Midtown DentistryWelcome to Midtown Dentistry’s Hygiene Team

We would like to welcome you to our practice and take this opportunity to familiarize you with our history and mission. We are extremely happy and excited to have you as a member of our growing team!

History

Midtown Dentistry started 16 years ago by Dr. Jonathan Penchas in a historically renovated 103 year old home on Westheimer Road. Our practice initially consisted of Dr. Penchas, one assistant, one front office staff/manager, and one part-time hygienist. We had 4 operatories in addition to our detached lab for in-house lab work. Within the last 3 years, we have expanded our main office to include 6 operatories, all equipped with the latest state of the art equipment. We now have 5 doctors and 15 staff members and still growing!

Mission

As a hygienist at Midtown Dentistry, you are not here to just “clean teeth”. Our primary purpose is to provide the highest quality dental hygiene care to all our patients. We strive to provide quality, comfortable care to all adults and children in a warm, welcoming, friendly, and relaxed atmosphere. Each patient deserves our focused attention and best efforts to make his/her experience one that stands far above the norm. Our practice depends on the success of these efforts.

Employment

The purpose of this hygiene manual is to inform our hygiene team members of general office/hygiene policies. It is subject to change as needed.

This handbook is not an employment contract and is not intended to create contractual obligations of any kind. Neither team members nor Dr. Penchas/Midtown Dentistry are bound to continue the employment relationship if either chooses, at its will, to end the relationship at any time. This is referred to as at will employment and is part of most employment situations.

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Dental Hygienist’s Role and Duties

Considered the primary patient educator of the practice, your role is to help patients learn how their oral health impacts their overall health and what steps they can take to improve it. You are accountable for letting the patients know about all the problems that you see, the potential consequences if the problems are left untreated, and what solutions the Doctor is likely to propose. You help create value and increase the patient’s motivation to choose treatment.

The following responsibilities fall under the scope of Dental Hygienist:

Hygiene

Help your patients understand and believe in what constitutes a “Healthy Mouth,” Update patient’s medical history, record blood pressure, uncover any new conditions, etc. Perform a comprehensive periodontal evaluation including probe depths, bleeding points,

recessions, mobility, furcation, etc. Chart any progress/decline and advise the patient. Identify failing dental restorations, decay and/or open contact. Use the intraoral camera to educate patients about their oral health and potential

treatment that is necessary. Perform oral prophylaxis, polish and educate patients on home care instructions. Explain, educate, and perform periodontal treatment on all patients as needed Discuss any unscheduled treatment with patients, and use visual tools and verbal skills to

educate and motivate them. Summarize your findings to the patients and educate them about the potential

consequences if their condition is left untreated. Educate the patients regarding the next steps that the Doctor will likely recommend. Uncover any issues or concerns that the patient may have and alert the appropriate person (i.e., Treatment Coordinator).

Advise the Doctor when a patient is ready for exam. Inform the Doctor of the patient’s periodontal score, what was completed during the visit, any unfinished treatments, recall intervals and any medical/personal concerns the patient may have.

Emphasize the need for continuous care and make the recommended next appointment interval.

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Other Duties

Perform a “Trust Transfer” to either the Scheduling Coordinator or Treatment Coordinator.

When available, assist in the cleanup and setup of treatment rooms. Sharpen hygiene hand tools and instruments and make recommendations when pieces

need replacing/reordering. Participate in the Morning Huddle by reviewing patient charts prior to meeting and

identifying scheduling concerns, unfinished treatments, patients who are difficult to work on, etc.

Assist in asking “A” patients for referrals. Assist in building a “Trust Factor” with all patients. Assist to uncover patients’ needs. Cover other areas within the practice as needed and when needed. Serve as Patient Referral Liaison.

Expectations

Meet daily production goals for the Hygiene schedule. Use intraoral camera on patients to highlight problems/concerns/issues or the patient’s healthy mouth. Use the “Standards of Care” as a guideline for treatment required, and the “Healthy Mouth Baseline” as a comparison. Assist in identifying treatment required for patients, and monitor the results.

I have reviewed the roles and responsibilities listed above and agree to follow them as part of my daily performance.

Doctor Dental Hygienist

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Getting Started

We want your first days at Midtown Dentistry to run as smoothly as possible. Here are some things to keep in mind when getting started.

Attire/Appearance:

1. Your radio “walkie-talkie” is a part of your uniform. It should be worn at all times throughout the day. This is our source of communication, so you are not “Complete” without this. Your radio should be given to you by our management team when you were hired or on your first day at work. Every team member should have their name on the back of their radio. Your unit should has a charging base and must be recharged at the end of the day before you leave, so it can be ready for use the next morning.

2. Wear clean and matching scrub pants and top. 3. A white lab jacket must be worn over your scrubs. 4. Makeup, hair, jewelry, clothing, and fragrances should be subdued. Fingernails should

be kept short so they do not interfere with the performance of work. 5. If you have long hair, it must be pulled back and tied in to a ponytail. 6. Clean tennis shoes or equivalent are approved for wear with scrubs. Shoes must be worn

with socks. 7. Oral hygiene is essential as a dental team member. You are expected to brush, floss, and

use mouthwash as necessary during a workday.

**A good rule of thumb: Dress for Success and keep the patients perspective in mind**

Do’s and Don’ts

1. Please make your best effort to be pleasant and courteous to patients at all times. Patients are the reason we are in business.

2. Personal telephone calls are allowable as long as they are brief during your break time or in between patients. Abuse of the brief guideline may result in a change to this policy. Pagers and cell phone ringers must be kept virtually silent throughout the day and stored in your locker. You are not allowed to have your cell phones on the counter in the operatories. Unless there is an emergency, patient care is always more important than a personal phone call or conversation.

3. Our computers are for work use. Team members are not allowed to use them for personal use or to gain access to “Social Media” websites etc. They can be used to check your email through our office websites or to obtain work related information to provide to patients.

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Starting Out

If you have just graduated from hygiene school or have been “out of practice” for a couple of years, it is normal to feel as if you need extra time to accomplish everything that needs to done during a hygiene appointment. This will also be true even if you’ve been practicing for some time in another office just simply because you are not familiar with where everything is placed, systems, etc. Here at Midtown Dentistry, we will make every effort to help make your day run quickly and smoothly.

HYGIENE APPOINTMENTS (Appointment time allowances):

75 Minutes for:

1. New Patients2. Scaling and Root Planning Patients – typically 4 quadrants are performed in one

appointment, unless patient chooses not to, or because of insurance coverage (some insurance companies will only allow 2 quadrants to be scaled at each appointment).

This should be enough time to not just “clean teeth”, but to organize the whole experience for your patient.  Can you make this experience so significant that your client would willingly drive past 50-100 other hygienists to get to you?  This is how good you are expected to be.  We will do everything to help you achieve this goal. Your time in the operatory with your patient should be spent taking x-rays, treating, and educating your patients. You will have help breaking down and setting up your operatory.

45 Minute Hygiene Appointments:

1. Recall Appointment2. Full Mouth Debridement3. Implant Maintenance Prophylaxis4. Periodontal Maintenance Prophylaxis

We are a team here at Midtown Dentistry and we are here to support and help make your job run smoothly.  Think through and organize in your mind on how to develop a winning relationship with your patient.

Since every patient you meet will be a “new patient” to you, here is how we would like for you to start your relationship with this client.

1. Introduce yourself with a handshake.  (EX: “Good Morning Mr. Smith, my name is Loan, I’m the hygienist and I will be taking care of you today.”

2. State (not explain) that you have not had the opportunity to clean his/her teeth before.  As they are sitting upright in the dental chair, take their blood pressure and review their medical/dental history. 

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3. BE CONFIDENT! Give your client the impression that you are “in control.”  That you will use all the necessary resources to insure them the best dental cleaning appointment they have ever experienced.

IF YOU FEEL LIKE YOU NEED ADDITIONAL TIME WITH YOUR PATIENT, PLEASE TALK TO YOUR HEAD HYGIENIST/SUPERVISOR.

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Being the BEST HYGIENIST you can be!!

Here at Midtown Dentistry, we do not expect you to do 100 prophies a day, only robots in an assembly line can possibly do that! However, as a hygienist, if you are with your patient and have no interaction with them, just clean their teeth and release them, you are realistically resembling a robot.

Patients know us as the “teeth cleaning lady”. Well, some patients do not realize that we went to hygiene school to not only learn how to clean teeth, but also about oral cancer, pharmacology, nutrition, systemic conditions, etc.

Just remember that a patient can choose to go to any dental office they want to. Prove to them that you are not only here to “clean their teeth”, let them know that you truly care about their oral health and you will educate and provide them with tools/products to help them improve their home care.

Make a Difference:

As the hygienist, majority of the times, you are the first clinical staff that the patient will interact with. This is your chance to prove to your patients that this is why Midtown Dentistry is different than any other dental office they have ever been to!

Educate your patients Give home care instructions Talk to them about gum disease (most do not know the difference between gum disease

and periodontal disease) Tell them why you are measuring their “gum pockets” and show them what the probe

looks like. Recommend prescription fluoride toothpaste and rinses for home care if you see decay

and give them home care instructions Take intra-oral pictures and show them where they have decay If they need dental treatment, explain to them what is involved and how many

appointments it will take. While performing the clinical oral cancer screening, let them know what you are doing

and you are looking for. Always use terminology that is easy for them to understands (EX: do not say caries, say

decay instead) Be considerate of their feelings and anxiety level. Some patients have a lot of dental fear

and if so, a prophy does not have to done during their first appointment. We want them to get comfortable with us first. They can always come back and treatment be done under IV sedation or Halcion.

BE THE BEST HYGIENIST YOU CAN BE by leaving a lasting impression on the patient when they leave! Will they just simply feel like they just got their “teeth

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cleaned” or will they leave thinking “Wow, I have learned things today that I have never been taught before!”

Here is an example of being a Just a Hygienist and being the Best Hygienist you can be!

Being Just a Hygienist :

Mr. Smith comes in for his appointment. Loan, the dental hygienist, greets him, gets him seated, and takes his blood pressure. She takes four bite-wing x-rays and starts his dental cleaning. She does not inspect the x-rays that she just took. Although she sees decay in numerous teeth, she proceeds with the cleaning and calls Dr. Penchas in to do the exam. She did not tell Mr. Smith that he had any decay at all. Dr. Penchas comes in to do the exam and tells Mr. Smith that he has decay and that he will need fillings and some of the teeth will need crowns and possible root canals. Mr. Smith is completely surprised because he was not aware of this and is shocked to learn that he will need about $10,000 in dental work.

What do you think this patient is now thinking?

1. Why was nothing communicated to me when she was cleaning my teeth?2. Is this dentist lying to me because I am not feeling any pain?3. I am going to leave and not come back.4. I am going to leave a negative review for them because I do not believe them. I

think they are lying to me.

Same Scenario – Being the Best Hygienist you can be!

Mr. Smith comes in for his appointment. Loan, the dental hygienist, greets him by shaking his hand and introducing herself. She seats him, ask him if there are any changes in his health history, and ask if he is having any problems with any of his teeth. She takes his blood pressure and lets him know that he is due for bite-wing x-rays. She tells him that the bite-wing x-rays are taken once a year to detect any decay between his back teeth. She takes the x-rays, inspect them, and she points out the areas of the decay in the x-rays to Mr. Smith and lets him know that some of these areas of decay are fairly deep, and that those teeth will need to have fillings, crowns and possible root canals. She reassures him that she will check the teeth in the mouth and after the cleaning, Dr. Penchas will come in for the exam and let him know what treatment he will need. Loan gives Mr. Smith protective eyeglasses and lays Mr. Smith’s chair back. She checks all the teeth for decay, checks the pocket depths of all the teeth, and performs the oral cancer screening (clinical and with the OralID light). As she is doing each procedure, she explains to Mr. Smith what she is doing, why she is doing it, and what she is looking for. She takes intra-oral pictures to show Mr. Smith the teeth that are decayed. Loan now does Mr. Smith’s cleaning. She points out to him the areas where there is build-up and stains, polishes, his teeth, and applies the fluoride. Because of the decay that she sees, Loan tells Mr. Smith that he will get a prescription for a toothpaste/rinse that is

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high in fluoride that he will use at home to help prevent/slow down the progression of decay. She also recommends that he buys an automatic toothbrush and gives him very specific oral hygiene instructions (rinse, floss, brush). She has already shown Mr. Smith the intra-oral pictures that she took of the decayed teeth, so he is well aware of where the cavities are and has an idea of what treatment will most likely be needed. She tells Mr. Smith that she will see him again in 3 months for his next dental cleaning and that Dr. Penchas will come in to do the exam.

Loan gets Dr. Penchas and lets him know in advance what she saw in the Mr. Smith’s mouth, what treatment she feels he needs, and that Mr. Smith was shown the x-rays and intra-oral pictures. Dr. Penchas enters the treatment room for the exam. Mr. Smith was informed of the treatment that was needed and he was not at all surprised because he, at this point, has already seen the areas of decay (both on the x-rays and the intra-oral pictures) and was briefed on the treatment that was needed by Loan before Dr. Penchas came in to see him. He was presented with the treatment plan by the treatment coordinator, given his prescription for his fluoride toothpaste, and the dental work was scheduled. Loan shook his hand and told him that she will see him in 3 months for his next dental cleaning.

What was this patient thinking?

1. Wow, this hygienist knows what she is talking about!2. No one has ever told me that I needed to rinse, floss, and then brush in that same

exact order and why.3. Well, my teeth are not hurting but they are obviously decayed because I can see

them in x-rays that the dental hygienist just showed me. 4. I actually understand what all is involved in my dental treatment, how long the

procedures will take, and how many times I will need to come back. 5. I will use that prescription toothpaste as she instructed because I really want to

prevent my teeth from getting decayed.

As you compare the two examples, put yourself in the patient’s position. Which office will you continue to come back to, which office would you recommended to your family and friends to? Ask yourself these questions when you are treating your patients and don’t forget…..a patient has a choice of where they can go. Being the best hygienist you can be by making your patient’s experience with you and Midtown Dentistry a reason for them to want to continue to come see us as well as referring their family and friends.

It is your job to let the patient know where they have cavities (even it is in every single tooth). It is neglect if you do not! It is the patient’s choice whether or not they want to

have it treated! If you have done all this and given them their treatment options, you have done your job, it is now up to them!!

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Possible Reasons Why Patients Do Not Return for Recall Appointments

Do you ever wonder why your patients don’t come back for recalls?  Yes, there are some patients who do not value their dental health, etc. - but here are some other possibilities:

1. You didn’t inspire confidence in the client

You were tense, nervous You acted confused, unsure of yourself You didn’t seem to have a routine treatment procedure (jump  around, pick-up, hunt for

instruments, talk to yourself) You seemed preoccupied - didn’t pay much attention to the  client You allowed yourself to be interrupted, spent time talking with staff and seemed to

ignore your client Your appearance isn’t professional (hair, nails, etc.)

2. You were not CONFIDENT

3.  Didn’t treat the client as a special person rather than a set of teeth

4.  Make your client wait

5.  Didn’t appear to care if the client wasn’t comfortable

6.  Didn’t explain what you were doing

7.  Criticizes the client

A good way to start your career with us at Midtown Dentistry is to observe your lead hygienist for one week.  This will give you the opportunity to work with her on a variety of patients and their need for different hygiene and dental treatment (EX: new patients, recare patients, and patients with implants, partials, crowns, bridges, fillings, and esthetic dentistry). This observation will give you the opportunity to build the confidence and knowledge you will need to explain different types of treatment options available for your patient.

KEEP IN MIND: We do our best to keep our patients happy, however, there are times when you can bend over backwards and still cannot satisfy some. We at Midtown Dentistry know that our team members will always make every effort to make our patients happy, so we stand behind

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you 200%. Always be courteous to your patients and ask for help from your supervisor if you ever need help addressing any issues!

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Stay on schedule

Punctuality!

Clients hate to be kept waiting.  When you start an appointment more than 5 minutes behind schedule, you have either announced to your client that you:

1. Don’t care about them

2. Are incompetent

Either way, you lose.  Be prepared for the day. You should arrive 10-15 minutes before huddle. This will give you time to accomplish the following.

1. Get your mind organized for the day.

2. Make sure your operatory is set-up and ready to go (EX: make sure room is CLEAN and water bottles are filled – this will prevent you from running out of water during a procedure and having to stop to refill it).

3. Review the charts of the clients you will see that day so you are treating people not teeth.  What recent treatment have they received that you want to follow up on (EX: what was done at their previous hygiene and dental appointment, what dental treatment is still needed?)

Please make every effort to stay on schedule. However, there will be times when you will run behind. Here are some reasons why you might run behind schedule and these are reasons that cannot be controlled by you.

1. The client was late.  (However, patients who are 15-20 minutes late should be rescheduled, unless a hygienist does not have a patient immediately following). In a nice and courteous way, let your patient know that because he/she is late, you are only able to accomplish a certain number of things today during this hygiene appointment. (EX: Good morning Mr. Smith! How are you? I was worried about you because you are running 15 minutes late, but I am glad that you here and okay. Let’s go ahead and get started and see what we can get done today.”).

2. The doctor was late checking.  Make sure you have everything ready for the doctor.  Explain to your client that the doctor will be a few minutes.  Ask them if they would like to read a magazine.  Can you get them anything else to help them be comfortable?  Then excuse yourself.  Tell the doctor/dental assistant which room your patient is in. If there is dental treatment that is needed, chart the treatment in the computer (dental treatment will appear red) and let a treatment coordinator know before moving on to your next appointment. You can also put on a post it note and place on your instrument tray to let the doctor know what you see or want him/her to check if you are not in the room Get your next client and move to another room.

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3. Your patient has questions about their treatment. If you need help with a patient’s questions about their treatment plan, get a treatment coordinator. Go ahead and get started on your hygiene appointment first then let your patient know that the doctor and treatment coordinator will be in to answer any questions they might have about their recommended dental treatment.

4. Patient has a difficult mouth to work on (EX: Implant maintenance, heavy staining, heavy build-up…etc.). Watch your time! If the patient has heavy calculus than a Full Mouth Debridement should be done and they will need to come back for Scaling and Root Planning

5. Implant patients might require implant clips to be changed out. This could take additional time. Get help from a dental assistant or doctor if possible.

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Hygiene New Patient Check-List

Review Health History (Is premedication needed?) Is patient having any pain/discomfort Take Blood Pressure X-rays (Panoramic and 4 Bitewing X-rays). Take Periapical x-rays if

needed. Patient needs to sign X-ray Refusal Form if they refuse x-rays. Complete Dental Charting Complete Periodontal Charting Check for decay Chart treatment Use intra-oral camera to take Intra-oral pictures Intra/Extra-oral examination (Oral Cancer Screening) Clinical examination and Oral-ID Light (Patients should be informed that

the Oral-ID Light is a special Fluorescent Light that is used once a year to detect any abnormal tissue that cannot be seen with the eye. There is a $23.00 charge (code D0431) for the Oral-ID procedure. Clinical oral cancer screening is done at no additional charge during every exam.

Inform patient of type of cleaning needed (EX: Full mouth, SRP). If full mouth is needed, ask treatment coordinator or front desk to determine patient’s out of pocket expense before starting procedure. If patient needs SRP, explain to them what Scaling and Root Planning / Deep Cleaning is and why it is necessary. Perform prophy, full mouth debridement, or SRP (based on time availability). However, patient must be informed of cost for full mouth debridement and SRP prior to procedure.

Brief patient on the treatment recommendations (EX: fillings, crowns, implants, bridge, etc.) and prepare them for what is needed before the doctor comes in. This will get them mentally prepared for what to expect before the doctor comes in.

Let your patient know when you will see them next (EX: SRP appointment or 3-6 months recall).

Let your patient know that your treatment coordinator and the doctor will come in to do an examination. You can write down (on paper/sticky note) when you recommend the patient come back for recall as well as areas of possible decay that you might see, the need for nightguard, lesions in the mouth, etc….

If the patient told you that they are interested in orthodontics, having wisdom teeth removed..etc.. (any treatment that will need a referral), please

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let your treatment coordinator and doctor know so that way the patient can be given a referral to the specialist. The referral must then be put in to Dentrix Patient Chart.

Get doctor and treatment coordinator, show them the x-rays, and let them know about your patient and what you saw in the mouth (decay, missing teeth, etc.).

Introduce the doctor and treatment coordinator to patient. Thank your patient and you can now leave the room.

Charts must be completed on all patients and signed by you, the treating hygienist. If any of the doctors performs any dental work on the patient, the dental assistant will write the notes and the doctor will then sign those notes. Just remember that Clinical notes are written so that anyone in this office can read the note and know why the patient was here, what was done, who saw them, what was recommended, etc….

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Hygiene Recall Patient Check List

Health history update (have front office give patient health history update form to fill out when they check-in). A written and signed health history update should be done once a year.

Review medical history. Ask patient for any changes and put in to clinical notes. Some patients may have an updated “paper” list of medications. This can be scanned in to their document center.

Ask patient if they are having any pain/discomfort that needs to be addressed. If so, take appropriate x-rays that are needed.

Take bitewings (once a year) Take Panoramic (once every 3 years or yearling if implant patient) Check gum pockets and address areas of concern (recommend more frequent

recall interval, scaling, Arestin placement if needed). Any extra fees need to be addressed before procedure/placement. Gum pockets need to be checked at every recall appointment, however, a complete periodontal charting does not NEED to be done except for once a year. If localized scaling or Arestin is done/placed than the periodontal charting must be completed to represent the rendered treatment.

Check for decay Chart any treatment Oral/Extra-oral cancer screening Perform prophy, implant prophy, periodontal maintenance Make recall interval recommendation Call the doctor for a recall examination Give patient a goody bag Walk patient to the front office. Let the front office team member know

when you would like patient to come back for recall and if patient needs any dental treatment, let treatment coordinator or front office team member know what dental treatment is needed and with which doctor. The treatment and fees must be discussed by treatment coordinator or front office team member.

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Determining Patient Recall Appointment Intervals

More and more your recall appointments will develop into the major factor in our practice. The more you can develop a long-term caring attitude with a client, the greater the chance they will accept your advice and our best dentistry.

Effective determination of appropriate recalls for patients is essential for good preventive care. Every patient is not a 6-month recall. The recall interval is very specific for each client.

Importance of proper recall interval:

1. Ensure that dentistry already done is properly maintained2. Diagnose new problems when they first start3. Prevent future problems for the patient4. To upgrade the quality of dentistry for your patients

You cannot fulfill these obligations, which satisfy the objectives of your recall system, unless the patients come in, and you do not motivate patients to come in unless they perceive the need to do so. The “See you in 6 months” makes each patient average and people don’t want to be “average”.

We have developed a unique system that categorizes varying levels of dental health. These structured levels are separated between decay and gum disease. Level I is our healthiest group, level II presents with mild risk for disease, level III presents with moderate risk of disease and level IV is our group that is a severe risk for disease.

It is important to let our patients know in what level they are, what risk factors they have and what interventions they need to move to the next level. The level that a patient is in helps determine their recommended interval for cleanings, decay X-rays, full set of X-rays, doctor exams, etc. It is important to motivate your patient to move to the next level. This is important for their health and can also show the patient how to lower dental costs.

To help motivate patients, we have created a Control Gum Disease brochure and a Stop Decay Now brochure to send home with each client so they have something to follow and help them with their goals.

Reinforcing the 3 W’s of Recall

Why: Give patients a specific reason other than having their teeth cleaned as to why they need to return for recall. Maybe you point out a perio pocket or a large filling that may need to be crowned.

Ex. “Mrs. Jones you have a deep pocket of 5 mm with heavy bleeding when I was cleaning your teeth and checking your gum pockets today. I will check that area again when you come back in

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three months. If that pocket does not shrink when you come back than we might need to perform a deep cleaning. This will help reduce your risk of heart disease.”

When: Now give patient a specific when they are to return “I need to check that area at Christmas time.” Mentioning a holiday that falls in that month can further help the patient to remember when they should return.

What: Tell the patient what to expect when they returnEx. “At your next visit, Mrs. Jones, we’ll be checking that pocket and cleaning your teeth.”

Determining Proper Recall

1. 5 – 6 months recall largest # of our patients – a lot of old fillings to watch, moderate buildup of stains tartar gums slightly puffy some bleeding. Use 5 or 7 month intervals rather than 6 whenever possible. This will personalize the time with your client and help them feel more special and that you are custom designing their treatment.3. 2- 4 month recall Patients with active periodontal problems, heavy bleeding, inflammation, or even heavy staining.  STM Recall

Many of our clients have completed our soft tissue management (STM) program. These clients require meticulous:

1. Root planning2. Probing3. Client communication

Flag these clients in your mind before you start the day. When you have your initial conference with them, be sure to mention their past program. Ask how their gums feel. Ask how they are doing on their home care program. Reinforce. Be positive.

When the appointment is completed, the patient’s gums will fit into one of four categories:

A. Controlled Periodontitis1. Pocket readings are same or better2. No increased tooth mobility3. No bleeding4. Good homecare

B. Advancing Periodontitis1. Disease is progressing in one of 3 stagesa. Gradual1. Some pocket depths increasing 1/2 mm2. 1 3 teeth can be lost over a 5 7 year periodb. Slow1. Several pockets of 2 mm increases

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2. Lose 4 9 teeth over a 10 15 year periodc. Steady advanced1. Pocket depth increase generally 2 4 mm2. Loss of 10+ teeth over the next 10 years

C. Uncontrolled Periodontitis1. Client doesn’ta. Provide good home careb. Show up for recall appointments on schedule2. Pocket depths are increasing

D. Refractory Periodontitis1. Client doing everything possible2. Pockets are increasing

Although these categories are valuable diagnostically, we only have three categories that count:

A. Controlled Periodontitis1. Pockets 5 mm or less2. Extend from 3 month recalls to 4 month recalls. This will probably be their recall interval forever.

B. Advancing Periodontitis gradual1. Definite warning that periodontal surgical intervention may be necessary.2. Stay at 3 month intervals

C. All other diagnoses1. Prepare client for an evaluation with Dr. ______________, our periodontist.2. Alert your doctor.

Determining length of recall appointment

It is the hygienists’ responsibility to decide the length of the recall appointment. At this level, most will be one hour. However, within three months your average appointment will be 45 minutes. When you decide the length of your next appointment, here are factors to consider:

1. Need for anesthesia or nitrous oxide2. X rays3. Doctor’s exam4. Oral hygiene review5. Amount of stain and calculus6. “Talkativeness”7. More than 6 months past due for cleaning – add 1 unit

People are more apt to return for their reexaminations if they feel there is a valid reason to return.

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People only hear what they want to hear in certain situations in the hospital emergency room, they repeat instructions 7 times and still the patient is not always aware of what they should be doing.The doctor, the hygienist, the front desk person, and occasionally the assistant should all repeat the following information to the patient during re-exam, during the doctor’s exam an during check out.

The patient will be more apt to remember the month that we want them to return if we associate the month with an event:

Jan After the New YearFeb Around the Valentine’s DayMarch – St. Patrick’s Day or hopefully when spring startsApril When winter’s over, EasterMay Just before school is out, Memorial DayJune Just after school is out. Flag DayJuly After the 4thAug Before school startsSept After Labor DayOct Before HalloweenNov Before ThanksgivingDec Before Christmas

Always say to the client “You will want to see the doctor again for a reexamination in February before Valentine’s Day because he is concerned about your gum tissue and wants to check it at that time”

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Hygiene Prophylaxis Steps and Protocols:

When our patients come to Midtown Dentistry for their cleanings, no matter which hygienist they see, we want them to have the same “First-Class” Experience. By doing so, we want all of our hygienists to following these steps. These methods will also help the hygienist in their daily life by reducing hand and back fatigue.

PLEASE FOLLOW THESE STEPS:

1. Always use the Cavitron or Piezo first (on low power to help reduce patient discomfort)2. Follow-up with hand instruments3. Polishing (on all patients and all teeth – we DO NOT believe in SELECTIVE

POLISHING) Use rubber cup with prophy paste Use prophyjet or Kavo Handpiece for patients with heavy stains

4. Fluoride treatment Apply Foam Fluoride Apply Fluoride Varnish

5. Use a warm towel or give patient a warm towel to wipe his/her mouth or face.

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Hygiene Standard Tray Set Up:

Saliva ejector Dental hygiene kit (contains mirror, probe/explorer, sickle anterior scaler,

sickle posterior scaler). Disposable prophy angle or screw on rubber tip Prophy paste Gauze squares Cotton tip applicator

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Rinse, Floss, and Brush

What is your belief? Do you think the right order should be to rinse, floss, then brush or brush, floss, and then rinse? What you recommend to your patients should be what you believe works?

It is a good idea that all our hygienist make the same recommendations so that the patients do not get confused.

Our belief is to:

1. Rinse first2. Floss second3. Brush last

And this is why:

Rinsing first (pre-rinse) to reduce the number of bacteria in the mouth. This reduces the number of bacteria that can go in to the blood stream before flossing and brushing which will stir up the bacteria. Rinsing can be done again last for the “nice fresh feeling in the mouth”.

Flossing second to not only remove the bacteria that lives below the gums, but also to remove any food debris from between the teeth. This way, the fluoride in the toothpaste can penetrate between the teeth and help prevent decay or stabilize the incipient decay already there. If flossing after brushing than there is still debris between the teeth which will block the fluoride in toothpaste from going between the teeth.

Brushing last because now that interproximal areas are free of debris (after flossing) than the fluoride in the toothpaste can penetrate between the teeth.

You will find that most people do complete opposite, which is to brush, floss, then brush. Once you explain these steps to them, it makes perfect sense as to why it is done in this order!

****Please talk to your hygiene manager if you have any questions****

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What to do when your patient NO SHOWS for his/her hygiene appointment!

1. Was the patient’s appointment confirmed? If so, how was it confirmed (Example: by phone, demandforce, email)?

2. Check with the front office to see if the patient called to cancel/reschedule their appointment, was called by the front office team member, or missed their appointment.

3. Was the missed appointment rescheduled? If so, when was it rescheduled for? Patients who miss/no show for their appointment should be scheduled at least 3 weeks to one month out.

4. Make a notation in the clinical notes about the missed/no show appointment. After 2 missed appointments, the patient will be charged a $40 fee (this should be done by a front office team member).

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Use Free Time Effectively

There will be times in your day when you have free time. The sign of a potentially great staff member is how you use this time. Here’s a list of tasks that will make our office run better.

1. Hygiene instruments are sharpened and put away.2. Supplies are plentiful and stocked in rooms.3. Refill irrigating syringes with chlorhexidine/hydrogen peroxide.4. Make patient goody bags (toothbrush, toothpaste, floss)5. Help with recall6. Make sure all your chart notes are complete and signed.7. Handouts are in order and there are enough. 8. Thoroughly clean your hygiene operatory9. Review your patients charts for the next day - get organized.

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Periodic Examination Protocol

After the patient’s dental cleaning, you will:

Notify the doctor that your patient is ready for an examination. Call for the doctor on your radio, but if you do not get a response within 30 seconds, please look for him/her. He/she may in a treatment room and not able to hear you.

If the doctor is in surgery, or not available to come in for the exam (within 3 minutes), please ask your patient if another doctor can come in to perform the periodic exam (Please see Script following).

If the patient is fine seeing the other dentist, please bring in the dentist and introduce him/her to your patient.

If the patient is not willing to see the associate dentist/other dentist available then let them know that there will a long wait before they can be seen. Offer them coffee, water, tea, and even another appointment to come back for an exam. (Please see Script following)

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Script for Hygiene Recall Patients (Exams)

1. Mr/Mrs ______________________, Dr. ________________ is unavailable right now. I would like to bring in our associate, Dr. ______________ to do your exam. May I get him/her now?

Mr/Mrs_______________________, this is Dr. ____________. He/She will be doing your exam today.

2. Mr/Mrs_______________________, Dr. _________________is unavailable right now. I would like to bring in our associate, Dr. _______________to do you exam. May I get him/her now?

IF THE PATIENT SAYS NO, THEY ARE WELCOME TO WAIT FOR THEIR REGULAR DOCTOR!!!

I understand, you are welcome to wait for Dr. __________________. Let’s go out to the reception room, where you will be more comfortable and get a cup of coffee or water, if you like. One of the assistants will get you in a treatment room for your exam as soon as possible. It may be 10-15 minutes.

The advantage to option 1 is the patient meets our associates and is familiar with them the next time they come in. This allows the opportunity to offer the associates to do any future treatment, if necessary.

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Protocol for Patient Referrals

When a patient is being referred to a specialist for a specific need, these steps must be taken:

1. Make sure that name of doctor patient is being referred to is put in to patient’s chart and chart notes

2. Patient is given that doctor’s business card3. An email is sent to that doctor’s office (encrypted email) with the reason for

the referral and any x-rays attached. This letter needs to be saved in to the patient’s chart as well.

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X-RAY GUIDELINES

New Patients:

Panoramic X-ray

4 Bitewing X-rays

Recall Patients:

Every Year - 4 Bitewing X-rays

Every 3 Years – Panoramic X-ray

Implant Patients:

Panoramic X-ray once a year

Please look at your x-rays to see if they need to be retaken or if there is any possible radiographic pathology that will require a Periapical view, Panoramic, or even CT Scan.

****Edentulous patients still need to have a Panoramic X-ray taken. Please remember to explain to the patient that although they do not have

any teeth, the x-ray will detect any cancer, cysts, abscesses, or other abnormalities that is not clinically detectable in the mouth****

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Periodontal Probing

Probing should be done on every patient during every hygiene appointment. You do not have to chart it every single time (unless there are 5mm. > pockets), but a completed periodontal charting must be done in the system at least once a year. A patient’s periodontal status can change very quickly and the only way to monitor it is by probing every time they come in.

When probing:

Walk the probe around the circumference of the tooth in 1mm increments, keeping the probe in the sulcus.  Record 3 depths -mesial, central, distal on both the facial and lingual.  This means that even though you’ll only be recording 6 measurements, you’ll be checking many more areas.  Record the deepest markings. Round off to whole numbers.  Probe the proximal areas very carefully.  This is where most bone loss begins.

Here are the factors to consider that determine the accuracy of your probing.

1. Size of the probe – we use probes with 3, 6, 9, 12 mm. marks2. Do not force the probe (particularly with inflammation present, you may  

push through the attachment)3. Dimensions of the pocket4. Access to the pocket5. Angle at which you probe – probe as close to the proximal contact as

possible6. Calculus in the pocket7. Health of the gums (The healthier the tighter, the harder to    get to the base.)8. Your accuracy - clear away saliva, blood by drying9. The response (pain) of the client, (the greater the amount of inflammation,

the greater the pain) topical anesthetic can help

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There are so many factors involved in probing accuracy that you really need to see a 2 mm change to know the pocket has actually altered.  You can get a 1-1 1/2 mm change due to “operator error.”

Periodontal charting should include:

a.  Mobilityb.  Furcation involvement

1. Class I - Detectable, but can’t enter2. Class II - Can enter3. Class III- An instrument will pass through4. Class IV -  You can see through

c.  Gingival recessiond.  Bleeding upon probing (lack of bleeding is a good sign of health)

Recall patient with 5 mm > pocket with bleeding:

1. After probing, explain to the patient that they have deep gum pockets and what this indicates.

2. Perform prophylaxis3. Irrigate with chlorhexidine4. Place Arestin (if patient is not allergic to Tetracycline and agrees on the

fees)5. Go over Arestin aftercare 6. Make recare interval recommendation (typically 3 months)

You can choose not to place the Arestin, however, please explain to the patient that if depths of the gum pocket and bleeding does not improve when they come back in three months for their recall appointment than Scaling and Root Planing may be necessary.

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Stages of Periodontal Disease

The 4 Stages of Gum DiseaseThe stages of periodontal disease are determined based on the amount

of damage to bone and gum tissues around teeth. Gum disease treatment depends upon the stage and type of periodontal disease, ranging from a simple professional dental cleaning up to extensive periodontal surgery, soft and hard tissue grafting or dental implants to replace teeth that have been lost or cannot be saved.

Periodontal disease also known as gum disease is a progressive inflammatory disease of the gingival and bone tissues that surround and support teeth. Periodontal disease is the main cause of tooth loss after the age of 30 and it is believed that around 80% of the population above the age of 30 may experience the disease some time in their life.

The depth of periodontal pockets is a critical measure for determining the stage of gum disease and evaluating the risks for the patient's oral health.

1. GingivitisGingivitis is the first stage of gum disease representing the mildest form of periodontal

disease. Gingivitis is an inflammation of the gums characterized by redness, swelling, and sometimes bleeding during brushing or probing.

The gums become irritated by the toxins produced by the bacteria of dental plaque and tartar that have accumulated on teeth and gums as a result of poor oral hygiene. Gums get inflamed, loosening their attachment to the tooth and exposing previously covered enamel. The space between the gum and tooth (sulcus) gets deeper, forming a periodontal pocket. The depth of pockets is about 1-4mm when measured during periodontal probing.

At this early stage of gum disease, damage can be reversed with proper dental hygiene, since the teeth are still firmly planted in their sockets without any bone or connective tissue damage. Gingivitis may have only mild or no symptoms, but if left uncontrolled, it can progress to a more advanced stage of gum disease called periodontitis. Gingivitis may persist for years before the inflammatory process becomes destructive. Tooth scaling, root planing and improved oral hygiene are common treatments for gingivitis.

The main characteristics of this stage of gum disease are:

the condition is reversible there is no permanent loss of jaw bone around teeth

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Gingivitis cannot be easily distinguished from early periodontitis with a simple visual examination. In order to determine the exact stage of gum disease, the dentist has to perform a periodontal examination (probing).

2. Early PeriodontitisPeriodontitis is the more dangerous form of periodontal disease.

Infection and inflammation has spread to the bone supporting the teeth. When gum disease has progressed to the periodontitis stage, the supporting bone and fibers that hold the teeth in place start to get irreversibly damaged. The stages of periodontitis are defined as early, moderate, and advanced. The main factor for the classification to a certain stage of the disease is the degree of destruction of the supporting bone.

In the initial stage of periodontitis plaque bacteria continue to penetrate deeper between the teeth and gums. The environment becomes suitable for the establishment of anaerobic bacteria under the gums. Gingival pockets are formed below the gumline.

Greater inflammation and swelling of the gums Gums begin to separate from teeth below the cemento-enamel junction Gum bleeding when probing or brushing Pocket depth up to 4-6mm Infection reaches bone - Slight bone loss Unpleasant breath or taste Subgingival accumulation of plaque and calculus

Treatment of early periodontitis includes tooth scaling and root planning accompanied by improved oral hygiene. Despite the bone damage, the amount of bone loss in this stage of periodontal disease is minor so that usually no additional treatment is required.

3. Moderate PeriodontitisThe surrounding connective tissues and alveolar bone become are seriously infected.

Bacterial toxins and the body's enzymes fighting the infection break down the bone and connective tissue that hold teeth in place. First signs of tooth mobility appear due to bone loss.

Gums recession – teeth appear longer Root surface exposed - sensitivity - root decay Persistent bad breath Bleeding gums Pocket depth of 6-7mm Moderate bone loss (20 - 50%)

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Periodontal abscesses may develop Teeth may begin to loosen, drift and look separated

Moderate periodontitis is one of the most critical stages of periodontal disease, because some ‘damage control’ is yet possible before the condition reaches a phase when teeth cannot be saved. Surgical treatments of gum disease can stop the progress of the disease but the damage is not reversible.

4. Advanced PeriodontitisThis final stage of periodontal disease is characterized by severe infection, loosening teeth

and tooth loss.

Constant bad breath and bad taste Spontaneous gums bleeding Sensitive teeth due to exposed roots Pocket depth over 7mm Pus drainage in the mouth due to periodontal abscesses Severe bone loss (more than 50%) Teeth drifting out of place Teeth become loose or fall out

Teeth become so mobile and the bone loss so severe that in many cases they can not be saved and have to be extracted. In other cases, teeth extraction is necessary in order to clear the infection. The advanced stage of periodontitis can be reached in some cases without intense visible alerting symptoms despite the severe underlying bone damage.

Extensive periodontal gum surgery that includes soft and hard tissue grafting are necessary in a treatment effort to save the affected teeth. Unfortunately the prognosis is not good if the condition has reached to this advanced stages of periodontal disease.

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TREATMENT/THERAPIES for the 4 STAGES of GUM DISEASE

Patient should always be informed of his/her condition with treatment recommendations.

STAGE I – Gingivitis:

Prophylaxis Oral hygiene instructions Make recommendations for :

1. Automatic toothbrush2. Type of floss3. Type/Name/Brand of mouthrinse

Recall interval 2-6 months depending on severity

STAGE II – Early Periodontitis:

Full Mouth Debridement Scaling and Root Planning Sub-gingival Irrigation with chlorhexidine Placement of Arestin (if patient is not allergic to Tetracycline) Post care instructions, home care instructions Fine scale/polish appointment 2 – 4 weeks later Recall interval: 2-4 months

STAGE III – Moderate Periodontitis:

Full Mouth Debridement Scaling and Root Planning Sub-gingival Irrigation with chlorhexidine Placement of Arestin (if patient is not allergic to Tetracycline) Post care instructions, home care instructions Fine scale/polish appointment 2 – 4 weeks later Recall interval: 2-4 months Refer to Periodontist if needed

STAGE IV – Advanced Periodontitis:

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Full Mouth Debridement Scaling and Root Planning Sub-gingival Irrigation with chlorhexidine Placement of Arestin (if patient is not allergic to Tetracycline) Post care instructions, home care instructions Fine scale/polish appointment 2 – 4 weeks later Recall interval: 2-4 months Refer to a Periodontist

Stage 2, 3, and 4 Periodontal Disease Patients should also be given:

Oral hygiene instructions Make recommendations for :

1. Automatic toothbrush2. Type of floss3. Type/Name/Brand of mouthrinse

Home care recommendations and instructions are always a must! If a chlorhexidine rinse is recommended, they should be informed about the staining that can be caused (the staining is superficial, but can be difficult to remove, especially for patients with leaking/rough composite fillings).

Types of periodontitis (advanced gum disease)

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Periodontitis can be classified in several sub-types based on differences regarding bacterial etiology, host response and clinical disease progression. According to the American Academy of Periodontology, there are three types of periodontitis depending on the manifestation of the periodontal disease:

Chronic periodontitisChronic periodontitis (a.k.a. adult periodontitis) is the most frequent type of periodontitis

and is characterized by pocket formation and slowly progressing gum recession. The condition may first appear in adolescence due to poor oral hygiene but in most cases it is after mid-30s when the clinical symptoms become significant. If chronic periodontitis symptoms are ignored, the loss of bone and gum tissue will lead to tooth loss. It can be further divided into 3 stages; early, moderate and advanced stage.

Aggressive periodontitisAggressive periodontitis (a.k.a. early onset periodontitis) is a dangerous type of periodontal

disease that can cause tooth loss in a short period of time. Common symptoms are the fast increase in the depth of periodontal pockets and the rapid loss of bone structure.

Sometimes the condition is localized affecting one or no more than 3 teeth in patients with good oral health. Generalized aggressive periodontitis affecting the whole mouth requires immediate treatment to prevent extensive tooth loss. Genetic factors and immune deficiencies are considered as causes of aggressive periodontitis in addition to the microbial etiology of gum disease.

Depending on the age when the condition first appears it used to be classified as:

Pre-puberty AP is a rare type of periodontal disease found in children less than 12 years old that can cause the loss of primary and/or permanent teeth. The disease is usually related to genetic disorders and may appear with the eruption of the first primary teeth.

Juvenile periodontitis begins at puberty and is defined by severe bone loss commonly limited around the first molars and incisors. It is more aggressive than other types of periodontal disease causing very rapid vertical bone loss across the teeth roots. Juvenile periodontitis is usually asymptomatic without the usual symptoms of gum disease such as gums inflammation or gum bleeding.

Rapidly progressive periodontitis occurs in the early 20s to mid-30s. Severe inflammation and rapid bone and connective tissue loss occur, and tooth loss is possible within a year of onset.

The goal of treatment in aggressive periodontitis is to fight the microbial etiology and (if possible) the contributing risk factors. Treatment methods are similar to those used for chronic periodontitis, including oral hygiene, tooth scaling and root planning, and periodontal gum surgery if needed.

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Periodontitis as a Manifestation of Systemic DiseasesPeriodontitis as a manifestation of systemic diseases is more often associated with younger

age patients. Systemic conditions such as heart disease, leukemia, respiratory disease, and diabetes or disorders such as Down syndrome are associated with this form of periodontal disease.

A medical examination is required in cases of early-onset periodontitis to identify the presence of any systemic disease that might have triggered the periodontal disease.

Other types of periodontal diseases

Acute Necrotizing Ulcerative GingivitisAcute Necrotizing Ulcerative Gingivitis (ANUG) is a severe and painful type of

periodontal disease, which causes deep ulcerations of the gingival tissues. The condition is usually triggered by poor oral hygiene and poor nutrition. If left without treatment, the bacterial infection can lead to the necrosis of gum tissues and may spread to other areas of the body.

Acute Necrotizing Ulcerative Gingivitis is a much more severe condition than normal gingivitis, causing open gum sores and finally the death of the gum tissue.

Pregnancy gingivitisPregnancy gingivitis is one of the most common dental problems during pregnancy. The

condition is directly associated with the hormonal changes in the body of pregnant women.

PericoronitisPericoronitis is a common dental problem of the gums in young adults at the age of 17-24

when the wisdom teeth normally erupt (break through the gum) in the mouth. It is a painful inflammation caused by the infection of the soft gingival tissues (gums) over or around a partially erupted tooth, most often a wisdom tooth.

Periodontal-endodontic lesionsPeriodontal-endodontic lesions are another type of periodontitis that is related with

infected hard tooth tissues except of the gums. In this condition an infection from a decayed tooth root may spread to the adjacent bone and gum tissues creating deep pockets around the tooth and leading to bone loss.

Desquamative gingivitisOne of the most painful but rare types of periodontal disease is a condition called

desquamative gingivitis. The outer layers of the gums separate from the underlying tissue and peel away, exposing the inner layers and causing acute pain. This type of gum is more common in women after menopause.

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Patients that we treat before referring to a Periodontist!

The following are patients that we can treat in our office and then refer to a periodontist as needed for evaluation/treatment. Most of these patients will benefit initially with a Full Mouth Debridement on their initial visit followed by Scaling and Root Planning. After their fine scale/polishing appointment, these patients will be seen every 2-6 months for their periodontal maintenance cleanings. These periodontal maintenance appointments can be changed based on the patient’s needs.

These patients include any patient who demonstrates during their recare visit or any dental examination any of the following risk factors/indicators known to contribute to the progression of periodontal diseases:

Early onset of periodontal diseases Unresolved inflammation at any site (Ex: 5mm. pocket or more with

bleeding upon probing, inflammation, exudate) Pocket depths 5 mm. or more with bleeding Vertical bone defect Radiographic evidence of progressive bone loss Progressive tooth mobility Anatomic gingival deformities Exposed root surfaces A deteriorating risk profile such as patients with:

Diabetes Pregnancy Cardiovascular disease Chronic respiratory disease Any patient who is a candidate for the following therapies who

might be exposed to risk from periodontal infection, including but not limited to the following treatments:

1. Cancer Therapy2. Cardiovascular Surgery3. Joint-Replacement Surgery4. Organ Transplantation

Based on their individual needs and periodontist recommendation, some of these patients will benefit from alternating visits with our office and their treating periodontist’s office.

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Which Patient(s) Should We Refer To a Periodontist?

Any patient with:

Severe chronic periodontitis Furcation involvement Vertical/angular bony defect(s) Aggressive periodontitis (formerly known as juvenile, early-onset, or rapidly

progressive periodontitis) Periodontal abscess and other acute periodontitis conditions Significant root surface exposure and/or progressive gingival recession Peri-implant disease Any patient with periodontal diseases, regardless of severity, who the

referring dentist prefers not to treat.

Periodontists that we refer to:

Dr. Todd Scheyer3400 S. Gessner, Ste. 102

Houston, TX 77063(713) 783-5442

Ets.perio@swbell.netwww.periohealth.com

Dr. Robert Friedberg9601 Katy Frwy., Ste. 360

Houston, TX 77024(713) 464-9728

Friedberg1@sbcglobal.net

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Understanding Gum Recession

In the 19th century, one of the colorful ways that someone was getting older was to say that s/he was “long in the tooth”. This was their way of observing that older people would get gum recession that made teeth look longer.

As you know, gum recession occurs when the attached gingival pulls away from the cervical of the crown of the tooth. The main causes of recession are:

1. Tooth is in a facial position2. Heredity can cause thin gum tissue or poor bone support3. Aggressive tooth brushing4. Periodontal disease5. Frenum pulling on the gums

When this recession occurs we will chart and monitor it if:

1. The condition appears stable2. Okay 1-3 mm of recession has occurred

If the condition is not stable, we will refer to our Periodontist to treat. She has several options:

1. Control periodontal disease and monitora. Scale and root planeb. Re-evaluate at next cleaning

2. Soft tissue graft to create more attached gingival to cover more of the root and prevent further lossa. Procedure – A thin piece of tissue is taken from the roof of the mouth or from the adjacent teeth and grafted onto the area of recessionb. Procedure may involve more than 1 toothc. Benefits1. Reduce chance of further gum recession2. Help cover exposed roots3. Improve appearance of the smile4. Reduce root sensitivity

Be sure to evaluate the surgical site at the cleaning after the surgery and:a. Do not Perio. Probe for at least 6 months or as instructed by the periodontistb. Draw your dentists’ attention to the site

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Steps to follow Before/After A Deep Cleaning/Scaling and Root Planing Procedure:

Before Scaling and Root Planning procedure is performed on a patient, all treatment fees and consents must be signed.

Please check in document center to make sure that treatment fees have been signed by patient. If you do not see a signed treatment plan, please print or have the front office print a copy for you to have the patient sign. Even if the patient said that they are aware of how much they owe and has already signed a treatment plan, if there is no signed treatment plan in document center, it needs to be printed and signed again!

Make sure that the patient is aware of how much they will need to pay for the procedure. (Example of what to say: Did the front office go over the fees with you? Are you aware of how much you will be responsible for today’s treatment?)

The patient’s portion or amount owed should be noted in the appointment notes section. If not, please have a front office team member (Ime or Denise Gilbert) find out and inform the patient of the amount owed before starting the procedure. We cannot start any procedure before the patient is aware and okay with how much they will have to pay!

Give patient the consent for Scaling and Root Planning. Please read this consent and familiarize yourself with it so that way you can explain to the patient what they are signing (I have attached a copy with this list). Let them know that this consent will also give you permission to perform the Scaling and Root Planning/Deep Cleaning procedure.

Inform the patient that after the deep cleaning/SRP procedure, they will come back in about 2-4 weeks for fine scale/polish. This is a follow-up visit to make sure all root surfaces are smooth and to re-evaluate gum pockets to see if the pockets have “shrunk” and “reattached” to the teeth. It is always best to use words that are easy for them to understand.

Inform the patient that from now on, since a Deep Cleaning/SRP procedure has been done, their dental cleanings will now be called “Periodontal Maintenance” cleanings.

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After SRP is completed, please go over the POST-CARE INSTRUCTIONS with your patient.

If Arestin was placed, please remind them to not floss in the area where the antibiotic was placed for one week. Patient should be informed that if there is any swelling and pain in the area where the Arestin was placed, they should call our office to have it flushed out (even if it is after hours). However, if more severe reaction occurs, then of course dial 911. Allergic reactions to Arestin happens to less than 1% of the population so reassure your patient that they will most likely be fine, however, you are just letting them be aware of it.

Give your patients Sensodyne toothpaste or any type of “sensitive” toothpaste we might have available on the hygiene shelf.

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Steps to follow Before/Ater A Deep Cleaning/Scaling and Root Planning Procedure:

Before Scaling and Root Planning procedure is performed on a patient, all treatment fees and consents must be signed.

Please check in document center to make sure that treatment fees have been signed by patient. If you do not see a signed treatment plan, please print or have the front office print a copy for you to have the patient sign. Even if the patient said that they are aware of how much they owe and has already signed a treatment plan, if there is no signed treatment plan in document center, it needs to be printed and signed again!

Make sure that the patient is aware of how much they will need to pay for the procedure. (Example of what to say: Did the front office go over the fees with you? Are you aware of how much you will be responsible for today’s treatment?)

The patient’s portion or amount owed should be noted in the appointment notes section. If not, please have a front office team member (Ime or Denise Gilbert) find out and inform the patient of the amount owed before starting the procedure. We cannot start any procedure before the patient is aware and okay with how much they will have to pay!

Give patient the consent for Scaling and Root Planning. Please read this consent and familiarize yourself with it so that way you can explain to the patient what they are signing (I have attached a copy with this list). Let them know that this consent will also give you permission to perform the Scaling and Root Planning/Deep Cleaning procedure.

Inform the patient that after the deep cleaning/SRP procedure, they will come back in about 2-4 weeks for fine scale/polish. This is a follow-up visit to make sure all root surfaces are smooth and to re-evaluate gum pockets to see if the pockets have “shrunk” and “reattached” to the teeth. It is always best to use words that are easy for them to understand.

Inform the patient that from now on, since a Deep Cleaning/SRP procedure has been done, their dental cleanings will now be called “Periodontal Maintenance” cleanings.

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After SRP is completed, please go over the POST-CARE INSTRUCTIONS with your patient.

If Arestin was placed, please remind them to not floss in the area where the antibiotic was placed for one week. Patient should be informed that if there is any swelling and pain in the area where the Arestin was placed, they should call our office to have it flushed out (even if it is after hours). However, if more severe reaction occurs, then of course dial 911. Allergic reactions to Arestin happens to less than 1% of the population so reassure your patient that they will most likely be fine, however, you are just letting them be aware of it.

Give your patients Sensodyne toothpaste or any type of “sensitive” toothpaste we might have on the hygiene shelf.

Informed Consent for Gum Treatment Utilizing Scaling & Root Planning (SRP)

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Diagnosis: After careful examination of my condition the Doctor has informed me that I have periodontal disease. I understand that periodontal disease weakens the support of my teeth by separating the gum from the teeth and possibly destroying some of the bone that supports the tooth roots. The pockets caused by this separation allows for greater accumulation of bacteria, plaque, and tarter under the gum and can result in further erosion or loss of bone and gum supporting the roots of my teeth. I have also been made aware of the fact that if left untreated, periodontal disease can cause me to lose my teeth and I can have other adverse consequences to my general health.

1. Recommended Treatment: In order to treat my periodontal condition, the Doctor has recommended that my treatment include SRP to remove the inflamed and infected tissue and to thoroughly clean the roots with the ultrasonic scalers and hand scalers (Ultrasonic scalers my adversely affect how a cardiac pacemaker functions). The use of Antibiotics (Arestin) and antibacterial rinses is also an important part of the procedure and must be taken as prescribed.

2. Principal Risk and Complications: Any time the oral soft and hard tissues are manipulated, whether by drill, scalpel, or laser, there is always a possibility and risk of unexpected and undesirable side effects. These complications, although rare, include and are not limited to: post-surgical infection, swelling, bleeding, headache, TMJ/jaw joint pain, tooth/gum pain, tooth sensitivity to hot, cold, sweets: shrinkage of gum tissues, muscle soreness, soft tissue numbness, and cracking of the corners of the mouth. It is important to note here that in spite of observing every possible reasonable precaution- prior to nerve damage, infection, tooth trauma may have pre-existed in a tooth as an asymptomatic, chronic state. Dental procedures in general can sometimes turn a chronic, pre-existing problem in a tooth to an acute one. I therefore understand that complications that sometimes arise in the teeth after any type of dental or gum treatment may not have occurred as a direct result of the periodontal treatment.

3. Expected Results and No Guarantee: There is no method currently available that will predict how the gum and bone will heal following any periodontal procedure. I understand that some aggressive and/or more persistent forms of gum disease may require a second procedure (Laser or conventional) if the initial results are not satisfactory. In addition, the success of any periodontal procedure can be affected by other factors such as: pre-existing medical conditions, failure to comply with post-surgical instructions, and non-compliance in the wearing of occlusal/night guard if one is recommended.

4. Expected Benefits: The purpose of SRP and other periodontal procedures is to reduce the infection and inflammation associated with gum disease and to reduce the amounts of harmful bacteria present in the gum pockets which have been shown in studies to contribute to other health problems such as heart disease, stroke, respiratory diseases and pre-term child births. Studies also indicate that the rate of periodontal deterioration may be significantly increased in periodontal patient who also have osteoporosis or diabetes. With diabetic patients, not only are they more prone to gum disease, but the gum disease itself may also make it more difficult for them to control their blood sugar levels. Additional benefits of laser periodontal therapy include minimal post-op pain and swelling in most cases, reduce halitosis (bad breath) an increase sense of well-being.

5. Necessary Follow-up Care and Self-Care: I understand that the success of any periodontal procedure is extremely dependent on the good home-care and regular 3-month maintenance visits. Failure to comply with the follow-up visits and self-care may result in treatment failure and relapse to the present condition. The periodontal protocol that the Doctor is recommending for you will provide your gums with the environment it needs to stimulate healing. It is up to you to maintain that environment in order to realize treatment success.

6. Arestin: Arestin Microspheres is a sub-gingival sustained-release product, containing the antibiotic Minocycline Hydrochloride (a member of Tetracycline class of antibiotics). It should not be used in a patient that has known allergies to Tetracycline. Arestin is dispensed in powder form & used in conjunction with the scaling and root planning procedure. This combination treats periodontal disease more effectively than SRP alone. This powder is placed inside the infected periodontal pockets just after dental professional scaling & root planning procedure. The antibiotic kills the bacteria for up to 30 days. Reactions reported with the use of Arestin includes, but are not limited to, anaphylaxis, angioneurotic edema, urticarial, rash, swelling of the gums/face, and pruritis.

Insurance Benefits: Your routine hygiene visits will now be considered by most insurance companies as “Periodontal Maintenance” instead of “Basic” Prophylaxis (i.e. routine cleanings). Once you have scaling & root planning, your dental care goes to a higher level. Most insurance companies consider ALL periodontal work to be

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basic & will reimburse at that level. You may have a deductible & different rate of reimbursement. Some insurance companies will allow up to 4 Periodontal Maintenance cleanings a year instead of 2 Basic dental cleanings a year. It is your responsibility to contact your insurance carrier to verify your benefits.

I have been informed the following areas have been planned for scaling and root planning:

Upper Arch: Right Left Lower Arch: Right Left

I have read and agreed to the foregoing. I have had the opportunity to ask treatment related question and have been advised of the risk and benefits of treatment. I understand that it is necessary to complete all phases of recommended treatment and agree to do so. All my questions have been answered.

____________________________________________ ______________________________Patient Name / Signature Date

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Arestin® Periodontal Treatment

DO NOT ADMINISTER ARESTIN to patients who are allergic to TETRACYCLINE!

What is it?Arestin® is a bioresorbable gel containing minocycline (a tetracycline derivative) microspheres.  It has been FDA approved for treatment of gum disease after a deep cleaning procedure known as scaling and root planning.

How does it work on gum disease?When placed in a periodontal pocket, Arestin® maintains a high-level of antibiotic right at the gum disease site without exposing the rest of the body to antibiotics.  This allows treatment using one-hundredth the usual pill-form dose.  It directly fights the gum disease infection for 30 days.

Let your patient know that in order to get the best results from treatment with Arestin®, they must follow these directions.

Avoid touching the treated areas. Wait 12 hours after your treatment before brushing teeth. Wait one week before using floss, toothpicks, or other devices designed to

clean below the gumline. Avoid foods for 1 week that could hurt your gums. Don’t chew gum or eat sticky foods. After one week, resume flossing around the treated teeth on a daily basis.

Remember, to tell your patient that they must do their part.  After your Arestin® therapy, if you don’t brush at least 2 times per day and floss every day, then any dental treatment of their gum disease will not work effectively.

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Arestin Consent Form

We have recommended the placement of ARESTIN below your gums to kill the bacteria that causes gum/periodontal disease. ARESTIN is an antibiotic powder (Minocycline Hydrochloride) that is placed below your gumline by your dental professional at the time of Scaling and Root Planning/Deep Cleaning or during a routine periodontal maintenance/dental cleaning. This antibiotic helps create a healthier environment below the gums by getting rid of the bacteria for 30 days after it is placed.

This antibiotic should not be used if you are allergic to Tetracycline. This antibiotic should not be used if you are pregnant. While some insurance companies do not have coverage for ARESTIN, we

feel strongly that it helps to improve your health. We cannot guarantee coverage or payment by insurance carriers. Prescription: If you have prescription coverage, you may reduce the cost by

purchasing the antibiotic through your local pharmacy. Ask us how. You have _______ pockets that will benefit from the placement of

ARESTIN. The cost for ARESTIN application will be $_____________.

_______________________________ _________________________

(Patient’s Name/Signature) (Date)

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Implant Prophylaxis

Implants are the newest area of dentistry.  There are no connective tissue fibers attaching the implant to the bone.  However, there is a perimucosal seal that stops toxic substances from working down around the implant and destroying the implants bone support.

The ideal periodontal relationship is attached gingiva around the implant.  If the gingiva is not attached, watch closely for inflammation.  Look closely for any:

1. Color changes2. Inflammation3. Texture of tissue around the implant(s)4. Bleeding5. Stability of Implants

 Cleaning is “a new ball game.”   Remember:

1. No metal instruments, only use plastic/titanium instruments2. Use implant Piezo or Cavitron tip3. Use fine prophy paste and rubber cup if polishing is necessary, otherwise,

you can wipe with a gauze dipped in mouthrinse. 4. The exposed implant neck must be perfectly clean and smooth.5. Clean all implant access holes with implant tips/instruments6. Push on the tissue around implants to make sure there is no evidence of any

exudate.7. Use correct implant drivers to tighten implant bar(s)8. Make recommendations to patient about home care (Ex: interproximal

brush) – See following

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Implant Cleaning Aides

Make recommendations to your patients to help them make cleaning their implant(s) at home easy. They have invested a lot of money in these “New Teeth” and we want to make sure that they are able to keep them clean at home.

It is very important to recommend products that they can easily buy at their local store (Ex: Walgreens, Target, Walmart).

Cleaning Aides:

Interproximal brushes End tufted brushes Yarn with floss threaders Thornton floss made for implants Sonicare Airflosser Waterpick/irrigator Baby toothbrush

****Be realistic when you are recommending your cleaning aides (EX: It would be very difficult for a geriatric patient to use yarn with floss threader, instead, you would recommend a Sonicare Airflosser).****

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Implant Kit

The implant kit/cassette should include instruments especially made for cleaning implants.

Includes:

1. Cavitron Implant Tip2. Piezo Implant Tip3. Titanium Gracey Scalers4. Satin Steel Handle with plastic anterior Sickle and posterior Sickle

attachment tips.5. Plastic probe6. Hand mirror

****Ask your Hygiene Manager if you are not sure about how to use or insert any of the implant instrument(s) or tips****

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When are Implants Recommended?

Implants are the BEST WAY TO REPLACE missing tooth/teeth. As a hygienist, it is important to understand how to talk to your patients about replacing their missing tooth/teeth with implants. It is also important to understand the process and time involved.

Implants can replace:

1. Missing teeth2. Severely decayed teeth3. Teeth that are not salvageable due to failed root canal therapy4. Teeth that are broken at the gumline5. Fractures in the teeth that have extended down the root6. Abscessed teeth that cannot be saved and will need to be extracted7. Teeth with internal resorption8. Teeth with severe root resorption

Process after a tooth/teeth is extracted for implant treatment:

1. If a maxillary tooth/teeth is extracted and it is close to the sinus cavity, a sinus lift/sinus bump will most likely be done in order to have room for the future implant post. The doctor may choose to have the site heal before placing any bone grafting.

2. After the extraction, a bone graft is usually placed at the site. The bone graft will take 4 months to heal.

3. After 4 months, the patient will be scheduled to see the doctor for follow-up and a CT Scan to determine if there is enough bone to have the implant placed. CT Scan will also be used as a guide for the implant placement during the surgery.

4. Once the CT Scan is done and the doctor determines that implant can be placed, patient will have implant(s) placed. Implants will take 4 months to integrate with the patient’s bone.

5. Doctor will expose the implant by punching a small hole through the gum tissue. An impression will be made for the implant crown.

6. Patient returns for the implant crown

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Hybrid or Highwater Implant Denture

This type of implant denture is screwed on and not removable. It is not removed during a dental cleaning. The only time that it is removed is if there is an infection or problem with the implant/gum tissue around it. Use a special Cavitron Implant tip/Piezo implant tip and titanium or plastic hand scalers to clean this type of prosthesis. You must move the tips/scalers under the dentures to clean and flush out all debris. This type of implant denture has “holes” in it called Implant Access Holes. These are where the implants are located. All implant access holes are filled, however, a patient may come in for a cleaning and the filler material has come out. These holes MUST be cleaned out during the implant prophylaxis and refilled.

Implant Access Holes(None of these are filled)

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How to fill the Implant Access Hole

STEP ONE:

After removing all the debris from inside the Implant Access Hole (spray air to make sure that the hole is very clean), cut a piece of Teflon big enough to place inside the hole.

STEP TWO:

Using a probe or hand instrument, place the Teflon inside of the hole and push down until the hole is filled leaving just enough room on top to fill with flowable composite material.

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Fill all the empty Implant Access Holes with Teflon.

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STEP THREE

Use a flowable composite to fill the rest of the hole (place flowable composite on top of the the Teflon material). Fill the hole until the flowable is flushed with the teeth on the denture.

STEP FOUR

Light cure the flowable composite for 20 seconds. The implant access hole is now filled.

Teaching Patients How to Clean Their Hybrid Denture at Home

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Below are items that can be used, in addition, to a toothbrush to help your patient keep their prosthesis clean at home.

1. A proxybrush/interdental brush 2. End-tufted brush3. Thornton implant floss4. Sonicare Airflosser or other types of oral irrigating units5. Yarn with a floss threader6. Superfloss

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All-on-4 Dental Implant TechniqueThe All-on-4 technique allows people missing all their teeth to receive a permanent bridge on as few as 4 dental implants- in one day. Even people who think they are not an implant candidate because they don’t have enough bone are now able to get permanent teeth with the all-on-4 bridge. Almost all denture patients, people with failing bridges, severe bone loss from gum disease can have permanent teeth with this type of bridge.

This technique is a way of using implants to anchor a full arch bridge giving a very stable result, and is ideal because it is completed in a short space of time.  It can be used with patients who have lost substantial amounts of bone as it bypasses the need for costly and time-consuming bone grafts as it utilizes implants in a very different way from normal.

Normal implants are inserted into the jaw vertically, and when being used to replace a complete jaw are spaced out at intervals along the jawbone in order to give sufficient stability and support to both the implants and the bridge.  There is no lengthy healing

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process and the success rate of these kinds of implants is extremely high.

Types of Dental Partials

Dental partials are an option for patients who have some, but not all missing teeth. These patients are typically candidates for partials because they are not candidates for implants (i.e. diabetic patients/immune compromised for implants or opt not to have implants placed).

There are two types of Partial Dentures:1. Metal Partial2. Valplast or Flexite

Metal Removeable Partial Denture:

There are some advantages/disadvantages of a Metal Based Removeable Partial compared to the Valplast/Flexite Removeable Partial

Advantages: 1. More comfortable 2. As patient loses more natural teeth, teeth can be added to their existing

partial3. Can be adjusted

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Disadvantages: 1. Heavier2. It is metal, so not as esthetically appealing

Valplast or Flexite Removeable Partial Denture

Advantages:1. Are not as heavy as the metal based partial2. Esthetically more appealing3. Flexible

Disadvantages:1. Teeth cannot be added to it2. Not as comfortable, although they are lighter

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Types of Dental Implants

Single Implants

Implant Bar: An Overdenture is snapped on top of the implant bar using “clips”

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Another implant bar

Photo of Mandibular Implant bar with overdenture

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What To Do If a Patient’s Overdenture Is Loose

The “clips” on the overdentures can wear out over time and cause the overdentures to get loose. These clips can be changed out during the patient’s hygiene appointment.

1. The clip(s) are taken out of the overdenture and a new clip placed (ask the doctor or head dental assistant for help).

2. The clips are charged individually (you must charge out Code: D6080 – Implant Maintenance Procedure for) EX: 4 clips were changed out then charge D6080 x 4

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When Does a Tooth Need a Crown?

These are reasons why a tooth will need a crown:

A large existing filling with recurrent decay A large existing filling with cracks/fractures Part of the tooth is broken and the doctor determines that it can be saved

(often times in conjunction with Root Canal Therapy) Part of the tooth is chipped Decay around the margin of an existing crown or veneer

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Code When Treatment Planning for a Crown:

Full Fees (No insurance): 2740 – Crown

Insurance Patient:

2740 – Crown2950 – Crown Build-up

Lab Fees : Applies only to Insurance Patients

For Insurance Patients, lab fees MUST be presented to patient and added to treatment plan for EACH CROWN. See “Script for Crown Lab Fee Upgrade”

D0054 – Anterior teethD0052 – Posterior teeth

KAVO Air Polishing Handpiece

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This handpiece is wireless/portable and can be used in all the operatories. We have it stored in its black case located on the hygiene shelf. The KAVO uses prophy pearl powder which is also located on the hygiene shelf.

The Kavo box should contain:

(2) Removable tips An adaptor which will allow you to connect the KAVO hand piece to the

slow hand piece line attached to your dental unit. (2) Powder containers/jars which screws on to the end of the KAVO hand

piece.

How to Set-Up and Use the Kavo Air Polisher

1. Attach the adaptor on to the KAVO hand piece by snapping/pushing it on

2. Line up the adaptor with the right line (slow speed – the line that the prophy hand piece is attached to) and screw in place

3. Attach a tip on to the KAVO hand piece by lining up the small ball with the void at the top of the hand piece and turn/twist making sure that the red dots are lined up. This locks the tip in place. If you do not turn/twist the tip until the red dots line up, the tip is still loose and will fly off when the unit is activated because of the air pressure!

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4. Fill the powder container to the fill line and twist it onto the KAVO unit.

After Using the KAVO Hand piece

The tips can be twisted off and sterilized. If there is still powder left in the container, it can be used again. Please make sure that the adaptor is placed back in to the box. The adaptor

DOES NOT get sterilized! The KAVO hand piece can be wiped down with Cavicide and placed back in

the black box. The KAVO box should be put back on the hygiene shelf for later use.

Intra/Extra-Oral Cancer Screening

This must be done at every appointment, does not matter whether it is a new patient appointment or recall appointment!

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Clients are very concerned about oral cancer.  Review their health history for danger signs: Do they smoke?  Is there a history of cancer in their family?  Have they had cancer?

Explain to these high risk groups how important this exam is! Complete Oral Examination An oral cancer examination is completed routinely on all patients during new patient

appointment and recall appointments. The complete oral examination should include both INSPECTION and digital PALPITATION of extra-oral areas as well as of the intraoral structures.  Adequate lighting, a tongue depressor, a dental mirror, gauze and a rubber glove or finger cot are the only material requirements.

- Dentures should be removed before the exam.  A local anesthetic spray may be needed for some to examine the base of the tongue and pharynx.

- Tenderness of the TMJ joint, color edema or bleeding of the gum, consistency of the saliva, odor of the breath, color and coating on the tongue should all be noted and if abnormal investigated further.

EXAM 1.  Look for skin blemishes, pigmentation, moles, asymmetry and swelling. 2.  Look at the neck for swelling or color changes.  Palpate the neck, two fingers next to

the tongue pressing on the floor of the mouth while the other palpates the mandibular lymph nodes, (enlargement means infection).

3.  The cervical chain is best identified by palpating deeply with two fingers. 4.  Palpate the TMJ joint bilaterally with the mouth closed and then wide open.  Note

tenderness, crepitus and deviation of the lower   jaw on opening. 5.  Examine the lips with the mouth closed and then open.  Note the color, texture, any

surface abnormalities, or swelling. 6.  Palpate the lips for any induration. 7.  Examine visually and by palpation the mandible.  Mucobuccal fold and frenum with

the mouth partially open.  Palpate the entire area.   Look for the color, character, and any swellings of the mucosa   interproximaly and in the vestibule.

8.  Using the fingers as retractors and with the mouth wide open, examine the inner aspect of the left cheeks and other areas covered   by the buccal mucosa.

9.  Inspect the dorsum (top) of the tongue with the tongue at rest and the mouth partially open for any swelling, ulceration, coating or   variation in size, color or texture.

10. With the tongue protruded look for any deviation, tremor, asymmetry or limitation of motion.  Note any variations in texture, size or   color.

11. Wrap a wet 2×2 gauze around the tip of the protruded tongue. Ask the client to say “Ahh” and observe the base of the tongue and circumvallate papillae.

12. Hold the tongue with the gauze and move it to the pts’ left.  Look at the entire lateral border of the tongue and its attachments to   the floor of the mouth back to the anterior pillar.  Do the same with the right side of the tongue.

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13. Release the tongue and tell pt. to touch the tip to the palate. Look at the ventral surface and note any varicosities and   swellings.  Inspect the floor of the mouth for swellings or other abnormalities.

14. Palpate the entire tongue, including the base for any induration. 15. Palpate the entire floor of the mouth - identify the submaxillary gland. 16. With the mouth wide open and the pt’s head back, gently depress the base of the

tongue with a mirror.  Inspect and palpate the hard   palate. 17. Observe and palpate the soft palate and uvula. 18. Instruct the pt. to say “Ahh” and inspect both fauces, the anterior pillars, and the

posterior pillars. 19. The nasopharynx may be examined by placing the mirror behind the uvula.  Have the

pt. breath through the nose and mouth. 

Oral Examination Using the Oral ID Fluorescent Light (An Adjunct to Clinical Oral Cancer Screening

Watch Demo Video on www.OralID.com/sampleexam

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This is one of the latest technology available on the market today to detect any abnormal tissue in the oral cavity. At Midtown Dentistry we use this method in addition to the visual/clinical oral cancer screening. There is an extra charge for this procedure ($23.00 – Code D0431). Patients must be informed of the cost, which is most likely, not covered by insurance. They will responsible for this fee, if they want the procedure done, and as a courtesy, we will file it to their insurance company. If their insurance company covers it, they will be reimbursed by the dental insurance company.

Using the same technique used when performing the visual/clinical oral cancer screening, but using a fluorescent light. The hygienist should wear protective eyewear (yellow glasses) which is included in the box holding the light.

OralID is an adjunctive screening device that uses fluorescence technology to help clinicians identify oral abnormalities. It is easy to use and non-threatening to patients. Dentists and hygienists can use OralID to increase the efficacy of oral exams without incurring additional per-patient costs. One needs only to wipe it down between uses with a disinfecting wipe. OralID is battery operated, which means it can be used in multiple operatories.

OralID is a battery-operated, hand-held oral examination light used as an adjunctive device for oral mucosal screening. The device emits a visible blue light (435–460 nm) that one shines directly into the oral cavity.

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OralID is shipped with the necessary eyewear to use the device. Wearing the special OralID eyewear enhances the visual effects of the blue light during the oral exam. When the blue light from OralID shines on healthy oral tissue, it fluoresces green. However, when it shines on abnormal tissue, it appears dark due to a lack of fluorescence.

OralID comes with two pairs of eyewear: one fitted pair and one that fits over eyeglasses. The clinician and the assistant may each wear a pair during the examination. However, if desired, the patient may wear a pair of the eyeglasses, but it is not necessary to do so for safety purposes.

Do you have literature I can use to educate my patients about oral cancer and why a dentist would use OralID to perform an examination?Yes, we have two patient education trifolds that focus on the latest developments in oral cancer detection and HPV (human papillomavirus). The patient trifolds are Sex, Drugs & Oral Cancer and Oral Cancer (the latter is a PG-rated version suitable for all ages).

How often do I have to replace the “bulb”? How much does the bulb cost?OralID does not use a bulb of any kind, which is in contrast to some of the other devices available. The device uses LED technology.

What type of batteries does OralID use? How many? Is it mandatory that we only use the brand of batteries provided in the OralID kit?OralID uses two CR123A lithium batteries. The kit you receive contains four CR123A batteries. These batteries can be purchased at your local drug store. ONLY Duracell® or Energizer®, which are high-quality, U.S.-manufactured batteries, should be used. We recommend that batteries be purchased directly through us as this guarentees the quality of the battery and also provides a substantial savings over what can be purchased at retail locations.

How would I take clinical images when using OralID?You will need a special filter over the camera lens. Our two options are the:

1. DSLR Camera Filter Adapter Kit (FS-XX - 52, 55, 58, 62, 67, 72, 77 mm) or2. SmartFilterID (FS-18) that allows the user to easily image the oral cavity using a smart

phone.

Which insurance code is applicable when I use OralID on patients?You may use dental insurance code D0431, which is noted specifically for "adjunctive screening

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technologies" in order to screen for oral abnormalities.

Does the room need to be dark when I use OralID?The room light does not need to be turned off. Given the intensity of the light coming from OralID, turning off the overhead exam light will be sufficient to perform a thorough examination.

How can I disinfect OralID when there is no sheath to use with it?OralID can be disinfected via a simple wipe-down process. We recommend that you use CaviWipesTM or an equivalent to wipe down the entire device after each use.

What if I get a new staff member after my staff has already attended the OralID Team Training session?Free training for new staff members, or a refresher course for anyone who wants one, is available on a weekly basis at the www.OralID.com website. One of our goals is superior customer service, and this means we’re here for you as long as you own an OralID. We want everyone to be educated about "Sex, Drugs & Oral Cancer."

Different fluorescent devices use different wavelengths (colors), so what’s the difference?Whether it is violet or blue, there is no major difference between different color fluorescence technologies used in the dental field. This technology, no matter what color it uses, has been proven to be a vital aid in the discovery of oral cancer, pre-cancer and other tissue abnormalities.

CAUSES OF DRY MOUTH:

Dry mouth can be caused by some the following factors:

Medicines

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The more medicines a person takes, the more likely they are to suffer from chronic Dry Mouth. Many everyday medicines cause Dry Mouth, including over-the-counter cold remedies and antihistamines. Anti-depressants, some beta-blockers, anti-hypertensives and diuretics can also cause or contribute to Dry Mouth.

The conditions below are often treated with drugs known to include Dry Mouth as one of their side effects or associated directly with Dry Mouth symptoms.

Acne Addiction Allergy Alzheimer’s Anxiety Asthma Infection Viral Infections Appetite Suppression Arthritis / Joint Pain Asthma / Lung Conditions Attention Deficit Disorder Bladder Control Bladder / Urinary Tract Infections Cancer Congestion (nasal/sinus) Cough / Cold Crohn’s / Ulcerative Colitis Depression Diabetes Diarrhea Epilepsy Erectile Dysfunction Glaucoma Heartburn / GERD / Ulcer Heart Disease Heart Arrhythmias High Blood Pressure Hepatitis C High Cholesterol HIV Intestinal Hyper-motility Irritable Bowel Syndrome Kidney Disease Lou Gehrig’s disease Low testosterone (andropause) Migraine

Age

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As people get older, they tend to take more medicines; half of all Americans aged 60-plus take three or more prescription medicines on a regular basis. This is the primary reason why older people are more likely to suffer from chronic Dry Mouth. Older people are also more likely to suffer from cancer and Sjögren's Syndrome.

Sjögren’s Syndrome

Dry Mouth is one of the major symptoms of Sjögren’s syndrome. This is a chronic condition, in which the body’s immune system malfunctions and attacks the body’s tear and salivary glands.

Diabetes

All types of uncontrolled diabetes can cause increased urination or an underlying metabolic or hormonal problem, which can result in Dry Mouth.

Cancer and Its Treatment

Neck and head cancer patients who have been surveyed ranked Dry Mouth as one of their most distressing symptoms. Chemotherapy affects the salivary glands and causes a near-total reduction in saliva flow. Many never regain their full flow.

Parkinson's disease

Medications used to treat Parkinson's disease can often cause Dry Mouth.

Managing Patients With Dry Mouth:

Patients with Dry Mouth are at higher risk for RAMPANT tooth decay! Help your patience lower their risk for tooth decay by making these recommendations:

Drinking a lot of water Keep their mouth lubricated by using a mouth gel or mouth spray made especially for

Dry Mouth

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1. Biotene Gel for dry mouth2. Oral Balance moisturizing mouth spray

Always use Sugar-Free products Recommend products with Xylitol (Xylitol is an artificial sweetener, however, when

added in dental products and used, the Xylitol actually forms a barrier on the teeth that blocks the decay causing bacteria to break down enamel causing the decay.)

Recommend CARIFREE products (which can be ordered directly by the patient at www.carifree.com). Carifree products contain high fluoride and xylitol.

Recommend products with high fluoride1. Prescription 5000 ppm Fluoride Toothpaste or Rinses such as:

Colgate Prevident Toothpaste or Mouth Rinse Colgate Prevident Toothpaste specially formulated for Dry Mouth Fluoridex Toothpaste

Amounts of Fluoride in Products

As a hygienist, it is important to know how much fluoride is in products that are sold over the counter and used in our office. Our job is to educate our patient so that way they will know how to better improve their oral home care.

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Example: Jane came in for her dental cleaning today and you take bitewing x-rays. If the x-rays show interproximal decay, not only should you show her the incipient decay present in the x-rays, but she should also be given a prescription for Colgate Prevident 5000 ppm toothpaste to be used at home to either reverse or stabilize those areas of decay.

Listed below are products that are commonly used by patients that contain fluoride and the amounts of fluoride in them:

1. Over-the-Counter toothpaste – typically contains no more than 1,100 ppm fl2

2. Fluoride Varnish – 22,000 ppm fl23. Neutral Sodium (foam/gels) – 6,800 ppm fl24. APF (Acidulated Phophate Fluoride in foam/gel) – 9,600 ppm fl25. Colgate Gel-Kam – used for hypersensitivity/caries – 0.4% stannous fluoride6. Colgate Prevident Rinse – 0.2% Neutral Sodium Fl27. Colgate Prevident Toothpaste/Fluoridex Toothpaste – 5,000 ppm fl2

****An easy way to explain to your patient is that Fluoride is measured by PPM (parts per million) and not mg (milligrams).****

Antibiotic Pre-Medication Guidelines for Dental Procedures(For Prevention of Infective Endocarditis)

Guidelines from the American Heart Association – Published April 2007

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Patients No Longer NeedingTo Take Antibiotic Pre-Medication

(Most Patients)

Mitral Valve Prolapse Rheumatic Heart Disease Bicuspid Valve Disease Calcified Aortic Stenosis

Patients Still RecommendedTo Take Antibiotic Pre-Medication

(Few Patients)

Artificial/Prosthetic Heart Valves History of/Previous Infectious

Endocarditis

In conclusion:

For most heart patients, this means you will no longer be asked to pre-medicate prior to dental treatment. For more information on this subject, you can go to:www.ada.orgwww.americanheartassociation.org

If a patient has been prescribed pre-meds by a medical doctor, he/she may want to inform their physician of the new guidelines and ask in which category above they belong.

Some patients are recommended by their physician/surgeon to take pre-meds before any any dental procedure for the rest of their lives.

Antibiotic Pre-Medication Regimens for Dental Procedures(For Prevention of Infective Endocarditis)

Guidelines from the American Heart Association – Published April 2007

REGIMEN – Single Dose

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Patients No Longer NeedingTo Take Antibiotic Pre-Medication

(Most Patients)

Mitral Valve Prolapse Rheumatic Heart Disease Bicuspid Valve Disease Calcified Aortic Stenosis

Patients Still RecommendedTo Take Antibiotic Pre-Medication

(Few Patients)

Artificial/Prosthetic Heart Valves History of/Previous Infectious

Endocarditis

SITUATION AGENT (30 – 60 minutes before procedure)

Adults Children

Oral Amoxicillin 2 grams 50 mg/kg

Unable to to take oral medication

AmpicillinOR

Cefazoline orCeftiaxone

2 g IM or IV

1 g IM or IV

50 mg/kg IM or IV

50 mg/kg IM or IV

Allergic to Penicillins orAmpicillin – Oral

regimen

ClindaymycinOR

CephalexinOR

Azithromycin orClarithromycin

600 mg

2 g

500 mg

20 mg/kg

50 mg/kg

15 mg/kg

Allergic to Pencillins orAmpicillin and unable

to take oral medication

ClindamycinOR

Cefazolin orCeftriaxone

600 mg IM or IV

1 g IM or IV

20 mg/kg IM or IV

50 mg/kg IM or IV

Review Health History On Every Client

Review the health history of clients at their recall appointments. This is always done immediately after the blood pressure.  If the patient has had hepatitis, rheumatic fever, drug allergic, or if there is a need for premedication, make sure that this “flagged” in the computer

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system in the patient’s chart so it will pop up as an alert when the patient’s chart is open. Don’t wait!  You might forget!  Ask the patient if there has been any changes in their health or medications they are taking since their last visit.  A patient should update their health history once a year, even if there has been no changes. This should be done at the front office when the patient checks in for their appointment. Make a note of any changes to the patient’s health history, medications, etc. in your clinical notes. If the patient’s health status now requires them to be premedicated, then they need to be given antibiotics before dental procedure.

Here is a list of clients who should be prophylactically covered with an antibiotic before any significant treatment.

Previous infective endocarditis Mitral Valve Prolapse with regurgitation Prosthetic Heart Valve Coronary Bypass less than 6 months ago Congenital Heart Disease (CHD) Heart Transplant Bone marrow transplant First 2 years after joint replacement Clients on these medical therapies

In reviewing clients health history, if one of the above conditions exists and patient is unaware of pre-medication needs, our office policy is:

- Explain to patient how their condition related to potential bacterial infection and why pre-medication is necessary

- Ask patient about his/her allergies (to Penicillin specifically) or medical conditions and give recommended premed dose and continue appointment.

Bacterial Endocarditis

BE is heart damage caused by bacteria lodging on the valve or endocardium.  Protecting the client that has some damage is very important to prevent further heart damage.  There are many misconceptions concerning BE.  Here are the facts as of 1995.

1.  Only 27% of physicians and 37% of dentists follow American Heart Association BE guidelines.

2.  Most BE of dental origin is caused by poor oral hygiene, not dental procedures performed on clients not covered with an antibiotic.  It   is the cumulative exposure that causes the BE.

3.  The AHA antibiotic regimens don’t provide 100% safety from BE. Many people have antibiotic resistant strains of bacteria.

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4.  Premedication is not necessary for injections.  However, premedication is necessary for procedures that cause significant bleeding.

5.  Oral premedication is preferred over antibiotic injections.

6.  Miral Valve Prolapse clients should only be pre-medicated if there is evidence of valvular regurgitation.

7.  Problems of antibiotic over-use make it important to prescribe only when necessary.  To avoid:

o Anaphylaxiso Pregnancy caused by blockage of action of birth control pillso Development of resistant strainso Gastro-intestinal tract upseto Added cost

**If client is already on penicillin, s/he should also be pre-medicated with Clindamycin since they will have developed some penicillin resistant bacteria.**

****Please watch online video demonstration****

http://www.hu-friedy.com/products/instrument-sharpening/automated-sharpener/sidekick-sharpening-kit.html

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Description

The Hu-Friedy Sidekick® Sharpener makes routine maintenance sharpening of scalers and curettes fast and easy. This straightforward device guides you and your scaler to sharp, consistent results time after time.

Points of Performance

Easy-to-use guide channels and vertical backstops allow simple positioning of scaler and curettes to provide consistent sharpening results every time.

Provides consistent sharpening results aiding in instrument life. Cordless, lightweight, portable sharpening ... anywhere, anytime. Reciprocating stone does the work so you don’t have to. Maintains sharp blade and accurate angles.

The Sidekick® sharpener is designed to perform routine maintenance sharpening of scalers and curettes. It is not designed to recondition severely dull instruments. For instruments that are very dull, a professional sharpening service is recommended.

Features & Benefits

Easy to use guide channels allow simple positioning of scalers and curettes, providing consistent sharpening results every time

Toe Guide allows for finishing sharpening of universal and Gracey curettes Reciprocating stone does the work of sharpening so you don't have to Replacement stones available in Coarse and Medium Grits Cordless, lightweight and portable sharpening can be used anywhere by any staff

member.

Common Questions that Patients Ask

American Dental Association Seal of Approval – This seal indicates the product is safe and effective.  As of 1995, 450 over the counter products and 1300 dental practice items have received this seal.

Mouthwashes - Antiplaque/ Anti-gingivitis

How do they work?  These mouthwashes reduces the number of bacteria in the mouth that causes gum disease.

Are they effective?  Two name brands have the seal of acceptance from American Dental (ADA): Listerine (many generic versions also have the seal) and prescription-only Peridex (or Perigard).  All other rinses, including those that claim to loosen prior to brushing, have not been shown to be effective. However, these mouthrinses contain a high percentage of alcohol, therefore, should not be used on patients that have dry mouth.

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Who needs them?  People with gingivitis or a physical disability such as arthritis that limits their ability to brush and floss.

Are there side effects?  Peridex contains chlorhexidine, which can cause temporary tooth stains increase tartar, and alter the sense of taste.  Most have shown sanguinaria, an herbal extract in Viadent, causes tissue sensitivity in some clients.

Anticavity

How do they work? The fluoride in this type of mouthwash binds with tooth enamel, making it more resistant to decay.

Are they effective?  When used after brushing with a fluoride toothpaste, ADA-approved over-the-counter rinses, which contain .05% fluoride, reduce cavities up to 40% more effectively brushing alone. Patients should not eat, rinse, or drink for at least 30 minutes after using a fluoride rinse.

Who needs them?  Adults who have receding gums, eat a high-sugar diet or have scant saliva flow as a result of illness or medication. (Saliva contains many antibacterial agents and helps rinse away cavity-causing food particles.)

Prescription Fluoride Toothpaste and Mouthwashes (EX: Colgate Prevident toothpaste/mouthrinse, Fluoridex 5000 ppm Fl2 toothpaste) should be recommended for home use to children or adults in orthodontic treatment, individuals with dental fluorosis/amelogenesis imperfecta, or rampant decay. More severe cases should include the use of CARIFREE products which contains xylitol to prevent decay. Carifree line of products can be ordered directly from the company on www.carifree.com .

Are there side effects?  No.

Anti-Bad Breath

How do they work?  Mouthwashes contain flavorings that camouflage bad breath.  (Some claim to contain ingredients that kill bacteria and other causes of odors.)

Are they effective?  They reduce bad breath for 10 minutes an hour, but as soon as the bacteria return, so does the odor.

 Who needs them?  People with gum disease, a major cause of bad breath. Persistent bad breath may also be caused by medications /uncontrolled diabetes and sinus conditions.  Clients will need to see their doctor to determine the cause.

Are there side effects? No.

At Midtown Dentistry, we use BreathRX mouthrinse in all of our operatories, but we also recommended other alcohol-free mouthrinses such as: Crest ProHealth, Colgate Total. These mouthrinses are more accessible to the patients because they can buy them at any local store / pharmacy.

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Our mouthrinses are stored in the hygiene supply shelf and, at times, we will have sample sized mouthrinses that can be given to the patient.

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Take Blood Pressure and Pulse on Every Patient

The patient’s blood pressure needs to be taken before any procedure is started.

“Blood Pressure” is the pressure exerted by the blood against the arterial walls.  It is described as the number of mm the arterial pressure can push up a column of mercury.

A high blood pressure makes you 6 times more likely to have a heart attack and 7 times more likely to have a stroke.

- Take the blood pressure of every patient 11 yrs. and older at the beginning of each appointment.

- We have wrist blood pressure cuffs in every room. Please ask your supervisor if you are not sure how to operate your blood pressure cuff.

- Tell the pt. what the reading is and what it means (high - low -normal).

- For accurate readings – no smoking, exercise, caffeine 30 minutes before reading, rest 1 minute before reading.

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Blood Pressure Classification

In 2004 blood pressure standards were updated by the American Heart Association. New findings have increased the importance of systolic (the high number) blood pressure (SBP).SBPis now considered the key risk factor in cardiovascular disease (CVD). We refer all clients to their physician if their reading is above 140/90.  All adults fall into 1 of 4 categories.

          SBP            DBP        MRF        Dentist Guidelines

< 120          < 80         Yes/No         Normal

120-139      80-89       Yes/No     Routine dental treatment OK; discuss high blood pressure guidelines

140-159      90-99       Yes/No     Hypertension Stage 1: Routine dental treatment OK; consider sedation for complex dental or surgical procedures; refer for medical consult

160-179      100-109    No            Hypertension Stage 2: Routine dental treatment OK; consider sedation for complex dental or surgical procedures, refer for medical consult

160-179      100-109    Yes         Urgent dental treatment OK; refer for medical consult

180-209      110-119     No          No dental treatment without medical consultation; refer for prompt medical consult

180-209      110-119     Yes         No dental treatment; refer for emergency medical treatment

> 210          > 120         Yes/No    No dental treatment; refer for emergency medical treatment

SBP= systolic blood pressure

DBP= diastolic blood pressure

MRF=medical risk factor

Pre-hypertension – at increased risk of Cardio Vascular Disease and should begin lifestyle modification. The risk of a stroke or heart attack doubles for every 20/10mm HG increase above 115/75.

Lifestyle Modifications to Manage Hypertension

Modification Recommendation Approximate SBP Reduction (range)

Weight Reduction Maintain normal body weight (body mass index 18.5 – 24.9 kilograms per square meter)

5-20 millimeters of mercurw/10kg weight loss

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Adopt DASH Eating Plan Consume a diet rich in fruits, vegetables and low-fat dairy products with a reduced content of saturated and total fat.

8-14 mm Hg

Salt Reduction Reduce salt intake to no more than 2.4 grams sodium or 6g sodium chloride

2-8 mm Hg

Exercise Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day most days of the week)

4-9 mm Hg

Moderation of Alcohol Consumption Limit consumption to no more than 2 drinks (2 ounce or 30 milliliters ethanol; for example, 24 oz beer, 10 oz wine, or 3 oz 80 proof whiskey) per day in most men and no more than one drink per day in women and lighter weight people.

2-4 mm Hg

- Stress, medications may change systolic more than diastolic

- If the reading is above 200 systolic (first sound) or 100 diastolic (end of sounds) ask the patient if their doctor has checked it  recently and stop the appointment.  Place client on N2O for 5 minutes.  If numbers drop below our cut off, continue appointment.  If numbers too high, stop appointment.

- If they have not been to their physician recently fill the BP referral form out (these forms are located in the black bins behind op 4 & 10).

Many of the physicians are very “touchy” about dental personnel interpreting blood pressures.  Be sure to emphasize to your client that we are only “screening” their blood pressure.   We still contact their physician so they can just call their physician to arrange an appointment to have it thoroughly evaluated.

- Be sure to inform the doctor while you are giving him your report on the patient so he can be aware of the problem

- If BP is substantially high for them - retake BP at the end of appt.  to see if the first reading was false due to nervousness of patient. If the reading is still high, fill out the referral form and place it on the dentist’s desk for his signature.

- For clients over 50 the systolic (higher number) is the most important.  Clients with systolic blood pressure over 140 should be referred for evaluation.

Dental management of high blood pressure

1. Use N20-O2

2. Avoid local anesthetics within vasoconstrictors

3. avoid gagging the client

Pulse Procedure

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1.  Palpate radial artery

2.  Time with second hand on a watch for 15 sec.

3.  Counting beats multiply by 4 = pulse for 1 min. (This procedure is not regularly recorded in our office records)

 

BP Procedure (client seated, sleeve rolled up loosely)

1.  Allow client to sit upright for a few minutes (5 minutes is ideal ) before taking BP.  No limbs crossed.

2.  Position  so that arm is slightly flexed at an angle - arm is bare and lined even with heart level, palm up and resting on arm of chair.  Feet on the floor.

3.  Cuff should be at least 20% bigger than diameter of arm (we have several sizes)

4.  Place cuff so that the inflatable bladder is directly over the brachial artery 1 inch above the elbow joint

5.  Palpate the radial artery

6.  Close the valve and inflate cuff and note at what mm of mercury that the pulse is no longer felt, open the valve

7.  Place head of the stethoscope over the brachial artery (center of the elbow) just inferior to the cuff

8.  Once again close the valve, inflate the cuff inflating about 20-30 mm beyond the point at which the radial artery was no longer felt.     ex.  radial pulse ceased at 120 mm - pump cuff up to 140-150 mm

9.   Slowly deflate cuff - 2-3 mm per sec.    Listen for the first “tap” - this is the systolic pressure.    Then listen for the point at which the “tapping” sound can no longer be heard - this is the diastolic pressure

10.  Re-pump the cuff up 15 mm higher than the top reading you took. Again slowly deflate the cuff and check your first reading.  (ALWAYS TAKE 3 READINGS and average them if concerns.)

Watch out for:

1.  If arm is tensed, BP reading will be increased.

2.  IF BP cuff is on clothing sleeve, the reading will be inaccurate.

3.  You will see the dial move before you hear the sounds.  However, it is the sounds that are important.

4.  If you get a borderline high reading, take a second reading later in the appointment.

5.  If the reading is higher than 100 diastolic, client needs to be informed of high BP.   Do tell your dentist before beginning your appointment.  S/he will recommend having your clients BP checked by a physician.

Attempt to lower the BP before starting the cleaning by use of N2O2. Retake BP after 5 minutes on nitrous.  If the BP drops below 210/120, proceed with treatment.  If the BP remains too high, abandon treatment for the day and fill out Doctor consult form for your dentist’s signature and send a physician consult on BP problem.  Encouraging client to see his physician as soon as possible.

Fill out a physician request form.  Place form and client’s folder on dentist’s desk.

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Wait to reschedule any treatment until we hear from physician.

Safe Handling of Hazardous Materials

A. General Policy Statement

HAZARD COMMUNICATION PROGRAM

COMMITMENT

We are  firmly committed to providing a safe and healthy work environment. It is a matter of office policy as well as an important public program under the OSHA Act. We have implemented this Hazard Communication Program as outlined herein. Safe handling of hazardous materials is like wearing a seatbelt – expensive and uncomfortable, then, one day, it will save your life. Dr.  will have the overall responsibility for coordinating the program for the Health Park Dental office located at 110 S. Tippecanoe Drive, Suite A, Tipp City, Ohio 45371.

ACCESS TO THE WRITTEN PROGRAM

All, or any part of this written Hazard Communication program is available to employees, their designated representatives, the Assistant Secretary of Labor for Occupational Safety and Health (OSHA), and the Director of the National Institute for Occupational Safety and Health (NIOSH). This is available from the person named above for review and copying.

GENERAL  Our office will rely on material safety data sheets (MSDS) from our suppliers to meet hazard determination requirements. B. The purpose of this program is to ensure that this office is in compliance with the OSHA Hazard Communication Standard (HCS) 29 CFR 1910.1200. C. Every hazardous substance known to be present in the workplace will be listed on the “hazardous chemicals Inventory”. D. The identity of the substance appearing on the “Hazardous Chemicals Inventory” will be the same name that appears on the manufacturer’s label, in house label, and the MSDS for that substance. E. The “Hazardous Chemicals Inventory” will serve as an index to the MSDS’s files.

MATERIAL SAFETY DATA SHEETS

A. A material safety data sheet (MSDS) containing the information required by the Hazard Communication Standards will be kept for each substance listed on our “Hazardous Chemicals Inventory.” The MSDS will be the most current one supplied by the chemical manufacturer, importer, or distributor. You have the right to view these. B. For each new chemical ordered an MSDS shall be required with the shipment. The chemical’s name shall be added to the “Hazardous Chemicals Inventory” and the MSDS to the MSDS book. C.

MSDS DEFINITIONS

A material safety and data sheets (MSDS) containing the information required by the Hazard Communication Standards will be kept for each substance listed on our “Hazardous Chemicals Inventory”. Many words have very specific uses in hazardous communications. The following definitions will make it easier for you to read these manufacturers sheets. Don’t try to memorize them. If you see one of those words on a label, use this as a dictionary reference.

Acute Effect An adverse effect with severe symptoms occurring very quickly, as a result of a single excessive over exposure to a substance.

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Acute Toxicity – The adverse effects resulting from a single excessive overexposure to a substance. Usually a figure denoting relative toxicity.

Asphyxiant A vapor or gas that can cause unconsciousness or death by suffocation. Most are associated with a lack of sufficient oxygen to promote life.

Boiling Point Temperature at which a liquid turns to a vapor state. This term is usually associated with the temperature at sea level pressure when a flammable liquid gives off sufficient vapors to promote combustion.

“C” or Ceiling In terms of exposure concentrations, this is the number that should never be exceeded even for a short period, for a substance.

Carcinogen A substance capable of producing cancer in mammals.

CC Cubic Centimeter A volume measurement usually associated with small quantities of liquid. One quart has 946 cubic centimeters.

Chronic Effect An adverse effect with symptoms that develop or recur very slowly, or over long period of time.

Chronic Toxicity The adverse effects resulting from prolonged or repeated exposures to a substance, usually used as an indicator or relative toxicity for exposures over great lengths of time.

Combustible A term used to classify liquids, gases or solids that will burn readily. This term is often associated with “flash point”, which is a temperature at which a given material will generate sufficient vapors to promote combustion.

Concentration A figure used to define relative quantity of a particular material. Such as a mixture in air of 5 ppm acetone in air.

Corrosive A material with the characteristic of causing irreversible harm to human skin or steel by contact.

Decomposition The breakdown of materials or substances into other substances or parts of compounds. Usually associated with heat or chemical reactions.

Dermal Used on or applied to the skin.

Dermal Toxicity The adverse effects resulting from exposure of a material to the skin usually associated with lab animal tests.

Distributor a business, other than a chemical manufacturer or importer, which supplies hazardous chemicals to other distributors or to manufacturing purchasers.

Evaporation Rate The rate at which a liquid material is known to evaporate, usually associated with flammable materials. The faster a material will evaporate, the sooner it will become concentrated in the air, creating either an explosive/combustible mixture or toxic concentration, or both.

Exposure/ Exposed an employee is subjected to a hazardous chemical in the course of employment through any route of entry (inhalation, ingestion, skin contact or absorption, etc.) and includes potential (e.g., accidental or possible) exposure.

Flammable a chemical that falls into one of the following categories:

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1. Aerosol, flammable an aerosol that, when tested by the method described in 16 CFR 1500.45, yields a flame projection exceeding 18 inches at full valve opening, or a flashback (a flame extending back to the valve) at any degree of valve opening.

2. Gas, flammable a. A gas that, at ambient temperature and pressure, forms a flammable mixture with air at a concentration of thirteen (13) percent by volume or less; or b. A gas that, at ambient temperature and pressure, forms a range of flammable mixtures with air wider than twelve (12) percent of volume, regardless of the lower limit;

3. Liquid, flammable any liquid having a flashpoint below 100 degrees F (37.8 C), except any mixture having components with flashpoints of 100 F (37.8 C) or higher, the total of which make up 99 percent or more of the total volume of the mixture.

4. Solid, flammable a solid, other than a blasting agent or explosive as defined in 1910.109(a), that is liable to cause fire through friction, absorption of moisture, spontaneous chemical change, or retained heat from manufacturing or processing, or which can be ignited readily and when ignited burns so vigorously and persistently as to create a serious hazard. A chemical shall be considered to be a flammable solid if, when tested by the method described in 16 CFR 1500.44, it ignites and burns with a self sustained flame at a rate greater than one tenth of an inch per second along its major axis.

Flashpoint the minimum temperature at which a liquid gives off a vapor in sufficient concentration to ignite.

Foreseeable emergency any potential occurrence such as, but not limited to, equipment failure, rupture of containers, or failure of control equipment which could result in an uncontrolled release of a hazardous chemical into the workplace.

General Exhaust A term used to define a system for exhausting or ventilating air from a general work area. Not as site specific as localized exhaust.

“G” Gram A unit of weight. One ounce equals about 28.4 grams.

Hazard Chemical Any chemical, which is either a physical or health hazard.

Hazard warning any words, pictures, symbols, or combination thereof appearing on a label or other appropriate form of warning which convey the hazards of the chemical(s) in the container(s).

Health hazard one that include cancer causing, toxic, or highly toxic agents, reproductive toxins, irritants, corrosives, sensitizers, hepatoxins, nephrotoxins, agents that act on hemopoetic system, and agents that damage the lungs, skin, eyes, or mucous membranes.

The term “health hazard” includes chemicals which are carcinogens, toxic, or highly toxic agents, reproductive toxins, irritants, corrosives, sensitizers, hepatotoxins, nephrotoxins, neurotoxins, agents which act on hematopoietic system, and agents which damage the lungs, skin, eyes, or mucous membranes. Appendix A provides further definitions and explanations of the scope of health hazards covered by this section, and Appendix B describes the criteria to be used to determine whether or not a chemical is to be considered hazardous for purposes of this standard.

Ignitable A term used to define any liquid, gas, or solid which has the ability to be “ignited” which means having a flash point of 140 degree F or less.

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Immediate use that the hazardous chemical will be under the control of and used only by the person who transfers it from a labeled container and only within the work shift in which it is transferred.

Incompatible Materials that could cause dangerous reactions from direct contact with one another.

Ingestion Taking in of a substance through the mouth.

Inhalation The breathing in of substance in the form of a gas, liquid, vapor, dust, mist, or fume.

Inhibitor A chemical added to another substance to prevent an unwanted change from occurring. Irritant A chemical that causes a reversible inflammatory effect on the site of contact however is not considered a corrosive. Normally, irritants affect the eyes, nose, skin, mouth, and respiratory system. LC Lethal Concentration In lab animal tests, this is the concentration of a substance which is sufficient to kill the tested animal. LC50 Lethal Concentration 50 In lab animal tests, this is the concentration of a substance required to kill 50% of the group of animals tested. LD Lethal Dose The single dose concentration of a substance required to kill 50% of the lab animals tested. L.E.L. Lower Explosive Limit The lowest concentration, or percentage in air, of a vapor or gas that will produce a flash fire when an ignition source is introduced. Local Exhaust The system for ventilating or exhausting air from a specific area such as in welding operations. More localized than general exhaust. Material safety data sheet (MSDS) means written or printed material concerning a hazardous chemical, which is prepared in accordance with paragraph of this section. Melting Point The temperature at which a solid changes to a liquid. mg Milligram A unit of measurement of weight. There are 1000 mg in one gram of a substance. mg/m3 Milligrams per Cubic Meter A unit of measurement usually associated with concentrations of dust, gases, or mists in air. mppcf Million Particles per Cubic Foot A unit of measure usually used to describe airborne particles of a substance suspended in air. Mixture any combination of two or more chemicals if the combination is not, in whole or in part, the result of a chemical reaction. Mutagen A substance or agent capable of altering the genetic material in a living cell. Normally associated with carcinogens NFPA National Fire Protection Associated An organization that promotes fire protection/prevention, and establishes safeguards against loss of property and/or life by fire. The NFPA has established a series of codes identifying hazardous materials in order of flammability, with 0 being non burnable up to 4 which means it will burn spontaneously at room temperature. Olfactory Relating to the sense of smell. Oral Used in or taken through the mouth into the body. Oral Toxicity A term used to denote the degree at which a substance will cause adverse health effects when taken through the mouth. Normally associated with lab animal tests. Oxidizer a chemical other than a blasting agent or explosive as defined in 1910.109(a), that initiates or promotes combustion in other materials thereby causing fire either of itself or through the release of oxygen or other gases. Oxidizing Agent A chemical or substance that brings on oxidation reactions by providing the oxygen to promote oxidation. PEL Permissible Exposure Limit An exposure concentration established by the Occupational Safety & Health community, which indicates the maximum concentration for which no adverse effects will follow. Physical hazard a chemical for which there is scientifically valid evidence that it is a combustible liquid, a compressed gas, explosive, flammable, an organic peroxide, an oxidizer, pyrophoric, unstable (reactive) or water reactive. PPB Parts per Billion A unit of measurement for the concentration of a gas or vapor in air. Usually expressed as number of parts per million parts of air. PPM Parts per Million A unit of measurement for the concentration of a gas or vapor in air. Usually expressed as number of parts per million parts of air. Pyrophoric a chemical that will ignite spontaneously in air at a temperature of 130 F (54.4 C) or below. Reactivity The term, which describes the tendency of a substance to undergo a chemical change with the release of energy, often as heat. Reducing Agent In an oxidation reaction, this is the material that combines with oxygen. Respiratory System The breathing system, including the lungs and air passages, plus their associated nervous and circulatory components. Responsible party someone who can provide

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additional information on the hazardous chemical and appropriate emergency procedures, if necessary. Sensitizer A substance that on first exposure causes little or no reaction, however, with repeated exposure would induce a marked response not necessarily to the exposure site. Usually associated with skin sensitization. Specific chemical identity the chemical name, Chemical Abstracts Service (CAS) Registry Number, or any other information that reveals the precise chemical designation of the substance. Specific Gravity The weight of a material compared to the weight of an equal volume of water. Usually expresses a material’s heaviness. A material with a specific gravity of greater than 1.0 will sink to the bottom of water, whereas a material with a specific gravity of less than 1.0 will float on top of water. STEL Short Term Exposure Limit The maximum allowable concentration of a substance that one can be exposed to for less than 15 minutes and not produce adverse health effects. Teratogen A substance or agent, usually associated with cancer, that when exposed to a pregnant female will cause malformation of the fetus. Usually associated with lab animal tests. TLV Threshold Limit Value A term used by the Occupational Safety & Health community to describe the airborne concentration of a material to which nearly all persons can be exposed to day in and day out, and not develop adverse health effects. Toxicity The sum of adverse effects of exposure to materials generally by mouth, skin, or respiratory tract. TWA Time Weighted Average The airborne concentration of a material to which a person can be exposed over an 8 hour work day (an average). UEL Upper Explosive Limit The highest concentration of a gas or vapor in air that will sustain or support combustion, when an ignition source is present. Unstable (reactive) a chemical which in the pure state, or as produced or transported, will vigorously polymerize, decompose, condense, or will become self reactive under conditions of shocks pressure or temperature. Vapor Density A term used to define the weight of a vapor or gas as compared to the weight of a vapor or gas as compared to the weight of an equal volume of air. Materials lighter than air have a vapor density of less than 1.0, whereas materials heavier than air have a vapor density greater than 1.0. Vapor Pressure A number used to describe the pressure that a saturated vapor will exert on top of its own liquid in a closed container. Usually, the higher the vapor pressure, the lower the boiling point, and therefore the more dangerous the material can be, if flammable. Water reactive a chemical that reacts with water to release a gas that is either flammable or presents a health hazard. Carcinogen a chemical that can cause cancer Corrosive a chemical that causes visible destruction of, or irreversible alterations in, living tissue by chemical action at the site of contact following an exposure period of four hours. This term shall not refer to action on inanimate surfaces. Highly toxic a chemical that can kill you more quickly than a chemical labeled toxic (sed toxic) Irritant a chemical, which is not corrosive, but which causes a reversible inflammatory effect on living tissue by chemical action at the site of contact. Sensitizer a chemical that causes a substantial proportion of exposed people or animals to develop an allergic reaction in normal tissue after repeated exposure to the chemicals

Toxic a chemical falling within any of the following categories: 1. A chemical that can kill you when taken orally When administered by continuous contact for 24 hours (or less if death occurs within 24 hours) with the bare skin 3. When breathed Target organ effects the following is a target organ categorization of effects, which may occur, including examples of signs and symptoms and chemicals that have been found to cause such effects. These examples are presented to illustrate the range and diversity of effects and hazards found in the workplace, and the broad scope employers must consider in this area, but are not intended to be all inclusive. Labeling It is impossible to remember all of the hazardous materials you’ll come in contact with. For this reason, we use hazardous labels. Here are some precautions for our labels. 1. Never remove or deface a hazardous label from a container 2. Make sure the bottle is labeled 3. Make sure all labels are easy to read DENTAL OFFICE SAFETY The following general descriptions deal with several groups of chemicals that may be in products handled in the dental office. The hazard potential depends on the amount of exposure and individual sensitivity. In most dental

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offices the amounts of chemicals and the risks should be small. The risks and hazards can be further reduced if recommended procedures and precautions are taken. For information on specific products, always refer to the material safety data sheets (MSDS) in Dr. Smith’s office. If any of the information here varies from that on an MSDS, always rely on the MSDS first and foremost. General Precautions Handle chemicals properly in accordance with manufacturer instructions. Avoid skin contact with chemicals. Minimize chemical vapor in the air. Do not leave chemical bottles open. Do not use flame near flammable chemicals. Do not eat or smoke in areas where chemicals are used. When appropriate, wear protective eyewear and masks. Know proper cleanup procedures. Dispose of all hazardous chemicals in accordance with MSDS instructions and applicable local, state and federal regulations. E. List of Hazardous Chemicals Here is a list of the hazardous materials we use in dentistry and their hazardous component. It is the responsibility of the chemical manufacturer or importer to determine if their material will be hazardous to us. They will note those hazards on their labels (flammable, causes skin irritation, etc.) Review this section for updates once or twice a year.

CHEMICAL NAME            MAY BE FOUND IN               MSDS ON FILE

 

Acetic acid                          Photographic solutions

Acetone                              Solvents

Adhesives                           Impression kits

Aluminum oxide           Polishing disks

Articaine

Asbestos                              Some cast ring liners

Battery fluids                      Batteries

Benzene

Benzoyl peroxide         Resin systems, denture resins

Beryllium                              Nickel-based casting alloys

Butane

Calcium carbonate              Polishing agents

Carbon tetrachloride    Solvents

Catalysts                               Caustics

Chloroform                           Solvents

Chromium                               Casting alloys

Cleaning agents

Cobalt                                      Casting alloys

Copper                                    Amalgam, casting alloys

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Cresol, all isomers                 Endodontic materials

Cyanide as CN           Plating solutions

Detergents

Dibutylphthalate                   Impression materials

Etching agents

Ethyl acetate                         Solvents

Ethyl acrylate                         Resins

Ethyl alcohol                         Solvents, sterilizing agents

Ethyl chloride                       Solvents, topical refrigerants

Ethyl silicate                             Silicate investments, impression materials (condensation silicones)

Ethylene oxide                          Sterilizing agents

Flammables

Fluoride dust                     Fluoride-containing composites

Formaldehyde            Sterilizing agents

Glutaraldehyde                        Sterilizing agents

Hydrochloric acid        Pickling solutions, bleaching agents

Hydrogen fluoride        Etching agents for porcelain

Hydroquinone               Methacrylate and denture base resins, photographic solutions

Iodine                                      Iodophor disinfectants and antimicrobial hand cleansers

Isopropyl alcohol

Solvents, wiping agents

Janitorial supplies

Lead/inorganic lead        impression materials (some compounds polysulfides)

 

Lidocaine

LPG (liquid petroleum Burners gas)

Mercury                                    Amalgam

Mercury, organic                   Topical antiseptics

Methyl acetate                           Solvents

Methyl alcohol                           Denatured alcohol

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Methyl methacrylat              Denture base resins

Methylene chloride             Solvents

Molybdenum, insoluble             Casting alloys (chromium-compounds cobalt alloys, stainless steel)

Nickel, metal and          Nickel-based casting alloys, soluble compounds stainless steel orthodontic                                                    appliances

Nitric acid                                 Pickling solutions, some bleaching solutions

Nitrous oxide                             Nitrous oxide

Oil mist, mineral                         Handpiece lubricants

Petroleum distillates      Solvents, waxes, jellies

Phenol                          Disinfectants

Phosphoric acid                         Etching agents, phosphate cements

Phthalic anhydride     Resins

Picric acid                             Pickling agents

Plastics

Platinum, soluble salts Impression materials (addition silicones)

Platinum                                   Casting alloys

Propane                                    Burners

Resins

Rouge                                      Polishing agent

Silica, amorphous        Composite resins, impression including natural materials diatomaceous earth

Silica, crystalline                       Composite resins, porcelain;(quartz) investments

Silicon carbide                          Polishing disks, cutting wheels

Silver, metal and                       Amalgam, endodontic points, soluble compounds\casting alloys, 

Sulfuric acid                              Etchant for alloys, copper plating solutions

 

Talc, nonasbestos form             Gloves

 

Tantalum                                   Nickel-chromium-cobalt alloys

 

Tin, inorganic compounds         Amalgam, polishing pastes

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Tin, organic compounds            Impression materials     (condensation silicones)

 

Titanium dioxide           Porcelain, impression materials

 

Toluene                                    Solvents

 

Trichloroethane                         Solvents

 

Uranium, insoluble       Porcelain

 compounds

 

Vinyl chloride                           Maxillofacial plastics, mouth guard trays

 

Xylene                                      Solvents

 

Zirconium compounds                Porcelain, polishing pastes

Look for other chemicals that are potential hazardous using these resources: 1. Regulated by OSHA in 29C FR Part 110, Subpart 2, Toxic and Hazardous Substances 2. Included in the American Conference of Government Industrial Hygienists latest edition of Threshold limit values for Chemical Substances and Physical Agents In the Work Environment. 3. Found to be suspected or confirmed carcinogens by the National Toxicological Program in the latest edition of the Annual Report on Carcinogens, or by the International Agency for Research on Cancer in the latest edition of their monograms.

D. Examples of Safe Handling of Hazardous Materials The following pages list various hazardous materials and Midtown Dentistry’s safety procedures. Learn them. When you know how to handle these materials safely, have one of the dentists “check you out.” Material Safety Data Sheets are available. The following pages (F1 to Fg) are furnished by OSHA to help you understand the MSDS.Here are some general precautions: Handle chemicals properly in accordance with manufacturer instructions Avoid skin contact with chemicals Minimize chemical vapor in the air Do not leave chemical bottles open Do not use flame near flammable chemicals Do not eat or smoke in areas where chemicals are used When appropriate, wear protective eyewear and masks Know proper cleanup procedures Dispose of all hazardous chemicals in accordance with MSDS instructions and applicable local, state, and federal regulations. Never throw away any material safety data sheets that come with materials give them to Dr. Smith. He will review them to make sure they are complete. Manufacturers MSDS are available by Dr. Saleh’s office in the blue notebook labeled “MSDS” All incoming hazardous materials/chemicals need to be labeled when unpacked. Acid Etch solutions and gels Examples: Solutions and gels for acid etch

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techniques associated with placement of composites, sealants, and orthodontic brackets usually contain phosphoric acid. Hazards: Acid burns and possibly sloughing of tissue, eye damage. DO: Handle acid soaked material with forceps or gloves. Clean spills with a commercial acid spill cleanup kit. Avoid skin or soft tissue contact. Rinse with a large amount of running water in case of eye or skin contact. Flammable Gases Examples: Nitrous oxide and oxygen, liquefied petroleum gas (LPG). Hazards: Fire. DO: Test periodically for leaks. Avoid contact between compressed oxygen gas and lubricants or grease. Avoid having sparks or flames near flammable gases. Flammable liquids Examples: Solvents such as acetone and alcohol. Hazards: Fire or explosion. DO: Store flammable liquids in tightly covered containers. Provide adequate ventilation. Have fire extinguishers available at locations where these liquids are used. Avoid sparks or flames in areas where flammable liquids are used. METALS Beryllium Examples: Beryllium dust and fumes arise from the melting, grinding and milling of some base metal alloys. Hazards: Contact dermatitis, corneal burns, inflammation and scarring of respiratory tissues. DO: Wear gloves, eye protection and NIOSH approved mask when casting, polishing or grinding these alloys. Provide adequate local exhaust ventilation for all operations in casting areas. Use power suction methods rather than air hoses to remove dust from clothing and to clean machinery. Dispose of wastes, storage materials or contaminated clothing in sealed bags. Amalgam (mercury) Examples: Bulk mercury; precapsulated alloy; scrap amalgam. Hazards: Fine tremors, nausea, and loss of appetite, diarrhea, depression, fatigue, increased irritability, allergic manifestations, contact dermatitis, pneumonitis, nephritis, headache, insomnia, dark pigmentation of marginal gingiva, loosening of teeth. DO: Work in well ventilated spaces. Avoid direct skin contact with mercury. Store mercury in unbreakable, tightly sealed containers away from any source of heat. Salvage amalgam scrap; clean out the dental traps in the assistant carts. Never flush amalgam scraps down the drain. Clean up spilled mercury using appropriate procedures and equipment; do not use a household vacuum cleaner. Place contaminated disposable materials in polyethylene bags, seal, and label. Recycle these bags with a qualified recycler. Nickel Examples: Nickel containing dental alloys, gold alloys, solders. Particles released during fabrication and grinding of nickel containing alloys. Hazards: Allergic manifestations, irritation to eyes and respiratory systems. DO: Use protective eyewear and NIOSH approved mask when grinding nickel containing alloys. Use high velocity evacuation systems. Nitrous Oxide Hazards: Based on laboratory animal studies, high exposure may cause adverse health effects. DO: Steps should be taken to minimize the vapor concentration of nitrous oxide in the dental suite. Use a scavenging system. Check nitrous oxide machines, lines, hoses, and masks for leakage. Maintain adequate ventilation.

Other Metals Examples: Casting alloys and alloys for amalgam. Hazards: Metal dusts and fumes may irritate eyes and respiratory systems. Contact dermatitis. DO: Wear protective eyewear and NIOSH approved mask while grinding metal prostheses. Organic Chemicals Examples: Alcohols, ketones, esters, solvents, and monomers such as methyl methacrylate and dimethacrylates. The halogen containing organic liquids used in dental offices primarily include chloroform and carbon tetrachloride and some solvents and cleaners. Hazards: Fire, allergic manifestations, contact dermatitis, irritation to mucous membranes, respiratory problems, central nervous system depression, headache, drowsiness, loss of consciousness, nausea, liver and kidney damage, possible mutagenesis. DO: Avoid skin contact Avoid excessive inhalation of vapors. Work in well ventilated areas. Use forceps or gloves when handling contaminated gauze or brushes. Keep containers tightly closed when not in use. Store containers on flat sturdy surfaces. Clean outside surfaces of containers after use to prevent residual material from contacting the next user. Use a commercially available flammable solvent cleanup kit in case of spills. Photographic Chemicals Hazards: Contact dermatitis, irritation of eyes, nose, throat and respiratory system from vapors and fine particulates of chemicals. DO: Use protective eyewear. Minimize exposure to dry powder during mixing of solution. Avoid skin contact with photographic chemicals and solutions by wearing heavy duty

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rubber gloves. Work in well ventilated areas. Clean up spilled chemicals immediately. Wash off chemicals with large amounts of water and a pH balanced soap if contact occurs. Store photographic solutions and chemicals in tightly covered containers. Plaster and other gypsum products Examples: Gypsum products contain silica and calcium sulfate. Hazards: Irritation and impairment of respiratory system. Silicosis. Irritation of the eyes. DO: Use plaster and other gypsum products in areas equipped with an exhaust system. Use protective eyewear and NIOSH approved mask while handling powders or trimming models. Minimize exposure to powder during handling. Caution Every liquid should be in a marked container. The container must have a warning label clearly displayed. If you transfer a liquid from one container that has a warning label to a second container, it is your responsibility to make sure that this second container has the same warning label affixed to it also. H. Safety Hotlines Chemical Emergency Preparedness Hotline CERCLA (SARA Title III) ……………………. 1 800 535 0202 Chemical Transportation Emergency Center (CHEMTREC) 24 Hour ………………………… 1 800 424 9300 CMA Chemical Referral Center ………………… 1 800 CMA 8200 EPA RCRA, Superfund, Hazardous Waste Hotline Office of Solid Waste and Emergency Response ……………….. 1 800 424 9346 EPA, Small Business Hotline …………………. 1 800 368 5888 National Response Center ……………………. 1 800 424 8802 (Report chemical releases, radiological incidents) National Safety Council …………………….. 312 527 4800 NIOSH National Institute of Occupational Safety and Health ……………… 1 800 356 4674 OSHA, Health Standards ……………………… 800-582-1708 Safe Drinking Water Hotline …………………. 1 800 426 4791 Substance Identification ……………………. 1 800 848 6538 US DOT HOTLINE …………………………….. 1 202 366 4488J. Proper Labeling Many chemicals used in dentistry are dangerous. The label on the bottle helps you to know when to be careful handling an item. To protect yourself and others: 1. Never deface or remove a Label from a container 2. If you change a liquid or other dangerous material from one container to another, be sure to duplicate and fix a copy of the label on the new container. 3. Some items will need a label a. Any waste container that could hold contaminated waste b. Any container holding reusable contaminated instruments c. The refrigerator that contains dental supplies d. Washer 4. If a container is not labeled let Dr. Smith know. You and he will decide on the proper label. Dr. Smith is responsible for assuring compliance with this labeling requirement in accordance with 29CFR 1910. 1200. 5. All containers of hazardous chemical, which are the responsibility of this office, will be labeled with at least the following information: Identity of the hazardous chemical(s) Appropriate hazard warnings Manufacturer’s or distributor’s name and address 6. Such containers may also be placed in a designated location where the location is labeled and the containers are returned to that designated location after use. Incoming shipments of chemicals shall be reviewed for appropriate labeling and then determine if there is an MSDS available for each chemical received. 7. Read the label on every material the first time you use it 8. The words “caution,” “danger,” “harmful if absorbed by skin,” etc. are precautionary statements and do no identify specific hazards. 9. No hazardous chemicals will be accepted for use in the facility, or shipped to any outside location, unless labeled with at least the following information: 10. When transferring a product to an unlabeled container place a copy of the original label on the new container Identity of the hazardous chemical(s) Appropriate hazard warnings Name and address of the chemical manufacturer, importer, or other responsible party Labels can be confusing to read. Here are some hints to help you. 1. The effectiveness of a disinfectant is determined by how quickly (if at all) it can kill M. Tuberculosis. The contact kill time can vary from 3 to 9 minutes. 2. Some disinfectants need to be diluted. Others are used full strength. Read carefully. 3. Many disinfectants work better at higher temperatures. Never heat a disinfectant. Centigrade can be converted to Fahrenheit if you remember 20 degrees Celsius = 68 degrees Fahrenheit and 25 degrees Celsius = 77 degrees Fahrenheit.

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If a label doesn’t include all the necessary information, send them a copy of the following letter:Dear Sir or Madam: I purchased ____________________ of (amount/size) _______________________________ on ______________ (name of product) (date) from your company. I took delivery of the product on ____________ (date) but did not receive any Material Safety Date Sheets (MSDS) with my order. Please send me the appropriate MSDS immediately so I will be in compliance with OSHA regulations regarding training of my employees about the hazards of this product. Thank you for your cooperation. Sincerely,

K. Hazardous Waste Pick Up At present we use sharps containers (red plastic container on each C&S area). For pick up, sharps containers sealed with red cap go in Biohazard box under C&S on Pierson side. Pick ups are last Tuesday of every month.

L. Training As in the rest of dentistry, the safe handling of hazardous materials information will improve and change rapidly. You will be kept up to date on these changes by 1. Staff meetings 2. Updates in the manuals 3. An annual staff meeting These topics will be covered as per 1910. 1200(h) 1. Provisions of the Hazardous Communication Standard 2. Hazardous chemicals in your work area 3. Location and availability of our hazard communication program, MSDS’s, and chemical lists 4. How to detect presence of a hazardous chemical in the workplace 5. The physical and health hazards of chemicals in the workplace 6. How to protect yourself from these hazards a. Information on work practices b. Emergency procedures c. Required personal protective equipment 7. Details of our program a. Labeling b. MSDS’s c. How to read and use MSDS information 8. Accidents and their management 9. Value of vaccination for Hepatitis B EMPLOYEE INFORMATION AND TRAINING PROGRAM POLICY We will provide employees with training when new hazardous chemicals are introduced and added to the “chemical inventory list”, or before non routine tasks are to be performed that could involve exposure to hazardous chemicals. The extent of information transmitted to employees during training sessions will be dictated by the degree of hazard presented by the chemicals. The applicable MSDS’s the text of the OSHA Hazard Communication Standard (1910.1200), the inventory list of hazardous chemicals, and this written program will be used as sources of information during the training sessions. CONTRACTOR POLICY Outside contractors must be provided with all necessary information concerning the potential hazards of the substances to which they may be exposed and appropriate protective measures required to minimize their exposure. Whenever possible, the contractor or agency management should be provided with a list of the hazardous chemicals and the safety data sheets for the materials their employees will be using in the course of their work in our area. Outside contractors shall also provide MSDS for all hazardous chemicals not considered consumer products used within this establishment, which could potentially expose our employees.

M. CERTIFICATION OF TRAINING ON HAZARD COMMUNICATION This is to certify that I have been trained and informed on the hazards and precautions associated with the use of hazardous chemicals in my work as required in the companies written hazard communication program. Please have the following areas checked to indicate your understanding: [ ] Overview of the requirements contained in the Hazard Communication Rules, 1910.1200. [ ] Aware of location of copy of OSHA’s Occupational Exposure to Blood born Pathogens; Final Rule. This is the definitive source for all in Formation on infection control. It is located in Dr. Smith’s lateral file. [ ] Understand what an MSDS is and the meaning of its various sections. [ ] Chemical hazards present in my workplace operation. [ ] Location and availability of our written hazard communications program, the list of hazardous chemicals, and the MSDS’s for these chemicals. [ ] Physical and health effects of these chemicals. [ ] Methods and observation techniques used to determine the presence or release of hazardous chemicals in the work area. [ ] How to lessen or prevent exposure to these chemicals through usage of control/work practices and

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personal protective equipment. [ ] Steps the company has taken to lessen or prevent exposure to these chemicals. [ ] Safety or emergency procedures to follow in the event of exposure to these chemicals. [ ] How to read container labels, review and interpreted MSDS’s to obtain appropriate hazard information.

Employee signature ______________________ Date ________________

Trainer _________________________________ Date ________________

Doctor __________________________________ Date ________________

Preventive Care/Prophies on Patients

Preventive Care

Goal: Our goal is for the patient to have the best preventive care appointment ever - and know it!  We have the opportunity to make the patient’s hygiene appointment as meaningfully different as eating at McDonalds vs. eating at a fine Dayton restaurant.  Both places serve the same basic purpose, to satisfy your hunger.  The quality of the experience though is entirely different.

Our goal is for you to be more than a tooth cleaner.  Why should a patient drive past 100 dentists to get to us?  Are we that good?  Would perfectly clean teeth justify this?  Remember we sell caring, concern, gentleness, kindness, comfort, acceptance, compassion, warmth, appreciation, love, competence, empathy, credibility, confidence, conviction, sensitivity - not fillings and crowns.  “The hygienist is the most important person in dentistry” - quoted Dr. Chuck Smith.

Hygiene Philosophy

Your job as a hygienist is not to “save” poor, unfortunate dental patients.  Many hygienists believe they are “doing their job” or “doing what’s best” by providing the care they would want for themselves. After all, this is a variation of the Golden Rule, isn’t it?  You’re right, I think the answer is no!  Here are several reasons while your “help” may work against your client.

1.  “Help” assumes that the person assisted got better from the clients’ perspective!  Often a health care worker will storm into   “save the day” only to find out that the client has different   values and attitudes about dentistry.  The hygienist’s well   intentioned “help” turns out to be unappreciated “interference” in   someone’s life.

2.  “Help” also assumes that the client had a choice - whether to willingly accept the assistance or not.  Hygienists (and   assistants, secretaries, and dentists) often get in a hurry, survey   a technical problem, and supply a technical answer - without having   a heart to heart discussion with the client.

3.  Hygienists often think their job is cleaning teeth.  Clients have a large number of reasons (benefits) for using a hygienist’s   services:

a.  Fear of dental disease

b.  Improve business

c.  Avoid major dental expenses

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d.  1000 more - almost as many reasons (or combinations) as there are clients

4.  Hygienists often think there is little for clients to learn.  Clients want to find out about all the newest ideas - and get their questions   answered knowledgeably.

5.  Hygienists think people come to get their teeth cleaned.  Clients believe they are coming to satisfy their own individual, personal  needs.

6.  Hygienists often organize their appointment time for their convenience and efficiency.  Clients want their own convenience to come first. If the client’s values are different than yours and you demand a behavior change (brush, floss, fluoride, diet, etc.) you may get it, but at a price.  The price is the loss of the chance to develop an adult relationship with your client.  When you accept a parent/child relationship, you have two ways to get changed behavior:     1.  Threats - “If you don’t do this, you’ll lose your teeth!” (or variations of it)     2.  Manipulations - Look for “hot buttons”  Wouldn’t you like to (save money, be sexy, avoid pain, etc.)?  Both of these techniques can work, but at a price!  Since the client has accepted a childlike position to your parent, s/he can respond like a child.   1.  Punish you by not doing what you expect.    2.  Failing and blaming you for the failure.  After all, it was your idea!

The check-off sheet is designed to help you avoid manipulating people and enjoy them by developing an understanding of who they are, what their values are, and why they believe what they do.

At first, this will seem very time consuming and inefficient.  Why not just tell them what to do?  After all, it’s their mouth.  I show them how, then they either do it or not.  Some people just aren’t very responsible.  Does that sound familiar?  Don’t get stuck with this. Compare the above paragraph with this next paragraph.

When your clients accept ownership of their problems, their success is your success.  Ownership implies that they;

a.  Participate in discovering with you what the problem is - is there more than one (of course), how extensive, etc.

b.  Spend time to discover what their attitudes and values are that led to the behavior that allowed these problems to develop.

c.  Decide on a new behavior supported by a modification of their value system that will help them solve the problem that they have defined.

d.  Try out various alternatives until your clients find the “right way” for them.  Your job is to provide these alternatives in a supportive, loving, non-judgmental environment.

e.  Cementing the relationship occurs when your clients can put the problem and chosen solution into their own words.  Now you are only a resource that the clients will use to achieve their goals!

Before your patient’s appointment, review your patient’s chart to see when they were last here and what kind of treatment did they have done. This could also refreshen your memories of your last conversation with them (EX: where they went on their last vacation, birth of a grandchild…etc.) to help you know your patients as people.  Patient’s are stunned when they realize that you remember an event that happened to them the last time they saw you. The average RDH’s career last 2 1/2 years.  If you focus on people rather than on teeth to the best of your ability you will have a long and honored career!

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Your treatment notes should always be written, but don’t get caught in the “trap” of leaving the room just to finish up your notes when your treatment coordinator or doctor is in the room and you do not know what is discussed. You are robbing yourself of the time you need to spend with your clients developing relationships.

Use your own judgment in deciding on a personal continuing care (recall) appt. for the patient and discuss it with them.  Try to avoid the standard 6-month interval.  This will personalize their future appointments.

Be sure to introduce the Dr. by name to all new clients s/he hasn’t seen before.  Use the client’s preferred way to be addressed (formal or informal).  If the client has been in before “Dr. ________, John is with us today!” look through the client’s chart.  If this is the first time your client has seen this doctor, TELL THE DOCTOR!  If the client is a child, introduce both the child and the parent.

Your dentist will signal when he/she is ready to begin the exam by saying something to you like “Well, how did everything look today?”

Don’t make the dentist ask 20 questions.  Give him a complete report on your patient.  Begin by telling something that has happened recently non-dental about your patient.  You’ve just spent 30- 60 minutes with your client.  What topics (personal) have been most interesting?  Bring your dentist into this conversation.  Give your dentist about 1 minute to follow up on this and then interrupt if necessary to begin your pink sheet report.  This is your chance to show Doctor and the patient you are more than a tooth cleaner.

1. Begin by reviewing any treatment completed in the last 12 months

2.  Explain all findings on pink sheet.  Follow the sequence as written on the pink sheet, focused on notes you made in the right hand column.  This sequence is in the normal order on which we build.

1)      Gums,OHI,CAexam – discuss bleeding points, pocket depths (changes)

2)      Decay – discuss teeth in 1-32 order, slowly allowing dentist to evaluate each area before moving on to the next, include watches and your post-treatment discussion, X-rays questions, concerns that client has

3)      TMJ, missing teeth

4)      Bite

5)      Esthetics

6)      Recommended recall/x-ray/doc exam interval

For example, if the gums aren’t healthy or there is a decay problem, we wouldn’t discuss replacing missing teeth.  Try to advance each client one level each recall.  This will insure you meet all the commitments you need each quarter, also.

2.  Make notes on any treatment that is needed on the treatment-scheduling sheet.  Include who is to do the treatment and how much time is needed on the orange treatment routing sheet.

The doctor doesn’t need to examine after every cleaning appointment. Ohiolaw requires a doctor’s exam annually.  Every time a doctor examines, two negatives occur:  The doctor must break away from the client he is treating.  The hygienist must wait for the doctor.

The dentist should plan to examine a client at certain specific times:

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1.  Once annually

2.  When x-rays are exposed

3.  When you see any disease

4.  If the client requests it

One way to reduce the inconvenience of the dentist’s exam is for the dentist to examine at any time during your appointment rather than waiting for you to finish.  Be sure to check for decay, gum disease, missing teeth, esthetics, etc. after you have seated your client. 

Write up notes on what you did today including recall and time needed on the yellow treatment sheet.  Also note any significant conversation that the dentist had with your patient.  What treatment did the dentist suggest that the client denied?

Thank patient for coming today: “I really enjoyed meeting you today.  I recommend that I see you again in ___ months. 

Give toothbrush and floss.  Sometimes you may give fluoride, floss threaders, perioaides, etc.  Use your own judgment.

Escort patient to front desk.  Explain to receptionist what the patient needs and thank the patient for coming in.  Ask for referrals.

The last 4 minutes, like the first 4, are the most important in building a solid relationship with your client.  This last impression is the one your client leaves with - and remembers the longest.

Dismiss Client, Clean Up, Set Up

1.  When the dentist exits, upright the client, offer a rinse, remove the bib.

2.  Reinforce any treatment recommendations as you guide your client to the front desk.

3.  Pass your client to a specific front office team member.  “Mrs. Walker, Judy will arrange your next appointment.”

4.  Return to your operatory, put on a pair of nitrile gloves and clean up the operatory.

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Notes When Scaling

Scaling

1.  Ask patient if they are familiar with the scaling procedure.

2.  Explain the value of scaling teeth & why we want smooth roots:

“The smoother the teeth, the harder for food and bacteria to attach to it and the harder to get decay and gum disease.”

If scaling and root planning is necessary, than typically all four quads will be performed during one appointment visit, unless insurance coverage does not allow four quadrants done at one time. This reduces the number of visits necessary for the patient. The client must be comfortable for this appointment.  You will be expected to use some methods to achieve this. Our method of choice is to use the topical anesthetic administered sub-gingivally in an irrigating syringe. The other option is to have the doctor give patient anesthetic injection. If patient prefers to have procedure done through sleep dentistry (Halcion) of IV Sedation, this should of already been discussed and treatment planned prior to patient’s scheduled scaling appointment.

Use the cavitron whenever possible it is quicker and often more comfortable than hand scaling.  The cavitron: the ultrasonic unit consists of a handpiece assembly (prophy jet and cavitron), interchangeable prophylaxis inserts, and a foot control.  The cavitron is an adjunct to manual scaling, and it is primarily used for patient with gross calculus.  It may also be used to remove overhanging restorations.  The ultrasonic instrument is based on the use of very high frequency sound waves and the vibratory action fractures the deposit and causes it to be removed from the tooth.

Run water through the tubing to the ultrasonic unit for about 10 seconds.  When there is a steady drip out of the tubing then insert the prophylaxis cavitron tip.  Push the foot control again until there is a maximum mist about the working tip to prevent overheating.  There are two adjustment knobs - one for water and one for power.  The power setting is usually set on Medium but can be adjusted to low or high - depending on patient’s general sensitivity.  In adjusting water flow, the greater the water flow, the lower the water temperature; the lesser the water flow, the higher the

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water temperature.  If during treatment, you feel the handpiece getting very warm, you need to correct the temperature by increasing the volume of water flow.

Use the high-powered suction to reduce water spray, remove excess water and debris from the patient’s mouth.  Place the suction opposite the cavitron. The ultrasonic method is principally for treatment when deposits are gross, but is not applicable for preventive scaling measures when small deposits are removed at frequent recall appointments.

Ultrasonic treatment is contra-indicated for a patient with a cardiac pacemaker.  It disrupts the electrical impulses the pace-maker sends to the heart. Always follow the cavitron with hand instruments to do the final smoothing.  Increasing the water spray to the cavitron will often decrease sensitivity.

Special Considerations for Esthetic Restorations

1.  Read your client’s chart.  The remarks section should warn you which teeth needs special care.

2.  Use a curette instead of a scaler.

a.  You’ll have more control and increased tactical sensation.

b.  Less chance of scratching porcelain.

3.  If scratching occurs, use Diaglaze to repolish.  If this is not done, the scratches can stain and pick up plaque.

4.  Don’t use pumice or even our standard prophy pastes on a prophy cup    - too abrasive.  Plain toothpaste or our Gel Kam is okay.

5.  Use the cavitron on low power and ProphyJet/Kavo only if heavy stains are present

6.  Remove proximal stain by using a small fine grit sandpaper strip. If this doesn’t work, go to a medium.  Keep moving up until the stain is gone.  Repolish with a fine grade.  Be careful not to polish off the contact.

7.  If you find an overhang or rough area at a margin, don’t remove it, tell your dentist.

8.  Use a composite polisher (Prisma Gloss, Euamelize, or Composi - Glaze) on all anterior restorations or aluminum oxide

9.  Check gingival margins of restorations used to close diastemas.

10. Keep 4 grades of flexidiscs and 3 grades of sandpaper strips and    several bullet shaped and cup shaped rubber polisher in your room at all times.

11. Use a double-ended plastic instrument to retract the gums or    papilla when you are polishing margins.

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12. Write on the outside of the folder and in the remarks section    “bonded veneer.”

13. Toothpastes too abrasive for composite

Advanced Formula Crest Colgate Aqua Fresh Pearl Drops Topol Baking Soda

14. Best paste (smoothest) Rembrandt

15. Polishing teeth - use 2 grades of Nupro

Nupro Plus (extremely coarse) for strain removal (grade 30+) Nupro Medium (19.7) for general use Nupro Fine (7.3) for porcelain/composite restoration

16. Clients should avoid high alcohol mouthwashes.  They can weaken a composite bond.

17. Mark in the client’s chart where esthetic restorations are located.

18. To remove stains, go from least to most abrasive: Aluminum oxide (Enamelize) Enhance rubber discs - Sof-lex discs, then reverse back to Aluminum oxide to remove scratches.

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Do’s and Don’ts When Writing Your Clinical Chart Notes

Update all medical history including most recent medications that patient is taking

Document all treatment that the doctor recommends Don’t make uncomplimentary comments (“nasty person”). Don’t criticize the care from previous offices. Don’t guess about possible reasons for problems. Don’t second guess a treatment performed that didn’t work. Document all details of a client’s non-compliance with recommended

treatment. Document all informed consent forms. Document all client contacts - including telephone calls and letters. Chart the complete date on all entries - initials at the end. Use only standard abbreviations. Document any prescription the patient was given. Document all patient instructions and handouts given.

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Protocol When Your Equipment is Not Working

When any of your equipment is not working/broken, please inform your supervisor immediately. A ticket will be written/emailed to the appropriate company or service provider.

List of Equipment:

Computer TV Any handpieces X-ray sensors Intra-oral camera Water leaks Cavitron/Piezo machine and tips Towel warming machine

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Charting, Continuing Care, and Scheduling

The key to your success as a hygienist is your ability to motivate your clients to return at regular intervals for recall appointments. You’ll accomplish this by being technically competent and establishing a good personal relationship with each client.

One of the best ways to ensure your success is to personalize your recall message to your clients.

When you complete the appointment, fill out the treatment sheet. Decide on a motivational note that makes the most sense for your client. Tell them what you believe is the primary reason they should return and at what interval. When the computer cards come to your clients, it will reinforce what you told them.

Review the dentrix modules: Family file, Ledger, Tooth Chart, Office Manager. As a hygienist, you will spend 95% of your time in the tooth chart.

To Print the Schedule in Dentrix:1. Open the appointment book module and look at the day and providers you want to print2. Click File, Print appointment book view3. Make sure the following are check marked:a. Print day noteb. Print perfect dayc. Print amount4. Click Print5. You must repeat these steps for each Dr. /Hygienist schedule you would like to print.

Tooth Chart Ideas for Dentrix1. Perio Charting – Click on the Perio icon2. Primary or Permanent Teeth or Mixed Dentition – you can select Prim/Perm on the taskbar3. Graphic Chart for patient with gum problems – In the perio chart, click on Options, then Graphic Chart to show difference between their gum line (in blue) and where the gum line should be (in burgundy). You can zoom in on a section – in Perio chart, click options, Quadrant Zoom (this will bring up a magnifying glass) then click on the area you want to see. You can also print this chart for the patient to take home.4. Medical Alert – if the patient has an alert the cross icon will be red – always check this and add medical alerts.5. Clinical Notes – if you want to add special notes for this patient6. Procedure buttons – hygienists can choose the procedures they do most often

To Chart the Existing Treatment and Conditions in Dentrix:1. Open the tooth chart2. Select the tooth and then click the Conditions box or existing treatment3. Click the EO box – which will enter the procedure into the notes4. Click on the + box and that will hold down the existing condition box until done charting.

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How to set a “flag” a patient (alert) in Dentrix:1. Double click on patient you want a flag on2. Click into patient info.3. Click on flag on upper rt. Side of tool bar4. Determine date for flag to appear in computer/patient (start end vs. always)5. Click onto description and give explanation for flag. (ex. Recall)6. Click onto note and give further information if necessary (ex. 4u prophies)7. Click on cont. care, create new appt., & family file in box or rt side – they should turn blue8. Click on show symbol (flag) on appt. under options9. Click OK

Set the correct Continuing Care details / Set Commitments:So that the next time you schedule a cleaning for this patient, it will default to the correct time, set it right now:1. Select patient in family file2. Double Click the Continuing Care box3. Double click on the patient, then type of recall (or commitment) – this will bring up the default settings for this patient’s cleanings4. Click on the specialist box, then choose your name from the list5. Click on the time box – this will bring up a screen for you to set the amount of time needed. Make sure all the boxes have an X in them. Click okay and okay again to close the default setting screen.6. Click okay to close the Continuing care screen.

To Schedule Cleanings:1. Open appointment book module2. Double click the time you want to schedule the appointment in your column. Select patient. This will bring up a screen to enter what treatment you are scheduling.3. Click continuing care button and if a date shows up in the box, highlight it and then click okay.4. Select provider5. Click Initial box and choose Periodic Ex and Prophy-Adult or Prophy-Child6. Set length of appointment – Dentrix defaults to 45 minute cleaning. You may need to adjust the time.7. Select your name in the staff list.8. Click okay

It is important to click the continuing care button (step 2). This will attach the continuing care appointment to the cleaning appointment you are setting. This lets the computer know that this patient has an appointment for their continuing care (recall) – so when you pull up the list of patients due for recalls, it will know those patients with appointments scheduled (if you have attached their continuing care to the appointment) so you will know not to call them again. This saves tons of time since you don’t have to look in the appointment book before calling each

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patient to make sure they don’t already have an appointment. Obviously this is a very important part in managing our recall system.

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Understands and Helps with Recall System

Understanding the recall system is important because it provides the hygienist’s with the steady flow of patients to fill his/her schedule. Setting the continuing care interval is important in order to establish a list of recall patients. This continuing care list provides the hygiene coordinator with a list when she is calling patients to schedule their recall appointments.

It is extremely important to discuss with your client the reason for them to return for their next cleaning and the proper time interval. Develop a good communicating adult to adult dialogue. An effective hygienist will have 85-90% of her clients returning on time for their check ups. The correct motivational tool to accomplish this is to find out why your client wants to return and how soon. To be successful you must satisfy your client needs. When you complete your appointment, determine the reason your client needs to return. Discuss it with your client.

We have a comprehensive recall system to stay in contact with our clients.

Here are the contacts a client will receive from our office:

EmailPhone call Letter

If the client still does not schedule, then we continue to try to send them a letter/email to inactivate them.

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COMMON MEDICAL CONDITIONS

Many of the more common medical conditions of the geriatric patient are listed below:

A. ANGULAR CHEILOSIS1. Appears at corners of mouth as extremely sore crevices.2. Can be Candida Albicans fungus infection3. Associated with loss of vertica dimension sometimes4. Associated with Vitamin B-complex deficiency5. Treatment – Nystatin ointment three times daily

B. APHTHOUS ULCERS1. Extremely tender single multiple ulcers with yellow brown depressed centers surrounded by red halo lesion on tongue, inner surface of lips, or gingival or buccal mucosa.2. Not caused by virus3. Thought to come from emotional stress. Look for allergies, diabetes, bowel disease and endocrine disorders.

C. ARTHRITIS1. Most specifically, rheumatoid arthritis2. Present in about one percent of the population3. Affects females 2-3 times as much as males4. Can be in T-M joint and affect jaw movements5. Frequently associated with physical or emotional stress

D. ARTERIOSCLEROSIS1. Most common of coronary artery diseases2. Associated with hypertension, diabetes, obesity and old age3. Predilection for males and occurs most often in 50-59 age group4. Basically, two typesa. Angina pectoris – mild, transient ischemiab. Myocardial infarction – damage to heart muscle due to coronary artery occlusion5. Careful with dental treatment with these patients

E. BURNING MOUTH1. Many causes – psychological, nutritional, neuritis

F. BELL’S PALSY1. Abrupt facial paralysis. Drooping of corner of mouth and therefore drooling. Speech and eating difficulty.2. Self-cleansing is difficult to impossible. Automatic toothbrush.

G. CANDIDIASES (Thrush)1. Caused by fungus Candida Albicans2. Creamy, white patches which, when removed, reveals an inflamed, painful mucosa.3. Results from poor fitting appliances, poor oral hygiene, immune suppression, radiation therapy, long term antibiotics/steroids4. Treatment – Mystatin mouth rinses and oral hygiene instruction

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H. CEREBRAL PALSY1. Severe attrition, malocclusion, mouth breathing, drooling, tissue biting. Lack of normal chewing and swallowing process. No natural cleansing mechanism. Usually on soft diet.2. Use mouth prop. Allow individual to do brushing using an adaptation. Follow up with automatic toothbrush.

I. CEREBROVASCULAR ACCIDENT (STROKE)1. Third major cause of death in the elderly2. Patient may exhibit speech problems and hemiplagia3. Partial paralysis could affect oral care4. Patient’s head may be tilted to one side with “drooling” saliva5. Special and understanding care given to these patients

J. CHRONIC BRONCHITIS1. Usually persons who have lived in heavily polluted areas or are heavy smokers2. Recurrent coughing spells, with or without sputum3. Chronic inflammation can eventually cause lack of lung function

K. COMOTOSE1. Consult with attending physician2. May need mouth prop3. Brush with prescription fluoride, chlorhexidrine spray twice daily

L. DIABETES1. Approximately 2% of population is diabetic2. Is a disturbance of carbohydrate metabolism due to an inadequate secretion of insulin from pancreas3. Two main types of diabeticsa. Juvenile (“brittle” diabetic)1. harder to control – must be careful in dentistry to prevent hyperglycemia and post-operative infectionsb. Adult-onset – no real problem if patient is taking insulin and observing diet4. Overgrowth of tissue, bleeds easily, bone loss5. May require antibiotic prophylaxis

M. DOWN’S SYNDROME1. Missing and abnormally shaped teeth2. Individual may fail to profit from educational experience and instruction. Follow up with toothbrush.

N. DILANTIN HYPERPLASIA1. Overgrowth of gingival tissues2. Tx – excellent oral hygiene3. Try to avoid surgery

O. DYPSNEA1. Shortness of breath2. May be due to any number of chronic pulmonary diseases3. Patient may exhibit chronic coughing

P. GASTROINTESTINAL1. Gastritis, ulcers, diarrhea, constipation, and intestinal obstruction are common disorders

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2. Patient may compromise diet, thereby adversely affecting such body functions as healing and response to stress

Q. GLOSSODYNIA (“BURNING TONGUE”)1. May be noted especially in females aged 50 – 602. May be local or systemic factors3. Sometimes associated with Vitamin “B” complex deficiency

R. HERPES SIMPLEX1. The virus manifests clinically as multiple shallow ulcers on the oral mucosa and/or the vermillion border of the lip2. Client may eat less due to pain3. Treatment is symptomatic with the disease being self-limiting and usually subsiding in seven to ten days4. Application of Abreva (5 times per day until symptoms disappear) as treatment

S. HYPERKERATOSIS1. Presents clinically as a white patch on the oral mucous membrane which cannot be wiped off with a cotton roll or finger pressure.2. Most frequent sites are the cheeks, angles of the lips, the alveolar mucosa, tongue, lip and floor of the mouth3. Differential Diagnosis by simple observation it is not possible to distinguish pre-malignant Leukoplana from benign hyperkeratosis. The presence around the lesion border of thin atrophic mucosa must be considered highly suspicious and a biopsy is advisable.

T. LICHEN PLANUS1. An inflammatory disease of the skin and mucous membrane.2. Characterized by kerototic lesions of various patterns, lace-like – white patches on tongue and buccal mucosa.3. Tx – topical steroids or anti-fungals4. Seems to happen to nervous persons who “keep it inside.”

U. MUSCULAR DYSTROPHY1. Shifting, spreading, or protrusion of teeth. Loss of cheek and lip control. Open-bite.2. Automatic toothbrush. Sufficient time allotted for individual to complete brushing.

V. NUTRITIONAL DEFICIENCIES AND RESULTANT DISORDERS1. A major concern in geriatric patients is the presence of subclinical or marginal malnutrition.2. Symptoms may be absent or difficult to interpret.3. The deficiencies may occur as a result of:a. Primary deficiency, where there is a lack of nutrients in the dietb. Secondary (conditioned) deficiency which results from failure to absorb or to properly utilize nutrients, increased nutrient requirements, i.e.: illness, etc., or excessive exertion.4. In the geriatric patient, the process between marginal and frank nutrition is more easily precipitated.5. Nutritional deficiencies can affect the oral structures.a. Vitamin B2 (Riboflavin) deficiency can result in angular chelosisb. Chronic Niacin deficiency results in pellagra, characterized by neurologic, mucous membrane and gastrointestinal symptoms.c. Vitamin C deficiency results in general weakness, retarded wound healing, petechial patches due to fragility of capillary walls. Gingival bleeding and marked bone resorption.

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d. Vitamin A deficiency affects epithelial structures and, if severe, interferes with amelogenesis.e. Vitamin D influences tooth formation indirectly by regulating calcium-phosphorus metabolism.

W. PARKINSONISM1. Tremors in muscles of chewing, tongue, bruxing, tongue thrust, trouble swallowing.2. Instruction in toothbrushing. Will usually need assistance in brushing. Watch for aspiration.

X. PETECHIA1. A minute rounded spot of hemorrage – on the surface, such as skin, mucous membrane or serous membrane.

Y. RHEUMATIC FEVER1. A patient with a history of rheumatic fever is a candidate for rheumatic heart disease.2. Vegetations develop on the heart endocardium and, if severe enough, will prevent proper functioning of the heart valves.3. Primary medical concern is to prevent bacterial endocarditis. This is best done by prophylactic treatment with penicillin.

Z. VENEREAL DISEASE1. GONORREHEA – An infectious disease involving chiefly the mucous membranes of the genitourinary tract, occasionally the eye, with possible hematogerious spread to serious and synovial membranes in other parts of the body.2. SYPHILIS – A chronic contagious venereal disease capable of involving any organ or tissue and characterized by florid (bright red) manifestations, frequent relapses, and years of asymptomatic latency.3. Examining gloves are indicated when suspected.

AA. XEROSTOMIA1. Dry mouth – as a result of :a. Failure of saliva glands to developb. Disturbance of innervation of salivary glandsc. Systemic disease – diabetes, Vit. B Complex deficiency, post-menopause syndrome, psychic influences, aging, or irradiation2. Treatment – Symptomatic, frequent intake of fruit juices may moisten the mouth and produce some salivary stimulation.

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Thorough knowledge of preventive dentistry:

Which Includes: Fluoride, perio aid, brush, floss, keys, sealants, kids preventive are

This information, as it should be presented to the client, is contained in the two client handouts: “Kids” and “Preventive Dentistry.”

Here is some other information

1. Tartar Control Toothpastea. Advantages1. Reduce supragingiva calculus buildup by as much as 35%2. Less tenacious calculus3. Easier recall appointment (extend number of months between recalls?)4. Improved health of gums5. Better esthetics

2. Fluoride supplementsa. Background1. Ingested, fluoride replaces hydroxylions and forms fluorapetite crystals. These are smaller and less soluble than hydroxyapetite crystalsb. Sold in 2 forms1. Drops2. Chewable tablets – best if chewedc. Adjusted for water supplyd. Over consumption can lead to fluorosise. Home filtration units may receive fluoride, so sink water should be tested

3. Water Testing – Fluoricheck – cost $12a. If a child’s home has it’s own well water supply, the fluoride content must be determined before a supplement can be given.b. Discuss with parent.c. Kit contains a sample bottle in a postage paid preaddressed boxd. Results reported to parents and us by mail so we can prescribe supplement.

4. Topical fluoride (30-40% reduction in decay)a. Gel – best if patient will use it at home regularly-see section #221. Fluoride concentration APF – 12,300 ppm, Naf – 9000 ppm2. Tray application 4 minutes3. Foam – reduces risk of ingestion4. Not used in children younger than 65. Carries reduction of 21%

b. Tray – 4 minute in office at PC appointments if bottle won’t work1. Seat patient upright to minimize material swallowed.

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2. Try in F trays to assure coverage slightly past distal of last molar.3. Dispense just enough foam into tray to cover teeth when patient closes into tray.4. Have patient rinse with water to clear food debris (prophylaxis is not necessary).5. Clear saliva.6. Air dry teeth well & insert trays (lower tray first).7. Start 4 minute timer & place where both clinician & patient can see it.8. Use saliva ejector to clear excess F & saliva throughout contact time.9. Remove trays & ask patient to expectorate for 1 minute, but do not rinse.10. Instruct patient not to eat or drink for 30 minutes.

c. Topical fluoride benefit is additive – the more times used, the better, but child must be old enough to spit (not swallow)-Fluoriguard has 5 times more fluoride than Crest.

5. Fluoride varnish (available as 5% sodium fluoride = 22,600 ppm fluoride)a. Used since 1970 in Europeb. Duraphat – cover crowns after prophy for those prone to decayc. Advantages versus gels/forms (2009 Christianson)1. On teeth longer2. Higher fluoride level 22,600 ppm versus 12,000 ppm3. Less ingested4. No gagging5. Caries reduction primary dentition 33%, adult teeth 46%6. Ideally applied 4 times a year

d. Indications1. Reduce decay potential2. Reduce sensitivity3. Children 3 and younger (don’t use gel)

e. Clinical tips1. Isolate, air dry a quadrant2. Apply generously (quadrant takes 1-4 minutes)3. Apply quickly for smoothness4. Moisten cheek after application so cheeks will not pull off varnish5. Don’t cover facial of anteriors (looks better)6. Best use with 5000 ppm toothpaste, not in place of7. Client – soft diet rest of day and do not brush or floss

6. Dentrificesa. Over the counteri. 1000-1100 ppmii. Best is twice dailyiii. Can start at age 2iv. Decay reduced 24%b. Prescription

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i. 5000 ppmii. Use in place of regular dentrificesiii. Fifty-seven percent (57%) caries decrease

7. Xylitol gum contains no sugar and has an anti-caries effect

8. Chlorhexidrine rinsea. very anti-cariogenicb. reduce plaquec. toothpaste inactivatesd. kills streptocaucus

9. Power toothbrushesa. fluid dynamics create turbulence that disrupts biofilmb. avoid timer-it’s not how long (2 minutes), it’s how well

 

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Patients with Dental Fear

Some patients have fear of being in a dental office because of different things that happened in the past.

Whatever the reason may be, it is our job to make them as comfortable as possible. As the hygienist, often times, you are the first clinical personnel that this patient will meet.

1. Talk to them and make them comfortable2. Assure them that everything will be fine3. Let them know that the hardest thing for them to do was to make this

appointment. 4. We will hold their hand every step of the way. 5. Not doing a dental cleaning on this patient on their initial visit is the best

option. 6. Let them know that we will just take x-rays, look in the mouth, and the

doctor will come visit with them. 7. Let them know that we have methods to help them relax if any dental

treatment is needed.

Options:

1. IV Sedation – Administered in our office by an anesthesiologist

2. Sleep Dentistry – patient is given a prescription for Halcion

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Sleep Dentistry

Patients who choose to have dental treatment done through sleep dentistry is given a prescription for Halcion on the day that dental treatment was discussed. All dental fees, treatment, and consents should have been signed before the day of treatment. A patient who is on Halcion will not/does not remember anything, therefore, everything must be discussed and signed before the day of treatment.

Patient must be informed that:

They must have prescription filled and they need to bring the medication here on the day of appointment. They DO NOT take any of this medication at home.

Patient must have someone, other than a taxi, bring them to our office for their appointment and pick them up. We will not treat a patient who is dropped off by a taxi.

Patient must arrive at the office 45 minutes prior to their appointment time.

On the day of appointment:

They should arrive 45 minutes before their scheduled appointment time. They will bring medication with them. The hygienist/assistant will walk the patient to the operatory and seat them. The patient will give you their bottle of medication (typically 4 tabs of .25

mg. of Halcion). Make sure that the patient has not already taken any of the Halcion pill.

Place blood pressure cuff and pulse oximeter on patient. Unit should be set to automatically monitor every 5 minutes. Print out the results at the end of appointment to be scanned in to the patient’s chart.

Give patient two (.25 mg.) tabs of Halcion and a bottle of water. You may start your hygiene procedure appromately 15 minutes after

medication was given to patient.

****YOUR PATIENT MUST BE ATTENDED TO AT ALL TIMES. YOU CANNOT LEAVE THE ROOM AT ANY GIVEN TIME. IF YOU NEED

ANYTHING PLEASE USE YOUR RADIO TO CALL AN ASSISTANT TO HELP YOU!****

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Understands and Uses Nitrous Oxide

All consents must be signed before nitrous can be administered. The pulse oximeter must be placed and monitored/recorded every five minutes. The printout will be scanned in to the patient’s chart.

When not to use nitrous oxide

1. Impediments to adequate breathing2. Drug and substance abuse3. Mental disorders4. Pregnancy5. Recent middle ear surgery6. Surgical treatment to the ocular area with a gas bubble7. Conditions where gas distention is problematic8. Use of antidepressants, psychotropic drugs, sleep-inducing medication9. Bieomycin sulfate therapy10. Severe cardiac conditions11. Cystic fibrosis12. Unknown or dubious medical history or health status

Four situations to use nitrous

(1) Person is nervous…we respond… “I hear what you’re saying – we have developed ways to control that” (new patient typically).(2) Scaling/root planning patients(3) Patient appears uncomfortable during appointment(4) Recall patient that has used nitrous in past

One of our first client centered, and therefore most important, tasks to learn in this level is how to start the client using nitrous oxide. Here are the potential benefits to our client from using nitrous oxide:

1. Decreases fear (lowers blood pressure, pulse rate, and respirations)2. Analgesic3. Can easily relax and cooperate4. Time passes more quickly(slight amnesic effect)5. Reduces gagging, saliva, and tongue movements6. Muscles relax more less chance of cramps7. Won’t remember as much about appointment

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8. Contraindications1. first pregnancy trimester2. nasal obstruction3. chemical dependency4. recent eye surgery5. mental illness

What advantages to us when our client is more relaxed?

1. The less chance they will move quickly and be injured2. Treatment will go more quickly3. We are under less strain when the client relaxes4. Pride when the client says “its the best visit I’ve ever had to the dentist!”5. The office atmosphere is more calm and relaxed6. Happy clients come back and bring their friends7. Just another way to visibly show the client that we are a modern, caring office8. Allow us to use long well planned appointments

Is it safe?

1. Used in “modern” dentistry since 19602. Nitrous oxide is an inert gas that enters and leaves the bloodstream unchanged3. The client is always conscious4. No known allergic reactions to nitrous

Problems

1. Person can feel claustrophobic2. Not effective for some people3. Unmanageable children won’t cooperate4. Chemical dependent or psychiatric care clients shouldn’t use it5. People with colds shouldn’t use could pass on to next user6. Can cause an upset stomach (leading to vomiting) if dosage is too high

A. First, learn some of the history of nitrous oxide. While you are discussing whether a client wants to use it or are inducing a client it is useful information to share.1. It was discovered about 200 years ago.2. Around 1850 Horace Wells, a dentist, was watching a stage show where a “professor” induced a volunteer from the audience with nitrous. As the man laughed, he ran his leg into the side of a table and, even though his leg was bleeding, he didn’t notice the pain.3. This dentist then began to use nitrous in his practice. This was the first time doctors had a way to remove pain.4. Nitrous was used at 100%. The patient was induced and before they passed out – and within a few minutes would die of asphyxiation, the leg was cut off or the tooth pulled. Then, before they smothered, they were placed on 100% oxygen and revived.5. Later, ether and then local anesthetics like Novacaine were developed. They were easier to use

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and took the place of nitrous.6. In the 1960′s dentists began to use nitrous again, but in a different way. Instead of trying to use it to deaden pain by making the patient unconscious, they used a light level to relax the patient. This light level allowed the patient to breath 3-4 times the amount of oxygen they would get in normal air (20%). There were no known reactions and no side effects.7. Now, about 40% of dentists use nitrous.

B. What safety procedures are used?1. Color coding won’t allow reversing the twoa. Green – oxygenb. Blue – nitrous1. Size and shape of the attachments is different for oxygen and nitrous oxide.2. Flow meter to measure ventilation.3. Variety of mask sizes4. An alarm is attached at the secretary’s desk warns us when the oxygen runs out.5. All exhaled nitrous oxide is sucked away from the operatory and vented out of the building. This reduces our air concentrations from about 2000 parts per million to about 25 parts per million.6. Open operatories allow huge room air mixing.7. Nitrous oxide monitoring.8. Limit client talking9. Paddle fans must be on10. Flow meters calibrated every 5 years

C. Discussion with the client who has never used nitrous1. Perfectly safe – no allergic reactions, the weakest of all anesthetic gases.2. Feeling comes on in 3-5 minutes – and goes away as quickly (client can drive home safely)3. Won’t lose consciousness – actually controls themself – if breath through nose will get sensation, goes away if breath through mouth4. A warm, relaxed, floating sensation for most people, for some it isn’t effective, others can feel claustrophobic, recommend try it – if not like it, we’ll remove it.

D. Administering Nitrous Oxide

When you seat the client, look at his/her yellow treatment sheet. Have they used nitrous before? If they have, your questions should indicate you are familiar with their past treatment. Mrs. Brown, you’ve used Nitrous Oxide during treatment in the past. Would you care to use it today?

If this is a new client, or there is not record of nitrous in the treatment sheet, ask them differently. Mrs. Brown, (new client) have you used nitrous oxide to make your treatment more comfortable in the past? Or Mrs. Brown, (established client), in reviewing your record, I don’t see that you’ve used nitrous oxide. Would you care to use it today?

If your client asks you about it, you can say. Mrs. Brown, nitrous oxide is a totally safe method to help you be more comfortable during your treatment. There are not allergic reactions and virtually no side effects. It takes only a few minutes for you to notice the effect and it goes away

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quickly when we’re finished. It gives you a warm, light, relaxed, floating sensation. Your doctor will do everything else the same with or without you using it. If you would care to try it, I’ll start it. If you don’t like it, I’ll take it off and we’ll not use it again.

If the client prefers not to use nitrous, make a note of it in the remarks section of the client’s yellow treatment sheet.

If the client decides to use nitrous and they have used it in the past, plug in the lines, attach the suction to the ventline. Turn on the oxygen only, set the indicator at 6 liters, and then place the nosepiece on. If you put the nosepiece on before your turn on the gases, the client will have trouble breathing. Have the client adjust the nosepiece to fit snugly around the nose. Ask your client to make sure that no air is blowing into their eyes. Do NOT leave pt. unattended while on N2O for longer than 3-4 minutes.

Make sure the breathing bag is not over (cause excessive leakage around mask) or under inflated. Do not talk with the client. This contaminates the operatory. Use the lowest concentration of N2O possible to reduce the amount of N2O you could breathe. Remind your client to breathe in and out through the nose. If the client continues to breathe through mouth or talk, reach over and turn nitrous off and let the client breathe oxygen only. Do not say anything to the client. They may not even realize what you have done.

Many apprehensive clients prefer to use N2O during injections and the difficult parts of an appointment (tooth preperation, scaling, etc.). As soon as the difficult portion is finished, place the client on 100% O2. If your client uses the N2O throughout the appointment, when the appointment is almost over, the doctor will place the client on 100% oxygen for at least 3-5 minutes. After 5 minutes, the breathing bag only contains oxygen. Never use the oxygen flush button. You’ll know a client has the right amount of nitrous when your client:1. Is smiling2. Hands are relaxed3. Comfortable, pleasant4. Treatment is going well

Be sure to have one of the staff let you try the nitrous oxide so you understand the experience.

The dentist will say, Mrs. Brown, I’ve turned off the nitrous oxide. You’re breathing pure oxygen now. This should leave you feeling relaxed and refreshed, like you’ve had a good nap. Isn’t this a great way to have a dental treatment? If the client isn’t given enough oxygen to flush his/her system, they may develop a headache.

When you are introducing nitrous oxide to children, use some different words. Amy, Dr. Smith got laughing gas just for kids. They really enjoy it. Here’s what it looks like. (putting it up against your nose) It’s like what airplane pilots wear. All you do is breath in and out your nose for a few minutes. Some of the kids feel like they’re flying an airplane, others feel like a clown. I like to know what you’re feeling like. Most of the kids today have felt clowny. You tell me how you feel. It smells like a balloon.

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If a client is getting too much nitrous oxide, you will notice one or more of these symptoms:1. Not talk rationally2. Uncoordinated movements3. Uncontrolled laughing, crying4. Uncooperative, irritable5. Uncomfortable6. Nausea, sweating

Your doctor will reduce the level of nitrous by 10% and monitor him/her closely. Continue further reductions of 10% per minute until your client is comfortable.

If your client loses color, begins to sweat, increases salivation, swallows frequently, or feels nauseous, place him/her on 100% oxygen immediately. There are several causes for nausea:1. Depth of sedation2. Length of sedation3. Client’s emotional status4. How recently has eaten5. Constant changes in chair position

If your client is going to vomit, remove the nosehood. Turn the head to the side. Hold an emesis basin under the chin. When finished, put a cold compress on the forehead and replace the nosepiece and turn on 100% oxygen.

Finally, there are potential health hazards to us when nitrous is used. Spontaneous abortions, depressed blood cell formation, as well as liver and kidney dysfunction have been reported in hospital room personnel. These people are exposed in a closed room to high concentrations.

Most experts believe that exposure to 3000 hours over 10 years is a heavy exposure.

Nitrous oxide is stored in fat tissue. Therefore, the heavier a client, the more time s/he should be on 100% oxygen. Even though no studies show any damage to dental personnel, use every precaution.1. The rooms are wide open.2. We use an exhaust system that takes the waste nitrous out of the office.3. Make sure the nosepiece fits well.4. Remind the client to breath through nose.5. Turn on the ceiling fans.6. Place client on 100% oxygen as soon as possible.7. Don’t talk with client.

A. Remove client from nitrous oxide1. Start client on 100% oxygen while we still have 5 minutes left in the treatment.2. Tell the client, You have been breathing 2-3 times the amount of oxygen that you get in room air. This will leave you feeling relaxed and refreshed, just like you had a good nap. Isn’t this a great way to sit through a dental appointment?3. Don’t remove the nosepiece until your client feels back to normal.

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Some clients may shiver as they return to normal. Cover them with a blanket. They will return to normal quickly.

B. Clean up1. The outside of the nosepiece should be put in cold sterile solution.2. The inside nosepiece should be statimed after each use.

C. Extremely Apprehensive Clients

1. Premedicate the night before and then 1 hour before using one of:a. 15 30 mg Dalmainb. 10 20 mg Valiumc. 2 mg Atavand. 30 mg Cerax2. 1 Lomotil tablet 1/2 hour before appointment for those who vomit easily

D. Contra indications to using nitrous1. History of chemical abuse2. Nasal obstruction (mouth breather)3. Sever psychic problems4. Upper respiratory infection (cold, flu, etc.)5. Mentally Challenged6. Feelings of claustrophobia7. Emphysema, bronchitis

E. Maintenance1. Dailya. Listen for any poor connection to floor connectorb. Look for any cracks or wear areas in rubber goodsc. Make sure all connections are secured. All tanks secure in N2O roome. All unused cannistors covered

2. Four times per year.a. Use a soap solution to check all rubber goods for leaks. Be sure to wash soap off completely.b. Use a soap solution to check all connections in N2O room.

3. Every 10 yearsa. Return N2O head to manufacturer to check calibration.

Your Safety

Nitrous oxide is safe for clients with good health histories. The person at risk is you. A 1980 study of 61,000 American dentists and chairside assistants indicated that women assistants exposed regularly to nitrous oxide had a 50% increase in congenital abnormalities in newborns.

In our office we use every safety device to protect you.

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1. Well fitting nose pieces2. Good staff instructions3. Paddle fans to circulate air4. Open operatory design5. Scavenging system6. Waste gas is exhausted out of the building

You have learned all the necessary safety procedures. These include:

1. Make sure the mask fits well. Don’t use 2×2′s to plug spaces, find a nose piece that fits.2. Start and end the gas flow with O2 until the nosepiece is in position.3. Encourage the client not to talk and to breathe in and out through the nose.4. Use a soap solution to make sure there are no leaks in the rubber goods and connections

 

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Understands and Recommends Fluoride

Stannuous FL gel is no longer applied in the office after a cleaning. The patients can expect a 40% reduction decay by using 5000 PPM FL applied daily. The following chart shows carries reduction by fluoride concentration (study form the 80′s)

One-year carries increment results (visual-tactile exam supplemented with radiograph exam)Treatment %Reduction1100 ppm F –1700 ppm F 11.0%2200 ppm F 18.6%2800 ppm F 20.4%

Who needs the FL gel:1. All children after they are able to spit great prevention (unless parents object!)2. Kids with decay3. Adults with decay problem4. Adults with exposed roots (to prevent root caries)5. Adults with root sensitivity (to lower hypersensitivity)6. Clients undergoing radiation therapy7. Clients in braces8. Clients with reduced salivary flow9. Clients with a lot of restorative work

Application directions:1. Put FL gel on toothbrush and brush thoroughly2. Spit out no rinse, no eating or drinking for at least 1/2 hour3. The more applications the better, but bedtime is best

Insurance covers fluoride for children under 19 years on a 6 month basis.

Important facts to know about FL safety:The lethal dose ranges from 32 64 mgm FJ/kg for adults. For children the minimum dose that could cause toxic signs and symptoms is 5mgm FL/kg.

Fluoride Toxicity:Signs and symptoms acute FL toxicity include nausea, vomiting, diarrhea, abdominal pain, cramps, a weak pulse, hypotension, and pallor nerve and respiration depression and cardiac irregularities.

Emergency Treatment:Minor upsets try first to induce vomiting and then give milk or antacids and watch for several hours. Metallic ions (calcium, magnesium, and iron) in these products combine with FL to reduce absorption.

If > 5.0 mgm/kg ingested prompt hospitalization may be required, onset to acute toxicity is very rapid.

This information is important to know, but don’t scare the parent. Simply tell them: “This is a prescription item. If your child swallowed half a bottle they could get sick. Be sure to keep it out of their reach most of the time.

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Fluoride

1. In office application does not include rinsesa. Preventive1′ D1203 – child – all types of applications (also use D1203.3 for low risk fluoride varnish)2′ D1204 – adult (probably no coverage)b. 1206 moderate to high cavity risk documented1′ Adults with visible need (poor hygiene, diet, existing decay, etc.)- add narrative for coverage2′ Fluoride varnish – 1206 not to desensitize a tooth/quadrant, only a decay control (whole mouth) – covered if moderate to high risk of decay2. D9910: Desensitizing

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Helps clients stop smoking

In 1965, 40% of Americans smoked. By 1987 only 29% of Americans smoked. This means that 750,000 lives were saved from smoke related deaths. Every year the percent shrinks a little more. Someday ash trays will be as hard to find as spittoons are today.

That’s good news, but why should hygienists and dentists get involved with helping people stop smoking? Remember one third of Americans still smoke and our job is to help them improve their health not just teeth. FOR EVERY SIX SMOKERS THAT QUIT, ONE LIFE IS SAVED.

1. We see people on a regular basis. We can follow up on their progress.

2. We see them over many years. We can help reinforce the abstinence.3. Clients are used to getting health suggestions from us.

4. Since we try to develop adult relationships with people, we can be effective in this complex problem.

Look for stages of readiness for changea. No ways – Don’t want to think or talk about it. Try to plant ideas discuss benefitsb. Maybe – Interested, but haven’t tried to stop. Offer them your help.c. Trying – In the process of stopping. Encourage them, offer help if they need it.d. No Luck – Tried to quit, but started again. Help build their self esteem and confidence that they could stop if they tried again. Post failure(s) only helped prepare them for what they need to do this time to be successful. Offer help.

Point out these smoking related symptoms1. Bad breath2. Hairy tongue3. Calculus increased4. Gum disease5. Acute Necretizing Ulcerative Gingivitis someone who smokes 10 cigarettes a day has 10 times the chance of contracting ANUG6. Tooth discoloration7. Gum irritation8. Leukeplakia9. Oral cancer

We recommend Nicorette, Habitrol, or Nicoderm patches and gum to help our clients. It was first available in the U.S. in 1984.

Smokeless tobacco1. The use of smokeless tobacco is increasing2. Smokeless tobacco is not less harmful than smoking

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a. Cancerb. Gum recession with bone loss

Stop smoking clinics have a success rate of 20 35%. Also, 20 35% of people who stop, start again within 6 months. Be sure to ask how your client is doing at the next check up.

Some resources for you if you want to read more are: Nicotine: An Old Fashioned Addiction and The Smoker’s Book of Health, and http://www.smokescreen.org/ses.

What Can a Hygienist do?

Please read and learn our stop smoking brochures. Remember,a. Every year 6 out of every 10 smokers try to quit.b. Nicotine is eliminate from the body 24 hours after quittingc. Carbon Monoxide is eliminated in 48 hours

Here’s a way to approach your clients

a. Ask if they use tobaccob. Advise clients to stop1. Stress the benefits not the damages.2. Personalize the message for each client. Show them the damage in their own mouths.3. Don’t badger the clients if they don’t want to stop and document the smoking in the chart.4. Let clients who aren’t ready to quit yet know you are here when they are ready.

c. Assist the client in stopping1. Set a quit date2. Give them our handouts3. Let them know about Good Samaritan smoke cessation programs, also 1-800-QUIT NOW

d. Follow up1. Call or send a letter in 1 2 weeks to see how they are doing

e. For women only1. Why women smokei. Maintain or reduce weightii. Reduce stress, depression, and angeriii. Peers, friends, or parents smokeiv. They want to be perceived as mature, sexy, and sophisticated

2. Helping women to stopi. They need more group support. Ask them to get friends to help or sign up for a stop smoking clinicii. Learn new stress coping mechanismsiii. Reinforce teens they can be different from the crowdiv. Ugly! Yellow teeth/fingernails, bad breath, wrinkled skin around mouth, discolored hairy tongue

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v. Reproductive age damage baby, 10x risk of heart attack if on birth control pillsvi. 8 of 10 smokers begin before the age of 18

vii. 6 stages of smoke cessationa. Not intending to stopb. Thinking about it occasionallyc. Seriously planning to quit soond. Actually quit and trying to prevent relapse (average person quits 5 times before being successful)e. Off for awhile, but still fighting the smoking urge (70% relapse in 3 months)f. Free of urge to smoke

Encourage your clients to become Active Copers, not Passive Sufferers!

Here are some of the benefits when smoking stops

Within 20 minutes of last cigarette:blood pressure drops to normalpulse rate drops to normal ratebody temperature of hands and feet increases to normal

After eight hours:carbon monoxide level in blood drops to normaloxygen level in blood increases to normal

After 24 hours:chances of heart attack decreases

After 48 hours:nerve endings start to regrowability to taste and smell improves

After 72 hours:bronchial tubes relax, making breathing easierlung capacity increases

Two weeks to three months:circulation improveswalking becomes easierlung function increases up to 30%

One to nine months:coughing, sinus congestion, fatigue, shortness of breath decreasecilia regrow in lungs, increasing ability to handle mucus, clean the lungs and reduce infectionbody’s overall energy level increases

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Five years:lung cancer death rate for average smoker decreases from 137 per 100,000 people to 72 per 1,000,000 people

Ten years:pre cancerous cells are replaced with normal cellsrisks of other cancers, such as those of the mouth, voice box, esophagus, bladder, kidney, and pancreas decrease.

Smoking involve 3 factors1. Physiological2. Psychological3. Habitual

The 2 primary signs of addiction are:1. Smoke within ½ hour of waking2. Withdrawal symptoms if the person doesn’t get to smokea. Craving of nicotineb. Irritabilityc. Anxietyd. Fatiguee. Restlessnessf. Difficulty concentrating

Treatments1. Chantix (approved in 2006)a. Significantly reduce pleasure of smoking2. Nicotine patch plus nicotine gum or nasal spray3. Zybana. Doubles quit ratesb. Can be used with nicotine nasal spray

Be sure to give your clients a copy of our Quit Smoking brochure.

ALL THESE BENEFITS ARE LOST WITH JUST ONE CIGARETTE A DAY!!!!!

SMOKELESS TOBACCO

Research shows that in 1989, 15-20% off all adolescent men use smokeless tobacco. About one half of them have pre-cancerous lesions in their mouth. The chances of a smokeless tobacco user getting oral cancer, is 400% greater than non- users.

What is tobacco snuff?

1. An organic carcinogen nitrosonornicotine (NNN) which produces malignant tumors in the trachea, esophagus, liver and mouth.2. Some contain high amounts of sugar that increase blood sugar levels and TOOTH DECAY.

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3. Some contain salts for flavoring which contribute to increase risks of high blood pressure andkidney disease.

Additional Risks

Nicotine addictionHeart Problems (HBP, blood clotting problems, poor circulation and increased heart rate)Cancer (oral, palate, tongue)Teeth and gum problems

In our office we recommend the product “Mint Snuff” to clients who want to stop using smokeless tobacco. It does not contain nicotine or any dangerous chemicals so it does not help with the physical addiction, but it does help with the habit of using smokeless tobacco and the psychological dependency.

The information is kept in the third drawer from the bottom in the middle row of drawers behind room. There are brochures on the risk and samples of “Mint Snuff”.

Our job is to provide this information and support to our clients who are interested in quitting and to perform an oral cancer screening on all our patients. If we notice any keratinized tissue or pre-cancerous lesions we need to take intraoral pictures and document our findings in the patients chart. Possible biopsy.

SPIT TOBACCO

Cigarettes aren’t the only problem. Spit tobacco has as many damaging side effects as cigarettes. Chew tobacco is chewed, while snuff is held between the cheek and gums.

When helping clients to stop they have two choices1. Cold turkey – hard for most people2. Taper down- cut back by ½ your usual amount per day

Ideasa. Leave the tin at home, then throw it awayb. Use substitutes (sugar free candies, sunflower seeds, or mint leaf snuff)c. When is the need greatest and when is the habit (after meals, etc) the worse.d. Avoid being around friends/workers who use, when they are usinge. Switch to a lower nicotine brand. This makes your nicotine withdrawal easier when you quitf. Don’t start smoking as a substitute.g. Let friends/co-workers know you are quitting and you may be edgy for a couple of weeks.h. Exercise 30 minutes/day, keep busyi. Withdrawal symptoms get better after two weeksj. If you slip, go right back on your plan

Extra help

1. Nicotine replacementa. One pinch = 4 cigarettes

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b. Nicotine patch (see handout)c. Nasal spray – not as good as the patchd. Zyban – non-nicotine tablet to be used for 7-12 weekse. Support group – increases chance of success

2. When the urge hits – delay – it last only a few minutes

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Hygienist and Repetitive Stress Injuries

Carpal Tunnel Syndrome can stop your career. In some cases it can start almost immediately with no warning. It can start with pain in your fingers that later radiates up to your elbow.

The median nerve travels from the forearm into your hand through a “tunnel” in your wrist. The bottom and sides of this tunnel are formed by wrist bones and the top of the tunnel is covered by a strong band of connective tissue called a ligament. This tunnel also contains nine tendons that connect muscles to bones and bend your fingers and thumb. These tendons are covered with a lubricating membrane called synovium which may enlarge and swell under some circumstances. If the swelling is sufficient it may cause the median nerve to be pressed against this strong ligament which causes carpel tunnel.

Mild cases may be treated by applying a brace or splint which is usually worn at night and keeps your wrist from bending. Resting your wrist allows the swollen and inflamed synovial membranes to shrink; this relieves the pressure on the nerve. These swollen membranes also may be reduced in size by medications taken by mouth called non-steroidal anti-inflammatories. In more severe cases, your doctor may advise a cortisone injection into the carpal tunnel. This medicine spreads around the swollen synovial membranes surrounding the tendons and shrinks them, and, in turn, relieves the pressure on the median nerve. The dosage of cortisone is small and when used in this manner it usually has no harmful side effects. The effectiveness of non-surgical treatment is often dependent on early diagnosis and treatment.

In those patients who do not gain relief from these non-surgical measures it may be necessary to perform surgery. The site of the operation is made pain-free by local anesthesia injected either into the wrist and hand or higher up in the arm. This may be done by your orthopedic surgeon or an anesthesia doctor. The surgery itself is called a “release” – cutting the ligament that forms the roof of the carpal tunnel to relieve the pressure on the median nerve. The surgery is usually performed in an outpatient facility and you are generally not required to stay overnight.

Your doctor can explain to you the likelihood of non-surgical or surgical treatment based on your own individual circumstances.

Symptoms

1. Wrist pain radiating up the arm to the shoulder2. Swelling and tenderness in forearm3. Numbness, burning and tingling in thumb, index, and long finger that can be reproduced by bending the wrist down for one minute4. Clumsiness, weakness5. Hand pain at night6. Morning stiffness7. Decreased range of motion8. Deformity

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9. Cramping10. Difficult to make a fistIf you notice any of these symptoms, tell Patty or Dr Smith immediately. Do not ignore thesesymptoms. Early intervention may avoid surgery.

Risk factors in dentistry (for most cases, there is no known cause)

1. Poor positioning or same posture for long periods of time2. Mechanical stress from small diameter instruments3. Tug-back from cords4. Ill fitting gloves5. Repetitive movements of hands or wrist for long periods of time without breaks6. Arthritis, Diabetes7. Thyroid gland imbalance8. Using fingers rather than hands9. Menopause or other hormonal imbalances10. Pregnancy11. Dull instruments12. Vibration from ultrasonics while using tight grasp and poor wrist position

Reduce the risks (See #3 in this level)

A. Reduce grip force1. Use large handled instruments to reduce grip pressure2. Practice a light grip3. Keep instruments sharp4. Use proper fitting gloves5. Polish selectively

B. Change body position often to reduce fatigue1. Periodic stretching exercises2. Don’t schedule an STM for longer than an hour

C. Alternate vibrating and hand instruments to reduce vibration in hands1. Use ultrasonics as much as possible2. Hand instruments designa. Wide diameter, hollow textured handlesb. Pick a weight that feels right to you

D. Properly fitting gloves are very important1. Avoid tight fit at wrist and fingers2. Don’t wear expandable wristband watches

E. Proper instrumentation1. Limit wrist and finger motions

These are the standard concerns noted in hygiene. Can you think of any other risks?

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Types of musculoskeletal disorders

A. Cervical Myofascial Pain Syndrome1. Symptomsa. Neck pain and stiffnessb. referred pain and sensory disturbances2. Treatment Recommendationsa. Ergonomic changesb. Analgesic medicationsc. Modalities for the relief of muscle tightnessd. Physical therapy with an emphasis on stretching

B. Rotator Cuff Tendonitis (caused by working with elbow too high)1. Symptomsa. Shoulder pain especially with overhead activitiesb. A feeling of shoulder weakness secondary to painc. Interference with sleep secondary to paind. Cracking sounds in shoulder when arm moved2. Treatment Recommendationsa. Anti-inflammatory medication, rest, strengtheningb. Modification of activities to specifically avoid shoulder internal rotation and excessive overhead reachingc. Subacromial steroid injection

C. Lateral Epicondylitis (tennis elbow) muscles that pull wrist upwardSymptomsa. Pain over the lateral epicondyle region especially when you make a fist, turn forarms down, when elbows are straight2. Treatment Recommendationsa. Tennis elbow counterforce braceb. Wrist splintsc. NSAIDS, ice, rest,d. Corticosteroid injection into lateral epicondyle regione. Physical therapy for pain-relieving modalities and wrist extensor strengthening3. Prevention- exercise program to strengthen muscles

D. Medial Epicondylities (golfers elbow)- muscles that pull wrist downward1. Symptomsa. Pain over medial epicondyle region especially during activities2. Treatment Recommendationsa. Tennis elbow counterforce brace worn over medial epicondyle regionb. Wrist splintsc. NSAIDS, ice, rest, avoid movements that increase paind. Corticosteroid injection into lateral epicondyle region

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e. Physical therapy for pain-relieving modalities and wrist flexor strengthening3. Prevention- exercise program to strengthen muscles

E. De Quervain’s Tenosynovitis (caused by repetitive use of thumb1. Symptomsa. Aching discomfort along the base of the thumb (worse with ulnar deviation of the wrist)b. Occasional pain migration into forearm2. Treatment Recommendationsa. Eliminate wrist ulnar deviationb. Temporary use of thumb splint (6 weeks)c. Corticosteroid tablets or injectiond. Surgical release of tendon sheath (refractory or recurrent cases)

F. Carpal Tunnel Syndrome1. Symptomsa. Pain tingling, numblessb. Finger/hand incoordinationc. Rapid onset hand fatigued. True hand weakness (severe cases only)e. Nocturnal symptom exacerbationf. Positive flick sign2. Treatment Recommendationsa. Ergonomic modification (change your technique)b. Wrist splintc. Analgesic medicationd. Vitamin B6e. Corticosteroid tablets or injectionf. Carpal ligament release surgery (refractory or recurrent cases)

G. Cubital Tunnel Syndrome1. Effects that ulnar nerve where it crosses the elbow (funny bone)2. Symptomsa. numbness or weakness in little finger or forth finger3. Treatementa. Elbow pad during the dayb. elbow spling (limit to 45% angel of motion ) to wear at nightc. Surgery as a last resort

H. Arthritis1. Usually begins in middle age or older2. Repetitive actions make it worseI. LupusJ. Gout

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Conservative Treatments

1. Temporary work applicationsa. Rest allows the swollen and inflamed synovial membranes to shrink, relieving pressure on the nerveb. Exercisesc. Aspirin or ibuprofen to reduce inflammation

2. Professional help – reversiblea. Refer to a healthcare professional1. Evaluation – we will provide any needed informationa. description of your tasks and potential repetitive stress hazardsb. available work restrictionsc. a copy of the OSHA proposed standardd. offer for health care professional to perform work place walk through2. Management3. Follow up4. Written opinion to you and a copy to HealthParka. opinion about medical condition related to your injury and what job hazards might havecaused itb. any health condition not related to injury should not be included in the reportc. any temporary work restrictionsd. any other physical activities that could aggravate this injuryb. Hand/wrist brace to wear all the time or at nightc. Cortisone injections (quick improvement, short duration)d. Physical therapy – ultrasound, cold packs, electrical stimulation

3. Usually an OSHA reportable incident ifa. lasts 7+ consecutive daysb. lost 1+day of workc. cannot do all work functions

Work restriction continues until1. You are cleared to return to full time duties2. Your job is modified to eliminate the injury producing situations3. 6 months have passed4. Pay during this period will be determined

Surgery1. Usually done on an outpatient basis2. Local anesthesia3. Cut ligament that forms roof over carpal tunnel to relieve pressure on median nerve4. Expect 6 8 weeks before you could return to work

You currently1. Understand that repetitive stress injury risks

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2. Have reviewed with team leader recommended approach to avoid these injuries3. Have discussed any ideas to reduce these potential injuries

_____________________________________ _________________________Teamleader                                              date

 

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Understanding Tooth Decay

Most of us grew up believing they should get their teeth cleaned twice a year. People are surprised to learn that this honored interval wasn’t developed by dentists. Here’s the story:

In the 1930′s the most popular radio show was “Amos and Andy.” The show was sponsored by Ipana toothpaste and they finished every show “Brush your teeth twice a day, see your dentist twice a year”. In the prefluoride 1930′s when decay was rampant and most people were constantly getting decay, seeing a dentist twice a year allowed the dentist to do fillings quickly enough to at least not lose teeth due to huge cavities.

Today, this 30″s approach to continual repair makes no sense. Using our new concepts of Minimally Invasive Dentistry, you will take over responsibility for your own health. In fact, today we know that you brush your teeth not to clean them, but to:1. Disrupt the plaque2. Deliver chemotherapeutic agents

The healthier you are, the fewer services you need from us. This has several advantages for you:1. Save money2. Less drilling3. Your natural teeth will last a life time

A 2003 study by Data Analysis center based on 77 million claims submitted to the Delta Dental insurance company shows that a filling placed in a permanent tooth for a 10 year old child will end up costing this person on average over $2,000 by the time she/he is 79 years old and $1,000 by the age of 40! There are several reasons for this huge cost.

The Tooth Death Spiral

1. The filling needs to be replaced as it wears outa. Tooth colored fillings in 7-10 yearsb. Silver fillings in 10-15 years

2. Each time a filling is replaced, more of the surrounding tooth is lost and the tooth becomes weaker. As a result the new filling won’t last as long.

3. Eventually this large filling can:a. Allow the tooth to break, requiring a crownb. Lead to an abscessed tooth requiring a root canal

4. Finally, if the break down continues the tooth can be lost requiring major treatmenta. Implantb. Fixed bridgec. Removable appliance

To control the decay you must understand how decay works.1. Decay is an infectious, communicable bacterial infection caused by only 2 types of bacteria that produce acid that dissolves tooth structure.

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2. Before decay creates a hole (cavity) in the tooth, it can be healed. In fact, teeth are constantly being attacked by acid and healing themselves many times each day.

The bacteria in the plaque around the tooth eat the available sugar and make acid. The acid begins to dissolve the calcium and phosphorous out of the tooth, leaving a white area of initial decay. In the past, we thought decay was a continuous process. The longer we waited to cut out the decay, the worse it got. Now we know how to reverse this process. However, if the decay is not reversed, the acid weakened area of the tooth will collapse, creating a cavity which must be restored.

There are 4 steps to controlling decay risk:1. Acid producing bacterial control2. Reduce your risk level3. Remineralize (heal) decayed areas that have not yet created a hole in the tooth. When the pH is above 5.5, the calcium and phosphorus ions in saliva begin remineralization.4. Follow up and maintenance.

In the last century, patients worried about getting cavities. Today, in the 21st century, we treat decay as a process – and a cavity is the last step in the process.

So treating decay has moved from the 19th century model – see it, cut it out, to the 3 step 21st century model.1. See the decay2. Determine if it can be healed or not3. Determine if more areas of decay might occur

MOST IMPORTANT! DO NOT PUSH AN EXPLORING POINT INTO AN OCCLUSAL GROOVE WITH ANY FORCE. You will very likely create a cavity that now cannot be remineralized.

In 2005 you will begin to see a new term in dentistry – Caries Management By Risk Assessment (CAMBRA). Teeth mineralize and demineralize at least 2-3 times everyday due to:1. rise/fall in pH in the mouth2. calcium and phosphate level in the saliva3. fluoride available on the tooth surface

In fact, a tooth that has had an acid attack and then healed itself is stronger than a tooth that hasn’t been attacked.

Techniques we use to detect decay: We currently do not use the Diagnodent or any other unit to detect decay.

1. Color/texture (in order of severity) of the tootha. White shiny, smooth, hard – inactive lesion (no intervention needed)b. Brown/black areasc. White to black areas that are chalky- Chalky, rough to the explorer = active lesion that probably can be healed (no intervention needed)

2. X-raysc. Occlusal-must progress 3mm below surface to see3. Explorer

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Characteristics That Affect Decay

1. Saliva (increased saliva raises pH, adds Ca, K, and H to teeth, flushes carbohydrates)a. Quantityii. Unstimulated – invert lower lip, dry with 2×2, should see saliva in 60 seconds.iii. Simulated – chew gum, spit into cup, 4ml + in 5 minutes (.7ml/minute)b. Qualityiv. Consistency – watery, not ropeyv. pH 5.5+ buffers acid (the higher the number the more basic the better)vi. level of strep mutans and lactonacillic. Diagnosis – evert lower lip, dry with gauze, should take 30 seconds to see more saliva beads2. Cariogenic bacteria (those that create acid) – mainly lactobacilli and s. mutans – will be tested in the future.3. Fermentable carbohydrates (sucrose, glucose, fructose, starch) support bacteria – diet diary4. No fillings needed in more than 2 years5. Home oral hygiene6. Cavitation or x-rays showing decay penetrating the enamel. These areas need to be restored7. Sugar drinks/snacks more than 3 times/day

Currently, 50% of the fillings done in general dental practice are due to reoccurring decay. In controlled clinically studies it’s 2-3%. The huge difference is because most dentists don’t bother to show the client how to heal the decay and prevent the further tooth destruction around the restoration.

Treatment

Today, we will use the medical model to try to heal the infection. In the medical model symptoms lead to a diagnosis than a treatment regimen is established to heal the infection. When all remedies fail, surgery is discussed.1. Fluoridated water2. Fluoridated toothpaste/mouth rinse3. Fluoride varnish4. Chlorhexidrine5. Xylitol6. ACP

According to current research and technology, dental caries is identified as an infectious multifactorial bacterial disease dominated by streptococuus mutans and generally followed by an increase in Lactobacilli. A carious lesion is initiated by the demineralization of the inorganic component of the tooth, which is accompanied by disintegration of the organic portion from acids generated by the attached dental plaque. The viability of the bacteria is regulated by the frequency of refined carbohydrates intake and the failure in controlling plaque accumulation on the tooth, which allows the bacteria to remain and flourish.

The carious dentin lesion is characterized by two distinct layers with different ultramicroscopic structures and chemical compositions. The external layer is heavily infected by micro-organisms. This outer “infected dentin” layers has collagen fibers loosened by an irreversible breakdown of the intermolecular cross-links that consist of denatured and unstructured enamel and dentin debris.

Underneath the infected layers, the inner carious dentin layer (or “affected dentin” layer) consists of a zone of demineralized dentin containing solid collagen fibers with an undisturbed molecular structure. The original dentin tubules are present and supported by a collagen matrix. Although this layer is

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comparatively free of microorganisms, it is often demineralized by the acids generated from bacteria in the infected layer. Removal of the first layer of infected carious dentin eliminates the viable microorganisms and the destructive demineralization process, thus preserving the remaining dentil tissues. Understanding the carious process allows for proper diagnosis and treatment of the disease and provides maximum protection of sound issue.

Today we use CAMBRA (Cavies Management by Risk Assessment) to decide how aggressive we will be in attacking a clients decay. There are 2 phases1. Assess client’s cavies risk2. Treatment intervention

There are the 21st century steps we will take in our intervention

A. Restorations1. Minimal treatment sequencea. Enamel chip – Bond with compositeb. Enamel dentin chip – bond with compositec. Enamel/dentin chip with exposure – pulp cap, then bond with composited. Decay on margin of filling1. cut out and repair2. use sealant on open margins3. polish away small areae. Veneeri. save as much tooth as possibleii. use 3.5 mm depth gaugef. Crowng. Build up to support crownh. Endo/post/core/crowni. Implantj. Bridgek. Partial denture

2. Restore cavitated areas with materials containing fluoride whenever possiblea. Severe decay/dry mouth – keep margins of crown below the gum lineb. Certainty of decay progressionc. Esthetic concernsd. Functional concerns

3. Sealants used fora. Deep grooves, inactive white, brown or black spotsb. Open margins of decay free old fillings can be sealed to extend their life

4. Amalgams accumulate less plaque and the plaque is less cariogenic than on composite

5. Ditched amalgams are almost always decay free. The fact that you can stick an explorer in the ditch has no diagnostic value.

6. Characteristics of recurrent decaya. Softening of tooth surface

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b. Discolorationc. Wetness

7. Salvage existing crowns/bridgesa. small chips – smooth and polishb. large fractures – redo crownc. decay around crown margins1. X-rays won’t show extent of decay since X-ray won’t penetrate metal or some cores2. Procedure – anesthetic, round bur to clean out decay, Se-bond, amd. bridge loose on 1 end – cut it off

B. Chemotherapeutic approaches1. By 2015 we should be able to test for decay causing bacteria, in the meantime we will observe the results of their activity and make assumptions.2. Treatment steps     a. 12% chlorhexidrine (CHX) mouth rinse1. ½ ounce swished for 30 seconds twice daily2. Fluoride and sodium lauryl sulphate neutralize CHX, so wait 30 minutes after CHX before brushing3. Decay causing bacteria are very sensitive to CHX4. When CHX is stopped, the decay causing bacteria returns to normal levels in 3-6 months.5. CHX should be used for 1 week, the switch to fluoride paste for 3 weeks. This will help prevent the CHX from staining the teeth.6. Stop when cavities activity controlled

    b. Fluoride varnish (Duraphat) – least important factor (optional)1. Decay reduction of 38% when applied 2-4 times annually2. Clean teeth with brush/floss, isolate a quadrate with cotton rolls, wipe with gauzes 2×2′s apply varnish, let set for 2 minutes, even if in contact with saliva.3. After application:a. No eating for 2-4 hoursb. Do no brush/floss until next morning

     c . Xylitol1. A unique, natural 5 carbon chain carbohydrate found in fruits/vegetables (all other carbohydrates are 6 carbon chains) that cannot be digested by decay causing bacteria to produce the acid that demineralizes teeth. Tastes like sugar2. Some studies show that Xylitol actually helps remineralize teeth3. 2 pieces of gum or 3 mints should be used consecutively for a total of 5 minutes, 5 times daily4. The higher the Xylitol content, the more effective it is.5. Mothers who used Xylitol regularly had children with less decay.6. Using Xylitol and prescription strength fluoride increased the resistance to decay by almost 74%7. Bacteria ingesting Xylitol does not create plaque that can adhere as well to the sides of the teeth (easier to clean off).

    d. Diet1. Substitute non-sugar items for worst sugar offenders2. Substitute xylitol where possible for sugar snacks

e. Fluoride prescription1. Advantages

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a. Reduces decay causing bacteria in the plaque.b. Slows enamel decayc. Heals enamel attacked by decay by formation of fluorapatited. Modifies surface of enamel so plaque doesn’t stick as well

2. Choicesa. Toothpaste (5000ppm) 2x/dayb. Custom tray – (5000ppm) for 5 minf. Low saliva Rate (See Dry Mouth Handout)g. Calcium-phosphate toothpaste – less importanth. Glass ionomeeri. Acid resistant

Recall Interval Based on Decay Potential

A.) Severe risk of decay1. Concernsa. Every 3 months to clean your teeth and review your progressb. Decay x-rays annually

c. Current decayd. Obvious plaque/gum diseasee. Inadequate salivaf. Irregular dental cleaningsg. Frequent sugarh. Poor OH

2. Interventionsa. Brush on prescription fluoride – use before bed, spit, don’t rinse – a 40% decay reduction (3 weeks each month)b. Chlorhexidrine mouth wash – rinse for 30 seconds, spit, spit – use the 4th week each month in place of your fluoride prescription, paste. Use Colgate Total for this week.c. Electric toothbrush – more effective than a hand brushd. Diet review – final 1-2 high sugar food/drinks and substitute non-sugared productse. Use xylitol products – reduce decay 38-45%f. Your preventive care appointments with us.1. Every 3 months to clean your teeth and review your progress2. Decay X-rays annually

B.) Moderate risk of decay1. Concernsa. Decay in last 2 yearsb. White spot lesionsc. Gum diseased. Ortho appliances

2. Interventionsa. Brush on prescription fluoride-use before bed-brush, spit, don’t rinse-a 40% decay reduction (3 weeks each month).b. Chlorhexidine mouth wash-rinse for 30 seconds, spit use the 4th week each month in place of your

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fluoride prescription, paste. Use Colgate Total for this week.c. Electric toothbrush-more effective than a hand brush.d. Diet review-find 1-2 high sugar food/drinks and substitute non-sugared products.e. Use xylitol products-reduce decay 38-45%f. Your preventative care appointment with us1. Decay x-rays annually2. 6 month cleanings – just like in the 1930′s

C.) Mild risk of decayYou still have a potential for decay, but you have several recalls with no problems. Your recall interval will begin to stretch out from 6 months toward once annually. This will reduce the cost of your dentistry by 50%.1. Brush on prescription fluoride-use before bed-brush, spit, don’t rinse-a 40% decay reduction2. Use xylitol products-reduce decay 38-45%3. Your preventative care appointment with usa. Every 6-12 months (varies)b. Decay x-rays every 2 years

This client handout will help you understand xylitol’s role.

Xylitol – Epic

Xylitol is one of dentistry’s newest, best decay fighters. European studies over the last 20 years show xylitol reduces the potential for decay by 30-60%, if it’s used for 5 minutes, 3 times per day. It also has 40% fewer calories than sucrose sugar.

The advantages of xylitol are:

1. As sweet as sugar2. No bitter tastes3. 40% fewer calories4. Can be used in cooking5. Reduces the number of decay causing bacteria6. Helps heal decayed areas7. Reduces the ability of plaque to stick to the sides of the tooth (easier to keep clean)8. Is a natural sweetener found in many fruits and vegetables9. Increases the effectiveness of chorhexidrine mouth rinse10. Many be an alternative to sealants11. Can be used as substitute for sucrose sugar

Unfortunately, xylitol is expensive compared to sugar and other sugar substitutes. We recommend xylitol for our patients, but due to the expense our healthiest group may choose to not use it. Everyone else will save money since one of our smallest fillings would cost almost as much as a year’s supply of xylitol.

Xylitol is manufactured in 2 forms

1. Gum advantagesa. Stays in mouth at least 5 minutesb. Increases saliva flowc. Improves acid buffering of saliva2. Mints (must suck, not chew)

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Epic offers $35 first order free (plus shipping and handling). This offer is only available if you sign up at HealthPark. We will give them your telephone number so you can get the $35 offer and they will call you to answer your questions and outline their program of regular use of their xylitol.

Here are Terms of the Epic Agreement.

1. You begin or have had a thorough evaluation in our office within the las 2 years2. Thoroughly clean your teeth3. You buy/use xylitol as recommended daily4. You return on time for your regular recall appointments

IF YOU GET A CAVITY AFTER YOU START THIS PROGRAM, THEY WILL REFUND ALL THE MONEY YOU SPENT WITH THEM IN THE LAST 12 MONTHS.

Notes

1. Safe to use during pregnancy.2. Mothers using xylitol 3 months after delivery reduced decay in her child by the age of 2.3. Not to be used by children under five years old.4. Caution – using more than 20 grams of xylitol at one time or 65 grams per day may cause diarrhea.5. Other products have xylitol, but to be effective, it must be the first ingredient listed.6. Fluoride and xylitol can be used together.7. More information www.epicdental.com, 1-866-920-42008. Start with 5 year old children.9. 2 grams 5 times per day for 3-5 minutes provides maximum protection (number of times more important than number of grams)

Other companies selling xylitol. Xylitol must be listed as the first ingredient to be effective.

A. Available at commercial outlets1. Carefree gum – Nabisco2. Tic Tac – silvers3. Trident Advantage – Warner Lambert4. Everest, Stat Alert – Wrigley5. Koolerz – Hershey’s

B. Available for bulk purchase1. Epic – $35 free offer: www.epicdental.com pr at 1-800-920-42002. X clear Thera gum 40% discount for bulk 1-800-920-3386

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FINAL NOTE

If you are not sure about any information listed in this manual, please talk to your supervisor!

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