Self-Study Course Series-6 hours CE credit Principles of Public … · 2020-03-04 · Principles of...
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Self-Study Course Series-6 hours CE credit
Principles of Public Health and Evidence-based Guidelines for Preventive Dentistry
Introduction
Completion of this six hour online CE course will not only meet the requirement for the establishment of a Written Protocol Agreement in the state of Tennessee but also provide a well- rounded public health educational opportunity. The guidelines for a one hour online course suggest three hours of study time, so the course could take up to 18 hours of preparation.
A self-study text will be used as the reading material and test questions will include case studies
for which the textbook information will be applied. The self study text “Preventing Medical Emergencies: Use of the Medical History, 3rd Ed.” (Pickett, Gurenlian, 3rd Ed. Lippincott Williams & Wilkins, 2014) provides the self study reading material for the courses dealing with patient assessment and preventing or managing medical emergencies. The text can be secured in hard copy or in digital format, and can be ordered from Amazon.com, the LWW website (http://www.lww.com -- use SEARCH function to locate book), or from other online textbook sites. The digital download is immediate and allows the participant to begin the coursework immediately. The lowest price is usually at the Amazon.com site. When beginning the Public Health CE course, the participant should order the reading material for courses two through five so it will be available and promote continuing with the course information in a timely manner.
The six hour CE begins with a two hour section on the objectives of public health and evidence-based guidelines for preventive dentistry. Sections two through four provide one hour of credit each and will deal with patient assessment and use of the medical history to identify potential medical emergencies; and strategies to prevent the emergency, and guide proper development of a treatment plan for a variety of medically complex conditions. Section five provides the final one hour credit and will include HIPAA laws, the procedure for applying for a written protocol agreement and ethics for clinical practice.
Page 2 is the answer sheet for all sections. Please print and submit Page 2 to TDHA for grading. TDHA will grade the test and upon receiving a passing score of 75%, the course participant will be sent a Certificate of Completion. A copy of the certificate should accompany the application for a written protocol agreement submitted to the Tennessee Board of Dentistry. The TN Dental Hygienists’ Association does not submit any information on behalf of any participant.
The cost of the course is $90.00 for TNDHA/ADHA members and $100.00 for all other participants. Please send test answer sheet, appropriate payment and, if applicable, a copy of ADHA membership card to the TNDHA Treasurer:
Susan Melton, RDH 5320 Custis Lane Knoxville, TN 37920 [email protected] Questions regarding the course process may be addressed to the above treasurer. Questions
regarding course content cannot be answered by the treasurer.
Principles of Public Health and Evidence-based Guidelines for Preventive Dentistry
Answer Sheet
Enter answers below. Please submit this answer sheet for all 5 courses contained in the Public Health Self Study to TNDHA for
grading. Upon receiving a passing score of 75%, the course participant will be sent a Certificate of Completion. It is recommended
that a copy of the certificate accompany the application for a written protocol agreement submitted to the Tennessee Board of
Dentistry. The TN Dental Hygienists’ Association does not submit any information on behalf of any participant.
The cost of the course is $90.00 for ADHA members and $100.00 for all other participants. Please send this test answer sheet,
appropriate payment and, if applicable, a copy of ADHA membership card to the TNDHA Treasurer.
Susan Melton, RDH, 5320 Custis Lane, Knoxville, TN 37920 [email protected]
Participant Information
NAME ____________________________________________________________________________________
ADDRESS ________________________________________________________________________________
__________________________________________________________________ZIP_____________________
PHONE _________________________________________E-MAIL___________________________________
METHOD OF PAYMENT
o CHECK-Payable to TNDHA OR ○ CREDIT CARD
CC# ______________________________________________ Exp. ________________ CVV _______________
CHOOSE ONE:
o ADHA MEMBER $90.00-must submit copy of membership card
o NON-MEMBER $100.00
Section 1
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Section4
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Section 5
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Course Objectives
1. The first course in the series will identify essential components of preventive dentistry and the
goal of public health programs.
2. Evidence based guidelines for preventive dentistry will be reviewed by using the current clinical
practice guidelines for caries control.
3. Access to high level evidence from the American Dental Association (ADA) systematic review
website will be provided.
4. The 2012 ADA/Food and Drug Administration guidelines for selection of patients for dental
radiographs will be provided.
Course Instructions
Public health programs make available basic healthcare for the majority of people. To meet this
objective, the course will direct the reader to professional evidence-based guidelines for current
prevention strategies addressing the most common oral diseases. In addition, free access to the highest
level of evidence, the systematic review (SR), will be provided and selected SRs will be accessed which
involve products used for improving oral health. A national randomized survey of practicing dental
hygienists (http://www.ncbi.nlm.nih.gov/pubmed/11318004) revealed that knowledge of caries
epidemiology and preventive techniques was low. This course will contain national guidelines for
efficacious methods (ones that work) for caries prevention.
Courses two through five will use the self-study text “Preventing Medical Emergencies: Use of the
Medical History, 3rd Ed.” (Pickett, Gurenlian. Lippincott Williams & Wilkins, 2014) as the self-directed
reading material for the courses dealing with Patient Assessment and Preventing or Managing Medical
Emergencies. Either the hard copy paperback text or the digital download version can be used.
As each section of the course is used and links accessed, there will be written instructions on
information that applies to various risk groups or ages. Objectives will be identified at the beginning of
each section and test items will relate to these objectives so reader should make sure answers for the
objectives are found as materials are examined. Most information is found at the ADA Clinical
Recommendation site at http://ebd.ada.org/en/evidence/guidelines . Your computer will need to have
internet access and be connected to the internet. Before the link is accessed from this instruction page,
place the cursor over the link; use the method of pushing the CTRL button and clicking the underlined
URL link. The internet link will open in a new window. This allows you to toggle between the course
instructions/ objectives and the information in the internet link (ADA clinical guidelines). When you
reach the ADA or American Academy of Periodontology (AAP) Clinical Guideline, right click the specific
guideline link, and select “Open Link in New Tab”. This allows the reader to toggle between the Clinical
Guideline page and the specific guideline being examined. Since several guidelines are available on the
ADA Clinical Recommendations page, this can save time when taking the course. Course participants can
toggle between the INSTRUCTION page objectives and the Clinical Guideline link to read and apply the
information to a hypothetical case.
Section 1: Basics of Public Health for Prevention of Oral Disease (Two hours)
Dental caries, pulpal infection, and periodontal disease are the most common oral diseases. Evidence-
based clinical practice guidelines will be used to guide the practitioner in identifying evidence-based
preventive strategies for caries and periodontal disease. These guidelines will also guide management of
pulpal infection and of periodontal disease. National professional guidelines will be the resources for
this information.
Dental Caries
Dental caries is a bacterial infection that results in demineralization and breakdown of hard tooth
surfaces. Current strategies to remineralize these areas with fluoride provide the basis for reversal of
caries. When irreversible caries has developed, the treatment involves restorative dentistry which
requires a visit to a dentist. The most advantageous strategy for this disease risk is to prevent dental
caries. The three most effective, evidence-based methods to prevent dental caries involve use of
fluoride therapy/products, application of sealants, and to advise against dietary practices that lead to
caries (http://jada.ada.org/content/142/9/1065.full.pdf+html) .1 The dietary practices are not defined
but can include lowering the frequency of eating sugar and eating foods between meals that do not
initiate an acid attack in the mouth. This can include elimination of between meal snacking, especially
with sweet foods; having sweet foods at the mealtime only; and eating nonretentive foods as snacks
(e.g. an apple is better than raisins or dried fruits, cheese is good and regular popcorn is not an acid
producing food). At the link above primary strategies for caries prevention are explained in the ADA
policy on Nonfluoride Caries Preventive Agents1 where the three primary strategies for prevention of
dental caries are listed. This policy published in 2011 identifies non-fluoride products which have
scientific evidence for caries prevention and those products without scientific evidence for an anticaries
effect. The guidelines stress the nonfluoride products are adjunctive agents and should be used (1) only
in patients at high risk for caries and (2) only after the primary strategies have been used, but more help
is needed. The executive summary link includes an abstract that states “The panel concluded that
certain nonfluoride agents may provide some benefit as adjunctive therapies in children and adults at
higher risk of developing caries. These recommendations are presented as a resource for dentists to
consider in the clinical decision-making process.” The important thing to note is that any “nonfluoride
anticaries product” is recommended to be used only in patients at high risk for caries and only as an
adjunct to primary therapies. The evidence for efficacy of nonfluoride agents is not strong so the word
“may” is used in the abstract. There is also a chair side summary of the recommendations which can be
printed and used as a reference at
http://ebd.ada.org/~/media/EBD/Files/6869_ChairsideGuideNonFlouride.ashx . Children typically
experience enamel caries and adults/ elderly experience both enamel and root surface caries.
Objectives for test items: List the three primary therapies to reduce dental decay.
Identify which adjunctive therapies have evidence for additional caries prevention when a high risk for caries exists and use of primary therapies did not reduce decay progression. Access the Chair side Guide link for a quick summary of the recommended products and those not recommended.
Differentiate between nonfluoride products recommended to reduce enamel caries and those to reduce root surface caries.
Sealant guidelines for caries prevention – Sealants can be used on deciduous teeth or on
permanent dentition surfaces. They have been reported to be 99% effective to reduce dental caries
when placed properly. The ADA clinical practice guidelines2 for when sealants should be placed is
available at ADA Clinical Practice Recommendation site at
http://ebd.ada.org/~/media/EBD/Files/report_sealants_summary.ashx . Scroll down the Guideline titles
and find “SEALANTS”. At the ADA Clinical Recommendations site, click the “sealant” link and select the
executive summary link from the list to find the recommendation for placement of sealants and answers
to clinical questions. An important guideline to note is in TABLE 3 (scroll down to find this table
information). The decision to place a sealant is made following a caries risk assessment and sealants can
be applied to the appropriate “at risk” tooth surfaces in children, adolescents and adults. Early,
noncavitated carious lesions are acceptable for sealant application. Two types of sealant products are
available and resin based products are recommended to be used in a traditional situation. Examine
“Placement Techniques” in Table 3 to find do’s and don’ts in technique and product selection. Clinical
pictures of early, noncavitated lesions (Fig. 1-5) are illustrated in the chair side guide for sealants at
http://ebd.ada.org/~/media/EBD/Files/report_sealants_summary.ashx .
Objectives:
Identify circumstances when a sealant should be placed. [A chair side guideline is available at http://ebd.ada.org/~/media/EBD/Files/report_sealants_summary.ashx .]
Identify which tooth surfaces should receive a sealant.
Identify the recommendation for an early noncavitated lesion in enamel surface.
Identify conditions when a resin-based sealant should be selected and situations when a glass ionomer cement sealant is best.
List techniques that improve sealant retention or reduce sealant retention
Guidelines for Topical Fluoride Application
Topical In office fluoride products are applied at dental appointments for the purpose of reducing the
risk for caries. There are ADA Clinical Practice Guidelines3 (Nov 2013) available on the Clinical
Recommendation site at http://ebd.ada.org/en/evidence/guidelines . [Hold CTRL key down and double
click the underlined link and it will open in a new tab.] Find the category labeled “Topical Fluoride” and
click on the link. A list is shown that contains the official recommendations, an executive summary of the
recommendations and a Chairside Guide that summarizes the recommendations. [You can toggle
between the guidelines and these instructions and objectives.] The ADA recommendations involve
selecting the patient who might benefit from topical fluoride application in the dental office, and are
based on having an increased risk for caries. Topical fluoride application for children at various ages and
also for adults is addressed. Look at the chair side guide [Right click the link for the chair side guide,
select “open in a different tab”] for a shorter summary of the recommendations. At the top are the
recommendations based on the strength of evidence for risk for caries (Low, Moderate, and High, Expert
Opinion) and the ages of the patients. Notice no individuals in a “low risk” are likely to benefit from
topical in-office fluoride as the statement is made “Patients at low risk of developing caries may not
need additional topical fluorides other than over-the-counter fluoridated toothpaste and fluoridated
water”. Notice also that for children <6 years of age, fluoride varnish is the only form of fluoride
recommended. Scroll down to the bottom of the chair side guide to learn the criteria for the various
caries risk categories. Access the Executive Summary of the Clinical Recommendations from the ADA
Clinical Recommendations site and look on page 1284. Table 5 identifies the variety of topical fluoride
products and the ages of the patient where each applies. Notice only the 4 minute application is the
preferred procedure. The scientific evidence for effectiveness of one minute application is not evidence-
based and is discouraged. In addition, when it has been determined that topical fluoride application is
indicated, twice yearly applications are recommended. Either sodium fluoride or acidulated phosphate
fluoride products are effective.
Objectives:
Describe criteria to determine caries risk and identify which caries risk groups are likely to benefit from in-office topical fluoride treatment, and those unlikely to benefit.
List the forms of topical fluoride products and the types recommended for use in the dental office, based on age and caries risk level.
Apply the recommendations made in the systematic review of the literature to a case.
Fluoride supplementation recommendations for communities without water fluoridation are available at
the National Clearing House site (http://www.guideline.gov/content.aspx?id=34445). These
supplements must be prescribed by a DDS and are not available over the counter. They would only be
recommended when the water being consumed is less than 0.7ppm. The recommendations are not
included in the course but available for review if the client lives in an area where fluoride concentration
in the drinking water is low and the caries risk is moderate to high. A dentist must prescribe this
product.
Management of pain and infection for pulpal infection.
There is a 2007 review of the literature4 on treatment of pulpal infection at
(http://www.medicinaoral.com/pubmed/medoralv12_i2_p154.pdf) but guidelines are only available
from the Canadian Dental Association (http://www.cda-
adc.ca/_files/dental_profession/practising/clinical_practice_guidelines/full_version.pdf) .
This information can be accessed when individuals having a
WRITTEN PROTOCOL agreement desire direction on management of
pulp infection and pain. The 2007 review, in the section on
“Treatment of Odontogenic Infection”, identifies the initial therapy
of incision and debridement to reduce the bacterial load [push Ctrl key and while holding it down push
the key F and put words “infective bacterial load” in the box, select NEXT in the lower part of the box]. In
the 2002 Canadian guidelines find the section “The Clinical Question” [ctrl F method again, put “general
dentist” in box] and look at the target population characteristics (chronic apical infection not included in
these guidelines]. Look at 6.1 Draft Key Recommendations [use ctrl F again]. Notice on page 9 of the CPG
for emergency management of acute pulp infection, antibiotics are not recommended to reduce pain
and only nonsurgical (incision/drainage) or root canal therapy is recommended. Pain can be controlled
with ibuprofen or another NSAID analgesic. Opioids (e.g. hydrocodone or hydrocodone/ibuprofen/
aspirin/acetaminophen combination products) are not the first choice for analgesia or pain relief.
When pulpal infection in children is investigated, guidelines are available from The American Academy of
Pediatric Dentistry (2009). Updated official guidelines for management of acute pulpitis/apical
periodontal infection can be found at
http://www.aapd.org/media/Policies_Guidelines/G_AntibioticTherapy.pdf. The guideline begins with a
discussion of the problems that have developed when antibiotics are overused. A section on
recommendations advises conservative use of antibiotics and general principles to consider when
deciding whether or not to use antibiotics. Those wounds determined to have an increased risk for
infection (open lacerations, fractures) are recommended for antibiotics. For pulpal infection (second
section of recommendations), the recommendation involves using a pulpotomy to remove the bacterial
burden of caries and NOT prescribing antibiotics. More information can be read at the reader’s
convenience at http://www.aapd.org/media/Policies_Guidelines/G_Pulp.pdf.
Objectives:
Identify the first line of treatment when pulpal infection or an abscessed tooth is found.
In the Canadian guidelines identify the initial therapy for acute pulp infection and if antibiotics are recommended.
Apply the American Academy of Pediatric Dentistry clinical guideline to the patient in the photo above.
These therapeutic actions can be completed only by a dentist. For adults, tooth extraction is also
recommended. In children, pulpotomy can resolve the pain and is often used until the root canal
matures and an endodontic procedure can be accomplished at a later date. This is a perfect example of
why a written protocol agreement between hygienists and a dentist is useful to provide oral care to
underserved and vulnerable populations.
Periodontal Disease
The third most common oral problem relates to periodontal disease. You will leave the ADA Clinical
Recommendations site now and [be sure to hold CTLR key down and click the URL] go to the Academy of
Periodontology website at http://www.joponline.org/doi/pdf/10.1902/jop.2011.117001. This link
includes the July 2011 American Academy Periodontology policy6 on “Comprehensive Periodontal
Therapy: A statement by the AAP”. The policy begins with the scope of therapy and states that proper
treatment, control of biofilm and regular maintenance care are the hallmarks of maintaining the
dentition. Patient values and follow through on periodontal care need to be included when risk factors
are considered. In the section describing “treatment” the first therapy is oral hygiene education
regarding how risk factors can be controlled. This is followed by the importance of removing hard and
soft deposits which, in the general practice of dentistry, involves the dental hygienist. The last treatment
recommendations include various periodontal surgical procedures and occlusal assessment, followed by
post treatment evaluation and periodontal maintenance.
A discussion of how these guidelines can be used by the practitioner is available at
http://www.dimensionsofdentalhygiene.com/2011/11_November/Features/Navigating_the_Clinical_Ro
ad_Map.aspx. This latter paper can be read on the reader’s personal time.
The AAP statement is intended to serve as a clinical road map for any dental professional who
supervises, administers, teaches, or regulates the provision of periodontal therapy. This includes dental
hygienists who are generally on the front lines of treatment and patient education. They provide a great
education tool that helps hygienists explain to patients the causes and extent of periodontal disease and
why periodontal treatment is needed. Issues to include in education programs are
What is the reason for regular periodontal maintenance treatment?
Can periodontal disease be cured with treatment or only arrested?
What are the best methods to prevent periodontal disease?
Objectives:
Identify elements of the scope of periodontal treatment.
Discuss the rationale for treatment of periodontal disease to a patient.
Identify therapeutic procedures a dental hygienist contributes in the management of periodontal disease.
List therapeutic options for management of periodontal disease. See Course Introduction for instructions on taking the Self-Test.
References 1. Council on Scientific Affairs. American Dental Association. (2011). Non-fluoride caries preventive
agents. Retrieved from http://jada.ada.org/content/142/9/1065.full.pdf+html. 2. Council on Scientific Affairs. American Dental Association. Evidence-Based Clinical
Recommendations for the Use of Pit-and-Fissure Sealants. JADA 2008; 139:257-68. Retrieved from http://ebd.ada.org/~/media/EBD/Files/report_sealants_summary.ashx.
3. Weyant RJ, Tracy SL, Anselmo T et al. Topical fluoride for caries prevention: Executive summary
of the updated clinical recommendations and supporting systematic review. JADA 2013;
144(11):1279-1291. Retrieved from
http://ebd.ada.org/~/media/EBD/Files/JADA_updated_executive_summary_Nov_2013.ashx.
4. López-Píriz R, Aguilar L, Giménez MJ. Management of odontogenic infection of pulpal and
periodontal origin. Med Oral Patol Oral Cir Bucal 2007; 12:E154-9.
5. American Academy of Pediatric Dentistry. Council on Clinical Affairs. Guideline on Use of Antibiotic Therapy for Pediatric Dental Patients. 2009. Retrieved from http://www.aapd.org/media/Policies_Guidelines/G_AntibioticTherapy.pdf.
6. American Academy of Periodontology. Comprehensive Periodontal Therapy: A Statement by the American Academy of Periodontology. J Periodontal 2011. Retrieved from http://www.joponline.org/doi/pdf/10.1902/jop.2011.117001.
PUBLIC HEALTH SELF STUDY
SECTION ONE Self Test
ANTI-CARIES STRATEGIES
1. The three evidence based methods to prevent dental caries includes all of the following EXCEPT
one. Which is the EXCEPTION?
a. Brushing and flossing
b. Dietary advice to avoid practices that promote caries
c. Fluoride therapy
d. Sealant application
2. For the client at high risk of dental caries who follows advice for caries control what adjunctive
product can be used to reduce the risk for root caries?
a. Amorphous calcium products or casein derivatives
b. Chlorhexidine/thymol varnish
c. Xylitol lozenges
d. Xylitol gum
SEALANTS
CASE: The 5 year old patient is drinking apple juice from a “sippy cup”, waiting for the dental
appointment. Oral examination reveals the patient has caries in deciduous maxillary anterior incisors.
The occlusal pits of posterior deciduous molars are stained but do not appear to have carious
involvement. The patient does not complain of pain. Patient can brush teeth effectively when asked to
demonstrate how he brushes his teeth. He has copious salivation during the examination.
3. Identify teeth that should receive a sealant.
a. Mandibular incisors
b. Maxillary incisors
c. Occlusal surfaces of deciduous teeth
d. Sealants are not indicated for this patient.
4. Can placement of a sealant on an early noncavitated lesion stop the progression of caries?
a. Yes
b. No
5. For clinical situations which pose a high risk for moisture contamination, which is the preferred
type of sealant product?
a. Glass ionomer cement sealant
b. Resin based sealant
6. Use of self-etching agents, which do not involve a separate etching step are
a. Likely to produce an inferior bond.
b. Recommended for use due to more rapid treatment time.
c. Recommended for use due to superior bonding results.
APPLICATION CHAIRSIDE TOPICAL FLUORIDE
CASE: A 70 year old patient who comes annually for a dental examination and cleaning is seated in your
chair. She has had annual oral prophylaxis treatments for the past six years since entering the practice.
She requested bite wing x-rays two years ago since she planned to leave the country and wanted to
make sure no dental disease was present before she left. No disease was found on the radiographs and
the clinical exam revealed intact margins in restorations, presence of 28 teeth, 3rd molars extracted
when patient was a teenager and probe depths 1 to 2 mm, pink firm gingivae, no bleeding on probing.
The patient chief complaint was “need teeth cleaned”.
7. What caries risk group does this patient history describe?
a. Low risk
b. Moderate risk
c. High risk
8. Which of the following forms of topical fluoride is recommended for children <6 years old?
a. Sodium fluoride foam
b. Acidulated fluoride gel
c. Sodium fluoride varnish
d. Chlorhexidine/thymol varnish
9. The clinical evidence for the effectiveness of one minute topical fluoride treatments is
a. Available in lab experiments only.
b. Of moderate quality revealing effectiveness in the mouth (in vivo).
c. Of high quality revealing effectiveness in the lab only.
10. For individuals at moderate to high risk for caries in-office fluoride applications should be
recommended
a. Every 3 to 6 months
b. Every 12 months
c. None of these
PULPAL INFECTION
11. When acute pulpal infection is found in a patient (experienced by throbbing pain, presence of
obvious caries) what is the first line of therapy to resolve the infection in the Canadian
Collaborative Practice guidelines?
a. Antibiotic therapy for 10 days
b. Incision and drainage
c. Root canal therapy
d. Both b and C are recommended
12. The American Academy Pediatric Dentistry guidelines recommend _____ for the patient in the
photo in the directions for course one.
a. Antibiotic therapy and pulpotomy
b. Pulpotomy only
c. Tooth extraction
PERIODONTAL DISEASE – AAP GUIDELINES
CASE: A 42 year old patient presents for periodontal treatment. The chief complaint is “My gums hurt
and I have some pus coming from my gums”. The medical history reveals regular use of cigarettes, no
recent medical problems, and a healthy condition. Vital signs are all within normal limits. Historical
information reveals last dental appointment five years earlier, when the patient was diagnosed with
periodontal disease and “deep scaling” was performed over four appointments. He did not return for
follow up care. Periodontal examination revealed generalized plaque along the gingival margin, probe
depths of 4 to 6 mm, generalized bleeding on probing, and purulent exudates localized to the
mandibular molar area. Supragingival and subgingival calculus deposits were generalized throughout the
mouth.
13. Which of the following findings in the case reduce the likelihood that the dentition will not last
for the patient’s lifetime?
a. Irregular dental appointments
b. Presence of biofilm and calculus
c. Failure to follow periodontal maintenance
d. All of the above
14. All of the following features should be included in the risk assessment for periodontal disease.
Patient decisions and values are included. Which risk factor can be diminished by dental
hygiene procedures?
a. Regularity of periodontal maintenance visits
b. Habit of tobacco use
c. Thorough removal of calculus
d. Regular home based plaque control
15. Treatment procedures for periodontal disease recommended in the AAP guidelines include all of
the following EXCEPT one. Which is the EXCEPTION?
a. Training on oral hygiene and how to reduce risk factors
b. Meticulous removal of calculus deposits
c. Periodontal procedures to eliminate periodontal pockets
d. Selective extraction of teeth or roots
e. Placement of fixed crown and bridge appliances to stabilize teeth
Section 2: Patient Assessment and Use of the Medical History to Identify Potential Medical
Emergency Situations (one hour credit)
This section will be completed to meet part of the requirements for establishing a written protocol
collaborative agreement. The self study text “Prevention of Medical Emergencies: Use of the Medical
History, 3rd Ed.” is used for didactic information. This text includes self-study questions to validate
understanding of information when the health history review occurs. Case studies follow at the end of
each chapter providing an avenue for information to be applied to a clinical situation. Chapters 1
through 5 will be included in SECTION TWO.
Chapters 1 through 4 - Use of the Health History Review to Identify Risks in Oral Procedures
Section one this Public Health course prepared participants to find current evidence-based information
for preventive treatments and agents related to caries. The American Dental Association (ADA)
guidelines for use of fluoride products and sealants were examined. Recent ADA/Food and Drug
Administration guidelines guiding selection of patients for dental radiographs were included.
Additionally current American Academy of Periodontology (AAP) guidelines for periodontal care were
examined. These resources provide the primary base for strategies practitioners can use to plan patient
management in a collaborative practice, both for children/adolescents and for adults/elderly.
Chapter 1 – Read pages 1 to 16. Objectives for this one hour course are in bold font. Each chapter
identifies specific objectives included.
Pages 1-2 identify key terms with definitions used in the reading. Look over these terms to ensure
understanding of the terms. Page 2 lists medical conditions included in the chapter.
The best way to prevent a medical emergency during oral procedures is to gain vital information before
the treatment begins, through a comprehensive review of the health history. This practice is often
referred to as “risk assessment”. The current guideline developed by the American College of Cardiology
for assessment of the patient with a history of serious heart disease, prior to delivery of oral care,
involves asking questions to determine the level of “functional capacity”. These questions should be
asked when the patient has experienced a heart attack (myocardial infarction), angina (substernal pain),
tachycardia or fibrillation (rapid, irregular heartbeat), or any condition in which the cardiovascular
system is seriously affected (see Box 1.2, p. 10).
Functional capacity is explained on page 3 and metabolic requirement (MET) values listed in Table 1.1.
Questions to determine if the 4 MET level has been met are on page 3 (bottom), right column. When
functional capacity meets a 4 MET level, a cardiac medical emergency risk is low and dental procedures
can be initiated. The old advice to “wait six months before dental treatment” no longer is recommended
and has been replaced with assessment of functional capacity. Professional guidelines are currently
based on a systematic review of evidence, and there was no evidence to support “waiting 6 months”.
Risk classification using ASA system is identified on pages 4-5. When it is determined patient health falls
into ASA I through III treatment can continue. For ASA IV and above medical clearance is required.
The ADA Health History two page form (pages 6-7) is used to identify important information needed
when determining risks for providing oral care. Each item on the health history will be discussed in the
self study course and those questions relating to a potential medical emergency will be identified, along
with how to prevent the emergency, and how to manage the most likely emergency, should it occur.
Blood pressure in children, adolescents and adults is discussed on pp. 5, 8 -12. Table 1.2 lists categories
for adults, aged 18 and higher. In adults, BP values equal to or greater than 180/110 should not receive
oral procedures until a medical release has been received in written form. This protects the dental team
if legal events develop. Table 1.3 includes values for children aged 3 to 17. The national guidelines
suggest BP should be measured in all health settings at age 3 and above. Use these tables to assess the
stage of blood pressure when patient assessment occurs. Pediatric patients with BP over values listed in
Table 1.3 should be referred for medical evaluation; however, a limit has not been established for “do
not treat” decisions in children. Self-study items related to this information are found on pp. 12-13.
Answers found on pg. 221 for all self study items.
The chapter concludes with guidelines on evaluating pulse, respiration, and temperature vital signs.
Stress reduction protocols are described since stress can impact all vital signs. Self study questions are
included in these sections, as well.
Consider the questions in the REVIEW section, pg. 16. Answers are on page 221.
Examine the case A study. Answer the questions which follow the case. Answers provided on page 221.
Chapter 2 explains why the ADA Health History begins with screening questions on tuberculosis (TB). TB
is reducing overall, but certain population groups have an increased prevalence of TB. Dental procedures
are contraindicated when active TB exists. When responses to screening questions suggest active TB, the
patient should be referred to the local Public Health facility for medical evaluation. This is the health
organization specially trained to identify and manage TB. For collaborative practices serving immigrant
populations this could be important, since TB is more often found in foreign born individuals. Dental
professionals are recommended to have the Mantoux TB skin test. How often the test is needed relates
to the degree of risk for TB in the community within which they live or practice. The local Public Health
Department can provide this information. Read chapter 2 and answer self-study questions, review
questions and cases A and B. Answers are on page 222 at the end of the text.
Chapter 3 discusses health history items that provide information on dental experiences and oral
hygiene habits. Read pp. 25-39, review key terms and note medical conditions discussed in chapter.
Questions are presented in red font. Each question is followed with information regarding how patient
responses apply to the clinical situation and clinical considerations are discussed on pp. 28-30. Review
the Self Study items to measure understanding of the information. Answers on pg. 222.
The question related to “problems with previous dental treatment” is very important as it directly
relates to the most common emergency to develop in the dental chair, syncope (fainting). For anxious
patients a stress reduction protocol should be considered to reduce the risk (prevent) for loss of
consciousness due to “faint”. Stress reduction is discussed and management of loss of consciousness
explained (pg. 33) and illustrated (Fig. 3-1). Hyperventilation is another potential emergency for anxious
patients (pg. 33-34). Breathing into the hands is an easy method, rather than trying to find a paper bag.
Talking the patient through slowing the breathing rate has been successful while the patient cups hands
over the mouth (Fig. 3-2).
Chapter 3 continues (pp. 34-38) with other health history questions that can impact treatment plan
decisions. Purchase of the text provides a code to access color photographs on THE POINT web site,
explained at the beginning of the text. A new resource in the 3rd edition is a collection of videos
demonstrating management of the most common emergencies to occur in dental offices. Review the
self – study questions, review questions and cases. Answers are provided pg. 222.
Chapter 4 includes medical health assessment and drug information. Read pp. 40 to 51. Before
beginning treatment the drug regimen the patient is taking should be reviewed. It can occur that the
patient forgets to report a medical condition for which a drug is being taken. Comparing the medical
information provided by the patient with the drugs being taken can help to identify this failure. Medical
problems within the past few years should be followed up to determine if the condition is resolved or
how it is being managed and stabilized. Potential side effects of drugs should be investigated in a drug
reference for relevance to oral procedures (oral side effects, postural hypotension risk, bleeding risks,
etc.). Potential emergencies related to drugs and/or herbal supplements are discussed on pp. 43-49. For
unconsciousness, the patient should be placed in the supine position so blood can get to the brain
easily. When hyperventilation develops having the patient breathe into cupped hands to re-breathe
carbon dioxide is effective, while calmly encouraging slowing of the breathing rate. Although it was
suggested in the past to delay dental procedures involving bleeding when the patient is taking aspirin,
clinical studies show this is not necessary. For excessive bleeding digital pressure usually stops the
bleeding by stimulating clot formation. High doses of aspirin prior to surgical dental procedures (but not
nonsurgical dental hygiene instrumentation) need medical laboratory evaluation to determine the effect
on platelet levels. Review the self-study items for comprehension of information, and look at the
REVIEW questions and cases. Answers are found at the end of the text.
Chapter 5 includes more drug information, specifically consideration of antibiotic prophylaxis (AP)
when the patient has a joint replacement or if the patient takes bisphosphonates (Fosamax, others) for
osteoporosis. The information in the chapter discussing total joint replacement was changed December
2012 when a new joint policy was released by the ADA and the American Academy of Orthopedic
Surgeons (AAOS).1 The new policy no longer recommends AP prior to dental procedures when knee or
hip replacements are reported. However, the new policy statement was given a “limited” value for the
scientific support since only one case control study was available on which to make the
recommendation. Practitioners were advised to use professional judgment when deciding to follow a
recommendation based on limited science. For this reason, it is likely many orthopedic M.D.s will still
require AP for their patients with prosthetic joint replacements. A new feature in the guidelines is a
Shared Decision Making Questionnaire. This can be found in the ADA link on the new guidelines. The
information in Ch. 5 can be applied when AP is requested in patients with total joint replacement.
Indications in Box 5.1 illustrate potential risks for prosthetic joint infection. Since AP is no longer
recommended, there were no antibiotics included in the current guidelines. If the orthopedist advises
AP, that physician should prescribe the drug to be taken prior to dental procedures. Given this new
guideline statement the only official organization to recommend AP prior to dental procedures is the
American Heart Association and indications have been greatly reduced (previous history of IE was
retained, but heart murmur and mitral valve prolapsed were deleted). AP for cardiac conditions will be
discussed in a later chapter.
The chapter ends with a discussion of bisphosphonate (BIS) drugs which have been reported to lead to a
rare side effect that affects bone in the jaws, called bisphosphonate-related osteonecrosis of the jaw
(BON). This condition was recently changed to anti-resorptive agent related osteonecrosis of the jaw
(ARONJ). Both bisphosphonates and denosumab, an anti-resorptive agent similar in action to BIS agents,
are implicated. The ADA developed guidance for dental treatment when oral anti-resorptive agents are
used, or intravenous bisphosphonates have been received in the past.2 Review the self study items for
the previous guidelines and examine the current guidelines supplied in the reference section and
available on the web (URL links in bibliography below). Examine the REVIEW section and the two cases
for this population of patients, remembering the updated guidelines.
See Course Introduction for instructions on taking the Self-Test.
References
1. American Academy Orthopedic Surgeons, American Dental Association (2012). Antibiotic
prophylaxis for bacteremia in patients with joint replacements. Available at
http://ebd.ada.org/~/media/EBD/Files/dentalexecsumm.ashx. Accessed August 28, 2014.
2. American Dental Association. Council on Scientific Affairs (2011). Managing care of patients
receiving anti-resorptive agents. Available at
http://www.aae.org/uploadedFiles/Publications_and_Research/Endodontics_Colleagues_for_Ex
cellence_Newsletter/BONJ_ADA_Report.pdf. Accessed August 28, 2014.
PUBLIC HEALTH SELF STUDY
SECTION TWO Self-Test
1. Which of the following blood pressure values in an adult recommend no dental procedures to
be initiated?
a. 120/80
b. 160/90
c. 180/110
d. None of these
2. When a patient has a history of myocardial infarction (heart attack) patient assessment should
begin with
a. Asking if it has been six months since the event
b. Calling the physician to ask for permission to treat
c. Determining the functional capacity to meet the 4 MET level
3. When screening questions for tuberculosis suggest active disease is present in the patient, what
is the suggested patient management procedure?
a. Refer patient immediately to public health for medical assessment.
b. Continue with oral exam but delay restorative or periodontal treatment.
c. Call the patient’s physician for permission to treat.
4. What medical test is used to monitor for TB in a dental professional?
a. Tyne skin test
b. Mantoux TB skin test
c. Blood test for antibodies to TB
d. Chest X-ray
5. If syncope develops during the dental procedure, which of the following procedures should be
implemented?
a. Place in upright position and place the head between the knees
b. Lower the chair back to place in supine position
c. Move patient to floor and use Trendelenburg position
6. When the patient wears a removable maxillary dental appliance which of the following
conditions is likely?
a. Papillary hyperplasia
b. Formation of torus palatines
c. Lingual gingival hyperplasia
7. Anxiety experienced by the dental patient leads to which of the following conditions?
a. Hyperventilation
b. Syncope
c. Loss of consciousness
d. All of these
8. The most effective procedure to stop gingival bleeding is
a. Digital pressure over the bleeding area.
b. Topical application of epinephrine.
c. Transfer to hospital for platelet infusion.
9. If patient presents with symptoms of reflux (GERD) or nausea, treatment is best completed in
a. Supine position
b. Upright position
c. Prone position
10. Antibiotic prophylaxis can be considered for which of the following situations?
a. Having a hip or knee joint replacement
b. Having a history of infective endocarditis
c. Having a port for kidney dialysis
Section 3: Allergic Reaction Emergencies (one hour credit)
Section two reviewed the importance of taking and reviewing the medical history (MH). A long standing
guideline is that the best way to prevent medical emergencies during oral procedures is to “take a good
medical history”. This involves not only identifying the potential emergency situations, but also asking
the right questions to identify the level of risk for positive responses on the MH and understanding the
significance of the patient response. This is followed by critical thinking or professional judgment to
identify risks during treatment and how to minimize those risks. In the case of screening for
tuberculosis, the risk is on the practitioner. In settings that could be established by the written protocol
collaborative agreements patients may include groups at high risk for TB. Participants in the course
should pay close attention to the follow up question discussions, the prevention section and
management of the case or the potential emergency sections. In some cases, the drug section may
identify information that has been overlooked by the person completing the MH document. These two
sections should be compared (drug information and reported health history) to ensure complete
information has been obtained.
Topics included in Section Three
In section three, the self-study text guides the participant to review potential allergic reaction
emergencies. Since many states allow dental hygienists to administer local anesthesia (LA), there is the
risk for an emergency involving unconsciousness (usually due to fear and anxiety about the procedure),
systemic effects from the vasoconstrictor if injected into the circulation (tachycardia, increased blood
pressure) and allergy to a component within the LA cartridge. Substance Abuse is included in the
chapter regarding potential clinical problems and interactions with LA agents. Resources for “stop
smoking” programs are included, as well as a prime requirement for patient interest in quitting the
tobacco habit. Issues related to the female sex (pregnancy, lactation, menopause, osteoporosis) are
discussed with a focus on medications which could be taken in this population and the clinical
consideration relationships. Antibiotic prophylaxis, in general, is included in chapter 8 of the self study
text. The section ends with consideration of potential clinical problems associated with increased
bleeding, either from disease or from use of anticoagulant/antiplatelet drugs.
Chapter 6 – Allergies to Drugs, Environmental Substances, Foods, and Metals
Read pages 63-73, examining the Key Terms and medical condition sections as you begin. Are there any
terms with which you are not acquainted? There is a question on the current ADA Health History asking
about allergies to various drugs and substances which could be used during oral procedures. When a
positive response is given the first question to ask involves why the patient thinks an allergic reaction
occurred and what response occurred. Allergy is characterized by rash, hives, erythema, itching, and
ranges from these mild reactions to the most severe, namely respiratory constriction and loss of blood
pressure (anaphylaxis) (Box 6.1). Patients often confuse allergy with a drug adverse effect, such as
nausea and vomiting. To determine if a true allergy occurred follow up questioning must include a
request to describe the allergic reaction.
In oral procedures, latex allergy is possible (pg. 69). The use of latex products can incite an allergic
reaction in those patients who are sensitive to latex. Anaphylaxis is possible in latex allergy. Some
special needs patients, such as those with cystic fibrosis, have an increased risk for latex allergy.
Collaborative agreements will likely involve individuals with special needs, so special medical problems
should be considered. Allergy to local anesthetics (LA) is most likely with topical anesthetics. There are
two main classes for anesthesia in dentistry, namely amides (low potential for allergy) and esters (high
potential for allergy). Since the only ester classification anesthetic products used in dentistry are
tetracaine and benzocaine, both topical agents, these are the most risky products. The injectable ester
anesthetic, Novocain, is no longer on the market. Few people are allergic to amide classification LAs
(lidocaine, prilocaine, articaine, etc.) Practitioners should question the patient about allergy before
applying a topical anesthetic. Symptoms of “nausea” or “fainting” are not allergic reactions. Nausea is
usually a side effect from a drug and fainting is most likely due to fear of a dental procedure. Examine
the follow up questions in the green boxes and discussion section on pages 69-72. A history of hay fever
or seasonal allergy puts a patient at increased risk for allergy from products used in dental care.
However if the patient has been exposed to the product to be used by the RDH/DDS team more than
once, and no reaction occurred, the allergy risk is minimal to none.
Examine the cases on pp. 73 and test yourself regarding implications of allergy.
Controlled Substances and Addiction, ch. 7
Read pages 74—86. When the patient admits to having a substance abuse problem, care should be
taken if a vasoconstrictor is included in the local anesthetic. If it cannot be determined the patient has
not “used” marijuana, methamphetamine, cocaine or heroin in more than 48 hours, the best LA to
select would be a LA without the vasoconstrictor or one with at least a 1:200,000 concentration. Box 7.1
lists “red flags” to identify the METH user. Box 7-2 lists treatment plan implications for substance
abusing patients. Alcohol abusers may have liver damage. Liver dysfunction leads to increased bleeding
and a medical consult about bleeding risks for an individual with cirrhosis of the liver or severe liver
dysfunction is indicated. When offering a successful smoking cessation program, it is essential to
determine if the patient has a desire to stop smoking. There are several resources to help individuals
who use tobacco products stop using. Tennessee has a free “Quit Line” available to assist individuals to
stop smoking (http://health.state.tn.us/tobaccoquitline.htm). The local community resources should be
investigated and, for those patients who want to stop smoking, referrals can be made. For practices who
want to offer smoking cessation programs, the American Dental Hygienists’ Association has an “Ask,
Advise, and Refer” program for ADHA members. Smoking cigarettes has been shown to result in
periodontal disease, as well as, a poor healing response after periodontal treatment. This may be a
factor to influence the patient to seek help to stop smoking.
Dental professionals in TN who abuse drugs or alcohol can receive assistance in treatment for addiction
from the Concerned Dental Professionals Committee, which is part of the TN Dental Association. The
Concerned Dental Professionals Committee is a peer assistance program provided by the Tennessee
Dental Association and partially funded through a grant from the State of Tennessee. The program
offers consultation, referral and monitoring for dentists, dental hygienists, and registered dental
assistants whose practice is impaired, or potentially could be impaired, due to the use of drugs or
alcohol, or from having a psychological or physiological condition. Contact information for this group is
found in the RESOURCES section at the end of this course. Self study question answers, review answers
and case study answers are at the end of the text. Answer the REVIEW section and examine the case
studies on page 87. Test yourself on the problems of addiction.
Women’s Issues and Antibiotic Prophylaxis
Read pp. 88 -98 and apply the information in Ch. 8 to the cases at the end of the chapter.
For pregnant patients most drugs should not be used. Dental agents in Pregnancy Categories A or B are
the safest ones to use. Products in Pregnancy Category C or above have greater risk for fetal deformity.
Safe agents include lidocaine for local anesthesia (Category B). Antibiotics should be investigated in a
drug reference for the pregnancy category. Tetracyclines are contraindicated (Category D). It is safe to
expose the pregnant woman to dental x-rays, so long as proper shielding is used (lead apron with
thyroid shield).
In November 2012 the Food and Drug Administration, Public Health Service division collaborated with
the American Dental Association to update guidelines for when dental x-rays can safely be taken.
Receiving dental x-rays during pregnancy was included. The “As Low As Reasonably Acceptable” rule
(ALARA) should always be applied and no dental x-rays should be taken until a clinical exam has been
completed and a need for radiographs is identified. According to the ADA, only a dentist should
prescribe dental radiographs. The RDH should not make the decision under current ADA guidelines.1
The most likely emergency situation to occur in the dental office during pregnancy is supine hypotensive
syndrome (pg. 91). Review prevention and management recommendations. Lactation considerations
and taking birth control pills are discussed on pp. 91-92.
Lactation is an issue to consider when treating the woman who is breast feeding. Clinical considerations
for medication use in a breast-feeding patient include2
1. Advise the patient to minimize the breast-fed child’s exposure to drugs the mother is receiving,
such as by timing feedings after drugs are no longer in system or pumping and discarding milk.
2. Recognize potential drug effects in the child and make recommendations to the patient about
monitoring or responding to these effects.
3. Consider adjusting dosage of needed drugs during lactation.
4. Understand the effects of the drug on milk production and explain these effects to the patient
clearly, if a drug is prescribed by the DDS. Use a drug reference.
5. Ascertain whether the drug is present in human milk and if so, how much?
6. Realize the effects of the drug on the breast-fed child and explain these effects to the patient
clearly.
Hormone replacement therapy (HRT) is less common than in past years. For women taking HRT (or
birth control pills) blood pressure (BP) should be monitored as estrogen can increase BP in some
individuals. Estrogen has been reported to increase gingival bleeding, although the mechanism is not
fully understood. Effective oral hygiene is the most reasonable recommendation.
Women who are taking antiresorptive therapy for osteoporosis should be monitored for
osteonecrosis of the jaw (ONJ). In this disorder the alveolar bone dies, the overlying gingival tissue
becomes necrotic, as well, and a disabling condition results. There are no known methods to
prevent development of ONJ, but it is felt that oral health may help reduce the risk for development
of the condition. When this disorder is observed (exposed bone will be seen), the patient should be
referred for care by an oral surgeon. There are no contraindications for dental hygiene services but
the case should be evaluated by the DDS in cooperation with an oral surgeon before tooth
extraction.3
In 2007, the American Heart Association published guidelines for the use of antibiotic prophylaxis
(AP) when the patient reports a variety of cardiovascular conditions. These are listed in Table 8.2,
along with the antibiotic regimen to follow. The guidelines no longer list heart murmur or mitral
valve prolapse as indications for AP. A case example is presented on pg.97 for a patient with
periodontal disease. Box 8.4 gives an example of the different regimen to use when dental
treatment must occur in a short period of time and multiple appointments are required. Review self-
study questions as you read the chapter, answer review questions and case study questions.
Answers at back of text.
Blood Related Abnormalities
Read pages 100 – 1118, Ch. 9 and apply information to self study items and the cases at the end of
the chapter.
Uncontrolled bleeding is most likely to occur when the patient is taking warfarin (Coumadin) an
anticoagulant drug. The antiplatelet agents (Plavix, aspirin) are less likely to cause uncontrolled
bleeding. Increased bleeding with antiplatelet agents can usually be controlled with digital pressure
over the gingival area. For patients taking warfarin (Coumadin) regular blood tests are needed to
determine the INR value. This value determines risk for excessive bleeding. Values 3.5 or less are
acceptable for periodontal treatment and oral surgery. Bleeding would be managed as for any
bleeding (direct pressure, gauze over area, GelFoam, as needed). For hereditary conditions that
reduce clotting factors (hemophilia, others) consultation with a physician is needed. Platelet infusion
may need to be completed before dental surgical procedures are attempted in an individual with
hemophilia. Periodontal procedures expected to result in heavy bleeding should be communicated
to the patient’s physician and a request for guidance made.
Blood related viral disease (hepatitis B, C, HIV, others) can be transmitted to dental personnel.
Pages 107-113 discuss considerations for dentistry. Standard precautions are established, with use
of barriers during oral procedures, to avoid transmission to health care personnel. Each year
licensed dental health professionals in TN must complete a course on infection control which
includes requirements established for safe practice in dentistry. Occupational exposure
recommendations were updated in 2013 and are included in this course (pp.112-113). These
exposures are the only emergency situation dealing with blood borne diseases. Complete all self
study items, review questions and cases. Answers are at end of text.
See Course Introduction for instructions on taking the Self-Test.
RESOURCES
Healthcare Provider Guide to Successful Tobacco Cessation Intervention. Available at
http://health.state.tn.us/Downloads/TQL_intervention.pdf. Accessed August 28, 2014.
Concerned Dental Professionals Committee. Tennessee Dental Association. Information available in
Peer Assistance tab at http://health.state.tn.us/boards/Dentistry/complaints.htm. Accessed August
28, 2014.
References
1. U.S. Department of Health and Human Services, Food and Drug Administration, Public
Health Service, American Dental Association, Council on Scientific Affairs. (2012).
Dental radiographic examinations: Recommendations for patient selection and limiting
radiation exposure. Retrieved from
http://www.ada.org/~/media/ADA/Member%20Center/FIles/Dental_Radiographic_Examination
s_2012.ashx. Accessed August 28, 2014.
2. Donaldson M. Goodchild JH. Pregnancy, breast-feeding and drugs used in dentistry. The Journal of the American Dental Association. 2012; 143(8):858-871.
3. Hellstein JW, Adler RA, Edwards B. et al. Antiresorptive therapy for prevention and treatment of osteoporosis: Executive Summary of recommendations from the American Dental Association Council on Scientific Affairs. JADA 2011; 142(11):1243-1251. Available at http://jada.ada.org/content/142/11/1243. Accessed August 28, 2014.
PUBLIC HEALTH SELF STUDY
SECTION THREE Self-Test
1. Prevention of medically related emergencies includes all of the following EXCEPT one. Which is
the EXCEPTION?
a. Identifying the most likely emergency situation(s)
b. Posing the relevant follow up questions regarding potential adverse events
c. Using critical thinking to analyze patient responses
d. Making a plan to minimize risks during treatment
e. Always taking a partner to assist during any adverse situation
2. Allergy to agents used in dental practice involves which of the following?
a. Ester-type local anesthetic agents
b. Latex
c. Penicillin
d. All of the above
3. A patient response of “nausea and vomiting” represents a (an) __________ reaction.
a. Allergic
b. Side effect
c. Poison-related
d. Stress-related
4. For the client with a history of abusing cocaine, which of the following precautions are
indicated?
a. Monitor vital signs for abnormal values
b. Instruct the client to refrain from using drugs for two days prior to dental appointment
if local anesthesia is planned
c. Use standard precautions during oral procedures
d. All of the above
5. For a client to be successful to stop smoking after a tobacco cessation program, which of the
following is most necessary?
a. A desire to quit the habit
b. Insurance program to cover program costs
c. Pharmacologic therapy
6. Oral disease associated with using tobacco products include
a. Nicotinic stomatitis
b. Hairy tongue
c. Periodontal disease
d. Squamous cell carcinoma
e. All of these
7. Dental professionals who abuse drugs or alcohol can get assistance on finding resources for
recovery through use of the Concerned Dental Professionals Committee in Tennessee.
a. True
b. False
8. Which of the following drugs used in dentistry is contraindicated for use during pregnancy?
a. Lidocaine
b. Tetracycline
c. Penicillins
9. Dental radiographs can be exposed for a pregnant client when which of the following safety
procedures is used?
a. Coverage of the body midsection with a lead apron
b. Consent form is properly completed
c. Patient is in second trimester of pregnancy
d. F speed film is used
e. Digital radiography is used
10. When antibiotic prophylaxis is recommended to prevent infective endocarditis, what
recommendation on dosing is suggested by the American Heart Association?
a. Take 30 minutes prior to dental appointment
b. Take 60 minutes prior to dental appointment
c. Take within 2 hours following the appointment
d. All of the above
11. For the patient who is allergic to penicillin and who is indicated to receive antibiotic prophylaxis
prior to a dental appointment, which of the following is an alternative antibiotic?
a. Clindamycin
b. Tetracycline
c. Metronidazole
d. Levofloxacin
12. For the client taking warfarin (Coumadin), which INR lab result is required before periodontal
debridement can safely be completed to avoid excessive bleeding?
a. INR of less than 2
b. INR of no more than 3.5
c. INR of between 3 and 5
CASE STUDY – you can use a drug reference or other resources for professional judgments
A patient in her 8th month of pregnancy presents for an emergency appointment due to pain around
tooth #30. Medical history reveals good health and vital signs of pulse 80 bpm, respiration 22
breaths/min, blood pressure 110/60 Hg, Rt. Arm, sitting. Oral exam reveals caries in tooth #30 and a
periapical radiograph reveals normal bone at the apex of the tooth. Restorative treatment is planned.
13. Which local anesthetic agent should be selected?
a. Mepivacaine (Carbocaine)
b. tetracaine (Cepacol)
c. lidocaine (Xylocaine)
14. What analgesic would be indicated for postop pain?
a. Acetaminophen
b. Ibuprofen
c. Hydrocodone/acetaminophen (Lortab)
15. Which of the following clinical judgments is appropriate for the relief of infection and pain in
this patient?
a. Delay dental procedures until after baby is born
b. Proceed with emergency restorative procedures
Section 4: Proper Development of a Treatment Plan (one hour credit)
Section Four will continue reviewing medical conditions relevant to treatment plan formulation and
dental management. The Pickett & Gurenlian text, Chapters 10 through 14 will be reviewed in this
section with a focus on treatment considerations. Updated guidelines related to medical conditions in
this section will be included in this course.
Ch. 10 Medical Conditions Involving Immunosuppression
Medical conditions discussed in this chapter are identified on pg. 121. Read pages 120-142, consider the
self study questions and the cases at the chapter end. The chapter begins with a discussion of important
considerations when treating a patient during malignancy.
When the immune system is compromised, the healing response is negatively affected. This is a prime
consideration if oral procedures will cause a tissue injury (such as tooth extraction or periodontal
debridement). Conditions discussed which may involve a specialized care plan, and physician consult,
could include receiving treatment for a malignancy, diabetes mellitus, lupus erythematosus and organ
transplant.
Cancer treatments
Malignancies are treated in various ways – surgical resection of the tumor, chemotherapy with toxic
drugs, radiation therapy to cause necrosis in tumor cells, and stem cell transplants. Each therapy has
adverse effects on the tissue cells which could potentially impact the dental management plan. Medical
consultation is essential to provide well managed care and reduce the risk for medical complications.
The “miracle mix” included on page 122 has been used for a palliative effect in dentistry for many years,
however a recent systematic review by the Oncology Nursing Association1 found no evidence the
compounded formulation provides reduction in pain, nor prevents mucositis. The group does not
recommend “Miracle Mix” and says it costs the patient extra expense, for no likely benefit. They
recommend a baking soda/water (1 T. per 1 cup water) rinse for palliative effects. Mucositis associated
with all three cancer therapies is the most distressing oral complication and new guidelines for
prevention of mucositis2,3 reveal the best way to reduce development of mucositis is implemented by
the oncology team during cancer therapies (holding ice in mouth while receiving chemo, taking a drug
that prevents mucositis before and during cancer therapy). The dental professional cannot help to
reduce the pain associated with mucositis, other than recommending the baking soda/water rinse,
according to the oncology literature.4 In 2012 the National Cancer Institute updated guidelines for
management of mucositis4 and this paper is freely available on the internet. Pages 124-25 provide
recommendations to manage potential oral effects of cancer treatment, including xerostomia and pain
in the mouth. Reviewing the blood values for platelets and the neutrophil count is essential prior to
implementing oral procedures which can result in bleeding [Box 10-1] or which may need an adequate
healing response (i.e. neutrophil count less than 1000 cell/mm3 means no oral procedures should be
implemented). The dental professional can help the patient if a supplemental fluoride product is needed
to prevent dental caries during cancer therapy. Products are discussed on page 125-26. The federal
government (National Institute for Dental and Craniofacial Research) has information available for both
the dental team and the patient regarding oral care (Box 10.2, Fig 10.1). Potential emergencies and
management considerations involve assessment of the patient needs (lab test results, oral
complications, etc.) and development of a plan that addresses that information.
Diabetes mellitus (DM)
Diabetes is fairly common in the U.S. population and the prevalence of type 2 DM is increasing each year
due to the obesity epidemic. It is estimated that the actual prevalence is higher than reported since
many individuals with DM are undiagnosed. Uncontrolled DM can result in multiple medical
complications, including cardiovascular disease, increased infections and poor healing. The relationship
to periodontal disease involves the “increased infection and poor healing” feature of uncontrolled DM.
Potential oral side effects of uncontrolled DM are illustrated on page 130 and can be accessed for the
color image on The POINT internet site of the book publisher. The most common medical emergency for
this condition involves hypoglycemia and the risk for and prevention of this emergency is discussed on
pages 132-133. The follow up questions for DM are important to investigate to identify risks during oral
care.
Systemic Lupus erythematosus (SLE)
This condition is an autoimmune (AI) disease and often is accompanied by other AI conditions. In the
past heart murmur (common in SLE) was indicated for antibiotic prophylaxis (AP), but this indication was
dropped by the American Heart Association in 2007. Glomerulonephritis is associated with SLE and in
the past was suggested as a need for AP, but there are no official recommendations for AP when the
kidney is affected. Medical consult should include the drug therapy to manage effects of SLE and the
drugs are likely to result in oral side effects. The condition cannot be cured and is managed by
pharmacologic measures.
Rheumatoid arthritis
This AI condition can accompany other AI diseases or develop on its own. The main effect on oral care is
to assess the ability to grasp the toothbrush and floss if the fingers are affected. The drug therapy
involves medications to reduce the host response and reduce pain. Many individuals with this condition
have joint replacements from damage to bone and joint areas due to the condition. Medical
consultation with the orthopedist regarding AP prior to oral procedures should be investigated.
Currently the American Academy of Orthopaedic Surgeons and the American Dental Association
guidelines (2012) do not recommend AP for hip and knee replacements.5,6,7 However, some orthopedists
may still recommend AP prior to dental procedures. A new feature in the 2012 guidelines is a shared
decision making tool that involves the patient in the decision whether to take AP prior to dental
treatment.6 The executive summary of the document clarifies the main issues in the new guidelines and
is much shorter to read.7
Organ Transplant
Individuals with an organ transplant must take antirejection drugs to prevent rejection of the
transplanted organ [pp. 139-42]. These drugs lower the immune response and may affect infection in
the oral cavity, as well as the healing response. Medical consultation is needed to determine the effect
on the patient’s body of the transplant therapy. The transplant physician should be asked for guidance
as the care plan is developed. The plan will be greatly influenced on the patient response to
antirejection therapy and the health of the transplanted organ.
Review the self –study items, Review questions and cases presented at the end of the chapter to test
your recollection of clinical applications. Answers are at the end of the text.
Chapter 11 – Cardiovascular System
Cardiovascular disease is common in older individuals and represents the #1 most common reason for
death in the U.S. This chapter discusses the important follow up questions to ask, and the importance of
assessing functional capacity (FC) to identify risks for cardiac problems during treatment. In the past,
some texts recommended delaying dental treatment for 3 to 6 months after a heart attack (also known
as myocardial infarction [MI] or acute coronary syndrome [ACS]). This suggestion was dropped in 2004
when the American College of Cardiology developed updated guidelines for noncardiac procedures in
individuals with a history of MI. Assessment of functional capacity [FC] was discussed in course two.
Read pages 144- 160, take the self study tests and review the case studies at the end of the chapter.
Angina pectoris, MI –read pp.146-48
The differentiation between angina and a MI is confusing as the two conditions involve the same initial
sign: pain in the chest. Individuals with a history of angina often carry nitroglycerin. The text identifies
the limit of no more than 3 sublingual tablets during a 10 minute period of emergency management.
Angina is usually managed by allowing the patient to rest for 5 minutes. This often will resolve the
symptom, however nitroglycerin can also be used concurrently with rest. Prior to initiating oral
procedures, ask the patient who reports angina, “How do you manage angina? When was your last
angina attack? What usually causes it?” Knowing this information prior to a possible event is important.
Since having completed training in CPR before approval for license renewal, dental professionals are
trained to respond to ACS/MI and interaction with EMS. The text discusses possible scenarios and
management procedures.
Heart murmur, valvular disease
These conditions are no longer recommended for AP however when a valve replacement is present, the
individual is indicated for AP. A risk for bleeding exists as this patient must take anticoagulant drug
therapy. Information provided in course three addresses potential bleeding problems in this situation.
An INR of 3.5 is usually the recommended limit for this medical condition. Periodontal debridement can
be provided with no risk for hemorrhage in an INR of 3.5. Simple tooth extraction can also be
completed, however for multiple tooth extractions, medical consultation should be completed to
determine the risk for excessive bleeding.
Heart failure (HF)
This condition was formerly referred to as “congestive heart failure”. The terminology was changed
several years ago to heart failure, with no designation between right sided HF and left sided HF. When
HF is reported, the most likely impact on dental treatment is to determine if the patient prefers an
upright chair position. Of course, initial investigation should involve the degree of control for the
condition, but poorly controlled HF results in fluids collecting in the lungs. It is essential to assess FC for
this cardiac condition. The disease is classified as A, B, C, D, according to the degree of disease control.
Pulmonary edema or congestion represents an ASA IV risk and dental treatment should be delayed until
the disease is better controlled. Medical consultation would provide answers to these issues.
Heart Attack (myocardial infarction)
MI is the most frightening emergency to occur in the dental office. Dental professionals in all states are
required to take cardiopulmonary resuscitation courses to manage MI. The newest guidelines call for
waiting one month before giving the patient dental treatment. Prevention and management is
discussed.
Hypertension or hypotension
Excessive blood pressure [BP] is the cause many CVD conditions. Taking BP is considered essential, a
standard of care, prior to starting dental tx. Review dental considerations of this medical condition and
the applications to clinical practice [pp. 154-55].
Implanted cardiac pacemaker or devices
In the past, it was thought ultrasonic scalers would not be used when this medical device was present.
All manufacturers of pacemakers state there is no contraindication for ultrasonic scalers as the shielding
mechanisms protect them from disruption, so long as the ultrasonic is 3 feet away from the device.
Stroke (cerebrovascular accident)
A pre-stroke condition called transient ischemic attack (TIA) should be investigated: when the event
occurred, how it was treated, and the risk for a future stroke. If the patient cannot answer the follow up
questions for this medical condition, consultation with the physician that treated the event is indicated.
Some individuals have a TIA and recover completely; others have additional events and are at risk for
stroke. The information required to develop a professional judgment when developing an oral care plan
is discussed on pages 157 -158. A weak association exists between periodontal disease (PD) and CVD but
no evidence exists that PD causes CVD. According to a systematic review published by the American
Heart Association, patients should not be told periodontal tx will improve symptoms of CVD as no
evidence shows periodontal tx improves the disease symptoms. Surrogate markers (CRP, carotid intima
media thickness) are not useful as a proof that PD improves CVD.
Migraine
This can be a debilitating condition for those affected. Follow up questions are identified and
recommendations for care would be based on the responses to those questions. Ensuring the overhead
dental light does not irritate the eyes is an issue with some patients.
Review self-study items, the Review section questions and the case studies to test your memory of
important concepts. Answers are at back of text.
Chapter 12 – Neurologic Disorders
This chapter includes abnormalities or diseases affecting the brain and nerves innervating muscles and
tissues. Management for many of the patients with special needs is discussed in this chapter. Read
pages 162 – 179 for important issues to consider and essential questions to ask before planning care, for
indicated needs based on responses to those questions, and prevention and management of possible
emergencies. Test yourself with the self study questions and answer the case questions at the end of the
chapter.
Seizure (epilepsy)
The text discusses the various types of seizures and the signs and symptoms of the various classifications
of seizures. The most difficult management is for the tonic clonic or convulsive seizure. Prevention
mainly includes the patient takes the prescribed antiseizure medication as this is the most likely reason
for recurrent seizure (not taking the drugs). Questioning about “Have you had a seizure during dental
treatment?” is important to ask. It is important to note that many etiologies can exist that manifest in
seizure. Traumatic brain injury can leave those affected with seizure. Many of the intellectually disabled
clients have seizures. The chapter provides prevention and management recommendations should this
event occur during dental treatment. There is a question on the medical history about “blackouts”. This
is a sign of epilepsy and questioning should investigate if the blackouts are recent and if they occur
multiple times. A referral for medical evaluation might be important as epilepsy may be occurring but is
not yet medically diagnosed.
Blackouts, fainting
History of “blackouts” is a sign of seizure disorder and follow up questioning to determine if symptoms
of seizure have occurred. Fainting or loss of consciousness could be related to seizure, but true “faint” is
an anxiety disorder.
Sleep Disorder, Chronic pain
These conditions may have multiple etiologies (causes). Investigate the reason for the sleep disturbance
or pain, and manage the case based on the etiologic reason. Consider the likelihood of choking during
the appointment. Alterations in dental chair positioning may be needed to make the patient with
chronic pain more comfortable.
Mental Health and Developmental neurologic conditions
This section of the chapter deals with a variety of conditions. For individuals with mental health
disorders the medications usually result in chronic dry mouth and resultant dental caries. Behavior
management may be an issue to deal with. Questioning may include a caregiver for the patient to get
accurate information. Read pages 171-179 for the various conditions discussed. Management of care for
Special Needs populations is new to the 3rd edition of the text. Box 12-5 includes resources found on the
Web for management recommendations. Various issues of this population and the variety of conditions
are discussed. The Special Care Advocates in Dentistry organization has essential information. This free
website has modules for dental management involving a variety of disabilities.8
Review self-study items, Review section questions and Case studies. Answers at end of text.
Chapter 13 GI Disorders and Respiratory Disease
Read pages 180-189, test understanding of information using the self study questions and review the
cases at the end of the chapter. Most of these conditions have probably been seen in clinical practice
and the clinician is familiar with oral signs and specific dental management considerations. Eating
disorders are discussed and recommended management provided. Respiratory conditions are included
and discussed. Asthma and cystic fibrosis are included. For chronic obstructive pulmonary disease
(COPD) the relationship to cigarette smoking is important and offering resources for smoking cessation
(discussed in an earlier course) should be offered to the patient who wants to try to quit. When COPD
develops, the patient may already have tried to stop smoking as the M.D. would likely have suggested
stopping the habit. Dental management, of course, would involve determining the risk for respiratory
obstruction during a supine chair position and making adjustments, as indicated by symptoms and
disease control. The chapter ends by discussing management for choking and airway obstruction. This
emergency situation can occur in a healthy patient, if objects fall into the airway. This can occur during
scaling, if a crown or inlay is removed and falls into the throat.
Chapter 14 Glaucoma, kidney disease and thyroid disorders
Medical conditions in this chapter are listed on pg. 191. Read pages 191—201, test yourself using the
self study questions and review the cases involving these medical disorders. There are no new guidelines
for these conditions so the information should be familiar. The client with chronic renal failure will be
very ill and unlikely to present to the regular dental office, however for collaborative written protocol
agreements that involve going out into the community and serving homebound individuals, it might be a
medical condition to deal with. Medical consultation is vital as there are many problems that may need
to be considered. For the client on dialysis, blood pressure would be taken on the arm WITHOUT the
port used for dialysis. Providing care around the days scheduled for dialysis is a question to ask the
physician. It may be best to schedule oral care for the day after dialysis as the anticoagulant used during
dialysis is no longer affecting bleeding. Management for renal transplant is included, although organ
transplant was discussed in an earlier chapter.
Hyperthyroidism
The client with thyroid disease can include an overactive thyroid (hyperthyroidism) or an underactive
thyroid (hypothyroidism). In fact medical treatment for hyperthyroid can result in making the client
develop hypothyroidism. Careful consideration of vital sign values is an important component to identify
a potential emergency of “thyroid storm”, discussed on page 200-201.
See Course Introduction for instructions on taking the Self-Test.
References
1. Harris DJ, Eilers J, Harriman A, et al. Putting evidence into practice: evidence-based
interventions for the management of oral mucositis. Clin J Oncol Nurs 2008;12(1):141-
52. Available at
http://guideline.gov/content.aspx?id=15700&search=management+of+oral+mucositis+
and+chemotherapy. Accessed August 28, 2014.
2. Migliorati C. Hewson I, Lalla RV et al. Systematic review of laser and other light therapy
for the management of oral mucositis in cancer patients. Support Care Cancer 2013;
21:333–341.
3. Peterson DE, Ohm K, Bowen J et al. Systematic review of oral cryotherapy for
management of oral mucositis caused by cancer therapy. Support Care Cancer.
2013;21:327–332.
4. National Cancer Institute. Oral Mucositis. 10/23/2012. Available at
http://www.cancer.gov/cancertopics/pdq/supportivecare/oralcomplications/HealthProfessional
/page5. Accessed August 28, 2014.
5. American Dental Association, American Academy Orthopedic Surgeons. Collaborative Guidelines
for Prevention of Prosthesis Infection and Dental Treatment. Available at
http://www.aaos.org/research/guidelines/PUDP/dentaleditorial.pdf. Accessed August 28, 2014.
6. Shared Decision Making Tool. Chairside Guide for ADA/AAOS Antibiotic Prophylaxis and
Prosthetic Joint. Available at
http://www.ada.org/~/media/ADA/Member%20Center/FIles/DentalSDMTool.ashx. Accessed
August 28, 2014.
7. Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
Executive Summary on the AAOS/ADA Clinical Practice Guideline. Available at
http://www.ada.org/~/media/ADA/Member%20Center/FIles/dentalexecsumm.ashx. Accessed
August 28, 2014.
8. Special Care Advocates in Dentistry. Modules for dental management. Available at
http://saiddent.org/modules.php. Accessed August 28, 2014.
PUBLIC HEALTH SELF STUDY
SECTION FOUR Self-Test
1. For the client receiving chemotherapy the neutrophil count should be above _______before
dental treatment should proceed.
a. 1000 cells/mm3
b. 5000 cells/mm3
c. 10,000 cells/mm3
2. When therapies are received that affect platelets, what is the minimum number of platelets
needed to avoid excessive bleeding?
a. 1000/mm3
b. 10,000/mm3
c. 50,000/mm3
d. 250,000/mm3
3. Which type of diabetes involves no insulin secretion?
a. Type 1
b. Type 2
c. Gestational DM
4. The most likely medical emergency in the patient with diabetes mellitus is
a. Syncope
b. Hypoglycemia
c. Myocardial infarction
d. Stroke
5. Therapy for rheumatoid arthritis can result in all of the following medical issues EXCEPT one.
Which is the EXCEPTION?
a. Immunosuppression
b. Bleeding issues
c. Poor healing
d. Uremic toxicity
6. Individuals with rheumatoid arthritis may have other autoimmune diseases. Prophylactic
antibiotics are strongly recommended for the dental management plan.
a. Both statements are false
b. Both statements are true
c. First statement is true, second statement is false
d. First statement is false, second statement is true
7. Stable angina is characterized by which of the following?
a. Relief after sublingual use of nitroglycerin
b. Relief after rest
c. Both of these therapies
8. The client with a history of cardiac valve replacement should be evaluated for which of the
following conditions?
a. Immunosuppression
b. INR of 3.5
c. Hypertension
9. For the cardiac patient needing local anesthesia the recommended cardiac dose of
vasoconstrictor in local anesthesia is no more than
a. One cartridge of 1:100,000
b. Two cartridges of 1:50,000
c. Two cartridges of 1:100,000
10. Elective oral care should be postponed when blood pressure exceeds
a. 160/90 mm Hg
b. 170/100 mm Hg
c. 180/110 mm Hg
d. 220/220 mm Hg
11. For individuals with medical conditions classified as ASA IV, what is the dental management
recommendation?
a. Provide antianxiety meds before treatment
b. Institute a stress reduction protocol
c. Do not treat
12. Signs of stroke include all of the following EXCEPT one. Which is the EXCEPTION?
a. Headache
b. Unequal pupil size
c. Hypotension
d. Incoherent speech
13. Elderly clients taking a beta blocker or calcium-channel blocking agent for migraine may be at
risk for which of the following conditions?
a. Hypertension
b. Orthostatic hypotension
c. Syncope
d. Nausea and vomiting
14. Convulsions are characteristic in which form of seizure disorder?
a. Absence seizure
b. Complex partial seizure
c. Tonic clonic epilepsy
15. The most common oral manifestation of bulimia is
a. Erosion of enamel
b. Stomatitis
c. Tongue thrust
16. Which local anesthetic is recommended for a client who presents with an allergy to sulfites?
a. Lidocaine, 1:50,000
b. Benzocaine topical
c. Mepivacaine, plain
d. Articaine, 1:100,000
17. Prevention of airway obstruction during oral procedures can occur through
a. Use of a saliva ejector to remove oral secretions
b. Tying dental floss to cotton rolls or clamps
c. Use of a rubber dam
d. All of the above
18. For the client receiving dialysis due to kidney failure, what consideration exists during the
assessment of physical health and health history?
a. Blood pressure procedure
b. Assessment of breath odor
c. Chair position
19. Maintenance of body temperature, growth, and regulation of body functions is controlled by
which gland?
a. Adrenal
b. Thyroid
c. Parathyroid
d. Pituitary
20. Signs of uncontrolled hyperthyroidism include
a. Elevated blood pressure
b. Pulse rate over 100 bpm
c. Thyroid storm
d. All of the above
Section 5: Elements of Written Protocol and Ethics (one hour credit)
Access to care is an increasingly and complicated global issue and continues to promote passionate discussions that have been resulting in tangible results. As of January 2013, there are 4,600 dental Health Professional shortage areas (HPSA) in the country. Health Professional shortage areas are based on a dentist (DDS) to population ratio of 1:5,000, meaning that there are 5,000 more people than dentists.
The vulnerable and underserved populations face persistent and systemic barriers to accessing oral health care. These barriers are numerous, complex and include social, cultural, economic, structural, and geographic factors.1 For example, in 2008, 4.6 million children did not obtain needed dental care because their families could not afford it. In 2011, there were approximately 33.3 million underserved individuals living in dental HPSA.1 A version of this can be found in the summary of “Improving Access to Oral Health Care for Vulnerable and Underserved populations” pp. 18-33, at http://www.hrsa.gov/publichealth/clinical/oralhealth/improvingaccess.pdf.
Written protocol collaborative agreement
This agreement between a dentist and hygienist(s) was passed into legislation and signed into law on
May 10, 2012 by Governor Bill Haslam.
In August 2011, the American Dental Association published strategies outlining how to respond to the
situation when people cannot access dental care
(http://www.ada.org/~/media/ADA/Advocacy/Files/topics_access_whitepaper.ashx). These suggestions
may be helpful when establishing a collaborative agreement in a written protocol.
History of Written Protocol
In 2010, a special committee on workforce models was established to research workforce models with
greatest opportunity to benefit consumer needs in Tennessee and expand the scope of practice of
dental hygienists. The definition of a registered dental hygienist was expanded and the time period
between the examination of a patient by a supervising dentist and the service provided by a dental
hygienist was extended from seven (7) months to eleven (11) months. Revised rules governing the
practice of dental hygienists occurred in January, 2011 and can be found at
http://www.tn.gov/sos/rules/0460/0460-03.20110120.pdf.
During the term of Diana Saylor, RDH, President of TN Dental Hygienists’ Association (TDHA) 2011-2012,
TDHA association members led efforts to develop a bill allowing a collaborative practice between
dentists and hygienists. The goal was to expand the opportunity of oral care to underserved populations
in TN and models utilized in Arkansas and New Mexico were evaluated. The TN Commissioner of Health,
Dr. John Dreyzehner, supported the proposed legislation and representatives from TN Dental
Association (TDA) indicated they would help devise a bill to allow collaborative practice agreements,
later called “written protocols” to address the inability to receive oral care by disadvantaged and
underserved populations. A stakeholder meeting including representatives from TDHA, TDA, the
Academy of General Dentistry and a representative from the Commissioners’ office met to discuss,
negotiate and get final agreement on a Bill to be submitted to the Subcommittee of Health and Human
Resources Committee. The bill sponsor, Senator Jim Tracy, advocated for approval of the Bill in the
Health and Welfare Committee and the Bill was passed with amendments. This final version of the Bill
was passed unanimously in the Senate 28-0. The Bill went to the House with approved amendments
where it passed unanimously 95-0. This bill was signed by the Speaker of the House, Representative
Beth Harwell, and the Speaker of the Senate Lt. Governor, the Honorable Ron Ramsey. On May 10, 2012,
Governor Bill Haslam signed the final Bill which can be found at http://tndha.org/wp-
content/uploads/2013/04/Final-Bill2012.pdf. The Application for Dental Hygienists to Practice Under
Written Protocol form can be downloaded at http://health.state.tn.us/boards/Dentistry/PDFs/PH-
4187.pdf.
What is Written Protocol?
A written protocol is a written agreement between a dentist and hygienist that sets forth standing
orders for a working relationship to provide preventive oral health care in alternative settings. These
alternative settings can include nursing homes, skilled care facilities, nonprofit clinics, and public health
programs. A written protocol agreement describing the oral procedures to be completed and the setting
and location of the program must be submitted to the TN Board of Dentistry (BOD), although no
approval comes from the Board. The request for written protocol status, along with evidence of all
parties having completed a six (6) hour Public Health continuing education course, must be submitted in
advance of beginning the program for oral care. The board will receive each written protocol submitted
and keep those on file which meet the minimum requirements enumerated in subsection (f) of the
dental practice act. Those received by the board and determined not to be complete shall be returned
to the submitting dentist within thirty (30) days of receipt with a request for the additional information
required. The dentist may then re-submit an amended written protocol to the BOD.
Requirements for Written Protocol in Tennessee must be met before notifying the Board of Dentistry of
the collaborative agreement.
General requirements
Have evidence of active practice as a licensed dental hygienist for at least five years
Current license to practice dentistry in TN for both the dentist and hygienist
Have practiced two thousand (2,000) hours in the preceding five years of the written protocol
OR evidence of teaching dental hygiene courses for two of the preceding three years in a dental
hygiene program accredited by the American Dental Association Commission on Dental
Accreditation
Evidence of completion of six (6) hours of public health continuing education within the past
two years.
No dentist may enter into a written protocol agreement with more than three dental hygienists
at any one time. No hygienist can enter into a written protocol agreement with more than three
dentists.
The supervising dentist(s) must process all patient billings.
Each written protocol agreement will be valid for two years, after which time it must be
renewed through resubmission to the Board of Dentistry.
Each written protocol required for off-site practice under general supervision by a DDS shall be
submitted to the Board of Dentistry by certified mail/return receipt requested and shall include
at a minimum (1) the names, addresses, telephone numbers and license numbers of the
supervising dentist(s) and dental hygienist(s); (2) the name, address, telephone number and
pertinent identification of settings where the dental hygiene services are to be performed; (3) a
statement signed by the dentist(s) that the dentist(s) and the dental hygienist(s) meet all
minimum standards for general supervision, as well as those required for practice under a
written protocol as stipulated in the section 63-5-108 of the TN Code Annotated of the dental
practice act.
A member of the team will be assigned by the dentist to record Occupational Safety and Health
Administration (OSHA) exposure incidents and/or assume duties of an assigned OSHA officer.
The supervising dentist must notify the Board of Dentistry within ten (10) working days by
certified mail/return receipt requested or electronic mail when the written protocol is no longer
in force.
Settings
Nursing homes
Skilled care facilities
Public health programs
Nonprofit clinics
“Nursing home” means any institution, place, building or agency represented and advertised to the
general public for the express or implied purpose of providing care for one or more nonrelated persons
who are not acutely ill, but who require skilled nursing care or related medical services. This term
(convalescent home, long term care facility) is also used to describe a residential facility for individuals
with chronic illness or disability, particularly older people who have mobility and eating problems.
Residential care can be provided in a nursing home, convalescent home, skilled nursing facility, care
home, rest home, intermediate care facility, or “old folk’s home”. These settings are a place of residence
for people who require constant nursing care and have significant deficiencies with activities of daily
living.
Non-profit clinics may be identified as 501c3 organizations. This type of organization is also known as a
nonprofit or charitable organization approved by the Internal Revenue Service (IRS) and is given tax-
exempt status because the organization meets the requirements defined in Section 501c(3) of the IRS
code. Federally Qualified Health Centers are nonprofit centers. Non-profit clinical facilities often are
associated with a hospital or medical school, devoted to the diagnosis and care of outpatients. It can
also include a medical establishment operated by medical specialists working in cooperation and sharing
the same facilities.
Skilled Care Facilities (SCF) are health care settings used when a patient needs skilled nursing or
rehabilitation staff to manage, observe, and evaluate care. Generally, SCF offer a level of care that is
lower, or less intense, than inpatient hospital care. Medical care ordered by a physician and which must
be given or supervised by a licensed health care professional is provided in SCFs
(http://www.medicare.gov/coverage/skilled-nursing-facility-care.html . Care that can only be provided
by trained medical personnel and may require specific licensure or credentials is given in a SCF. As well,
care involving certain treatments to be provided only licensed professional practitioners may be
provided at SCF.
Public Health Programs
Public health settings are alternative settings, which can provide opportunities to collaborate with a
local Public Health Department and Worldwide Health Organization (WHO). This might include programs
focused on the science and art of preventing disease, prolonging life and promoting health through the
organized efforts and informed choices of society, organization, public and private communities and
individuals. WHO identifies core functions of public health programs by providing leadership on critical
health matters and engaging in partnerships where joint action is needed. The WHO sets norms and
standards for health by promoting and monitoring their implementation. Ethical and evidence-based
policy options are disseminated and worldwide health situations and health trends are assessed and
monitored by the WHO. A setting in this category is defined as “a setting where people actively use and
shape the environment, or create or solve problems relating to health.” 1Examples of settings include
schools, work sites, hospitals, villages, and municipalities. Actions to promote health in this setting can
be varied and often involve some level of organizational development, programs which reach the
general public, and those that gain access to community services.
Services to Provide
Educational, diagnostic, preventive and therapeutic services as defined in the rules
http://www.state.tn.us/sos/rules/0460/0460-03.20110120.pdf .
The review of the health history, dental history and chief complaint, and taking and evaluation
of vital signs
Removal of hard and soft deposits and stain from human teeth to the depth of the gingival
sulcus
Polishing natural and restored surfaces of teeth
Placing preventive materials on tooth surfaces
Taking or completing diagnostic images (radiographs) and procedures
Performing clinical examination of teeth and surrounding tissues for diagnosis by the dentist
Collection of data for diagnostic and therapeutic reasons and keeping of an adequate treatment
record
Ethical Considerations for Written Protocol
The dental team working under the written protocol shall set and maintain established protocols for
infection control by the Centers for Disease Control and Prevention. The dental hygienist(s) shall be
responsible for record keeping and compliance with Health Insurance Portability and Accountability Act
(HIPAA) regulations regarding patient privacy. Appropriate OSHA record keeping protocols will be used
and documented as required by OSHA regulations. In the case of any exposure incident(s), the dental
collaborative team will provide the appropriate documentation to the assigned OSHA officer of the
facility where the written protocol relationship takes place and to the assigned OSHA officer in the
practice of the supervising dentist. Proper documentation assigned to the HIPAA officer where the
written protocol agreement take place will be kept in a private location. Protocols for management of
medical emergencies in the written protocol setting will be established by the collaborative team. The
dental hygienist shall comply with the appropriate protocols for management of medical emergency
situations (as described in the self study text used for this online course).
Communication within the written protocol agreement
The dental hygienist(s) will maintain an appropriate level of contact, communication, and consultation
with the supervising dentist in the written protocol agreement. This can be completed by on site
meetings, via tele-dentistry devices or via telephone, facsimile, electronic mail or electronic imaging
software or devices. Communication and consultation will involve management decisions for relevant
clinical situations or health history indications.
Financial agreement
Payments will be made from funding resources to the supervising dentist. In order to file an electronic
claim to a third party payer, whether by private insurance or Medicaid, each member of the
collaborative team must obtain a National Provider Identifier (NPI). An NPI is a 10 digit number, assigned
for free by the federal government. This number serves as a permanent identifier of the healthcare
provider(s), and can be carried forward in the case of relocation or licensure in a different profession.
Dental hygienists in TN are not directly reimbursed by either Medicaid or by private insurers at the
present time. However, even if third party resources are not billed directly, dental practitioners can
apply for NPI because it may facilitate billing submitted by a health department or other entities for
services provided. For more information about the NPI and how to obtain one, contact the National Plan
and Provider Enumeration System (NPPES) directly by phone at (800)465-3203 or visit the NPPES
website at https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart
Liability Insurance
Liability insurance should be held by the employer in the written protocol agreement. This insurance
may be limited to protection of the employer/supervising dentist and patients served by the employer.
Individual employees in a written protocol agreement may have limited protection and limited access to
the legal defense services provided to the policy holder. All parties in a written protocol should have
liability insurance that provides coverage for potential lawsuits. Self-employed individuals need
individual protection and additional protection of the business. Professional liability insurance coverage
is generally restricted to matters relating to patient care and does not cocfer4 loss or damage to
equipment, or general negligence issues. For this reason, the professional guidelines included in this
course should be considered when guidelines for clinical practice in a written protocol are established.
The dental hygienist who is a member of the American Dental Hygienists’ Association can get
information from ADHA on professional liability and other types of insurance for self-employed dental
hygienists. Equipment replacement insurance can also be investigated at https://www.personal-
plans.com/adha/welcome.do
Ethics of professional care
Ethics is generally defined as the moral principles that govern a person’s or groups’ behavior. These values dictate that we engage in health promotion and disease prevention activities. When we look at the dental hygiene profession, our professional code of ethics guides us to a higher level of ethical consciousness, decision making, and practice. We are duty bound to practice our vocation in a manner that reflects our ethical and professional standard of care. According to the American Dental Hygienists’ Association, the objectives of the Dental Hygiene Code of Ethics are:
To increase our professional and ethical consciousness and sense of ethical responsibility. To lead us to recognize ethical issues and choices and to guide us in making more informed
ethical decisions. To establish a standard for professional judgment and conduct. To provide a statement of the ethical behavior the public can expect from us. We are obligated to practice our profession in a manner that supports our purpose, beliefs, and
values in accordance with the fundamental principles that support our ethics. We acknowledge the following responsibilities:
Our core values (listed below) teach us that people have the right to be treated with respect. They have the right to informed consent prior to treatment, and they have the right to full disclosure of all relevant information so that they can make informed choices about their care.
Confidentiality We respect the confidentiality of client information and relationships as a demonstration of the value we place on individual autonomy. We acknowledge our obligation to justify any violation of a confidence.
Societal Trust We value client trust and understand that public trust in our profession is based on our actions and behavior.
Non- malfeasance We accept our fundamental obligation to provide services in a manner that protects all clients and minimizes harm to them and others involved in their treatment.
Beneficence We have a primary role in promoting the well-being of individuals and the public by engaging in health promotion/disease prevention activities.
Justice and Fairness We value justice and support the fair and equitable distribution of healthcare resources. We believe all people should have access to high-quality, affordable oral healthcare.
Veracity We accept our obligation to be truthful and assume that others will do the same. We value self-knowledge and seek truth and honesty in all relationships.
Professional Negligence and Malpractice
Negligence is an example of an unintentional tort; a dental hygienist did not intend to harm the patient,
but his or her action or inaction inflicted harm. Negligence is the failure to perform a clinical action
(prophylactic or therapeutic) at the reasonable and acceptable standards of the profession with the
result of harm to the patient. A mistake without harm does not constitute negligence. In dental hygiene
practice, negligence may be an act of omission or commission; both are considered negligence.
Professional negligence is neglecting to perform a procedure or action that is part of a standard of care,
or adopting behavior that is doing or failing to do what a reasonable and prudent dental hygienist would
do under the same circumstances. It may occur at any time during the various stages of patient care,
including during assessment, treatment, and follow –up.
At times, a patient may contribute to the negligence or harm. This is contributory negligence. The
patient has not taken reasonable care to protect his or her safety and this has contributed to the injury
or harm. For example, a patient may not take prophylactic pre-medication as instructed before a
procedure. The dental hygienist who treats a patient without asking if the premedication was taken is
considered negligent. However, the patient has also contributed to negligence by not following
instructions. If harm results from not being pre-medicated, the dental hygienist is considered negligent,
but the patient is also held contributory to negligence.
Malpractice and Standard of Care
Professional negligence that causes harm is malpractice (bad practice). For malpractice to occur, it
must be established that an individual, patient was harmed because of a lack of standard of care.
Standard of care is the minimal level of care that is recognized by a professional group. Malpractice
results from ignorance, lack of skill, neglect in applying skills, professional misconduct, and practice
contrary to established rules. In other words, failing to keep informed does not protect one from being
guilty of malpractice.
Alternative Settings
In many cases, less supervision is needed in public health settings or institutions. For example, dental
hygienists in Tennessee can now provide services in nursing homes, skilled care facilities, non-profit
clinics, and public health programs without the physical presence of a dentist. However, a dentist must
have examined the patient and made the patient a patient of record prior to any dental hygiene
treatment.
See Course Introduction for instructions on taking the Self-Test.
References
1. Tennessee Dental Hygienists’ Association. Written Protocol. Available at http://tndha.org/wp-
content/uploads/2013/04/Written-Protocol-toolkit.pdf. Accessed August 28, 2014.
2. Code of Ethics. American Dental Hygienists’ Association. https://www.adha.org/resources-docs/7611_Bylaws_and_Code_of_Ethics.pdf. Accessed August 28, 2014.
3. Jurisprudence, and Practice Management in Dental Hygiene/Vickie J. Kimbrough – Walls, Charla
J. Lauter, -3rd ed., copyright 2012 by Pearson Education Inc., Upper Saddle River, New Jersey
07458
PUBLIC HEALTH SELF STUDY
SECTION FIVE Self Test
1. Allowable parties to engage in a written protocol agreement in Tennessee include all of the
following EXCEPT one. Which is the EXCEPTION?
a. A dentist and a hygienist
b. A dentist and up to three hygienists
c. Three dentists and a hygienist
d. There is no regulation against having more than three dentists or hygienists in an
agreement
2. Which of the following regulations must be included in the written protocol agreement?
a. OSHA regulations
b. HIPAA regulations
c. CDC Infection Control regulations
d. All of the above
3. All of the following settings can be involved in a written protocol agreement EXCEPT one. Which
is the EXCEPTION?
a. Nursing Home
b. Skilled Nursing Center
c. Mental Health facility
d. Nonprofit Clinics
4. The supervising dentist must notify the Board of Dentistry within ten (10) working days by
certified mail/return receipt requested or electronic mail when the written protocol is no longer
in force.
a. True
b. False
5. Who must process billings for payment for services provided in a written protocol?
a. Dentist
b. Hygienist
c. Office manager for written protocol setting
6. The causes of malpractice are professional misconduct, unreasonable lack of skill, lack of fidelity in performance of professional duties and practice contrary to established rules
a. True b. False
7. The failure to ask and document Premedication, failure to detect and document oral cancer,
failure to update health history, failure to detect, document and inform patient of perio condition and the injury of a patient are:
a. Laws pertaining to dental hygiene b. Most common lawsuits against dental hygienists c. elements in lawsuits regarding informed consent
8. Non-malfeasance is defined as
a. The dismissal of the patient without ample and proper notice
b. The term geared toward the patient’s self-determination”, the patient’s right to
make their own choice about their treatment and the freedom of choice and right to
privacy
c. The term that says the practitioner is to do no harm and provide services to protect
all patients from harm
d. The purpose of the Dental hygiene code of ethics
9. We contribute to the health of society; all people should have access to oral health care; Individuals are entitled to make health choices; We are qualified by licensure; We function interdependently and we are responsible for our actions. These concepts are known as:
a. Moral weakness b. Civil law c. Justice d. Basic beliefs
10. Ethics involves an expression of values whereas jurisprudence involves legal precepts.
a. True b. False