Arrange the following seven steps in the educational process in their correct order.

. Expressing

needs

. Stimulating motivation
. Recognizing needs

. Evaluating results
. Reinforcing learning

. Acting to achieve goals

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Educational Process:

. Step 1: recognizing

-the for treatment needs. Then the dentist hlps the patient to recognize his own needs.
.
.

needs

dentist recognizes educational needs as he checks

-the patient to state his own needs.

Step

2: expressing

needs

dentist records educational needs and helps the

motivation arouses and maintains interest. The Step 3: stimulating motivation dentist may appeal to imer needs or use artificial stimuli.

. Step 4: setting goals

They must be meaningful, attractive

.
Step 5: acting to achieve goals

these may be short-range or long-range guides to

activiry

and attainable.

should be directed toward specific goals.

activity is necessary to leaming. The activity

. Step 6: reinforcing learning

-review

and repetition aid in retention

oflearning.

this aids in judging what the patient has learned and Step 7: eyaluating results how effective the dentist's teaching has been. This can help clariff or redefine the
goals.

Note: Keep in mind that each leaming situation won't follow these steps in exact sequence. but most situations will include all ofthe steps in some form.

. Needs are driving forces that prompt

person to act

. The

process of leaming is continual and multiple

as a person attempts to

. Leaming occurs
. Telling

satisff his needs

a person what he needs may convince him that a behavior change is desirable

. Expressing

needs helps to pinpoint them for the dentist and patient

as important as recording treatment needs

. Recording educational needs can be

.

All ofthe above statements

are truc

CoplriSht O2011,2012 - Denral Dcks

. The first statement . The first statement

is true; the second statement is false is false; the second statement is true

. Both statements are true

. Both

statements are false

CoplriSht O 201 I,20 l2 , Dental Decks

Remember: in terms ofneeds and learning:

'Motivation stimulrtes
. . . . . .

a pcrson to act

on his needs

. Motivation is a fundamental part of every learning situation . Motivation may be artilicial o. built-in
Neds and goals may provide motivation Patients rarely leam without some kind ofmotivation

Motivation arouses and maintains interests

less remote and more e|sily attained Goals should be attrrctive and attainable in ordcr to bc meaningful

Short-range goals are

Goaldirected activity is ncccssary forlearning

Stratcgies for behNvior chenge:

. Assessment: in ordcr to changc a bchaviof you must first asscss thc bchavior. This should includc thc following: - Identify the problem - Consider motivation - Consider reqdiness - Consider willingness to ch&nge - Considcr ability to change - Collect baseline data - As the plan is implemented, continually reassess the bchaviorto monitor thc progrcss Behavioral strategies: ' Altering antecedants/stimulus control: RememberBehavior theory (ABC nodel)- Behavior is sandwiched bctwcen Antecedants (onrcs belbrc the beh@iorl and Consequences /d stimulus thdt o es ajier d behavior).

fd

rrirfrlrs t dr

. Shaping (stimulus-response theory): Remember: Operant conditloning (theor.r- ofB. F S&i/,ner- Changes in behavior are tbc rcsult ofan individual's response to cvcnts (stirmr) that occur in the environmcnt. Whcn a particular Stimulus-Responsc (S-R) pattem is rcinfbrccd f/e o/d?r/r, the individual is conditioned to rcspond. The Premack principle: The principle states that a prefefted behavior may bc an eflective rcinforcer ofa less prcfcrred activity. . Allering consequences/providir g feedback

Behavior can be defined as a determined, purposeful unit of activity. Each term can be further examined:

. Determined: the assumption that behavior is lawful and has determinants . Purposeful: the assumption that behavior is goaForiented, that it seeks to achieve

. Unit of activity:
elements

positive and reduce negative need or motivated states what a person does that can be reported or described as discrete

Example: Teeth do not behave, individuals do. Observing that a pulpal or periodontal problem exists is a common behavior for the dentist. Avoiding the dentist, even though an objective need exists and the patient requires treatment, is a common behavior for patients. Both meet the criterion ofbeing determined, purposeful units of
human activity.

Beha!'ior management is the means by which the dental health team effectively and efficiently performs treatment for the patient and, at the same time, instills a positive
aftitude.

. Postue . Facial expression

. Eye contact
. Body position (physical proximity to another)

. Gesticulations

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. Operant conditioning
. Classical conditioning . Observational leaming

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Eyes should be directed toward the patient and engage the patient's eyes as frequently as is comfortable for the talker and the listener

Communication is basic to all aspects ofthe dentist-patient relationship. Without proper communication, whether it be verbal or nonverbal, the dentist-patient relationships will fail.
Components of nonverbal communicationl

Touch Proximity . Postur and orientation

. .
. Body movemcnts and

. Facial expression . Gaze and eye contact

. Paralanguage
appearance

gestures . General

Note: Nonverbal communication is continuous. automatic. rich. and subtle. Rememberi "Acceptable" nonverbal behavior varies with age, sex, ethnic background, geographical
region, culture and situation. Whcn presenting treatmentplans always use open-ended questions (those that ca hot be answered with a simple 'j,es't or'rol?. These types ofquestions are the most elTective in helping patients to express their understanding ofthe proposcd treatment plan. When reviewing oral hygiene, havc the patient repeat what you have gone over with him or her When communicating with childrcn, try to reinforce positive behavior by telling the child exactly or specifically what he is doing well.

Listening techniques: paraphrasing (repeatihg ih one s owh \4,o/ds, that someone has said), interpret^tion (identi.fr,ing the uhdellyihg tteason for a communication), and prep.ratio'l (preparing to listen hy setting aside appropriate tine for discussion, fi ee from distraction).

....,
I
.

Nofe4,

*-- -_

l. Empathy involves the ability to experience the feelings ofanother individual. or "to walk in their shoes." It is very important in the dentist-patient relationship. 2. Rapport is a mutual sense oftn:st and openness betwecn individuals. It also is very important in the denlist-patienl relationship.

I Prt'tu i!"d",.

-l.+
r|l

[F*r "".d",

(t.coidilioosd3liftuius)

{uiconditionede.ron6)

Pahful intaatilal

rcu

oracr

t lx*:g:"":j
(Neulral alimubs)

A stimulus leads to a response. Ifindividuals in white coats are the ones who give painful injections that cause crying, the sight ofan individual in a white coat soon may prcvoke an outburst of crying. Ifthis is not reinforced, the conditioned response will no longer occur This is referred to as extinction ofthe conditioned behavior: Example of chssical conditioningi
(Schenatic on the left)

Olr'tisr witr syrira

(Co.rdlaoned sltlnulxs)

fF*-'*.d't

A. Before conditioning a painful injection would elicit a fearful reaction. B. During conditioning the neutral stimulus ofthe dentist with the s)'ringe is linked together with the painful injection. C. After conditionrng the denlisl \ ilh a s)Tinge

(6o.rdi{ond tespome)

will

encourage a fear reaction.

Operant Conditionilg is the term used by B.F. Skinner to describe the effects ofthe consequences of a panicular behavior on the future occurrence ofthat behavior. There are four types of Operant Condirioning: Positive reinforcement, Negative reinforcement, Punishment, and Extinction. Both positive and negative reinforcement shengthen behavior while both punishment and extinction weaken behavior.

Observationaf fearnitrg (modeli g) is acquired through initiation ofbehavior observed in a social context. There are two distinct stages in observational leaming: acquisition ofthe behavior by obsewing it and the actual performance ofthe behavior Having an open dental office design may aid the dentist in this method. Children can watch other cooperative children and this may rub offon them.
pected to leam a mode ofbehavior

Remember: Relative maturity modifies expectations ofa child's behavior in that a child cannot be exuntil he has matured to a stage at which he is ready for such leam-

inu.

. Destructive aggression

. Inward aggression
. Constructive aggression

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Coplright O 201l-2012 - Denral Decks

. Direct question . Probing question . Laundry list question

You are not afraid ofneedles, are you?

How are you doing with your brushing and flossing? How are you? Is it easier to hold the brush this way? What else did you notice about your gums?
Is the pain throbbing, aching, dull or sharp?

. Open-ended question . Leading question

. Facilitating question

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Constructive aggression is an act of self-assertiveness in response to tion for purpose of self-protection and preservation.

a threatening ac-

Inward aggression is destructive behavior that is directed against oneself.

Note: An aggressive personality is
a

personality with behavior patterns characterized by

initability, tantrums, destructiveness or violence in response to frustration.

. Direct question

"**
***

it easier to hold the brush this way? These types ofquestions ask the patient for a specilic bit ofinformation.

-Is

. Probing question

lse did you noticc about your gums? -What Thse types ofquestions ask for more specilic info.mation thatthe patient offers spontanously.

. Lauddry list question the pain throbbing, aching, dull or sharp? -ls *** These types ofquestions ask the patient to respord from among a list of altemative adjectives or descriptions provided.
ar you doing with your brushing and flossing? These trpes ofquestions request information in the patient's own words and specify a general content area,

. Open-ended question

***

-How

. Leading question

***

These types ofquestions entice

"You are not afraid ofneedles, are you?" a patient to answer a specific way.

. Facilitating question

***
\ote:

are you?" -"How These types ofquestions encourage the patient to say more,

without specirying

an area or topic.

Thcse are all verbal communication behaviors.

a

\\'hen communicating with

patient be careful with the following verbal techniques:

. Presuming - Instead: ask rather than presume . Interrogating/probing - Instead: carefully inquire

instead ofasking very direct questions . Abstraction/vagueness - Instead: be as specific as you can . Giving advice - Instead: provide information and educate the patient so that he or she may make an informed decision . Providing reassurance - Insterd: provide accurate information, fully discuss any patient concems or questions, and offea support

Important: Professionalism is an essential component ofthe dentist-patient relationship. It is characterized by confidence, carc, wamth, and appropriate ethical, professional behavior

. The "know-it-all" patient . The anxious patient

. The shy patient . The talkative patient

. The stubbom patient

8 Copright O 201l-2012 - Denhl Deck

. Neglectful . Overprotective . Manipulative . Hostile

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Dental anxicry is probably thc major management difficulry for dentists. Anxiety refers to a h)?othetical psychological construct which is: . Anticipatory . Associated to a specific event (but not al^,ays)

. Unpleasant to experience; and . Takes time to dissipate

Some !hing! lo do ro reduce patienr anxiety:

Explain procedures before doing them

children

Use the Tell-Show-Do method, particularly with

. Forewarn aboul rhc possibilitv ofpain . Let patient know how long the procedure should take
. Give patient some control over the procedures and pain fe.s'., ,"dise your hand iftoufbel anything) . Acknowledge that you understand that they are neryous and will do eve44hing possible to make them comfortable . Build trust between you and the patient Cognitive-behavioral interuentions to reduce patient anxiety:

I "..,. . '*'

. Diaphragmatic breathing . Systematic desensitization . Progressive muscle relaxation . Biofeedback . Guided imagery with diaphragmatic breathing . Use praise . Hrpnosis . Use distractions fmusi., rideos, etc.) . L Most dentists say that they themselves become anxious with an anxious patient. \otsi 2. Most patients who are anxious have had a traumatic experience in a dental or medical
setting

will give a good indication whethe. a patient is feeling pain during dental treatment. 4. Continually assess the level ofpatient arL\iety throughout their heatment by using SUDS (subjecti'e unit of distress scale/, asking patient to rate their lcvel ofanxiety form 0 frone at all) to 10 (the highest he or she has ewr experienced).
3. Watching a patient's eyes or eyebrows

These demanding attitudes usually start with appointment times and can extend to directing the course ofdiagnosis or treatment.

***

insist on remaining with the child in the dental op-they eratory regardless ofthe situation or age ofthe child. Note: Pointing to the lack ofapprehension ofa young child and the importance ofestablishing one-to-one relationship between the child and dentist usually satisfies most overprotective parents.

. Overprotective parents

. Hostile parents they to curiosity, but distus,.

. \eglectful

question the necessity for treatmefi (this is usl!.tllj, not due

parents they fail to maintain appointments, miss recall visits or do not o\ersee oral hygiene ofthe chilc. \oteg -*-;-::

1. Overprotective parents usually have children who are shy, docile and manageable. 2. Children with defiant behavior are usually said to be stubborn or spoiled. 3. For children who are hostile or angry, tly to identify the underlying source of these emotions (this holds true for adult patients as well).

A panic reaction is a special type of fear, sometirnes regarded

as a

"fear offear itself."

Someone who experiences fear will not necessarily be anticipating a negatiye event, their response will occur at the moment th

unpleasant vent

(e.

g.,

pain) occurs.

. The first statement is true; the second statement is false

. The first statement is false; the . Both

statements are true

second statement is true

. Both statements are false

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Ashley, a 32-year-old woman, comes in for her routine cleaning appointment. Stephanie, the hygienist, finds that Ashley has not been following the home care program that was rcommended six months ago. Stephanie believes that Ashley's problem is a managment deliciency and not a skills deficiency. Which ofthe following is the best course of action for Stephanie?

. Accept that Ashley might never change her habits

. Provide Ashley with

a pamphlet on periodontal disease

. Meet with her supervising dentist to determine the future course ofaction

. Go over brushing and flossing techniques

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. Fear generally refers to the anticipation ofa threat elicited by an extemal object that is generally agreed to be harmful. Note: In evaluating a patient's dental fears, take ^ote the

of what he/she dental offrce.

ys, how he/she behaves, and also how he/she appears while in

Note: Fear is distinguished from anxiety on the basis ofthe person's ability to locate the threatening agent "out there" and to recognize the clear presence of a behavior that will reduce perceived danger. Patients who are fearful or anxious witl do anything to put off making dental appointments.

. Stress is a term used to describe a general disturbance in psycho-physiological adaptation. It implies a person who is being maladaptively influenced by more than one
negative or aversive factor Note: Ofthe three terms, stress is most associatd with response aspects. Stress, anxiety and fear are simultaneously negative or aversive emotional states, full of symploms that can motivate through a process ofthreat appraisal. The interaction ofthe intensity ofan emotional response with threat appraisal determines the content ofthe behavior that will follow whether or not to show up at the dentist's oflice, to submit to an injection, to accept the need for an extraction or filling, etc.

Four elements common to all fears: l. Fear of the unknown 2. Fear ofphysical harm or bodily injury 3. Fear of loss ofcontrol
4. Fear ofhelplessness and dependency

Important: Understanding the above elements offear allows effective planaing for treatment of fearful and anxious Datients.

Since this is not a skills deficiency problem, reviewing home care techniques is not going to solve the problem. Ashley knows what to do. Now Stephanie and Ashley's supervising dentistjusl need to find a way to motivate Ashley to find the time to brush and floss.

l. It has been shown that the most effective way to teach oral hygiene skills is by having the patient participate in repeated, supervised training sessions. 2. The best time to determine a patient's plaque index (in order to assess the elkctiveness of q patient s home care) is at the beginning ofan appointment. 3. Rather thanjust asking a patient about his or her home care skills, have the patient show you. 4. Maintaining a 4-year-old child's healthy dentition starts with educating the
parent. 5. Having your teeth cleaned and examined on a regular basis and keeping them
clean on a daily basis at home is the best way to prevent periodontal disease. 6. The following patient information is necessary in order to plan dental hygiene care: health history dental history dietary analysis, and periodontal examtnatlon.

. Aversive conditioning

Successive approximation

'

Hypnodontics

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. The Health Maintenance Model . The Health Role Model . The Health Belief Model . The Leading Circle Model

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Behavior shaping is an operant conditioning technique used in behavior therapy in which new behavior is produced by providing reinforcment for progressively closer approximations ofthe final desired behavior It is a common nonpharmacologic technique. Proponents of this theory hold that most behavior is learned and that leaming is the establishment ofa connection between a stimulus and a response. For this reason, it is sometimes called stimulus-response (S-R) theory. When shaping behavior, the dental assistant or dentist is teaching Young children are led through these procedures step by step.
a

child how to behave.

Behavior shaping is regarded as a learning model. A general rule about leaming models is that the most efficient leaming models are those that follow the leaming theory model
most closely.

Example: Attempting to change several aspects ofa patient's oral hygiene regimen should be done one aspect at a time (sequentialfit). Have the patient mimic the conect oral hygiene behavior This will increase the chances of succeeding in changing this patient's
behavior.

\ote: Aversion conditioning

is a technique in which punishment, unpleasant or painful stimuli are used in the suppression of undesirable behavior In dentistry, it is known as the Hand-Over-Mouth technique or HOME.

The Health Belief M odel (HBM) is a psychological model that attempts to explain and predict health behaviors. This is done by focusing on the attitudes and beliefs of individuals. The HBM was first developed in the 1950s by social psychologists Hochbaum, Rosenstock and Kegels working in the U.S. Public Health Services. The model was developed in response to the failure ofa fiee tuberculosis fB) health screening program. Since then, the HBM has been adapted to explore a variety ollong- and short-term health behaviors, including sexual risk behaviors and the transmission of HIV/AIDS.

ret}
Hl,|3nlrr8 gtutc,!t LYnutr tfiat|raLuflgtt

W;r:r:ti:rtrr,;,, ffialt,:,.
r$glE gta of prcsvE *rasls
ffi!:i
PEFCE;VED

pfEvo|lr GactEal

3AitrBS

FOR

*Y
ttacar@ scasr,5cts
ATTSTS|'IIY

t
PE*CETIIDIHEEII

&a

of Ll,.rEss o* [(xmY

>

lJGt$|(XlD

*.fr*.
rcrnr

drcsrona
The Health Belief Model suggests that individuals will act to prevent disease only when they blieve that they ar susceptible to it. Also true is that a patient's compliance is affected by their perception ofthe severity ofa disease as well as the length ofa trcatment regimen.

. Behavior evaluation
. Behavior therapy

. Behavior shaping
. Behavior training

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To understand the development ofhuman behavlor you need to

understand the basic concepts of maturation and learning.

. The first statement is true; the second statement is false . The first statement is false; the second statement is true . Both sbtements are true

. Both

statements are false

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o 20ll-2012

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Behavior modific ation (behavior therapy) is a kind of psychotherapy that attempts to modi$' observable, maladjusted pattems ofbehavior by the substitution ofa new response
or set ofresponses to
a

given stimulus,

Psychologists have developed many techniques for modifying patients' behaviors by using the principles of leaming theory. Examples of techniques:

Classical conditioning: a form of learning in which a previously neutral stimulus

comes to elicit a given response through associative

training,

. Operant conditioning: a form of learning in which the person undergoing therapy

is rewarded for the correct response and punished for the incorect response

. Aversion conditioning: a technique in which punishment, unpleasant or painful

stimuli are used in the suppression ofundesirable behavior. In dentistry, it is known as the Hand-Over-Mouth technique or HOME. . Modeling (behavior shaping): a technique in which the person leams a desired response by observing it being performed . Systemic desensitization: a technique used for eliminating maladaptive anxiety associated with phobias, The procedure involves the construction by the person ofa hierarchy of anxiety producing stimuli and the general presentation of these stimuli until they no longer elicit the initial response of fear.

Note: These methods are used mostly in pediatric dentistry.

Four major fields of behavior:

1. Personal social: this is usually a function

ofenvironment, work, play and society.

2. Motor: starting point to access mahrrity. 3. Language: vocalization, words, sentences, facial and manual movements. 4. Adaptiye: use ofmotor capacity and solutions to practical behavior

. Describe . Be specific . Be evasive . Be responsive . Pay attention

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. Psychophysiological reactions

Stress, anxiety and fear

. Preventive oral health behavior . Pain

17 Copyrigh O 20ll-2012 - Denral Decks

Remember: The best way to show a patient that you care about what he/she is telling vou ls to use eve contact.

AversiY conditions: . Psychophysiological reactions . Stress, anxiety and fear

. Pain
Note: These conditions are perceived as aversive and the dentist-patient interaction seeks to minimize them. Nonaversiye conditions:
Communication-gathering information, identifying problems, giving information (as rz presentalions) . Preventive oral health behavior . Management of exceptional patients such as the physically or emotionally disabled for these patients, gradually expose them to the dental office
case

Note: These conditions are perceived as nonayrsiye and the dentist-patient interactions seeks to maximize them.

Dental fear is dehned as an unpleasant mental, emotional, or physiologic sensation derived from a specific dental related stimulus. Dental anxiety is nonspecific uneasiness, apprehension. or negative thoughts about what may happen during a dental appointment. A dental phobia exists when a dental appointment is avoided or endured with intense anxiety. Phobias

interfere with normal routines. Fear, anxiety, and pain are interrelated people will endure severe pain before seeking professional care, often because olthe fear associated with pain. As pain increases, anxiety increases; as anxiety increases, pain becomes enhanced and therefore less tolerable. Dental fear and anxiety can come from different sources, but are often from a previous bad dental experience, hearing ofbad experiences from family or fiiends, or a general fear ofneedles. Research has shown that between 50o/o to 85Yo of all dental fear happens during childhood or adolescence.

. Behavior theory (ABC) model

Stages ofchange model

Social cognitive theory

. Contemporary community (public) health model

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. Truthfulness . Documentation . Preparedness . Flamboyance

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Thc Stsges of change model 1SCM, was originally dcvc lopcd in rhe late | 970's and carly | 980's by James Prochaska and Carlo Diclcmcnlc at thc Univcrsity ofRhode Island whcn they werc strdying how smokcrs wcrc ablc to give up thcir habits or addiction. Thc SCM model has bccn applicd to a broad range ofbehaviors including wcight loss, injury prcvention, ovcrcoming alcohol. and drug problems among othcrs. The idea behind the SCM is that bchavior change does not happen in one step. Rather, pcoplc tcnd to progress through dif]'crcnt sragcs on thcir way to successful change. Also, each ofus progrcsscs through the stages at our own ratc.

'fhe stages of change arei

. Precontemplation: (ly'ot yet @knolrledging that there is a problen behurior rhot eeds b be chunged) . Con tcmpfstion: (,.1c1", o$'ledging that there is a problen but ot yet rea\) or sure oJ i anti g to make a chanse) . Preparation/Determin (G e t ti ng rc ad)' to c han ge ) ^tionr behayior) . Action,^ryilfpo*er: anging

. M^inten neei (l''laintainine the behalior change) . Rclapsc: fRet!,rirg to older hehayior\ and ahu .lo,ing the new changes)
Thc Social cognitive theory /SCO explains howpcoplc acquirc and maintain ccrtain bchavioral patlcms, whilc also providing the basis for inlcrvcntion stratcgies. Evaluating bchavio.al changc dcpcnds on thc factors environmentj people and behavior. Thc thrcc factors cnvironmcnt, pcoplc and bchavior are constanlly influencing cah othcr Bchavior is not simply thc rcsult ofthc envi.onmcnt and thc pclson, just as the environment is not simply the rcsult ofthc Dcrson and behavior Thc cnvironmcnt Drovidcs models for bchavior, Thc Contemporary community apr,6/ic, health model is a prcvention model which considers a number offactors, including social, cultural, economical, and environmcntal factors ashaving a significant influcncc on onc's hcalth bc-

fC',,

Behalior theory 1,1ACrr.r.1er: Behavioris sandwjchcd bctwccn Antecedants

(a

gimulus that comes belbre the be-

,drtdl,

and Conscquences

snmuh$ that comes ali?r u behalrior).

. \ot3 '''.., ';

L Assumptions ofBehaviorism:
. A1l spccics ofanimals lcam in similar /e9rd1) \'ays wilh the same guiding principies . To undcrstand lcaming proccsscs, focus on stimulus and rcsponscs . In tcmal process should be cxcludcd from thc sludy of icaming . Leaming is cvidenced by a behavior change . Organisms arc blank slatcs al birth . Leamins is a rcsult ofcnvironmcntal cvcnts

Risk management in dcntistry has bccn dcvclopcd ovcr thc ycars by concentrating on rccording trcatmcnt in dcntal rccords and informing patients ofthe proposed treatmcnt bcforc trcating thcm. By intcgrating pmcticc managcmcnt concepts with risk managcmcnt tcchniqucs, dentists can reduce risk managcment exposure and improve patients'
awarcncss, undcrstanding and follow{hrough on thc trcatmcnt

oftheir denral nceds.

Documentation is aD csscntial part ofrisk managcmcnt. In tho cyes of many courts, *If it is not written dorvn, it did not happen," mcaning that signiflcant happmings should bc written down and that the courts will not rcly on your rtemory scvcralycars aftcrthc fact. particularly in cascs ofdcntal malpmcticc. Thcrcforc, dental rccords must bc thorough, consistent, and complete. Theyshould include not only actual visitsbut misscd visits and other evidcncc ofnon-

lmportrnt points to rcmemberi

. An',thing tbat you $,rite down is discovrabl, thercforc, don't wdtc anything youdon't want read aloud in courl . Whcn an incidcnt occurs, your insurancc company should bc put on noticc . Once you have writlen something, donlt go back and change it whcn a lawsuit is filcd. If you havc sccond thoughts, do them as an addendum- Never chsnge anything you wrote, ifyou make a legitimalc mistake, d.aw a singlc line through the cfior (so it still can be rearrl, mark "criot" and initial and datc it. . Be specific: wrilc facts only, not opi|]ions . Be objective: avoid personal characterizations, instead state spccific bchavior. Do not create facls. Be complete

. Be timly . 8e readable (\|rite legibl ,) . Maintain integrity ofthe chsrtr make conections or alteralions according to approvcd proccdures . Nerer make or sign an entry for somcone clsc or vicc vcrsa
. Countersign carefully: you become . Document ir|formed consent
as responsible as the person who

originally signed

Strtute of limitations:
thc injury.

is 2 ycars and starts running

fiom the moment of discovcry of an injury not from the timc

of

Confidentiality: rhc oriainal chan tecord) is your property and, by law, must bc rctaincd by you. Copics ofcharts and x-rays may bc providcd to thc paticnt or an attomcy with a signcd authorization by thc paticnt. Note: You can
chaqc copying fees for this scrvicc-

. 3s0" F (t 7T C)

.2s0"F
.

(r2f c)

4sv

F (237 C)

8e" F

(3f

C)

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. 5 minutes
. 20 minutes . 40 minutes . 2 hours

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The proper time and temperature for autoclaving is 250' F (l21" C) for l5-20 minutes. *** These conditions will yield 15 lbs. pressure of steam per square inch.

Moist heat destroys bacteria by denaturation ofthe high protein-containing bacteria. The autoclave provides sterilization when used at 250' F (121" C) for 15-20 minutes because it applies the heat under pressure, which greatly speeds up the denaturation process when compared with boiling water. Usually only ten minutes is required to destroy all of the bacteria, but the increased time is allowed for penetration when the instn-rments are
wrapped in thick towels.

l. The effectiveness ofautoclaving is best determined by culturing bacterial spores. Biological monitors are referred to as "spore tests." 2. Spore testing ofautoclave units is recommended weekly (at a minimum). 3. Process indicators are another method used to ensure the sterilization process is being performed properly. Important: This method only demonstrates that certain physical conditions (temperature) haye been reached. This method does not show that the microorganisms have been eliminated. Key point: Process indicators do not replace biological monitors. 4. Precleaning is the most important step in instrument sterilization. 5. Debris acts as a barrier to the sterilant and sterilization process. 6. Ulhasonic instrument cleaning is the safest and most ellicacious method of precleaning.

The proper time and temperature for dry heat sterilization is Note: 340' F (l7C O for I hour is also effective.

32f

R (160" C)

for

2 hours.

Items which are usually sterilized by dry heat can be autoclaved. They should be removed immediately after the cycle to diminish the possibility of corrosion of the instruments and dulling of sharp points or edges (carbon steel instruments).

Important: Dry heat destroys microorganisms by causing coagulation of proteins.

Advantages

ofdry heat:

. Effective and safe for sterilization ofmetal instruments

. Does not dull or corrode instruments

Disadvantages of dry heat:

. Long cycle . Poor penetration . Will ruin heat-sensitive materials

Note: Instruments must be dry before both dry heat sterilization and ethylene oxide sterilization. Water will interfere with the sterilization nrocess.

12 minutes

. l5-20

minutes

. 20-40 minutes . 2 houls

22
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10 minutes

. I hour

. l0 hours
. 24 hours

CopFighr O 20ll-2012 - Dental Decks

The proper time and temperature for unsahuated chemical vaporization is 27V F (13? Q for 20-40 minutes. *** These conditions will yield 20 lbs. pressure ofsterilizing vapor The principal operation ofthis system is similar to that ofsteam sterilizers but instead of distilled water, a solution ofalcohol, formaldehyde, ketone, acetone and water is used to produce the sterilizing vapor.

The temperature and pressure required for chemical vapor sterilizers are greater than those for the autoclave.
The major advantage ofthis system is that it does not rust or corode metal instruments. including carbon steel. Disadvantages include instruments must be dried completely before processing, a special chemical solution must be used and it will destroy heat-sensitive plastics.

heat transfer sterilization requires the following, 375'F (l9f Q with a cycle time of 12 minutes for wrapped instruments and 6 minutes for unwrapped instru-

\ote: Rapid
ments.

2% glutaraldehyde is an alkalizing agent highly lethal to essentially all microorgalisms if sufficient contact time (10 hours) is provided and there is absence of extraneous organic material.

Advantages of glutaraldehydes:

. Most potent category ofchemical germicide

. Capable ofkillingspores (aJter 10 hours) . EPA registered as chemical sterilant . Can be used on heat sensitive materials
Disadvantages of glutaraldehydes:

. Long period required for sterilization . Allergenic . Not an environmental disinfectant . Extremely toxic to tissues

Notrgj:

l. In hospitals,
msn1.

glutaraldehydes are used to sterilize respiratory therapy equip-

'ae*;

Z. Alcohols, chlorhexidine, and quatemary ammonium compounds are disin-

fectants.
3. Important: Just immersing dental instruments in cold disinfectants will not destroy spores or hepatitis viruses (they are rcsistant to physical and chemical agents).

. Nonionic detergents
. Anionic detergents

. Cationic

detergents

24
Coplrighr O 201l-2012 - Dental Decks

. Disinfection

. Sterilization
. Cleaning . Decontamination

25
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Detergents are "surface-active" agents composed of a long-chain, lipid-soluble, hydrophobic portion and a polar hydrophilic group, which can be a cation, an anion, or a nonionic group. These surfactants interact with the lipid in the cell membrane through their hydrophobic chain and with the surrounding water through their polar group and thus disrupt the membrane.

Quaternary ammonium cornpounds (e.g., benzalkonium chloride) are cationic detergents. They are used as disinfectants and antiseptics. Gram-positive bacteria are the most

susceptible to destruction. These compounds are not sporicidal, tuberculocidal, or viricidal and are inactivated by anionic detergents (soaps and the iron in hard water).

Anionic surface-acting substances include synthetic anionic detergents and soaps. These substances alter the nature of interfaces to lower surface tension and increase cleaning. Their primary value appears to be their ability to remove microorganisms mechanically
from the skin surface. ftlote: Nonionic chemicals do not possess any antimicrobial properties.

Disinfection is the killing of many, but not all, microorganisms. It does not include the destruction of spores. The term disinfectart is reserved for chemicals applied to inanimate surfaces (Iqb tops, counter tops, headrests, light handles, etc.). They not considered safe for use on living tissue. Note: Mycobacterium tuberculosis is the^re benchmark organism for disinfectants.

Antiseptics are chemical agents similar to disinfectarts, but they may be applied safely to living tissue. Alcohol is the most cornmonly used antiseptic to reduce the number of pathogenic microorganisms on the skin surface. Note: Soap only removes microorganisms.

Note: Remember the doctrine of sterilization

ilize!!!
Remember:

Do not disinfect what vou can ster-

1. The immersion ofdental instruments in cold disinfectants will not destroy spores or the hepatitis viruses (they are resistant to physicol and chemical agents). 2. Liquids are generally sterilized t y filtration. The most commonly used filter is composed ofnitrocellulose and has a pore size of 0.22um. This size will retain all bacteria and spores. Filters work by physically trapping particles larger than the pore size.

. Bacteria

. Spore-forming
. Virus

. Fungi

26
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@

201| '2012 - Dnral Decks

. Alcohol

. Chlorine . Formaldehyde . Phenol

27
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+** A major distinction between highJevel disinfection and sterilization is the ability of sterilization to kill spores of spore-formingbacteria (Bacillus and Clostridium).
Because bacterial spores are resistant to boiling (100 " C at sea level), they must be exposed to a higher temperature; this cannot be achieved unless the pressure is increased. For this purpose, an autoclave chamber is used in which steam at a pressure of l5 lb./in. reaches a temperatue of l2l' C and is held for 15-20 minutes. This kills even the highly heat-resistant spores ofClostridium botulinum, the cause of botulism, with a margin of safety. Note: Bacillus spores are the benchmark organisms for sterilization. If a process kills these spores, it will also kill everything else.

Saturated stelm (autoclave) has proven to be the most practical, the most economical, and the most currently efiective sporicide. It is also the most efficient method for destruction ofviral and fungal microorganisms. Remernber: Moist heat destroys bacteria
by denaturation ofthe high protein-containing bacteria.
The steam autoclaves are made to operate in the following ranges:

. .

121' C (25C F) at a pressure of l5 pounds per square inch (psi) for l5 - 20 minutes 134' C (27f F') at a pressure of30 psi for a minimum of3 minutes ('flash cycle")

To positively destroy all living organisms, the minimum, required temperature is

l2lo

c 05f

F).

Note: The autoclaving time will vary directly with the type of the load placed into the
chamber. The 3-minute "flash cycle" is best indicated for unwrapped instrrlments. When instruments are wrapped, a longer sterilization cycle is required to permit adequate penetration of steam for proper disinfection.

Chlorine is the active component ofhypochlorite (bleach), which is used as a disinfeclant. Generic sodium hypochlorite solutions are generally recommended by the CDC as an alternative to other proprietary germicides for disinfection ofenvironmental surfaces. A dilution of l:100 with water (approximately 500 ppm chloride) is acceptable after proper precleaning of visible material from surfaces. It is best to renew the dilution at least weekly. Bleach solutions should be used with caution as they are corosive to metals.

Disinfectants are antimicrobial agents that kiII (germicide) or prevent the growth fmicrobiostatic) ofpathogenic microorganisms. Disinfectants are not considered safe for
use on living tissue (as opposed to antiseptics which are) and are applied only to inanimate objects (counter tops, Iight handles, headrests, etc.).

Phenol was the original disinfectant used in hospitals, but is rarely used as a disinfectant
today because it is too caustic.

Note: Concntration and contact time are critical factors that determine the effectiveofan antimicrobial agent against a particular microorganism. Any or all ofthe three major portions ofmicrobial cells can be affected: the cell membrane, cytoplasmic contents (particularly en4tmes), and nuclear material.
ness

Remember for disinfectants:

better than alcohol-based. 2. Pump spray is btter than aerosol spray,

1. Water-based is

. Hexachlorophene . Phenol

. Ethylene oxide . Isodine

2a

Cop)rigl

201I-2012 - Denhl Decks

. The first statement is true; the second statement is false

. The first statement is false; the

. Both statements are true . Both statements are false

second statement is true

29
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Ethylene oxide gas has been widely used as a sterilization agent, particularly for
prepackaged, disposable plastic ware in hospitals. This gas is fairly toxic to humans and is also flammable, so that its general use is limited. Exposure of materials to ethylene gas must be performed in special sealed chambers. Items must be cleaned and dried thoroughly before the sterilization process. Note: Using a heated unit, sterilization can be achieved in 2 to 3 hours at l20o F 48.9" C).

Advantages of ethylene oxide sterilization:

. Ilighly penetrative

. Does not damage heat-sensitive materials (rubber, cotton, plastic, etc.) . Evaporates without leaving a residue
. Works well for rnaterials that cannot be exposed to moisture

Important: Ethylene oxide functions as an alkylating agent by irreversibly inactivating cellnlar nucleic acids (DNA) and proteins.

Thcbasisofthecunentsrandard(formerlr,'universol")infectioncontrolprecautionswasfirstrecommendcd br" the CDC in 1987- The purpos was to protect health care workers 1l1Cl4 from occupational transmission of all bloodbomc infectious diseases during provision of patient care. \!hile many heakh professionals fbcused on rhc IIuman Immunodeficiency Virus /H/l/.) as the major risk, accumulated evidcnce clcarly dcmonsrraied that thc hcpatitis B virus /HBr, $as responsible fbr infection in l0-30% ofexposed, susceptible HCW. Concentrat ion s of H BV in thc b lood of a chronic carier cirn mngc bctwccn I ,000,000 to I 00,000,000 virion s per ml, in contras! to significantly lo\irer \'iral loads demonstrated for both IIIV-infectcd persons and person *ih AIDS. viral concentrations detected in hepatitis C virus r41Cl, int'ected individuals range bctu,een those notcd for HBV and HMhus, \\.e target the most infectious bloodbome palhogcn wilh our infection control sBndards. Precaurions rhat minimize potential HIV spread, also by inference, prevent cross-intection ofless infectious
mrcrootganlsms,

lmport:rnt: Most percrilaneous injuries occur outside the patienl's mouth, most on the hands ofthc dcntist. Burs $ ere rhe most common sourcc (379lo). follo\a,cd by ryringc ncedles (3096), sharp instruments (219u"). and orrhodontic $ires (6!/0)-

30olo after percutaneous

injury

from ar infected person

Hepatitis C virus; a
SS RNA virus

0.3% from petcutaneous Blood tests exposurs and 0.09 for mucous (ELISA and Western membrane exposures

Mycobacterium tuberculosis which thrives in the lungs

Tubcrculin skin
sputum cultures, chest x rays

tes1,

. Antiseptics

Sterilants

. Disinfectants . Decontaminants

30
Cop),right O 20ll-2012 - Dental Decks

. Chlorhexidine gluconate
. Triclosan

. Isopropyl alcohol . Both chlorhexidine gluconate

. All of the above
and triclosan

31 Cop,,righ! O 201l-2012 - Dental Decks

Sterilization is defined as the use ofphysical or chemical procedures to destroy all microbial life, including bacterial endospores.
Disinfection is less lethal than sterilization, and involves a chemical process ofmicrobial inactivation which destroys virtually all pathogenic microorganisms on inanimate surfaces (i.e., counter tops, Iight handles, bracket trays), but not necessarily all microbial
forms (i.e., spores).

Antiseptics are agents that are used on living tissue. Alcohol is the most commonly used antiseptic. Antiseptic compounds inhibit but do not necessarily destroy microorganisms. Disinfectants are used on non-living things such as floors, counter tops, etc. They are usually stronger and are too toxic to be used on living tissue. Disinfectants are lethal for pathogenic microorganisms. A common disinfectant is bleach.
Many people are confused about the difference between soap and detergent. Soaps and detergents are not the same thing, although both are surfactants, or surface active agents, rvhich basically means a washing compound that mixes with grease and water Soaps are made of materials found in nature. Detergents are synthetic (although some ofthe ingredients are natural); they were developed during World War II when oils to make soap were scarce. Note: Plain soap physically removes microbes but does not kill them.

:{ote: Surfactants are commonlv included in most disinfectants to ensure full wettability ofall surfaces.

Chlorhexidine gluconate is a skin antiseptic and an antimicrobial agent. It is a relatively rapid-acting antiseptic that is effective against both gram-positive and gram-negative bacteria and some fungi. It combines excellent surface adherence characteristics and the best residual effect ofany agent currently on the market. The antimicrobial action ofchlorhexidine gluconate is attributed to the disruption ofthe microbial cell membrane and precipitation of cell contents. Triclosan is a potent wide spectrum antibacterial and antifungal agent. It
has been shown to be effective in reducing and controlling bacterial contamination on the hands. Triclosan appears to kill bacteria mainly by inhibiting fatty acid synthesis.

Isopropyl alcohol is also used for hand hygiene procedures, but products containing 6080% alcohol DO NOT use water, hence the term waterless hand hygiene.

. Bactericidal . Bacteriostatic

. Substantive
. Fungicidal

Coptl ight O

201 I

,2012 - Dental Decks

. Bacillus stearothermophilus . Pseudomonas aeruginosa . Hepatitis B virus . Mycobacterium tuberculosis

33 CopFight C 201 I -2012 - Dental Drcks

The use ofbactericidal chemicals is preferable to those which are "static." The latter do not directly kill or inactivate microbes, but instead inhibit their metabolism and replication. These affected organisms can remain viable but inactive for extended intewals. Application of"cidal" agents or processes are designed to ensure microbial inactivation.

Bactericidal products:

'

Sporicidin

. Envirocide
. Mada Cide-l . Biozide . Cetylcide II

. SaniZide Plus

Antimicrobial activity against Mycobacterium tuberculosis is recognized as a significant benchmark criterion for disinfectant effectiveness. While tuberculosis is not transmitted via inanimate environmental surfaces, the morphology arrd structure ofthe tubercle bacilli make them relatively resistant to penetration by a number oflow-level disinfectant chemicals.

High-level disinfection is a process in which chemical sterilants are used in a marurer that kills vegetative bacteria, tubercle bacillus (mycobacterral, lipid and nonlipid viruses, and fLngi, but not allbacterial spores, ifthey are present in high numbers. High-level disinfectants include: glutaraldehyde, sodiurr hypochlorite 1,000 ppm (l:50 dilution of household bleach), and boiling. Note: The application of high-level disinfection in dentistry is limited because virhrally all dental instruments are heat-stable and can be sterilized in an autoclave.

Intermediate-level disinfection kills vegetative bacteria and fungi, tubercle bacillus, and lipid and nonlipid viruses. Intermediate-level agents, such as phenols, iodophors, sodium
hypochlorite 500 ppm (1:100 dilution oJ household bleacr), and certain preparations containing alcohols (60-90% isopropyl) are able to penetrate the wax and lipid outer layers surrounding mycobacteria. Designed for cleaning of environmental surfaces.

Low-level disinfection kills only vegetative bacteria, some fungi, and lipid viruses, but not the tubercle bacillus. These products (quqternaty ammonium compounds and qccelerated hydrogen peroxide products) are designed for daily cleaning and disinfection ofall surfaces in the office.

. Proteins
. Accelerators

. Com starch powders

. Anti-oxidanls

34
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Dental Decks

. Destroy all pathogens

. Inhibit pathogen growth

. Reduce the concenhation of pathogens . Weaken the virulence of pathogens

Copyright C 201 l -20 12 - Dental Decks

Only a few of the more than 250 proteins found in the sap from the rubber tree Hevea brasiliensis are responsible for causing the Type I, immediate, IgE-mediated reactions to natural rubber latex. These are water-soluble macromolecules that can leach out oflatex gloves when a person perspires, or be detected on the surfaces ofother products containing natural rubber latex (NRL).
Three types ofreactions can occur in persons using latex products:

. Irritant contact dermatitis: it is the most common reaction to latex products. Signs
include the development ofdry itchy, irritated areas on the skin, usually the hands. . Allergic contact dermatifls (delayed hypersensitivity) results from exposure to chemicals added to latex during harvesting, processing, or manufacturing. These chemicals can cause skin reactions similar to those caused by poison ily. As with poison ivy, the rash usually begins 24 to 48 hours after contact and may progrcss to oozing skin blisters or spread away from the area ofskin touched by the latex. . Latex allergy (immediate hypersensitiviq,) can be a more serious reaction to latex than iritant contact dermatitis or allergic contact dermatitis. Reactions usually begin rvithin minutes of exposure to latex, but they can occur hours later and can produce various symptoms. Mild reactions to latex involve skin redness, hives, or itching. More severe leactions may involve respiratory s).rnptoms such as runny nose, sneezing, itchy eyes, scratchy throat, and asthma (di.fficult breathing, coughing spells, and wheezing). Rarely, shock may occur; but a life-threatening reaction is seldom the first sign oflatex allergy. Such reactions are similar to those seen in some allergic persons after a bee
snns.

The simplest way to approach environmental surface disinfection is to adhere to a basic premise ofaseptic technique-clean it first. All disinfectant products include specific label instructions for cleaning prior to disinfection.

Cleaning is defined

as the physical removal

ofdebris.

Two effects result from efficient cleaning: I . A reductjon in the number of microorganisms present. 2. The removal of blood, tissue bioburden, and other debris which can interfere with disinfection.

. Cold sterilization
. Proper handwashing with sterilizing antiseptics . Heat sterilization

. Immersion of contaminated items in chemical sterilants

CoDriglt

O 20ll-2012 - Dental Decks

. Irritation dermatitis
. Type I immediate latex allergy . Type IV delayed latex allergy

Superfrcial fungal infections on the fingers

37
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The use of heat has long been recognized as the most eflicient, reliable, biologically monitorable method of sterilization. During a routine cycle using an autoclave, unsaturated chemical vapor sterilizer, or dry heat unit, cell death is accomplished via heat inactivation ofcritical enzymes and other proleins within microbial cells.
The recommendation stating that all reusable items that come in contact with a patient's blood, saliva, or mucous membranes must be sterilized using heat is now routinely acceoted and used in dental facilities

A number ofpublished reports have cited data suggesting that between 20-307o ofhealth care workers suffer from occasional or chronic dermatitis on their hands. The most common manifestation ofthe condition is irritation dermatitis. This reaction is caused by skin

irritation from using gloves and possibly by exposure to other workplace products and chemicals. It can also result from repeated hand washing and drying, incomplete hand
drying, use ofcleaners and sanitizers, and exposure to powders added to the gloves.
Signs include the development ofdry itchy, irritated areas on the skin, usually the hands. Health care workers located in colder climates may also experience chapping during the winter months.

. Autoclave

. Dry heat sterilizer

. Chemical

used on contaminated counter tops

. Handwash agent

38

Coplrigl O 20ll-2012 - DertalDecks

. Wear vinyl or nitrile gloves . Wear hypoallergenic latex gloves . Get an exemption and not wear gloves . Refuse to treat them

39 Coplrisht
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Deck

The term antiseptic is used for antimicrobial agents that are applied onto living tissues. Liquid antimicrobial preparations for handwashing, such as chlorhexidine gluconate,

parachlorometaxylenol, idophors, and triclosan are examples. Chemical solutions, sprays, or wipes applied onto inanimate counters or other environmental surfaces are termed disinfectants. Note: The primary reason for using chemical disinfectants and antiseptics is to control the number ofpathogens and exhibit some killing action. These agents are not to be used for sterilization.

A wide variety of latex-altemative infection control items have appeared in the marketplace within the last l0 years. The most widely recognized are newer generations ofvinyl or nitrile gloves which do not cross-react with latex allergens. Products with the designation "hypoallergenic" are no longer to be labeled latex altematives, as they contain latex with a chemical coating over the latex.
Note: Studies over recent years showed that not all latex-allergic persons were able to
use hypoallergenic gloves, since many Type I allergic individuals still developed allergic manifestations when using these gloves.

Remember: Reactions usually begin within minutes of exposure to latex, but they can
occur hours later and can produce various symptoms. Mild reactions to latex involve skin redness, hives, or itching. More severe reactions may involve respiratory syrnptoms such as nrnny noseJ sneezing, itchy eyes, scratchy throat, and asthrna (dilrtcuh breathing, coughing spells, and wheezing). Rarely, shock may occur; but a life-threatening reaction is seldom the first sign of latex allergy. Such reactions are similar to those seen in some allergic persons after a bee sting.

. Disinfection

. Sterilization
. Pasteurization

. Sanitization

40 coplright O
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. Human Irmunode ficiency Yirus sal) Blood Precautions

(HII)

is the most infectious target of Standard (Univer-

. Hepatitis B Yirus (HBV) is the most infectious target of

Precautions

Standard (Universal) Blood

. Hepatitis C Yin:s (HCIt) is the most infectious targe! of Standard (Universal) Blood
Precautions

. Epstein-Barr Virus (EBV)

Precautions

rs the most infectious target

of Standard (Universal) Blood

41

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201l-2012 - Dental Decks

Sterilization: the destruction or removal of all forms of life, with particular reference to microbial organisms; the limiting requirement is destruction ofheat resistant spores.
Disinfection: the use ofchemical agents to accomplish the destruction ofpathogenic microorganisms, but not necessarily all pathogen or resistant spores, on inanimate surfaces.

Pasteurization: the treatment of dairy foods, such as milk, for short intervals with heat, to kill certain, disease-causing microorganisms; the target of pasteurization is the destruction of Mycobacterium tuberculosis.
Sanitization: the treatment of water supplies to reduce microbial levels to safe public
health levels.

HIV is the most infectious bloodbome pathogen known, and infection control precautions aimed at preventing this viral transmission, have also been shown to be effective in preventing HIV and HBV cross-infection.

. Antisepsis

. Sanitization
. Disinfection

. Sterilization

42
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. Exposure

is not synonymous with infection

. Do not disinfect when you car sterilize . Sterilization

mandatory

of all clinical instruments and inanimate environmental

surfaces is

. Known AIDS patients can be treated using Standard Bloodbome Precautions

13
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Antiseptic:

a chemical that can be administered safely to extemal body surfaces or mucous membranes to decrease microbial numbers. Antiseptics cannot be taken internally.
a

Disinfectant:

chemical agent used to destroy microorganisms on inanimate objects such

as dishes, tables, and floors. Disinfectants are not safe

for living tissues.

Disinfection: the process of reducing the numbers of or inhibiting the growth of microorganisms, especially pathogens, to the point where they no longer pose a threat of
disease.

Sterilization is the process by which all microbial life is killed. Bacterial spores are the most resistant ofmicrobial life to killing. Ifthe sterilization process is effective in killing bacterial spores, all other pathogenic and nonpathogenic microorganisms are presumed killed. The spore test, or biologic monitor, is the only true test of sterility.
l\Jote: The routine use ofbiologic monitors results in early detection ofsterilization problems so that corrective measures can be taken.

It is not possible, nor necessary to sterilize all environmental surfaces which become contaminated during patient care. In many instances, because ofthe relatively low risk of
microbial transmission, thorough cleaning ofthe surfaces is sufficient to break the cycles of cross-contamination and cross-infection. Ideal chemical disinfectants should:

. Kill

as many microbes as possible in the shortest time possible

. Not damage the object being decontaminated or humans or animals . Not be affected by the presence oforganic material . Be compatible with soaps, detergents, and other chemicals

. Be inexpensive

and stable during storage

. 80% ofpersons have no signs or symptoms

. lt is transmittd primarily in infected blood
. There is a vaccine to prevent hepatitis C

Signs and symptoms include:jaundice, fatigue, dark urine, abdominal pain, loss ofappetite, and nausea

44
Coplright C 201l-2012 - Dental D4ks

\
c mlcroorganrsms ln a nosr

or compromised is known rs

a/an:

. Nosocomial infection

Secondary infection

. Opporfunistic infection
. Medical infection

45
CopFight O 20ll-2012 - Dental Decks

***

This is falsel there is no vaccine to prevent hepatitis C

Hepatitis C virtls (HCV) is trarsmitted primarily in infected blood. Historically, parenteral drug abusers, persons receiving transfusions, organ recipients, and hemophiliacs receiving factor VIII or IX were shown to be at high risk ofHCV infection. More recently, persons receiving tattoos or undergoing body piercings have been infected via contaminated, unsterilized needles.

The percentage of people living with a wide variety of immune compromised conditions continues to increase. Along with the clinical manifestations ofthose types ofdiseases there can be accompanying deficiencies in aspects of host imrnune defenses. The selerity of deficiency can range from mild to life threatening, and predispose the compromised person to infections by organisms which would not usually occur in other people \{ith intact innate and specific immuniry.

Immune-compromised persons are those that have a weakened, under-developed or

malfunctioning inrnune system. This dehnition includes: HIV infection, cancer, an organ transplant, Primary Immune Deficiency disorders, some severe autoimmune disorders,
persons on immunosuppressive medications and other illnesses that can weaken the immune svstem.

. Daily . Twice per day . Whenever is convenient . Between patients

46
CopFighr O 201l'2012 - Denral Decks

' IsA
.Ion .loF

'

IgG

47
CopltiShr O 20ll-2012 - Dental Decks

Face masks should be changed at least with every patient and more often if healy spatter is generated during treatment. If a mask is wom longer than 20 minutes in ar aerosol environment, the outside surface ofthe mask becomes a nidus ofpathogenic bacteria rather than a barrier.

Latex allergy is a reaction to certain proteins found in nalural rubber latex, a product
manufactured from a milky fluid derived from the rubber tree (Hevea brasiliensls) found in Africa and Southeast Asia. Ifa person has a latex allergy, their body mistakes latex for a harmful substance. Their immune system triggers certatn cells (B-cells differentiate into

pltsma cells) to produce immunoglobulin E (,IgEl antibodies to fight the latex component (the allergen). The next time the person comes in contact with latex, the IgE anribodies sense it and signal their immune system to release histamine and other chemicals
into their bloodstream.
These chemicals cause a range of allergic signs and symptoms. Histamine is partly responsible for most allergic responses, including runny nose, itchy eyes, dry throat, rashes and hives, nausea, diarrhea, labored breathing and even anaphylactic shock.

Later sensitivity can occur in tbese ways: . Direct contact: The most cornmon cause oflatex allergy is direct contact with latex, such as by wearing latex gloves or by contact with latex-containing products. . Inhalation: A person can develop a latex allergy by inhaling latex particles. Latex
products, especially gloves, shed large amounts oflatex particles, which can become airbome. Comstarch is sometimes used on the inside ofgloves to make them easier to put on and take off. The comstarch absorbs latex proteins, but when the gloves are snapped during application or removal, the latex laden particles fly into the air. The amount of airbome latex from gloves differs greatly depending on the brand ofglove used.

. Disinfection . High-level disinfection . Sterilization involving the use of heat

. Both disinfection and sterilization involving the use ofheat

4A

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. Lower, longer . Higher, longer . Lo\r'er, shorter

. Higher, shorter

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The use of heat has long been recognized as the most efficient, reliable, biologically monitorable method of sterilization. During a routine cycle using an autoclave, unsaturated chemical vapor sterilizer, or dry heat unit, cell death is accomplished via heat inactivation ofcritical enzymes and other proteins within microbial cells.
The recommendation stating that all reusable items that come in contact with a patient's blood, saliva, or mucous membranes must be sterilized using heat is now routinely acceptcd and used in dental facilities

This method ofrapid heat transfer achieves sterilization in t 2 minutes at 375"F (190'C) for wrapped items and in 6 minutes for unwrapped items. *** Important: Note:The manufacfurer's recommendations must be followed for these systems.

FDA-approved, forced air, dry heat convection ovens are appropriate for sterilization of heat-stable instruments and other reusable items employed in patient care. They use a higher temperature than other dry heat units, and there is controlled intemal air flow within the chamber In contrast to the traditional tlpe ofdry heat sterilizers, a rapid heat transfer unit can achieve sterilization of items in substantially shorter times, while still offering the advantages ofdry heat.
.A,dyantages of

rapid heat transfer sterilization:

.It

has a shorter cycle time than regular dry heat units

. It does not dull cutting edges . Items are dry after cycle
Disadvantages of rapid hat transfer sterilization:

. Instrument must be dried before packaging and placement in chamber . It destroys heat-labile items . It cannot sterilize liquids . It is generally unsuitable for dental handpieces . Unwrapped items become contaminated quickly after cycle

Personal protective equipment clini(

. Short . Long . Long

sleeve, high neck sleeve, high neck sleeve,

hrtle neck

. Whatever your preference

50 Cop)right O 20ll-2012 - Dental Decks

. Mercury . Nitrous oxide

. Chemicals

used for

film developing

. All ofthe above

51

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- Dertal Decl6

For optimal protection, clinicjackets or coats are required to be long sleeved and high necked. This requirement was installed to minimize the potential for exposed skin to contact, and therefore become contaminated with, a patient's blood, saliva, or other potentially infectious material.

Contaminated laundry is defined by the Standard as laundry that has been soiled with blood or OPIM (saliva) or may contain sharps. The following rules apply to the handling ofcontaminated laundry in the dental office:

. It must be handled as little as possible . Contaminated laundry should be bagged at the location ofuse . It will not be sorted or rinsed in the location ofuse . Bags for storage or transport will be labeled with a biohazard label or color coded red
. Contaminated laundry must be handled with gloves and other appropriate PPE
The dental office has several choices in dealing with contaminated laundry (which will be protective govns or scrubs in most oJJices):

. Personnel may use disposable gowns . The office may use an outside laundry service
. A rvasher and dryer may be used on-site . An unincorporated dentist may take laundry home . One employee may be appointed to take laundry to a laundromat using appropriate
PPE. This person must be trained in handling contaminated laundq., must wear the appropriate PPE, and must transport the laundry in an orange/red bag or one that has the biohazard symbol.

Mercury is cxtremely common in dentistry and is used most often in amalgam capsules. It is also available in bulk form and found in scrap amalgam. Associated hazards include nausea, loss of appetite, diarrhea, fine tremors, depression, fatigue, increased initability, headache, insomnia, allergic manifestations, contact dermatitis, pneumonitis, nephriiis, dark pigmentation ofthe marginal gingiva, and loosening ofthe teeth.

When working with mercury: L Work in well-ventilated spaces and avoid direct skin contact. 2. Store mercury in unbreakeble, tightly sealed containerc away ftom all heat sources. 3. Salvage amalgam scrap and store in tightly sealed containers covered with sulfidc solution. 4. Clean up spilled mercury using appropriate procedures and commercially available cleanup kits. 5. Use high speed suction (equipped with trdps and.fiker)when frmshing or removing amalgams6. Periodically check the operatory's atmosphere for mercury vapor. lmportant: The current OSHAstandard for mercury is 0.1 mg per cubic meter

ofair

avemged over an s-hour

$ork shift.

Photographic and radiographic chemicals are used in developing and fixing radiographic film. [fused carelcssl). they caD cause contact dermatitis and irritation ofthe eyes, nose, throat, addrcspiratory system from vapors and fine panicles. Proper manipulation ofthese chemicals includes the following:

L Use protective eyewear; wear healA-duty rubber glor.es to avoid skin contact.

:. \,finimize

exposure to dry powdcr during the mixing ofsolutions.

i.
{.

urork in well-ventilated areas.

Clean up spilled chemicals immediately. 5. Regularly launder clothing that comes in coniact with photographic solutions. 6. Store photographic solutions and chemicals in tightly covered containers. is used in conscious sedation. IIigh exposure may cause adverse effects, especially neuropathies and spontaneous abortions. When using nitrous oxide/oxygen, use the minimal concenlration necessary to achieve the desired level ofsedation. Use a scavenging system and always maintain adequate ventilation. Priodically check nitrous oxide machines, lines, hoses, and masks fbr leakage. Note: The acceptable maximum exposure level allowed by OSHA for nitrous oxide is 1000 ppm.

\itrous oxide

. Tuberculosis . AIDS

. Hepatitis B . Hepatitis
C

52

Coprighr O

201 l-2012 - Dental Dcks

. Mandatory Precautions

. Regular Precautions

Standard Precautions

. OSHA Precautions

CoplriSh O

201

l-2012'

Dental Decks

OSHA also is concemed about Hepatitis B and other bloodbome diseases, but AIDS is the disease that prompted regulatory action. In 1986, unions representing health care workers petitioned OSHA for an emergency rule to protect their members from work place exposure to the human immunodeficiency virus (HIV) and the hepatitis B virus (HBV). OSHA denied the petition but agreed lo adopt a permanent rule on exposure to bloodbome pathogens through the regular rule making process. It took five years to develop the rule. It applies to hospitals, physicians' offices, nursing homes, other health care settrngs, emergency response personnel and funeral homes, as well as dental offices.
1. Bloodborne Pathogns means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B vrlus (HBV) and human immunodeficiency vrrus (HIV). 2. Other potential infectious materials (OPIMI) means (l) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures (only in dental procedurcs is saliva considered a potentially infectious material), any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (ather than intact skin)

fronr a human (living or dead); and (3) HlV-containing cell or tissue cultures, organ cultures, and HIV- or HBv-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

is the primary stratcgy to bc uscd to rcducc the risk oftransmission ofpathogens from moist body substances and applies to all patients regardless ofthcir diagnosis or presumed infcction status. Hcalthcarc workers must avoid all contact with moist body substances by the usc olPcrsonal Protcctive Equipmcnt /PPt), work practiccs and cnginccring controls.

Toda!, Standard Precautions

A thorough mcdical history should be obtained for all patients at thc first visil and updatcd and revicwcd at subscqucnt visits. Howeverj sinccnot allpaticntswith infcctious discases canbe identified by medical history physical cxatninalion or rcadily available laboratory tests, the CDC has int oduccd thc concept ofslandard (/o/rnerl), "Un ersal")
prccautions. Thc term Standard foz erb' Unfuersal) prccavtions mcans that all procedures are performed wcrc lnown to be infcctious.
as

though thc paticnts

Personal protective equipment /PPtr: PPE is dcsigncd to protcct thc skin and thc mucous mcmbrancs ofthc eyes, nosc, and mouth ofdcntal hcalth-carc pcrsonncl from cxposurc to blood or othcr potcnrially idcctious matcrial.

. Gloves: Dcrial health carc personncl musr wear glovcs to prcvcnt contamination ofthcir hands whcn touching mucous mcmbmncs, blood, saliva, or otltcr potentially infectious matcrials and to rcducc the likclihood that microorganisms on thcir hands will bc tmnsmjttcd to patients during dcntal paticnt-care procedurcs ' \lasks: Dcntal hcalth-care personncl should wcar a surgical mask that covers both their nosc and mouth during proccdurcs and paticnfcare activitics that arc likcly lo gcncratc splashcs or sprays ofblood or body fluids. A surgicalmask protects thc paticrt against microorganisms gcneratcd by thc wcarcr and also protects dentalhcalth carc pcrsonncl from largc-particle droplct spattcr that may contain bloodbome pathogens or othcr infcctious micrcorganisms. Whcn a surgical nask is used, it shoDld be changcd between paticnts or during paticnt trcatmcnt ifit bc-

. fl e}}ear: Dental hcalth carc pcrsonncl should wear protcctive eyewear with solid side shiclds or a face shield during procedurcs and patientcare activities likely to gcncralc splashcs or sprays ofblood or body fluids. Prctcctive cycNcar protccts the mucous membranes ofthc cycs from contact with microorganisms. Protcctivc cycwcar fbr palicnts also can protcct their cyes from spatter or debris generated during dental proccdurcs. Reusable protcctive cycwcarshould bc clcancd with soap and water, and when visibly soiled, disiifected between patients. . Protective cfothing: Various types ofprotcctive clolhing (e.g., gowns, jac&6, arc wom to prevcnt contaminalion of strcct clothing and to protcct lhc skin ofpcrsonncl from cxposure to blood and body fluids. Whcn thc gown is wom as pcrsonal protcctivc cquipmcnt /i.e., wren spatter and spmt ofbloo.l, saliva, or other pote tia ! infectio s nalerial is anlicipdtedr, the slecves should bc long enough to protect thc forcarms. Protcctivc clothing should be changed daily or sooncr ifvisibly soiled. PeNonnel should remove protectivc clothing before leaving thc work arca.

. Tuberculosis . Hepatitis A . Hepatitis B . Infectious mononucleosis

54 Coplrighr

o 201l-2012

- Dental

Dsks

. Non-contaminated sharps

. Contaminated
. All sharps

sharps

. OSHA

does not regulate sharps

Cop]'righr O 201i-2012 - Dmral Decks

The federal standard for occupational exposure to bloodbome pathogens requires employers to provide the vaccination for hepatitis B. You must offer to provide vaccination (and boosters should these be rccommended in thefuture) to all ernployees who have occupational exposure, at no cost to the employees. The employee may refuse to be vaccinated, but OSHA will require proofthat an employee has refused.

You must offer vaccination to a new employee within l0 working days of initial assignment to a position involving exposure. OSHA requires the employee to be trained regarding hepatitis B and the vaccination prior to being offered vaccinarion.

Remember: OSHA considers part-time, temporary and probationary workers as employees.

Any FDA-approved hepatitis vaccine is acceptable. Curently, these are Recombivax

HB and Engerix-B.

\ote: It is important

to stress to your employees that hepatitis B has been a long-standing occupational threat in dentistry. HBV is a hardy virus and it only takes a low concentration to transmit the virus and infect someone.

The rule defines "contaminated sharps" as any contaminated object that can penetrate the skin, including, but not limited to, needles, scalpels, broken glass, broken capillary tubes and exposed ends ofdental wires. There may be other objects used in your oIfice that are sharps, and ifthey become contaminated with blood or other potentially infectious materials, including saliva, then they are regulated. Use and care ofsharp instrumcnts and needles:

1 Should be considered as potentially infective and must bc handled with extraordinary care to prevent unintentional injuries. 2. Disposable syringes and needles, scalpel blades, and other sharp items must be placed into puncturc resistant containers locatcd as close as practical to lhe area in which they were used. To prcvent needle stick injurics, disposable needles should not be recapped: purposcfully bent or broken; renoved lrom disposable syringes; or otherwise manipulated by hand after use. 3. Recapping ofa needle increases the risk ofunintentional needlestick injury. There is no evidcnce to suggest that reusable aspirating-type syringes used in dentistry should be handled diflerently from olher syringes. Needles of these devices should not be recapped, bent, or broken before disposal. J. Cenain dental procedures on an individual patient may require multiple injections ofanesthetic or other medications from a single sy,ringe, it would be more prudent to place the unsheathed needle irlto a "stcrile field" between injections rather than to recap the needle between injections. A ne\\ (sterile) syringe and a fresh solution should be used for each patient. lnformation about recapping: The rule generally prohibits bending, recapping, breaking,
shear-

ing. or removing sharps. However, recapping with a one-handed mcthod ("scoop technique") or using a mcchanical device is permitted. Such techniques ensure that needles are never pointed at or moved towa.d the practicing health care worker or other workers, either on purpose or accidentally. Neweq self-shcathing anesthetic syringes and needle devices do not require any movemenls
associated with recapping.

. All employees, training program, minimal cost, non-working hours . Most employees, training seminar, minimal cost, non-working hours . Most employees, training program, no cost, working hours . All employees, training program, no cost, working hours

56 Coplrighr O 2011-20!2 - Denral Decls

. Only when treating patients that are klown to have AIDS . Only when treating patients that have ANUG
. When treating all patients

. Only when you want to

Copyright O 20ll-2012' Denral Decks

Training is the key to OSHA compliance. The haining must include:

. A copy of the standard and an explanation of its contents . A general explanation ofthe epidemiology, symptoms and modes oftransmission

of

bloodborne diseases . An explanation of the office's xposure control plan and how the enployee can obtain a copy of it .Information about the office's protocol for gloves, gowns, masks and eyewear (or Jbceshields), including the type ofequipment available, where it is located, when it is to be used and how it is to be removed, handled, decontaminated and disposed of . An explanation of how to recognize tasks that may involve occupational exposure and how to prevent or minimize such exposure (e.g., how to use a sharps containers properly) . Information on the hepatitis B vaccine, including efficacy, safety, how administered. benefits ofbeing vaccinated, and that it will be offered fiee ofcharge . Information on how to handle emergencies involving occupational exposure (whqt a(tiotls to tqke and whom to contact) . An explanation ofthe office protocol for handling exposure incidents, such as injuries fiom contaminated sharps (how to report the incident, follow-up medical care, and evaluatton)

. An explanation of the biohazard labels used in the offrce . An opportunity for interactive questions and answers with the trainr

Masks and protective eyewear are required when splashes, spray, splatter or droplets ofblood or other potentially infectious materials, including saliva, may be generated and eye, nose or mouth contamination can be reasonably anticipated. Note: A surgical mask must be wom under a faceshield unless the face shield has fuIl peripheral protection at the sides and under the chin. The mask protects the dental health care worker from splashes and spatters to the nose and mouth. The rule states that if eyewear is required, it must be goggles or glasses with solid, not perforated. side shields. The rule specifically requires the employer to ensure that employees use the protective clothing and equipment.

Remember:
I . The Centers lor Disease Control suggest a new mask for each patient. 2. \'lasks should have at least 95-997o filtering fficiency for small particle aerosols /-1 ro

3 pnt).

An effective face mask will prevent passage oforganisms, have minimal leakage, and filter panicles. The shape, material, and degree ofabsorption ofthe mask will influence its ef.1.

ticiency.

,\otei, of the

-g";i

L Splatter consists oflarge, visible particles, 50pm or largel that fall within 3 feet patient's mouth, coating the face and outer garments of the dental care provider 2. Mist consists ofdroplets that approach or exceed 50pm. Mist tends to settle from
the air after

l0 to

15 minutes.

3. Aerosols are invisible particles that range in size from 5 to 50pm and can remain floating in the air for hours.

. Insurance records
. Attendance records

. Medical records if employee is involved in an occupational exposure . All ofthe above

58

Copright O 20ll-2012 - Dental Decks

. Blood or other potentially infectious materials, including saliva in dental procedures

Items that would release blood and other potentially infectious materials, including salir,a, ifcompressed

. Items that are caked with dried blood or other polentially infectious materials and
are capable ofreleasing these materials during handling
. Non-contaminated sharps

. Pathological and microbiological waste containing blood or other potentially infectious materials, including saliva

59
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The employer must maintain a medical record for each employee whosejob involves occupational exposure to blood and other potentially infectious materials. The record

must include:

. The employee's name and Social Security number . A copy of the employee's hepatitis B vaccination

statns (dates and medical records

regarding the employee s ability to receive the yaccination) . Medical opinions and evaluations

. Test results . Details about exposure incidents (routes of exposure, how they occurred)
Note: The medical records must be maintained for the duration ofthe employment plus 30 years. Also, the record must be kept strictly confidential. Also: . Each employee is entitled to review his/her own medical record. . The OSHA-required records must be transferred to the new owner Ifyou simply go out ofbusiness and there is no new owner, you must notifo the director ofthe National Instirute lor Occupational Safety and Health QVIOSH) atleast three months before you
intend to dispose ofthe records and offer to transmit tlre records to NIOSH.

Ke! point: Regulated waste includes blood and items contaminated with blood or other porentially infectious mateials (OPIM). It is rhe employer's responsibility to determine the existence ofregulated waste. This determination should not based on actual volume of blood, but rather on the potential to release blood. fe.g., \then compacted in lhe waste contqiner). If an OSHA inspector determines that sufficient evidence of regulated waste exists, either through observation, (e.g., a pool of liquid in the bottom of q contqiner, dried blood flaking off during handling), or based on employee intewiews, citations may be issued.
OSHA has provided some additional guidance for the determination ofregulated waste. OSHA stated that bandages which are not saturated to the point ofreleasing blood or OPIM if compressed would not be considered as regulated waste. Similarly, discarded feminine hygiene products do not normally meet the criteria for regulated waste as defined by the standard. Beyond these gr.ridelines, it is the employer's responsibility to determine the existence of regulated waste. Regulated waste must b placed in containrs that are closable, constructed to contain all contents and prevent leakage, and labeled appropriately. The containr must be closed prior to removal to prevent spillage or protrusion ofcontents. The rule also requires that ifthe outside ofthe container becomes contaminated, it must be placed in a second container that has the same characteristics. The ned for a second containr is extremely unlikely in a den-

tal office,
Remember: OSHA is concemed with regulated waste produced at the dental office; the EPA regulates the transportation ofwaste from the dental office.

. All skin

contact with blood or other potentially infectious fluids during the course one's duties while at work

of

. Any reasonably anticipated skin, mucosal, eye or parenteral contact with blood or other potentially infectious fluids during the course ofone's duties while at work .

Aly reasonably anticipated skin, mucosal, eye or parenteral conlact with blood or other potentially infectious fluids during the course ofone's duties while at work or at home preparing for work
course ofone's duties while at work but onlv when natients are in the oflice

. All eye or mucosal contact with blood or other potentially infectious fluids during the

60

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O 201l-2012 - Dental Decks

. Occasional Safety

and Habits Administration and Health Administration

. Occupational Safety

. Occupational Services and Hygiene Administration . Optional

Standards and Health Administration

61 Cop),right O 20ll-2012 - Denral Decks

OSHA includes saliva in dental procedures in the definition of "other potentially infectious materials" (OPIMs) because saliva may be mixed with blood in some dental procedures. OSHA concluded, therefore, that saliva should be treated as potentially infectious even though scientists believe that bloodbome diseases are not transmitted via
saliva. The following should be included in the procedures for evaluating an exposure incident:

. .

State the policies that were in place at the office at the time ofthe incident State the enginering controls (i.e., needle recapping device, sharps container, rubber dam) andwork practices that were in place at the office at the time ofthe incident . State the prsonal protective equipment (gloves, lqb coats, e/c) that were in use at the office at the time ofthe incident

OSHA is a federal agency, created by Congress in 1971, to protect workers from

hazards in the work place.

The Occupational Safety and Health Adminishation aims 1o ensure worker safety and health in the United States by working with employers and employees to create better working environments. Since its inception in 1971, OSHA has helped to cut workplace fatalities by more than 60 percent and occupational injury and illness rates by 40 percent. At the same time, U.S. employment has doubled from 58 million workers at 3.5 million worksites to more than 115 million workers at 7.2 million sites. Remember:

L OSILA is concemed with regulated waste within the dental office. 2. The EPA (Environmental Protection Agency) regulates the transportation of waste from the dental office (biohazard waste, mercury, x-ray fixer, etc.).

.5 to l0

seconds

. l0 to 15 seconds
. 20 to 30 seconds
. 40 to 50 seconds

Coptrighr

2011-2012, Denial Declc

. Hepatitis B . Tuberculosis . Hepatitis C . Herpes simplex virus infection

Cop}Tighr O 201 l-2012 - Dental Decks

Also the CDC recommends the following: . Run source water through the water lines with the handpiece attached for several minutes at the beginning ofthe day . Follow the manufacturer's instructions for proper waterline maintenance . Use sterile saline or sterile water for swgical procedures involving the cutting ofbone

Important: Antiretraction valves: . Are used on handpiece and air-water syringe

hoses to prevent the retraction

of fluid

back into the tubing . Prevent patient mateial (luids) from getting into the water lines . Reduce the dsk of cross-contamination to another patient

Remember:
I . Handpieces should be autoclaved between patients. 2. Disposable saliva ejecto6 cannot be reused.

3. Reusable air-water syringe tips must b autoclayd (disposable air-water q,ringe

rips are atailable).

\ote:

The FDA (Food and Drug Administration) is responsible for regulating handpieces

and making recomrnendations for sterilization procedures for then.

\ote.

l. Noise induced hearing loss (from high-speed and low-speed handpieces, etc.) develops slowly over time and is caused by any exposure regularly exceeding a daily average of90 decibls (dB). Protective measues are recommended when the noise level reaches 85 dB with fiequency ranges from 300 to 4800 cycles per second (cps). 2. Eye protection is required for the operatot assistant, and patient when using a laser.

.accines *'ere plasma-derived, but the vaccines in current use are genetically engineered. HB' antibody titer tests are reconmended r -2 months after coripletion of the vaccine senes ro r erifv that the health care worker is protected. Anti-HBs titers decrrne in 30-50% of adults rvithin 8-10 years after vaccination. However, it is believed that the immune memon remains intact for at least 20 years after immunization.

Remember: As a dentist (emptoyer) you must offer to provide vacclnatron to all em_ plol ees rvho have occupational exposure. Any FDA_apiroved hepatitis vaccine is ac_ ceptable. Currently, these are Recombivax HB and Engerix_B. Note: The first-generation

Tle Hpatitis B Virus is usually transmitted by one ofthe following methods: L Percutaneous inoculation

:. Sexual intercourse i. Prenatal transfer

The center for disease control has identified the following groups as being high risk: . Iv drug users

. Persons receiving transfusions or blood products . Health care workers who may come into conracr with body fluids

. Homosexual/bisexual males

\ote:

Treat each patient and instrument as potentially infectious versal ") infection control precautions.

standard (/a rmerly ,,uni_

. Hazardous waste . Toxic waste

. Infectious waste

Coplrighr O

201

64 l'?012 - Dental Decks

. Only ifthey have contacted blood . Between every other patient

. Only when they become wom out . Between all patients

Coplright O 201 I -20 l2 - Dental Dects

Hazardous waste is waste that causes harm or injury to the environment.

Infectious waste is waste that contains strong enough pathogens in sufiicient quantity to
cause disease. This includes materials contaminated with blood or bloody saliva, such as extracted teeth, gauzes, gloves, and gowns. Important: This material must be collected separately and disposed ofby licensed waste firms.

Noninfectious waste includes elements such as plastic covers or cups, patient bibs, and
others. There are no guidelines for their disposal.
1.

All infectious

waste is contaminated, however, not all contaminated waste

-:Notegi '.,n;:,.t:

is infectious /nray zot be able to cause disease). 2. Not all hazardous waste is toxic (may not be poisonous).

Gloves and gowns are required when you reasonably anticipate skin contact with blood or other potentially infectious materials, including saliva. This means that if you reasonably anticipate the forearms will be spattered with saliva or blood, then forearms must be covered.

Anl go*n

or clinicjacket that prevents blood or other potentially infectious materials, rncluding saliva fiom reaching work clothes, street clothes or skin is considered adequate. Fluid-resistant gowns are not required unless it is anticipated that large amounts ofblood, saliva or other body fluids will soak through the gown to the employee's clothing. OSHA appears to consider cotton or cotton/polyester clinic jackets or lab coats as satisfactory barriers for most routine dental procedures. When surgical procedures are

perfornred involving large quantities of blood (e.g., trauma surgery), additional personal protective equipment, such as long-sleeved gowns, are required. According to OSHA, the selection is to be based on the quantity and tlpe of exposure expected.

Note: When handling chemical agents, contaminated sharps or cleaning

a dental

ofiice,

you should wear protective eye wear, a mask, and healy-duty utility or nitrile gloves. These gloves should be wom for safe pick-up, transporl, clcaning, and packing ofcontaminated instruments. Thcy should not be wom when handling or contacting clean surfaces or items.

Important: Exam gloves are not appropriate for instrument cleaning or any housekccping procedurcs in the dental office.

. ADBC's

. MSDS's . HGPF'S . TRDP's

Copyrighr O 20ll-2012 - Denul Decks

. A comprehensive rule that sets forth the specific requirements OSHA believes will
prevent the transmission ofbloodbome diseases to patients

. A comprehensive rule that sets forth the specific requirements OSHA believes
prevent the transmission ofbloodbome diseases to employers

will

. A comprehensive rule that sets forth the specific requirements OSHA believes will
prevent the transmission ofbloodbome diseases to employees

. All ofthe above

CopFight O 201l-2012 - Dental Decks

***

MSDS stands for Material Safety Data Sheets.

Chemical manufacturers and importers are rquired to obtain a material safety data sheet lor each hazardous chemical they produce or import. Distributors are responsible for ensuring that their customers are provided with a copy of these MSDS's. Employers must have an MSDS for each hazardous chemical which they use. Employers may rely on the infomation received from their suppliers.

Key points on MSDS:

. The role of MSDS's under the rule is to provid detailed information on each hazardous chemical, including its potential hazardous effects, its physical and chemical characteristics and recommendations for appropriate protective measures.

. MSDS'S must be readily accessible to employees when they

are in their work areas during their work shilis. This may be accomplished in many different ways. You must decide what is appropdate for your particular work place. Some employers keep the MSDS's in a binder in a central location. As long as employees can get the information when they need

it. any approach may be used. . The emolovees must have access to the MSDS's themselves.

\ational Fire Protection Association's color and number method is used to easily identiS information about various hazardous chemicals on the MSDS's and product label.
The
The four colors used are:

. Red: identifies \ote:

. Blue: identifies the health hazard

the fire hazard . \'ellolv: identifies the reactivity or stability ofa chemical

. White: identifies the required PPE when using this chemical The level ofrisk for each category is indicated by the use of numbers

0 to 4. The higher

the number, the greater the danger.

It

imposes a number of requirements: Employers covered by the standard must make exposure determinations and develop an exposure control plan . They must also use engineering and work practice controls to prevent employee exposure and develop a system to evaluate exposure incidents . It requires training all employees who provide or assist in providing patient care, as well as those who clean operatories, instruments, and gowns

Remember: through this standard, OSHA directs that: 1. Uniform clothing wom in the dental office should be laundered at the dental office or an outside service, not at an employee's home. L Offices are using barrier techniques, communicating hazards to employees (train irgl. performing proper cleaning of offce and offering hepatitis B vaccinations. Route of transmission: a route of hansmission is the process by which a pathogen is
transferred to a susceptible host through:

. Direct contact: transmits infection by person-to-person contact . Indirect contact: the spread of infection by an inanimate object . Droplets or aerosols: the spread of disease through the air by droplets that contain
pathogens

. Parenteral contact: the transmission ofpathogens by piercrngthe skin (intravenously, subcutaneously, or intramuscularly) through an accidental or intentional stick with a needle or other sharp instrument that is contaminated with blood or other body fluid.

. Always
. Never . Only where it is permitted and not in conflict with applicable laws or regulation . Only ifthe exposed employee gets sick following the exposure

68 Coprighr O 201| -2012 - Dental Decks

OSHA'S Bloodborne Pathogens Standard requires that a writtn exposure control plan be reviewed:

. Biannually

. Monthly . Every 3-5

. Amually
years

69
Copyrighr O 20ll-2012 - Denral Decks

The standard further requires that the exposed employee be informed of any laws or regulaions conceming disclosure ofthe identity and infection status ofthe source patient. The standard does not, therefore, require dental employers to violate any applicable privacy laws.

An exposure incident is defined

as a specific occupational incident involving eye, mouth, other mucous membnne, non-intact skin or parenteral contact with blood or other potentially infectious materials, including saliva. The most common example is an injury from a cont-

aminated sharp. Following a report ofar exposure incident, the employer must make immediately available, at no cost to the employee, a confidential medical evaluation and follow-up that includes: . Documntation ofroute(s) ofexposure and circumstances in which the incident occurred . Identification and documentation of the sourc individual, ulless the employer can
establish that identification is infeasible or prohibited by state or local law

. Results of testing of the source individual's blood, ifthey axe available . Collection and testing of the employe's blood gfteE consent is obtained
. Medically indicated prophylaxis . Counseling . Eyaluation of reported illnesses in the weeks following the incident
The employer must provid the following information to the health care professional who performs the evaluation: . A copy of the OSHA standard . A description of th employe's duties as they relate to the incident . Documentation of route(s) of exposure and circumstances under which exposure oc-

curled

. Rsults ofth source individual's blood testing (ifavqilqble) . All medical records releyant to treatmnt ofthe employe, including vaccination stattus, which are the employer's responsibility to maintain

The plan must be reviewed and updated after any changes in knowledge, practice, personel, guidelines, or regulations that may affect occupational exposure. The plan should document consideration and implementation ofappropriate safer devices that are designed to eliminate

or minimize occupational exposure. This documentation must include evidence that empployees who use the devices have had input into the identification, evaluation, and selection ofthe devices.

Exposure control plan (ECP): the standard requires that every employer have a writtn exposure control plan designed to liminate or minimize mployee exposure to bloodborne diseases. Basically, the plan must set forth your office policies and protocols to protect employees from these diseases.

OSHA requires that the plan contain the following elements:

schedule your office is implementing OSHA's requirements for: barrier techniques, hepatitis B vaccination, housekeeping, disinfection ofcontaminated work surfaces and equipment, handling regulated waste, post-exposure evaluation and followup, comrnunication ofbloodbome pathogen hazards to employees, and record keeping. the plan should outline your office protocol for when gloves, gowns, masks and eyewear (orfaceshields) are to be used; when and how you will provide haining for employees; your specific practices for disinfection; how you launder gowns forsite or using a set"vice); where you keep records, such as training and medical records and the OSHA standard; your office policy on the hepatitis B vaccination: and your office pro-

. How and on what

*** For example,

tocol for handling regulaled waste.

. It must be accessible to employees! and it must be updated at least annually and whenever necessary to reflect offlce changes (e.g., new procedures thqt allect occupational exposure, new positions). The plan must also be provided to OSHA upon request.

. Identification

. Hazardous ingredients . Fire and explosion data . AII ofthe above

70
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. Engineering controls

. Work practice controls

. Needle and sharp instrument handling techniques . Gloves, masks and protective eyewear . Patient screening and testing

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MSDS information includes: . Identification (chemical and common names) . Hazardous ingredients

. Physical and chemical characteristics (boiling point, vapor pressure, etc.)

. Fire and explosion data . Health hazard data . Reactivity data . Spill and disposal procedures . Protection information . Handling and storage precautions, including waste disposal

. Emergency and first-aid procedures . Date of preparation of the MSDS

. Name and address of manufacturer

Whenever possible, engineering controls should be used. Work practice controls

(i.e., techniques) are subject to human error and noncompliance. Gloves are minimally

protective against cuts and sticks and relatively few percutaneous injuries are sustained to the face. Standard precautions obviate patient screening and post-incident testing can rule out. rather than reduce, exposures.
Sharps include scalpel blades, sginges, injection needles, burs, and others. Remember: Most states require special collection and storage ofcontarninated sharps. Treatment rooms mr.rst have sharps containers that must be collected by biohazard waste

firms.

. Sterilized and disposed of with regular office trash

. Disposed ofas regulated waste

. Sterilized and

disposed ofas regulated waste

. All ofthe above

. None ofthe above

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. Patient

. Employee . Employer
. All of the above

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To prevent release of mercury vapor into the environment, mercury-containing items should not be placed in heat sterilizers or in regulated medical waste intended for incineratron.

Amalgam waste recyclers accept exfacted teeth. The ADA addresses this issue in its Best Management Practices (BMPs) for Analgam Waste.

OSHA is a Federal Agency/a division ofthe U.S. Deparftnent ofl-abor. Regulations from OSHA require all employers to provide safe and healthful working conditions for employees through standards or regulations.
These rules and regulations

fall into 3 categories:

and equipment

. General Safety Standard: fire, building . Hazard Communication . Bloodbome Pathoeens

. At initial placement ofthe employee

. On a semi-annual

basis

. During working hours . At no cost to the employee

7a coptright O 20ll-2012 - Denral Decks

. Creation ofthe Occupational Safety

and Health Adminrstration (OSHA)

. Identification of human immunodeficrency virus (HIY)

. Introduction ofhepatitis B vaccine

. Description ofmicrobial contamination ofdental unit waterlines

. American Dental Association directive that devices

be routinely sterilized

used

in intraoral treatment should

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Training ofemployees must be conducted:

. . . .

At initial placement in position

Reviewed arurually With documentation of attendance by employee During work hours At no cost to the employee
as soon as possible

Note: General safety standards require training

for all new hires.

***

The first published description of dental unit waterline contamination occurred in

, Not{ 'Bg

2. 1L. first ADA report on infection control was in 1978. 3. Heptavax-B became available in 1982, one year before the identification

of

HIV.

. Count ofantibodies to M. tuberculosis

. Reading 24 hours after injection . Measurement of diameter

. Localized reddening
. All ofthe above

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. Centers for Disease Control and Prevention . Occupational Safety and Health Administration . Food and Drug Adminishation . Environmental Proteclion Agency

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The diameter ofcutaneous induration at the injection site determines the test result. The test is read at 48 hours. Erythema is disregarded.

The Department ofHealth and Human Services fDdHt is the U-S. govemment's principal agency for protecting the health ofall Americans and providing essential human services, especially for those who arc least able to help themselves. DI{llS agencies involved with the delivery, funding, and research aspects of oral health includ:

(Centen for Disease Control and Pret)ention)t one of the I J major operating components of the Department ofllealth and Iluman Services ffll/Sl, which is the principal agency in the United States govemment for protecting the health and safety ofallAmericans and for providing cssential human services. CDC monitors and maintains records ofall diseases found in the U.S., and develops recommendations to prorect the health ofthe population. The CDC also formulates health care worker guidelines and recomnrendations for the preveDtion ofinfectious diseases. . FDA (LiS. Food dnd Drug Adminislrution), Ihe FDA promotcs and prctects the public health by belping safe and effective products reach the market in a dmely way; monitors products forcontinued safety after the) are in use; and helps the public get the accumte, sciencc-based information needed to improve health. . ACF Lldrfiinistrotiott for Children arrd ies): the ACF is responsible for federal programs that promotc thc cconomic and social well-being of familics, children, individuals, and communities and is responsible for the Head Start proglam. . C\lS (Centersfor Medicare.tnd Medicaid Serrrtes): the CMS administers the Medicare and Medicaid proerams. *hich provide health care !o about one in every fourAmericans. HRSA(Eealth Resources and Sentices AdminrStratirr): HRSA providcs acccss to essential heahh carc sen ices for people who are low-income, uninsured, or who live in rural areas or urban neighborhoods wherc

. CDC

Fa,

health care is scarce.

.IHS (lndia Health Serrr-ce): the cans and Native Alaskans.

IIIS focuses on the goal ofraising the health siatus ofNative Ameri-

is the world's prcmier medical research organization, supponing more than 38,000 research projects nationwide. Note: The NIDCR (Ndlional Institute of Dental and Cranio/acial Resedlcrl is among its institutes. . AHRQ (Agency for Healthcarc Research and Qualr'ryl: thlr AHRQ supports resarch on healtb car sysrems, health care quality and cost issues, access to health care, and effectiveness ofmedical treatments.

. XIH (National lftstitutet of Health)| theNIH

. A false negative test . A true negative test

. A false positive test . A true posltive test

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. Specificity

. Sensitivity
. Reliability . Validiry

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A test can produce two kinds oferors: a false positive res.ull (meaning that the test indicates presence ofthe disease when it is, infact, not there) or a false negative resJ.lt (meaning that the test indicates absence ofthe disease when it is in Jbct present).

ln general, a population of tested individuals may be divided into four groups:

. True Positives: those who test positive for a condition and are positive ft.e., have the condition) . False Positives: those who test positive, but are negative (i.e., do not have the cond-

ition) . True Negatives: those who test negative and are negative

. False Negatives:

those who test negative, but are positive

In order to evaluate the quality of a diagnostic test, it is necessary at a minimum. to know its validity, relia-

biliiy. sensiiivity, and specificiry

. \hlidityi refeN to whether the questions asked by the study are answered by thc method. Note: to be reall] \'alid. a test should be highly sensitive, specific. and unbiased. . Reliabilit!: is equal to the repeatability and reproducibility ofa test. Note: A reliable test would p.oduce
\ eh- similar results when used to measure a variable at different times. . Sensitivit!: is defined as the percent ofpersons with the disease who are correctly classified as having the disease /lro.re v'ro ,ave the disease). - True Positive /fP): those who have the diseasc - False negative /FN/: those who are incorrectly classified as not having the disease

. Specificit]: is defined

as the percent ofpersons without the disease who arc corrctly classified ha\ing the disease /t ose who do not hare the disease). - True \egative 1fN./: those who do not have the disease - False Positive fFP): those who have the diseasc but .re not identified by the test

as

not

Inferential statistics: is used ro make claims about the populations that give rise to the data collecled. This requires ihat \ve go beyond the data available to us. Consequently, the claims we make about populations are always subject io error; hence the term "inferntial statisticr" and not deductive statistics- lnferential statistics encompasses a variety ofprocedures to ensure tltat the infercnces are sound and rational, even though lhey rnay not al$als be conect. In short, inferential statistics enables us lo make confident dec isions in the face ofuncertainty.
1. The P

value is

probabiliry. h is the final arithmetic answer that is calculated by a statistical

test ofa hlpothesis (?/0 called the null hypothesit. Its magnitude informs the rcse.rcher as to lhe validity of the hlpothesis, thar is, whether to accept or reject the h'?othesis as worth keping. results are called "statistically signilicant." Note: If it's below .05 f5yor, reject the H0 its abo.qe .05 (594),accepr the H0 results are called "not statistically significant," 2. Corrlation/correlation coefficidt (r,/: quantifies the relationship between variables fr and.r. 3- Mutliple regression: provids a mathematical model oflinear relationship between a depndent and two or more independent or predictor va ables. 4. Chi-squ.re is a statistical test commonly used to compare observed data with data we would expect to obtain according to a specific h)?othesis. 5. t-test is used to analyze the statistical difference between two means.

-the

-th

If

. Quality assurance

. Quality evaluation . Quality

assessment

. Quality inspection

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. Periodontal Disease lndex (PDI)

. Simplified Oral Hygrene Index (OHI-S)

. Periodontal Index (P1)

. Gingival index

(G1)

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the measurement ofthe quality ofcare and the implementation ofany necessary changes to either maintain or improve the quality ofcare rendered.

Quality assurance is

The dilferences in these definitions are important: quality assessment is lirnitcd to the appraisal ofwhether or not standards ofquality have been met, whereas quality assurance includes the additional dimension of action to take the necessary conective steos to imDrove the situation in the future. The following concepts relate to quality assurance:
1. Structure: rcfc$ to the layout and cquipment of a facility. 2. Process: involves the actual services that thc dentist and assistant perform for thc patients and how well they perform. 3. Outcome: is the change in health status that occurs as a rcsult ofthe care delivered.

Informed consent: from

a legal perspective, there are three components that need to be addressed

in the informed consent process for dental treatment:

. cxplanation ofa procedure in such a way that a competent adult patient will undcrstand it . cxplanation and asscssmclt ofrisks and bcnefits ofthe procedure, or the consequcnccs if no
procedure is performed . discussion of altemative interventrons

\ote:

There also is the moral duty not to act against a patient's will. Apatient should not be coerccd inlo. unduly influenced to, receive inducements to or be intimidated into having a procedure.

Important: It is important to realize that it is not the written word but thc interaction between denlist and patient that is the foundation ofinfonned consont. The process ofobtaining informed consent should not be looked on as a legal necessity and a duty, but rather as a virtue of good dental
practice.

***

For this reason, neither ofthese indices is considered the best method !o measure periodontal disease.

Historically, several indexes were developed in an attempt to provide a standardized method ofmeasuring periodontal disease among groups ofpeople in epidemiologic studies, most nolably th Periodontal Index fP1./, the Periodontal Disease Index fPD, otRamqord , and thc Gingival Index 1G.r. The PI and PDI both combine gingivitis and periodontitis into a single tooth score or avemge score for the individual or group. The Pl identifies two levels of gingivitis, depending on its extent, and two severity levels of periodontiris, depending on the severity ofperiodontal destruction. The PDI, a modification ofthe PI. measures gingivitis and periodontitis separately, but similarly to the PI, combines these measures to generate an overall score for the indiYidual. Th PDI diflers from the PI in that it distinguishes three levels ofgingivitis sevcriry based both on the exten! of the inflammation around the tooth and the severity ofthe inflammalion. The PDI also diffrs from rh. Pl in its measurement of periodontitis by quantitatively measuring loss of attachment with a periodon:al probe. dcfining dcgrees ofperiodontitis severity based on the amount ofattachment lost. A total score lor the indi\ idual is achievcd by avcraging the individual tooth scores.

Remember: The Gingival Index fGI, ofLoe and Sillness was introduced in the early 1960s to provide an inder that solely measured inflammation of the gingiva and would allow a clear distinction to be made b.nveen the location or quantity ofgingivitis and the severity or quality ofthc gingivitis. Thc GI accomplishcs this by applying a four-category qualitative assessment (nonkal, mild, t oderale, or se|erc in.llonnation) to four sitcs (r,e.!ial distal, buccal, and lingual surfaces) on each examined tooth. Each area is scored on a 0 to 3 ordinal scaie. These values can then be averaged to yield a score for an indi\ idual. The GI has become a mainstay index ofgingivitis over the past 30 years.

.
.

l.The Gingival Index

fG,

and the P-M-A,(sta dttlgJbl

Papilla0-Man,ror^ro"r"O, ur"

,r-ote*:

confined to measurements within the gingiva. 2. The Plaque Index fP, is used to determine accumulatiol of plaque. l.The Sulcus Bleeding I ndex asr1./ is used to determine bleeding and the gingival health.

OHI and OHI-S are debris indices. DMFS and DMFT are caries indices. 6. The best timc to pe'fotm an index (peiodontal or plaque) is at thc bcginning ofthe app4. The
5.

ointment.

. TSIF . DMFS . DMFT

. CPITN

a2

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1.0

Tooth #14

.1.5

Surface Buccal

Sloiris'

.2.0
.2.5

Lingual
Mesial

Distal

83 Coprright O201l-2012 - Dental Decks

Epidemiological me{sures: . DMFT/DMFS: The conventional method ofdefining dental caries in a population is to measurc either the number ofteeth or the number oflooth surfaces lhat are decaycd. missing. of filled as a result ofcaries. When !his measure is applied to thc permanent dentition. the acronyms Dl\lFT and DMFS are used; when thc measure is applied io the primrry dentition. the acronyms deft and dfs are used, with e indicating a carious primary tooth that is indicated for extraction. The DMF is an irreversible index.
The results ofthe DMFT index yield a group's cNries susceptibilil. It has received practically univcrsal acceptance and is probably thc best known ofall dental indices.

Limitations ofthe DMFT index (or

dn.v

caries inder):

L DMF values {re not relatd to the numbr ofteth at risk. 2. DMF index can be invalid in older adults bccause tecth can become lost for reasons other than caries. 3. DMF index can be misleadins in children whose tecth have been extracted for orthodontic reasons. 4. Dl\ll cannot bc u'ed for root caries. 5. DMF cannot account for sealed teeth.

\ote$ '.

L The prevalence ofcaries in the Unitcd Statcs has declined substantially betueen the early 1970s and the late 1980s due to fluoridation, thc use offluorides, and othcrprcventive measures.

DMFS for U.S. childrcn agcs 5 through 17 was 7.1 during thc carly 1970s; this lalue dropped to 2.5 by the late 1980s, a 6570 reduction,
2. The mcan

In addition, the proportion ofDMFS that is cithcr untrcatcd carics or missing surfaccs has also dramatically fallen during this period. .1. Baby bottlc tooth decay (Early Childhood Ccrries) affects approximatcly 57o of inlants in the United States. Ethnic minoriry and lower socioeconomic status children are at the greatest risk.

l.

i.The prevalence ofcoronal caries has declined in reccnt decades among U.S. adults undcr Still nearly all dentate U.S. adults have at Ieast onc dccayed or filled tooth. 6. The average root surface DFS for U.S. adults is approximately equal to one surfaoe. 7. Chronic periodontitis js the most common form o f periodont itis- Its prcvalence, extent, and severity increase with age.
age 45.

***

Plaque index for this tooth = 2+l+2+3 / 4 = 2.0

Silness and Loe dcveloped a Plaque Index fP, designed to be used along with thcir Gingival Indcx /G,l/. The same surfaces ofthe same teeth are scored as jn the CI and a 0 to 3 scale is again used. The principal difference befwccn thc PI and thc OHI-S approach is that the plaque index scores the plaque present according to its thicknes$ at the gingival margin rather than its coronal extent.
Criteris for thc Plaoue lndcx
0

No p:aque

A film ofplaque adhcring to lhc f.Ec gingival margin ard adjaccnt area ofthc tooth. Thc plaquc may be seen i ilu only afier application ofdisclosi'g solution orby runninssp1obc
across rhe rooth suri-acc.

Voderatc accumllation ofsoft deposits witbin the gtugival pocker, or the tooth and silgival marsin which can be seen \rith lhc raked cyc.
Abundancc of soft mattcr within

tlc gingival

pocket and/or on lhc looth nnd gingi!l inargin.

L The plaque index

has been extensively uscd

but does not have uriversal acccptability.

.\ote.. 2. According to some studies, 80-907o ofchildren have inflammatory pcriodontal discase '..:,.,,..'(gitlgi|ili.tot'pet'iodotltitis)bytheageofl5.Localizedacutegingivitisisthcmostcommon - '-" ' fonn. Epidemiologic studies show the strongest relationship between prcvaletce and severity ofperiodontal
disease

with oral hygiene and age.

The Community Periodontal Index ofTreatment Needs fCPlfN, was deveioped in 1978 by the World Health Organization ffHOJ. It is used primarily for epidemiologic studies. The majoi difference bctween thc CPITN and other indices is that it determincs not only thc severity of gingivitis (bleedlrgl and pcricrdontitis lpocket probing depth), but also provides information concerning thc typc ofdiscase process and therefore also the extent oftherapy that is neccssary The CPITN does not considcr thc attachment loss on individual teeth, rathcr only thc clinical situations requiring tteatment fi.e., gingir'ol in.flamnotion, bleeding, calcttlus, pockel probing depth). Note: The CPITN is mcasured and ascertained

using a special probe on all teeth

. Reversible index . Ineversible index

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. First-party dentistry

. Second-party dentistry
. Third-party dentistry . Founh-party dentistry

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A dental index is a data collection instrument used to numericallv exDress the oml health status ofa DoDulation.

Important: An irreversibl index is one that measures conditions which cannot be reverscd fdental caries). A reversible index measures conditions that canbe changed. (plaE)e and bleeding). Epidemiological measures-Commort Indices: . Dec.yed-missing-filled teeth index fDMFI): an irreversible index
used to determine total dental caries y on permanent teeth. It has received practically universal accepexperience, past and present. It is used tance and is probably the best known ofall dental indexes. Remember: The DMFS index is th same as the DMFT index except it records tooth surfaces involved instad ofteeth.

Important: The primary dentition

uses the deft and defs index f/ec at'ed, extracle.l..filled teeth or surfaces).

. Gingival index (GI) ofl-oe and Silness: is a reversible index that solely measures inflammation ofthe gingiva and allows a clear distinction to be made berween the location or quantity ofgingivitis and the severity or quality ofthe gingivitis. Note: The oldest rcvenible index is probably the P-MA (standikgfor Papillary-Margi al-Auached). With better understanding ofthe inflammatory process,
it gave way to the Gingival Index Periodontal indices:

fG, ofloe and Silness

in the early 1960s

. PeriodoDtal Index fPl/: a reversible inder which combines gingivitis and periodontitis into a single tooth score or average score for the individual or group. . Periodontal Disease Index fPrI, ofRamliord: a reversible index which combines gingivitis and periodontitis into a single tooth score or avemge score for the individual or group. Note: The PDI gave us lhe -R4mtord teeth," an examination ofsix teeth taken to.cpresent the whole mouth. The "Ramliord teth" are the maxillary right first molal left central incisor, and lcft first premolar, the mandibular left first molar. right central incisor, and right first premolar . Community Periodontal Index ofTreatment Needs (CPITN/: a rversible index that provides not only conclusions about the incidence ofperiodontitis in a population, but also about the xpense, in both tim and money, that will be necessary for treatment ofa population group. . Simplified oral hygien index fOLlJ): a reversible index used to measure oral hygiene staos by using a debris index and a calculus index. These components are added to obtain a single score. . Plaque index: a reversible index used to assess the thickness ofplaque at the gingival margin.

The major forms

ofthird-party reimbursement cunently in

use are:

Usual, customary, and reasonable (UCR) fee:. reimbursement is based upon the dentist's usual charge, unless the charge exceeds certain paramete$. In order to determine UCR fees, dentists must usually become panicipating providers with a plan and agree to file their fees periodically. . Table of allowances: the third-party payer generally determines what fees it is willing to pay
for each procedure. The participating dentists agree to charge plan members these prenegotiated fees as payment in full, or the plan may allow th dntist to engage in balance billing, which allows the dentist to charge the patient any difference between what the plan pays and the dentist's UCR l'ee. . Fee schedules; is a list of fees established or agreed to by a dentist for the delivery ofspecific dental services. A fee schedule usually presents payment in full, whereas a table ofallowances might not. Note: Medicaid would be an example. . Capitation: the dentist is paid a fixed amount, usually on a monthly basis, directly by the capitation plan. For this fixed paymcnt the dentist agres to provide specified dental services for patients who present and who are assigned to him or her by the capitation plan. . Reduced fee for service: is corrunonly associated with Preferred Provider Organization (PPO) plans. The participating dentist agrees to provide care for fees usually lower than other dentists in a particular geographic arca. Panel ofproYiders:

. Closed panel: dental services provided by salaried dentists at specified locations only. . Open panl: dental services provided by any dentist willing to accept third party payment.
Note; Dentistry is financed rnainly through fee-for-service self-pay. 56% ofall dental expenses are paid out ofpocket by the patient. Third-party payers represented by private insurance pay about 33% oftotal dental expenses, followed by govemment-financed orpublic programs f,'.e., Medicaid, Velerans Alfairs) .

The maior obiective of public health programs is:

. Prevention . Cost efficiency . Teamwork

. All ofthe above

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. The first statement is true; the second statement is false . The first statement is false; the second statement is true . Both statements are true . Both statements are false

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The fundamental principles ofpublic health are prevention, cosr efficiency and teamwork. Prevntion is rhe major objective ofpublic health programs because it ntails ethics, teamwork and cost elliciency.

. ll

is more elhical to prevenl disease than to cure ir . Teamwork is necessary to handle large groups elliciently . Cost efliciency plays a major role because preveDtion is cheaper than

curc

Educrtion plays

an important role in public health because it decreases the need for govemment intervention.

In othe. words, when people leam why regulations are ofvalue they will comply. For example, when people leam how many lives are saved yearly by wearing satbelts, then they are morc inclined to wear them. . Primary prevention: or preventing a disease before it occurs, is the most elfective way to improve health
and control costs. Examples include community water fluoridation and sealants.

. Scondary prcvention: is treating or controlling the disease after it occurs, such restomhon.

as

placing an amalgam
a

. Tertiary prevention: is limiting a disability from a disease, or rehabilitating an individual with ity, such as providing dentures for those who have lost all oftheir teth. Prevention may be accomplished at an individu l (in offce or at hone.) or community level:

disabil-

L Community water fluoridation: The CDC has said that "Community water fluoridation is the single most effective and efficient means for preventing dental caries in children and adults regardless ofrace or income level." Community water fluoridation is defined as the adjustment ofthe concentration offluonde of a community water supply for optimal oral health. The recommended level of fluoride lor a communit-v \\ater supply in the United States raiges iiom 0.7 to 1.2 ppm offluoride, depending on the mean ma\imum daily airtemperature over a s-year period.. In the U.S. most communities arc fluoridated at about I ppm. which is equivalenl to 1.0 mg offluoride per liler ofwater. At this level fluoridated water is odorlesi. colorless, and tasteless. Th ffectiveness ofcommunity water fluoridation is currently 20o/" to 40n/". :. School watr fluoridation: was developed and tested in the U.S. in the 1960s for use in rural schools $ rth an independent water supply. The major difference between school water fluoridation and communi!} \\'arer fluoridation is that the recommended concenoation for school water fluoridation is 4.5 times the conceniration offluoride recommended for community water supplies. The higher concentrations are recommended to compensate for part-time exposure because children spend only part oftheir time at school. Sodies have shown that a 209lo to 307o reduction irl caries can be expected when children have consumed
schoolwater fluoridation for l2 years.

Topical fluoride: thc application oftopical fluoridc to the teeth increases toolh rcsistancc to carics. Thc fluoridc can bc delivcrcd eithe. brushed as a vamish or in a tray as a gel. . Fluoride varnishes: fluoridc vamish is not intendcd to be as pcmancnt as a fissure sealanlt mthcr it is a vehiclc for holding fluoridc in close contact with thc (ooth for a period oftimc. vamishcs arc a way ofusing high fluoride concentratiors in small amounts ofmatcrial. This kind offluoridc may bc cspccially uscful to prcvent root surface carics among lhc growing numbcrs ofoldcr aduits who havc girrgival rcccssion. In addition, fluoridc var' nishcs maybc cspcc ially atractivc for usc with disablcd childrcn and bcd-bound patients who still havc thcirown
tccth.

Fluorid supplements; are availablc only by prcsc.iption and arc intcndcd for usc by childrcn living in non-fluoridatcd arcas. For optimum bcncfits, use offluoride supplcmcnts should bcgin whcn a chiid is 6 months old and bc conrinucd daily until thc child is l6-ycars-old.
. Tabletsr thc child chews thc tablct for approximately 30 seconds. Thc rcsullant solution is thcn swishcd bctween the recth foranothcr 30 seconds and thcn swallowcd. Thus thisprocedure providcs both systcmic and topical bcn.iits. Srudics havc shown thc daily use of fluoridc tablcts on school days willprovide a 30o/orcduction in new carics
has bccn uscd in schools in the Unitcd States for nearly thrcc decadcs. It is lhc mon popular school-based fluoride rcgimen in the Unitcd Statcs. Studics have dcmonstrated thatdcntal carics can b. reduccd bt_ about 25% to 28% by rinsing daily or wcckly in school with dilutc solutions offluoride. Rinsing $cckl! Nith a 0.2% neutral sodium flr-roridc or'aF) solution is more common than daiiy rinsing with a 0.05% \aF solulion.

. \Iouth rinse: fluoride mouth insc

OInce-based preventive methods:

childrcroccurs on lhc chcwing surfaces, thcuse offluoridcs and pir and fissure sealants is rccdcd to provide nearly total caries prevcntion. Thc cflcctivcncss of dcntal scalants has been rrported in thc rangc of 5lyo to 67yo. . Fluoride gels: thc most common fluoridc compound uscd is acidulatcd phosphalc fluoride f/PFr' APF has apH
r Seelants: si)tcc most decay among school-aged

ofabout 3.0. Thc most common concentration is 1.23o%, usually as NaR in orthophosphoric acid. Home-based preventive methods: . Brushing: with a fluoride toothpaste should be done twice per day using a pea_sized amount ofloothpaste. . Fluoride gels: contain either stannous fluoride (0.4%) or sodium fluoride (l.0%) and are formulated in a nonaqueous gelbase that does not contain an abrasive system. The gel shouldremain in the mouth for4 minutes, and then spit out thoroughly.

. Morally obligated to report child abuse . Ethically obligated to report child abuse . Legally obligated to report child abuse
. All of the above

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. Incidence
. Prevalence . Epidemiology

. Frequency

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Dentists are morally, ethically and legally obligated to report a suspected case
abuse.

ofchild

Once an injury of a suspicious nature is obseryed, the dentist's first and immediate responsibility is the protection ofthe child. Reports should be made to the designated state agency f.rociol service,s or polic'e). Dentists must familiarize themselves with the exact Drocedures to be followed in their own
states.

NotS:.

l. Child abuse most commonly involves newborns and children up to the age ofthree years. 2. Dentists are also ethically obligated to identify and refer cases of domestic violence. Practitioners should become familiar with the physical signs of domestic violence, especially because 680/o ofbattered women's injuries involve
the face. 45% the eves. and 12% the neck.

Incidencc and prevalence arc closcly rclated. Preralence (the proportion oJ a populalion )+ith a prcblen at a desig,a/e,? rnre) dcpcnds on both thc incidcncc /lre rd te of nev problem during a period oftine) znd the duration ofthc Thc incidence ofdiscasc (also knotvn as rhe cunuldliw incidence) isrhcnumbcrofnew cases ofa diseasc that occur rn ]r popularion at risk ofthc discasc during a spccific time period. It is expressed as a rate.

L Prcvalence

is a more

relevant mcasurc than incidcncc when asscssing thc impact ofaproblcm wilhin

\otea

a commudit-v and to asscss thc subscqucnt nccds,

:. Rememberi

Incidcnce is a rate and requires a unit is cxprcsscd as a pcrccntage ofthe population. l. Frequency is simply a count.

oftirnc, r'hcreas prevalence is

proportion and

is thc srudy ofthe distriburion and delerminants ofdisease. In public hcahh, groups ofpeople arc stud:cJ ro ans$ cr qucstions about ctiology ofdiscascs, prcvcntion. discasc pattcms, and allocation ofrcsourccs.

Epidmiologl

Communicable Disease

. D;scasc tmnsmined from one host to anolhcr \on-communicable Discase

. \or transmiltcd fion onc host lo anothcl . Usually caused by onc's own normal flora or an cnvironmcntal rcsefloir

Important information to remember:

I - Thc grcat majority oforal and phar),ngcal canccG arc squamous ccll c|rcinoma /SCC). 2- Oral canccr rcmains twicc as prcvalent in males as in fcmalcs, and ncady twicc as many deaths occur in malcs as in fcmalcs. Oral canccr is closcly rclatcd to incrcasing agc, alcohol consumption and smoking arc thc nain risk

factors. 3. Canccrs ofthe lip and orel cavity account for about two-thirds of all rcw oml and pharyngcal canccrs, with thc tongue being thc most common sitc olcanccrs ofthc oml caviry. 4. Ovcrall thc s-ycar survival ratc for oral and pharlmgcal canccrs is about 5002. Howcvcr, survival ratcs vary considcrably dcpcnding on the cancer sitc, gender, and race. Note: The 5-year survival rates for cancer ofthe lip afc about 90%, ollbc tonguc it is about halfthat and is only about 20% amonS male African-Amcricans. womcn tcnd to have higher survival ratcs with thc cxccption ofcanccr ofthc lip. 5. Er,vthroplssia, rathcr than lcukoplakia, is oficn thc first sign of cancerous change in a lesion.

. Increase bias

Decrease bias

. Have no change on bias

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. To encourage mental and physical efficiency . Promotion through organized community effort . Individuals acting alone can solve any problem

. The science and art of preventing disease

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Important: Both require justification, however, because when randomized and blinded, subjects have no say in their choice ofexperimental treatment nor do they have information about what experimental treatment they are receiving.

A "randomized study" is a study in which all subjects have an equal chance ofbeing
assigned to either the study or control group.

Statistical probability is such that the assumption can then be made that the groups differ from each other only in terms ofthe agent under study. Any uncontrolled variables influencing the outcome are likely to affect subjects in both groups equally. For this reason, researchers prefer the random assignment method for placing subjects into either the study or control group. When subjects are unaware ofwhether they are in a test or control $oup, this is said to be a blind study. When neither participants nor examiners know the group allocations /test or control groups) it is called a double-blind study. Note: One means of achieving a blinded study is with the use ofplacebos.

Tuo variables used in research studies: l. Dependent variable is the variable whose value depends on those of others; e.g., in the formula x = 3y + z, x is the dependent variable. 2. Independent variable is the variable whose value determines that of others; e.g., in the same formulas as above, y and z are the independent variables.

C.E.A. Winslow defined public health as "the science and art ofpreventing disease, prolonging life and promoting physical health and e{ficiency through organized community
efforts." Three principles of public health: 1. A problem exists 2. Solutions to the problem edst 3. The solutions to the problem are applied A public health problem must meet the following criteria:

A condition or situation that is widespread and has an actual or potential cause of morbidity or mortality . There is a perception on the part ofthe public, govemment, or public health authoriG
ies that the condition is a public health problem.

Dental public health has been defined by the American Board ofDental Public Health as follows: "The science and art ofpreventing and controlling dental diseases and promoting dental health through organized comrnunity efforts." It is that form ofdental practice which sewes the community as a patient rather than the individual. It is concemed with the dental health education ofthe public, with applied dental research, and with the administration ofgroup dental care programs as well as the prevention ard control ofdental disease on a community basis.

. Disease . Rasons . Death . Birth

as to why disease and death occur in a population

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. Capitation fee
. Fixed fee . Contractual fee . Managed fee

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Vital statistics are quantitative methods routinely collected by epidemiologists and public health professionals. They are uscd to monitor and evaluate thc life history ofa specific population. Vital
statistics include: . Morta,lity (also called death rate) rcflects the number ofdeaths caused by a specific disease. It is thc ratio ofthe number ofdeaths caused by the disease to the total number of cases ofthe disease at a specific time. . Morbidity (lllness) is the incidence ofa specific disease within a given population. . Natafify is the birth rate (ratio of biths to the general population). . Birth-death ratio l.also called the ital inder/ is the numbcr ofbirths in a given year divided by the number ofdeaths in a given year lt is an indication ofthe populatior growth, stability or

reduction. . Crude death rate is thc ratio ofthe number ofdeaths occurring within population to thc total population during that time.
and to evaluate hcalth program eflectiveness.

given time period and

Note: These statistics are used to identifu community health needs, to estimate health care costs
Olher comnon terms in Epidemiology:
. -{ttack rate; the proportional number ofcases developing in the population that was exposed ro thc infcctious agent . Endemic: a discase or other occurence that is constantly present in a population . fpidemici a diseasc or othcr occuncnce whose incidcncc is higher than expected . Index case: the first identified case of a disease in an outbreak or epidemic . Outbrerk: a cluster of cases occuning during a brief time interval and affecting a spccific population; an outbreak may be the onset ofan epidemic . Pandemic: a worldu ide cpidcmir . Portal of entry: surface or orifice through which a disease-causing agent enters the body . Portal of exit: surface or orifice from which a discasc-causing agent exits and disseminates . Reservoir: the natural habitat of a disease-causing organism

Dental managed care is an arrangement whereby a third-party p yer (e.9., insurance company, Jbderol goyernment or corpolation) mediatesbetween doctors and patieots, negotiating fees for sewices and oversees the types of heatment given.

Eramples of managed-care practices:

. D-H\IO (Dental Health Maintenance Organization): is the We of plan most commonly associated $ irh dcntal managed care. It is usually a self-contained staff-model practicc in which no distinction is made betw,een the providers ofinsurance and the providers ofhealth carc. This type ofplan is also calLed a capitation dental plan. . D-PPO (Dentat Preferred Pro|ider Organization) . D-lP,\ tDenvl Indi dtldl Praclice Association)
1.

The D-PPO ard D.IPA represent groups ofdoctors who pmctice in the community and are

\ors

distinct from the insurance provider Howeveq an insurance agcncy contracts with the
proliders for discounted rates and may refer patients to these providers exclusively.
D-PPOS and D-IPA s q?ically involve contracts between insuers and a number ofdentists. Paticnts arc allowed to choose from whom they will receive dental trcatment fiom depending upon rlrhether or not the dentists participates in the PPO anangement. Participants of HMOS are much more limited in the selection ofdentists liom whom they can rcceive treatment.

2.

Pa] mnt to the dentist for these managed-carc proglams is usually made on a capitation basis. A capirarion fee is usually a fixed monthly payment paid by a canier to a dentist based on the numbcr ofparients assigned to the dentist fortreatment. This fee is the same regardless ofhow much or how little care is delivered.

Delivery models: Dental managed care plans can be desigled with diff'ercnt delivery models which includei

. Staff rnodel: usually has one or more dental offices that use salaried staffdentists. . Network model: uses multiple dental oflices in va.ious locations and is the most common method
ofdelivering dental benefits in managed dental care. . Closed model: also known as Exclusive Provider Organization, the paticnts have a limited choice ofoffices where they can go to obtain dental care. This model is often used in a D-HMO or PPO plan.

. The dental profession and insurance companies

. The dental profession . The dental profession . The dental profession

and public health board ofdirectors and society and the local govemment

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. Dentists cannot deny anyone care due to

disability

. Dental offices must undergo structural charges to allow access for the disabled

. Dentists cannot dismiss employees

due to a disability

. Patients with HIV are not Drotected under the Americans with Disabilities Act

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dental profession holds a special position oftrust within society. As a consequence, society affords the profession certain privileges that are not available to membcrs ofthe public-at-large. In rctum, the profession makes a commitment to society that its members will adhere to high ethical standards ofconduct. These standards are embodied in the ADA Principles ofEthics and Code of Professional Conduct (ADA Code). T\e ADA Code is, in effect, a written expression ofthe obligations arising liom the implied contract bgtween the dental profession and society. Members ofthe ADA voluntarily agree to abide by the ADA Code as a condition ofmembership in the Association. They recognize that continued public trust in tht- dental profession is based on the cornrnitrnent ofindividual dentists to high ethical standards

Tle

ofconduct.
The ADA Code has thre main components:

. The Principles of Ethics

. The Code ofProfessional Conduct . The Advisory Opinions

Five fundamental principles form the foundation ofthe code:
1. Justice ("fairness' ?: the dentist has a dury to treat people fairly. the dentist has a duty to respect the

patient's.ights to self-determination and confi dentiality. l. Bnelicence f"do good'): the dentist has the duty to be kind and to give the highest quality ofcare that onc is capable of. .{. Nonmaleficence f"do ho hd n")ithe dentist has a duty to refrain ftom harming the patient. 5. \'e.acity ("truthfuhtess'): the dcntist has a duty to communicate tluthfully. Remember: The dentist is responsible for providing information and dental care, however, ultimately
ihe patient is responsible for maintaining his,4rer own oral health f6rushing, llossihg, etc.).

L Autonomy f"sely'governance")i

\oter

The Good Samaritan law' enacted in all states, provides immunity ftom suit for specified health practitioners who render emergency aid to victims of accidents, provided there is no evidence ofgross negligence. Import{nt: Not all states include dentists in the Cood Samaritan law.

***
Act.

This is false; patients with HIV are protected under the Americans with Disabilities

Both state and federal statutes deline disability as having the following:

l. A physical or mental impairment that substantially limits one or more ofthe major
life activities of such individual.

f. A record ofsuch impairment.

i.

Being regarded as having such impairment.

. Cause . Cure . Extent . Mortality

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. Title ofstudy
. Abstract

. Introduction and literature review

. Vethods . Results . Discussion

. Summary

and conclusion
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*** In addition. thc findings ofthesc studics oftcn providc thc basis for ihc gcncration ofhypothcscs conccming discasc causation and prcvcntion, which can be further invcstigatcd cpidcmiologically.
f,pidemiological studies can be organizcd inlo thrcc calegories:

l. Descriptive epidemiology:

is uscd to quanti ry discasc status in the community. The major pammctcrs of intcrcst

arc preralence and incidence.

- The prevalence ofdiscasc is the proportion ofcxisting cascs ofa discasc in a population at onc point in time or during a spcci ficd pcriod of limc- 11 is expressed as a perccntagc and rangcs from 096 to | 00%. pruvalence = Numbcr ofocoplc with thc discasc Tolal nunrber ofpcoplc at risk - Thc incidence ofdiscasc is thc numbcr casc during a spccificd

ofnew

cases

ofa discasc that occur in

a DoDulation at risk

ofthe dis-

lime pcriod.

Incidence
2.

Numbcr ofncu'cascs ofthc discasc Total numbcr ofpcoplc at risk

Anall_tical epidemiology: also callcd "observaaional epidemiology", is uscd in an attcmpt to asscss thc rcla tionship bct$cen cxposurcs and discasc by obscrving cxposurc-discasc associations as lhcy naturally occur in thc popula(ion undcr study. Thc three main t),pcs ofobscrvational cpidcmiologic studics arc thc: - Cross-sectional study: looks al both thc cxposurc ofinteresl and the discasc outcomc at thc samc poinl in
rintc.

Case-control study: identities subjects on lhe basis of\\'hether thc disease ofinterest is prcscnt rnd thcn, by ofa history looks for associalion bctwccn thc discase and one or morc parst cxposures. - Cohort study: idcntifics subjccts acco.ding to whcthcr thcy havc a particular exposurc ofinterest and then tbllows drcm over limc to scc ifan associalion cxiss bclwccn thc cxposurc and thc dcvclopmcnt of onc or
mcans

morc discascs. 3. Erperimental epidemiologv: is uscd primarily in intcrvcntion studics. Once thc cliology has bccn cstablishcd, rhe rcscarchers try to dctcrminc thc cflcclivcncss of a particular program ofprcvcntion. Thcsc studics can be dilidcd into t\r'o main typcs: - Clinical trirlsr arc conductcd to lcst ncw prcvcntivc orlhcrapcutic agcnts, with subjccls assigned by the in\'csiigalor to diflcrcnt treatment groups, usually according lo some fo.m of random assipnmcnt. Wcll-dcsigncd clinical trials usc a double-blind design. , Community trisls: in siiuations in which an intcrvcntion can bc practically evaluatcd only at thc community level, a community lnal can bc conductcd. Thc group as a lvholc is studicd rathcr than thc individuals in

Format ofa Research Study

1. Tiale

of study; topic and focus ofstudy

2.

Abstract
- Research focus - Mthod - Summary ofresults - Concluding statement - Key words

3. lntroduction and litrature revie$ - Importance

- Literature rcview - Statement ofintent, theory and hypothesis

4. Methods - Sampling stmtegy - Measurement sttategigs and measurement instruments - Experimental design - Statistical analytical procedures 5. Results 6. Dlscussion - Review and surrrnary ofresults - Discussioa ofresults and comparison to theoretic preseltation or hypothess 7. Summarv aDd conclusion 8. Bibliography and refere[ces

. Inferential statistics
. Descriptive statistics . Informative statistics

. Reliability statistics

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. Copayment

. Coinsurance
. Deductible

. Balance billing

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Familiaritywith biostatistics, or thc mathcmatics ofcollection, organization, and interpretation ofoumeric datahaving to dowith living organisms, is essential for today's health care professional. Statistics can be dcfined as the practicc, study, or result of the application of mathcmatical functions to collcctions ofdata in ordcr to summarize or cxfapolatc thc data. Statistics can be used in two \4'ays: to dcscdbc data, and to make infcrcnces from thcm.

. Dcscriptive statistics:

are

away of summarizing

daCa

or letting oncnumbcr stand for

group ofnumbcrs. Thclc

are lbrcc ways wc can summarizc data

- Tabular rcprcsentation ofdata - Graphical fcprcscntation ofdata - Numerical rcprcsentation of data

. Inferential statisaics: allow someone to gencralizc from ahc samplc ofdala to a largcr group ofsubjects. Frequencydist butions; In statistics, a frequency distribution is a tabulation ofthcvalues that one onnore variablcs
takc jn a sample.

. Normsl distribution: In many natural proccsscs, random variation corrforms to a particular probability distribution kno$n as the normal distribution, which isthe mostcommonly observed probability distrjbution. Thc shapc ofthc normal distribution resembles that ofa bell. so it somelimes is refcncd lo as the "bell curve." Note: The mean, mode and the medium are the same value. Skewed distribution: A skcwcd distribution is asymmctrical with dispcrsion skewed to the lcfi or right ofthe median. D'spcrsion skewed to the right is said to be positive with the mean being Sreater than thc mode and me\Ieasures of central tendencvi . ]lean: thc mean or average is Ihe value obtained by adding all the mcasuremcnts and dividing by the numbcr

of

. lledian: rhe median is the middlc mcasurcmcnt in a set ofdata wherc halfthc data is above and halfthe data is bclow the numbcr . \Iode: the mode is thc most frcqucnt mcasurcmcnt in a sct ofdata. \leasures of dispersion:
Range: is thc simplcst mcasurc ofvariability. It is the diffcrcncc bctwecn thc highcst and lowcst valuc in lhc distribution. . Both variance and stsndard deviation ncasurcs variability within a distribution. Standard deviation is a numbcr that indicates how much on avcmgc cach ofthc valucs in thc distribution deviatcs ftom thc t\1c n (or cente, ofthc distribution. Kecp in mind that variancc measurcs thc sanc thing as slandard dcviatior (dispercion of scores i a distributioti). Variance, howcvcr. is thc avcragc squarcd deviations about thc mcan. Thus, variancc is

'

thc square ofthe standard dcviation.

Terms to bc familiar with:

. Deductible: the amount ofeligible expenses a cove.ed person or family must pay each year from his/her own pockct bcforc thc plan will makc paymcnl tbr cligiblc cxpcnscs. On family policics, dcductibles are typically pcr pcrson and usually havc a maximum of2 or 3 famjly membcrs that will need to mccl thc dcductiblc. . Copayment: a cosfsharing arrangement in which an insured pays a specified cha.ge for a spccilicd service, such as $25 for an office visit. The insured is usually responsible fbrpayment at thc timc the service is rcndcrcd. lfa plan has copaymcnts on dcntal ofllcc visits, this chargc typically docs not counl toward coinsurance and dcductible palanents becausc thc scrvicc is covcred bcforc thc dcductiblc and coinsurance. . Coordinrtion ofBenefits /COrr: a provision in lhc contract that applics when a person is covercd undcr more lhan onc dcntal plan. [t requires that paynent ofbenefits be coordinated by all plans to climinale over-insurancc or duplication of bencfits. . Coinsurlnce: thc portion ofcovered dental care costs for which the covered pcrson has a financial responsibiliN, usuall)' a fixcd pcrccntagc- Coinsumncc usually applics aftcr thc insurcd meets his,lrer dcductiblc. . Bslance billing: is the firralt illcgal practicc ofdcntal officcs and othcr mcdical facilities billing patients lbr ihc balance bcfrvccn what they want to charge their patients for services and what thc insurancc company has alrcad\ rcjmburscd thcm. 'Reasonable and Customary /R & C/: a tcrm uscd to rcfcr to thc commonly chargcd orprevailing tees tbr dental scniccs Nithin a geogrlphic arca. A fcc is gcncrally considcrcd to bc rcasonable ifit falls within thc paramctcrs olthc a\'cmge or commonly charged fce for the particular service within that spccific community. 'Preferred ProviderOrg nizstion (PPO, a dcntal carc dciivcry armngcnlcnt which olTe.s acccss to participating pro\ iders a1 rcduccd costs. PPOS provide insurcds incentivcs, such as lower deductiblcs and copaymcntsi to lrsc providers in the network- Nctwork provideN agree tonegotiated fees in exchange for thcirprcfcrrcd providcrsta. Point-of-Service Plrn IPOS): adcntal insurancc plan that offcrs mcmbcrs options for diflircn t dclivcry systcms such as DMO. PPO. ctc. . Participating Provider: a denlal provider who has been conlracted to rcndc. dcntal scrvices 10 insurcds at a prc-

. Out-of-Network Provider: a dcnlal care provider with whom a managed carc organization does not havc a contract lo providc dcntal care services- Because the beneficiary musl pay eitho all ofthe cosls ofare from all ourof-nctwork providcr or thcir cosGsharing requirements aregreatly increased, dcpcndingon the particularplan a bcneficiary is in. . Netrvork: a list ofdcntisls who provide dental care services |o the bcncficiarics ofa spccific managed carc orSanlzatlon,

negoliatcd fcc.