IV. V. VI. VII. VIII.

Cannabinoids (Marijuana) Depressants Dissociative Anesthetics Hallucinogens Opioids and Morphine Derivatives Stimulants Other Compounds Emerging Drugs

MEDICAL EFFECTS OF DRUG ABUSE I. II. III. IV. V. VI. VII. VIII. IX.

Cardiovascular Effects Neurologic Effects Gastrointestinal Effects Kidney Damage Liver Damage Musculoskeletal Effects Respiratory Effects Prenatal Effects Infections

TREATMENT METHODS I. II.

Behavioral Therapies Drug Withdrawal Medications

DENTAL HYGIENE PROCESS OF CARE I. II. III. IV. V. VI.

Assessment Intraoral Examination Dental Hygiene Diagnosis Care Planning Implementation Evaluation

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Explain key terms and concepts related to the metabolism, intoxication effects, and use patterns of alcohol. 2. Identify physical health hazards, medical effects, and oral manifestations associated with alcohol and substances of abuse. 3. Interpret names of the most commonly abused drugs and describe their intoxication effects and methods of use. 4. Discuss modifications for the dental hygiene process of care for patients who are chemically dependent. Recognize patients who are cognitively impaired and cannot be treated in a safe manner. 5. Employ the National Institute on Drug Abuse Quick Screen to assess patients who are at risk for alcohol or substance abuse and provide resources for the patient to seek help.

INTRODUCTION When an individual consumes a substance such as drugs or alcohol, their brain produces large amounts of dopamine. Dopamine is a neurotransmitter which triggers the brain’s reward system. After repeated drug or alcohol use, the brain is unable to produce normal amounts of dopamine on its own, resulting in the individual to increase their usage of the substance leading to an addiction.1 Patients who develop a drug or alcohol dependence may “premedicate” themselves when a stressful situation such as a dental appointment is anticipated; therefore, direct questions and observation of symptoms at each appointment are required to determine if a patient is cognitively impaired to prevent complications. There is no classic cultural, socioeconomic, or educational profile for one who has a substance abuse disorder. A patient’s medical and dental history does not always provide the information necessary to determine whether the patient uses substances at all, or the level of dependency. It is a professional responsibility of the dental hygienist to: View substance dependency as an illness and to be aware of the characteristics that suggest a possible condition. Address the issues of an appropriate dental hygiene care plan for the patient who has become dependent on a substance.

ALCOHOL CONSUMPTION I. Clinical Pattern of Alcohol Use Abstinence and low-risk use. For women, low-risk drinking is defined as no more than three drinks on any single day and no more than seven drinks per week. For men, it is defined as no more than four drinks on any single day and no more than 14 drinks per week.2 Figure 59-1 shows what constitutes a standard drink.

FIGURE 59-1 • What Is a Standard Drink? In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is found in: 12 ounces of regular beer, which is usually about 5% alcohol; 5 ounces of wine, which is typically about 12% alcohol; and 1.5 ounces of distilled spirits, which is about 40% alcohol. Graphic was designed by Anthony Portillo, adapted from the National Institute on Alcohol Abuse and Alcoholism. (From National Institute on Alcohol Abuse and Alcoholism. Retrieved from https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/whatstandard-drink.)

Moderate alcohol use is defined as up to one drink/day for women and two drinks per day for men.2 The individual can function appropriately in work, family, and social situations. Unhealthy alcohol use increases an individual’s risk for neuropsychiatric conditions, gastrointestinal diseases, cancers including oropharyngeal, intentional injuries such as suicide, unintentional injuries, and cardiovascular disease. Binge drinking occurs when an individual excessively drinks in a short period, typically four drinks for women and five drinks for men in about a 2-hour period, increasing blood alcohol concentration (BAC) levels to 0.08 g/dL.2 Heavy alcohol use increases a patient’s risk for infectious diseases such as pneumonia or tuberculosis (TB) as the immune system becomes more compromised. The Substance Abuse and Mental Health Services Administration defines heavy alcohol use as binge drinking on 5 or more days in the past month.2 Alcohol Use Disorder (AUD), also known as alcoholism, is a pattern of alcohol use in which one has difficulty controlling his/her drinking, being preoccupied with alcohol, continuing to use alcohol even when it causes problems, having to drink more to get the same effect, or having withdrawal symptoms when blood alcohol levels decrease or if one ceases to drink.3

A. Effects of Alcohol Intoxication The following are the effects of alcohol intoxication4: Behavioral changes: aggressiveness, mood instability, impaired judgment; impaired social or occupational functioning; impaired attention and memory; stupor or coma. Physical characteristics: slurred speech, lack of coordination, unsteady gait, and nystagmus. Complications: irresponsible actions in work and family settings. Accidents with resultant bruises, fractures, or brain trauma. Vehicular accidents. Suicide.

B. Consequences of Underage Drinking5 Binge drinking. Drinking and driving. Suicide. Sexual assault. High-risk sex. Alcohol-induced mental impairment.

C. Signs of AUD AUD, also known as alcoholism or alcohol dependence, is a disease which includes four main symptoms: Craving: A strong need or compulsion to drink. Loss of control: The inability to limit one’s drinking to a safe level despite the negative impact it may be having on one’s responsibilities to work, school, or family/relationships. Physical dependence: Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiousness, when alcohol use is stopped after a period of heavy drinking. Tolerance: The need to drink greater amounts of alcohol to reach a level of desired intoxication. Other signs include amnesia and binge drinking.6

II.

Etiology

A. Genetics Although there is no single gene directly linked to alcoholism, a combination of genes related to alcoholism and mental illness can increase the risk of developing alcoholism by 20%.7

B. Biopsychosocial Alcohol-specific parenting is a distinct and influential predictor of

adolescent alcohol use partially shaped by parents’ own drinking experiences. Children of alcohol-dependent parents are two to six times more likely than the general population to develop AUDs. Additionally, children raised by alcohol-dependent parents are exposed to a higher level of multiple risk factors leading to alcohol-related problems8: Mental and behavioral disorders and adverse family environments. Decreased sensitivity to intoxication effects of alcohol.

C. Environmental Psychological stress, family, peers, and social forces. Current lifestyle, culture, advertisements, and economics. Motivational factors: both emotional (stress reduction, mood enhancement, social rewards) and cognitive (conscious and unconscious beliefs about alcohol) may play a role in an individual’s decision to drink.

METABOLISM OF ALCOHOL I. Ingestion and Absorption Upon intake, alcohol is absorbed promptly from the stomach and small intestine into the bloodstream. Transported to the liver for metabolism.9

II.

Liver Metabolism More than 90% of ingested alcohol is converted into acetaldehyde, then acetone, and finally into carbon dioxide and water by the action of various liver enzymes. High acetaldehyde levels and chronic alcohol consumption impair liver function and lead to liver damage.9

III. Diffusion Within 5 minutes after ingestion, alcohol can be detected in the blood. Alcohol is quickly diffused into all cells and intercellular fluid of the body. Less than 10% is excreted directly through the lungs, skin, and kidney (breath, sweat, and urine). A person’s alcohol level can be determined by several tests of the blood, urine, saliva, or water vapor in the breath.9

IV. Blood Alcohol Level (BAC) Alcohol-impaired driving accounted for 31% of the traffic-related fatalities in 2014 in the United States. Drivers are considered alcohol-impaired when their BACs are 0.08 g/dL or higher. BAC measurement reflects a person’s drinking rate and rate of

metabolism. Alcohol is metabolized more slowly than it is absorbed. The BAC increases when alcohol is consumed faster than previous drinks are metabolized. The rate at which the body will absorb and metabolize alcohol is based on factors such as age, gender, percentage of fatty tissue in the body, and whether food is also being metabolized.10 The characteristic effects exhibited at various levels of blood alcohol can be seen in Figure 59-2.

FIGURE 59-2 • Blood Alcohol Concentration (BAC) Levels Represent the Percent of Your Blood That Is Concentrated with Alcohol. A BAC of 0.10 means that 0.1% of your bloodstream is composed of alcohol. Legal intoxication level in most states is 0.080 BAC. (From Graphic designed by Anthony Portillo. Adapted from: Aware Awake Alive. Retrieved from https://awareawakealive.org/educate/blood-alcohol-content.)

HEALTH HAZARDS OF ALCOHOL Prolonged alcohol use causes many serious medical disorders. Alcohol consumption has been identified as a cause for more than 200 diseases, health conditions, or injuries that can affect various organs or body systems. A few are mentioned here.

I.

Brain Alcohol interferes with the brain’s communication pathways, slowing down the transfer of neuro-transmitters. These neurotransmitter disruptions can change mood and behavior, and make it harder for a person to think clearly or move with adequate coordination.11

II.

Heart

Drinking excessively for a long period will lead to damage to the heart such as11: Cardiomyopathy. Arrhythmias. Stroke. High blood pressure.

III. Liver Disease Chronic alcohol abuse is the most frequent cause of morbidity and mortality from liver diseases. Alcoholic liver disease (ALD) includes the following conditions11,12: Fatty liver with degeneration: early stages are reversible with abstinence. Alcoholic hepatitis: inflammation of the liver. Early fibrosis: healthy cells replaced by scar tissue. Cirrhosis: scarring of the liver with irreversible damage.

Individuals with hepatitis C virus (HCV) are more susceptible to ALD.

IV. Digestive System Alcohol ingestion alters the stomach mucosa, stimulates gastric acid secretion, and affects gastric function. Desquamation of the stomach lining (acute gastritis) may result in bleeding lesions. Alcohol causes the pancreas to produce toxic substances that can eventually lead to pancreatitis. Injury to small intestines: diarrhea, weight loss, and vitamin deficiencies.

V.

Nutritional Deficiencies

Alcohol provides an excess of caloric intake. With the intake of large quantities of alcohol, the individual loses interest in nutritious food, which leads to many deficiencies. Deficiencies result from malabsorption of vitamins and essential nutrients. Secondary malnutrition develops from direct effects of alcohol on the gastrointestinal tract; malabsorption and maldigestion occur after cellular changes in the intestinal wall.

VI. Cancer Risk Excessive alcohol use can increase the risk of developing certain cancers, including cancers of the11: Oral cavity. Esophagus. Pharynx. Liver. Breast.

VII. Immunity and Infection Those who abuse alcohol have a diminished immune response, suppression of immune system defense, and disturbed function of neutrophils. Risk for many bacterial infections is increased, particularly pulmonary diseases (pneumonia, TB) and viral infections (hepatitis B and C).11

VIII. Nervous System A. Central and Peripheral Early changes affect intellectual actions, judgment, and learning ability. Long-term alcohol abuse combined with malnutrition can lead to damage of both central and peripheral nervous systems. Prolonged and heavy alcohol consumption leads to chronic brain damage.

B. Wernicke–Korsakoff’s Syndrome Wernicke–Korsakoff’s syndrome is a brain disorder of the cerebellum resulting in a vitamin B1 (thiamine) deficiency associated with chronic alcohol consumption. Two syndromes are involved as follows13: Wernicke encephalopathy causes brain damage in lower parts of the brain (thalamus and hypothalamus) leading to symptoms of mental confusion, ocular dysfunction, and gait disturbances. Korsakoff’s psychosis: results in permanent brain damage resulting in persistent knowledge and memory problems characterized by forgetfulness, easy frustration, lack of muscle coordination, and amnesia.

IX. Reproductive System

Alcohol affects every branch of the endocrine system, directly and indirectly, through the body’s organization of the endocrine hormones. Female: increased risk for menstrual disturbances, infertility, and miscarriage, stillbirth, or premature delivery.14 Male: diminished testicular function and male hormone production resulting in increased risk for impotence, infertility, and reduction of secondary sex characteristics.15

FETAL ALCOHOL SPECTRUM DISORDERS (FASDS) FASDs are a group of conditions that can occur in an individual whose mother drank alcohol during pregnancy. These conditions include issues with the individual’s cognitive, physical, or behavioral abilities.16

I.

Alcohol Use during Pregnancy There is no known safe amount of alcohol use during pregnancy. There is no safe form of alcohol during pregnancy; all forms of alcohol are harmful. Complete abstinence during pregnancy is safest to prevent FASD. Prenatal alcohol exposure is cited as the leading preventable cause of birth defects and intellectual disability.17 Box 59-1 lists terminology and abbreviations for FASD.

BOX 59-1 Fetal Alcohol Spectrum Disorders (FASD) Terminology and Abbreviations • Fetal Alcohol Syndrome (FAS): FAS represents the most involved end of the FASD spectrum. Fetal death is the most extreme outcome from drinking alcohol during pregnancy. People with FAS might have abnormal facial features, growth problems, and central nervous system (CNS) problems. People with FAS can have problems with learning, memory, attention span, communication, vision, or hearing. They might have a mix of these problems. People with FAS often have a hard time in school and trouble getting along with others. • Alcohol-Related Neurodevelopmental Disorder (ARND): People with ARND might have intellectual disabilities and problems with behavior and learning. They might do poorly in school and have difficulties with math, memory, attention, judgment, and poor impulse control. • Alcohol-Related Birth Defects (ARBD): People with ARBD might have problems with the heart, kidneys, or bones or with hearing. They might have a mix of these.

Source: Centers for Disease Control and Prevention (CDC). Fetal Alcohol Spectrum Disorders (FASD). Facts About FASDs. https://www.cdc.gov/ncbddd/fasd/facts.html. Accessed April 2, 2018.

A. Why Alcohol Is Dangerous during Pregnancy Alcohol passes freely across the placenta. Increased incidence of spontaneous abortions and stillbirths associated with alcohol consumption. Alcohol consumption anytime during pregnancy can inhibit the fetus to grow properly (low birth weight), and negatively affect proper development of the brain or central nervous system. Consumption during the first 3 months of pregnancy can cause the infant to have facial dysmorphology as shown in Figure 59-3.

FIGURE 59-3 • Facial Features of Fetal Alcohol Syndrome. Child presenting with the characteristic pattern of abnormal facial features diagnostic for fetal alcohol spectrum disorders, including short palpebral fissure lengths, smooth

philtrum, and thin upper lip. (Porth, Carol Mattson. Essentials of Pathophysiology: Concepts of Altered Health States, 4e. Lippincott Williams & Wilkins.)

An infant born with FAD will have to overcome several impairments such as physical, social, psychological, and intellectual disabilities.17 Common characteristics associated with FASD are listed in Box 592.

BOX 59-2 Characteristics of an Individual with Fetal Alcohol Spectrum Disorder • • • • • • • • • • • • • • • •

Abnormal facial features, such as a smooth philtrum and thin upper lip Small head size Shorter-than-average height Low body weight Poor coordination Hyperactive behavior Difficulty with attention Poor memory Difficulty in school (especially with math) Learning disabilities Speech and language delays Intellectual disability or low IQ Poor reasoning and judgment skills Sleep and sucking problems as a baby Vision or hearing problems Problems with the heart, kidneys, or bones

Source: U.S. Drug Enforcement Administration. Drug Scheduling. https://www.dea.gov/druginfo/ds.shtml. Accessed April 2, 2018.

B. Other Factors Other poor health habits often accompany the use of alcohol, including inadequate diet and use of tobacco.

The use of prescription or illicit drugs with alcohol can increase the risk of adverse outcomes.

ALCOHOL WITHDRAWAL SYNDROME Withdrawal syndrome consists of disturbances that occur after abrupt cessation of alcohol intake in the alcohol-dependent person. Withdrawal signs appear within a few hours after drinking has stopped. Even a relatively small decline in blood concentration can precipitate the syndrome.

I.

Predisposing Factors Malnutrition, fatigue, depression, and physical illnesses aggravate withdrawal symptoms.

II.

Signs and Symptoms Tremor of hands, tongue, and eyelids. Nervousness and irritation; anxiety. Malaise, weakness, and headache. Dry mouth. Autonomic hyperactivity: sweating, rapid pulse rate, and elevated blood pressure. Transient visual, tactile, or auditory hallucinations. Insomnia. Grand mal seizures. Nausea or vomiting.

III. Complications A. Alcohol Hallucinosis Auditory and visual hallucinations can develop within 48 hours after the abrupt stop or reduction of heavy alcohol intake of longstanding dependency.

Symptoms: may last weeks or months. Impairment is severe with schizophrenic symptoms, although schizophrenia is not a predisposing factor. Delirium is not present.

B. Alcohol Withdrawal Delirium or Delirium Tremens Alcohol withdrawal delirium tremens symptoms include: A more severe reaction to a reduction in blood alcohol levels. May occur within 1 week of cessation of heavy alcohol intake. Features: marked autonomic hyperactivity: rapid heartbeat, hypertension, fever, and sweating. Vivid hallucinations (visual, auditory, tactile). Delusions and agitated behavior; tremor. Confusion and disorientation.

TREATMENT FOR AUD I. Types of Treatment There are different types of treatment for AUD. Behavioral treatments Individual therapy to help the patient develop skills to stop drinking as well as coping skills to avoid relapse. Marital and family counseling to help the patient build a strong social support system. Medications Naltrexone (ReVia®) pill form taken once a day or to reduce craving for alcohol. Naltrexone is an opiate antagonist which interferes with the neurotransmitter system. Therefore, if a patient drinks alcohol while on Naltrexone, euphoria will not result.18 Acamprosate (Campral®) is a pill taken three times a day to alleviate negative symptoms of prolonged abstinence such as insomnia, anxiety, and restlessness.19 Disulfiram (Antabuse®) is a pill taken daily that will cause nausea/vomiting, flushing, and heart palpations if taken with alcohol. Disulfiram is used as a deterrent to alcohol consumption.19 Mutual-support groups Alcoholics Anonymous and other 12-step programs provide peer support for individuals who are trying to quit drinking or have quit and are trying not to relapse.

II.

Treatment Settings There are different treatment settings: Inpatient. Outpatient. Patients with AUD should start with their primary physician for

overall health assessment and assistance in determining the appropriate treatment option and resources.20

ABUSE OF PRESCRIPTION AND STREET DRUGS With the legalization of medical and recreational marijuana in many states and the opioid crisis occurring in many regions in our nation, every dental hygienist in current practice will encounter a patient with a chemical dependence issue and should be able to provide care in a safe manner for this patient.

RISK MANAGEMENT FOR PRESCRIPTION DRUGS OF ABUSE A major problem facing health care is the diversion of prescription medications with a high potential for abuse. Substances are classified in the U.S. Drug Enforcement Administration drug schedule according to use and abuse potential as listed in Box 59-3.

BOX 59-3 U.S. Drug Enforcement Administration Drug Schedule Classifications Schedule I No accepted medical use; extremely high potential for abuse; high potential for psychological and physical dependency. Some examples of Schedule I drugs are: heroin, lysergic acid diethylamide, marijuana (cannabis), 3,4methylenedioxymethamphetamine (ecstasy), methaqualone, and peyote. Schedule II Has medical use but high potential for abuse; relative potential for psychological and physical dependency. Some examples of Schedule II drugs are: cocaine, methamphetamine, methadone, oxycodone (OxyContin), fentanyl. Schedule III Has medical use; moderate abuse potential but less than Schedule II. Some examples of Schedule III drugs are: Tylenol with codeine, ketamine, anabolic steroids, testosterone. Schedule IV Abuse potential exists, but less than Schedule III. Some examples of Schedule IV drugs are: Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Talwin, Ambien, Tramadol. Schedule V Abuse potential exists, but less than Schedule IV. Some examples of Schedule V drugs are: cough preparations with less than 200 milligrams of codeine or per 100 milliliters (Robitussin AC), Lomotil, Motofen, Lyrica, Parepectolin.

Source: U.S. Drug Enforcement Administration. Drug Scheduling. https://www.dea.gov/druginfo/ds.shtml. Accessed April 2, 2018.

I.

Prevention of Opioid Addiction in the Dental Office All members of the dental team should take responsibility to prevent opioid addiction.21 Dentists should register with and utilize prescription drug monitoring programs to promote the appropriate use of controlled substances. Prescription pads are not recommended for use to avoid alterations and abuse. Dentists should consider nonsteroidal anti-inflammatory analgesics as the first-line therapy for acute pain management. Patients should be educated regarding their responsibilities for preventing misuse, abuse, storage, and disposal of prescription opioids. All members of the dental team should seek continuing education in addictive disease and pain management.

MOST COMMON DRUGS OF ABUSE The most common drugs of abuse are alcohol and those found in the categories in this section. Examples of the substance names in each category and the commercial and street names are listed in Table 591. TABLE 59-1 • Most Commonly Abused Prescription Drugs

Source: National Institute on Drug Abuse. Commonly Abused Drugs. https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/commonly_abused_drugs.pdf Accessed April 2, 2018.

I.

Cannabinoids (Marijuana) Despite cannabis use being illegal at the federal government level, as of January 2018, 30 states and the District of Columbia have legalized marijuana for either medical or recreational use.22 The three basic types of cannabis, used for recreational or medicinal purposes, are called marijuana/weed, hash, or hash oil.23 All three types contain more than 85 cannabinoids found within the plant, with tetrahydrocannabinol (THC) and cannabidiol (CBD) being the two best known cannabinoids.24 THC is the primary psychoactive compound of the plant which can make a person feel paranoid or anxious. CBD is nonpsychoactive, so patients do not feel “high” using cannabis with this strain, rather

gain the medicinal and therapeutic benefits cannabis can offer for medical relief.24

A. Medical Marijuana Use Patients use medical marijuana as an alternative to manage pain, anxiety, depression, migraine headaches, and sleep problems.25 Synthetic oral (THC) medications such as nabilone (Cesamet®) and dronabinol (Marinol®) can be prescribed to reduce nausea and vomiting symptoms related to chemotherapy treatment or AIDSrelated conditions.26,27 Nabiximol oromucosal sprays (Sativex®) containing THC can help reduce pain and muscle spasticity in patients suffering from multiple sclerosis, spinal cord injuries, fibromyalgia, or rheumatoid arthritis.27 Children and adolescents with drug-resistant epilepsy have experienced a decrease in seizure occurrences with CBD added into their therapy.28

B. Different Forms of Marijuana Inhaled29,30 Cigarette forms called joints. Cigars hollowed out and filled with cannabis called blunts. Can use a hookah pipe or bong which filters the smoke through water. Vaping—a fine mist is inhaled instead of smoking the cannabis to reduce a person’s exposure to carcinogens. Dabbing uses hash oil (most potent type) in a wax form. Oral Edibles are when marijuana is added to foods or beverages. Edibles take longer for the person to feel the effect (up to 2 hours) because it must be digested and metabolized. Edibles can present a dosing challenge for some users, and the intensity of edibles is much greater causing full-body,

psychoactive effects with much longer lasting duration times of several hours. Many edible users prefer consumption before bedtime to aid with sleeping and wake up not feeling high but pain free.31 Pill or capsule forms of marijuana (discussed in “Medical Marijuana Use” section). Oral tinctures (liquid cannabis) or oromucosal sprays (also discussed in the “Medical Marijuana Use” section) are applied sublingually for a rapid response (5–30 minutes).30,31 Topical There are forms of cannabis delivery that can provide medicinal benefits without cerebral stimulation. Examples are topical creams or oils for localized pain relief or reduction of inflammation to an area.32 Alternative For more general body distribution with nonpsychoactive effects, there are cannabis suppositories that can be inserted vaginally like a tampon. This provides an alternative for those who cannot tolerate the edibles or for patients who do not want to be exposed to the carcinogens of smoking, vaping, or dabbing. Rectal cannabis suppositories take only 10–15 minutes to take effect, directing the cannabinoids into the bloodstream, bypassing metabolism in the liver, and allowing the therapeutic effects to last 4–8 hours without impairing the user’s cognition.32 Individuals who utilize the inhalation forms of marijuana, similar to tobacco use, are associated with increased risk of cancer, lung damage, and oral health disease, such as oral cancers, periodontitis, and dental caries.33,34

II.

Depressants A drug that suppresses the central nervous system to calm or sedate the patient. Depressants are taken to relieve anxiety, promote sleep, and

manage seizure activity. Examples are downers, sleeping pills, ludes, rophies, alcohol.

III. Dissociative Anesthetics A form of general anesthesia that promotes dissociation from the environment but not necessarily complete unconsciousness. Sometimes used for short diagnostic or surgical procedures. Drugs such as synthetic cannabinoids, synthetic cathinones, ketamine, piperazines, and some plant-based drugs such as khat and kratom are examples of new psychoactive substances (NPS). In the past few decades, ketamine has gained popularity as a club drug due to its euphoric qualities. Street names: angel dust, Special K.

IV. Hallucinogens Chemical substances that produce mind-altering or mental perception-altering properties. These drugs act on the central nervous system leading to the user seeing and hearing phenomena that do not exist. A disorder associated with the use of these substances can produce hallucinogen persisting perception disorder, commonly known as “flashbacks.” 3,4-methylenedioxymethamphetamine (MDMA) or Ecstasy or Molly, a popular drug among teens and young adults, widely used at nightclubs and bars (also used as a club drug). Molly, which is slang for molecular, refers to the pure crystalline powder form of ecstasy. MDMA is classified as a stimulant, but is known for its hallucinogenic effects. Examples are lysergic acid diethylamide (LSD), peyote, dimethyltryptamine, and magic mushrooms.

V.

Opioids and Morphine Derivatives

Narcotic substances made from the Asian poppy or produced as synthetic drugs with the effects of opium: they result in analgesic and euphoric effects. Opioids are one of the most commonly prescribed as analgesics, anesthetics, antidiarrheal agents, and cough suppressants. Heroin is one of the most commonly abused drugs of this class: it can be injected, smoked, or snorted. Heroin use changes the functioning of the brain, increasing dependence of the drug. Other opioid drugs include morphine, OxyContin® (oxycodone), Vicodin® (hydrocodone), Percodan® (oxycodone), and Percocet® (oxycodone). Although these opioids are prescribed legally for medical use to treat pain, the medications can lead to addiction resulting in similar harmful consequences as illegal heroin use. Vicodin® (hydrocodone) is a schedule III drug and its potency is between codeine and oxycodone. It is an analgesic and pain reliever, and has a high risk for addiction and dependence. OxyContin® (oxycodone) is a schedule II drug, a narcotic pain reliever to treat moderate to severe pain. Has high risk for addiction and dependence with use. Percodan® (oxycodone/aspirin) is a schedule II drug and a nonsteroidal anti-inflammatory drug, narcotic, and analgesic used to treat moderate to severe pain. High risk for addiction and dependence exists with use. Percocet® (oxycodone/acetaminophen) is a schedule II drug and a pain reliever to treat moderate to moderately severe pain. High risk for addiction and dependence exists with use. Fentanyl is an opioid that is 80 times more potent than morphine and 50 times more potent than heroin. Intravenous Fentanyl can be used as an anesthetic and analgesic for surgical procedures. Duragesic® is a Fentanyl transdermal patch used to manage chronic pain by slowly releasing fentanyl through the skin into the bloodstream over 48–72 hours. Actiq® dissolves quickly and is absorbed through the sublingual mucosa to provide rapid analgesia. This is especially beneficial

for patients undergoing cancer treatment to treat pain that has a rapid onset with intensity.35 Street-produced Fentanyl, which is produced in China and trafficked through Mexico, has generated the opioid and heroin crisis in many American cities which has led to fatalities.35 Fentanyl users do not fit the typical illicit drug user characteristic, since many became addicted from a surgical procedure or to treat chronic pain conditions, and became addicted to opioids as a result.35 Naloxone (Narcan®) is a nasal spray that blocks the effects of opioids in overdose situations. Many first responders carry Narcan®, especially in cities where opioid overdosing is prevalent. Individuals or families with a family member battling an opioid addiction are encouraged to carry Narcan® to counter an opioid overdose situation and many dental offices and clinics include it in the emergency kit.

VI. Stimulants A class of drugs that enhances brain activity. Stimulants cause an increase in mental alertness, attention, and energy; they improve motor skills and elicit a general sense of well-being. They increase cardiac and respiratory function and speed up metabolism. Stimulants include drugs such as cocaine, crack cocaine, amphetamine, and methamphetamine. Cocaine hydrochloride powder can be “snorted” through the nostrils, or, when mixed with water, can be injected intravenously. Crack cocaine is a cocaine alkaloid in the form of a small rock. Crack is cocaine that has been processed from cocaine hydrochloride to a free base for smoking. It is easily vaporized and inhaled and exhibits an extremely rapid onset of effects. Amphetamines are prescription medication used to treat attention-

deficit hyperactivity disorder and narcolepsy. They increase alertness, focus, and energy. Common prescription stimulants are dextroamphetamine (Dexedrine®), dextroamphetamine/amphetamine (Adderall®), methylphenidate (Ritalin®, Concerta®). Slang terms for prescription stimulants include Speed, Uppers, and Vitamin R. Methamphetamine (meth, speed) is taken orally, intranasally (snorting the powder), by intravenous injection, or by smoking. Meth users are resistant to local anesthesia.26 Ice, a very pure form of methamphetamine (seen as crystals under high magnification), produces an immediate and powerful stimulant when smoked.

VII. Other Compounds A. Anabolic Steroids Used to build muscles and for increased performance. May produce a feeling of well-being or euphoria, followed by lack of energy and irritability. Short-term effects may lead to mental problems such as paranoia, extreme irritability, delusions, impaired judgment, and violent outbursts. Long-term effects include depression, kidney decline or failure, liver damage, enlarged heart, hypertension, and elevated blood cholesterol levels which increase the risk of stroke and heart attack, even if the user is of a young age. Gender-specific effects in males can cause shrinking testicles, decreased sperm count, baldness, development of breasts, and increased risk for prostate cancer. In females, steroids can cause growth of facial hair or excess body hair, male-pattern baldness, changes in or stop in the menstrual cycle, enlarged clitoris, and a deepened voice. Age-specific effects in teenagers can result in stunted growth if

steroids are used before the teen’s growth spurt.

B. Inhalants A breathable chemical vapor that produces psychoactive effects. Capable of producing intoxication, abuse, and dependence. Inhalants can come in different forms: solvents, aerosol sprays, gases, or nitrites. Available in a wide variety of commercial products: paint thinners, gasoline, glue, spray paint, computer cleaning dusters, liquid aroma, leather cleaner, or balloons filled with nitrous oxide are just a few common household examples. Nitrous oxide used in medical and dental settings also presents a risk for abuse. A substance-soaked cloth (called huffing) or substance placed in a paper or plastic bag (called bagging) is applied to the nose and mouth and vapors are inhaled. Intoxication is characterized by mild euphoria and a change in the perception of time. Causes relaxation of the smooth muscle and a decrease in oxygencarrying capacity of the blood. Toxic reactions: vomiting, headache, hypotension, and dizziness.

VIII. Emerging Drugs A. Synthetic Cathinones (Bath Salts) Bath salts contain two man-made stimulants mephedrone and methylone which effect the brain much like MDMA (Ecstasy). Bath salts are usually in the form of white or brown crystal-like powder which can be swallowed, snorted, smoked, or injected. Synthetic cathinones are part of a group of drugs called “NPS.” Synthetic cathinone affects the brain similar to cocaine, but is 10 times more powerful. Bath salts can produce such effects as paranoia, hallucinations,

increased sex drive, panic attacks, or excited delirium. Bath salts are marketed as an inexpensive alternative to methamphetamine or cocaine. Synthetic cathinones consumers can purchase products online and in drug paraphernalia stores under a variety of brand names, which include Bliss, Cloud Nine, Lunar Wave, Vanilla Sky, or White Lightning.

B. Desomorphine (Krokodil) Desomorphine is a synthetic opioid first synthesized in the U.S. in 1932 and used for surgical procedures because it was 8–10 times more potent than morphine with a fast onset. It was later discontinued as other medications were found to be more effective and longer lasting. A street form of desomorphine reemerged in the early 2000s in Russia called krokodil, with the name being related to its chemical name α-chlorocodide, and for the damage that occurs to the skin with intravenous use, resembling crocodile leather.36,37 Homemade production of krokodil is inexpensive compared to heroin use, but very toxic. The user will mix 5–10 codeine tablets with paint thinner, gasoline or lighter fluid, hydrochloric acid, iodine, and red phosphorus. The drug is injected and since no filtration process has occurred, skin, blood vessels, muscles, and bones in the injected area are immediately damaged and eventually necrosis of the area occurs. These conditions usually lead to amputation or death. Since desomorphine has a short half-life, krokodil users have to inject often to obtain their high, decreasing their life span to 1–2 years from their initial injection without intervention.38,39 The first reported case in the U.S. was seen in the emergency department of John Hopkins School of Medicine in Baltimore, MD. The patient was a 23-year-old female who complained of pain and nonhealing ulcers in her forearms where she had injected krokodil 12 months previously. The patient grew more concerned as the area of injection initially had purulent drainage,

but had become malodorous as the area became necrotic.40 Due to the use of red phosphorus in the street form, cases of jaw osteonecrosis in both maxillary and mandibular jaws have been reported in users of krokodil. The necrotic areas leave exposed alveolar bone with empty dental sockets. Surgical removal of the necrotized areas in krokodil users who have gone through withdrawal has had some cases with low rates of reoccurrence.41,42

MEDICAL EFFECTS OF DRUG ABUSE I. Cardiovascular Effects Studies show illicit drug abuse has an adverse effect on the cardiovascular system. Intravenous drug use can lead to collapsed veins and bacterial infections of the arterial system and heart valves.43 Cocaine in particular causes vasoconstriction in the coronary arteries increasing blood pressure, atherosclerotic phenomena, thrombus formation, and myocardial infarction.44

II.

Neurologic Effects All addictive drugs target the reward centers in the brain allowing the user to experience euphoria. Repeated drug abuse will alter the structure of the brain making it more difficult for the user to reach euphoric levels, requiring increased levels of the drug which increases the dependency.45 These alterations in the brain can lead to: Memory lapses. Decision-making or attention problems. Lack of impulse control. Increase in mental health issues which include depression, suicidal thoughts and behaviors, anxiety, paranoia, aggression, or hallucinations.45 Users of addictive drugs are twice as likely to suffer from mood and anxiety disorders than the general population.46 Chronic abuse of volatile solvents, such as toluene, damages the protective sheath around certain nerve fibers in the brain and peripheral nervous system. This extensive destruction of nerve fibers is clinically similar to that seen with neurologic diseases such as multiple sclerosis.47

III. Gastrointestinal Effects Cocaine in particular has been associated with gastrointestinal complications and abdominal pain.48 Cocaine reduces blood flow to the intestines which can lead to ulcerations and even severe bowel gangrene.44 Many drugs of abuse have been known to cause nausea and vomiting leading to appetite loss, malnourishment, and significant weight loss.48

IV. Kidney Damage Chronic drug use causes toxicity to several organs including the kidney. Drugs affect renal function either through the toxic effects of the drug or by a reduction in kidney function. Pain medications, alcohol, antibiotics, and illegal drugs can all cause kidney damage if not used properly. In addition, substance abusers tend not to keep hydrated with water which negatively impacts the proper function of the kidneys. Chronic use of drugs that increase blood pressure will lead to renal failure. Shared needles or nonsterile injecting techniques increase the user’s risk for contracting infections such as viral hepatitis.49

V.

Liver Damage

The liver detoxifies drugs, chemicals, and alcohol that are ingested. Changes in liver function due to drug abuse decrease the metabolism of drugs: when not able to break down properly, the drug can remain at a toxic level. Chronic abuse of heroin, inhalants, and steroids may cause significant liver damage.50 The consumption of alcohol and cocaine together compound the danger each drug poses.

The liver combines cocaine and alcohol to form a toxic metabolite called cocaethylene.51 Cocaethylene intensifies cocaine’s euphoric effects, potentially increases the risk of sudden death.

VI. Musculoskeletal Effects Steroid use during childhood or adolescence increases sex hormone levels, which signal the bones to stop growing. This will result in the steroid user having stunted growth, unable to reach their full height potential.52 Other drugs such as MDMA (Molly) or methamphetamine may cause severe muscle cramping and overall weakness.52

VII. Respiratory Effects Drug abuse can lead to a variety of respiratory problems: Inhaling cannabis can lead to the same respiratory effects as smoking cigarettes or cigars; increased risk for bronchitis, emphysema, and/or cancer. Smoking crack cocaine can cause lung damage and severe respiratory conditions. Opioid use may cause breathing to slow and block air from entering the lungs. If the user suffers from asthma, opioids will increase breathing complications. Inhalants are comprised of toxic chemicals that damage sensitive lung tissue when inhaled.53

VIII. Prenatal Effects Prenatal drug abuse has been associated with: Miscarriage. Premature birth. Low birth weight. Increase of behavioral and cognitive problems in the child.54

Drug use such as heroin during pregnancy can cause a condition in the infant called neonatal abstinence syndrome (NAS) in which the infant is born dependent on opioids. An infant born with NAS requires hospitalization to treat symptoms such as seizures, fever, and weight loss or dehydration. The infant is typically treated with opioid replacement, either oral morphine solution or methadone. Emerging studies show sublingual buprenorphine was found to be superior to morphine or methadone. Infants treated with buprenorphine had a significantly shorter course of treatment and decreased hospital stay.55 Inhalant abuse by expectant women can result in fetal solvent syndrome with abnormalities similar to those occurring in FASD.56

IX. Infections Infections have been recognized as one of the most serious complications among drug users. There are many reasons why drug users are at greater risk for infections such as the following: Unsterile injection techniques and/or contaminated drug paraphernalia. Adulterants (or cutting agents) may be deliberately added to street drugs to enhance their effects, resulting in lower purity of the drug. This will also increase cutaneous abscesses in the drug users. Unsafe sex practices and/or multiple sex partners. Living conditions such as overcrowded housing or homeless shelters or in unsanitary environments such as living on the streets. Malnourishment in conjunction with the toll of the drugs on the body leads to a weakened immune system. Poor hygiene. The type of infections drug users are at risk for are multiple. The

following are a few examples57,58: Pulmonary TB and respiratory tract infections including community-acquired pneumonia. Endovascular—infective endocarditis. Skin and soft tissue—abscesses and cellulitis located at injection sites. Bone and joint—septic arthritis and osteomyelitis (an extension of soft tissue infection). Sexually transmitted infections—gonorrhea, chancroid, herpes simplex virus-2, bacterial vaginosis, trichomoniasis, candidiasis, human immunodeficiency virus, hepatitis B virus, and HCV.57,58

TREATMENT METHODS Chronic drug addiction causes changes in the brain involved in reward and motivation, learning and memory, and control over behavior. Drug addiction can be treated but it is complex. Successful treatment should include the following steps59: Detoxification. Behavioral therapies. Medication (for opioid, tobacco, or alcohol addiction). Evaluation and treatment for co-occurring mental health issues such as depression and anxiety. Long-term follow-up to prevent relapse. The principles that characterize the most effective drug abuse treatment can be found in Box 59-4.

BOX 59-4 Principles of Drug Addiction Treatment 1. Addiction is a complex but treatable disease that affects brain function and behavior. 2. No single treatment is appropriate for everyone. 3. Treatment needs to be readily available. 4. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5. Remaining in treatment for an adequate period of time is critical. 6. Behavioral therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. 7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. 8. An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. 9. Many drug-addicted individuals also have other mental disorders. 10. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11. Treatment does not need to be voluntary to be effective. 12. Drug use during treatment must be monitored continuously, as lapses during

treatment do occur. 13. Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary. Source: National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide. 3rd ed. Principles of Effective Treatment. https://www.drugabuse.gov/publications/principles-drug-addiction-treatmentresearch-based-guide-third-edition/principles-effective-treatment. Accessed April 2, 2018.

I.

Behavioral Therapies Behavioral therapies help patients modify their attitudes and behaviors toward drug use and encourage healthier life choices. Behavioral therapy sessions can be provided in an outpatient or inpatient setting. Inpatient settings are more structured and supervised. The following are examples of behavioral therapies59: Cognitive-behavioral therapy helps patients recognize, avoid, and cope with the situations in which they are most likely to use drugs. Multidimensional family therapy—designed to help improve family functioning if patient still lives at home and include the family in the recovery plan. Motivational incentives (contingency management), which uses positive reinforcement to encourage abstinence from drugs.

II.

Drug Withdrawal Medications

Medications and devices can help suppress withdrawal symptoms during the detoxification process. In November 2017, the Food and Drug Administration approved an electronic stimulation device called the NSS-2 Bridge. This device is placed behind the ear and sends electrical pulses to stimulate certain brain nerves to help with opioid withdrawal symptoms.59 Medications such as methadone can be used to manage

withdrawal symptoms, prevent relapse, and treat co-occurring conditions.

A. Methadone (Dolophine®, Methadose®) A full opioid agonist meaning it is an opioid that can reduce withdrawal symptoms and cravings by activating opioid receptors in the brain without producing the euphoric high. Misuse of this narcotic medication can increase addiction or result in overdose or death. It is used in long-term maintenance for patients recovering from heroin or opioid addiction. Methadone can be administered 2.5–10 mg intravenously, intramuscularly, or subcutaneously every 8–12 hours. Can also be administered orally initially, 20–30 mg for the initial dose, additional 5–10 mg given every 2–4 hours. The goal is to get the patient to a 40 mg/day maintenance level.59–61

B. Buprenorphine (Subutex®) Buprenorphine/Naloxone (Suboxone®) A partial opioid agonist meaning it is an opioid that can activate and block opioid receptors in the brain to reduce or eliminate withdrawal symptoms without producing the euphoric high. Buprenorphine is a schedule III drug versus methadone which is a schedule II drug; therefore, the potential for abuse is lower. It is available for sublingual administration both in a stand-alone formulation (Subutex®) or in combination with naloxone (marketed as Suboxone®). Buprenorphine is administered in 2 or 8 mg tablets taken once or twice a day sublingually.59–62

C. Naltrexone (Vivitrol®/ReVia®) This medication is not an opioid, it is an opioid antagonist, blocking

the brain’s opioid receptors preventing the user from reaching the euphoric phase, and making the potential for misuse less. Vivitrol® is injected once a month or ReVia® can be taken orally one 50 mg tablet a day. Naltrexone/ReVia® is also prescribed for patients recovering from alcoholism. It does require full detoxification to use (usually 3–10 days of no opioid use).59,61

D. Other Medications Additional medications may be prescribed during the detoxification phase including: Benzodiazepines—to reduce anxiety and irritability. Antidepressants—like Prozac or Zoloft to counter depression. Clonidine—reduces sweating, cramps, muscle aches, and anxiety. It can also stop tremors and seizures.

DENTAL HYGIENE PROCESS OF CARE Every patient appreciates an atmosphere with open communication, but this is especially important in caring for patients who are chemically dependent. The clinician should assure the patient that any information shared will be kept confidential in accordance to Health Insurance Portability and Accountability Act laws, but in order to treat the patient safely, the clinician has to know what substances are in the patient’s system. It is imperative that a thorough assessment be completed and documented. If the patient is cognitively impaired by a substance, legally the patient cannot consent to care and cannot be treated.

I.

Assessment

A. Patient History The medical health history questionnaire should inquire about substances used, how patient administers the substance (i.e., intravenously, smoked), quantity, and time of the last dosage. Identify all current medications (both prescription and substances of abuse) in order to investigate drug–drug interactions with any medications that may be used in the oral health setting such as local anesthesia (see Chapter 11). A medical consult with the patient’s physician and/or addiction specialist should be conducted prior to any dental care to determine the patient’s readiness for treatment and to determine if there are any conditions requiring antibiotic prophylaxis. Conduct the medical health history examination utilizing a motivational interviewing approach to establish a nonjudgmental environment and encourage the patient to communicate openly and freely with the clinician (see Chapter 24).

B. Screening: National Institute on Drug Abuse

(NIDA) Quick Screen NIDA has developed a screening tool for health professionals to assess if a patient is abusing alcohol, tobacco, prescription medications for nonmedical purposes, or illegal substances. The NIDA Quick Screen tool incorporates the Five A’s (Ask, Advise, Assess, Assist, Arrange) Steps to Intervention. The NIDA website provides an online interactive form to complete on a mobile device or chairside. A paper version is also available for the patient to complete, along with Clinicians Resource and Reference Guides. The NIDA website can be found at https://www.drugabuse.gov/ and the screening tools can be found by going to the Medical and Health Professionals link and finding the Drug Screening and Assessment Resources which contains a chart with links to a variety of screening. One tool easily used online for assessment is the NIDA-Modified ASSIST, https://www.drugabuse.gov/nmassist/.

C. Vital Signs Record information in patient record. Blood pressure frequently is increased when alcohol and other drugs like stimulants are used; fluctuations can be particularly significant. Increase in heart rate with cannabis use.

D. Clinical Examination Information in the patient history may not reveal the extent of a patient’s drug use. Clinical observations along with the medical history may provide a high degree of suspicion. Observations to note during the interview could include: Inability to focus or recall simple concepts like phone number or

address. May exhibit rapid mood swings or display paranoia or disorientation. May start to complain about dental pain requesting a prescription for specific pain medications. Depression, suicidal/homicidal thoughts, or agitation could indicate a drug overdose and requires immediate emergency care.

E. Extraoral Examination Alcohol signs Breath and body odor of alcohol and of tobacco: Many alcohol users are also heavy tobacco users. Tremor of hands, tongue, eyelids: Signs of withdrawal. Skin: Redness of forehead, cheeks, dilated blood vessels that produce spider petechiae on the nose; may worsen preexisting acne rosacea. Face color: Light yellowish brown may indicate jaundice from liver disease. Eyes: Red, baggy eyes or puffy facial features; bloated appearance. Evidences of trauma: Facial injuries related to falls when intoxicated. Alcohol abusers are especially prone to traumatic accidents. Lips: Angular cheilitis related to poor nutrition. Parotid glands: Swelling. Personal appearance Does the patient look much older than their age stated on their health history form? Lack of interest in proper dress and personal hygiene. Wears long sleeves to cover needle marks. Dramatic weight loss and/or emaciated appearance. Head and neck Patients smoking or vaping substances are at greater risk for cancers in the head and neck region.

Eyes Wears sunglasses to conceal dilated or constricted pupils and eye redness, or to avoid bright light because of eye sensitivity. Pupils dilated (amphetamine, LSD, cocaine, marijuana). Pupils constricted (heroin, morphine, methadone), as shown in Figure 59-4.

FIGURE 59-4 • Examination of the Pupils. Pupil on left: Pinpoint or constricted; occurs in the use of morphine, opioids, and heroin. Pupil on the right: Dilated; occurs in shock, heart failure, other emergencies, and in the use of hallucinogens, cocaine, marijuana, methamphetamines, and amphetamines. (From Graphic designed by Anthony Portillo. Adapted from: National RX Drug Abuse Summit: Orlando, FL. 2012. Retrieved from http://nationalrxdrugabusesummit.org/2012-summit/.)

Red, inflamed, bloodshot (only if cannabis contains THC). Nose Inhaled or snorted substances can damage nasal structures causing frequent nosebleeds or patients may constantly be

sniffing or wiping their noses. Nasal septum perforation (cocaine snorting). Arms Needle marks may be noted when assessing blood pressure. Heroin use can cause subcutaneous abscesses called “popping” that leaves scarring. Behavior Sneezing, itching. Tendency to gaze into space; moodiness. Drowsiness, yawning; may sleep long hours. Appearance of intoxication or lethargic with or without the odor of alcohol. Slurred speech. Changes in habits, such as irregular attendance at appointments by one who was previously prompt. Possession of pills or capsules. Hallucinations or convulsions indicate need for immediate emergency care.

II.

Intraoral Examination Mucosa, lips, tongue Dry; drug-induced xerostomia, soft tissue abnormalities. Tongue coated; glossitis related to nutritional deficiencies. Burns and sores on lips from smoking crack or meth. Taste impairment. Gingiva Generalized poor oral hygiene; heavy biofilm is typical. Calculus deposits may be generalized, depending on patient neglect. Moderate to severe gingival inflammation. Gingival enlargement. Gingiva that bleeds spontaneously or on probing. Gingival lesions resulting from the direct application of cocaine. Higher incidence of periodontal disease, particularly destructive

periodontitis.63 Necrotizing gingivitis. Palate Perforation of palate due to chronic cocaine snorting (Figure 595).

FIGURE 59-5 • Nasopalatal Defect. Problems due to chronic cocaine snorting began to manifest themselves as nosebleeds followed by recurring sinus infections. Within 4 months, the patient discovered a pinhole in his palate. Each time he tried to swallow liquid it came out of his nose. (Photo courtesy of Peter Villa, DDS, FRDC.)

Teeth Chipped and fractured from falls and injuries; stained from tobacco use. Attrition secondary to bruxism especially among cocaine and meth users with increased tooth sensitivity. Erosion secondary to frequent vomiting, exposure to substances with low pH levels (oral application of cocaine, meth). Removable or fixed partial dentures: chipped or broken, may require frequent repairs. Dental caries

Increased risk factors: poor diet, lack of dental care, accumulation of biofilm, and xerostomia.63 Diet high in cariogenic substances. Generalized tooth decay especially on smooth and cervical surfaces and fewer restorations suggesting not accessing dental care on a regular basis.63 Open rampant carious lesions: abuse of methamphetamine, diet of sweets, alcohol, and sugar-sweetened beverages with decreased salivary secretion as shown in Figure 59-6.

FIGURE 59-6 • Rampant Dental Caries Due to Methamphetamine Use in a 24-Year-Old Patient Who Presented for Treatment After Serving Time In Prison and Going to Rehab; Patient Started Using Meth at Age 16, Initially Snorting the Powder and Progressed to Smoking the Drug. Although some teeth could have been saved, the patient chose to have all the remaining teeth extracted in order to receive full dentures. (Photo courtesy of Kessler BH, Dinnen M. Methamphetamine: oral effects and treatment. Inside Dent. 2010;6(2):44-46.)

Tooth loss. Oral pathologies

Oral candidiasis can be present with substance abuse due to immunosuppression. Due to immunosuppression and inadequate nutrition, tissue healing is poor. Leukoplakia and hyperkeratosis (referred as cannabis stomatitis) that can develop into malignant neoplasias. Erythroplakia. Oral papilloma. Mucosal infections. Complaints of “burning mouth.” Xerostomia.64 Temporomandibular joint (TMJ) TMJ tenderness due to grinding, clenching, or bruxism (hallucinogen users). Difficulty with opening and chewing. Indirect effects of drugs on oral health63 Substance abuse patients may delay dental and dental hygiene care due to dental anxiety and/or stigma of drug use. Any available money is used in the purchase of drugs; low priority on oral health. Dental care is on an emergency basis to alleviate any pain or discomfort, and to obtain prescriptions for drugs. Specific oral manifestations are associated with particular drugs. Examples can be found in Box 59-5.

BOX 59-5 Oral Manifestations of Abused Drugs A. “Meth mouth”: key ingredients used in meth manufacturing are corrosive64–66 • Meth smoker swirls heated, vaporized substances in the mouth. • Oral mucosa is irritated and burned, creating sores and leading to infection. • Rampant caries “meth mouth” resembles early childhood caries seen in young children; black, decayed teeth often fractured to the gumline. • Distinctive pattern of decay is on the buccal and cervical smooth tooth surfaces and proximal surfaces of the anterior teeth. • Snorting meth also causes chemical damage to teeth.

• Symptoms: xerostomia, dryness of the mouth from a lack of normal secretions. • Rampant dental caries on proximal surfaces and at the gingival margin. • Cracked teeth, excessive wear, tooth sensitivity, and difficulty in mastication from grinding and/or clenching. • Enamel erosion: corrosive acids in ingredients. • Periodontal infection: reduced blood supply and tissue breakdown. B. Cocaine abuse64 • Cocaine snorting is associated with perforation of the nasal septum and/or perforation of the palate (Figure 59-5). • Saddlenose deformity. • Erosive carious lesions from low pH level of cocaine powder. • Oral administration may result in gingival lesions, recession, and mucosal ulcerations. • Trismus. • Dental attrition due to bruxism. • Crack-cocaine smoking produces burns and sores on labial mucosa; open lesions expose user to infections. C. Lysergic acid diethylamide and “ecstasy,” hallucinogen drugs64,67 • Xerostomia. • Tooth wear associated with chewing and grinding. • Temporomandibular joint tenderness (ecstasy users). • Bruxism leading to trismus. • Rampant dental caries. • Topical use of ecstasy may result in tissue necrosis and mucosal fenestration. D. Cannabis users34,64,68-70 • Increased xerostomia. • Increased smooth-surface caries; higher decayed-missing-filled scores. • Increased periodontal infections. • Leukoedema. • Premalignant lesions of the oral mucosa. • Leukoplakia. • Increased oral infections due to immunosuppressive effects. • Inhaled cannabis users at higher risk for oropharyngeal cancers.

III. Dental Hygiene Diagnosis The patient who is actively dependent on a substance will probably not seek dental care except for emergency needs.

The dental hygienist cannot provide care until the patient is in recovery. The patient’s oral needs could be extensive. The dental hygienist should assess for the following diseases/conditions63: Head/neck swelling (lymph nodes). TMJ or occlusion issues. Oral cancer/pathologies. Xerostomia. Dental caries. Periodontal infections. Nutritional deficiencies.

IV. Care Planning Develop strategies to meet the individual needs of the patient as identified from the risk assessment and dental hygiene diagnosis. Recovering addicts may have some anxiety about taking medications in their attempt to achieve total body health. This could pose a problem if pain control is needed for extensive dental hygiene care. Therefore, pain control for procedures provided in the office and postoperative pain at home should be coordinated with the patient’s primary physician and/or addiction specialist. The following are care planning considerations: Oral self-care instruction beginning with daily toothbrushing. Once the patient can brush effectively, an appropriate interdental technique can be introduced. As the patient moves through their recovery, they may become more motivated and open to additional biofilm removal techniques. Use of fluoride toothpaste and fluoride mouthrinse without alcohol. Prescription fluorides may be necessary depending on patient caries risk. Office fluoride applications such as fluoride varnish and custom trays for home use if the patient will be compliant. A nightguard may be recommended if bruxism is present. Increase of water consumption, xylitol gum, or mints to address

xerostomia. Nutrition counseling may be necessary to address poor nutrition and/or caries risk. A 24-hour diet recall along with MyPlate can be used by the hygienist and the patient to identify goals to improve diet. Proper nutrition will be critical for adequate healing and to decrease the risk for dental caries. Short appointments may be needed if patient has anxiety. The patient should understand the importance of informing the clinician of any substances in their system that could potentially have a negative interaction with local anesthesia or other therapeutics the clinician may provide to the patient. Anesthesia and pain control may be more difficult to achieve because many substance abusers build up tolerance to various pain reducing effects. A consultation with the patient’s primary physician should provide the best method to plan for pain control.

V.

Implementation

The clinical procedures for dental hygiene care are greatly influenced by the many health problems resulting from drug use. If short appointments are required, the dental hygienist may only be able to complete limited care at each appointment. The dental hygienist should implement good stress reduction protocols for patients who are experiencing anxiety.

A. Preparation for Treatment Caution is needed for potential drug–drug interactions. Avoid pre-procedural rinse, antibacterial agents, and oral hygiene products containing alcohol for all patients with a past history or current alcohol use problem. The smallest amount of alcohol ingested by a patient being treated with disulfiram can cause an emergency. Additionally, any patient suffering from xerostomia should avoid

any product containing alcohol.

B. Periodontal Debridement Careful periodontal debridement to reduce the bacterial load and support healing is essential. Use of anesthesia: drug interactions, use of epinephrine, should have been approved during the consultation with the patient’s physician prior to treatment. Contraindications for the use of nitrous oxide/oxygen and medical considerations for local anesthesia with or without epinephrine are provided in Chapter 36.

C. Response to Therapy The usual oral tissue response expected following periodontal instrumentation may be limited by the following: Prolonged bleeding time; impaired clotting mechanism from chronic liver disease. Inability to obtain profound anesthesia. Impaired healing. Interference with collagen formation and deposition. Decreased immune system function. Increased susceptibility to postoperative care infection.

VI. Evaluation The evaluation of dental hygiene care occurs 6–8 weeks after initial debridement. Evaluate treatment plans and goals with the patient. Make changes according to the patient’s progress. Evaluate to determine the frequency of continuing care appointment; typically set at 3 months but should depend on many factors such as tissue response, patient’s level of motivation.

DOCUMENTATION Patient record medical alert box for possible substance abuse alerts dental personnel to: Use a nonalcoholic mouthrinse. Results of drug and alcohol screening. Any alerts or contraindications for treatment, that is, epinephrine in local anesthetic. Inappropriate behavior during appointments, such as aggressive or belligerent behavior. Document early oral signs/symptoms of substance abuse such as: Oral examination: ulcerations, infections, and xerostomia. Dental examination: dental caries in unusual sites or more extensive than previously documented. Periodontal examination: rapid changes in periodontal status. Patient education: relapse of previously good oral hygiene. Psychological reactions and/or aggressive behavior. Example documentation for a patient with substance abuse is found in Box 59-6.

BOX 59-6 Example Documentation: Patient with Substance Abuse S—A 65-year-old male patient presents for nonsurgical periodontal therapy with local anesthesia appointment. Patient admitted to daily marijuana use to control his arthritic pain, and drinks 4–5 beers most nights to unwind. O—BP 205/110 mmHg, pulse 89 bpm, and patient stated he has not seen his primary physician in years. A—Possible hypertension. The quick results of the NIDA Modified screening tool reveals Mr. Keile is an at-risk drinker. The patient is also at risk for illegal drug use with marijuana use that is not prescribed by his physician. P—Referred patient for medical consult to discuss possible hypertension and substance use addiction. Patient became upset upon finding out that no treatment could be initiated today with the patient’s blood pressure significantly elevated. Patient stormed out of the operatory and building before the medical consultation referral could be completed or any follow-up

appointments could be scheduled. Signed: _____________________________, RDH Date: ____________________________________

EVERYDAY ETHICS Mr. Keile is a 65-year-old man and a new patient to the practice. Dr. Jones has diagnosed Mr. Keile with Stage III Grade B periodontitis and recommends four quadrants of nonsurgical periodontal therapy with local anesthesia. At the initial dental hygiene appointment, the dental hygienist Sean assesses Mr. Keile’s medical history. Significant findings include the following: (1) BP 205/110 mmHg, pulse 89 bpm; (2) Mr. Keile states he smokes marijuana on a daily basis for pain control to manage his arthritis; (3) Mr. Keile has not seen his primary physician in years and was unaware of his hypertension status; (4) Mr. Keile drinks 4–5 beers most nights to unwind. Sean uses the NIDA Modified screening tool (https://www.drugabuse.gov/nmassist/) plugging in Mr. Keile’s substance use information. The quick results reveal Mr. Keile is an at-risk drinker. One or more days of heavy drinking places a patient at risk. With the patient’s daily use of marijuana, the patient is at risk for illegal drug use, especially since his primary physician did not prescribe the marijuana for him. Sean expresses his concern about Mr. Keile’s blood pressure and tells Mr. Keile he is referring him to his primary care provider for a complete physical examination. When Sean tries to dismiss Mr. Keile, Mr. Keile expresses his frustration that no treatment would be provided to him today, “I took time off from work to be here and you are telling me you are not going to clean my teeth?” In addition, Mr. Keile states, “I feel like I am being discriminated against for my marijuana use.” Sean tries to explain that he cannot treat him while his blood pressure is elevated without a medical consultation from Mr. Keile’s primary physician. Before Sean can walk Mr. Keile to the front reception area, Mr. Keile angrily gets up out of the dental chair and storms out of the building. Sean records the interaction and patient’s behavior in the patient’s chart. Questions for Consideration 1. Does the decision to postpone treatment for today violate Mr. Keile’s rights? Why or why not? 2. If Dr. Jones and Sean decide to terminate their practitioner–client relationship with Mr. Keile could this be considered “abandonment” or “discrimination” as Mr. Keile accused? 3. What ethical and legal considerations does Dr. Jones and Sean must consider when treating a patient who smokes marijuana and drinks alcohol

heavily daily?

Factors to Teach the Patient Explain how the substance use has affected the patient’s oral and general health. Discuss in a positive manner what the patient can do to improve their oral and general health. Emphasize the importance of regular dental and dental hygiene care. Also, point out their important role in daily biofilm removal at home. Encourage the patient to maintain a healthy diet. Proper nutrition will be crucial to their healing process. Discuss ways to modify diet to reduce caries risk such as replacing some or all sugar-sweetened beverages with water, use of xylitol-containing mints or gum, rinsing with water after a snack or sugar-sweetened beverage if brushing is not possible. Recommend daily topical fluoride if the patient is at high risk for caries. Avoid alcohol-containing products if the patient exhibits xerostomia or is recovering from alcohol. Illicit drug use during pregnancy can pose serious risks for unborn babies.

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for Wilkins’ Clinical Practice of the Dental Hygienist

References 1. National Institute on Drug Abuse. Drugs, Brain, and Behavior: The Science of Addiction. 2014. https://www.drugabuse.gov/publications/drugs-brainsbehavior-science-addiction. Accessed February 25, 2018. 2. National Institute on Alcohol Abuse and Alcoholism. Drinking Levels Defined. n.d. https://www.niaaa.nih.gov/alcohol-health/overview-alcoholconsumption/moderate-binge-drinking. Accessed April 14, 2018. 3. National Institute on Alcohol Abuse and Alcoholism. Alcohol Use Disorder. n.d. https://www.niaaa.nih.gov/alcohol-health/overview-alcoholconsumption/alcohol-use-disorders. Accessed April 15, 2018. 4. World Health Organization. Global Status Report on Alcohol and Health 2014. 2014. http://www.who.int/substance_abuse/publications/global_alcohol_report/en/. Accessed February 25, 2018. 5. National Institute on Alcohol Abuse and Alcoholism. Underage Drinking. 2017. https://pubs.niaaa.nih.gov/publications/UnderageDrinking/UnderageFact.htm. Accessed February 25, 2018. 6. U.S. National Library of Medicine. Alcoholism and Alcohol Abuse. 2018. https://medlineplus.gov/alcoholismandalcoholabuse.html. Accessed February 25, 2018. 7. National Bureau of Economic Research. Mental Illness and Substance Abuse. 2018. https://www.nber.org/digest/apr02/w8699.html. Accessed February 25, 2018. 8. U.S. National Library of Medicine. Alcohol Use Disorder. 2018. https://ghr.nlm.nih.gov/condition/alcohol-use-disorder#inheritance. Accessed February 25, 2018. 9. Cederbaum AI. Alcohol metabolism. Clinics in Liver Disease. 2012;16(4):667685. 10. National Center for Statistics and Analysis. Alcohol-impaired driving: 2014 data. In: U.S. Department of Transportation, ed. Washington, DC: National Highway Traffic Safety Administration; 2015. 11. National Institute on Alcohol Abuse and Alcoholism. Alcohols Affect on the Body. 2017. https://www.niaaa.nih.gov/alcohol-health/alcohols-effects-body. Accessed February 25, 2018. 12. Rehm J, Shield KD. Alcohol and mortality: global alcohol-attributable deaths from cancer, liver cirrhosis, and injury in 2010. Alcohol Res. 2014;35(2):174183. 13. U.S. National Library of Medicine. Wernicke-Korsakoff Syndrome. 2018. https://medlineplus.gov/ency/article/000771.htm. Accessed February 25, 2018. 14. Centers for Disease Control and Prevention. Alcohol and Public Health: Fact Sheets - Excessive Alcohol Use and Risks to Women’s Health. 2016. https://www.cdc.gov/alcohol/fact-sheets/womens-health.htm. Accessed

February 25, 2018. 15. Centers for Disease Control and Prevention. Alcohol and Public Health: Fact Sheets-Excessive Alcohol Use and Risks to Men’s Health. 2016. https://www.cdc.gov/alcohol/fact-sheets/mens-health.htm. Accessed February 25, 2018. 16. Centers for Disease Control and Prevention. Facts About FASDs. 2017. https://www.cdc.gov/ncbddd/fasd/facts.html. Accessed April 2, 2018. 17. Centers for Disease Control and Prevention. Alcohol Use in Pregnancy. 2016. https://www.cdc.gov/ncbddd/fasd/alcohol-use.html. Accessed February 27, 2018. 18. Substance Abuse and Mental Health Services Administration. Clinical advances in non-agonist therapies. In: U.S. Department of Health and Human Services, ed. Rockville, MD: National Institutes of Health 2016:50. 19. Substance Abuse and Mental Health Services Administration and National Institute on Alcohol Abuse and Alcoholism. Medication for the Treatment of Alcohol Use Disorder. In: U.S. Department of Health and Human Services, ed. Washington, DC; 2015:14. 20. National Institute on Alcohol Abuse and Alcoholism. Treatment for alcohol problems: finding and getting help. In: U.S. Department of Health and Human Services, ed. Washington, DC: National Institutes of Health; 2014. 21. American Dental Association. Policies and Recommendations on Substance Use Disorders. 2016. https://www.ada.org/en/about-the-ada/ada-positionspolicies-and-statements/policies-and-recommendations-on-substance-usedisorders. Accessed February 27, 2018. 22. Govering the States and Localities. State Marijuana Laws in 2018 Map. 2018. http://www.governing.com/gov-data/state-marijuana-laws-map-medicalrecreational.html. Accessed January 29, 2018. Versteeg PA, Slot DE, van der Velden U, van der Weijden GA. Effect of 23. cannabis usage on the oral environment: a review. Int J Dent Hyg. 2008;6(4):315-320. 24. Rella JG. Recreational cannabis use: pleasures and pitfalls. Cleve Clin J Med. 2015;82(11):765-772. 25. Ogborne AC, Smart RG, Weber T, Birchmore-Timney C. Who is using cannabis as a medicine and why: an exploratory study. J Psychoactive Drugs. 2000;32(4):435-443. 26. Bostwick JM. Blurred boundaries: the therapeutics and politics of medical marijuana. Mayo Clin Proc. 2012;87(2):172-186. 27. Howard P, Twycross R, Shuster J, Mihalyo M, Wilcock A. Cannabinoids. J Pain Symptom Manage. 2013;46(1):142-149. 28. Devinsky O, Marsh E, Friedman D, et al. Cannabidiol in patients with treatment-resistant epilepsy: an open-label interventional trial. Lancet Neurol. 2016;15(3):270-278. 29. Drug Enforcement Administration. Drug Fact Sheet-Marijuana. n.d.:1-2. 30. National Institute on Drug Abuse. Marijuana. December 12, 2017. https://www.drugabuse.gov/publications/research-reports/marijuana. Accessed

December 29, 2017. 31. Huestis MA. Human cannabinoid pharmacokinetics. Chem Biodivers. 2007;4(8):1770-1804. 32. Hutton H. Beyond THC: exploring the topical uses of cannabis. J Am Herbalists Guild. 2014;12(3):40-44. 33. Cho CM, Hirsch R, Johnstone S. General and oral health implications of cannabis use. Aust Dent J. 2005;50(2):70-74. 34. Rawal SY, Tatakis DN, Tipton DA. Periodontal and oral manifestations of marijuana use. J Tenn Dent Assoc. 2012;92(2):26-31; quiz 31-22. 35. U.S. Drug Enforcement Administration. Drug Fact Sheets-Fentanyl. n.d. https://www.dea.gov/druginfo/concern_fentanyl.shtml. Accessed March 28, 2018. 36. Grund JP, Latypov A, Harris M. Breaking worse: the emergence of krokodil and excessive injuries among people who inject drugs in Eurasia. Int J Drug Policy. 2013;24(4):265-274. 37. Florez DH, Dos Santos Moreira AM, da Silva PR, et al. Desomorphine (Krokodil): an overview of its chemistry, pharmacology, metabolism, toxicology and analysis. Drug Alcohol Depend. 2017;173:59-68. 38. Gahr M, Freudenmann RW, Hiemke C, Gunst IM, Connemann BJ, SchonfeldtLecuona C. “Krokodil”: revival of an old drug with new problems. Subst Use Misuse. 2012;47(7):861-863. 39. U.S. Drug Enforcement Administration. Desomorphine. 2013. https://www.deadiversion.usdoj.gov/drug_chem_info/desomorphine.pdf. Accessed March 28, 2018. 40. Haskins A, Kim N, Aguh C. A new drug with a nasty bite: a case of krokodilinduced skin necrosis in an intravenous drug user. JAAD Case Reports. 2016;2(2):174-176. 41. Hakobyan K, Poghosyan Y. Spontaneous bone formation after mandible segmental resection in “krokodil” drug-related jaw osteonecrosis patient: case report. Oral Maxillofac Surg. 2017;21(2):267-270. 42. Poghosyan YM, Hakobyan KA, Poghosyan AY, Avetisyan EK. Surgical treatment of jaw osteonecrosis in “Krokodil” drug addicted patients. J Craniomaxillofac Surg. 2014;42(8):1639-1643. 43. National Institute on Drug Abuse. Health Consequences of Drug Misuse: Cardiovascular Effects. 2017. https://www.drugabuse.gov/publications/healthconsequences-drug-misuse/cardiovascular-effects. Accessed March 28, 2018. 44. Riezzo I, Fiore C, De Carlo D, et al. Side effects of cocaine abuse: multiorgan toxicity and pathological consequences. Curr Med Chem. 2012;19(33):56245646. 45. National Institute on Drug Abuse. Health Consequences of Drug Misuse: Neurological Effects. 2017. https://www.drugabuse.gov/publications/healthconsequences-drug-misuse/neurological-effects. Accessed March 28, 2018. 46. Bose J HS, Lipari RN, Park-Lee E, Parker JD, Pemberton MR. Key substance use and mental health indicators in the United States: results from the 2015 national survey on drug use and health. 2016:1-74. Retrieved from

https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUHFFR1-2015/NSDUH-FFR1-2015.pdf. Accessed November 16, 2017. 47. National Institute on Drug Abuse. Inhalants. 2012. https://www.drugabuse.gov/publications/research-reports/inhalants/what-areother-medical-consequences-inhalant-abuse. Accessed March 28, 2018. 48. National Institute on drug Abuse. Health Consequences of Drug Misuse: Gastrointestinal Effects. 2017. https://www.drugabuse.gov/publications/healthconsequences-drug-misuse/gastrointestinal-effects. Accessed March 28, 2018. 49. National Institute on Drug Abuse. Health Consequences of Drug Misuses: Kidney Damage. 2017. https://www.drugabuse.gov/publications/healthconsequences-drug-misuse/kidney-damage. Accessed March 28, 2018. 50. National Institute on Drug Abuse. Health Consequences of Drug Misuse: Liver Damage. 2017. https://www.drugabuse.gov/publications/health-consequencesdrug-misuse/liver-damage. Accessed March 28, 2018. 51. Dasgupta A. 4—Combined alcohol and drug abuse: a potentially deadly mix. In: Alcohol, Drugs, Genes and the Clinical Laboratory. Amsterdam, Netherlands: Academic Press; 2017:75-88. 52. National Institute on Drug Abuse. Health Consequences of Drug Misuse: Musculoskeletal Effects. 2017. https://www.drugabuse.gov/publications/healthconsequences-drug-misuse/musculoskeletal-effects. Accessed March 28, 2018. 53. National Institute on Drug Abuse. Health Consequences of Drug Misuse: Respiratory Effects. 2017. https://www.drugabuse.gov/publications/healthconsequences-drug-misuse/respiratory-effects. Accessed March 28, 2018. 54. National Institute on Drug Abuse. Health Consequences of Drug Misuse: Prenatal Effects. 2017. https://www.drugabuse.gov/publications/healthconsequences-drug-misuse/prenatal-effects. Accessed March 29, 2018. 55. McQueen K, Murphy-Oikonen J. Neonatal abstinence syndrome. N Engl J Med. 2016;375(25):2468-2479. 56. White KM, Sabatino JA, He M, Davis N, Tang N, Bearer CF. Toluene disruption of the functions of L1 cell adhesion molecule at concentrations associated with occupational exposures. Pediatr Res. 2016;80(1):145-150. 57. National Institute on Drug Abuse. Health Consequences of Drug Misuse: HIV, Hepatitis, and other Infectious Diseases. 2017. https://www.drugabuse.gov/publications/health-consequences-drugmisuse/hiv-hepatitis-other-infectious-diseases. Accessed March 30, 2018. 58. Wurcel AG, Merchant EA, Clark RP, Stone DR. Emerging and underrecognized complications of illicit drug use. Clin Infect Dis. 2015;61(12):1840-1849. 59. National Institute on Drug Abuse. Treatment Approaches for Drug Addiction. 2018. https://www.drugabuse.gov/publications/drugfacts/treatmentapproaches-drug-addiction. Accessed March 30, 2018. 60. Srivastava A, Kahan M, Nader M. Primary care management of opioid use disorders: abstinence, methadone, or buprenorphine-naloxone? Can Fam Physician. 2017;63(3):200-205.

61. Uebelacker LA, Bailey G, Herman D, Anderson B, Stein M. Patients’ beliefs about medications are associated with stated preference for methadone, buprenorphine, naltrexone, or no medication-assisted therapy following inpatient opioid detoxification. J Subst Abuse Treat. 2016;66:48-53. 62. Dunlop AJ, Brown AL, Oldmeadow C, et al. Effectiveness and costeffectiveness of unsupervised buprenorphine-naloxone for the treatment of heroin dependence in a randomized waitlist controlled trial. Drug Alcohol Depend. 2017;174:181-191. 63. Baghaie H, Kisely S, Forbes M, Sawyer E, Siskind DJ. A systematic review and meta-analysis of the association between poor oral health and substance abuse. Addiction. 2017;112(5):765-779. 64. Shekarchizadeh H, Khami MR, Mohebbi SZ, Ekhtiari H, Virtanen JI. Oral health of drug abusers: a review of health effects and care. Iran J Public Health. 2013;42(9):929-940. 65. Boyer EM, Thompson N, Hill T, Zimmerman MB. The relationship between methamphetamine use and dental caries and missing teeth. J Dent Hyg. 2015;89(2):119-131. 66. Hamamoto DT, Rhodus NL. Methamphetamine abuse and dentistry. Oral Dis. 2009;15(1):27-37. 67. Taghi KM, Arghavan T, Maryam A, Pourya B, Elham MG, Gelareh T. Drug addiction and oral health; a comparison of hallucinogen and non-hallucinogen drug users. Int J Dent Oral Health. 2016;2(6):1-6. 68. Rechthand MM, Bashirelahi N. What every dentist needs to know about cannabis. Gen Dent. 2016;64(1):40-43. 69. Grafton SE, Huang PN, Vieira AR. Dental treatment planning considerations for patients using cannabis: a case report. J Am Dent Assoc. 2016;147(5):354361. 70. Schulz-Katterbach M, Imfeld T, Imfeld C. Cannabis and caries—does regular cannabis use increase the risk of caries in cigarette smokers? Schweiz Monatsschr Zahnmed. 2009;119(6):576-583.

60 The Patient with a Respiratory Disease Lisa F. Mallonee, RDH, RD, LD, MPH, Valerie G. Herring RDH, BsM, MEd, and Katherine A. Yee, RDH, BSDH, MPH

CHAPTER OUTLINE THE RESPIRATORY SYSTEM I. II. III. IV. V.

Anatomy Physiology Function of the Respiratory Mucosa Respiratory Assessment Classification

UPPER RESPIRATORY TRACT DISEASES I. II.

Modes of Transmission Dental Hygiene Care

LOWER RESPIRATORY TRACT DISEASES ACUTE BRONCHITIS PNEUMONIA I. II. III. IV. V.

Etiology Symptoms Categories and Role of Oral Bacteria Medical Management Dental Hygiene Care

TUBERCULOSIS I. II. III. IV. V. VI. VII.

Etiology Transmission Disease Development Diagnosis Medical Management Oral Manifestations Dental Hygiene Care

ASTHMA I. II. III. IV. V. VI.

Etiology Atopic (Allergic) Asthma Asthma Attack Medical Management Oral Manifestations Dental Hygiene Care

CHRONIC OBSTRUCTIVE PULMONARY DISEASE I. II. III. IV. V.

Chronic Bronchitis Emphysema Medical Management Oral Manifestations Dental Hygiene Care

CYSTIC FIBROSIS I. II. III.

Disease Characteristics Medical Management Dental Hygiene Care

SLEEP-RELATED BREATHING DISORDERS I. II. III. IV.

Etiology Signs and Symptoms Medical Management Dental Hygiene Care

DOCUMENTATION EVERYDAY ETHICS

FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying the chapter, the student will be able to: 1. Identify and define key terms and concepts related to respiratory diseases. 2. Differentiate between upper and lower respiratory diseases. 3. Describe the etiology, symptoms, and management of respiratory diseases. 4. Plan and document dental hygiene care and oral hygiene instructions for patients with compromised respiratory function. Patients with respiratory diseases have increased risks for complications due to decreased breathing function and treatment– drug interactions. Tobacco cessation: Many respiratory diseases are caused or aggravated by use of tobacco products. Dental hygienists have a unique opportunity to educate their patients about this health hazard. Emergency treatment: Patients with respiratory distress may need emergency care, which dental hygienists are prepared to prevent or provide when necessary. Signs and symptoms and medical emergency procedures for local anesthesia reactions, respiratory failure, airway obstruction, asthma attack, hyperventilation, anaphylaxis, and allergic reactions are found in Chapter 9. Oral–systemic link: Scientific evidence shows dental biofilm and microorganisms from periodontal infections can contribute to the initiation and/or progression of certain respiratory infections.1

Dedication of the dental hygienist to the prevention and control of periodontal infections can have a major influence on the overall health of the patient.

THE RESPIRATORY SYSTEM I. Anatomy Structures: sinuses, nasal cavity, larynx, pharynx, trachea, bronchi, lungs, and pleura (Figure 60-1A).2

FIGURE 60-1 • Structures of the Respiratory System. A: Structures. The major anatomic structures of the respiratory system are shown. Each bronchus branches

out to the bronchioles. B: Gas exchange. Exchange of oxygen and carbon dioxide occurs in the alveoli of the bronchioles.

II.

Physiology

The respiratory tract from nasal cavity to lungs serves as a passageway for air exchange (Figure 60-1A). Inhaled fresh air: warmed and filtered in the nasal cavity, enters the lungs. Exhaled air: with carbon dioxide, leaves the body. Gas exchange: at the cellular level, occurs in the alveoli at the ends of the bronchioles, as shown in Figure 60-1B. Cardiovascular system: functions with the respiratory system to pump oxygenated blood from the lungs to every cell in the body and deoxygenated blood back to the lungs for exhalation.

III. Function of the Respiratory Mucosa Figure 60-2 shows ciliated epithelial cells and mucus-secreting goblet cells that line the respiratory tract to make up the respiratory mucosa.

FIGURE 60-2 • Lining of the Respiratory Mucosa. Ciliated epithelial cells and mucus secreted by goblet cells help to remove foreign objects (dust particles). The material is coughed up and either expectorated or swallowed.

Mucus secreted from goblet cells moistens inspired air, prevents delicate alveolar walls from becoming dry, and traps dust and other airborne particles. Cilia assist in removing foreign material and contaminated mucus by a constant beating and wavelike motion that propels this material back into the larger bronchi and trachea where it can be coughed up and expectorated or swallowed. Lack of function results when the inflammatory process of asthma and chronic bronchitis initiates an overabundance of mucus. Congestion is created, and the cilia are prevented from assisting with normal breathing.

IV. Respiratory Assessment Respiratory disease assessment includes several objective measures.

A. Vital Signs Determination of vital signs (body temperature, pulse, respiratory rate, blood pressure) and also smoking status is considered standard procedure in dental patient care. Methods of determining vital signs are described in Chapter 12. Tobacco use is discussed in Chapter 32.

B. Spirometry Medical test that measures various aspects of breathing and lung function. Used to diagnose and monitor many lower respiratory tract diseases. Performed with a spirometer, a device that registers the amount of

air a person inhales or exhales and the rate at which air is moved in and out of the lungs. Figure 60-3 shows the use of a spirometer to evaluate lung function.

FIGURE 60-3 • Use of a Spirometer to Evaluate Lung Function. Person being tested takes in a full breath, seals their lips over the mouthpiece of the spirometer, and then blows out as hard and as fast as possible for at least 6 seconds. Nose clips may be applied to ensure no air escapes through the nose. (© Microgen/Shutterstock)

C. Pulse Oximetry Medical test that measures blood oxygen saturation levels.3

Performed with a pulse oximeter. Color of blood varies depending upon the amount of oxygen it contains. Pulse oximeter emits a light through the finger to calculate the percentage of oxygen. Any finger (excluding the thumb) can be used. Nail polish or a skin callous may interfere with reading. Intended only as an adjunct in patient assessment along with other methods of assessing clinical signs and symptoms. Healthy patients have an oxygen saturation of 97%–100%. Saturation of 91% or below signifies poor oxygen exchange. Figure 60-4 shows the use of a pulse oximeter to measure blood oxygen saturation levels.

FIGURE 60-4 • Use of a Pulse Oximeter to Measure Blood Oxygen Saturation Level. Color of blood varies depending on the amount of oxygen it contains. The pulse oximeter clips on any finger (except the thumb) and emits a light through the finger to calculate the percentage of oxygen in the blood. Nail polish and a skin callous may interfere with reading.

D. Chest Radiography (Imaging)

Indicates presence of pathologic density (radiopacity) in the lungs. Standard chest radiograph: shows a two-dimensional view of lung tissues. Computed axial tomography radiograph or computed tomography scan: shows a three-dimensional cross section of lung tissues.

E. Blood Gas Analysis Blood test to determine acid–base balance, alveolar ventilation, arterial oxygen saturation, and carbon dioxide elimination.

F. Cytology (Body Cells and Fluids) and Hematology Evaluation Examination of body cells, blood, and other fluids to determine the presence of microorganisms that cause respiratory diseases. Samples are taken from sputum, pleural cavity fluid, bronchial biopsy, or blood.

V.

Classification

Classification of respiratory diseases is listed in Table 60-1. TABLE 60-1 Classification of Respiratory Diseases LOCATION/STRUCTURES ACUTE

CHRONIC

Upper respiratory tract

Diseases of the nose, sinuses, pharynx, larynx Rhinitis (common cold) Sinusitis Pharyngitis/tonsillitis Influenza (flu) Seasonal Viral

Allergic rhinitis (hay fever)

Lower respiratory tract Diseases of the trachea,

Acute bronchitis Pneumonia

TB Asthma

lungs

COPD Chronic bronchitis Emphysema CF

COPD, chronic obstructive pulmonary disease; TB, tuberculosis. Source: Centers for Disease Control and Prevention. National Center for Immunization and Respiratory Diseases (NCIRD). Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/ncird/overview/websites.html. Updated July 26, 2017. Accessed February 2, 2019.

UPPER RESPIRATORY TRACT DISEASES The more common disorders of the upper respiratory tract are caused by infections or allergic reactions that result in inflammation. Signs and symptoms, etiology, medical treatment, and clinical evaluation assessment are summarized in Table 60-2. TABLE 60-2 • Summary of Upper Respiratory Diseases: Signs/Symptoms, Etiology, Medical Management, and Dental Hygiene Care—Clinical Evaluation Assessment

Source: Centers for Disease Control and Prevention. Get Smart: Know When Antibiotics Work (Treatment Guidelines for Upper Respiratory Tract Infections). Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/getsmart/campaign-materials/treatment-guidelines.html. Updated September 26, 2017. Accessed February 2, 2019.

I.

Modes of Transmission Inhalation of airborne droplets.4 Indirectly by contaminated hands or articles freshly soiled with discharge of nose or throat of infected person.4

II.

Dental Hygiene Care

A. Disease Prevention All healthcare professionals are encouraged to obtain immunizations for seasonal viral influenza. Observe standard precautions including respiratory hygiene and cough etiquette as listed in Table 60-3 to prevent transmission of pathogens from patient to clinician and to prevent healthcareassociated infections to the patient.5 TABLE 60-3 • Respiratory Hygiene and Cough Etiquette in Healthcare Settings To prevent transmission of all respiratory infections in healthcare settings, incorporate the following infection control practices as one component of standard precautions: Visual alerts

Post visual alerts: symptoms of respiratory infection and respiratory hygiene and cough etiquette.

Respiratory hygiene and cough etiquette

Use tissue to cover coughs and sneezes and discard in no-touch receptacle. Perform hand hygiene (hand washing with nonantimicrobial soap and water, alcohol-based rub, or antiseptic hand wash) after contact with respiratory secretions or contaminated objects.

Masking and separation of persons with respiratory symptoms

Offer masks to persons who are coughing and encourage coughing persons to sit at least 3 feet away from others in common waiting areas.

Droplet precautions

Observe droplet precautions (wearing a surgical or procedure mask for close contact) in addition to

standard precautions when examining a patient with symptoms of a respiratory infection, particularly when a fever is present. Source: Centers for Disease Control and Prevention. Respiratory Hygiene/Cough Etiquette. Atlanta, GA: Centers for Disease Control. https://www.cdc.gov/oralhealth/infectioncontrol/faqs/respiratory-hygiene.html. Updated March 25, 2016. Accessed February 2, 2019.

B. Appointment Management Delay treatment until patient is no longer infectious. Noninfectious status is determined by temperature returning to normal and regression of oral lesions such as erythematous lesions of the soft palate and erythema multiforme.6

C. Bacterial Resistance to Antibiotics Bacteria may become resistant to antibiotics within 14 days.7 For patients currently prescribed an antibiotic for a nondental condition (such as acute bacterial bronchitis or sinus infection): a different category of antibiotic will be necessary to treat an odontogenic (dental origin) infection.

LOWER RESPIRATORY TRACT DISEASES Considered to be a more serious infection. Diseases of the lower respiratory tract are listed in Table 60-1.

ACUTE BRONCHITIS An acute respiratory infection that involves large airways (trachea, bronchi).8 Primary symptom: cough with or without phlegm; may last up to 3 weeks. Lower respiratory tract disease symptoms: wheezing, shortness of breath, or chest tightness. Differentiated from pneumonia: no significant findings on chest radiography. A comparison of acute viral and bacterial bronchitis is listed in Table 60-4. TABLE 60-4 • Comparison of Acute Viral and Bacterial Bronchitis ITEM

VIRAL

BACTERIAL

Occurrence

Most prevalent

Least prevalent

Medical treatment

Supportive: bed rest, fluids May need inhaled bronchodilators and/or cough suppressant

Antibiotics: amoxicillin, macrolides, cephalosporin

Source: Centers for Disease Control and Prevention. Get Smart: Know When Antibiotics Work (Treatment Guidelines for Upper Respiratory Tract Infections). Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/getsmart/campaign-materials/treatment-guidelines.html. Updated September 26, 2017. Accessed February 2, 2019.

PNEUMONIA An infection and subsequent inflammation of the lungs that may be caused by viruses, bacteria, fungi, mycoplasma, or parasites.9 The respiratory tract of a healthy person is able to defend against organisms aspirated into the lungs. With diminished salivary flow, decreased cough reflex, swallowing disorders, poor ability to perform good oral hygiene, or other physical disabilities, there is an increased risk of aspiration and respiratory infection.

I.

Etiology

A. Viral and Bacterial Comparison of viral and bacterial pneumonias is listed in Table 605. TABLE 60-5 • Comparison of Viral and Bacterial Pneumonias ITEM

VIRAL

Occurrence

Most prevalent

Causative agent

Virus

BACTERIAL Least prevalent Bacteria Nosocomial Aerobic gram-negative bacilli Example: Pseudomonas aeruginosa Escherichia coli Klebsiella pneumonia Gram-positive cocci Example: Staphylococcus aureus Methicillin-resistant S. aureus Community acquired

Gram-negative cocci Example: Haemophilus influenzae Gram-positive cocci Example: Streptococcus pneumonia Signs and symptoms

Mild symptoms Cough, sputum Mild fever Dyspnea

Sudden onset Cough, purulent sputum High fever Dyspnea, tachypnea Pleuritic chest pain

Diagnosis

Patient history Physical findings Chest radiography

Patient history Physical findings Chest radiography Sputum sample

Medical treatment

Supportive: bed rest, fluids

Antibiotics

Source: American Lung Association. Symptoms, Diagnosis and Treatment. Chicago, IL: American Lung Association; 2018. http://www.lung.org/lungdisease/pneumonia/symptoms-diagnosis-and.html. Updated October 15, 2018. Accessed February 2, 2019.

B. Fungal Etiologic agent of pneumocystis pneumonia is Pneumocystis jirovecii (yee-row-vetsee). Susceptibility is enhanced by chronic debilitating disease in which immune mechanisms are impaired, such as in HIV/AIDS.

II.

Symptoms Fever greater than 100.4° F. Productive cough. Chest pain. Shortness of breath. Visible on chest x-ray.

III. Categories and Role of Oral Bacteria Pneumonia is often categorized by location and/or procedure.

A. Community-Acquired Pneumonia Infection occurring in an individual in the community (not in a healthcare facility).10 Person-to-person transmission.

B. Healthcare-Associated (Nosocomial) Pneumonia Infection occurring 48–72 hours after admission to a healthcare facility. A major cause of death in hospitalized patients. Commonly multidrug-resistant pathogens. More common in the very elderly >80 years and those with comorbidities. Bacteria in periodontal pockets may serve as a reservoir for lung infection, especially in institutional settings. Bacteria from oral biofilm are released into saliva and can be aspirated into the lungs. Contributing factors: Poor oral health, dependence on others to perform daily oral hygiene Oral colonization of periodontal and respiratory pathogens Influenced by periodontitis, are associated with nosocomial pneumonia. Nursing home–acquired pneumonia Owing to dysphagia from decrease in saliva, cough reflex, and/or swallowing disorders. Aspiration of saliva can be the main route of bacteria into the lungs and may lead to aspiration pneumonia. Hospital-acquired pneumonia

Ventilator-associated pneumonia: mechanically ventilated patients in the immediate care unit with no ability to clear oral secretions by swallowing or coughing. Nonventilator-associated pneumonia: biofilm forms on endotracheal tubes, catheters.

IV. Medical Management Viral: supportive treatment of bed rest and fluids. Bacterial: antibiotic therapy. Fungal: sulfa drugs.

V.

Dental Hygiene Care

Control of oral disease and periodontal disease for patients in nursing homes and hospitals will help prevent aspiration pneumonia. Use 0.12% chlorhexidine gluconate rinse prior to beginning treatment to reduce the bacterial load.11 Avoid use of ultrasonic scalers due to the production of aerosols.

TUBERCULOSIS Tuberculosis (TB) is a chronic, infectious, and communicable disease with worldwide public health significance as a cause of disability and death, especially in developing countries.12 Groups at high risk for exposure to TB include those who have been recently infected with TB bacteria or persons with medical conditions that weaken the immune system. Those at risk include13: Close contact with people infected with TB. Residing and working in institutional settings (prisons, nursing homes). From countries with a high TB incidence/prevalence. Injection drug users. People who abuse alcohol. Persons with HIV. Patients with diabetes, severe kidney disease, organ transplants head neck cancer. Patients undergoing specialized treatment for Crohn disease or rheumatoid arthritis. Malnourished or low body weight. Medical/dental care providers for any of the aforementioned high-risk groups.

I.

Etiology

Mycobacterium tuberculosis, a rod-shaped bacterium (tubercle bacillus), is the most common causative agent.

II.

Transmission Tubercle bacilli travel in airborne droplet nuclei in infected saliva or mucus from persons with pulmonary or laryngeal TB during forceful expirations (coughing, sneezing, talking, singing). The airborne droplet nuclei can remain suspended in the air for

hours.14 Inhalation and other modes of transmission are described in Chapter 5.

III. Disease Development Inhaled tubercle bacilli travel to the lung alveoli where local infection begins. While TB can affect any organ or tissue, M. tuberculosis is an aerobe and survives best in an environment of high oxygen tension, such as the lungs. Latent tuberculosis infection (LTBI) Within 2–10 weeks following exposure, immune response will limit further growth of M. tuberculosis, although not all bacilli will be eliminated. At this stage, the infected person is categorized as having LTBI. Approximately 5%–10% of people infected with M. tuberculosis and not treated for LTBI will develop TB disease during their lifetime.13,15 Comparison of LTBI and active TB disease including signs/symptoms, diagnosis, and medical treatment with TB drugs is listed in Table 60-6. TABLE 60-6 • Comparison of LTBI and Active TB Disease: Signs/Symptoms, Diagnosis, and Medical Management with TB Drugs ITEM

LTBI

ACTIVE TB DISEASE

Signs and symptoms of pulmonary TB

None

Early onset: Low-grade fever Nonproductive cough lasting 3 wk or longer Fatigue Unexplained weight loss Sweating at night Later onset: Fever Chills

Persistent cough with purulent sputum Hemoptysis Hoarseness (associated with pharyngeal TB) Chest pain Dyspnea Wellness of patient

Does not feel sick

Usually feels sick

Infectivity

Does not infect others

May infect others

TST, PPD, or Mantoux

Positive

May be positive

IGRA blood test

Positive

Positive

Sputum sample for AFB and culture

Negative

May be positive

Chest radiograph

Normal

Abnormal

Medical management for adults: commonly prescribed TB drugs

300-mg isoniazid (INH) taken daily for 9 mo (twice weekly if Directly Observed Therapy (DOT) is available). Alternate options include a 6 mo course of INH (twice weekly if DOT is available); a 3-mo regimen of INH and rifapentine once weekly OR rifampin (RIF) taken daily for 4 mo.

Various combinations of drugs taken daily for a minimum of 6 mo Drugs commonly prescribed: INH RIF Ethambutol (EMB) Pyrazinamide Therapy for multidrugresistant TB Bedaquiline fumarate

AFB, acid-fast bacilli; IGRA, interferon-gamma release assay; LTBI, latent tuberculosis infection; PPD, purified protein derivative; TB, tuberculosis; TST, tuberculin skin test. Source: Centers for Disease Control and Prevention. Treatment for TB Disease. Atlanta, GA: Centers for Disease Control and Prevention. https://www.cdc.gov/tb/topic/treatment/tbdisease.htm. Updated April 5, 2016. Accessed February 2, 2019; Centers for Disease Control and Prevention, National Center for HIV Viral Hepatitis STD and TB Prevention. Fact Sheet: Treatment Options for Latent Tuberculosis Infection. Atlanta, GA: Center for Disease Control and Prevention; 2016. https://www.cdc.gov/tb/publications/factsheets/treatment/ltbitreatmentoptions_revised.pdf Accessed February 28, 2019.

IV. Diagnosis A. Latent tuberculosis infection Two tests are available to determine exposure to M. tuberculosis. Tuberculin skin test (TST). Also known as Mantoux test, purified protein derivative (PPD) test. PPD is injected under the skin on the forearm. After 72 hours, the circumference of induration (hard swelling) is measured to determine exposure. A negative TST does not exclude TB disease in a person with signs and symptoms of TB disease. Interferon-gamma release assay (IGRA). Blood test to determine exposure to M. tuberculosis. IGRA blood test, as with TST, cannot differentiate LTBI from active TB disease. Laboratory sputum smear and culture is required.

B. Active TB Disease When tests to determine exposure to M. tuberculosis are positive, further examination is required to rule out active TB disease. Chest radiograph. Physical examination and evaluation of signs and symptoms. Preliminary diagnosis: Perform microscopic examination of sputum smears for acid-fast bacilli (AFB). The waxy cell wall of tubercle bacilli does not absorb the traditional water-soluble Gram stain and cannot be identified. However, when treated with an acid stain, the organisms appear pink and are named AFB. Definitive diagnosis: When AFB are seen on a stained smear of sputum, or other clinical specimen, a diagnosis of TB disease is suspected. However, the diagnosis is not confirmed until a laboratory culture is grown and identified as M. tuberculosis.

V.

Medical Management

A. Commonly Prescribed Drugs Commonly prescribed TB drugs are included in Table 60-6.

B. Directly Observed Therapy Observing the patient swallow anti-TB drugs is recommended for all LTBI and TB disease patients and will result in: High medication compliance. Prevention of multidrug-resistant bacterial development. Prevention of multidrug-resistant TB (MDR-TB) disease, which is more severe and difficult to treat.

C. Drug Resistance TB bacteria can become resistant (drugs are no longer effective in killing the bacteria).12 Types of resistance16 Primary resistance: individuals who have not been previously exposed to anti-TB drug treatments. Acquired resistance: individuals who have been previously exposed to anti-TB drug treatments. This is occurs frequently when a full course of anti-TB drug treatments is not completed. MDR-TB: TB bacterial resistance to at least two of the first-line (most preferred) drugs, isoniazid and rifampin.17 Extensively drug-resistant TB: TB bacterial resistance to isoniazid, rifampin, any fluoroquinolone, and at least one of three injectable second-line drugs.

VI. Oral Manifestations TB infrequently appears in the oral cavity from pulmonary organisms in infected sputum brought to the mouth by

coughing.13,14 Classic mucosal lesion: painful, deep, irregular ulcer on dorsum of the tongue as seen in Figure 60-5.

FIGURE 60-5 • Oral Ulcer on Tongue Caused by Mycobacterium tuberculosis. The classic oral mucosal lesion is a painful, deep, irregular ulcer on the dorsum of the tongue. (Courtesy of the United States Department of Veteran’s Affairs. From DeLong L and Burkhart N. General and Oral Pathology for Dental Hygienists. Baltimore, MD: Lippincott Williams & Wilkins; 2008.)

Lesions can also occur on palate, lips, buccal mucosa, and gingiva. A biopsy and laboratory culture of an oral lesion that reveals M. tuberculosis confirms a diagnosis of TB. Glandular swelling: cervical or submandibular lymph nodes infected with TB. Nodes may become enlarged.

VII. Dental Hygiene Care A. Implementation of Infection Control Measures Update medical history.

Recognize signs and symptoms of TB as listed in Table 60-6. Refer to the web resource for CDC guidelines on infection control and prevention of transmission of TB in healthcare settings. Create and routinely update written office/clinic protocols for: Educating and training staff. Instrument reprocessing and operatory cleanup. Identifying, managing, and referring patients with active TB disease. Assessing, managing, and investigating dental staff with positive TST (PPD).

B. Management of Patients with Symptoms or History of TB Potential infectivity dictates decisions regarding whether to treat a patient or refer to a physician for medical clearance.13 Active TB disease and sputum-positive TB Do not treat in the dental office or any outpatient facility. Treatment needs to be performed in a hospital with appropriate isolation, sterilization, and engineering controls. History of TB Use caution, obtain history of disease, treatment duration, and discuss signs and symptoms of disease. Consult with physician before treatment. Also consult with physician if adequate treatment time/appropriate medical follow-up is unclear or patient presents with signs or symptoms of relapse. Recent conversion to positive TST or blood test. Treatment is permitted after: Patient is free of clinically active disease Evaluation by physician to rule out active TB disease Verification by physician of receiving isoniazid for 6 months to 1 year to prevent active TB disease. When the patient has signs and symptoms of TB, postpone nonemergency treatment and refer to physician.

ASTHMA Asthma is a chronic respiratory disease consisting of recurrent episodes of dyspnea, coughing, and wheezing, leading to bronchial inflammation and muscle contraction.18

I.

Etiology

The exact cause of asthma is not completely understood. The following types are based on pathophysiology.

A. Extrinsic (Allergic or Atopic): Allergic Triggers from Outside the Body Most common type of asthma.19 Exaggerated inflammatory response triggered by inhalation of an environmental allergen (dust, pollen, tobacco smoke, mold, dust mites, or animal dander). Allergic stimulus leads to activation of airway epithelial mast cells.19 Steps of an immunoglobulin E (IgE)-mediated hypersensitivity reaction are shown in Figure 60-6.

FIGURE 60-6 • Steps of an Immunoglobulin E (IgE)-mediated Hypersensitivity Reaction. A: Initial exposure. On initial exposure to an allergen (dust, pollen), immunoglobulins (IgE) are produced and bind to mast cells. B: Subsequent exposure. On subsequent exposures, allergen binds to IgE on the mast cell. C: Mast cells respond by releasing asthma mediators (histamines, leukotrienes, prostaglandins). The asthma mediators cause bronchoconstriction, vasodilation, and mucus production, resulting in coughing, wheezing, and dyspnea.

B. Intrinsic (Nonallergic): Nonallergic Triggers from within the Body Intrinsic triggers: emotional stress, gastroesophageal reflux disease (GERD).20 Trigger may be unidentified. Obesity. Usually seen in adults.20

C. Drug- or Food-Induced (Nonallergenic, Nonatopic)

Aspirin. Nonsteroidal anti-inflammatory drugs (NSAIDs). Beta-blockers. Food substances: nuts, shellfish, milk, and strawberries. Tartrazine (yellow food dye). Metabisulfite preservative in food (wine, beer, shrimp, dried fruit). Metabisulfite preservative in drugs (local anesthetic with epinephrine).

D. Exercise Induced Vigorous physical activity: usually affects young people due to their level of activity. Thermal changes during inhalation of cold air may provoke mucosal irritation and airway hyperactivity.

E. Infection Induced Lung infections caused by viruses, bacteria, or fungi may provoke asthmatic symptoms. Treatment of the infection improves breathing.

II.

Atopic (Allergic) Asthma

Atopic asthma is one type of IgE-mediated hypersensitivity reaction.

A. Immunoglobulin E One of the five types of antibodies produced by the body. Provides the primary defense against environmental allergens (pollen, tobacco smoke, and food substances).

B. Normal Inflammatory Reaction IgE breaks down the allergens and removes them from the body.

Normally, such activity does not produce noticeable symptoms.

C. Asthmatic Hypersensitivity Reaction People with asthma are believed to “hyper-react” and produce more IgE antibodies than normal. The results can be symptoms of asthma: wheezing, coughing, and dyspnea.

D. How Allergens Trigger Asthma Steps in an IgE-mediated hypersensitivity reaction (Figure 60-6): On initial exposure to an allergen (dust, pollen, food), immunoglobulins (IgE) are produced and bind to mast cells (Figure 60-6A). On subsequent exposures, the antigen binds to the IgE on the mast cell (Figure 60-6B). Mast cells release asthma mediators, such as histamines, leukotrienes, and prostaglandins (Figure 60-6C). Asthma mediators cause bronchoconstriction, vasodilation, and mucus production. The result is wheezing, coughing, and dyspnea.

E. Summary of IgE-Mediated Hypersensitivity Reactions Local anaphylaxis: Allergen binds to mast cell in nasal cavity: results in allergic rhinitis (hay fever). Allergen binds to mast cell in bronchiole: results in asthma. Systemic anaphylaxis: Allergen (penicillin, bee venom, food substance) binds to mast cells throughout the body: results in a reaction sometimes referred to as anaphylactic shock.

III. Asthma Attack

A. Recognize Signs and Symptoms of Severe or Worsening Asthma Attack Chest tightness, sense of suffocation. Ineffectiveness of bronchodilator to relieve dyspnea. Wheezing, cough. Flushed appearance, sweating. Confusion due to lack of oxygen. Dilated pupils. Inability to complete a sentence in one breath. Tachypnea. Tachycardia.

B. Prepare for Possible Emergency Care Recognize signs and symptoms. Stop dental hygiene treatment. Rule out foreign-body obstruction. Assist with patient’s own bronchodilator inhaler. Administer supplemental oxygen by nasal cannula. Assist with the administration of subcutaneous injection or inhalation of epinephrine. Monitor vital signs. Call emergency medical service and initiate emergency procedures described in Chapter 9.

IV. Medical Management A. Diagnosis Conduct physical examination and lung function assessment (spirometry).18

B. Achieve and Maintain Asthma Control

Assess and monitor asthma severity and asthma control.18 The National Asthma Education and Prevention Program classification is based on four levels of severity and frequency of symptoms as well as pulmonary function assessment (spirometry).19 Intermittent. Persistent–mild. Persistent–moderate. Persistent–severe. Education: Patients are advised to have a written control plan from the physician explaining the process of disease, treatment options, and how to treat exacerbations (worsening of symptoms). Control of environmental factors (pollutants and allergens) and comorbid conditions that affect asthma (GERD, obesity, obstructive sleep apnea [OSA], rhinitis/sinusitis, stress/depression). Medications: There are two main types: long-term control medications and quick-relief medications. Categories and examples of asthma medications are listed in Table 60-7. TABLE 60-7 • Types, Categories, and Examples of Asthma Medications Long-Term Control: Used Daily for Persistent Asthma Corticosteroids Anti-inflammatory Decreases airway hyperresponsiveness. Preferred: inhaled corticosteroid for all levels of persistent asthma: oral– systemic corticosteroid for severe, persistent asthma

Beclomethasone dipropionate (Vanceril) (Prednisone)

Mast cell stabilizers: for mild persistent asthma

Cromolyn sodium (Intal)

Immunomodulators: for severe persistent asthma with sensitivity to allergens

Omalizumab

Prevents binding of immunoglobulin E to basophils and mast cells Leukotriene receptor antagonist: also Montelukast (Singulair) known as leukotriene modifiers (Zafirlukast) Interferes with leukotriene mediators that are released from mast cells, eosinophils, and basophils. Alternative: for mild persistent asthma Long-acting beta-2 agonists Inhaled bronchodilator with 12-hr duration Used in combination with other medications

Salmeterol, Formoterol

Methylxanthines: for mild persistent asthma Bronchodilator to relax smooth muscle

Sustained-release theophylline (Theolair, Theo-24)

Combination medication Anti-inflammatory medication used in combination with bronchodilator medication Short-Term Control: Quick-Relief Medication Short-acting beta-2 agonists (SABA): home use for relief of acute symptoms Bronchodilator to relax smooth muscle

Albuterol (Ventolin, Levalbuterol, Pirbuterol)

Anticholinergics Used in hospital emergency room and in inhalers Systemic corticosteroids For exacerbations used with SABAs to speed recovery and prevent reoccurrence of exacerbations Source: American Lung Association. Understand Your Medication. Chicago, IL: American Lung Association; 2018. http://www.lung.org/lungdisease/asthma/taking-control-of-asthma/understand-yourmedication.html. Updated June 4, 2018. Accessed February 27, 2019.

People with asthma are advised to get seasonal influenza vaccinations and may also benefit from immunotherapy (allergy injections). Asthma triggers: potentially harmful drugs to avoid Aspirin-containing medications (use acetamin-ophen). Sulfite-containing local anesthetic solution, such as epinephrine. NSAIDs. Avoid drugs that decrease respiratory function such as narcotics and barbiturates. Avoid harmful drug-to-drug interactions. Macrolide antibiotics (such as erythromycin) if patient takes theophylline. Erythromycin inhibits metabolism of theophylline, which can result in an increase in serum level and possible overdose. Discontinue cimetidine 24 hours before intravenous sedation in patients taking theophylline.

V.

Oral Manifestations

Beta-2 agonist inhalers: Cause a decrease in salivary flow and dental biofilm pH. Are associated with xerostomia and a possible increase in caries and gingivitis in patients with inadequate biofilm control. Increase in GERD with use of beta-2 agonists and theophylline, which may contribute to enamel erosion. Oral candidiasis may occur with high dosage or frequency of inhaled corticosteroids. Occurrence may decrease with use of a “spacer” or aerosolholding chamber attached to metered-dose inhaler. Rinse mouth with water after each use.

VI. Dental Hygiene Care Table 60-8 summarizes dental hygiene care before, during, and after treatment.19,20

TABLE 60-8 • Dental Hygiene Care for the Patient with Asthma TIME

DENTAL HYGIENE CARE

Before treatment

Remind the patient to bring inhaler (rescue drug) and/or other medications. Assess risk level: Review medical history, frequency/severity of acute episodes, and triggering agents. Questions to ask: In the past 2 wk, how many times have you: Had problems with coughing, wheezing, shortness of breath, or chest tightness during the day? Awakened at night from sleep because of coughing or other asthma symptoms? Awakened in the morning with asthma symptoms? Had asthma symptoms that did not improve within 15 min of using inhaled medication? Had symptoms while exercising or playing? Evaluate current symptoms: Reappoint if symptoms are not well controlled. Review current medications. See Table 60-7 for commonly prescribed asthma medications. Ask if all prescription medication has been taken. Schedule morning appointments for patients with nocturnal asthma (symptoms worsen at night). Have bronchodilator and oxygen available. May use patient’s bronchodilator as a preventive measure before the appointment. Obtain a medical consultation for patients with unstable or severe acute asthma or if on corticosteroid to determine necessity of steroid replacement and/or antibiotics to prevent infection. Provide a stress-free environment.

During treatment

Prevent triggering a hypersensitive airway by properly placing cotton rolls, fluoride trays, and suction tip. Use local anesthetic without sulfites. Fluoride treatment for all patients with asthma, especially those using beta-2 agonists. If asthma attack occurs, stop treatment, rule out foreign-body obstruction, initiate emergency procedures shown in Chapter 9.

After treatment

Home care instructions: advise patient to rinse mouth with water after using inhaler to decrease oral candidiasis. Analgesic drug of choice is acetaminophen (aspirin or

nonsteroidal anti-inflammatory drugs may trigger attack).

CHRONIC OBSTRUCTIVE PULMONARY DISEASE The term “chronic obstructive pulmonary disease (COPD)” is used to describe pulmonary disorders that obstruct airflow.21,22 Two of the most common diseases are chronic bronchitis and emphysema. Progressive disease that is not fully reversible.22 Characterized by chronic inflammation in the lungs and airways and a continual airflow limitation.22 The primary etiology is inhaling tobacco smoke with occupational and environmental pollutants as contributing factors. Tobacco use accounts for 8 of 10 COPD-related deaths.23,24 Motivating a patient with COPD to begin a tobacco cessation program can be one of the most rewarding aspects of dental hygiene practice.

I.

Chronic Bronchitis

A. Etiology Chronic bronchitis is defined as excessive respiratory tract mucus production sufficient to cause a cough, with expectoration (coughing up mucus) for at least 3 months of the year for 2 years or more. Obstruction caused by narrowing of small airways, increased sputum (phlegm), and mucus plugging. Difficulty breathing present on inspiration (breathing in) and expiration (breathing out).

B. Signs and Symptoms Chronic cough. Copious sputum. Chest radiograph abnormalities. Sedentary, overweight, cyanotic, edematous, and breathless,

leading to the term “blue bloater.”

II.

Emphysema

A. Etiology Emphysema is defined as a distension (widening) of the air spaces distal to terminal bronchioles due to destruction of alveolar walls (septa). Smoke injures alveolar epithelium destroying alveolar walls and creating large air spaces. Difficulty breathing only on expiration.

B. Signs and Symptoms Difficulty in breathing on exertion. Minimal, nonproductive cough (dry, no mucus). Barrel chest (enlarged chest walls) due to increased use of respiratory chest muscles. Weight loss. Chest radiograph abnormalities. Purses lips to forcibly expel air, leading to the term “pink puffer.”

III. Medical Management There is no cure for COPD. To decrease exacerbations, patients are encouraged to stop smoking, eliminate exposure to environmental pollutants, have adequate nutrition, drink water, and exercise regularly.21 Four medical intervention strategies are described as follows.21,22

A. Assess and Monitor Disease Confirm diagnosis with spirometry and determine severity. COPD is classified into five stages: at-risk, mild, moderate, severe,

and very severe. At-risk stage is defined by normal spirometry, but patients have chronic symptoms of cough and sputum production. Mild, moderate, and severe COPD has evidence of increasing airway obstruction on spirometry in each progressive stage. Very severe COPD is defined by severe airway obstruction with chronic respiratory failure. At this stage, quality of life is significantly impaired, and exacerbations may be life-threatening.

B. Reduce Risk Factors Tobacco cessation. Reduction of exposure to environmental indoor/outdoor pollutants. Examples: Ozone and industrial air pollution, automobile emissions, household cleaning products. Vaccinations for influenza and pneumococcal.21 Education on self-management. Periodontal infection, inadequate biofilm control, and lack of oral health knowledge are associated with increased risk of COPD.21,23

C. Manage Stable COPD Relief of symptoms: aerosol bronchodilators, inhaled corticosteroids, and other medications similar to those used to treat asthma. Pneumonia and seasonal influenza vaccinations. Antibiotics for infectious exacerbations. Pulmonary rehabilitation including a structured exercise program to relieve symptoms and improve quality of life. Surgery. In severe emphysema, the removal of part of one or both lungs may result in more space for the remaining lungs to function. Lung transplant. Oxygen therapy: A patient who uses oxygen (as shown in Figure 60-7) to improve breathing function may hold a portable unit

during treatment.

FIGURE 60-7 • Portable Oxygen Tank. A patient who uses oxygen to improve breathing function may hold a portable unit during treatment. (© rCarner/Shutterstock)

Types: Continuous flow: oxygen flows at a determined rate of liters per minute. On demand: oxygen flows during inhalation only, extending the period of time between oxygen tank refills. Precautions: oxygen promotes rapid burning. Keep away from heat, flame, or other ignition source (cigarettes, Bunsen burner).

D. Prevent and Manage Exacerbations

Infections, inhalation of irritants, and nonadherence to management programs lead to exacerbations.

IV. Oral Manifestations Similar to patients with asthma. Patients who use any form of tobacco have an increased risk of the following oral conditions24,25: Oral cancer. Nicotine stomatitis. Halitosis. Periodontal infections. Extrinsic tooth stain.

V.

Dental Hygiene Care

A. Before Treatment Precautions are needed when concurrent cardiovascular disease is present. Emergency procedures are outlined in Chapter 9. The following should be considered prior to initiating treatment25: Assess severity of COPD and breathing difficulty. Treatment may be performed on stable patients with adequate breathing. Identify patients who may experience exacerbation of symptoms under emotional stress. Monitor blood pressure. Appointment length may need to be modified. Chair positioning: upright or semi-upright to facilitate breathing, as shown in Chapter 8.

B. During Treatment Use antimicrobial preprocedural rinse. Avoid the use of power-driven scalers and air polishers.

Administer local anesthesia without epinephrine. Nitrous oxide–oxygen inhalation sedation: avoid with severe COPD and emphysema.

C. Patient Education Encourage patients to stop smoking. Tobacco cessation strategies are described in Chapter 32. Promote oral care and oral health knowledge in prevention and treatment of COPD. Discuss oral–systemic link between periodontitis and COPD. Teach and promote oral cancer self-examination. Schedule frequent periodontal and maintenance visits.

CYSTIC FIBROSIS Cystic fibrosis (CF) is an autosomal recessive gene disorder. Both parents must carry the genetic mutation for the disease to be transmitted to their children.26 CF is progressive and ultimately fatal. With improved multifaceted health care, many people now live beyond 30–40 years of age. Clinical signs and symptoms are shown in Box 60-1.

BOX 60-1 Clinical Signs and Symptoms of Cystic Fibrosis (CF) Early Stage • In infancy, failure to thrive • Persistent cough and wheezing • Recurrent pneumonia • Excessive appetite but poor weight gain • Salty skin or sweat • Bulky, foul-smelling stools (undigested lipids) Late Stage with Pulmonary Involvement • Tachypnea (rapid breathing) • Sustained chronic cough with mucus production and vomiting • Barrel chest • Cyanosis and digital (finger) clubbing • Exertional dyspnea with decreased exercise capacity • Pneumothorax • Right heart failure secondary to pulmonary hypertension Cystic Fibrosis Foundation. What Is Cystic Fibrosis. Bethesda, MD: Cystic Fibrosis Foundation. http://www.cff.org/AboutCF/. Accessed February 27, 2019.

I.

Disease Characteristics

The gene disorder affects the movement of salt and water in and out

of epithelial cells in the respiratory tract and exocrine glands (respiratory, pancreas, gastrointestinal) and results in thickened secretions. Main systems affected are described as follows.

A. Respiratory Tract Airways are filled with phlegm, similar to pus, leading to: Chronic sinusitis. Opportunistic bacterial lung infection. Both are difficult to eradicate, even with antibiotics, due to the ability of Pseudomonas aeruginosa to form biofilm.26

B. Pancreas and Intestinal Tract Thick mucus clogs pancreatic ducts. Clogged ducts prevent the release of pancreatic enzymes into the intestinal tract. Without enzymes, food is not properly digested or absorbed.

II.

Medical Management

Patients are encouraged to have regular physical activity and to adjust their diet to include pancreatic enzyme supplements, fat-soluble vitamins, liquids with high-salt intake, and caloric supplementation. Comprehensive medical care includes26: Antibiotics including inhalation solution: tobramycin sulfate nebulizer. Bronchodilators and anti-inflammatory agents. Chest physiotherapy. Postural drainage: patient is placed in various body positions to allow mucus to drain from the airway. Percussion (tapping): to loosen secretions.

III. Dental Hygiene Care

A. Oral Manifestations No specific oral lesions related to CF. Gingivitis associated with dry mouth.

B. To Facilitate Breathing Adapt chair positioning. Avoid use of rubber dam.

C. Summary Guidelines for Dental Hygiene Care Summary guidelines for dental hygiene care for a patient with a respiratory disease are listed in Table 60-9. TABLE 60-9 • Summary Guidelines for Oral Hygiene Care for Patients with a Respiratory Disease ITEM

DENTAL HYGIENE CARE

Medical consultation required when:

Signs or symptoms suggest respiratory disease. Examples: Cough/dyspnea at rest, hemoptysis, sputum, wheeze, chest pain, oxygen saturation level of 91% or lower as determined by pulse oximetry, or positive TB skin test (TST, PPD, Mantoux). The clinician is uncertain of the patient’s medical status, severity of disease, or level of control. Patient with systemic conditions has not seen a primary care provider within the past year. Patient has American Society of Anesthesiologists risk status class III or higher, as shown in Chapter 22. Patient has taken corticosteroids within the past 12 mo. Patient unsure of medications and dosages.

Stress reduction protocol

Prevent asthma attack; helpful for patients with COPD. Short morning appointments. Avoid precipitating factors.

Chair position

Semi-reclined or upright position may make breathing easier.

Anxiety and pain control

Local anesthetic: avoid epinephrine for patients with asthma/COPD. Nitrous oxide–oxygen may be contraindicated: For patients with upper respiratory infection or moderate/severe COPD. With upper respiratory tract obstruction or infection if nose breathing would be difficult or breathing apparatus cannot be sterilized or replaced. Be prepared to handle an emergency.

Analgesia

Avoid aspirin, aspirin-containing analgesics, and other NSAIDs as 10% of patients with asthma have aspirin-induced asthma.

Antibiotics

Patients with extrinsic asthma may have allergy to antibiotics.

Infection control

Standard precautions including respiratory hygiene and cough etiquette.

Emergency protocol

Recognize symptoms of respiratory distress. Terminate treatment. Emergency protocol is shown in Chapter 9.

Use of equipment that produces aerosols

Ultrasonic, sonic scalers, and polishing may be contraindicated. Septic material and microorganisms from biofilm and periodontal pockets can be aspirated into the lungs. For additional contraindications, see Chapter 39.

COPD, chronic obstructive pulmonary disease; NSAIDs, nonsteroidal antiinflammatory drugs; PPD, purified protein derivative; TB, tuberculosis; TST, tuberculin skin test. Source: Lozano AC, Perez MGS, Esteve CG. Dental Considerations in patients with respiratory problems. J Clin Exp Dent. 2011;3(3):e222-e227. Available from: http://www.medicinaoral.com/odo/volumenes/v3i3/jcedv3i3p222.pdf. Accessed February 2, 2019.

SLEEP-RELATED BREATHING DISORDERS Usually due to chronic airway obstruction.27 Primary snoring and OSA syndrome are common SRBDs.27

I.

Etiology Repetitive narrowing and closure of the of upper airway during sleep. Pharyngeal airway obstruction. In children, the most common cause is tonsillar hypertrophy.28

II.

Signs and Symptoms Interruption in sleep patterns. Snoring may cause tissue inflammation. Wake up with a dry mouth or sore throat. Associated with comorbidities, motor vehicle accidents, and occupational accidents.

III. Medical Management Continuous positive airway pressure (CPAP) machine (shown in Figure 60-8) increases air pressure in the throat so that the airway does not collapse when inhaling.29

FIGURE 60-8 • Continuous Positive Airway Pressure (CPAP). This machine is attached by a hose to the nose mask that is held in place while sleeping by straps. The CPAP machine increases the air pressure in the throat so the airway does not collapse when inhaling. (Picture courtesy of Dennis Freeman, DDS.)

Oral appliance therapy (OAT) is an effective treatment for mild-tomoderate sleep apnea and for severe sleep apnea when a CPAP is not tolerated by the patient.29,30 The mandibular advancement device shown in Figure 60-9 is the most common form of oral appliance used in clinical practice.

FIGURE 60-9 • Mandibular Advancement Splint (MAS). A splint that moves the mandible slightly forward that tightens the soft tissue and muscles of the upper airway to prevent obstruction of the airway during sleep.

The mandibular advancement splint moves the mandible slightly forward and tightens the soft tissue and muscles of the upper airway to prevent obstruction of the airway during sleep.30–32 Contraindications to OAT include periodontal disease, temporomandibular disorders, and insufficient number of teeth.33 Positional therapy to prevent postural drainage. Weight loss. Surgery.

IV. Dental Hygiene Care Assessment of oral tissues at each maintenance visit. Assessment of temporomandibular joint. Recommend non-alcohol–based mouth moisturizer/rinse. Bring mandibular advancement device to each continuing care

appointment for evaluation.

DOCUMENTATION Include in the patient’s permanent record: Alerts for dental personnel to the possibility of disease transmission or a medical emergency due to medical condition or allergy. Paper records: to protect patient confidentiality, place the medical alert box inside front cover. Electronic records: insert in a prominent area. Box 60-2 shows an example of medical alert notifications.

BOX 60-2 Examples of Medical Alert Notifications Medical alert notifications should not be visible on the outside of the patient record. Medical Alert: Asthma Medical Alert: XDR-TB

Medical consultation: file written reports and document telephone conversations. Patient’s current health status: especially related to signs and symptoms of respiratory disease, known allergies, current medications. Vital signs: including pulse oximetry. Oral examination: with attention to oral cancer screening and periodontal evaluation. Patient education: especially issues about dry mouth, tobacco cessation, and medication compliance. Changes in respiratory signs and symptoms during treatment and interventions performed. A sample progress note for a patient with a positive TST is shown in Box 60-3.

BOX 60-3

Example Documentation: Patient with a Positive TST

S—A 36-year-old patient presents for new patient examination. Patient reports she had a positive TST test 1 year ago. She states that she was treated and is not contagious. O—Called patient’s physician (Dr. Roberts). Spoke with nurse (Becky) who provided verbal summary and will also send written report to include in the patient’s record. Patient successfully completed regime of isoniazid for 9 months. Latest medical examination findings: • Chest radiograph—negative • Sputum smear and culture—negative • Signs and symptoms—none A—No signs of active TB disease; patient may receive any medical dental treatment without restriction. P—Proceeded with patient assessment and dental prophylaxis. Signed: _____________________________, RDH Date: ____________________________________

EVERYDAY ETHICS On a beautiful spring day, Lana Thomas arrived for her 3-month continuing care visit. Vicki, the dental hygienist, noticed a labored breathing pattern as they walked down the hall to the dental hygiene treatment room. She rechecked the patient history before beginning the intraoral assessment but found the information unremarkable. Lana reported taking an over-the-counter product for seasonal allergies, but it didn’t seem to be helping with her nasal and chest congestion. The patient also requested that she should not be placed so far back in the dental chair because it was difficult for her to breathe. Vicki began to reconsider her plan to use the ultrasonic scaler given the patient’s current condition. Questions for Consideration 1. What are the ethical responsibilities of a primary healthcare clinical dental hygienist when a patient presents with symptoms such as those of Lana Thomas? 2. How does each of the dental hygiene core values have an application as Vicki prepares her care plan for the immediate appointment? 3. Pair up with a partners to plan a conversation between Vicki and Lana to

explain: Procedures they will follow for this appointment, Need for medical clearance from Lana’s physician for using anesthesia and other treatments, and Special care Lana will need for her daily care because of the oral–systemic relationship that exists.

Factors to Teach the Patient Attention to respiratory hygiene and cough etiquette. The need for frequent hand washing to help prevent transmission of respiratory disease. The need for thorough daily cleaning and drying of toothbrushes to help prevent spread of infections. How using a new toothbrush and cleaning dentures/orthodontic appliances after bacterial infections can decrease possibility of reinfection. For elderly patients and those with chronic respiratory or cardiovascular disease, diabetes, or immunosuppressed conditions, the need for pneumonia and seasonal influenza immunization. To improve compliance in taking all prescribed medications, maintain a medication list and use pill containers that open easily and are labeled with large type. Options to combat medication-induced dry mouth. Educate the patient help avoid resistant bacteria by not requesting or taking antibiotics for a respiratory infection unless the infection has been determined by their physician to be bacterial rather than viral.34,35

ENHANCE YOUR UNDERSTANDING ONLINE RESOURCES (see the inside front cover for access information) Audio glossary Appendices SUPPORT FOR LEARNING (available separately) Active Learning Workbook for Wilkins’ Clinical Practice of the Dental Hygienist, 13th Edition INDIVIDUALIZED REVIEW Customized practice quizzing with Navigate 2 TestPrep for

Wilkins’ Clinical Practice of the Dental Hygienist

References 1. Sabharwal A, Gomes-Filho IS, Stellrecht E, Scannapieco FA. Role of periodontal therapy in management of common complex systemic diseases and conditions: an update. Periodontol 2000. 2018;78(1):212-226. 2. McLafferty E, Johnstone C, Hendry C, et al. Respiratory system part 1: pulmonary ventilation. Nurs Stand. 2013;27(22):40-47. 3. Jubran A. Pulse oximetry. Crit Care. 2015;19:272. doi:10.1186/s13054-0150984-8. 4. Seto WH, Conly JM, Pessoa-Silva CL, et al. Infection prevention and control measures for acute respiratory infections in healthcare settings: an update. East Mediterr Health J. 2013;19(suppl 1):S39-S47. 5. Centers for Disease Control and Prevention. Respiratory Hygiene/Cough Etiquette. Atlanta, GA: Centers for Disease Control. https://www.cdc.gov/oralhealth/infectioncontrol/faqs/respiratory-hygiene.html. Updated March 25, 2016. Accessed February 2, 2019. 6. Agado BE, Crawford B, DeLaRosa J, et al. Effects of periodontal instrumentation on quality of life and illness in patients with chronic obstructive pulmonary disease: a pilot study. J Dent Hyg. 2012;86(3):204-214. 7. Davies J, Davies D. Origins and evolution of antibiotic resistance. Microbiol Mol Biol Rev. 2010;74(3):417-433. 8. Kinkade S, Long NA. Acute bronchitis. Am Fam Physician. 2016;94(7):560565. 9. Thompson AE. Pneumonia. JAMA. 2016;315(6):626. 10. Franco J. Community-acquired pneumonia. Radiol Technol. 2017;88(6):621636. 11. Gupta G, Mitra D, Ashok KP, et al. Efficacy of preprocedural mouth rinsing in reducing aerosol contamination produced by ultrasonic scaler: a pilot study. J Periodontol. 2014;85:562-568. 12. Centers for Disease Control and Prevention (CDC). Reported Tuberculosis in the United States, 2017. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2018. https://www.cdc.gov/tb/statistics/reports/2017/2017_Surveillance_FullReport.pdf Accessed February 27, 2019. 13. TB Risk Factors. Centers for Disease Control and Prevention. https://www.cdc.gov/tb/topic/basics/risk.htm. Updated March 18, 2016. Accessed February 27, 2019. 14. Petti S. Tuberculosis: Occupational risk among dental healthcare workers and risk for infection among dental patients. A meta-narrative review. J Dent. 2016;49(suppl C):1-8. 15. Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: diagnosis of tuberculosis in adults

and children. Clin Infect Dis. 2017;15;64(2):111-115. 16. Kanabus A. Information about tuberculosis. Global Health Education (GHE). 2018. www.tbfacts.org. Accessed February 28, 2019. 17. Seaworth BJ, Griffith DE. Therapy of multidrug resistant and extensively drugresistant tuberculosis. Microbiol Spectr. 2017;5(2). doi:10.1128/microbiolspec. 18. U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute. Asthma Care Quick Reference Diagnosing and Managing Asthma. Bethesda, MD: NHLBI Health Information Center; 2002. Revised 2012. NIH Publication No. 12-5075. 19. Rabe, FK. Update in asthma 2015. Am J Respir Crit Care Med. 2016;194(3). 20. U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Full Report. Bethesda, MD: NHLBI Health Information Center; 2007:417. NIH Publication No. 07-4051. 21. Devlin J. Patients with chronic obstructive pulmonary disease: management considerations for the dental team. Br Dent J. 2014;217(5):235-237. 22. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. Revised 2018. https://goldcopd.org/wpcontent/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf. Accessed March 2, 2019. 23. Shen TC, Chang PY, Lin CL et al. Periodontal treatment reduces risk of adverse respiratory events in patients with chronic obstructive pulmonary disease: a propensity-matched cohort study. Medicine (Baltimore). 2016;95(20):e3735. doi:10.1097/MD.0000000000003735 24. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Accessed February 27, 2019. 25. Lozano AC, Perez MGS, Esteve CG. Dental considerations in patients with respiratory problems. J Clin Exp Dent. 2011;3(3):e222-e227. 26. Cystic Fibrosis Foundation. Frequently Asked Questions. Bethesda, MD: Cystic Fibrosis Foundation. https://www.cff.org/What-is-CF/About-CysticFibrosis/. Updated August 10, 2016. Accessed February 2, 2019. 27. Carstensen S. Obstructive sleep apnea’s connections with clinical dentistry. Sleep Med Clin. 2018;13:521-529. 28. Pinto JA, Kohler R, Wambier H, et al. Laryngeal pathologies as an etiologic factor of obstructive sleep apnea syndrome in children. Int J Pediatr Ororhinolaryngol. 2013;77:573-575. 29. Marklund M. Update on oral appliance therapy for OSA. Curr Sleep Med Rep. 2017;3(3):143-151. 30. Wojda M, Jurkowski P, Lewandowska A, Mierzwin´ska-Nastalska E, Kostrzewa-Janicka J. Mandibular advancement devices in patients with symptoms of obstructive sleep Apnea: a review. Adv Exp Med Biol. 2019. doi:

10.1007/5584_2019_334. 31. Policy statement on the role of dentistry in the treatment of sleep-related breathing disorders. American Dental Association; 2018. https://www.ada.org/~/media/ADA/Member%20Center/FIles/The-Role-ofDentistry-in-Sleep-Related-Breathing-Disorders.pdf?la=en. Accessed March 5, 2019. 32. ADA Evidence Brief: Oral Appliances for Sleep-Related Breathing Disorders. https://www.ada.org/~/media/ADA/Member%20Center/FIles/ADA_SCI_OralAppl_SRBD_Brie la=en. Accessed March 5, 2019 33. Minichbauer BC, Sheats RD, Wilder RS, Phillips CL, Essick GK. Sleep medicine content in dental hygiene education. J Dent Educ. 2015;79(5):484492. http://www.jdentaled.org/content/jde/79/5/484.full.pdf 34. Martínez-González NA, Coenen S, Plate A, et al. The impact of interventions to improve the quality of prescribing and use of antibiotics in primary care patients with respiratory tract infections: a systematic review protocol. BMJ Open. 2017;7(6):e016253. doi:10.1136/bmjopen-2017-016253. 35. Centers for Disease Control and Prevention. Antibiotic Use in the United States, 2017: Progress and Opportunities. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2017.

61 The Patient with Cardiovascular Disease Dianne Smallidge, RDH, BS, MDH, EdD, and Linda D. Boyd, RDH, RD, EdD

CHAPTER OUTLINE CLASSIFICATION INFECTIVE ENDOCARDITIS I. II. III. IV.

Description Etiology Disease Process Prevention

CONGENITAL HEART DISEASES I. II. III.

The Normal Healthy Heart Anomalies Etiology

IV. Types of Defects V. Prevention VI. Clinical Considerations

RHEUMATIC HEART DISEASE I. II.

Rheumatic Fever The Course of Rheumatic Heart Disease

MITRAL VALVE PROLAPSE I. II.

Description Symptoms

HYPERTENSION I. II. III. IV. V.

Etiology Blood Pressure Levels Clinical Symptoms of Hypertension Treatment Hypertension in Children

ISCHEMIC HEART DISEASE I. II.

Etiology Manifestations of Ischemic Heart Disease

ANGINA PECTORIS I. II.

Precipitating Factors Treatment

MYOCARDIAL INFARCTION I. II. III. IV.

Etiology Symptoms Management during an Attack Treatment after Acute Symptoms

HEART FAILURE I. II. III. IV.

Etiology Clinical Manifestations Treatment during Chronic Stages Emergency Care for Heart Failure and Acute Pulmonary Edema

CARDIAC ARRHYTHMIAS I. II. III.

Etiology Symptoms Treatment

LIFESTYLE MANAGEMENT FOR THE PATIENT WITH CARDIOVASCULAR DISEASE SURGICAL TREATMENT I.

Revascularization

II. III.

Cardiac Resynchronization Therapy Dental Considerations

ANTITHROMBOTIC THERAPY I. II. III.

Anticoagulant Therapy Direct Oral Anticoagulants Antiplatelet Therapy

DOCUMENTATION EVERYDAY ETHICS FACTORS TO TEACH THE PATIENT REFERENCES

LEARNING OBJECTIVES After studying this chapter, the student will be able to: 1. Identify the cardiovascular conditions that may be encountered in patients seeking oral health care. 2. Discuss the etiology, symptoms, and risk factors associated with cardiovascular conditions. 3. Discuss the impact of cardiovascular diseases on the oral cavity and their relationship to oral health. 4. Plan dental hygiene treatment modifications for the patient with cardiovascular disease.

INTRODUCTION Cardiovascular disease (CVD) includes conditions and diseases affecting the heart and blood vessels. Patients with cardiovascular conditions are encountered frequently in a dental office or clinic and may be from any age group, although the highest incidence is among older people. Although a causal relationship between periodontal disease and coronary heart disease (CHD) has not been proven, current data suggest the presence of periodontal disease may be a marker for CHD risk.1 Dental hygienists need to take responsibility to inform patients of the significant relationship between oral and systemic health and the related need for maintenance of healthy oral tissues and prevention of periodontal disease. The major CVDs are included in this chapter, with their principle symptoms and treatments as well as applications for dental hygiene care.

CLASSIFICATION Anatomic classification Diseases of the heart: pericardium, myocardium, endocardium, and heart valves. Diseases of the blood vessels and peripheral circulation. Etiologic classification Congenital anomalies. Atherosclerosis, hypertension. Infectious agents, immunologic mechanisms.

INFECTIVE ENDOCARDITIS Infective endocarditis (IE) is a microbial infection of the heart valves or endocardium with a high mortality rate.

I.

Description IE is a serious disease, the prognosis of which depends on the degree of cardiac damage, the valves involved, duration of the infection, and treatment. IE is characterized by the formation of bacterial vegetations on the heart valves or surface of the heart lining (endocardium). When IE develops, it directly affects the function of the heart.

II.

Etiology2 Microorganisms Streptococci and staphylococci are responsible for IE in most cases, with alpha-hemolytic streptococci being the most prevalent. As yeast, fungi, and viruses have been implicated, the choice of the name “infective” endocarditis is more inclusive than “bacterial” endocarditis. Incidence related to dental procedures: The majority of IE cases related to oral microflora are random bacteremias resulting from routine daily activities. An exceedingly small number of cases are believed to result from dental procedures. Risk factors2,3 Preexisting cardiac abnormalities: Bacteria lodge on the endocardial (valvular) surface during bacteremia. Prosthetic (artificial) heart valves: There is an increased number of patients who have had valve replacement surgery who are susceptible. Patients who have had prosthetic valve replacements have a risk of developing prosthetic valve

endocarditis. History of previous endocarditis. Intravenous drug abuse. Infected material is injected by contaminated needles directly into the bloodstream. Intravenous drug abusers are at high risk for endocarditis, which can initiate on previously normal valves. Precipitating factors Self-induced bacteremia: In the oral cavity, self-induced bacteremias may result from eating, bruxism, chewing gum, or any activity that can force bacteria through the wall of a diseased sulcus or pocket. Interdental aids for oral hygiene can also cause self-induced bacteremia. Infection at portals of entry: Infections at sites where microorganisms may enter the circulating blood provide a constant source of potential infectious microorganisms. In the oral cavity, organisms enter the blood by way of periodontal and gingival pockets, where many species of microorganisms are harbored. An open area of infection, such as an ulcer caused by an ill-fitting denture, may also provide a site of entry. Patients are exposed daily to bacteremias. Trauma to tissues by instrumentation: Bacteremias are created during general or oral surgery, endodontic procedures, periodontal therapy, scaling, and any therapy that results in bleeding.

III. Disease Process Transient bacteremia initiated4 Trauma to a mucosal surface such as the gingival sulcus during instrumentation releases bacteria into the bloodstream. Ease of entry of organisms directly relates to the severity of tissue trauma, quantity of bacterial biofilm, and the severity of inflammation or infection such as periodontitis. Bacterial adherence4 Circulating microorganisms attach to a damaged heart valve,

prosthetic valve, or other susceptible area on the endocardium. Proliferation of bacteria4 Microorganisms proliferate to form vegetative lesions containing masses of plasma cells, fibrin, and bacteria. Heart valve becomes inflamed, and function is diminished. Clumps of microorganisms (emboli) may break off and spread by way of the general circulation (embolism); complications result. Clinical course4 A small number of patients are symptomatic within 2 days, but usually symptoms appear within 2 weeks. Severe symptoms of fever, loss of appetite and weight loss, weakness, arthralgia, and heart murmurs require hospitalization. Diagnosis is based on symptoms, echocardiography, blood cell count, and positive blood cultures. Complications lead to eventual susceptibility to reinfection with IE, congestive heart failure (CHF), and cerebrovascular disease.

IV. Prevention The basic areas for attention in dental and dental hygiene care that contribute to the prevention of IE are as follows: Patient history Special content: Specific questions need to be directed to elicit any history of congenital heart defects, cardiac transplant, the presence of prosthetic valves, acquired valvular defects, or previous episode of IE. Consultation with patient’s physician: Consultation is necessary for all patients with a history of heart defects and any other condition suggesting the need for prophylactic antibiotic premedication. Withhold instrumentation: The use of a probe or explorer during assessment of the patient should be delayed until the medical status is cleared. Prophylactic antibiotic premedication

There exists no conclusive evidence that confirms the effectiveness or ineffectiveness of antibiotic premedication for the prevention of IE.4 Recommended regimens: Follow the current recommendations of the American Heart Association.2,3 Specific information can be found in Chapter 11. When antibiotic prophylaxis is indicated, verify the antibiotic was taken as prescribed. In the patient record, document the name of the antibiotic, time, and dosage taken by the patient. Dental hygiene care Oral health: Prevention and management of oral disease is necessary for each patient susceptible to IE. Education: Instruction in oral self-care such as brushing and interdental cleaning at initial appointments can be provided while the patient is under antibiotic coverage. Sequence of treatment: Biofilm removal instruction precedes instrumentation for scaling to bring the tissues to a healthy state. The more severe the gingival or periodontal inflammation, the higher the incidence of bacteremia during and following instrumentation. Instrumentation: Reduce the microbial population about the teeth and on the oral mucosa prior to instrumentation by having the patient brush, floss, and rinse thoroughly with an antimicrobial mouth rinse such as 0.12% chlorhexidine.

CONGENITAL HEART DISEASES I. The Normal Healthy Heart A diagram of the normal heart is shown in Figure 61-1 to provide a comparison with the anatomic changes that may appear in a defective heart.

FIGURE 61-1 • The Normal Heart. The major vessels and the location of the tricuspid, pulmonary, aortic, and mitral valves are shown.

In the healthy heart, the blood flows in one direction as each chamber contracts, with the valves acting as trap doors that snap shut after each contraction to prevent backflow of blood. The right side of the heart contains deoxygenated blood from the body cells on its way to the lungs for reoxygenation. The left side of the heart contains oxygenated blood from the lungs being pumped out to the aorta on its way to the cells of the body. The septal wall divides the left and right sides of the heart.

II.

Anomalies Anomalies of the anatomic structure of the heart or major blood vessels result following irregularities of development during the first 9 weeks in utero. The fetal heart is completely developed by the ninth week. Early diagnosis is necessary, but not all defects require treatment. Treatment usually involves surgical correction.

III. Etiology Causes may be genetic or environmental or a combination of both. Many are unknown. Genetic5,6 Heredity is apparent in some types of defects. An example of a chromosomal defect is Down syndrome in which congenital heart anomalies occur frequently. Environmental5,6 Most congenital anomalies originate between the fifth and eighth weeks of fetal life, when the heart is developing. Viral infections from the mother (rubella, cytomegalovirus). Drugs (thalidomide, isotretinoin). Drinking alcohol and use of cocaine. Exposure to industrial chemical solvents.

IV. Types of Defects The types of heart defects that occur most frequently are the ventricular septal defect, atrial septal defect, pulmonary stenosis, and patent ductus arteriosis.5 Defects (openings) in the septal wall cause a mixing of oxygenated and deoxygenated blood. Atrial and/or ventricular septal defects result in mixing of the blood from the left and right sides of the heart. Other defects include a passageway between the great arteries and veins, which also causes mixing of oxygenated and deoxygenated blood. Two of the more common congenital heart defects are described here. Ventricular septal defect5 In this type of defect, the left and right ventricles exchange blood through an opening in their dividing wall (septum). The oxygenated blood from the lung, which is normally pumped by the left ventricle to the aorta and then to the entire body, can pass across to the right ventricle through the septal defect, as shown in Figure 61-2.

FIGURE 61-2 • Ventricular Septal Defect. The right and left ventricles are connected by an opening that permits oxygenated blood from the left ventricle to shunt across to the right ventricle and then recirculate to the lungs. Compare with Figure 61-1, in which the septum separates the ventricles.

The severity of symptoms is directly related to the specific location and size of the defect. Small defects may close without surgical correction. Patent ductus arteriosus5 A patent ductus arteriosus means the passageway (shunt) is open between the two great arteries that arise from the heart, namely, the aorta and the pulmonary artery. Normally, the opening closes during the first few weeks after

birth. When the opening does not close, blood from the aorta can pass back to the lungs, as shown in Figure 61-3.

FIGURE 61-3 • Patent Ductus Arteriosus. An open passageway between the aorta and the pulmonary artery permits oxygenated blood from the aorta to pass back into the lungs. Arrows show directions of flow through the patent ductus. Compare with normal anatomy in Figure 61-1.

The heart compensates in the attempt to provide the body with oxygenated blood and becomes overburdened.

V.

Prevention

Prevention of congenital heart defects includes6: Rubella vaccination for women of childbearing age is highly advised

for those not vaccinated in childhood or those without confirmation of immunity by a laboratory test. For women of childbearing age who are health care providers, two measles, mumps, and rubella (MMR) doses at least 28 days apart (or one dose is one dose of MMR was previously administered) is recommended by the Centers for Disease Control and Prevention. No medications, including over-the-counter and herbal medications, are to be taken during pregnancy without prior consultation with the physician. Avoid tobacco use at least 1 month before pregnancy and throughout the pregnancy. Attain and maintain a healthy weight prior to pregnancy. Genetic counseling.

VI. Clinical Considerations Signs and symptoms of congenital heart disease Easy fatigue. Exertional dyspnea, fainting. Cyanosis of lips and nail beds. Poor growth and development. Heart murmurs. CHF. Dental hygiene concerns Prevention of IE: Certain defective heart valves are at risk for endocarditis from bacteremia produced during oral treatments. The American Heart Association recommendations for antibiotic prophylaxis are consulted for procedure with this group of patients.4 Elimination of oral disease: Prevention and management of oral disease.

RHEUMATIC FEVER AND HEART DISEASE7 Rheumatic heart disease is a complication following rheumatic fever. A rather high percent of patients with a history of rheumatic fever have permanent heart valve damage.7

I.

Rheumatic Fever Incidence7 Frequency of this condition in developed countries has declined significantly in the past several decades and is not common in the United States. Primarily effects children between the ages of 5 and 15 years. Etiology7 The onset of acute rheumatic fever usually appears 2–3 weeks after a beta-hemolytic group A streptococcal pharyngeal infection. Rheumatic fever and rheumatic heart disease are believed to be immunologic disorders caused by sensitization to antigens of beta-hemolytic group A streptococci. Prevention7 The persistence and severity of the pharyngeal infection are significant factors in determining whether rheumatic fever follows. Early diagnosis and treatment of streptococcal throat and pharyngeal infections are necessary. Symptoms of acute rheumatic fever7 Low-grade fever. Abdominal pain. Shortness of breath and chest pain related to cardiac issues. Joint pain with arthritis present in the ankles, knees, elbows and wrists as well as joint swelling with redness and warmth. Nosebleeds. Skin rash on trunk and upper parts of the arms and legs or

nodules on skin. Emotional instability. Muscle weakness with quick uncontrolled jerky movements affecting the face, feet, and hands.

II.

The Course of Rheumatic Heart Disease

Following the acute stage of rheumatic fever, symptoms do not usually persist, except the effects of the valvular deformity. Symptoms Stenosis or incompetence of valves; most commonly, the aortic and mitral valves. Heart murmur influenced by the amount of scarring of the valves and myocardium. Cardiac arrhythmias (CAs). Late symptoms include shortness of breath, angina pectoris, endocarditis, pericarditis, elevation of diastolic blood pressure (BP), enlargement of the left ventricle, and increasing signs of CHF. Practice applications The American Heart Association no longer recommends antibiotic prophylaxis prior to dental treatment for patients with this condition due to minimal risk of developing IE.4

MITRAL VALVE PROLAPSE8,9 I. Description The mitral valve is between the left atrium and the left ventricle (Figure 61-1). Oxygenated blood from the lungs passes from the pulmonary vein into the left ventricle, where it is pumped through the aortic valve and into the aorta for distribution to the body cells. When the mitral valve leaflets are damaged, the closure is imperfect and oxygenated blood can backflow or regurgitate. Mitral valve prolapse is the most common disorder of the valve that causes regurgitation.8,9 The mitral valve is prolapsed (becomes misaligned) backward into the atrium during systole.8,9

II.

Symptoms Most patients with mitral valve prolapse are asymptomatic.8,9 A small number of cases will have symptoms of palpitations, fatigue, atypical chest pain, and a late systolic murmur. When there is more severe involvement, an increase in frequency of palpitations and progressive mitral regurgitation is apparent along with a systolic click and murmur.8,9 Initial suspicion for diagnosis of valvular heart disease is the recognition of a heart murmur. The American Heart Association no longer recommends antibiotic prophylaxis during dental treatment for patients with this condition.

HYPERTENSION Hypertension means an abnormal elevation of Arterial Blood Pressure. It has been called the “silent killer.” Hypertension is responsible for more deaths from CVD than any other modifiable risk factor for CVD.10 Detection of BP for dental and dental hygiene patients has become an essential step in patient assessment prior to treatment. Early detection, with referral for additional diagnosis and treatment when indicated, can prove to be lifesaving for certain people. Knowledge of the health problems of patients is needed to ensure it is safe to provide treatment, that is, administration of local anesthesia, and to minimize risk for medical emergencies.

I.

Etiology

A. Primary Hypertension Incidence: Approximately 90% of all hypertension is primary.10 Predisposing or risk factors: Combinations of the factors listed are more significant than any one alone10: Tobacco use. Genetic predisposition. Overweight and obesity. Excess sodium intake. Physical inactivity. Inadequate potassium intake. Excessive alcohol intake.

B. Secondary Hypertension Incidence: About 10% of all hypertension is secondary to other underlying medical conditions.10 Causes of secondary hypertension may include10:

Renal disease. Obstructive sleep apnea. Drug or alcohol induced. Endocrine conditions, such as Cushing syndrome, hypothyroidism and hyperthyroidism hyperparathyroidism. Medications such as amphetamines, antidepressants, caffeine, herbal supplements (e.g., St. John wart), immunosuppressants, oral contraceptives,8 corticosteroids, recreational drugs.

II.

Blood Pressure Levels

A. Normal and High Blood Pressure Table 61-1 lists the normal readings for BP and the stages of hypertension for adults aged 18 years and older.10 TABLE 61-1 • Classification of Blood Pressure for Adults Aged 18 Years or Older BLOOD PRESSURE CATEGORY

SYSTOLIC (MM HG)

DIASTOLIC (MM HG)

Normal