DENTAL STUDIES POLICIES MANUAL (DSPM)

Transcription

1 DENTAL STUDIES POLICIES MANUAL (DSPM) FALL /17

2 DENTAL STUDIES POLICIES MANUAL ON-LINE PDF INDEX SECTION PAGE A. General Program Policies 22 B. Clinical Policies 35 C. Management of Medically Complex Clients 45 D. Dental Radiology Policies 81 E. Infection Control Manual 95

3 MONROE COMMUNITY COLLEGE DENTAL STUDIES INTRODUCTION Welcome to Dentistry. You are entering a field of health care that demands special attention when working with clients. The public at large has specific expectations for the behaviors, dress, and attitudes of those who deliver health-related services. As a health care provider, you must be cordial and respectful, without being impersonal, while obtaining intimate information and treating the client without embarrassment. For these reasons, standards for appearance and behavior during the educational process must be maintained. The policies contained in this manual pertain to academic progress and clinical protocols. Each Dental Studies student will be expected to adhere to these policies. You are preparing for responsibilities as a health care provider. These policies are realistic, with high expectations of your ability to follow them. Endeavoring to adhere to the policies in this manual will help you successfully perform your professional duties both in this program and your future employment. Violation of any of the following policies will be handled at the discretion of the supervising faculty and/or director. Violation could result in dismissal from a classroom or clinical experience with a subsequent loss of credit, or dismissal from the program in the event of critical infractions. Please remember that these policies are not arbitrary and have a function in your academic and clinical experiences. Your cooperation and compliance with these policies are considered essential to the completion of your program of study. Students unable to comply with these policies will be dismissed from the program, as they would be unable to succeed in a professional employment situation. If you have any questions regarding these regulations, please consult any faculty member or the director. Monroe Community College Dental Studies Programs have two primary functions. The first is to produce qualified dental personnel to meet the needs of the citizens of the State of New York. The second is to ensure that clients treated at the Viswanathan Dental Studies Clinic and external rotation sites receive the best possible dental health care within a reasonable period of time. In order to meet these two primary functions, clients, students, and faculty must accept the concept of comprehensive client care and implement this concept in the program s clinical facilities. Students should recognize and appreciate their clients contributions to the educational process. When treating clients, every effort should be directed to make clients feel they have the provider s undivided attention and that this responsibility is taken very seriously. Clients should be informed that they must act responsibly as well due to the critical roles they play in your education as a dental professional. 1

4 PROGRAM COMPETENCIES MCC ASSOCIATES DEGREE IN DENTAL HYGIENE Adapted with permission from the BSDH-Entry Level Program Competencies Document, Gene W. Hirschfeld School of Dental Hygiene, Old Dominion University, Norfolk, Virginia, accessed June, 2011: INTRODUCTION Competence is an acceptable, measurable, defined level of special skill and knowledge derived from education, experience, role modeling, and overall socialization. To be competent, an entry-level dental hygienist must perform at or above the acceptable, defined, program competencies. DOMAINS (D) Major Competencies (MC) SUPPORTING COMPETENCIES (SC) Foundational Knowledge (FK) DOMAINS (D) The organization of the document flows from the general categories that comprise the central domains of the curriculum, to the specific behaviors that reflect the foundational abilities expected of students at the course level. The domains should be viewed as themes or broad categories of professional focus that transcend numerous courses and learning activities. The concept of domains is intended to encourage threads of consistency, emphasis and focus that develop and advance throughout the curriculum. In this document, domains are labeled: I. Professionalism and Ethics II. Dental Hygiene Process of Care III. Health Promotion and Community Involvement IV. Professional Commitment and Advancement Major Competencies (MC) Within each domain, Major Competencies are listed. A Major Competency is defined as the ability to perform or provide a particular, complex service or task. The complexity of the service suggests that multiple and more specific abilities are required to support the performance of any Major Competency. 2

5 SUPPORTING COMPETENCIES (SC) THE MORE SPECIFIC ABILITIES ARE CONSIDERED SUBDIVISIONS OF THE MAJOR COMPETENCY AND ARE TERMED SUPPORTING COMPETENCIES. THE ACQUISITION AND DEMONSTRATION OF A MAJOR COMPETENCY REQUIRES A LEVEL OF MASTERY OF ALL SUPPORTING COMPETENCIES RELATED TO THAT PARTICULAR SERVICE OR TASK. WHILE LESS COMPLEX THAN A MAJOR COMPETENCY, A SUPPORTING COMPETENCY ALSO REQUIRES FOUNDATIONAL KNOWLEDGE. Foundational Knowledge (FK) Foundational knowledge is the product of didactic laboratory and clinical sciences instruction which imparts the information and experience that are prerequisite for satisfactory mastery of Supporting Competencies. The biomedical, dental, behavioral and clinical science all provide instruction at the foundational level and establishes the foundation for the entire dental hygiene care process. This education ensures an understanding of basic biological principles for student analysis and synthesis of the interrelations of the body systems when making decisions regarding oral health services within the context of total body health. These sciences provide the student with knowledge of oral health and disease as a basis for assuming responsibility for assessing, analyzing, planning, implementing and evaluating dental hygiene care. Didactic, small group discussion, seminar and laboratory instruction provide information and psychomotor experiences that enable students to acquire and demonstrate competence in the clinical setting. Domain/Program Competencies The program competencies define a level of practice for the new graduate, rather than predict the higher level of practice that will be attained by dental hygiene practitioners over their career. Supporting and foundational competencies are identified for each domain. I. PROFESSIONALISM AND ETHICS (D) A. Professional Behavior (MC) Professional behavior encompasses many components including a team approach, positive verbal and nonverbal communication, interpersonal skills, attention to feedback, protocol adherence, thorough and complete documentation and time management. The dental hygiene graduate must be able to practice using a team concept in a professional manner. 3

6 THE GRADUATE MUST BE ABLE TO: (SC) 1. PROVIDE ACCURATE, CONSISTENT AND COMPLETE DOCUMENTATION WHEN SERVING IN PROFESSIONAL ROLES (111, 114, 115, 121, 125, 212, 214, 215, 222, 224, 225, 228, SADHA); 2. COMMUNICATE EFFECTIVELY USING VERBAL, NONVERBAL WRITTEN AND ELECTRONIC COMMUNICATION SKILLS (110, 111, 112, 113, 114, 115, 121, 122, 124, 125, 212, 215, 222, 224, 225, 228, SADHA). B. Ethical Behavior (MC) The dental hygiene graduate must be able to discern and manage the ethical issues faced in dental hygiene. THE GRADUATE MUST BE ABLE TO: (SC) 1. INTEGRATE THE ADHA CODE OF ETHICS IN ALL PROFESSIONAL ENDEAVORS AND ADHERE TO LOCAL, STATE AND FEDERAL LAWS, RECOMMENDATIONS AND REGULATIONS FOR DENTAL HYGIENE ACTIONS AND SERVICE (113, 115, 121, 123, 212, 214, 215, 222, 224, 225, 228, SADHA); 2. SERVE ALL CLIENTS WITHOUT DISCRIMINATION, APPRECIATING THE DIVERSITY OF THE POPULATION (111, 112, 113, 121, 124, 212, 215, 222, 224, 225); 3. APPLY PRINCIPLES OF RISK MANAGEMENT TO MANAGE PROFESSIONAL RISKS AND PREVENT LIABILITY (111, 113, 114, 121, 212, 215, 222, 224, 225, 228); 4. EVALUATE THE SAFETY AND EFFICACY OF ORAL HEALTH PRODUCTS, INTERVENTIONS AND TREATMENT IN A SCIENTIFIC AND PROFESSIONAL MANNER (110, 112, 124, 125, 211, 212, 214, 215, 222, 225). II. DENTAL HYGIENE PROCESS OF CARE (D) The dental hygiene graduate is a licensed health professional who provides educational, preventive and therapeutic services in the support of optimal oral health. The dental hygiene process of care applies principles from the biomedical, clinical and psychosocial sciences to diverse populations. A. Assessment (MC) The dental hygiene graduate must be able to systematically collect, analyze and record data on the general, oral and psycho-social health status of clients using methods consistent with medico-legal ethical principles. 4

7 THE GRADUATE MUST BE ABLE TO: (SC) 1. ASSESS CLIENT CONCERNS, GOALS, VALUES AND PREFERENCES TO GUIDE CLIENT CARE (110, 111, 121, 122, 124, 125, 212, 214, 215, 222, ); 2. OBTAIN, REVIEW, UPDATE, INTERPRET AND IDENTIFY THE NEED FOR ASSESSMENT DATA PRIOR TO OR DURING DENTAL HYGIENE CARE (110, 111, 114, 115, 121, 125, 212, 214, 215, 216, 222, 224, 225, 226); 3. RECOGNIZE PREDISPOSING AND ETIOLOGICAL RISK FACTORS THAT REQUIRE INTERVENTION TO PREVENT AND CONTROL DISEASE (110, 111, 112, 121, 122, 123, 125, 129, 212, 213, 214, 215, 217, 219, 222, 225, 229); 4. IDENTIFY CLIENTS AT RISK FOR A MEDICAL EMERGENCY AND TAKE APPROPRIATE PRECAUTIONS TO MINIMIZE THOSE RISKS (110, 111, 114, 115, 121, 125, 212, 214, 215, 216, 222, 224, 225, 226). B. Diagnosis (MC) The dental hygiene graduate must be able to use critical decision making skills to reach conclusions about the client s human needs related to oral health and disease, based on all available assessment data. THE GRADUATE MUST BE ABLE TO: (SC) 1. ANALYZE AND INTERPRET THE DATA TO FORMULATE A DENTAL HYGIENE DIAGNOSIS RELATED TO AND CONGRUENT WITH THE DIAGNOSIS OF THE DENTIST AND OTHER HEALTH PROFESSIONALS AND OBTAIN APPROPRIATE CONSULTATIONS (111, 121, 122, 124, 125, 212, 214, 215, 222, 225). C. Planning (MC) The dental hygiene graduate must be able, through collaboration with the client and/or other health professionals, to formulate a comprehensive dental hygiene care plan. The care plan will delineate dental hygiene interventions to be provided that are evidenced-based, client-centered and related to the identified human need deficits. THE GRADUATE MUST BE ABLE TO: (SC) 1. ESTABLISH A PLANNED SEQUENCE OF EDUCATIONAL, PREVENTIVE AND THERAPEUTIC SERVICES COLLABORATIVELY WITH THE CLIENT, BASED ON THE DENTAL HYGIENE DIAGNOSIS (111, 121, 124, 125, 212, 214, 215, 222, 224, 225, 226, 228); 5

8 2. FORMULATE GOALS AND ESTABLISH EXPECTED OUTCOMES RELATED TO THE NEEDS AND DESIRES OF THE CLIENT AND THE DENTAL HYGIENE DIAGNOSIS (111, 121, 122, 124, 125, 212, 214, 215, 222, 225); 3. MAKE REFERRALS TO PROFESSIONAL COLLEAGUES AS INDICATED BY THE CARE PLAN (111, 121, 125, 211, 212, 213, 214, 215, 217, 219, 222, 225, 226, 229). D. Implementation (MC) The dental hygiene graduate must be able to provide specialized care that includes educational, preventive and therapeutic services designed to assist the client in achieving and maintaining oral health goals. THE GRADUATE MUST BE ABLE TO: (SC) 1. EDUCATE CLIENTS TO PREVENT AND CONTROL RISK FACTORS THAT CONTRIBUTE TO CARIES, PERIODONTAL DISEASE AND OTHER ORAL CONDITIONS (110, 111, 121, 122, 123, 125, 129, 212, 213, 214, 215, 216, 219, 225, 226, 229, SADHA); 2. UTILIZE ACCEPTED INFECTION CONTROL PROCEDURES (111, 113, 115, 121, 125, 211, 212, 214, 215, 222, 225); 3. OBTAIN RADIOGRAPHS OF DIAGNOSTIC QUALITY (111, 121, 215, 225); 4. APPLY BASIC AND ADVANCED PRINCIPLES OF DENTAL HYGIENE INSTRUMENTATION TO REMOVE DEPOSITS WITHOUT TRAUMA TO HARD OR SOFT TISSUE (114, 125, 214, 215, 225); 5. CONTROL PAIN AND ANXIETY DURING TREATMENT THROUGH USE OF ACCEPTED PHARMACOLOGICAL AND BEHAVIORAL TECHNIQUES (110, 111, 114, 121, 125, 214, 215, 216, 225, 226); 6. SELECT AND ADMINISTER THE APPROPRIATE CHEMOTHERAPEUTIC AGENT AND PROVIDE PRE- AND POST- TREATMENT INSTRUCTIONS (110, 124, 125, 125, 212, 214, 215, 219, 222, 224, 225, 229); 7. PROVIDE SUPPORTIVE DENTAL HYGIENE SERVICES THAT CAN BE LEGALLY PERFORMED IN THE STATE OF NEW YORK (111, 121, 124, 125, 211, 212, 214, 215, 222, 224, 225); 8. MANAGE MEDICAL EMERGENCIES IN THE CLIENT CARE ENVIRONMENT (111, 121, 125, 214, 215, 216, 225, 226) 6

9 E. Evaluation and Maintenance (MC) The dental hygiene graduate must be able to evaluate the effectiveness of implemented educational, preventive and therapeutic services and modify as needed. THE GRADUATE MUST BE ABLE TO: (SC) 1. DETERMINE THE OUTCOMES OF DENTAL HYGIENE INTERVENTIONS USING INDICES, INSTRUMENTS, EXAMINATION TECHNIQUES AND CLIENT SELF-REPORT AS SPECIFIED IN THE CLIENT GOALS (124, 125, 212, 214, 215, 222, 225); 2. COMPARE ACTUAL OUTCOMES TO EXPECTED OUTCOMES, REEVALUATING GOALS, DIAGNOSES AND SERVICES WHEN EXPECTED OUTCOMES ARE NOT ACHIEVED (124, 125, 212, 214, 215, 222, 225); 3. DEVELOP A PERIODONTAL MAINTENANCE PROGRAM (212, 214, 215, 219, 222, 225, 226, 229); 4. DETERMINE THE CLIENT S SATISFACTION WITH THE ORAL HEALTH CARE RECEIVED (125, 212, 215, 222,225). III. HEALTH PROMOTION AND COMMUNITY INVOLVEMENT (D) Trends toward consumerism, self-care, disease prevention, health promotion and health lifestyles means that clients, wherever they might be, want and need information on oral health and disease. Teaching and health promotion strategies are involved in the full range of dental hygiene actions directed toward helping diverse populations achieve oral wellness. A. Education and Communication (MC) The dental hygiene graduate must be able to promote the values of oral and general health to the public and organizations outside the profession. THE GRADUATE MUST BE ABLE TO: (SC) 1. IDENTIFY FACTORS THAT CAN BE USED TO MOTIVATE THE CLIENT FOR HEALTH PROMOTION, DISEASE PREVENTION AND/OR HEALTH MAINTENANCE (110, 113, 114, 123, 129, 212, 213, 215, 219, 222, 225, 229, SADHA); 2. EDUCATE OTHER INDIVIDUALS AND/OR ORGANIZATIONS ABOUT ACCESS AND DELIVERY OF SERVICES IN THE PROVISION OF ORAL HEALTH CARE (110, 113, 114, 211, 212, 214, 215, 217, 222, 225, SADHA); 7

10 3. PRESENT EDUCATIONAL INFORMATION TO DIVERSE CLIENT POPULATIONS IN A VARIETY OF SETTINGS USING APPROPRIATE TEACHING STRATEGIES (110, 113, 114, 211, 212, 215, 222, 225, 226, SADHA). B. Community Involvement (MC) The dental hygiene graduate must be able to initiate and assume responsibility for health promotion and disease prevention activities for diverse populations in a variety of settings. THE GRADUATE MUST BE ABLE TO: (SC) 1. ASSESS COMMUNITY ORAL HEALTH NEEDS, RISK AND AVAILABLE RESOURCES AND EVALUATE OUTCOMES FOR HEALTH IMPROVEMENT AND ACCESS TO THE HEALTHCARE SYSTEM (110, 113, 114, 212, 222); 2. PLAN, IMPLEMENT, AND EVALUATE COMMUNITY ORAL HEALTH EDUCATION AND SERVICES IN A VARIETY OF SETTINGS (110, 113, 114, 212, 222); 3. USE SCREENING, EDUCATION AND REFERRAL TO INTRODUCE CONSUMERS TO THE HEALTHCARE SYSTEM 110, 113, 114, 212, 215, 222, 225); 4. PROVIDE DENTAL HYGIENE SERVICES AS AN INTERDISCIPLINARY HEALTHCARE MEMBER IN A VARIETY OF SETTINGS (110, 113, 114, 212, 215, 222, 225). IV. PROFESSIONAL COMMITMENT AND ADVANCEMENT (D) For professional advancement and lifelong learning, the dental hygienist must be able to derive the relevance from rapidly changing information. Knowledge of the scientific method ensures that actions taken by the dental hygienist are based on scientific evidence, not merely on ritual, tradition, intuition or personal preference. A. Professional Commitment (MC) The dental hygiene graduate must be concerned with improving the knowledge, skills and values of the profession THE GRADUATE MUST BE ABLE TO: (SC) 1. ADVANCE THE VALUES OF THE PROFESSION THROUGH LEADERSHIP, SERVICE ACTIVITIES AND AFFILIATIONS WITH PROFESSIONAL AND PUBLIC ORGANIZATIONS (110, 113, 114, 212, 215, 222, 224, 225, SADHA); 8

11 2. ASSUME THE ROLES OF THE PROFESSIONAL DENTAL HYGIENIST (CLINICIAN, EDUCATOR, RESEARCHER, CHANGE AGENT, CONSUMER ADVOCATE, ADMINISTRATOR) AS DEFINED BY THE ADHA (110, 111, 113, 114, 121, 122, 212, 214, 215, 222, 225, 228, SADHA). B. Professional Advancement (MC) The graduate must pursue new knowledge on a continual basis due to the changing health care environment. THE GRADUATE MUST BE ABLE TO: (SC) 1. ASSUME RESPONSIBILITY FOR PROFESSIONAL GROWTH THROUGH LIFELONG LEARNING (110, 111, 112, 113, 114, 121, 122, 212, 215, 222, 224, 225, SADHA); 2. UTILIZE SCIENTIFIC LITERATURE IN ORDER TO MAKE EVIDENCE-BASED DECISIONS THAT ADVANCE THE PROFESSION OF DENTAL HYGIENE (110, 111, 112, 113, 114, 121, 122, 123, 129, 212, 213, 215, 216, 217, 219, 222, 225, 226, 229, SADHA). 9

12 EVALUATION OF PROGRAM COMPETENCIES To assure the incorporation of emerging information and achievement of appropriate sequencing and the attainment of student competence, the program has developed an evaluation mechanism that relates program domains, competencies and foundational knowledge to all dental studies courses. The following table lists the major domains and the related courses. DENTAL HYGIENE PROGRAM COMPETENCIES RUBRIC I. Professionalism and Ethics II. Dental Hygiene Process of Care III. Health Promotion and Community Involvement IV. Professional Commitment and Advancement Freshman Domains I. X X X X X X X X II. X X X X X X X X X X X X III. X X X IV. X X X X X X X Sophomore Domains SADHA I. X X X X X X X X X II. X X X X X X X X X X X X X X III. X X X X X X X X X X X X IV. X X X X X X X X X X X X STUDENT EVALUATION OF PROGRAM COMPETENCIES AND COURSES At the completion of each semester, every student is required to complete an evaluation of the specific courses in that semester. Refer to the Course Related Program Competency document and follow the directions to complete the evaluation that will assess the effectiveness of all courses as they support the program s goals and competencies. Points will be deducted from the final grade if the evaluation is not completed. 10

13 DEN 110 Dental Health Education DEN 111 Dental Radiography I DEN 112 Oral Anatomy and Physiology I DEN 113 Barrier Precautions and Infection Control Measures DEN 114 Dental Hygiene I DEN 115 Clinical Dental Hygiene I DEN 121 Dental Radiography II DEN 122 Oral Anatomy and Physiology II DEN 123 Oral Pathology I DEN 124 Dental Hygiene II DEN 125 Clinical Dental Hygiene II DEN 129 Periodontics I DEN 211 Dental Materials DEN 212 Community Dentistry I DEN 213 Oral Pathology II DEN 214 Dental Hygiene III DEN 215 Clinical Dental Hygiene III DEN 216 Dental Therapeutics I DEN 217 Dental Specialties DEN 219 Periodontics II DEN 222 Community Dentistry II DEN 224 Dental Hygiene IV DEN 225 Clinical Dental Hygiene IV DEN 226 Dental Therapeutics II DEN 228 Dental Office Management/Business Practice DEN 229 Periodontics III 11

14 PROGRAM COMPETENCIES MCC CERTIFICATE IN DENTAL ASSISTING 6/24/2015 Fall

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16 PROGRAM COMPETENCIES MCC CERTIFICATE IN DENTAL ASSISTING Adapted with permission from the BSDH-Entry Level Program Competencies Document, Gene W. Hirschfeld School of Dental Hygiene, Old Dominion University, Norfolk, Virginia, accessed June, 2011: INTRODUCTION Competence is an acceptable, measurable, defined level of special skill and knowledge derived from education, experience, role modeling, and overall socialization. To be competent, an entry-level dental assistant must perform at or above the acceptable, defined, program competencies. DOMAINS (D) Major Competencies (MC) SUPPORTING COMPETENCIES (SC) Foundational Knowledge (FK) DOMAINS (D) The organization of the document flows from the general categories that comprise the central domains of the curriculum, to the specific behaviors that reflect the foundational abilities expected of students at the course level. The domains should be viewed as themes or broad categories of professional focus that transcend numerous courses and learning activities. The concept of domains is intended to encourage threads of consistency, emphasis and focus that develop and advance throughout the curriculum. In this document, domains are labeled: I. Professionalism and Ethics II. Dental Assisting Practice III. Health Promotion and Community Involvement IV. Professional Commitment and Advancement Major Competencies (MC) Within each domain, Major Competencies are listed. A Major Competency is defined as the ability to perform or provide a particular, complex service or task. The complexity of the service suggests that multiple and more specific abilities are required to support the performance of any Major Competency. 14

17 SUPPORTING COMPETENCIES (SC) THE MORE SPECIFIC ABILITIES ARE CONSIDERED SUBDIVISIONS OF THE MAJOR COMPETENCY AND ARE TERMED SUPPORTING COMPETENCIES. THE ACQUISITION AND DEMONSTRATION OF A MAJOR COMPETENCY REQUIRES A LEVEL OF MASTERY OF ALL SUPPORTING COMPETENCIES RELATED TO THAT PARTICULAR SERVICE OR TASK. WHILE LESS COMPLEX THAN A MAJOR COMPETENCY, A SUPPORTING COMPETENCY ALSO REQUIRES FOUNDATIONAL KNOWLEDGE. Foundational Knowledge (FK) Foundational knowledge is the product of didactic laboratory and clinical sciences instruction which imparts the information and experience that are prerequisite for satisfactory mastery of Supporting Competencies. The biomedical, dental, behavioral and clinical science all provide instruction at the foundational level and establishes the foundation for the entire dental assisting standards of practice. This education ensures an understanding of basic biological principles for student analysis and synthesis of the interrelations of the body systems when making decisions regarding oral health services within the context of total body health. These sciences provide the student with knowledge of oral health and disease as a basis for assuming responsibility for patient education, implementation of treatment procedures, and preparation of supportive services for patient treatment and care. Didactic, small group discussion, seminar and laboratory instruction provide information and psychomotor experiences that enable students to acquire and demonstrate competence in the clinical setting. Domain/Program Competencies The program competencies define a level of practice for the new graduate, rather than predict the higher level of practice that will be attained by dental assisting practitioners over their career. Supporting and foundational competencies are identified for each domain. I. PROFESSIONALISM AND ETHICS (D) A. Professional Behavior (MC) Professional behavior encompasses many components including a team approach, positive verbal and nonverbal communication, interpersonal skills, attention to feedback, protocol adherence, thorough and complete documentation and time management. The dental assisting graduate must be able to practice using a team concept in a professional manner. 15

18 THE GRADUATE MUST BE ABLE TO: (SC) 1. ACCURATE, CONSISTENT AND COMPLETE DOCUMENTATION WHEN SERVING IN PROFESSIONAL ROLES (111, 110, 121, 120, 227, 228, SADAA); 2. COMMUNICATE EFFECTIVELY USING VERBAL, NONVERBAL WRITTEN AND ELECTRONIC COMMUNICATION SKILLS (110, 111, 112, 113, 211, 121,115, 227, 120, 228). B. Ethical Behavior (MC) The dental assisting graduate must be able to discern and manage the ethical issues faced in dental assisting practice and dental treatment. THE GRADUATE MUST BE ABLE TO: (SC) 1. INTEGRATE THE ADAA CODE OF ETHICS IN ALL PROFESSIONAL ENDEAVORS AND ADHERE TO LOCAL, STATE AND FEDERAL LAWS, RECOMMENDATIONS AND REGULATIONS FOR DENTAL ASSISTING ACTIONS AND SERVICE (110, 115, 120, 113, 211, 121, 228, SADAA); 2. SERVE ALL CLIENTS WITHOUT DISCRIMINATION, APPRECIATING THE DIVERSITY OF THE POPULATION (110, 111, 113, 115, 211, 227, 120, 121); 3. APPLY PRINCIPLES OF RISK MANAGEMENT TO MANAGE PROFESSIONAL RISKS AND PREVENT LIABILITY (110, 111, 113, 115, 121, 120, 227, 228); 4. EVALUATE THE SAFETY AND EFFICACY OF ORAL HEALTH PRODUCTS, DENTAL MATERIALS, INTERVENTIONS AND TREATMENT IN A SCIENTIFIC AND PROFESSIONAL MANNER (110, 112, 211, 227, 120, 122, SADAA). II. DENTAL ASSISTING CLINICAL PRACTICE STANDARDS (D) The dental assisting graduate is a licensed health professional who provides supportive services under the direction and supervision of a licensed dentist as well as provides treatment services to patients as allowable by state regulations. The clinical standards of dental assisting practice apply principles from the biomedical, clinical and psychosocial sciences to diverse populations. A. Assessment (MC) The dental assisting graduate must be able to systematically assist with and/or actively complete the collection, assessment and recording of data on the general, oral and psycho-social health status of clients using methods consistent with medico-legal ethical principles. THE GRADUATE MUST BE ABLE TO: (SC) 1. ASSIST WITH AND/OR OBTAIN, REVIEW, UPDATE, INTERPRET AND IDENTIFY THE NEED FOR ASSESSMENT (DIAGNOSTIC) DATA PRIOR TO OR DURING DENTAL TREATMENT UNDER THE DIRECTION OF THE DENTIST (110, 111, 211, 121, 227, 120, 122); 16

19 2. RECOGNIZE PREDISPOSING AND ETIOLOGICAL RISK FACTORS THAT REQUIRE PREPARATION AND/OR INTERVENTION TO PREVENT AND CONTROL DISEASE (111,112, 122, 227, 120, 122); 3. IDENTIFY CLIENTS AT RISK FOR A MEDICAL EMERGENCY AND TAKE APPROPRIATE PRECAUTIONS TO MINIMIZE THOSE RISKS (111, 115, 121, 227, and 120). B. Supportive and Clinical Practice Procedures (MC) The dental assisting graduate must be able to provide supportive functions under the direction of the dentist before, during and after treatment of the client as well as perform a variety of direct treatment procedures allowable by state regulations. These functions include educational, preventive and therapeutic services designed to assist the dentist and/or participate in completing treatment procedures to achieve the goals of the treatment plan and establish optimal oral health for the client. THE GRADUATE MUST BE ABLE TO: (SC) 1. EDUCATE CLIENTS TO PREVENT AND CONTROL RISK FACTORS THAT CONTRIBUTE TO CARIES AND OTHER ORAL DISEASES/CONDITIONS AND TO MAINTAIN RESTORATIONS AND FUNCTION. (111, 211, 121, 227, 120, 122, SADAA); 2. UTILIZE ACCEPTED INFECTION CONTROL PROCEDURES (110, 111, 113, 211, 121, 227, 120, 122, SADAA); 3. OBTAIN RADIOGRAPHS OF DIAGNOSTIC QUALITY (111, 121, 120); 4. PREPARE AND ASSIST WITH OR COMPLETE PAIN AND ANXIETY CONTROL STRATEGIES BEFORE, DURING, AND AFTER TREATMENT THROUGH USE OF ACCEPTED PHARMACOLOGICAL AND BEHAVIORAL TECHNIQUES (110, 111, 121, 227, 120) 5. APPLY CURRENT AND EFFECTIVE CONCEPTS OF CHAIRSIDE ASSISTING PRACTICES INCLUDING ERGONOMICS, FOUR-HANDED INSTRUMENT TRANSFER, OPERATORY MAINTENANCE, ISOLATION AND EVACUATION PROCEDURES, MANIPULATION OF MATERIALS/SUPPLIES AND PATIENT MANAGEMENT. (110, 211, 227, 120, 228, SADAA); 6. PREPARE AND PROVIDE PRE- AND POST-TREATMENT EDUCATION AND INSTRUCTIONS (110, 211, 227, 120, 122, SADAA); 7. PROVIDE SUPPORTIVE DENTAL TREATMENT SERVICES THAT CAN BE LEGALLY PERFORMED BY A LICENSED DENTAL ASSISTANT IN THE STATE OF NEW YORK (110, 111, 211, 121, 227, 120, SADAA) 17

20 8. PERFORM LABORATORY PROCEDURES UNDER THE DIRECTION OF THE DENTIST AND MANAGE COMMUNICATION AND SCHEDULING OF LABORATORY CASES. (110, 211, 227, 120); 9. PARTICIPATE DURING THE MANAGEMENT OF MEDICAL EMERGENCIES IN THE CLIENT CARE ENVIRONMENT (111, 211, 121, 227, 120); 10. PARTICIPATE IN A VARIETY OF OFFICE MANAGEMENT RESPONSIBILITIES INCLUDING MAINTAINING SCHEDULING AND CLIENT FLOW, PROCESS TREATMENT TRANSACTIONS, AND MAINTAIN HIPAA AND CONFIDENTIALITY REQUIREMENTS (115, 120, 228, SADAA). C. Evaluation and Maintenance (MC) The dental assisting graduate must be able to evaluate the effectiveness of implemented educational, preventive and therapeutic services and modify as needed. THE GRADUATE MUST BE ABLE TO: (SC) 1. DETERMINE THE CLIENT S SATISFACTION WITH THE ORAL HEALTH CARE RECEIVED (110, 227, 120, 122). III. HEALTH PROMOTION AND COMMUNITY INVOLVEMENT (D) Trends toward consumerism, self-care, disease prevention, health promotion, and health lifestyles means that clients, wherever they might be, want and need information on oral health and disease. Teaching and health promotion strategies are involved in the full range of dental assisting actions directed toward helping diverse populations achieve oral wellness. A. Education and Communication (MC) The dental assisting graduate must be able to promote the values of oral and general health to the public and organizations outside the profession. THE GRADUATE MUST BE ABLE TO: (SC) 1. IDENTIFY FACTORS THAT CAN BE USED TO MOTIVATE THE CLIENT FOR HEALTH PROMOTION, DISEASE PREVENTION AND/OR HEALTH MAINTENANCE (113, 211, 227, 120, and 122); 2. EDUCATE OTHER INDIVIDUALS AND/OR ORGANIZATIONS ABOUT ACCESS AND DELIVERY OF SERVICES IN THE PROVISION OF ORAL HEALTH CARE (113, 211, 227, 120, 122, SADAA); 3. PRESENT EDUCATIONAL INFORMATION TO DIVERSE CLIENT POPULATIONS IN A VARIETY OF SETTINGS USING APPROPRIATE TEACHING STRATEGIES (113, 211, 227, 120, and 122). 18

21 B. Community Involvement (MC) The dental assisting graduate must be able to collaborate with other dental professionals and/or initiate and assume responsibility for health promotion and disease prevention activities for diverse populations in a variety of settings. THE GRADUATE MUST BE ABLE TO: (SC) 1. PARTICIPATE IN THE ASSESSMENT OF COMMUNITY ORAL HEALTH NEEDS AS WELL AS THE PLANNING, IMPLEMENTATION, AND EVALUATION OF COMMUNITY ORAL HEALTH EDUCATION PROGRAMS AND SERVICES IN A VARIETY OF SETTINGS (122, 120, SADAA) IV. PROFESSIONAL COMMITMENT AND ADVANCEMENT (D) For professional advancement and lifelong learning, the dental assisting must be able to derive the relevance from rapidly changing information. Knowledge of the scientific method ensures that actions taken by the dental assistant are based on scientific evidence, not merely on ritual, tradition, intuition or personal preference. A. Professional Commitment (MC) The dental assisting graduate must be concerned with improving the knowledge, skills and values of the profession. THE GRADUATE MUST BE ABLE TO: (SC) 1. ADVANCE THE VALUES OF THE PROFESSION THROUGH LEADERSHIP, SERVICE ACTIVITIES AND AFFILIATIONS WITH PROFESSIONAL AND PUBLIC ORGANIZATIONS (110, 120, SADAA); 2. ASSUME THE ROLES OF THE PROFESSIONAL DENTAL ASSISTANT (CLINICIAN, EDUCATOR, RESEARCHER, CHANGE AGENT, CONSUMER ADVOCATE, ADMINISTRATOR) AS DEFINED BY THE ADAA (110, 111, 113, 211, 115, 121, 227, 122, 120, 228, SADAA). B. Professional Advancement (MC) The dental assisting graduate must pursue new knowledge on a continual basis due to the changing health care environment. THE GRADUATE MUST BE ABLE TO: (SC) 1. ASSUME RESPONSIBILITY FOR PROFESSIONAL GROWTH THROUGH LIFELONG LEARNING (110, 111, 112, 113, 211, 121, 227, 120, SADAA); 2. UTILIZE SCIENTIFIC LITERATURE IN ORDER TO MAKE EVIDENCE-BASED DECISIONS THAT ADVANCE THE PROFESSION OF DENTAL ASSISTING (110, 111, 112, 113, 211, 121, 227, 122, 120, SADAA). 19

22 EVALUATION OF PROGRAM COMPETENCIES To assure the incorporation of emerging information and achievement of appropriate sequencing and the attainment of student competence, the program has developed an evaluation mechanism that relates program domains, competencies and foundational knowledge to all dental studies courses. The following table lists the major domains and the related courses. DENTAL ASSISTING PROGRAM COMPETENCIES RUBRIC I. Professionalism and Ethics II. III. IV. Dental Assisting Clinical Practice Standards Health Promotion and Community Involvement Professional Commitment and Advancement Domains DAS 110 DEN 111 DEN 112 DEN 113 Fall Semester DEN 211 I. X X X X X II. X X X X X X III. X X X X IV. X X X X X X SADAA DAS 110: Preclinical Dental Assisting DEN 111: Radiology I DEN 112: Oral Anatomy and Physiology I DEN 113: Barrier Precautions and Infection Control Measures DEN 211: Dental Materials SADAA: Student American Dental Assisting Association Domains DAS 115 DAS 120 DEN 121 DAS 122 DAS 227 Spring Semester I. X X X X X X X II. X X X X X X X III. X X X X IV. X X X X DEN DAS 115: Orientation to Clinical Dental SADAA 228 Assisting Practice DAS 120: Basic Clinical Dental Assisting Practice DEN 121: Radiology II DAS 122: Advanced Biomedical Sciences for Dental Assisting Practice DAS 227: Dental Specialties Procedures DEN 228: Dental Office Management SADAA: Student American Dental Assisting Association X X X STUDENT EVALUATION OF PROGRAM COMPETENCIES AND COURSES At the completion of each semester, every student is required to complete an evaluation of the specific courses in that semester. Refer to the Course Related Program Competency document and follow the directions to complete the evaluation that will assess the effectiveness of all courses as they support the program s goals and competencies. Points will be deducted from the final grade if the evaluation is not completed. 20

23 GENERAL PROGRAM POLICIES

24 GENERAL PROGRAM POLICIES Regulations and Policies Student conduct policies exist under the Regulation and Policies section of the MCC College Catalogue. Any additional program standards and/or regulations are included in this manual. Student conduct shall follow both the intent and stipulations of the standards of conduct expected of professional health care providers. Students in the Dental Studies Programs are required to sign an Honor Statement (Appendix II), promising to observe College and Dental Program guidelines regarding academic honesty and avoidance of all forms of harassment and discrimination. Failure to comply with this commitment to the highest professional standards may result in disciplinary action within the Program and/or the College. Health Sciences Programs Policy and Procedures Appeal Process Students do have the right to have grades corrected for accuracy. The due process appeal procedure described below must be followed precisely to avoid forfeiture of the student s right to appeal. The given timeframe will be followed to expedite resolution of the issue and continuation of professional courses and clinical rotations without interruption. The Program Director s decision in the appeals procedure for due process is final. Step 1: Student notifies faculty/staff within five working days of grade posting. Step 2: Student and faculty meet immediately, or at mutually agreed time as soon as possible to resolve question. Step 3: If satisfactory resolution occurs, no further action is required. Step 4: If resolution is not reached within one day of receipt of decision from meeting in Step 2, the student must submit and hand-deliver a written request within one day to Program Director or Department Secretary (8-432). Step 5: The student, Program Director, and Faculty will meet to discuss the question. Step 6: The Program Director will review the findings, document the decision, and notify the student and appropriate parties in a timely manner. (Refer to College Catalog for further clarification of MCC Grievance Policy.) 1

25 Student Complaints to the Commission on Dental Accreditation Notice of Opportunity and Procedures to File Complaints with the Commission on Dental Accreditation Each allied dental program accredited by the Commission on Dental Accreditation must develop a procedure to inform students of the mailing address and telephone number of the Commission on Dental Accreditation. The Commission on Dental Accreditation defines a complaint, as an allegation that a Commission accredited educational program may not be in substantial compliance with Commission standards or the required accreditation procedures. The Commission on Dental Accreditation will review complaints that relate to a program s compliance with the accredited standards. The Commission is interested in the sustained quality and continued improvement of dental and dental related education programs but does not intervene on behalf of individuals or act as a court of appeal for treatment received by clients or individuals in matters of admission, appointment, promotion or dismissal of faculty, staff or students. The Commission, upon request, will make every effort to take reasonable precaution to prevent identity of the complainant to the program; however, the Commission cannot guarantee the confidentiality of the complainant. The Commission will consider only written, signed complaints; oral or unsigned complaints will not be considered. The Commission strongly encourages attempts at resolution, informally or formally, first be conducted through the program or the sponsoring institution s internal process prior to initiating a formal complaint with the Commission. A copy of the appropriate accreditation standards and/or the Commission s policy and procedure for submission of complaints may be obtained by contacting the Commission at 211 East Chicago Avenue, Chicago, IL or by calling extension 4653 by consulting the Student Handbook which contains the Commission s policies and procedures for submission of complaints. Dental Studies Programs Standards for Teaching and Evaluation To facilitate student learning, both students and faculty/staff have joint responsibilities in teaching and evaluation. Some of these are addressed by the policies and procedures listed in other sections of this manual, but others are of particular note and discussed in the following paragraphs. In the classroom, students and faculty/staff should strive to maintain the learning environment. Students who are unable to comply with classroom decorum will be asked to leave the classroom by the instructor. Disruptive activities that interfere with the learning of students and the instructor s presentation such as talking, reading newspapers or other materials, working on materials for other classes and talking on cell phones or beepers should be avoided. 2

26 Faculty/staff will provide students with complete, accurate course syllabi, including readings, assignments, and evaluation/testing dates and procedures. Course objectives and handouts are provided on a timely basis. Any updates and changes in the course material, presentation and evaluation/testing will be provided to students. They will also periodically evaluate their courses to update educational content and learning activities. For testing and evaluation in lecture, lab and clinical courses, students will abide by and report any violations of the College s Academic Policy (refer to college Catalog), protect their own work and conduct themselves in a manner that does not raise suspicion of any cheating or other plagiarism during examinations. Personal belongings should be placed inside bookbags and bookbags placed on the floor, with no items except pen, pencil, eraser, and scantron sheet(s) on the desk as requested by the instructor. During exams, students should attempt to space themselves in the room so that they are not directly adjacent to each other. Faculty will attempt to develop valid and reliable test banks for course materials. Cumulative exams may be utilized in courses. The final exam schedule for the term will be determined by the College and can be located on the MCC Website A-Z for final exam. The instructor will proctor the exam. Students may ask questions during the exam, but the proctor cannot provide exam question answers. Students who talk during the exam may be asked to leave and not complete the exam; students who arrive late might not be allowed to take the exam. Instructors will grade exams and return grades to students within a timely manner. Instructors utilize item analysis of exam questions in an effort to provide relevant, wellconstructed test items. Students may be afforded an opportunity to review and provide feedback of the exam and other evaluation practices. Make-up exams are at the discretion of the instructor. Privacy of Information The Health Insurance Portability and Accountability Act of 1996 (HIPAA) became effective April 14, The goal of this federal law is to protect the confidentiality of client protected health information (PHI) and avoid unauthorized disclosures of such information. The current edition of the ADA HIPAA document is located in the reception area of the Dental Clinic. All students in Dental Studies Programs will be required to participate in and certify completion of HIPAA training. Additionally, MCC s Dental Studies Program prohibits discussion of a client s medical condition with persons other than the client, his/her legal representative, and/or other health care providers involved in the care or treatment of the client, except upon written authorization by the client. Thus, one should refrain from discussing a client s care with other persons, including lawyers, unless a written authorization from the client has been obtained. 3

27 Written consent for release of client information MUST be in the form of a letter by the client (or designated legal representative), or a statement in the chart progress notes, signed by the client or designated legal representative, which gives consent to obtaining and/or sending written or verbal information about the client s medical condition from/to others. This protocol also applies to dental conditions, treatment and transfer of radiographs. A client s verbal consent is NOT sufficient. The permission to obtain or send information must be in written form with a copy retained in the client chart. Substance Abuse Policy Students enrolled in the Dental Studies Programs are prohibited from reporting to a clinical facility, lab or class under the influence of alcohol, unauthorized narcotics, or controlled drugs. Observed impairment of a student may be evidenced and identified by many factors including, but not limited to, reasonable suspicion and/or bizarre and unusual behavior. Reasonable suspicion is defined as a belief drawn from specific objective and articulated facts and reasonable inferences drawn from those facts in light of experience. Indicative factors may include, but are not limited to: 1. bizarre and unusual behavior, 2. repeated accidents, 3. unexplained mood swings, 4. an odor of alcohol on the breath, 5. disheveled appearance or poor personal hygiene, 6. blatant impairment of judgment, 7. chronic absenteeism or tardiness, and 8. unsafe clinical practice including errors of omission or commission. Faculty members responsibilities include identifying students who display physical and/or emotional conditions which may impede clinical assignment. The student(s) will be referred to Student Services. Reasonable suspicion that a student is impaired will be documented by at least two faculty members, or one faculty member and a licensed or certified professional at the clinical facility where the student is assigned. 1. After documentation, the student will be relieved of client care responsibilities, and will be given the opportunity to discuss the behavior with the two witnesses to the behavior. At this time, it is the responsibility of the student to disclose any prescription or nonprescription medications or drugs being taken, or any other relevant information. 2. The faculty member will then contact the Lead Faculty person and/or the Program Director, who will assess the situation and plan appropriate interventions which are detailed in the College Catalog. 4

28 Attendance Policy All students are expected to attend all classes. Second year Dental Hygiene students are required to attend evening clinic. Realize that lecture, lab and clinical time will not be repeated and situations may arise where it is impossible to make-up the hours missed. Therefore, it is imperative that classes, labs, or clinics not be missed unless absolutely necessary. Tardiness is considered unprofessional behavior and will not be tolerated. Attendance is defined as being on time and completely prepared for each clinic (regardless of whether a client is scheduled), laboratory, or classroom experience. Additionally, the student is expected to participate fully and remain for the entire time of each session. Any variance from this policy is at the discretion of the faculty member responsible for the class, clinic, or laboratory. Attendance requirements will be specified within the objectives of the class, clinic or lab at the beginning of the term. 1. Attendance at all dental clinics, labs and classes is MANDATORY. Students must notify the appropriate faculty member AND clinical site prior to each absence. Phone numbers for faculty and clinical sites will be provided. 2. The number of allowable absences for a lecture class is one hour of absence for each credit hour of the class. Point deductions will be taken from the final grade for each additional absence (see individual outlines). 3. For Dental Hygiene clinic, there are NO excused absences. Please see course outline for specific details. For Dental Assisting rotations see the course outline. 4. No client treatment absences will be made-up. Clinic rover assignments/x-ray must be rescheduled during the students regularly scheduled clinic time. Missed clinical and laboratory times may result in failure of courses. 5. Failure to prepare for clinical and laboratory experiences (such as failing to have sterilized instruments, appropriate PPE, or other required equipment, or not having current CPR training or required immunizations up-to-date), with the inability to participate in client care or related activities, will result in dismissal of the student from clinic or lab. Dismissal will be considered an absence. 6. Absence is allowed for a death in the family, serious illness, military duty and religious holidays. Contact program director immediately. 5

29 Rotations and Externships Rotations and clinical externships are intended to expose the student to real-world dental practice and opportunities to expand clinical skills into the dental specialties and general practice. As such, they are learning experiences, and students cannot be paid for their time in the rotations, even if they are employees of the dental offices at other hours outside the scheduled rotation hours. Students are not to recruit clients at off-campus rotation sites. All students must attend their rotations as scheduled. Rotations are assigned and are not optional. Hours missed on rotations are very difficult to make up. All facilities have clients scheduled and are depending upon your presence and participation. Be on time and eager to work as a team player with a pleasant attitude. If late/absent, the student must notify the instructor and the FACILITY, PRIOR to being late/absent. Students are guests in clinics/professional offices they must behave and perform so that they are welcomed and respected. Academic Progress Students must satisfy all assignments according to individual course guidelines in order to complete the course satisfactorily and move on sequentially. Incomplete grades will not be given in the Dental Studies Program. If the student feels she or he is having difficulty in any class, clinic, or lab, discussion with the instructor is strongly encouraged. Seeking help is nothing to be embarrassed about and may be the difference between passing and failing a course. Resources are available to students requiring help through the college and programs. Professionalism Initiative, responsibility, and willingness to work are considered highly desirable, and will be included in student grading. Professional behavior includes courteous conduct, promptness, quality care, and a willingness to help fellow students. Students should recognize the value of individual instruction and graciously accept constructive criticism whenever given. Faculty should be addressed with titles in all clinic/class sessions. Polite and respectful client care attitudes will be expected at all times, no matter how taxing the situation. Maintaining polite language and conversation exhibits respect for clients and fellow health care providers. Clients may not be relaxed as health care services are provided to them. A quiet, polite and gentle atmosphere is essential to provide the most pleasant experience possible for the client. 6

30 Absolute and total discretion and privacy with client records is required. State and federal statutes require strict confidentiality regarding client names and health conditions. Careful observation of one s surroundings when discussing a client s health condition is imperative. Consult with the clinical faculty and/or supervisors as needed. Additionally, only the student(s) caring for a client, the clinical faculty and the clinical assistant need to be aware of the client s health condition. Informing other students of a client s health condition who are not directly involved in caring for the client violates the client s right to privacy. This is a violation of ethics and professionalism, as well as the law. All students must sign and submit the MCC Privacy of Information Statement (see Appendix) to the Program Director. General Appearance The presence of other health care students in the building, other students throughout the campus, and visitors and clients on the premises require that Dental Studies students appear clean, neat, and relatively conservative at all times, regardless of the class responsibility for the day. Tight, revealing, or sloppy clothing, hairstyles or fashions that may attract attention and therefore disrupt the learning of others are not allowed. Dress classroom attire may be casual but should still portray a professional image. o no work-out, biking, or jogging shorts o no restrictive, tight, see-through, or revealing apparel o no halter, strapless, décolletage, or short, bare-midriff tops o no low-cut, navel-revealing jeans, shorts, pants, or thong underwear o no pants worn lower than the underwear Food and Drink No eating, drinking, or gum chewing is allowed in the clinic areas. Students are expected to maintain the microwave and changing room. Changing room is accessible to all Dental Studies students. NO alcohol or smoking is allowed on the MCC campus. Please observe the various posted signs. Smoking by Dental Studies students is discouraged. Cellular Telephones, Beepers and Other Electronic Devices Personal cellular telephones and beepers must be turned OFF while in the classroom, laboratory or clinical setting. In the classroom, the student s lack of attention to a lecturer and the disruption of others learning due to cell phone or beeper activity is unacceptable. In the clinic, attention to client care supersedes all other obligations. Cell phone or beeper activity should NEVER interrupt the clinician while providing client care. Check with your professor regarding the use of any other technology in the learning environment. Violation of this rule may result in dismissal of the student from the classroom, lab or clinic, with deductions in class/lab/clinic grades, including grades for Professionalism. 7

31 EMERGENCY calls from family members should be directed to Public Safety Public Safety will contact the student to whom the EMERGENCY message applies. MCC is connected to the campus wide emergency alert system. Small Children and Babies in the Workplace Prudent clinical and laboratory safety practices, as well as workplace ethics must be followed at all times. These practices prohibit the presence of young children and babies in areas that have a potential for exposure to radioactive materials, toxic or hazardous chemicals, aerosols and/or infectious agents, or possible injury from laboratory equipment or any other type of accident. Thus, the following policy has been adopted with regard to bringing children and babies into the workplace: No children or babies are permitted to accompany students or clients to clinics, labs, or classrooms. Compliance with this policy is mandatory. If an accident involving a child occurred, issues of both personal and institutional liability could arise. This policy also includes prohibiting the presence of unattended children in reception areas or family members in clinical operatory. Student Mail folders Located adjacent to the Radiology Lab, are labeled individual student mail folders on mobile carts. Each cart is assigned to a class. The mail folders may be used to leave a message for another student, or have work returned from faculty. Materials of value should not be placed in these boxes. Mail folders should be emptied on a daily basis, or, at least, regularly. At no time should client information be placed in a student mail folder or leave Bldg , 201-A and 203. Clinic Telephone Usage The telephones in the clinic are for use strictly for business purposes. These phones are not for personal use by students or clients. Incident Report Policy An Incident Report will be issued by faculty to a student when: a. The student s professionalism does not meet the expected standards for the course. b. The student fails to implement safe care as evidenced by lack of knowledge or physical skill, poor judgment, omission of procedures or commission of errors. c. The student displays unethical and/or inappropriate behavior. This report will be completed by faculty and reviewed with the student with the student prior to the next clinic, lab, or lecture. A plan for problem remediation will be developed by the student and faculty member. Both parties will sign the Incident Report. One copy is placed in the student s permanent file and one copy is given to the student. Any student who accumulates two Incident Reports must meet with the program director. Points will be deducted for each incident report as indicated in each course syllabus. Sample in Appendix 8

32 VISWANATHAN DENTAL HYGIENE CLINIC STANDARDS OF CARE Standards of Client Care: The standards of care set by the MCC Dental Studies Programs are client-centered for providing quality and individualized dental care. MCC Dental Studies Program students provide dental care that meet the following standards: 1. Health Considerations: All medical considerations will be addressed prior to therapy. Students will complete or update medical, dental and personal histories, and will record vital signs with appropriate explanations to the client. Upon completion the information will be reviewed and approved by clinical faculty. Medications will be reviewed and researched for contraindications during dental treatment. 2. Mechanisms for Examination Assessment: Prior to client treatment all examinations, therapy and assessment mechanisms will be explained prior to performance. Findings will be explained to the client and recorded in the client record. 3. Decision Process: All assessment, treatment planning and therapy will be discussed with the client and will include joint decisions made by the client, faculty/supervising dentist and student. 4. Treatment Implementation: Treatment plans and timelines will be discussed with the client and signed by the client prior to initiation of treatment. 5. Explanation of Treatment Services: All dental treatment will be discussed prior to commencing therapy for the client. 6. Dental Services: a. Client Care includes: i. OSHA, HIPAA & CDC Guidelines/Standards ii. Complete soft and hard tissue assessment iii. Assessment, planning, implementation and evaluation of oral health and oral hygiene iv. Instrumentation techniques appropriate and indicated by client presenting needs v. Reevaluation of previously treated areas vi. Management of pain control vii. Management of chemotherapeutic agents viii. ix. Management of tissue response Assessment, planning, implementation and evaluation of health issues (diet, tobacco use, etc.) x. Treatment completion with client compliance xi. xii. Development and management of recare maintenance program specific to client needs Radiographic services 9

33 PRIVACY OF INFORMATION STATEMENT EXPECTED PROFESSIONAL STANDARDS AND NORMS Professional standards and norms for all health care providers include areas of: professional behavior confidentiality client s rights informed consent privileged communication health care settings standards and norms Additionally, federal laws, including HIPAA, state regulations, licensure requirements, and practice acts detail use of specific information related to health care settings and professional behavior. As a student in the MCC Dental Studies Programs, I understand it is my responsibility to adhere to any and all of the above standards and regulations, in any clinical setting. The relaying, discussing, transferring, or using of any privileged information, or knowledge of events or actions by any verbal, written, electronic, computer, and/or other technology form(s) that concern identifying client information, health care agency information (institution or staff), MCC faculty and staff, fellow MCC students, or any other like information is strictly prohibited. Failure to comply with this directive in any way will result in disciplinary action which may include immediate dismissal from the program. IF I, the student, have any questions or concerns, or am unclear regarding this issue/topic I should contact the Director of Dental Studies Programs for clarification. NAME: Print name on line above SIGNED: Signature of person named above DATE: 10

34 PRINT NAME ACADEMIC HONESTY POLICY AND PROCEDURES & NON-DISCRIMINATION STATEMENT MCC DENTAL STUDIES PROGRAMS The College s Academic Honesty Policy will be applied to all Dental Studies courses. Signature acknowledges that you have read and are aware of the Academic Honesty Policy and Procedures at Monroe Community College. The Academic Honesty Policy is also outlined in the MCC Catalog/Student Handbook. ACADEMIC HONESTY In the academic process, it is generally assumed that intellectual honesty and integrity are basic responsibilities of the student. However, faculty members should accept their correlative responsibility to regulate academic work and to conduct examination procedures in such a manner as not to invite violations of academic honesty. Such violations consist mainly of cheating and plagiarism. Scope of practice violations will be considered a violation of academic and professional honesty. Definitions Cheating is defined as the unauthorized use or exchange of information by students or others for the purpose of achieving unfair advantage in the classroom or assessment process. Plagiarism is using someone else s work as if it were one s own, whether or not it is done intentionally. This includes, but is not limited to: using the exact language, using nearly the exact language, and using ideas without showing they originated in another s work. The work taken from another person or source (including publications, web sites, speeches, etc.) may be as little as an isolated formula, portions of a speech, a simple sentence, an idea, or as much as entire paragraphs, papers, or writings of professionals or other students; however, well-known, common knowledge is generally an exception. Omitting quotation marks when using language copied from another s work, failing to use citations for ideas or language taken from other authors, or failing to use one s own style of writing when summarizing and paraphrasing someone else s work constitute plagiarism. Any form of plagiarism is essentially an act of cheating. Specific concerns should be directed to your professor. Scope of Practice is defined as performing legally defined tasks delegated by the New York State Board of Dentistry by a licensed dental hygienist under the personal and general supervision of a New York State licensed dentist. Students are ONLY allowed to practice dental hygiene tasks and skills on a typodont outside of the supervised classroom setting. Live patient practice outside of a supervised classroom setting will result in disciplinary action. The academic honesty policy pertains to all instructional delivery methods offered at the College, including but not limited to classroom and online instruction, and self-study. 11

35 Some examples of academic dishonesty include but are not limited to the following: Taking an exam for another student. Having another student take an exam for you. Paying someone to write a paper to submit as your own work. Writing a paper for another student. Submitting the same paper for grading in two different courses without permission. Arranging with other students to give or receive answers by use of signals. Arranging to sit next to someone who will let you copy from his or her exam. Copying from someone s exam. Allowing another student to copy from you during an exam. Obtaining answers, information, translations, or material from a source (e.g., the nternet) without appropriate citation. Getting questions or answers from someone who has already taken the same exam. Working on homework with other students when the instructor does not allow it. Padding adding items on a works cited page that were not used. Unauthorized use of information stored in the memory of an electronic device (e.g., programmable calculators and cell phones) on a test or assignment. No information stored in any electronic devices may be used without explicit permission. Altering or forging an official document. Disciplinary Action Cheating, plagiarism and scope of practice violations may be an individual transgression of one student unabetted by anyone else, or it may involve the complicity of others. All students who are involved in a group action which makes cheating or plagiarism possible may be considered equally guilty of the transgression and may be subject to the same penalties as though they themselves had cheated or plagiarized. A faculty member who has evidence that a student is guilty of cheating, plagiarism or scope of practice violations shall initiate the appropriate disciplinary action. The faculty member is required to document the charges and the intended disciplinary action to the Student Services Office. However, no penalty shall be imposed until after the student has been informed of the charge of academic dishonesty and of the evidence upon which it is based, and been given opportunity to present whatever statement or evidence the student desired in his/her defense. 12

36 Thereafter if the student is found guilty, the faculty member shall assess a penalty within the course, consistent with the magnitude of the transgression. Such penalty may consist of a warning, reduction in grade for the course, or a grade of F for the course. If a student who commits an act of academic dishonesty withdraws from the course and would have earned a grade of F due to the academic dishonesty, the instructor has the right to change the grade from W to F. Such grade changes will be made by submitting an Academic Record Change Form to Registration and Records indicating the reason for the grade change as academic dishonesty. The student will be notified in writing by Registration and Records that the W grade has been changed to a grade of F due to academic dishonesty. Every case of academic dishonesty which affects a student s grade shall be promptly reported in writing to the appropriate department chairperson and the Vice President, Student Services. The Vice President, Student Services may initiate further disciplinary action in any case of repeated infractions, or in cases of complicity on a large scale. Such further disciplinary action shall be the discretion of the Vice President, Student Services and may result in probation, suspension or expulsion from the College. A record of the offense and the disciplinary action taken shall remain in the student s file. Non-Discrimination Statement: I also understand that all forms of harassment and discrimination, including but not limited to sexual, racial, disability, national origin, or religion are violations of the policies as stated in the College Catalog. Student Signature Date 13

37 CLINICAL POLICIES

38 CLINICAL UNIFORM AND APPEARANCE POLICIES The Program s designated scrubs in solid colors (no white or denim) must be worn for all clinical and preclinical sessions at MCC and all other clinical sites. Embroidery of scrubs: MCC Dental Studies and student 1st name and last initial must be embroidered on the left side Must be completed by 1 st week of classes. The scrubs must be clean, odor-free, and wrinkle-free. White leather or washable composite shoes are considered part of the uniform. Shoes may be laced, nursing-type or slip-on, or an all-white athletic shoe. Canvas tennis shoes are not acceptable. Shoes must be clean with clean white laces, if applicable. Minimally, clinic shoes must cover the toe, instep, and heel of the foot. Clog-style professional shoes may be worn, provided a heel strap secures the shoe to the foot across the heel, no perforations in any shoe. White crew or trouser socks, or knee-high or full-length hose must be worn. No bare feet, NO patterned, colored, or jeweled foot coverings, nor bulky or short sport socks are permitted. The lower leg must be fully covered when seated. Undergarments must be worn. No thong underwear, nor any patterns or colors that may be visible through the scrub top or pants may be worn. Scrub bottoms must cover undergarments and no mid-riff skin is allowed to show. A WHITE, BLACK, or MATCHING color crew neck, short sleeved, ¾ sleeved, or sleeveless tee shirt may be worn under scrub top for reasons of modesty and warmth. However, the undershirt should not hang below the bottom hem of the scrub top. Hair Whenever wearing the designated scrubs, the following regulations apply for the hair: Hair must be worn off the face, neat, conservative style, not hanging in the eyes, nor forward of the ears. Elaborate hair adornments are not permissible, fasteners must be non-fabric, hair colored and simple. Ponytails must be secured and not fall forward of the ears. Hair colors must be natural shades Hair must be secured prior to entering clinics and labs. Hair must remain secured until all clinical and lab functions are completed and the clinic/lab areas are exited. Breath Must be free of offensive odors (e.g. smoke/alcohol/onions/garlic) Make-Up A moderate amount of light or natural make-up may be worn. 1

39 Perfumes/Colognes No perfumes are permitted. Gum Chewing gum is not permitted during clinical and laboratory activities. Hands Hands must be well groomed Nails trimmed to finger-tip length. Bitten or chewed fingernails increase the possibility of infection to the operator. No acrylic or otherwise artificial nails are permitted. Nail polish is not permitted. Hands must be free of offensive odors (smoke/ alcohol/onions/garlic) Jewelry A small, plain wristwatch with a second hand or digital readout in seconds is permitted for timing procedures such as heart rate and respiration or treatment procedures. Small, clear, acrylic stud earrings may be worn during MCC labs and clinics. No hoop, decorative, elaborate, dangling, or large earrings are allowed. No other visible body piercings may be worn in the lab or clinical setting, including tongue piercings. No necklaces should be visible at the neckline of the uniform. A PLAIN, smooth wedding band may be worn. No prong-set gem (diamonds, or other) rings are allowed due to potential micro-leakage of the required gloves. Tattoos Tattoos must be covered whenever possible. 2

40 CLIENT TREATMENT POLICIES No student shall perform a clinic or lab assignment without the supervision of a faculty member. Proceeding with any client treatment, even seating the client, without faculty present is a serious infraction and will result in disciplinary action. 1. Client must sign in upon arrival. An MCC Dental Hygiene Brochure is available upon check-in. 2. Student is to follow Clinical Procedures for each client seen. 3. Clinician/Client confidentiality is of utmost importance. Definition of Client/Appointment Types New Client Clients who have never been seen for treatment in the MCC Dental Hygiene Clinic Reappointment Clients who are completing their sequenced treatment plan within the semester. This may take multiple appointments. Reevaluation (Recare 4-6 Weeks) Clients proposed treatment has been completed, client is returning for review of oral conditions, observation of tissue, comprehensive periodontal evaluation and/or oral hygiene self-care. Recall Clients who have a pre-existing client record and have been treated at the MCC Dental Hygiene Clinic. Recall interval is based on client needs (i.e. 3,4,6,12 months). It is assumed that clients follow referral recommendations. 3

41 Cancellations and Broken Appointments If a client calls any time prior to the scheduled appointment time and explains that he/she will be unable to keep the appointment, the appointment is considered a cancellation and notated in the electronic client record. If a client fails to call prior to the scheduled appointment time, calls after the time for the appointment, or fails to appear for the appointment, the appointment is considered a broken appointment. This is also noted in the electronic client record. Parent/Guardian Consent Legal Age Clients who are 18 years of age or older are considered able to make their own decisions regarding health care and therefore no other consent is required unless mentally compromised. Clients who are of age but unable to understand and make treatment decisions must have their legal guardian present throughout the client appointment. In New York State minors (younger than 18 years) who are under the care of parents or legal guardians must have the consent of their parents or legal guardians prior to any dental treatment. Parents or guardians must provide the information in the Health History and sign the Medical History form, consent for treatment, clinic policies, client rights and responsibilities. Parents or legal guardians are required to remain with minors for the duration of the appointment(s) in the MCC clinic waiting room. Supervising Dentist A NYS licensed supervising dentist must be available for consultation for medical history, oral examination findings, radiographic authorization, chemotherapeutic agents, and other services necessary for the dental hygiene and radiographic appointment. New York State Law dictates supervision requirements and corresponding dental hygiene and dental assisting functions. 4

42 LABORATORY AND CLINIC SAFETY POLICIES 1. Use PPE when treating clients, including classmates, whether in the clinic or the lab: gloves, mask, glasses, gown. 2. Safety glasses must be worn in the laboratory and clinic at all times for all procedures. 3. Closed-toe shoes must be worn in the clinic and the laboratory. 4. Mask must be worn when dispensing/mixing alginate or gypsum materials, mixing/handling amalgam, and for any other dust- or vapor-producing procedures. 5. Hair must be pulled back at all times, particularly when working with the lathe, model trimmers, or alcohol burners. Hair must be secured at all times in the laboratory and clinic. 6. When working with the model trimmer or lathe, no gloves are to be worn. 7. No loose clothing is to be worn around the lathe, model trimmers, or alcohol burners. 8. When working with monomer (temporary acrylic), special attention should be made to assure adequate ventilation. 9. Puncture-proof utility gloves are to be worn when preparing used instruments for sterilization. 10. All people working in the clinic and/or laboratory must become familiar with the locations and/or use of the following items: a. Fire Extinguishers = inside entry door of clinic (7-201) and lab (7-203) and one in hallway outside lab b. Fire Alarms = in hallway outside of clinic c. Emergency Exits Clinic (7-201) = doors to reception area, door to hallway, door to adjacent dental materials lab, door to radiology (7-201A) Laboratory (7-203) = door to adjacent clinic, door to hallway d. Oxygen = with emergency cart (7-201) in sterilization area when clinic is in session. e. AED (Automatic Emergency Defibrillator) = on wall outside entry door of clinic, closest to reception desk f. Emergency cart = in sterilization area during clinic sessions g. Eyewash Stations = sinks at back of clinic (7-201) and in dental materials lab (7-203) h. Safety Data Sheets = inside clinic (7-201) near teaching station. i. Emergency Numbers = Poison Control, Security, Fire, etc. posted on wall near clinic phone 5

43 ULTRASONIC AND AIR POLISHING Guidelines for Operator and Client Protection Operator Protection: All PPE s required plus Hair cover Face shield Face Mask (HBFE: High Bacterial Filtration Efficiency) Protective eyewear/glasses High Volume Evacuation (HVE) Note: Change face mask every 20 minutes to prevent moisture penetration due to an aerosol-producing environment. Client Protection: Drape client with plastic drape, large bib or towel Protective eyewear Cover hair Have client turn off hearing aid (or have them removed) 6

44 EMERGENCY FLOW CHART Student or Staff Member Notifies Faculty of Emergency Minor Emergency Situation Supervising Faculty Assessment Serious Emergency Situation Call Supervising Dentist X2761 Cell: Problem not resolved, follow serious emergency situation protocol Problem resolved and reported to Public Safety Sitter (faculty) directs: caller to call 2911, then 9911, then 2761 (Supervising Dentist) Gofer get AED, oxygen, emergency cart Blocker Keeps bystanders away, clears clinic in severe emergencies Emergency treatment of victim transferred to EMS team and victim transported out of MCC Clinic to hospital 7

45 EMERGENCY NUMBERS MONROE COMMUNITY COLLEGE PUBLIC SAFETY X-2911 EMERGENCY ONLY SAFETY OFFICE X-3151 Air Quality Safety hazard FACILITIES DEPARTMENT X-2813 Grounds problems/conditions Room temperature concerns Burned out/malfunctioning light bulbs Unusual facility noise Plumbing problems Snow/ice removal Any facility emergency of facility need not otherwise covered Elevator problems BUILDING SERVICES X-2593 Housekeeping problems/conditions Pest removal (mice, ants, etc.) Water spills, toilets overflowing POISON EMERGENCY SEXUAL ASSAULT AND/OR ABUSE Domestic Violence, Sexual Assault/Rape Child Abuse Alternatives for Battered Woman Hotline TTY Rape Crisis/Safe Center HOTLINE Local Child Abuse/Maltreatment HOTLINE Child Abuse & Maltreatment Report Center TTY GAS OR ELECTRIC EMERGENCY To report a natural gas odor and Emergency To report an Electric Interruption and Emergency TTY CRIME STOPPERS NYS TERRORISM TIPS LINE SAFE-NYS ( ) 8

46 VISWANATHAN DENTAL STUDIES CLINIC RECORD OF EMERGENCY Name: Date of Birth: Address: Physician s Name: Phone Number: Pertinent Medical History/Allergies: List of Medications or Herbal Vitamins: Emergency Contact: Phone Number: Date, Time and Location of Emergency: 2911 called: ( ) Yes ( ) No Physician called: ( ) Yes ( ) No Description of Injury/Emergency: Pre-episode Baseline Onset of EM 5 Min Later 5 Min Later 5 Min Later TIME BLOOD PRESSURE PULSE RESPIRATION PUPILS SKIN COLOR TEMPERATURE LEVEL OF CONSCIOUSNESS Response to Medications: Patient Transported by: ( ) Ambulance ( ) Faculty ( ) Family ( ) Other Person Completing Report Supervisor s Signature Date 9

47 MANAGEMENT OF MEDICALLY COMPLEX CLIENTS 10

48 MANAGEMENT OF MEDICALLY COMPLEX CLIENTS 1) Bleeding Problems (including Anticoagulants) ) Cardiac Problems (Heart Murmurs, Cardiac Defects, Prophylaxis Regimens) ) Cardiovascular Problems (High Blood Pressure, Congestive Heart Failure, Arrhythmias) ) Central Nervous System Problems (Seizures, Stroke) ) Diabetes ) Immunosuppression ) Infectious Diseases (Tuberculosis, Hepatitis, HIV, Herpes, Flu) ) Kidney Problems ) Liver Problems ) Pregnancy ) Prosthetic Joints ) Asthma

49 DENTAL MANAGEMENT OF MEDICALLY COMPLEX PATIENTS Bleeding Issues or Patients on Anticoagulants (1 of 12) Questions to Ask / Necessary Information: 1. How long have you had a bleeding issue or, depending on the situation, how long have you been on anticoagulant medication? 2. Describe your bleeding issue 3. Have you had problems with previous dental appointments? 4. What is the cause of your bleeding issue or why are you on anticoagulants? 5. Are your anticoagulants or bleeding issues due to low platelets? 6. What are your most recent laboratory results relative to your anticoagulation or bleeding issue status? Diagnostic Tests: 1. Bleeding issues secondary to liver disease: a) INR - international normalized ratios 2. Aspirin and other non-steroidal anti-inflammatory agents. a) Bleeding time. 3. Thrombocytopenia a) CBC with a differential (which will give platelet count) b) Bleeding time 4. Anticoagulant warfarin a) INR 5. Anticoagulant Plavix and newer agents a) There are NO reliable tests 12

50 Management During Dental Treatment: 1. No type of dental treatment should be rendered that has the potential for severe bleeding (i.e. extractions, scale/root plane). a) If INR greater than 3.5 Check with the patient s physician prior to treatment b) If bleeding time greater than 10 minutes c) If platelet count less than 60, If bleeding parameters greater than above, medical coordination is required. For example, the physician may decrease anticoagulant dose or provide packed platelets or prescribe supplemental vitamin K until bleeding parameters are brought into line consistent with dental treatment. It is preferred to maintain the patient s anticoagulation therapy without interruption, if at all possible. 3. With Plavix and newer anticoagulants, because there are NO reliable tests for bleeding risk, we are working blind, so it is recommended to proceed very carefully, taking the time to observe the patient s ability to coagulate at each step of the planned procedure and reducing the extent of the procedure if necessary. It is preferred to maintain the patient s anticoagulation therapy without interruption, if at all possible. 4. Pradaxa (dabigatran), Xarelto (rivoraxaban), Eliquis (apixaban), and Savaysa (edoxaban) are all members of a group of new oral anticoagulants that directly inhibit thrombin (factor IIa), thereby blocking the generation of fibrin. After ingestion, plasma concentrations of the drug peak within 2 hours. Nearly 85% of the drug is eliminated in the urine and they have a half-life of hours in patients with normal renal function. Patients usually take these drugs twice a day to maintain appropriate anticoagulant blood levels. As with warfarin, these drugs do not need to be and should not be suspended for dental procedures that have a potential for minimum or limited bleeding. Such procedures should include conservative hemostatic measures such as removal of granulation tissue and the use of hemostatic agents such as surgicel or gelfoam, and suturing. Because the half-life of these drugs is so short, it is suggested that consideration be given to performing the surgical procedure as late as possible after the last dose of the drug. Unless extensive bleeding is expected, there is no need to modify or suspend this anticoagulant therapy. However, if there is a risk of extensive or extended bleeding, then a consultation with the patient s physician is appropriate and consideration should be given to discontinuing the drug for 2 3 half-lives before the surgery (24 36 hours in patients with normal renal function). Depending on the reason for the need for the anticoagulant, it may be recommended to provide substitution therapy such as with low molecular weight mini-heparins, which should always be done in close collaboration with the physician prescribing the drug. 5. If hemophilic, have physician administer proper replacement factors and run necessary test to insure patient is within safe parameters. 6. During dental procedures minimize physical trauma and pack extraction sites that have the potential to bleed with local pressures and other coagulation procedures, i.e. Gelfoam. Obtain primary closure on any surgical sites, if possible. 7. Establish primary closure and/or put pressure on potential/actual bleeding site. Be Alert For: 1) Easy or prolonged bleeding with minimal trauma (i.e. probing, wedge placed between teeth for amalgam matrix) 2) Easy bruising / multiple bruises 13

51 Preventative / Precautions: 1. Assure the patient is aware of necessary lab tests that should be done close to the time of dental treatment (within a week, or closer if they have had previous problems). Some bleeding parameters can change quickly. 2. Avoid drugs that may cause drug interaction, such as erythromycin and ketoconazol, which inhibit warfarin metabolism. Also avoid drugs that can prolong bleeding, such as aspirin or other non-steroidal anti-inflammatories. 3. Encourage patient to keep you informed of any drug changes and their use of any over-thecounter medications and herbal supplements. 4. If client calls from home following treatment, instruct them to apply pressure with gauze or cloth to bleeding site for minutes. If bleeding persists, have client come into office immediately or to a medical emergency room (World Federation of Hemophilia ) Centers for Disease Control and Prevention Hereditary Blood Disorders Team Internet Address: HANDI/National Hemophilia Foundation Phone number: (800) Internet Address: - Excellent site on anticoagulants: different types, brands, uses, side effects, and dental precautions Comprehensive site on bleeding problems to recommend to your patients: 14

52 Cardiac Problems - heart murmurs, cardiac effects (2 of 12) Questions to ask / Necessary Information: 1. When was your heart problem first diagnosed? 2. Have you ever been hospitalized because of your heart problem? 3. Did the doctor ever say you needed prophylactic antibiotics prior to dental treatment? 4. Did the doctor ever say you didn t need prophylactic antibiotics prior to dental treatment? Diagnostic Tests: Medical consult to identify type of heart problem and whether prophylactic antibiotics are needed, if patient unsure. Please note: the American Heart Association Guidelines for the Prevention of Bacterial Endocarditis was revised in May of Most of the patients who previously needed prophylactic antibiotics for dental procedures, including those patients with diagnosed murmurs, now no longer need them. Management During Dental Treatment: PROPHYLACTIC ANTIBIOTIC COVERAGE FOR PREVENTION OF BACTERIAL ENDOCARDITIS Current American Heart Association Guidelines Published May 8, 2007, Circulation, Vol 115. Cardiac Conditions for Which Prophylaxis for Dental Procedures is Recommended* Prosthetic Cardiac Valve Previous Infective Endocarditis Congenital Heart Disease (CHD) 1. Unrepaired cyanotic CHD, including palliative shunts and conduits. Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure (endothelialization occurs within 6 months of procedure) 2. Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibits endothelialization) 3. Cardiac transplant recipients who develop cardiac valvulopathy If the patient s physician requests prophylaxis for the dental procedure, but the patient does not meet the ADA/AHA criteria for needing it, then the physician should prescribe the prophylaxis, the patient takes it under their direction, and they come to you for dental procedures. Except for the cardiac conditions listed above, antibiotic prophylaxis is no longer recommended for any cardiac condition or problem. 15

53 Cardiac Problems - heart murmurs, cardiac effects continued 1. If the patient needs prophylactic antibiotics, follow the American Heart Association guidelines below: Premedication requirements for patients with valvular heart disease or congenital cardiac defects. If in doubt, have the patient consult their physician as to need. Rx Disp Note *Rx Disp Sig Standard Regime Amoxicillin 500 mg. 4 tablets Sig take 4 tablets (2.0 g) minutes before procedure 1) Children 50 mg/kg. Do not exceed adult dose 2) No second dose is required for adults or children Standard Regime for Patients Allergic To Amoxicillin/Penicillin Clindamycin 150 mg. 4 tablets Take 4 tablets (600 mg) minutes before procedure OR *Rx Disp Sig Azithromycin 250 mg. 2 tablets Take 2 tablets (500 mg) minutes before procedure OR *Rx Disp Sig Clarithromycin 250 mg. 2 tablets Take 2 tablets (500 mg) minutes before procedure OR *Rx Disp Sig Cephalexin 500 mg. 4 tablets Take 4 tablets (2 g) minutes before procedure OR *Rx Disp Sig Note: Cefadroxil 500 mg. 4 tablets Take 4 tablets (2 g) minutes before procedure *Note: Cephalosposins should not be used in individuals with immediate p type hypersensitivity reaction (urticarial, angioedema, or anaphylaxis) to penicillins. Children s dosage. (Do not exceed adult dose) Clindamycin 20 mg/kg Ceplalexin 50 mg/kg Cepadroxil 50 mg/kg Azithromycin 15 mg/kg Clarithromycin 15 mg/kg 16

54 Cardiac Problems - heart murmurs, cardiac effects continued Patients Unable To Take Oral Medication Ampicillin 2 g IV or IM within 30 minutes before procedure. Children: 50 mg/kg IV or IM within 30 minutes before procedure. For Patients Unable to Take Oral Medication and Allergic to Ampicillin, Amoxicillin, Penicillin Clindamycin 600 mg IV within 30 minutes before procedure. Children: 20 mg/kg IV within 30 minutes before procedure. *Cefazolin 1 g IV or IM within 30 minutes before procedure Children: 25 mg/kg IV or IM within 30 minutes before operation. *Note: Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (uticaria, angiodema, or anaphylaxis) to penicillins. 2. If patient states they re unsure whether prophylactic antibiotics are needed and contact with their physician is not possible, then treat with standard guidelines if an emergency, or refer patient for medical consult to establish need or lack of need for antibiotic prophylaxis. 3. Document in the chart, the time and dosage of antibiotics taken for prophylaxis. Be Alert For: Flu-like symptoms within two days, most commonly within two weeks, rarely within four weeks following dental procedures. Such symptoms can be signs of bacterial endocarditis, even if the patient has been properly prophylaxed. If they have such symptoms they should see their physician. Preventative / Precautions: 1. Good oral hygiene. 2. Proper teeth cleaning, clorhexidine rinse prior to extractions to decrease magnitude of possible bacteremias. 3. Gingivitis, and, especially, periodontitis, increases the frequency, intensity, and duration of bacteremias. Stress to the patient that they should take their prophylactic antibiotic medication within the proper timeframe. 17

55 Cardiovascular Problems (3 of 12) (High blood pressure, arrhythmia, congestive heart disease (angina pectoris) Questions to Ask / Necessary Information: A. High blood pressure 1. How high does your blood pressure get? 2. Do you know what your blood pressure usually is? 3. What is your blood pressure when you are taking medications? 4. Have you had any problems / side effects with your blood pressure medication? 5. Have there been any recent changes in your medications? 6. Have you ever had hypertensive episodes when the high blood pressure could not be controlled? 7. Have you ever had to postpone dental treatment or had any problems with dental care, relative to your blood pressure? 8. Did you take your medication today? B. Arrhythmia 1. What kind of arrhythmia do you have? 2. What triggers the arrhythmia episodes? 3. Do you take your medication for your arrhythmia? If so, what medication, and did you take it today? 4. Is the arrhythmia effectively controlled with medication? C. Congestive heart disease 1. Do you get chest pains on exertion? 2. Can you walk up a flight of stairs without needing to rest to catch your breath or getting chest pains? 3. Do you take medications for your congestive heart failure? If so, did you take them today? Diagnostic Tests: A. High blood pressure: 1. Take blood pressure. 2. Depending on situation, take blood pressure at beginning and end of appointment. B. Arrhythmia: 1. Take patient s peripheral (radial, carotid) pulse and feel for arrhythmia C. Congestive heart disease: 1. Stress test by M.D. 18

56 Cardiovascular Problems - continued Management During Dental Treatment: A. High blood pressure. 1. Patients with optimal (<120 systolic and <80 diastolic) and pre-hypertensive ( /80 89 mm Hg) blood pressures are good candidates for all dental procedures and can normally receive local anesthesia with epinephrine 1:100, Patients with mild to moderate hypertension ( / mm Hg), require an overall assessment depending on the complexity of the planned dental procedure and patient s level of activity. Consider some type of sedation or delay elective treatment until blood pressure is controlled. 3. Greater than 180/110, no elective treatment until blood pressure under control. Even if dental emergency treatment is needed, consult with M.D. first to control HBP. Consider sedation with benzodiazepine (valium) or nitrous oxide. 4. In patients with controlled high blood pressure, using local anesthetic with a vasoconstrictor such as 1:100,000 epinephrine or its equivalent is appropriate. The ADA suggests a maximum of 40 µg ( 2 cartridges of 1:100,000 epi) then wait for at least 10 minutes. If no problems arise, additional cartridges can be administered. For patients with blood pressure above 140/90, epinephrine impregnated retraction cord should be avoided. B. Arrhythmia or congestive heart failure: 1. If patient s arrhythmia or congestive heart failure is controlled, no special precautions necessary. 2. If patient has an arrhythmic or congestive heart failure (angina pectoris) episode, dental treatment should be delayed. If arrhythmia occurs in the midst of treatment and it must be completed, discontinue until heart rhythm stabilized (may require hospitalization for cardioversion), then complete treatment quickly and calmly. 3. If angina pectoris occurs, stop treatment, administer oxygen, minimize stress and wait until the pain resolves. Continue as needed, if necessary, and patient feels capable of completing to a safe stopping point. 4. Local anesthetic with vasoconstrictor (1:100,000 epinephrine or equivalent) is appropriate, 1:50,000 concentration of epinephrine or equivalent should be avoided. Epinephrine impregnated retraction cord should not be used. Be Alert For A. High Blood Pressure: 1. Request patient inform you if they feel as though their blood pressure is increasing or if they are getting a headache. Some patients feel jittery, others feel as though there is increased pressure behind the cyes. 2. Profuse bleeding, beyond what would be expected. B. Arrhythmia: 1. Patient to inform you if they feel an arrhythmia. Sometimes this manifest as a coughing or catching feeling in the chest. Other times it is a feeling of light headedness. 19

57 Preventative / Precautions: Be reassuring with the patient. Under no circumstances should you panic as that will only increase the patient s anxiety which will cause the blood pressure to increase or the arrhythmia to intensify or be prolonged. An alert, concerned, everything is in control, we know what is happening and everything will be fine, professional demure is appropriate. Central Nervous System (4 of 12) (Seizures, stroke) Questions to Ask / Necessary Information: A. Stroke: 1. When did you have your stroke? 2. What loss of function occurred? 3. Have you recovered some function over time? 4. Have you ever had trouble with dental appointments or medical appointments? 5. Is there anything I need to know that will make you more comfortable or make it easier for you to deal with the dental appointment? 6. Are you taking any medication related to the stroke or to prevent another stroke? If so, what medication? B. Seizures: 1. What type of seizure do you have? 2. What stimulates a seizure and do you have an aura prior to the seizure? 3. What is the cause of your seizures? (i.e. head injury, born with problem) 4. How frequently and when (time of day) do they usually occur? 5. What type of medications are you taking to control the seizures? 6. Does the medication work? 7. Do you take the medication regularly or do you discontinued it at times? If you did discontinue, was it your decision or your doctor s and what happened? 20

58 Diagnostic Tests: A. Stroke: 1. If patient taking anticoagulant, then assess bleeding status (see Bleeding Problems management protocol) B. Seizure: 1. If patient unclear about types of seizure or medications, and seizures are poorly controlled, then medical consultation for the above information will be needed. Management During Dental Treatment: A. Stroke: 1. No special treatment considerations are necessary except those that the patient notes could be of value (modifying dental treatment procedures based on the patient s perceived needs has an enormous positive psychological benefit for the patient). 2. Depending on what areas have lost function, especially if the head and neck or oral cavity area are affected, certain types of dental prostheses may or may not be effective, i.e. removable prostheses may not be effectively retained without adequate muscle tone, so fixed prostheses or implant may be needed. B. Seizures: 1. Schedule patient early morning when they are well rested. 2. Patient should be instructed to take their medication properly for at least the several days prior to the dental appointment. 3. Patient should be questioned at dental appointment whether in fact they have taken the medication correctly. 4. If seizure occurs, it should be allowed to run its course. The primary concern will be protection of the patient so they don t hurt themselves and the protection of the dentist and staff so the patient doesn t hurt them. 5. Following a seizure, the decision to continue or discontinue treatment is based on the patient s condition (does the patient feel like he/she can complete the procedure?) and the treatment needed. Be Alert For: A. Stroke: 1. Signs of recurrence of stroke, such as slurred speech, confusion, loss of balance and inability to hold saliva in mouth, and transient ischemic attachs (TIA) manifest as fainting and dizziness, with spontaneous recovery. 2. Alert patient s guardian to any new stroke signs or symptoms so physician can follow up. 3. If patient taking anticoagulants, review Bleeding Problems protocol for additional alerts. 4. If stroke has effected swallowing, suction frequently. 5. If stroke has effected eyelids, protect/cover eyes as needed. 21

59 B. Seizures: 1. Be alert to dental / oral damage secondary to seizure. 2. Be aware of possible gingival hyperplasia secondary to Dilantin. Preventative / Precautions: Strokes and seizures: 1. Minimize stress, avoid procedures that may cause spiking of blood pressure, consider preprocedural anti-anxiety medication such as Valium, if patient is fearful. Seizures: 2. Good oral hygiene. The better the oral hygiene, the less likely or less severe gingival hyperplasia secondary to Dilantin. Diabetes (5 of 12) Questions to Ask / Necessary Information 1. Age first diagnosed? 2. Type of diabetes? 3. Medication being taken? 4. If Insulin is being taken, what is time interval and amount? 5. How often do you check your blood sugar? 6. Have you been hospitalized during the past year for problems related to your diabetes? 7. Is your diabetes well controlled or does it get out of control at times? Diagnostic Tests: *1. Fasting blood sugar (reflects current control, that day). (> 126 mg/dl) *2. Random plasma glucose > 200 mg/dl with symptoms (polyurina, polydipsia, unexplained weight loss) *3. 2 hour plasma glucose > 200 mg/dl following a 75g glucose load 4. Fructosamine test (reflects average control over last 2-3 weeks). 5. Glycated hemoglobin (HbA1c) (reflects average control over last 6-8 weeks). (>7% = problem) (*) official diagnostic tests for diabetes Management During Dental Treatment: 1. Patient should have eaten a balanced meal (includes fat and protein as well as carbohydrates) within the last two hours before coming to the dental appointment. 2. Patient should have taken their medications (if they take medications). 3. Food (Power Bar or some other balanced nutritional supplement) should be available if appointment lasts longer than two hours. 4. Early morning appointments. 22

60 Be alert for: 1. Periodontal problems. 2. Candidiasis / xerostomia. 3. Poor response to treatment, especially periodontal therapy. 4. Poor healing. 5. Slow healing. 6. Any dental infection should be treated promptly i.e. with antibiotics and appropriate incision and drainage. Preventative / Precautions: 1. Good home care. 2. Good glucose control. 3. Take medications predictably. Immunosuppression (6 of 12) Diseases: HIV, leukemia, primary immunosuppressive diseases Medications: Cancer chemotherapeutic agents, immunosuppression drugs used in organ transplant patients, corticosteroids to suppress severe auto-immune diseases. Questions To Ask / Necessary Information (Questions should be designed to evaluate the severity of the immunosuppression and the reason for it. Questions will vary depending on the reason the patient says they are immunosuppresed): 1. Why are you immunosuppressed? 2. How long have you been immunosuppresed? 3. Have you been hospitalized because of problems resulting from your immunosuppression, i.e. infections? 4. Are you taking any prophylactic medication to prevent infections because of your immunosuppression? 5. Has your doctor said that any special precautions should be taken during medical or dental treatment to prevent (prophylax against) possible infections? Diagnostic Tests: 1. CBC with a differential (especially platelet count, if planning surgery). 2. T-suppressor cell count (HIV patients). 3. Viral load (HIV patients). Management During Dental Treatment: 1. Depending on severity of immunosuppressants, laboratory tests, primarily CBC with differential, should be done immediately (within 5 days) of major invasive procedure, i.e. extractions, scaling and root planing, periodontal surgery. 2. If white count below 2,000, no elective treatment until white count restored. 3. If platelet count is less than 60,000, no elective treatment. If emergency treatment is needed with the risk of bleeding, then have physician give the patient a packet platelet prior to procedure. 23

61 4. If patient is severely immunosuppressed and infection is present, consider prophylactic antibiotics prior to oral surgical or periodontal surgical procedures. 5. Institute aggressive treatment of any dental infection, including antibiotics, incise and drain, and proceed with any necessary endodontic procedure or extraction. 6. Aggressively control any periodontal disease with proper cleaning and supplemental medication such as clorhexidine rinse. Be Alert For: 1. Periodontal infections 2. Yeast infections 3. Viral infections 4. Periapical problems, impacted teeth, poorly done endodontic procedures, oral ulcerations. Preventative / Precautions: 1. Prior to organ transplant or when patient is most immunocompetant, consider aggressive dental therapy to remove / resolve any possible dental problems, i.e. scale / root plane for periodontal disease, extract impacted teeth, complete any needed or expected endodontic procedures. Consider extracting teeth with compromised endodontic prognosis. 2. Good oral hygiene. 3. Prophylaxis for viral and fungal infections. Patient told to alert dentist or physician at first sign of any infection. Infectious Diseases (7 of 12) (Tuberculosis, hepatitis, HIV, herpes, the flu) Questions To Ask / Necessary Information: A. Tuberculosis: 1. When were you diagnosed? 2. Are you still having symptoms of active infection, such as coughing? Night sweats? 3. What medications have you taken and for how long? 4. Have you taken them as directed? B. Hepatitis: 1. What type of hepatitis do you have? 2. Are you actively infected at this time? 3. Have you had any signs or symptoms of your hepatitis? 4. Have you had any change in your liver function tests? 5. Have you taken any medication specifically to treat your hepatitis? 6. If you had hepatitis B, do you know your hepatitis antigen status? 24

62 C. HIV: 1. When were you first infected? 2. What is your current CD4 t-cell count? 3. What is your current viral load? 4. Have you had any bleeding problems? 5. Have you had any specific diseases related to HIV infection? 6. Are you taking any specific medications for HIV infection? D. Herpes / flu: (risk associated with these diseases is transmission to the healthcare provider? 1. Are you actively infected at this time? Diagnostic Tests: A. Tuberculosis: 1. If tuberculin test is positive, then an x-ray should be done. 2. If x-ray is positive, or if there is obvious active infection, then sputum test for tuberculosis baccilum should be done. B. Hepatitis: 1. Hepatitis antigens and antibodies should be run. 2. If patient has active hepatitis, then liver function should be run or request physician provide information as to liver function and coagulation status. C. HIV: 1. Current laboratory tests including t-cell count, viral load, CBC with a differential to give platelet count and white count should be done (refer to Pacific Protocols for the Dental Management of Patients with HIV Disease). D. Herpes / flu: 1. No specific laboratory tests need be run. 2. If patient is interested in which type of herpes they have, type 1 versus type 2, then antibody tests can be run. Management During Dental Treatment: A. Tuberculosis: 1. No elective treatment rendered until physician says patient is not infectious (sputum negative). 2. If emergency treatment is necessary, patient should be treated in a level 3 infection control facility with hepafilter mask and laminer airflow. 3. In an actively infected patient, the air expelled when coughing is infectious and should be avoided. B. Hepatitis: 1. Since all patients are treated as though they are infectious and universal precautions are applied, no special precautions are necessary when treating a patient actively infected with the hepatitis virus (If patient is having liver problems secondary to hepatitis, then review liver protocol). 25

63 Infectious Diseases continued C. HIV: 1. If patient is HIV infected but has had no medical problems, then no special precautions are needed. 2. Since all patients are treated as though they are infectious, the usual universal precautions are adequate for management. 3. If patient has signs and symptoms of immunosuppression, refer to protocols for patients with immunosuppression. 4. Review the patient s medications and any dental medications that may be used, to insure no drug interaction. D. Herpes / flu: 1. Since all patients are treated as though they are infectious, the normal universal precautions apply and patient is safe for treatment. 2. If patient is feeling so poorly that they don t feel strong enough for dental treatment, they should be re-appointed. 3. If patient having herpes attack, no special precaution is necessary though patient may want to have herpetic ulcer lubricated or even topical anesthetic applied to minimize discomfort associated with manipulation of oral cavity. Be Alert For: A. Tuberculosis: 1. Oral ulceration or head and neck ulceration, advanced forms of tuberculosis can manifest as what is termed caseating necrosis. Clinically it appears as an ulceration. These ulcers have a high content of tubercular bacilli. Patients with such ulcerations should not receive elective dental treatment until their T.B. infection is resolved. B. Hepatitis: 1. Be alert for signs of jaundice. Follow the protocol for liver dysfunction. C. HIV: 1. Be alert for oral manifestations of immunosuppression such as oral yeast infections, viral infections and periodontal problems. Follow the protocol for Immunosuppression. 2. Be alert for poor healing response and bone sequestration following extractions. D. Herpes / flu: 1. With herpes, avoid traumatizing tissue as it may trigger a herpes attack. 2. If patient knows that herpes attack is precipitated by trauma, consider prophylactic antiviral medication. Preventative / Precautions: A. Tuberculosis: 1. Faithful taking of medication. 2. Good personal hygiene, hand washing, and not coughing on anybody. 3. Good nutrition and rest. 26

64 B. Hepatitis: 1. See liver dysfunction protocol. C. HIV: 1. See immunosuppression protocol. D. Herpes / flu: 1. For herpes, keep lesion lubricated. 2. Consider antiviral therapy. 3. Remind patient that herpetic lesion is contagious, especially when blister present and up to two days after it bursts. Encourage them to observe appropriate personal hygiene and avoid mucous membrane contact with other people when active lesion present. 4. For flu, wash hands frequently. 5. Avoid coughing on people or possible contact with nasal secretions. Kidney Problems (8 of 12) Questions to Ask / Necessary Information: 1. What kind of kidney problem do you have? 2. Does it interfere with your everyday living? 3. Does it alter the way you eliminate medication? Diagnostic Tests: 1. BUN (blood, urea, nitrogen) 2. Creatine clearance rate Management During Dental Treatment: 1. Do not use drugs toxic to the kidney i.e. acetaminophen 2. Use caution and alter dosage form when using drugs eliminated by the kidney i.e. penicillin (often reduced to 500 mg two times per day versus four times per day) 3. If patient on renal dialysis, dental treatment should be done on the day following dialysis. 4. If patient has kidney transplant, see considerations under immunosuppression protocol. Be Alert For: 1. Drug toxicity because of accumulation. 2. Poor healing and oral ulcerations. Preventative / Precautions: 1. No special dental precautions needed Patient should be counseled as to potential toxicity problems from certain prescriptions and over-the-counter drugs, plus alcohol. 27

65 Liver Problems (9 of 12) Questions to Ask / Necessary Information: 1. How long have you had a liver problem? 2. What type of liver problem is it and how was it caused? 3. Do you feel unwell relative to the liver problem? 4. Have you noticed any problems such as bleeding, difficulty in metabolizing / digesting food, or increased or decreased sensitivity to medication, from the liver problem? 5. Do you ever get jaundice (do the whites of your eyes or your skin turn or look yellow)? 6. Have you ever needed to be hospitalized because of your liver problem? Diagnostic Tests: 1. SMA20 (specifically SGOT, AST, ALT) 2. PT & PTT 3. INR Management During Dental Treatment: 1. If bleeding problems, follow bleeding problem protocol. 2. If unable to metabolize drugs, avoid using drugs metabolized in the liver such as erythromycin and ketoconazol. Minimize local anesthetics. 3. If patient having problem with drug interactions, avoid drugs with high potential for drug interaction used in dentistry i.e. erythromycin and ketoconazol. 4. Avoid drugs with potential for liver toxicity i.e. acetaminophen, Tylenol and any other overthe-counter / nonprescription drug. Be Alert For: 1. Easy bleeding 2. Yellow tint to skin, oral mucosa, and the whites of the eye. 3. Poor healing 4. Oral ulcers Preventative / Precautions: 1. Good oral hygiene to minimize oral hygiene problems. 2. Avoidance of drugs that are toxic to the liver i.e. acetaminophen, alcohol. 28

66 Pregnancy (10 of 12) Questions to Ask / Necessary Information: 1. What month of pregnancy are you in? 2. Are you currently seeing a physician for your pre-natal care? 3. Has your physician referred you to a high-risk OB? 4. Do you have any physical limitations, bed rest orders, or changes to daily activities? 5. Have you had complications with prior pregnancies? Diagnostic Tests: None. Patient will make the diagnosis. Management During Dental Treatment: Comprehensive dental care during pregnancy is now the standard of care. Prevention, diagnosis, and treatment of oral diseases, including needed dental radiographs and use of local anesthesia, are highly beneficial and can be undertaken during pregnancy with no additional fetal or maternal risk when compared to the risk of not providing care. However, it is recommended that non-urgent and elective care be postponed, if possible, until postpartum. This would include elective surgical procedures, including asymptomatic wisdom tooth extractions, placement of dental implants, and bone grafting for implant site development. 1. First three months of pregnancy a) There are no restrictions for delivering any needed dental treatment. b) As with all dental treatment, minimize the amounts of medications. Lidocaine is the safest local anesthetic agent to use. There are NO contraindications for the use of local anesthetics with vasoconstrictors. c) Educate the patient about the value of good oral hygiene and good nutrition. 2. Second trimester and first half of third a) This is the most ideal time for all dental treatment needed or desired during the pregnancy. b) As always, minimize drug and medication exposure. c) Emphasize proper periodontal care and good nutrition. 3. Last half of third trimester a) Minimize dental treatment to necessary and/or emergency treatment. b) As always, minimize drug and medication exposure. c) To aid in preventing postural hypotensive syndrome in a pregnant patient during dental treatment, the Oral Health During Pregnancy and Early Childhood: Evidence-based Guidelines for Health Professionals recommends the use of a small pillow under the patient s right hip while positioning her in the dental chair. It is also recommended to allow the patient to turn on her side. 29

67 Be Alert For: 1. Periodontal problems: Besides the patient s own risk of bone loss, severe periodontal disease has been associated with low birth weight pre-term babies. Good periodontal health is paramount to minimizing this risk. 2. Pyogenic granulomas (pregnancy gingivitis). 3. Minimize all drug use. Preventative / Precautions: 1. Good home care. 2. Emphasize good nutrition (adequate protein, folic acid supplements), and to eliminate alcohol, tobacco, and recreational drug use. Prosthetic Joints (11 of 12) These guidelines have been revised to reflect the revised January 2015 guidelines on The Use of Prophylactic Antibiotics prior to Dental Procedures in Patients with Prosthetic Joints: Evidencebased clinical practice guideline for dental practitioners a report of the American Dental Association Council on Scientific Affairs [J Am Dent Assoc 2015:146(1):11-16] Please Note: Non-movable joints / bones (i.e. finger or toe bones), pins, wires, rods, bolts, screws once stabilized (greater than 6 months in place with no problems) are not covered by this protocol and there is no indication prophylactic antibiotic coverage for dental procedures would be valuable. Questions to Ask / Necessary Information 1. Which joint has been replaced? 2. Why was the replacement done? 3. Do you have diabetes or any medical problems including any inflammatory problems or any immunosuppression problems? Diagnostic Tests: No diagnostic tests required. Management During Dental Treatment: The American Dental Association and the Council on Scientific Affairs, in January of 2015, provided Clinical Recommendations relative to the Management of Patients with Prosthetic Joints Undergoing Dental Procedures. The primary recommendation is: In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infections. They go on to note: For patients with a history of complications with their joint replacement surgery and who are undergoing dental procedures that include gingival manipulation or mucosal incision, prophylactic antibiotics should only be considered after consultation with the patient and their orthopedic surgeon.* 30

68 Prosthetic Joints continued They advise: To assess a patient s medical status, review of a complete health history is always recommended when making final decisions regarding the need for antibiotic prophylaxis. There are no specific recommendations as to an antibiotic regime to be used, if the clinician feels it is needed. Instead they suggest to the clinician: *In cases where antibiotics are deemed necessary, it is most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regime, and, when reasonable, write the prescription. They provide the clinical reasoning behind the recommendations: 1. There is evidence that dental infections are not associated with prosthetic joint infections. 2. There is evidence that antibiotics provided before oral care do not prevent prosthetic joint implant infections. 3. There are potential harms of antibiotics including risks of anaphylaxis, development of antibiotic resistance, and opportunistic infections like Clostridium difficile. 4. The benefits of antibiotic prophylaxis may not exceed the harm for most patients. 5. The individual patients circumstances and preferences should be considered when deciding whether to prescribe prophylactic antibiotics prior to dental procedures. You should realize, as stated in the recommendation: This report is intended to assist practitioners in making decisions about the prophylactic use of antibiotics to prevent prosthetic joint infections. The recommendations in this document are not intended to define a standard of care, and rather should be integrated with the practitioners professional judgment and the patient s needs and preferences. In situations where the patient is medically compromised and may be prone to infections, such as uncontrolled diabetes, chronic steroid use, immunosuppressed for any reason, undergoing cancer chemotherapy, the joint has been infected or shown signs consistent with an infection before or it has been recently placed (less than 2 years), then the decision by the clinician or the patient to use prophylactic antibiotics may be prudent and the patient s orthopedic surgeon may not be available. In that case, if the clinician elects to prophylax the patient, it is reasonable to suggest using the medications in the 2003 AAOS/ADA guideline and in the current AHA guideline. These antibiotics would be the ones most effective against organisms most commonly found in a bacteremia associated with a dental procedure: amoxicillin, 2 g, 60 minutes before the appointment. If allergic to penicillins, clindamycin 600 mg or azythromyzin 500 mg, 60 minutes before the appointment. 31

69 Prosthetic Joints continued There are those that feel that the prophylactic antibiotic of choice should be one directed at the most common infecting organisms found in prosthetic joint infections, which are staphylococcal organisms (which are uncommon in the oral cavity). Based on this rationale, the appropriate antibiotic would be a cephalosporin: Cephalexin, 2 g, 60 minutes before the appointment. If allergic to penicillins, clindamycin 600 mg, 60 minutes before the appointment. 60 minutes before the appointment is suggested because prosthetic joint infections and endocarditis are not the same diseases and penetration into a prosthetic joint location may take longer than saturating a cardiac location. In reality, no one knows. Hence the note below: Please note: the above considerations as to an antibiotic regime are our respectful opinion. As noted in the guidelines, a consultation with an orthopedic surgeon would be the ideal way to identify an appropriate antibiotic regime and, as stated in the recommendations, ideally the orthopedic surgeon would write the prescription. It bears repeating, the ADA 2015 recommendations make it very clear that there there is no scientific evidence documenting the value of prophylaxing any dental patient for the intention of preventing a prosthetic joint infection. On the other hand, there is scientific evidence documenting side effects and complications from unnecessary antibiotic use. Essentially, not using antibiotics may be safer than using them. If you decide to use an antibiotic you should have a good reason and it would be prudent to write that reason in the patient s chart. Again, if a patient has a moveable prosthetic joint replacement, the 2015 guidelines state: In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection. The practitioner and patient should consider possible clinical circumstances that may suggest the presence of a significant medical risk in providing dental care without antibiotic prophylaxis, as well as the known risks of frequent or widespread antibiotic use. As part of the evidence-based approach to care, this clinical recommendation should be integrated with the practitioner s professional judgment and the patient s needs and preferences. If a patient has a prosthetic joint plus any of the other medical problems below, their risk of any infection increases and prophylactic antibiotics should be considered. Patients at Potential Increased Risk of Hematogenous Total Joint Infection Immunocompromised/immunosuppressed patients Inflammatory arthropathies (e.g. rheumatoid arthritis, systemic lupus erythematosus) Drug- induced immunosuppression Radiation-induced immunosuppression Patients with significant co-morbidities (e.g.: type 1 diabetes, obesity, smoking) Previous prosthetic joint infections Malnourishment Hemophilia HIV infection Insulin-dependent (Type 1) diabetes Malignancy 32

70 Prosthetic Joints continued Suggested Antibiotic Regimes for "At Risk" patients (select one of these antibiotics) Rx Amoxicillin 500 mg Cephalexin 500 mg Cephradine 500 mg Disp 4 tablets Sig Take 4 tablets (2 grams), 1 hour before procedure. Though no official recommendation is made relative to the appropriate antibiotic to use if a patient has an immediate type allergic reaction (urticaria, angioedema, anaphylaxis) to penicillin/amoxicillin (and, therefore, have a potential for a cross reacting allergy to the cephalosporins), a reasonable alternative, given the organisms found in the oral cavity, is clindamycin. If patient Allergic to Penicillin/Amoxicillin Rx Be alert for: Clindamycin 150 mg Disp 4 tablets Sig Take 4 tablets (600 mg), 1 hour before procedure. Pain in the joint following dental procedures. There is no specific time frame; an infection could arise at any time from any source, including a bacteremia secondary to dental procedures. The likelihood of a prosthetic joint infection secondary to dental procedures is rare. The patient should follow up any unusual discomfort within the joint with their physician. Preventative / Precautions: The risk of prosthetic joint infection secondary to dental procedures is very rare. It primarily occurs in unusual situations when comorbidities such as immunosuppression or other types of medical problems are present. These medical problems increase the susceptibility of any patient to any type of infection. In the long run, the best way to minimize any possible seeding of a prosthetic joint, by bacteria in the oral cavity, is to minimize oral cavity problems through good oral hygiene. There is no evidence to recommend for or against the use of oral antimicrobials such as 0.12% chlorhexidine. 33

71 Asthma (12 of 12) Asthma is: a chronic inflammatory disorder involving many cell types manifesting with episodes of chest tightness coughing labored breathing and wheezing all of which are related to bronchiole inflammation Symptoms may include: coughing wheezing respiratory distress muscle retractions nasal flaring cyanosis breathlessness Factors That Produce Airway Obstruction in asthma: Modification in respiratory secretions with mucous plugging of smaller airways Airway smooth muscle spasm Inflammation of: Eosinophil and lymphocyte infiltration and activation Mast cell activation Subepithelial collagen deposition Denudation of airway epithelium Edema of airway mucosa Common precipitating allergens that lead to the development asthma: tobacco smoke dust mites animal fur cockroaches pollens molds other airborne irritants including acrylic and other aerosolized dental materials These things can also contribute to the development of asthma: viral respiratory infections small birth size diet Source of asthma can be: 1. Intrinsic-asthma tends to be clients older than 35 and is often chronic in nature 2. Extrinsic-precipitated by allergens, viral infections, stress, cold, medication, emotional upset, physical activity 3. Mixed 34

72 These above factors can also aggravate asthmatic attacks. Additional triggers leading to asthma developing include: 1. wood smoke 2. physical activity 3. emotional upset 4. cold air 5. food additives 6. aspirin. 7. dental precipitants: tooth dust, dental materials, dental odors (acrylic)* People with asthma vary widely in their response to triggering factors. Type of Asthma Step 4 Severe Persistent Step 3: Moderate Persistent Step 2: Mild Persistent Step 1: Mild Intermittent Medications & Frequency of Use Inhaled Corticosteriods or inhaled b2 agonist or - Ipratropium bromide or - b2 agonist tablets/ syrup or oral Corticosteriods (all used daily) Inhaled Corticosteriods or Inhaled b2 agonist or - Ipratropium bromide or b2 agonist tablets/syrup (all used daily) Inhaled Corticosteriods or Cromolyn or Inhaled b2 agonist or Ipratropium bromide or b2 agonist tablets/syrup (all used daily) Inhaled b2 agonist or - Ipratropium bromide, but not more than three times per week (both used as needed) Symptoms Before Treatment Continuous symptoms Frequent worsening symptoms Frequent nighttime symptoms Limited physical activity Daily symptoms Worsening symptoms that affect activity Nighttime asthma symptoms about one time per week Daily use of short acting inhaler Symptoms are about two times per week but more often than one time per day Symptoms may affect activity Nighttime asthma symptoms are about two times per month Symptoms about two times per week Brief symptoms (from a few hours to a few days) Nighttime asthma symptoms about two times per month No symptoms and normal lung function between asthma "attacks" Treatment of Asthma. Treatment of asthma begins with client education, particularly about avoidance of precipitating factors 35

73 TREATMENT GOAL: CONTROL OF ASTHMA Goals of Treatment: Minimal (or no) chronic symptoms, including nighttime symptoms Infrequent episodes No emergency department visits Minimal need for additional b2 agonist No limitations on activities, including exercise Peak expiratory flow and normal or near-normal PEF Minimal (or no) adverse effects from medicine Oral Health Changes in Individuals with Asthma: Increased rate of caries development due to prolonged use of b 2agonists inhalers and medications taken to treat asthma that contain sugar. Reduced salivary flow due to inhaler use, dry mouth is an oral symptom associated with albuterol use. Increased prevalence of oral tissue changes. Increased levels of gingivitis or gum disease. Orofacial abnormalities that can interfere with dental treatment. Children with asthma who have the highest caries rates tended to be those who were young, usually under age 5. + Preventive dental treatment is a necessity to help prevent these oral health changes. Dental Care Recommendations for good dental care for clients with asthma: 1. Due to an increase in risk for cavities and gum disease asthmatics should: Increased frequency of dental maintenance visits with your dentist to prevent gum disease and cavities Fluoride interventions such as fluoride supplements, especially if using b 2 agonists inhalers Adherence to caries-prevention measures by following a good home care routine Possible need for antibiotic premedication Use of techniques to reduce stress Be sure to update your dentist about any changes in medications, date of last asthma attack, latest emergency visit to hospital due to asthmatic complications, and factors that cause an asthmatic reaction. Take your medications pre-op and bring them to the office with you. Ask for nitrous oxide to help reduce anxiety. 2. The use of nebulized Corticosteriods can result in: throat irritation, dryness of mouth candidiasis ( only 10 percent to 20 percent of the dose from an inhaler actually reaches the lungs; the rest remains between the tonsils and the voice box). Due to this decrease in saliva flow from using inhalers the following treatment recommendations should be followed: 36

74 To space the inhaler about two inches from your mouth, measure the distance with two fingers as shown. a. Use a spacer with inhaler medications. b. Rinse the mouth with water after steroid inhalation to minimize the potential for candida growth. 3. Often the best time for dental treatment appointments is mid to late morning so to reduce anxiety. MANAGEMENT IN DENTAL CARE Updating clients health history at every visit about these following factors will help you identify the risk of an acute exacerbation: Frequency of asthmatic attacks Precipitating agents Types of pharmacotherapy used Length of time since an emergency visit owing to acute asthma As a general rule, elective dentistry should be performed only on asthmatic clients who are asymptomatic or whose symptoms are well-controlled. The symptomatic person should not be treated, and the presence of asthmatic symptoms such as coughing and wheezing necessitate reappointment Be Aware Be aware of the potential for dental materials and products that exacerbate asthma. These items include: dentifrices fissure sealants tooth enamel dust methyl methacrylate fluoride trays and cotton rolls also have been implicated in promoting asthmatic events corticosteroid-dependent asthmatic people may have a higher tendency for having an adverse reaction to sulfites. Before Treatment When an asthmatic dental client seeks care, the dental professional must: Assess the client's risk level by taking an oral history of the illness. Ascertaining the frequency and severity of acute episodes. Reviewing the client s medications thoroughly (as they provide an indication of disease severity). Determining the client s specific triggering agents. It should be recognized that dental treatment can invoke a significant decrease in pulmonary function among asthmatic clients. It has been demonstrated that there is a reduction of lung function in 15 percent of asthmatic clients studied while receiving dental care. 37

75 During Dental Treatment The most likely times for an acute exacerbation are: 1. During and immediately after local anesthetic administration. 2. With stimulating procedures such as extraction, surgery, pulp extirpation. At each visit make sure: Confirm that they have taken their most recent scheduled dose of medication. Inhaled corticosteroids are used for maintenance therapy and do not improve an acute attack. The client s own metered-dose inhaler bronchodilator should be on hand at each visit to minimize the risk of an attack. Client s appointment should be in the late morning or the late afternoon. If the asthmatic client does not use a bronchodilator, make sure the emergency kit has both a bronchodilator and oxygen. Prophylactic dose of b 2 agonist bronchodilator could prevent diminished lung function during dental treatment. The H 1-blocking antihistamines, too, have been shown to be useful in blunting the bronchoconstrictor response with a pretreatment dose. Promethazine and diphenhydramine have the benefit of being antiemetic and sedative as well as antihistaminic. Anxiety is a known asthma trigger thus the dental environment is a common site for an acute asthmatic attack. Therefore, it should be ascertained that the client has taken his or her most recent scheduled dose of antiasthma medication before treatment. Additionally, substantive stress-management techniques should be used. The use of N 2O in clients with mild-to-moderate asthma can prevent acute stress related symptoms. However, because of its potential for causing airway irritation, N 2O is contraindicated for use in clients with severe asthma. It is advisable to obtain a medical consultation before administering N 2O to such clients. Consequently, clients with severe persistent asthma and those who are prone to severe abrupt episodes of airway obstruction are best given dental treatment in the hospital. 38

76 During treatment check for: 1. Improper positioning of suction tips 2. If fluoride trays or cotton rolls could trigger a hyperreactive airway response in your client. 3. Rubber dams should be used cautiously to avoid possible respiratory compromise or aggravation. 4. Avoid prolonged supine positioning. 5. Bacteria-laden aerosols from plaque or carious lesions and ultrasonically nebulized water also can be asthma triggers in the dental setting. 6. Additionally, aeroallergens such as tooth-enamel dust and methyl methacrylate have been reported to trigger asthmatic attacks. Emergency Protocol for Managing Asthmatic Exacerbation: Assessment of Severity Acute exacerbations are manifested by episodes of bronchospasm and resulting hypoxia and hypercarbia. Management strategy is directed at determining the level of hypoxia and correcting it. The following indicate that the exacerbation is severe: peak expiratory flow rate, or PEFR, is at or below 50 percent of reference value; oxygen saturation is below 91 percent; bronchodilator does not improve PEFR by at least 10 percent after two treatments; client has difficulty speaking; client is struggling for air. Managing an Acute Asthmatic Attack 1. Discontinue the dental procedure and allow the client to assume a comfortable position. 2. Establish and maintain a patent airway and administer b 2 agonists via inhaler or nebulizer. 3. Administer oxygen 6-10 liters via face mask, nasal hood or cannula. If no improvement is observed and symptoms are worsening, administer epinephrine subcutaneously (1:1,000 solution, 0.01 milligram/ kilogram of body weight to a maximum dose of 0.3 mg). 4. Document in time form the beginning of the event. 5. Alert emergency medical services Maintain a good oxygen level until the client stops wheezing and/or medical assistance arrives. 7. Begin diligent basic life support A, B,C,Ds activity as needed. 8. Escort client to hospital as needed. 1

77 General Oral Health Care Instructions Prescribe fluoride supplements for all asthmatic clients, but especially for those taking b 2 agonists Instruct clients to rinse their mouths after using an inhaler Reinforce oral hygiene instructions to help minimize gingivitis Be aware of possible need to prescribe antifungal agents for clients who chronically use nebulized corticosteroids Summary of Recommendations: Before Treatment 1. Schedule appointments for late morning or afternoon. 2. Assess severity of asthmatic condition. 3. Consider antibiotic prophylaxis for immunosuppressed clients 4. Consider corticosteroid replacement for adrenally suppressed clients 5. Avoid using dental materials that may elicit an asthmatic attack 6. Have supplemental oxygen and bronchodilators available in case of acute asthmatic exacerbation During Treatment Use vasoconstrictors judiciously Avoid using local anesthetics containing sodium metabisulfite Use rubber dams cautiously Avoid eliciting a coughing reflex Use techniques to reduce the client s stress: Avoid using barbiturates Avoid using nitrous oxide in people with severe asthma After Treatment 1. Be aware that some clients may have an adverse reaction to nonsteroidal anti-inflammatory drugs. 2. Use tetracycline cautiously. 3. Avoid use of erythromycin in clients taking theophylline. 4. Avoid use of phenobarbitals in clients taking theophylline. 5. Analgesic of choice for these clients is acetaminophen. Oral health care providers play a role that is important in terms of both the client's overall health and the systemic condition's effect on oral health. News Updates Dentists and dental hygienists should be attuned to adult clients who have asthma and exhibit signs of anxiety and/or other physical symptoms, or indicators of stress that can exacerbate asthma during or prior to dental treatment. Dental Anxiety, Dental Health Attitudes, and Bodily Symptoms as Correlates of Asthma Symptoms in Adult Dental Clients with Asthma Author(s): Linda Russell RDH, PhD, CHES Source: Journal of Dental Hygiene 2004; 78(3):3 Publisher: American Dental Hygienists Association 2

78 INTERNATIONAL NORMALIZED RATIO (INR) This test is the current way of monitoring anticoagulant therapy. Until now, prothrombin time (PT) and partial prothrombin time (PTT) were used to monitor anticoagulant therapy. These test have shown to be imprecise and variable depending on which lab had done the test. Different labs use different sources for their reacting substance for these tests. These test call for thromboplastin as reacting agent. This either comes from a human source or animal source. In 1985, the International Committee on Thrombosis and Homeostasis required that all the lots of thromboplastin have their international sensitivity index (ISI) indicated. This established a reference standard and allowed uniformity of results by the introduction of the INR calculated by the formula INR=PT ISI of the thromboplastin used in that lab. The INR index allows for the interpretation of Prothrombin Time with respect to other laboratories and provide a uniformity in the monitoring of anticoagulant therapy. The principle complications of irregular control of oral anticoagulants are bleeding and embo9lic (thrombotic) events (stroke and/or heart attack.) With the use of the INR system, these complications are very much reduced. The INR system is slowly being accepted by clinicians and labs; but still has some minor problems that need to be corrected. In any case, this system is much more reliable than a PT reading. The recommended INR goal for low intensity anticoagulant therapy is 2.5 (range of 2.0-3,.0) clients without prosthetic heart valves. When the INR is very low There is increased chances of intravascular thrombosis (Intravascular clotting). Higher INR indicates high intensity anticoagulant therapy and the physician should be consulted before major procedures to prevent a bleeding episode. The recommended INR goal for low intensity anticoagulant therapy 2.5 (range of 2.0 to 3.0) without prosthetic heart valve replacement for high intensity anticoagulant therapy 3.0 (range of 2.5 to 3.5) with prosthetic heart valve replacement Guidelines to Remember Always consult with physician for advice Minimize trauma at site of treatment Restrict scaling and root planning to a limited area o Example: 1 quadrant at a time Assess bleeding before proceeding with treatment Plan treatment beginning of day and early in the week 3

79 Abbreviated: AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) PHYSICAL CLASSIFICATION SYSTEM ASA I = A client without systemic disease, a normal healthy client, may be on preventive meds. ASA II = A client with mild systemic disease. ASA III = A client with severe systemic disease that limits activity but is not incapacitating. ASA IV = A client with incapacitating systemic disease that is a constant threat to life. ASA V = A moribund client not expected to survive 24 hours with or without operation. EMERGENCY = Emergency operation of any variety; E precedes the number, indicating client s physical status, e.g. (ASA E-III). Definitions: ASA I: Client is considered to be normal and health. Review of the client s medical history, physical evaluation, and any other parameters that have been evaluated, indicate no abnormalities. Client may be on medications (such as birth control pills) that are used for preventive, rather than therapeutic purposes. Physiologically, this client should be able to tolerate the stresses involved in dental treatment with no added risk of serious complications. Psychologically, this client should represent little or no difficulty in handling the proposed therapy. Therapy modifications are not usually required in this client group. ASA II: Client has mild systemic disease, or, is a health ASA / client with more extreme anxiety and fear toward dentistry. Client is generally less stress tolerant than an ASA / client; however, still represents minimal risk during treatment. Routine treatment is in order with possible treatment modifications or special considerations as warranted by the condition. Examples of modifications include the use of prophylactic antibiotics or sedative techniques, limiting the duration of treatment, and possible medical consultations. Elective dental care is warranted with minimal increase in risk to the client during treatment. Treatment modifications should also be considered. Several examples of an ASA II client are: (1) Client with adult-onset diabetes managing blood sugar with oral antihyperglycemic agents (2) Client with well-controlled epilepsy (3) Client with well-controlled asthma (4) Client with hyper- or hypothyroid condition, who is under care and currently euthyroid (5) ASA I client with upper respiratory infection (6) Healthy pregnant client (7) Healthy client with allergies, especially to drugs (8) Health client over the age of 60 (9) Adult with blood pressures between systolic and/or diastolic 4

80 In general, the ASA II client will be able to perform normal activity without experiencing distress such as undue fatigue, dyspnea, or precordial pain. ASA III: Client has severe systemic disease that limits activity but is not incapacitating. At rest, these clients show no signs and symptoms of distress, but will exhibit distress if they experience physiologic or psychologic stress. Elective dental treatment is not contraindicated, but client risk is increased. The need for stress reduction techniques and other treatment modifications is increased. Examples of an ASA III client are: (1) Client with stable angina pectoris (2) Client more than 6 months post-myocardial infarction (MI) (3) Client more than 6 months post-cardiovascular accident (CVA) with no residual signs and symptoms (4) Client with well-controlled insulin-dependent diabetes (IDDM) (5) Client with Congestive Heart Failure (CHF) with orthopnea and ankle edema (6) Client with Chronic Obstructive Pulmonary Disease (COPD) (emphysema, chronic bronchitis) (7) Client with exercise-induced asthma (8) Client with less well-controlled epilepsy (9) Client with symptomatic hyperthyroid or hypothyroid disorders (10) Client with blood pressures between systolic and/or diastolic ASA III clients can perform normal activities without distress, but may need rest during activities should they become distressed. ASA IV: Client has an incapacitating disease that is a constant threat to life. The client in this category has medical problem(s) that is (are) of greater significance than the planned dental treatment. Whenever possible, elective dental treatment should be postponed until such time as the client s medical condition has improved to at least ASA III. This client presents a significant risk during treatment. The management of dental emergencies, such as infection or pain, should be treated as conservatively as possible until the client s condition improves. Where possible, treatment should consist of the prescription of medications such as analgesics for pain and antibiotics for infection. In situations in which it is believed that immediate intervention is required, i.e. incision and drainage (I & D), extraction, or pulpal extirpation, it is recommended that the client receive such care within the confines of an acute care facility, i.e. hospital. Although the risk to the client is still significant, the chance of survival, should the acute medical emergency arise, will be increased. Examples of conditions of an ASA IV client are: (1) Unstable angina pectoris (pre-infarction angina), (2) A myocardial infarction in the last 6 months, (3) Blood pressure greater than 200/ and/or /115, (4) Severe CHF or COPD, requiring oxygen supplementation or wheelchair confinement, (5) CVA within the last 6 months, (6) Uncontrolled epilepsy, and (7) Uncontrolled IDDM with history of hospitalization. 5

81 In general, the ASA IV client will experience distress while at rest. ASA V: This client will not usually present him or herself for dental treatment as he or she is usually hospitalized and terminally ill. This category is contraindicated for elective dental treatment, but may need palliative treatment in the hospital setting. BLOOD PRESSURE LEVELS (Guidelines from the American Heart Association) Blood pressure is measured in millimeters of mercury (mmhg). The classifications in the following table are for persons who aren t taking antihypertensive drugs and aren t acutely ill. When systolic and diastolic pressures fall into different categories, the physician will select the higher category to classify the person s blood pressure status. Diagnosis of high blood pressure is based on the average of two or more readings taken at each of two or more visits after an initial screening. Classification of blood pressure for adults age 18 years and older, with recommended follow-up Category Systolic Diastolic Follow-up Prehypertension or Recheck in 1 year Hypertension STAGE or Confirm within 2 months STAGE or Evaluate within 1 month STAGE or or 110 or Evaluate immediately *Unusually low readings should be evaluated for clinical significance. (From the seventh Report of the joint National Committee on detection, evaluation, and Treatment of High Blood Pressure, NIH publication, 2003) 6

82 VITAL SIGNS BLOOD PRESSURE Adults Normal = <120/<80 Pre-hypertensive = /80 89 Children 3 years = 108 / 70 6 years = 114 / years = 122 / 78 Hypertension Stage 1 = /90 99 Stage 2 = > 160/>100 Refer to posted blood pressure classification guidelines posted in the clinic TEMPERATURE Adults Normal = 98.6 o F Range = 96.0 o F 99.5 o F Children 1st Year = 99.1 o F 4th Year = 99.4 o F 5th Year = 98.6 o F 12th Year = 98.0 o F Elderly Slightly lower = 96.8 o F PULSE Range = Beats Per Minutes (bpm) RESPIRATION Range = Respirations Per Minute (rpm) To convert Fahrenheit ( O F) to Centigrade ( O Celsius) ( O C) = o F 32, 1.8 = O C To convert Centigrade (Celsius) ( O C) to Fahrenheit ( O F) to = O Cx1.8, 32 = O F 7

83 DENTAL RADIOLOGY POLICIES 8

84 Monroe Community College Dental Studies Dental Radiography Policies The MCC Dental Studies program operates under the ALARA principle (As Low As Reasonable Achievable). All operating parameters employed shall result in the lowest possible radiation dose to the patient and still produce desired diagnostic information. The MCC Dental Studies Programs follow the ADA recommended guidelines for prescribing dental radiographs (Appendix, R1). Pregnant Students: According to New York State Sanitary Code, Chapter 1 - Part 16:53, dated April 18, 2001, the student/employee has the right to decide whether to declare her pregnancy or not. This written declaration must be voluntary and can be withdrawn at any time. Radiation safety and infection control is the responsibility of all individuals involved in taking dental x-rays. This includes faculty, students, clinical staff, and individuals assigned the responsibility for proper use and maintenance of radiation equipment and supplies. Students, faculty, and staff are not permitted to remove patient s digital images (radiographs) from the clinic area. No dental radiographs are taken after the fourteenth week during each semester. 9

85 Dental Radiography Infection Control Policies: Attire: Students shall adhere to the MCC Dental Clinic dress code for dental radiography. PPE s: eyewear, gloves, masks, gowns The following are to be disinfected before and after each patient: Chair Tubehead and PID Control Panel Mouse/Keyboard Activating Switch Countertops Lead Apron Sensors Protective Barriers are placed on: Headrest of chair Control Panel Mouse/Keyboard During patient exposure: Patient MUST be covered with appropriate lead apron/thyroid collar Student MUST announce X-RAY when exposing in operatories 1 & 2 Activating Switch Sensor Tray Student MUST remain behind protective barrier or 6 feet from source of radiation. Student will NOT obtain retakes without an instructor. It is the responsibility of the student who exposes the radiographs to follow through with all sterilization and clean-up procedures for each patient. If an X-Ray Rover is assigned to the Dental Radiography Lab/Clinic it is their duty to complete all sterilization and clean-up duties. Sterilization of Radiography Equipment Policies: 1. Sani-wipe all RINN (arm, aiming device - ring) equipment. 2. Package RINN equipment in the clear bags. Packaging instructions: RINN Anterior: Anterior arm, anterior aiming device (ring) RINN Posterior: Posterior arm, posterior aiming device (ring) 3. Place autoclave tape on bag; record date and student initials on the autoclave tape. 10

86 Dental Radiography Exposure Policies: Assess authorization for radiographs: o prescription from patient's dentist o prescription from supervising dentist Gather appropriate evaluation forms & disposition slip (Appendix, R2) Complete and/or review medical/dental health histories with patient Obtain Instructors authorization to begin exposure (wearing appropriate PPE s, scrubs, clinic shoes, etc.) Place a lead apron and thyroid collar on all patients for intraoral exposures. Shoulder/chest lead apron for panoramic exposures. Expose x-rays utilizing appropriate film-holding devices and sensor. If patient needs CRS and BWX, same student will take these radiographs, unless authorized otherwise. Instructor determines retakes and completes disposition slip. Retakes must be completed under direct supervision of dental hygiene instructor or supervising dentist. o Maximum number of retakes is: CRS (14 exposures) - 6 retakes BWX (set of 4 exposures) - 2 retakes All x-rays must be paid for with the exception of senior citizen or Medicaid. Releasing images to the patient at the appointment: o Images are released through the instructor s authorization. o Images are printed on quality digital paper and placed within an envelope, marked with the patient s name, and sealed. Photo Quality Paper Printing Procedures: Display set of images on computer screen Go to file Select x-ray 1 or x-ray 3 Select Print All Paper Printing Procedures: Display set of images on computer screen Go to file Select Brother Printer Select Print All *A referral letter will be sent to either the patient or their Dentist after images have been reviewed by a radiography instructor and supervising dentist. 11

87 Dental Radiography Documentation Policies: Must be recorded on the disposition form as "Released to Client". Must be recorded in the client chart under notes in EagleSoft. The student who took the radiographic survey is responsible for recording the following information in the patient s digital record: 1. Date of exposure 2. Number and type of radiograph (Example: 4 BWX - 1 retake; 18 PAX, 4 BWX) 3. Number of retakes (if none acknowledge with a 0) 4. Entry must be signed by student and instructor Evaluation Policies: Within one week after completing the radiographic survey, the student must complete evaluating the radiographs using the appropriate forms (Appendix R2-5) and leave the following items in the radiography instructor's folder: Disposition slip (complete with patient s full name, full address, & dentist) Completed CRS, BW, or PAN evaluation form(s) Paper copy of the images Completed referral letter 12

88 APPENDIX R1: ADA GUIDELINES FOR PRESCRIBING DENTAL RADIOGRAPHS 13

89 R2 SAMPLE DISPOSITION FORM Radiograph Disposition: SAMPLE ATTENTION: All information should be completed before submitting radiographs. PLEASE NOTE: Do not hand in radiographs until retakes are done, if needed. Name of Patient: John Doe Date: 3/14/00 No. exp.: BXW 4 PA 14 PAN 1 Student: BWX: Student s Name PA s: PAN: Student s Name Student s Name Paid or Reason for Non-Payment: Coupon Disposition of X-rays: Circle one: Gave to Pt date Mail to Pt or Mail to DDS Name & Address Name & Address Dr. David Lawrence 1000 East Henrietta Road Rochester, NY RADIOGRAPH RETAKES: RIGHT 2 retakes PAN: LEFT Molar Bicuspid Cuspid Central Cuspid Bicuspid Molar Molar Bicuspid Bicuspid Molar Instructor signature: BEllis DO NOT SIGN UNTIL COMPLETED 14

90 R3 SAMPLE CRS EVALUATION FORM CRS EVALUATION Student: Patient: Date: KEY: (Indicate how YOU would correct errors that occurred by utilizing the following symbols) M = mesial D = distal F = film PID = Position Indicating Device Move film up/increase vertical angulation ( PID) Move film down/decrease vertical angulation (PID) Mesial/distal movement of film/horizontal angulation (PID) STUDENT COMPLETES: 1. Cone Cut 2. Film Placement 3. Horizontal/Vertical Angulation (Note whether horizontal or vertical angulation error) 4. Processing/Exposure Error (Note whether processing or exposure error) Max Rt Molar Max Rt M/PM Max Rt PM/C Max Ctl Inc Film parallel to occlusal plane Max Lt C/PM Max Lt PM/M Max Lt Molar STUDENT COMPLETES: 1. Cone Cut Mnd Rt Molar Mnd Rt M/PM Mnd Rt PM/C Mnd Ctl Inc Mnd Lt C/PM Mnd Lt PM/M Mnd Lt Molar 2. Film Placement 3. Horizontal/Vertical Angulation (Note whether horizontal or vertical angulation error) 4. Processing/Exposure Error (Note whether processing or exposure error) 15

91 INSTRUCTOR COMPLETES: Input Factor(s) (- 2 pts ea film w/error) Patient Position (- 2 pts ea error) Film Placement (- 2 pts ea error) Points Deducted Recommendations (refer to key above) Vertical Angle (- 2 pts ea error) Horizontal Angle (- 2 pts ea error) Point of Entry (- 2 pts ea error) Retakes (1 st minus 3pts; 2 nd minus 6 pts; 3 rd minus 8 pts; 4 th minus 10 pts) *Deduction of points on retakes is at the instructors discretion and dependent upon, but not limited to, patient cooperation, anatomy, etc. PROFESSIONALISM (Up to 20 point deduction - Instructor reserves the right to determine point deduction). CRS SCORE (out of 100%) Students will receive NO credit for any evaluation if: evaluation(s) are not handed in within the one week time frame, evaluation forms are incomplete, and/or services are not documented in the patient chart. 16

92 CRS Evaluation Student Summary (BACK OF FORM) *ALL radiographs, evaluation forms, etc. are to be returned to your instructor within one week from the date of exposure. Students who fail to abide by this protocol will receive a 0 for the survey. Write a brief summary of the following radiographic findings: Missing (M), Impacted (IM) or Unerupted (UE) Teeth (utilize letter abbreviations i.e. #1 - UE): Restorations (AM amalgam; C composite/resin; PFM porcelain fused to metal), IDENTIFY - Overhangs (OH), Poor Contours (PC): Pulp changes (include endo, pulp stones, etc.): Carious lesion(s) (indicate tooth number, surface involved and whether incipient, moderate, advanced or severe): Calculus (indicate tooth number and surface): Bone level (WNL - Within Normal Limits; if not WNL note type, location, AND AMOUNT of bone loss): WNL Horizontal Vertical Generalized Generalized Localized Region: Localized Region: **AMOUNT OF BONE LOSS PER SEXTANT (measure CEJ to height of bone minus the norm 2): Sextant 1 Sextant 2 Sextant 3 Sextant 4 Sextant 5 Sextant 6 Crestal changes (type of change; condition of lamina dura; location of change: No Changes Indicate location: Loss of crestal radiopacity Indicate location: Crestal Fuzziness Indicate location: Reverse Contours Indicate location: Cratering Indicate location: Triangulation Indicate location: Interseptal bone changes Indicate location: Interradicular bone loss* Indicate location: *(Incipient/moderate/advanced) Crown/Root Ratio: Periapical Radiolucency: Attrition (if present indicate region): Other: 17

93 R4 SAMPLE BWX EVALUATION FORM BITEWING EVALUATION Student: Patient: Date: KEY: = Move film/pid up = Move film/pid to the distal/mesial = Move film/pid down = Move film/pid to the mesial/distal STUDENT COMPLETES: 1. Cone Cut = Film not parallel to occlusal plane *Record any errors in the table below utilizing the symbols found in the KEY above.* Rt Molar Rt M/PM Rt PM/C Lt C/PM Lt PM/M Lt Molar 2. Film Placement 3. Horizontal/Vertical Angulation (Note whether horizontal or vertical angulation error) 4. Processing/Exposure Error (Note whether processing or exposure error) INSTRUCTOR COMPLETES: Input Factor(s) (Possible Pts 8) Patient Position (Possible Pts 2) Film Placement (Possible Pts 8; 2 pts ea film) Pts (+/-) Recommendations (refer to key above) Vertical Angle (Possible Pts 8; 2 pts ea film) Horizontal Angle (Possible Pts 8; 2 pts ea film) Point of Entry (Possible Pts 8; 2 pts ea film) Retakes (1 st minus 4; 2 nd minus 6; 3 rd minus 8) Digital Mounting (minus 2pts each mounting error) *Additional pts deducted (see * below) BWX SCORE (out of 100%) *10 points will be deducted for each of the following errors: professionalism, documentation errors (including evaluation forms). *Automatic failure: infection control, radiation hygiene, failure to sign x-ray clinic sheet, not evaluating x-rays. *Incident Report (examples, but not limited to): failure to document exposures in services within patient chart, failure to evaluate radiographs, infection control, & professionalism. 18

94 Bitewing Evaluation Student Summary (BACK OF FORM) Students will receive NO credit for any evaluation if: evaluation(s) is/are not handed in within the one week of the exposure date, evaluation forms are incomplete, and/or services are not documented in the patient chart. Write a brief summary of the following radiographic findings: Missing (M), Impacted (IM) or Unerupted (UE) Teeth (utilize letter abbreviations i.e. #1 - UE): Restorations (AM amalgam; C composite/resin; PFM porcelain fused to metal), Overhangs (OH), Poor Contour (PC): Pulp changes (include endo, pulp stones, etc.): Carious lesion(s) (indicate tooth number, surface involved and whether incipient, moderate, advanced or severe): Calculus (indicate tooth number and surface): Bone level (WNL - Within Normal Limits; if not WNL note type, measure and record amount of bone loss) Crestal changes (type of change - reverse contours, cratering; condition of lamina dura; location of change): Interradicular bone loss (teeth involved; type -incipient/advanced) Other: 19

95 STUDENT R5 SAMPLE PANORAMIC EVALUATION FORM PANORAMIC EVALUATION DATE OF EVALUATION I. PATIENT DATE OF EXPOSURE STUDENT TO COMPLETE PARTS A, B, C & D : A. Please note with an x whether the following artifacts can be seen: SHADOW/ARTIFACT Visible Not visible Vertebral Column Submandibular Shadow Ear Soft Palate and Uvula Palatoglossal Air Space Nasopharyngeal Air Space Glossopharyngeal Air Space B. Please indicate with an x any visual alterations between normal and abnormal (note what abnormality is seen): Area Abnormal Cortical rim around the condylar head (intact or not intact; note R or L ) Right ramus, around inferior border of mandible to left ramus (fractures) Coronoid process (height) Mandibular alveolar bone (trabecular pattern) Zygomatic arch (intact) Maxillary sinus (symmetry) Nasal septum and fossa Maxillary Alveolar Bone (trabecular pattern) Carotid Artery/Hyoid Region Are calcifications visible? 20

96 C. Indicate below any other significant findings (i.e. missing/impacted/supernumerary teeth, radiopacities/radiolucencies, etc.): D. Indicate below any patient positioning error(s) noted on the image and how you would correct the error(s): INSTRUCTOR COMPLETES: (BACK OF FORM) Required Technique: Points Deducted: Instructor Comments: Cassette Placement (-5 points) Input-Adult/Child (-10 points) Radiodense Objects (-10 points) (piercings, eyeglasses, etc.) *Deductions of this category are at the Instructors discretion some piercings can not be removed Frankfort Plane (-10 points) Sagittal Plane (-10 points) Teeth appropriately fitted onto the bite-block (-10 points) Patients lips closed (-5 points) Patients tongue to palate (-5 points) Retakes (1 st 10 pts; 2 nd automatic failure of panoramic exposure) *Additional pts deducted - see below PANORAMIC SCORE (out of 100%) *10 points will be deducted for each of the following errors: professionalism, documentation errors (including evaluation forms). *Automatic failure: infection control, radiation hygiene, failure to sign x-ray clinic sheet, not evaluating x-rays. *Incident Report (examples, but not limited to): failure to document exposures in services within patient chart, failure to evaluate radiographs, infection control, & professionalism *Students will receive NO credit for any evaluation if: evaluation(s) is/are not handed in within the one week time frame, evaluation forms are incomplete, and/or services are not documented in the patient chart. 21

97 INFECTION CONTROL MANUAL DENTAL STUDIES PROGRAM MONROE COMMUNITY COLLEGE *Adapted with permission from: Significant revisions from: Debbie Kelly, RDH, MS Ed. Janella Spencer, RDH, MS Ed. Professor of Dental Hygiene Lexington Community College Monroe Community College faculty 1

98 INFECTION CONTROL The premise of infection control is that precautions minimize the risk of exposure to pathogens, thereby protecting health care professionals from occupationally acquired infections. If you have the potential to be exposed to blood, saliva, body fluids, or mucous membranes, either directly or indirectly during your workday activities, then you need to protect yourself by following infection control guidelines. Fluids and tissues are fomites that transmit infectious agents. Nearly all client care procedures expose dental professionals to body fluids and tissues. The most efficient way to prevent transmission of disease during client care is to integrate infection control methods with treatment procedures. Infection control should be the environment in which client care occurs. GOALS OF INFECTION CONTROL The purpose of infection control for dentistry is to prevent transmission of disease during dental treatment by using a concept called standard precautions. Using standard precautions for all clients prevents cross-infection among dental professionals and clients. OBJECTIVES PROTECT YOURSELF from occupational acquired infections; REDUCE the numbers of cross-infecting pathogens. BREAK the chain of cross-infection. APPLY standard precautions; TREAT every case as if the client had a positive diagnosis for hepatitis B, HIV infection or AIDS, tuberculosis, or other serious infectious disease. PROTECT clients from cross-infection. PROTECT dental professionals from liability for negligence and/or noncompliance with federal, state, and local regulations. GOAL OF THIS DOCUMENT The objectives of the Infection Control Program are achieved by strictly applying common sense principles related to seven components. These will be described thoroughly, as they are applied in the Dental Studies Program of the Monroe Community College. Revised April 2005, MCC revised 2014; as of F2016 2

99 COMPONENTS OF INFECTION CONTROL 1. Medical screening 2. Personal protection (prevention and management of exposures) 3. Instrument sterilization 4. Surface and equipment disinfection 5. X-ray asepsis 6. Dental laboratory asepsis 7. Liability 1. MEDICAL SCREENING Medical screening provides information about many aspects of a client; some of these may alert you to the need for prophylactic antibiotic premedication for the client or to refer the client for specialty medical or dental care. Medical screening may also warn you of the infectious disease status, but not always. Specific questions designed to help reveal infectious diseases should be asked at the first visit and at each subsequent appointment. For those clients who have contact with persons with infectious diseases, ask follow-up questions about the nature of the contact and refer them for diagnostic procedures, counseling and medical follow-up as indicated. Remember, the medical history cannot reliably identify all infectious clients without further testing. The CDC and ADA recommend that you treat all clients as potentially infectious and routinely use standard precautions to protect yourself from exposure to HIV and other blood- and body fluid-borne pathogens. The goal of infection control for dentistry is to block cross-infection through use of standard precautions. Standard Precautions: The CDC 1[1] and the ADA 2[2] recommend using a concept called "standard blood and body fluids precautions" with all clients to reduce the potential for exposure to blood- and body fluid-borne pathogens. This means that the blood and body fluids of all clients is considered infectious and treated accordingly. Standard precautions are embodied in standards of care for infection control recommended by the CDC and ADA. Standard precautions are intended to supplement rather than replace recommendations for infection control, such as hand washing. 1[1] 1987, MMWR, 36(2S); 1988, MMWR, 37(24) 2[2] 1988, JADA, 116 3

100 2. PERSONAL PROTECTION One of the most important aspects of infection control is the use of personal protective equipment and methods. They will protect you from infectious agents such as HIV, herpes simplex virus and mycobacterium tuberculosis that are transmitted by blood and saliva of dental clients. Use the following personal protection methods with all clients. Specific Items of Personal Protection General Vaccinations: Measles, Mumps, Diphtheria, Tetanus, Pertussis, Polio, Influenza Specific Vaccinations: Hepatitis B, Rubella Tuberculosis testing Hand washing Barriers Hidden dangers Handling sharps A. Vaccinations The Public Health Service considers vaccines to be the ideal method for preventing infectious diseases. Vaccines have been developed for several infectious diseases; measles, mumps, rubella, diphtheria, tetanus, pertussis, polio, and influenza. Because these infectious diseases can be transmitted by droplets, they pose occupational hazards for dental professionals whose immunity to many diseases may have declined. Vaccination records should be checked and dental professionals should be re-vaccinated for those diseases for which they have inadequate protection. B. Specific Vaccinations 1. Hepatitis B Hepatitis B is a serious blood-borne virus which can cause permanent and fatal liver damage. All dental professionals should be protected. Beginning in 1998 newborns were often given the Hepatitis B vaccine. There are several vaccines available for immunization against hepatitis B. They offer dental and other health care professionals protection against HBV and its sequela, including protection against possible transmission to family members. All attending dentists, dental hygiene students, client care staff, and others who have client contact or contact with materials that are contaminated with blood or saliva of dental clients are recommended to take the vaccine. 2. Rubella This viral disease (often called German measles) is usually a mild disease in children but is a more serious illness in adults, with 25 to 40% complaining of short-lived joint pain. The most serious effect of rubella is Congenital Rubella Syndrome. CRS occurs in the fetus whose susceptible mother becomes infected during the first trimester of pregnancy. Severely affected infants may have cataracts, sensorineural deafness, myocarditis, and mental retardation. 4

101 A rubella vaccine has been available since 1969; it is protective in about 95% of vaccines. Vaccination for rubella is via rubella vaccine or through a combined measles-mumps-rubella (MMR) vaccine that provide lifelong immunity. C. Tuberculosis Testing Tuberculosis is a communicable disease that is transmitted from an infected person to an uninfected person by respiratory secretions containing the Mycobacterium Tuberculosis bacterium, the causative agent of the disease. Person to person spread of tuberculosis is therefore usually through air. When people with tuberculosis of the respiratory tract cough, airborne infectious particles are produced. It requires prolonged exposure for the infection to spread. Infection control techniques are designed to minimize cross-infections by a pathogen such as TB, but they cannot eliminate the risk entirely. It is therefore very important for dental professional and student dental hygienist to employ standard precautions to reduce the likelihood of acquiring a tubercular infection. Clients suspected of having tuberculosis will not be treated in the MCC Clinic until obtaining clearance from the client s physician. Because TB has re-emerged as a health concern and because it is increasing in prevalence, all dental personnel are required to show proof of a negative TB test yearly. Monroe Community College Dental Studies Students can be tested free of charge at student health services. D. Hand Washing Hand washing is one of the most important infection control methods to reduce cross-infection. The CDC and ADA have recommended that strict attention be given to hand washing and the care of hands to reduce the risk of cross-infection of HBV, HIV and other blood- or oral secretion-borne infectious agents. The importance of hand washing is in no way reduced by the use of gloves. Hands may be contaminated by potentially infectious secretions of the client through small, inherent defects in gloves or by puncture or tear during treatment. These holes and micro-sized pores reduce the barrier protection provided by intact gloves resulting in contaminated hands. Because of this, it is especially important to wash hands after degloving and after touching inanimate objects likely to be contaminated by blood or saliva. WHEN SHOULD HANDS BE WASHED? At the beginning of the workday, before gloving Between client contacts, before gloving and after gloves are removed If gloves become torn or defective If hands become contaminated with blood or saliva or come in contact with inanimate objects contaminated with blood or saliva Before leaving the operatory or laboratory Prior to leaving the office for the day 5

102 HOW SHOULD YOU WASH YOUR HANDS? Do not use bar soap; it becomes contaminated and serves as a vehicle of infection. Liquid detergent dispensers are preferred. * Wet hands and wrists with warm water. * Apply an antimicrobial hand washing solution generously. * Lather and rub vigorously all surfaces of hands and wrists for at least 15 seconds. Rinse completely. * Dry hands using disposable, single-use paper towels. * Alcohol based antimicrobial hand sanitizers can be substituted when there are no visible contaminants CARE OF HANDS: If you suspect that you have encountered an accidental skin penetration you need to follow this procedure: Notify instructor Remove gloves (save) and wash hands Check for bleeding no? Yes? Follow Exposure Control Plan fill glove with water, if there is a leak the instruments are contaminated. Get a fresh set. If there is no leak, get fresh gloves and continue care. E. Barriers CDC and ADA recommended that attending dentists, dental hygienists, dental hygiene students, dental assisting students and clinical staff with exudative lesions or weeping dermatitis refrain from all direct client contact and from handling client care equipment until the condition resolves. Barrier techniques reduce the risk of exposure to blood- and body fluid-borne pathogens for dental health care workers, first, but also protect clients from possible transmission from the worker. Barrier techniques include gloves, masks, protective eye wear and protective clinical attire. Chin-length plastic shields must be worn over masks when using aerosol-producing equipment. Gloves: The physical barrier of disposable gloves furnishes protection from potentially infectious agents. As long as the gloves are not defective and do not tear during use, they reduce the risk of exposure to blood, saliva and mucous membranes. Gloves must be worn for all clients; for all intra-oral procedures; anytime there is the potential for contact with blood, saliva, or mucous membranes; or when touching contaminated objects or surfaces. Use examination gloves for all diagnostic and therapeutic dental procedures other than surgery. 6

103 Gloves should cover cuffs of long-sleeved clinic wear and wrist watches to protect bare skin from a potential exposure. Gloves should not be washed or disinfected for reuse. Detergents, disinfectants and alcohols damage glove material, causing micro pores and a tacky surface. The resulting defective gloves offer diminished barrier effectiveness. Reusing gloves presents a danger of cross-infection between clients 3[3]. Change gloves between client contacts. One pair of gloves is usually adequate for each client. However, gloves may need to be replaced during lengthy procedures such as treatment in the dental hygiene clinic. To maintain barrier integrity, change gloves at intervals less than two hours 4 [4]. Additionally, replace gloves if a perforation is noted (see above), after prolonged use or following complex procedures and those procedures involving materials that can degrade the glove. GLOVING PROTOCOL * Wear gloves for all treatment procedures. * Remove jewelry and wash hands. * Put on gloves. Do not wear jewelry with gloves. * Change gloves after each client contact; during lengthy or complex procedures; if gloves become defective; or if glove surface becomes tacky. * Remove gloves and wash hands as prescribed after treatment. Do not reuse gloves. Washing gloves is prohibited Never wear gloves outside cubicle or operatory for any reason. Remove gloves and wash hands before going to sterilization, x-ray room, or lab. Remove gloves if you use the restroom or leave the clinic area. Over-Gloving If it is necessary to handle objects such as charts, over gloves may be used. Over gloves are made of polyethylene and resemble food handler's gloves. This technique reduces the number of gloves used, yet maintains effective infection control for safety. Remember that over-gloves are contaminated on the inside. Masks Splashing or spattering of blood and saliva commonly occurs in the practice of dentistry. Because of this, wearing a mask is essential to protect mucous membranes of the nose and mouth. At least one health care worker has been infected with HIV as a result of a splash to the face and mouth. 5[5] To reduce potential exposures, wear a mask for all client contacts, even those procedures perceived to have minimal potential for spatter. Change masks after 1 hour. If mask becomes wet, change immediately. Microbes can penetrate a wet mask. A chin-length plastic face shield may be worn over masks. An ultra-high filtration (>95%, >/ = 3 microns) mask should be utilized. 3[3] CDC, 1988, MMWR, 37(24) 4[4] Otis & Cottone, [5] CDC, 1987, MMWR, 36(19) 7

104 Important considerations regarding masks * Choose a dome, ear-loop or a tie-on mask * Use a new mask for each client. * Do not reuse masks. * Change mask if it becomes wet. * Do not touch mask nor drape around the neck. Face Shields A chin-length plastic face shield must be worn using the ultrasonic scaler and airbrasive polisher to reduce potential spatter from these aerosols. Wash and disinfect the face shield between clients. Refer to the manufacturer's recommendations for appropriate disinfectant. Protective Eye Wear Protective eye wear protects the conjunctivae and periorbital membranes from infectious spatter. Wear protective eye wear with all clients for all clinical procedures. Also use protective eye wear in the dental laboratory and sterilization area when using equipment that creates droplets, spatter, chips or dust. Protective eye wear should fit closely at the bridge, brow, cheeks, and corners of the eyes. Use large-diameter, durable and scratch-resistant glasses with side shields. If corrective glasses are worn, they must be of large diameter. For those who wear contact lenses or "half glasses", over glasses with large-diameter lenses and side shields must also be worn. Wash and disinfect all protective and corrective eye wear between clients using a germicide that is EPA-registered as a tuberculocidal. Because mycobacteria represent one of the most resistant groups of microorganisms, a mycobactericidal germicide is also effective against other bacteria and viral pathogens. Some disinfectants cause damage to the plastic, so refer to the manufacturer's recommendations before using. Rinse and dry eye wear well after disinfection. Important considerations regarding protective eye wear * Wear protective eye wear for all client contacts. * Use large-diameter, durable, scratch-resistant eye wear with side shields. * Wash and disinfect eye wear between clients. * All clients must wear protective eyewear. Protective Clothing All personnel must wear garments that protect them from droplets, spatters and aerosols of blood or saliva of clients. These protective garments must cover street clothes or scrubs and must not be worn outside the treatment environment. Protective clothing must be a disposable gown. These garments must have long sleeves. Change protective clothing at least daily, and more often if visibly soiled. Contaminated protective attire may be a potential source of infection. After use, dispose of disposable gown appropriately. 8

105 Important considerations regarding protective clothing * Wear protective clothing for all clients. * Change and wash garments at least daily or more often if visibly soiled. * Do not wear protective attire outside of the clinical environment. F. Hidden Dangers Many seldom considered reservoirs of infection exist in and around the client care areas. For example, infectious bacteria and viruses remain alive on dental charts for lengthy periods of time and are potentially transmissible to dental personnel and clerical staff. Hidden sources of contamination include dental charts, and pens and pencils. No eating or drinking is allowed in Monroe Community College s clinical facility. MCC is a smoke-free environment. Paperwork Since January 2012 all patient documentation has been electronic. Some paper products are still used. Prevent contamination before the fact, rather than attempting to decontaminate afterward. Important considerations regarding the handling of dental charts * Avoid handling paper with contaminated hands, either gloved or bare. * Before handling the chart during treatment, over glove or remove gloves and wash bare hands. Alternatively, ask non-treatment personnel to handle charts. Pens and pencils. Writing instruments are easily contaminated with oral secretions that are potentially infectious. Mouse and keyboard. Computer equipment must be covered right before donning exam gloves. Important considerations regarding the handling of writing instruments or typing * Use over gloves or use bare hands when writing or obtaining materials * Clean and disinfect writing instruments used in client care areas after each client. * Remove plastic mouse/keyboard covers at the end of the appointment * Disinfect countertop * Avoid hand to mouth pathways. Never place a writing instrument in your mouth. G. Handling Sharps Any item that could puncture the skin such as needles, scalpel blades, explorers, curets, burs, orthodontic wires, or matrix bands are considered sharps. Sharps are contaminated and potentially infectious. Handle all sharps carefully and place disposable sharps, for example, needles, scalpel blades and orthodontic wires in a sharps container after use. While the emphasis of a sharps discussion is needles safety, other items with sharp tips, cutting edges, or the potential to have a sharp edge (carpules) also pose a threat. 9

106 Needle sticks constitute the most common type of occupationally-acquired exposure in the health care field 6[8]. Additional dangers include other sharps such as instruments, burs and orthodontic wires. Take precautions to prevent injuries caused by handling sharp armamentarium during procedures, especially while cleaning and during disposal. Assess when sharps are handled and modify unsafe practices. Include such seemingly unlikely exposures such as scratches on the forearm of an operator inflicted while reaching past the handpiece holder apparatus. Disposable needle shield After handing the dentist the syringe, place the needle shield and cap on the tray in a location where the dentist can easily use one hand scoop with the needle. After the dentist is finished, do not remove the cap after the re-sheathing has occurred. Important considerations regarding needle and sharps safety * Never move your hand in the direction of an uncapped needle. * Do not bend, break or cut used needles. * Do not recap needles directly by hand. Either use the "scoop" method or use a capping device. * Never lay an uncovered needle on the tray. * Dispose of needles and carpules in an approved sharps container in the operatory for transport. Do not carry sharps by hand. * Never dispose of needles in operatory waste container. Dispose of contaminated needles properly. To reduce the possibility of an accidental needle stick to clinical staff and housekeeping staff, used needles must be discarded into an OSHA-approved, puncture-resistant, breakage-resistant container, located in the clinic, which are sealed when ¾ full and removed by Monroe Community College s public safety and incinerated. Handling dental burs: To avoid injury from sharp, contaminated burs, the operator is responsible for removing all burs from the handpiece after treatment is completed. 3. INSTRUMENT STERILIZATION Sterilization is the process that kills all life forms--viruses, bacteria, fungi/mold and spores. It is the property of complete killing that distinguishes sterilization from disinfection. There is no such condition as "nearly sterile". A dental instrument is either sterile or it is not sterile. Sterilization is unique. To eliminate the risk of disease transmission, sterilize all reusable instruments, equipment and additional items after each use. That includes handpieces, ultrasonic scalers and prophy jets. Common methods of sterilization in dentistry are steam under pressure (autoclave), chemical vapor under pressure, dry heat oven and liquid chemical sterilants. 6[8] Jagger, et al

107 Sterilization of dental instruments protects from cross-infection. The most efficient way to manage sterilizing instruments is using procedure-specific instrument tray set-ups. This system offers protection from cross-infection caused by contaminated dental instruments. Other items commonly used in dentistry which must be sterilized after each client contact include burs, endodontic files and reamers, rubber dam frames and clamps, impression trays, sharpening stones, bite blocks, mouth mirrors and cotton pliers. The sterilization process has six steps. STERILIZATION PROCESS * consolidation and transport of instruments * cleaning * packaging instruments * sterilization * storage * sterilizer monitoring Consolidation and transport Upon completion of client care activities, instruments and equipment must be cleaned and packaged to be transported to the sterilization area and the operatory must be disinfected. Use the following guide for consolidation and transport of instruments and equipment. Important considerations regarding consolidation and transport Cleaning * Remove gloves and wash hands as prescribed. * Put on heavy-duty, puncture-resistance gloves. * Place non-sharps disposables in a waste container in the operatory. Follow specific rules decreed by Monroe county or the city of Rochester, (if any) for special handling and disposal of infectious waste. * Place sharps (needles, scalpel blades, anesthetic carpules, orthodontic wires, endodontic files, reamers or broaches, and other sharps) in a puncture-resistant sharps container located in the Sterilization area. * Do not discard sharps in operatory waste container. All instruments and equipment must be cleaned before sterilization. Cleaning can be accomplished in the Hydrim instrument washer or by ultrasonic cleaning. Sonication in a detergent solution achieves a high level of disinfection, though an enzymatic cleaner aids in breaking down blood proteins. Both methods minimize manual manipulation of instruments which reduces the risk of crosscontamination. Important considerations regarding instruments: Hydrim instrument washer. Operate Instrument Washer according to Manufacturer s directions * Glove with heavy-duty gloves. * Place instrument cassette in rack * Select appropriate cycle (P2 for pre-clinic, P4 for clinic). * Avoid cross-contamination, instruments are disinfected, not sterile. 11

108 Important considerations regarding instruments: Ultrasonic Cleaning * Glove with heavy-duty gloves. * Place instrument cassette in ultrasonic unit containing a detergent dissolved in tap water. * Sonicate for 12 minutes. * Drain. Pat cassette dry. Important considerations regarding Handpieces * Wipe handpieces and accessories with disinfectant to remove blood, saliva and debris. * Place in paper backed plastic pouches, label and seal. * Sterilize according to the manufacturer's instruction. Important considerations regarding Safety Glasses for clients * Rinse under running water to remove debris. * Wipe with surface disinfectant and allow to remain wet for recommended time. Important considerations regarding oxygen tank masks and tubing WRAPPING INSTRUMENT CASSETTE 1. Place cassette on wrap 2. Insert Chemical Indicator Strip 3. Fold wrap around cassette 4. Seal edges with indicator tape 5. Label cassette using masking tape. 6. Do NOT write on blue cassette wrap. DENTAL HANDPIECE STERILIZATION PROTOCOL 12

109 The handpieces we use do not require lubrication. After use wipe the outside of the Handpiece with a disinfecting wipe. Place in plastic/paper pouch. Place on the autoclave cart. When loading the autoclave these items should be placed paper-side up for ventilation. STERILIZATION The primary methods of sterilization of dental instruments and equipment are steam autoclave, chemical vapor and dry heat. The instruments and equipment used in the MCC Dental Hygiene Clinic are sterilized in a steam autoclave. Primary method of sterilization for stainless steel instruments and some expendables. Process at 132 o C (270 o F) for fifteen minutes; drying cycle requires an additional 30 minutes. Because a variety of steam autoclaves are available, it is essential that you follow the manufacturer s instructions for the correct temperature and time to process instruments for sterilization. Sterilizer Monitoring Sterilizers are monitored to ensure that they are actually sterilizing instruments and other items. Sterilizer monitoring systems consist of a set of indicators and a record keeping system. Three types of indicators are used: process indicators, activity indicators and biological monitors. Only a biological monitor provides proof that the contents of the sterilizer have been sterilized. Process Indicators The primary purpose of a process indicator is to reveal that a package has been exposed to the sterilization process - It does not mean that the instruments in the package are sterile. Commonly called "autoclave" tape, process indicators have heat-sensitive strips that change color when heat is applied, regardless of whether or not the temperature and/or time are insufficient for sterilization. Activity Indicator Activity indicators signal (by color change) that required conditions for sterilization have been attained inside the sterilizer. Activity indicators also do not signify that the instruments in the pack are sterile. Activity indicators are used for steam only. Biologic Monitors 13

110 Biologic monitors test sterilizers for their ability to kill bacterial endospores, the most resistant forms of life known. The ADA (Council on Dental Materials, Instruments, and Equipment, 1988) recommends that biologic monitors be used routinely to determine the adequacy of sterilizer function. There are biologic monitors specified for each sterilizer. For most dental practices, biologic monitoring should be done weekly. At the end of the sterilization cycle, check the activity indicator. Handle the biologic monitor as prescribed by the manufacturer. After processing the biologic monitor, record the results in the Sterilization Log Book. Failure of a Sterilizer If an indicator system shows that a sterilizer has failed to cycle properly, that is the contents are not sterilized, retrieve all the items processed since the last sterilization date and reprocess. Retest the sterilizer and have it repaired as necessary. Record keeping Record the results of the biologic monitor in the Sterilization Log Book at the end of the incubation period. Maintain all documentation for future reference. 4. SURFACE AND EQUIPMENT DISINFECTION Disinfection is a process using chemicals to kill most, but not all life forms. Disinfection does not kill spores and some viruses which differentiates it from sterilization. Surfaces contaminated with blood and saliva must be cleaned and disinfected before the next client is seated. Although HIV transmission from a contaminated surface has not been documented 7[9], surfaces must be disinfected. Studies at the CDC indicate that the number of HIV in blood on surfaces decreases with time, but it is not known how long the virus remains virulent 8[10]. Materials The technique of surface disinfection is quite simple and requires a minimum of experience to become proficient. The items required for disinfection are few. EPA approved intermediate-grade disinfecting wipes Heavy-duty, puncture-resistant gloves Face mask Protective eyewear 7[9] CDC, 1987, MMWR, 36(2S) 8[10] CDC, 2003, MMWR, 52 14

111 1. TUBERCULOCIDAL DISINFECTANT 9[11] At Monroe Community College we use an intermediate grade disinfectant (hospital grade with tuberculocidal). All surfaces (cabinets, chairs, light handles, etc) can be cleaned with one product. Because a variety of disinfectants are available, it is essential that you follow the manufacturer s dilution, contact time and temperature recommendations. 2. HEAVY-DUTY NITRILE GLOVES Use heavy-duty nitrile gloves at all times when disinfecting surfaces and equipment or handling contaminated items. Do not use exam gloves for disinfection and housekeeping tasks in dental operatories. Exam gloves are easily penetrated by sharp objects and edges. 3. FACE MASK Use a mask at all times when disinfecting surfaces and equipment. 4. PROTECTIVE EYE WEAR Use protective eye wear as described for all clinical procedures. Surface Disinfection Surface disinfection is a two-step process. Step 1 is the precleaning step. Step 2 is the disinfection step. Both steps are done wearing heavy-duty gloves. Step 1: Precleaning Step 2 Precleaning is essential for effective disinfection. Organic material such as blood, saliva and debris must be removed from surfaces before disinfecting. Organic matter reduces the ability of disinfectant to kill microorganisms. Be very meticulous with precleaning, using a wipe. Disinfecting Most microorganisms are killed during this process. Be very meticulous with disinfecting. Cover all touch surfaces. DISINFECTING PROCEDURE 1. Use disinfectant wipes. 2. Wipe to ensure complete coverage. 3. Allow surfaces to remain wet following manufacturer s specifications. 4. Dry surfaces if necessary. Leave disinfectant in corners, cracks and crevices for residual effect in difficult to clean and disinfect areas. 9[11] Disinfectant is defined as a germicidal chemical that is registered with the E.P.A. as a "hospital disinfectant." 15

112 Dental Studies Clinic Disinfection Protocol Dental Studies Students will thoroughly disinfect the operatory. PREPARATION FOR CLIENT CARE (a) HANDWASHING Thoroughly wash hands upon entering and leaving clinic and between glove changes Follow recommended procedures PERSONAL PROTECTIVE EQUIPMENT Examination gloves are changed for each client Utility gloves are worn for cleaning/sanitization tasks, disposing of waste, and handling of contaminated instruments Use overgloves to handle paper and to record during appointment Masks are worn during client care and during cleaning procedures Safety glasses with side shields (or face shields) are worn during client care and cleaning procedures Change barriers as needed Faceshields, worn with masks, used for aerosol-producing procedures DISINFECTING DENTAL EQUIPMENT (Beginning of clinic session) Wear PPE s Disinfect all items Disinfect all touch surfaces on the unit, mobile cart and operator stool Wait the designated amount of time. Place protective barriers (End of Clinic Session) Wipe instrument tips with damp gauze Bring cassettes to sterilization area wearing heavy-duty gloves Remove and dispose protective barriers and disposable items Run cleaning solution through saliva ejector or HVE Remove all visible blood, debris, etc. with disinfecting wipe Wipe all touch surfaces on unit, mobile cart, and operators stool with disinfecting wipe Wait the designated amount of time At the Beginning of Each Workday: * Flush all water lines (ultrasonic scalers and air/water syringe) for 20 seconds prior to the first use each day. After each client: Flush contaminated water lines for 20 seconds, and thoroughly scrub equipment with a disinfectant to remove adherent material. 16

113 5. DENTAL RADIOGRAPHY ASEPSIS Radiographs should be taken on dental clients using the same infection control standards as for other procedures. This includes personal protection (such as gloves, mask, eye protection, and protective clinic attire), sterilization of equipment and disinfection of surfaces and equipment. Aseptic operating procedures to be used before, during, and after exposures are as follows: Wearing exam gloves disinfect chair, x-ray tube head and cone, cover activator button with a barrier strip, cover computer keyboard and mouse. Place headrest on chair. Remove gloves. Wash hands. Gather all necessary items before seating the client: sterile XCP instruments, sensor, sterile cotton rolls, appropriate bite blocks. Everything should be placed on the x-ray tray - not on the counter top. Bring client into operatory. Review medical/dental histories. Obtain client and faculty signatures Seat client and place lead apron and thyroid collar on client. Wash hands. Put on gloves, mask and glasses. Review images, instructor will direct retakes Remove mask, gloves, glasses. Wash hands. Remove lead apron from the client. 6. LABORATORY ASEPSIS Due to the potential for injury in the lab, students are required to adhere to the following general safety precautions when working in the lab: Remove all rings and/or jewelry. Wear safety glasses. Wear a disposable gown over street clothes and/or scrubs. Pull long hair back or pin-up out of the working zone. Use disposable gloves and over gloves Use mask when appropriate Lab Procedures Disinfecting Alginate Impressions Use protective clothing, masks, glasses, and gloves when handling contaminated impressions. Remove saliva, blood, and debris from the impression with running tap water. Gently shake the impression to remove excess water Spray impression with disinfectant and place in sealed plastic bag per manufacturer s instructions. Carefully discard disposable items (gloves, masks, wipes, plastic bags) in proper OSHA approved impervious plastic bags. Dispose of impression trays 17

114 MONROE COMMUNITY COLLEGE DENTAL PROGRAM S BLOODBORNE PATHOGENS POLICY* The Monroe Community College (MCC) Dental Assisting and Dental Hygiene Programs are committed to addressing issues related to bloodborne pathogens, such as Human Immunodeficiency (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) in order to protect patients, students, faculty and staff as well as protect the rights of individuals who may have bloodborne infectious disease. Students are required to treat all patients assigned and as a result, the potential exists for transmission of bloodborne and other infectious diseases during patient care services. The purpose of the program s Bloodborne Pathogen Policy (BPP) is to minimize the risk of transmission of bloodborne pathogens, as well as minimize the risk to other environmental hazards. Policies will be reviewed annually and changes recommended as appropriate. The MCC Dental Hygiene Clinic and Dental Radiology Clinic are a safe place to provide and receive dental care. Current and generally accepted epidemiological information supports the conclusion that there is no significant risk of contracting bloodborne diseases through the provision of dental treatment when appropriate infection control procedures are followed. A key element of infection control is the concept of standard precautions, introduced by the Center for Disease Control and Prevention (CDC) as a means to reduce the risk of bloodborne pathogen transmission (e.g., the Human Immunodeficiency Virus [HIV], Hepatitis B Virus [HBV] and others) in healthcare settings. The primary principle behind standard precautions centers on the premise that medical history and examination cannot reliably identify all patients infected with bloodborne pathogens. All patients, therefore, must be regarded as potentially infectious. As such, applying standard precautions requires that infection control procedures (e.g., HBV vaccination, routine handwashing, use of protective barriers and care in the use and disposal of needles and other sharp instruments) are used for every patient. Admission/Employment The MCC Dental Assisting and Dental Hygiene programs will not discriminate against employees, students, applicants for admission or patients based solely on health status. Applicants who test positive for infectious disease or who are carriers of an infectious disease should seek counsel from their physician and the program director prior to application. Immunizations The risk for exposure to Hepatitis B is higher for MCC Health Care Providers (MCCHCP) than the general population, therefore, it is recommended that students start the vaccination process for Hepatitis B as soon as they receive acceptance into the program. A comprehensive medical history, physical examination, eye exam, dental exam, negative Tuberculin (Mantoux) skin test (negative chest x-ray if positive) and additional immunizations as stated in the MCC College Catalog are required. HIV testing Testing of MCCHCP and students for HIV is not required by MCC. However, health care workers and students who perform exposure-prone procedures on patients are encouraged to be tested voluntarily in order to know their HIV status. Obligation to report A student will be allowed to continue his/her education as long as their medical condition permits patient care and other individual s health are not jeopardized or at risk. In the event that an individual poses a risk to others, the Dental Assisting/Hygiene Program Director will assist the individual in obtaining counseling and advisement regarding their health and education. rev. 6/14 18

115 Confidentiality All information regarding the health status of an individual is confidential and protected by the Family Education Rights and Privacy Act of 1994 and the 1996 Health Insurance Portability and Accountability Act. Standard Precautions Standard precautions involve the use of protective barriers such as gloves, gowns, masks, and protective eyewear, which can reduce the risk of exposure of the MCCHCP s skin or mucous membranes to potentially infectious materials. Personal protective equipment for faculty and students is removed before leaving the clinic and disposed of properly by the in institution. In addition, it is recommended that all faculty and students take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices. In the event of injury, the Exposure Control Plan (ECP) is located in the Dental Studies Program Policy Manual (DSPPM) and in the emergency cart in the clinic. Bloodborne Pathogen & Infection Control Training The dental assisting and dental hygiene programs comply with all local, state, and federal infection control policies including the application of Standard Precautions as stipulated by current CDC Guidelines. Written policies and instruction on infection control protocol to minimize the risk of disease transmission is provided in courses throughout the curriculum. Compliance of safety practices is evaluated throughout the students clinical experience to ensure a safe educational and work environment. Infection control procedures are outlined in the Dental Studies Program Policy Manual (DSPPM). Enforcement of Practice Limitations or Modifications Any student or MCCHCP who engages in unsafe and/or careless clinical practices, which create risks to the health of patients, employees, or students, shall be subject to disciplinary action. When such actions are brought to the attention of the Program Director, the students or MCCHCP may be suspended immediately from all patient care activities pending a full investigation of the matter. Exposure to Bloodborne Pathogens MCCHCP or students who are exposed to a bloodborne pathogen in the course of their clinical care are expected to follow the procedures set forth in the DSPPM. If a student should be exposed to a patient s body fluids in a manner that may transmit a bloodborne or infectious disease, the student should follow the protocol outlined in the DSPPM. Environmental Hazards Environmental hazards of the dental healthcare environment include: disorders associated with repetitive activities, exposure to high decibel sounds, exposure to hazardous chemicals or substances, accidental injury, exposure to radiation and allergic reactions to latex or other chemical agents. Dental Hygiene Services Patients infected with bloodborne pathogens can be safely treated in the dental hygiene clinic. Current epidemiological evidence indicates that there is no significant risk of contracting bloodborne diseases through the provision of dental treatment when Standard Precautions are routinely followed. Therefore, all patients, regardless of HIV, HBV, or HCV status will be provided dental hygiene services in the MCC Dental Hygiene Clinic. Standard precautions for all patients will be followed. 19

116 Communication of Bloodborne Pathogen Policy to Dental Assisting Radiology and Dental Hygiene Clinic Patients The Dental Assisting and Dental Hygiene Program s Bloodborne Pathogens Policy is available to all patients in the Patient Information Center in the waiting room. Patients are asked to read and sign the Informed Consent form for dental hygiene and dental radiology clinic participation. Confidentiality All information regarding the health status of an individual is confidential and is considered protected health information used only for treatment. A privacy notice explaining the use of health information is provided to patients at the initial appointment. *Adapted with permission from Del Mar College s Bloodborne Pathogens Policy 7/12 DENTAL WASTE DISPOSAL GUIDE This diagram is intended as a disposal guide for some types of regulated waste. It is not intended to serve as a comprehensive list of all regulated wastes. Regulated Medical Waste Sharps Needles, blades, partially full carpules, carpules contaminated with biohazardous waste Sharps container disposed of via a registered medical waste hauler (in steriliz. room and rm ) Regulated Medical Waste Biohazardous Saturated gauze (blood and saliva 1. Mini biohazard bags 2. Biohazard bag located in sterilization room Hazardous Waste Amalgam waste (rare) 1. Stored in a container with a tight fitting lid 2. Affix a hazardous waste label and removed off site under a manifest by a registered hazardous waste hauler-(in rm-7-203) 20