CADHA26 • California Dental Hygienists and Assistants 2026

Table of Contents

CADHA26 • California Dental Hygienists and Assistants 2026

How to Receive Credit

NetCE 2 Hour Course #51294 • The California Dental Practice Act

51294 • The California Dental Practice Act

1. INTRODUCTION

2. DENTISTRY DEFINED: SCOPE OF PRACTICE

3. LICENSURE

4. VIOLATIONS AND PENALTIES

5. LAWS GOVERNING THE PRESCRIPTION OF DRUGS

6. REPORTING OF ABUSE AND NEGLECT

7. CONCLUSION

8. RESOURCES

Works Cited

NetCE 2 Hour Course #58584 • Infection Control for Dental Professionals: The California Requirement

58584 • Infection Control for Dental Professionals: The California Requirement

1. INTRODUCTION

2. INFECTION CONTROL REGULATIONS

3. MODES OF TRANSMISSION

4. STANDARD PRECAUTIONS

5. TRANSMISSION-BASED PRECAUTIONS

6. PROTECTING DENTAL HEALTHCARE WORKERS

7. CONCLUSION

8. DENTAL BOARD OF CALIFORNIA GENERAL PROVISIONS: SECTION 1005. MINIMUM STANDARDS FOR INFECTION CONTROL

Works Cited

NetCE 3 Hour Course #57001 • Implicit Bias in Health Care

57001 • Implicit Bias in Health Care

1. INTRODUCTION

2. DEFINITIONS OF IMPLICIT BIAS AND OTHER TERMINOLOGIES

3. MEASUREMENT OF IMPLICIT BIAS: A FOCUS ON THE IAT

4. THEORETIC EXPLANATIONS AND CONTROVERSIES

5. CONSEQUENCES OF IMPLICIT BIASES

6. DEVELOPMENTAL MODEL TO RECOGNIZING AND REDUCING IMPLICIT BIAS

7. CREATING A SAFE ENVIRONMENT

8. STRATEGIES TO PROMOTE AWARENESS OF IMPLICIT BIAS

9. INTERVENTIONS TO REDUCE IMPLICIT BIASES

10. ROLE OF INTERPROFESSIONAL COLLABORATION AND PRACTICE AND IMPLICIT BIASES

11. CONCLUSION

12. RESOURCES

Works Cited

NetCE 5 Hour Course #51914 • Dental Care for Patients with Disabilities

51914 • Dental Care for Patients with Disabilities

1. INTRODUCTION

2. AUTOIMMUNE DISEASES

3. IMMUNOSUPPRESSIVE CONDITIONS

4. DISEASES AND CONDITIONS AFFECTING NEUROMUSCULAR COORDINATION

5. CONDITIONS CAUSING COGNITIVE IMPAIRMENT

6. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

CADHA26 • California Dental Hygienists and Assistants 2026

Mark J. Szarejko, DDS, FAGD

Alice Yick Flanagan, PhD, MSW

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

CADHA26 • California Dental Hygienists and Assistants 2026

Expiration Date: 03/31/2027

How to Receive Credit

To complete this Special Offer for continuing education credit please go to http://www.netce.com/specials in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

51294 • The California Dental Practice Act

Mark J. Szarejko, DDS, FAGD

www.netce.com

Copyright © 2025 NetCE, All rights reserved.

Although its primary objective is to safeguard the public, the California Dental Practice Act is an excellent resource for dental professionals to ensure compliance with state law. The California Dental Practice Act is the body of laws in the California Business and Professions Code and the California Code of Regulations governing dental professionals, including dentists, oral and maxillofacial surgeons, orthodontists, dental assistants, and dental hygienists. The Act is intended to serve as a legal guideline for both professionals and the public regarding all aspects of dental practice.

Table of Contents

51294 • The California Dental Practice Act

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. DENTISTRY DEFINED: SCOPE OF PRACTICE

DENTISTS

DENTAL ASSISTANTS (UNLICENSED)

REGISTERED DENTAL ASSISTANTS

DENTAL HYGIENISTS

3. LICENSURE

LICENSE RENEWAL

ACTS LEADING TO SUSPENSION OF A LICENSE AND IN VIOLATION OF THE DENTAL PRACTICE ACT

4. VIOLATIONS AND PENALTIES

5. LAWS GOVERNING THE PRESCRIPTION OF DRUGS

6. REPORTING OF ABUSE AND NEGLECT

CHILD ABUSE AND NEGLECT REPORTING LAW

IDENTIFYING, DOCUMENTING, AND REPORTING ABUSE AND NEGLECT

ELDER AND DEPENDENT ADULT ABUSE AND NEGLECT

INTIMATE PARTNER VIOLENCE

7. CONCLUSION

8. RESOURCES

Works Cited

51294 • The California Dental Practice Act

Education Category. Management

Release Date. 02/01/2025

Expiration Date. 01/31/2028

Course Overview

Although its primary objective is to safeguard the public, the California Dental Practice Act is an excellent resource for dental professionals to ensure compliance with state law. The California Dental Practice Act is the body of laws in the California Business and Professions Code and the California Code of Regulations governing dental professionals, including dentists, oral and maxillofacial surgeons, orthodontists, dental assistants, and dental hygienists. The Act is intended to serve as a legal guideline for both professionals and the public regarding all aspects of dental practice.

Audience

This course is designed for all California dentists, dental hygienists, and dental assistants in all practice settings.

Accreditations & Approvals

NetCE Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement. 10/1/2021 to 9/30/2027 Provider ID #217994. NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. NetCE is approved as a provider of continuing education by the Florida Board of Dentistry, Provider #50-2405. NetCE is a Registered Provider with the Dental Board of California. Provider Number RP3841. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

NetCE designates this activity for 2 continuing education credits. AGD Subject Code 563. This course meets the Dental Board of California's requirements for 2 unit(s) of continuing education. Dental Board of California course #02-3841-26450. NetCE is authorized by IACET to offer 0.2 CEU(s) for this program.

Special Approvals

This course fulfills the California requirement for 2 hours of Dental Practice Act education.

Course Objective

The purpose of this course is to provide California dental professionals with a working knowledge of the contents of the California Dental Practice Act, ensuring that they practice legally and safely.

Learning Objectives

Upon completion of this course, you should be able to:

1. Define the scope of practice of dental professionals in California.

2. Describe the standards of licensure of and medication prescription by dental professionals in California.

3. Identify possible victims of violence or neglect and outline the appropriate response.

Faculty

Mark J. Szarejko, DDS, FAGD, received his dental degree from the State University of New York at Buffalo in 1985. He received fellowship from the Academy of General Dentistry in 1994.

Faculty Disclosure

Contributing faculty, Mark J. Szarejko, DDS, FAGD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

The California Dental Practice Act is the body of laws in the California Business and Professions Code (CBPC) and the California Code of Regulations (CCR) governing all dental professionals, including dentists, oral and maxillofacial surgeons, orthodontists, unlicensed dental assistants, registered dental assistants, and dental hygienists. The Act is intended to serve as a legal guideline for both professionals and the public regarding all aspects of dental practice. As defined in Section 1016.(b)1 of the CCR, continuing education on the California Dental Practice Act is required and must include instruction on utilization, scope of practice, prescribing laws, violations, citations, fines, licensure, the identification of abuse, and mandatory abuse reporting [1]. Of course, the Act is a much larger volume, so much so that it is beyond the scope of this course to elucidate every section. The Dental Practice Act is not intended to replace professional oaths and codes of ethics but does define actions and omissions that may lead to legal action and revocation of a license to practice dentistry in the State of California, the laws of which are continually evolving.

The Dental Board of California (a division of the California Department of Consumer Affairs), which consists of eight practicing dentists, one registered dental hygienist, one registered dental assistant (each practicing for at least five years), and five public members, is responsible for licensure of qualified dental health professionals, enforcement of the California Dental Practice Act, and improving the education of consumers and licensees [19]. The Board's highest priority is to protect the health and safety of the public.

In addition, the practice of dental hygiene is regulated by the Dental Hygiene Board of California, the first of its kind in the United States [20].

2. DENTISTRY DEFINED: SCOPE OF PRACTICE

According to the American Dental Association, dentistry is defined as "the evaluation, diagnosis, prevention, and treatment of diseases, disorders, and conditions of the oral cavity, the craniomaxillofacial area and the adjacent structures and their impact on the human body. This care is provided by dentists within the scope of their education, training and experience in accordance with the ethics of the profession and applicable law" [2]. The CBPC and the CCR provide specific information regarding utilization and scope of practice for dentists, unlicensed dental assistants, registered dental assistants, and registered dental hygienists, as evidenced in the following sections [1].

DENTISTS

CBPC Section 1625. Dentistry is the diagnosis or treatment, by surgery or other method, of diseases and lesions and the correction of malpositions of the human teeth, alveolar process, gums, jaws, or associated structures; and such diagnosis or treatment may include all necessary related procedures as well as the use of drugs, anesthetic agents, and physical evaluation. Without limiting the foregoing, a person practices dentistry within the meaning of this chapter who does any one or more of the following [24]:

(a) By card, circular, pamphlet, newspaper, Internet website, social media, or in any other way advertises themselves or represents themselves to be a dentist.

(b) Performs, or offers to perform, an operation or diagnosis of any kind, or treats diseases or lesions of the human teeth, alveolar process, gums, jaws, or associated structures, or corrects malposed positions thereof.

(c) In any way indicates that the person will perform by themselves or their agents or servants any operation upon the human teeth, alveolar process, gums, jaws, or associated structures, or in any way indicates that the person will construct, alter, repair, or sell any bridge, crown, denture or other prosthetic appliance or orthodontic appliance.

(d) Makes, or offers to make, an examination of, with the intent to perform or cause to be performed any operation on the human teeth, alveolar process, gums, jaws, or associated structures.

(e) Manages or conducts as manager, proprietor, conductor, lessor, or otherwise, a place where dental operations are performed.

The Board requires that dentists ensure that each patient of record receives a copy of the Dental Materials Fact Sheet (provided by the Board) prior to the placement of his or her first dental restoration [25]. The Dental Materials Fact Sheet details the comparative risks and benefits of available dental restorative materials. The patient must sign an acknowledgment of receipt of the fact sheet, and a copy of the acknowledgment must be placed in the patient's record.

DENTAL ASSISTANTS (UNLICENSED)

Although unlicensed dental assistants are not Board approved, their duties and actions are governed by the Act and they are required to complete coursework in the Dental Practice Act, infection control, and basic life support. Failure to follow the regulations set forth by California law can result in fines and/or imprisonment. As defined in CBPC Section 1750.(a), "A dental assistant is an individual who, without a license, may perform basic supportive dental procedures, as authorized by Section 1750.1 and by regulations adopted by the board, under the supervision of a licensed dentist" [1]. Basic supportive dental procedures are those procedures that have technically elementary characteristics, are completely reversible, and are unlikely to precipitate potentially hazardous conditions for the patient being treated. A licensed dentist is responsible for assuring unlicensed dental assistants' competence and ensuring that they complete required coursework (e.g., two-hour Dental Practice Act, eight-hour infection control, basic life support) and maintain certification in basic life support (if employed for longer than 120 days). Specific duties pertaining to dental assistant practice can be found in CCR Section 1085 [28]. General information regarding regulations pertaining to dental assistants is located in CBPC Sections 1740–1777; although these sections are not discussed in this course, they should be periodically reviewed to ensure self-compliance with the act. The CBPC may include additional duties for various dental assistant professions.

CCR Section 1085. Dental Assistant Duties and Settings.

(a) Unless specifically so provided by regulation, a dental assistant may not perform the following functions or any other activity which represents the practice of dentistry or requires the knowledge, skill and training of a licensed dentist:

1. Diagnosis and treatment planning;

2. Surgical or cutting procedures on hard or soft tissue;

3. Fitting and adjusting of correctional and prosthodontic appliances;

4. Prescription of medicines;

5. Placement, condensation, carving or removal of permanent restorations, including final cementation procedures;

6. Irrigation and medication of canals, try-in cones, reaming, filing or filling of root canals;

7. Taking of impressions for prosthodontic appliances, bridges or any other structures which may be worn in the mouth;

8. Administration of injectable and/or general anesthesia;

9. Oral prophylaxis procedures.

(b) A dental assistant may perform such basic supportive dental procedures as the following under the general supervision of a licensed dentist:

1. Extra-oral duties or functions specified by the supervising dentist;

2. Operation of dental radiographic equipment for the purpose of oral radiography if the dental assistant has complied with the requirements of section 1656 of the Code;

3. Examine orthodontic appliances.

(c) A dental assistant may perform such basic supportive dental procedures as the following under the direct supervision of a licensed dentist when done so pursuant to the order, control and full professional responsibility of the supervising dentist. Such procedures shall be checked and approved by the supervising dentist prior to dismissal of the patient from the office of said dentist.

1. Take impressions for diagnostic and opposing models, bleaching trays, temporary crowns and bridges, and sports guards;

2. Apply non-aerosol and non-caustic topical agents;

3. Remove post-extraction and periodontal dressings;

4. Placement of elastic orthodontic separators;

5. Remove orthodontic separators;

6. Assist in the administration of nitrous oxide analgesia or sedation; however, a dental assistant shall not start the administration of the gases and shall not adjust the flow of the gases unless instructed to do so by the dentist who shall be present at the patient's chairside at the implementation of these instructions. This regulation shall not be construed to prevent any person from taking appropriate action in the event of a medical emergency.

7. Hold anterior matrices;

8. Remove sutures;

9. Take intra-oral measurements for orthodontic procedures;

10. Seat adjusted retainers or headgears, including appropriate instructions;

11. Check for loose bands;

12. Remove arch wires;

13. Remove ligature ties;

14. Apply topical fluoride, after scaling and polishing by the supervising dentist or a registered dental hygienist;

15. Place and remove rubber dams;

16. Place, wedge and remove matrices;

17. Cure restorative or orthodontic materials in operative site with light-curing device.

For the purpose of this section, a supervising licensed dentist is defined as a dentist whose patient is receiving the services of a dental assistant in the treatment facility and is under the direct control of said licensed dentist [1]. Direct supervision is defined as supervision of dental procedures based on instructions given by a licensed dentist who must be physically present in the facility when the procedures are performed.

REGISTERED DENTAL ASSISTANTS

Registered dental assistants (RDAs) are Board-licensed professionals who may perform a greater range of duties than unlicensed dental assistants. Specific information pertaining to RDAs' scope of practice can be found in CCR Section 1086, and general information regarding regulations pertaining to RDAs is located in CBPC Sections 1740–1777, which should be reviewed periodically to ensure self-compliance with the act [28].

CCR Section 1086. RDA Duties and Settings.

(a) Unless specifically so provided by regulation, the prohibitions contained in section 1085 of these regulations apply to registered dental assistants.

(b) A registered dental assistant may perform all functions which may be performed by a dental assistant.

(c) Under general supervision, a registered dental assistant may perform the following duties:

1. Mouth-mirror inspection of the oral cavity, to include charting of obvious lesions, existing restorations and missing teeth;

2. Placement and removal of temporary sedative dressings.

(d) A registered dental assistant may perform the following procedures under the direct supervision of a licensed dentist when done so pursuant to the order, control and full professional responsibility of the supervising dentist. Such procedures shall be checked and approved by the supervising dentist prior to dismissal of the patient from the office of said dentist.

1. Obtain endodontic cultures;

2. Dry canals, previously opened by the supervising dentist, with absorbent points;

3. Test pulp vitality;

4. Place bases and liners on sound dentin;

5. Remove excess cement from supragingival surfaces of teeth with a hand instrument or floss;

6. Size stainless steel crowns, temporary crowns and bands;

7. Fabrication of temporary crowns intra-orally;

8. Temporary cementation and removal of temporary crowns and removal of orthodontic bands;

9. Placement of orthodontic separators;

10. Placement and ligation of arch wires;

11. Placement of post-extraction and periodontal dressings;

12. Apply bleaching agents;

13. Activate bleaching agents with non-laser light-curing device;

14. Take bite registrations for diagnostic models for case study only;

15. Coronal polishing (Evidence of satisfactory completion of a board-approved course of instruction in this function must be submitted to the board prior to any performance thereof).
This procedure shall not be intended or interpreted as a complete oral prophylaxis (a procedure which can be performed only by a licensed dentist or registered dental hygienist). A licensed dentist or registered dental hygienist shall determine that the teeth to be polished are free of calculus or other extraneous material prior to coronal polishing.

16. Removal of excess cement from coronal surfaces of teeth under orthodontic treatment by means of an ultrasonic scaler. (Evidence of satisfactory completion of a board-approved course of instruction or equivalent instruction in an approved RDA program in this function must be submitted to the board prior to any performance thereof.)

(e) Settings. Registered dental assistants may undertake the duties authorized by this section in a treatment facility under the jurisdiction and control of the supervising licensed dentist, or in an equivalent facility approved by the board.

Registered Dental Assistants in Extended Functions

Registered dental assistants in extended functions (RDAEFs) are Board-licensed dental professionals who have a greater breadth of permitted duties than RDAs. Specifics regarding these allowed duties can be found in CCR Section 1087 [28].

CCR Section 1087. RDAEF Duties and Settings.

(a) Unless specifically so provided by regulation, the prohibitions contained in Section 1085 apply to RDAEFs.

(b) An RDAEF may perform all duties assigned to dental assistants and registered dental assistants.

(c) An RDAEF may perform the procedures set forth below under the direct supervision of a licensed dentist when done so pursuant to the order, control and full professional responsibility of the supervising dentist. Such procedures shall be checked and approved by the supervising dentist prior to dismissal of the patient from the office of said dentist.

1. Cord retraction of gingivae for impression procedures;

2. Take impressions for cast restorations;

3. Take impressions for space maintainers, orthodontic appliances, and occlusal guards;

4. Prepare enamel by etching for bonding;

5. Formulate indirect patterns for endodontic post and core castings;

6. Fit trial endodontic filling points;

7. Apply pit and fissure sealants;

8. Remove excess cement from subgingival tooth surfaces with a hand instrument;

9. Apply etchant for bonding restorative materials.

(d) Settings. Registered dental assistants in extended functions may undertake the duties authorized by this section in a treatment facility under the jurisdiction and control of the supervising licensed dentist, or in an equivalent facility approved by the board.

In addition to the duties outlined in CCR section 1087, section 1753.5 of the CBPC states that RDAEFs may conduct preliminary evaluation of the patient's oral health, including, but not limited to, charting, intraoral and extra-oral evaluation of soft tissue, classifying occlusion, and myofunctional evaluation, and perform oral health assessments in school-based, community health project settings under the direction of a dentist, registered dental hygienist, or registered dental hygienist in alternative practice [1]. RDAEFs may hold an orthodontic assistant permit, a dental sedation assistant permit, or both.

DENTAL HYGIENISTS

Registered dental hygienists (RDHs), registered dental hygienists in extended functions (RDHEFs), and registered dental hygienists in alternative practice (RDHAPs) are Board-licensed occupations administered by the Dental Hygiene Committee of California, and the California Dental Practice Act contains the main body of laws and regulations that govern their practice.

The Dental Hygiene Committee of California was created by the Board and consists of seven governor-appointed positions: two public members, four dental hygienists, and one practicing dentist; in addition, there are two public members appointed by the Senate Committee on Rules and the Speaker of the Assembly, respectively [20]. Responsibilities of the Dental Hygiene Committee include adopting regulations; issuing, reviewing, and revoking licenses; developing and administering examinations; determining fees; and updating continuing education requirements for all dental hygiene licensure categories. The Act contains specific information regarding the permitted duties and settings of RDH practice (CCR Section 1088), RDHEF practice (CCR Section 1089), and RDHAP practice (CCR Section 1090) [28]. Additional laws and regulations pertaining specifically to dental hygiene practice are located in CBPC Sections 1900–1966.6. These sections should be periodically reviewed to ensure self-compliance with the Act.

Registered Dental Hygienists

CCR Section 1088. RDH Duties and Settings.

(a) Unless specifically so provided by regulation, the prohibition contained in Section 1085(a), subsections (1) through (8) of these regulations shall apply to duties performed by a registered dental hygienist.

(b) A registered dental hygienist may perform all duties assigned to dental assistants and registered dental assistants, under the supervision of a licensed dentist as specified in these regulations.

(c) Under general supervision, a registered dental hygienist may perform the following duties in addition to those provided by Section 1760(b) of the Code:

1. Root planing;

2. Polish and contour restorations;

3. Oral exfoliative cytology;

4. Apply pit and fissure sealants;

5. Preliminary examination, including but not limited to:

1. Periodontal charting;

2. Intra and extra-oral examination of soft tissue;

3. Charting of lesions, existing restorations and missing teeth;

4. Classifying occlusion;

5. Myofunctional evaluation.

6. Irrigate sub-gingivally with an antimicrobial and/or antibiotic liquid solution(s).

7. The following direct supervision duties of dental assistants and registered dental assistants:

1. Dental Assistant.

1. Taking impressions for diagnostic and opposing models;

2. Applying non-aerosol and non-caustic topical agents;

3. Removing post-extraction and periodontal dressings;

4. Removing sutures;

5. Taking intra-oral measurements for orthodontic procedures;

6. Checking for loose bands;

7. Removing ligature ties;

8. Applying topical fluoride;

9. Placing elastic separators.

2. Registered Dental Assistant

1. Test pulp vitality;

2. Removing excess cement from supragingival surfaces of teeth;

3. Sizing stainless steel crowns, temporary crowns and bands;

4. Temporary cementation and removal of temporary crowns and removal of orthodontic bands;

5. Placing post-extraction and periodontal dressings.

(d) A registered dental hygienist may perform the procedures set forth below under the direct supervision of a licensed dentist when done so pursuant to the order, control and full professional responsibility of the supervising dentist. Such procedures shall be checked and approved by the supervising dentist prior to dismissal of the patient from the office of said dentist.

1. Placement of antimicrobial or antibiotic medicaments which do not later have to be removed;

2. All duties so assigned to a dental assistant or a registered dental assistant, unless otherwise indicated;

3. Periodontal soft tissue curettage (Evidence of satisfactory completion of a board-approved course of instruction in this function must be submitted to the board prior to any performance thereof);

4. Administration of local anesthetic agents, infiltration and conductive, limited to the oral cavity (Evidence of satisfactory completion of a board-approved course of instruction in this function must be submitted to the board prior to any performance thereof);

5. Administration of nitrous oxide and oxygen when used as an analgesic, utilizing fail-safe type machines containing no other general anesthetic agents. (Evidence of satisfactory completion of a board-approved course of instruction in this function must be submitted to the board prior to any performance thereof.)

(e) A registered dental hygienist may undertake the duties authorized by this section in the following settings, provided the appropriate supervision requirements are met:

1. The treatment facility of a licensed dentist;

2. Licensed health facilities as defined in Section 1250 of the Health and Safety Code,

3. Licensed clinics as defined in Section 1203 of the Health and Safety Code,

4. Licensed community care facilities as defined in Section 1502 of the Health and Safety Code,

5. Schools of any grade level whether public or private,

6. Public institutions, including but not limited to federal, state and local penal and correctional facilities.

7. Mobile units operated by a public or governmental agency or a nonprofit and charitable organization approved by the board; provided, however, that the mobile unit meets the statutory and regulatory requirements for mobile units,

8. Home of a non-ambulatory patient, provided there is a written note from a physician or registered nurse stating that the patient is unable to visit a dental office.

9. Health fairs or similar non-profit community activities. Each such fair or activity shall be approved by the board.

Any other facility must be approved by the board.

Registered Dental Hygienists in Extended Functions

CCR Section 1089. RDHEF Duties and Settings.

(a) Unless specifically provided by regulation, the prohibitions contained in Section 1085(a) (1) through (8) shall apply to RDHEFs.

(b) An RDHEF may perform all duties assigned to dental assistants, registered dental assistants and registered dental hygienists.

(c) An RDHEF may perform the procedures set forth below under the direct supervision of a licensed dentist when done so pursuant to the order, control and full professional responsibility of the supervising dentist. Such procedures shall be checked and approved by the supervising dentist prior to dismissal of the patient from the office of said dentist.

1. Cord retraction of gingivae for impression procedures;

2. Take impressions for cast restorations;

3. Take impressions for space maintainers, orthodontic appliances and guards;

4. Prepare enamel by etching for bonding;

5. Formulate indirect patterns for endodontic post and core castings;

6. Fit trial endodontic filling points;

7. Apply etchant for bonding restorative materials.

(d) Settings. Registered dental hygienists in extended functions may undertake the duties authorized by this section in a treatment facility under the jurisdiction and control of the supervising licensed dentist, or an equivalent facility approved by the Board.

Registered Dental Hygienists in Alternative Practice

CCR Section 1090. RDHAP Duties and Settings.

(a) Unless specifically so provided by regulation, an RDHAP may not perform the following functions or any activity which represents the practice of dentistry or requires knowledge, skill and training of a licensed dentist:

1. Diagnosing and treatment planning;

2. Surgical or cutting procedures on hard or soft tissue;

3. Fitting and adjusting of correctional and prosthodontic appliances;

4. Prescribing medication;

5. Placing, condensing, carving or removal of permanent restorations, including final cementation procedures;

6. Irrigating and medicating canals, try-in cones, reaming, filing or filling of root canals;

7. Taking of impressions for prosthodontic appliances, bridges, or any other devices which may be worn in the mouth;

8. Administering local or general anesthesia, oral or parental conscious sedation.

(b) Under the supervision of a licensed dentist, an RDHAP may perform the duties assigned to registered dental hygienists by Section 1088, under the same levels of supervision and in the same settings as specified in that section, in addition to those duties permitted by Section 1768(b)(3).

(c) Independently and without the supervision of a licensed dentist, an RDHAP may, upon the prescription of a dentist or a physician and surgeon licensed in California, perform the duties assigned to a registered dental hygienist by Section 1088(c).

1. All prescriptions shall contain the following information:

1. The pre-printed name, address, license number, and signature of the prescribing dentist or physician and surgeon.

2. The name, address and phone number of the patient.

3. The date the services are prescribed and the expiration date of the prescription. The prescription shall be for dental hygiene services and, if necessary, include special instructions for the care of that patient.

Prior to the establishment of an independent practice, an RDHAP shall provide to the board documentation of an existing relationship with at least one dentist for referral, consultation, and emergency services [1].

3. LICENSURE

All individuals practicing dentistry in California, with the exception of unlicensed dental assistants, must hold a current, valid license issued by the Board; California does not grant reciprocity with other states or nations. The Act requires that dental professionals meet certain education requirements, submit the correct applications and fees, pass the appropriate examinations, and submit a set of fingerprints. Fingerprinting is also required for license renewal if not previously conducted by the California Department of Justice (DOJ) or if records no longer exist [21]. Fingerprinting within California must be conducted using the DOJ Live Scan system; fingerprint records from other institutions (e.g., Department of Motor Vehicles) are not suitable, although ink-on-card fingerprints made at a law enforcement agency are acceptable if unable to travel to California. The required fingerprint cards must be requested from the Dental Board by phone or email [21]. The fingerprints will be used to conduct a criminal history record check and a state and federal level criminal offender record information search.

Issuance, review, and revocation of RDH/RDHEF/RDHAP licenses and the development and administration of license examinations for these auxiliaries are handled by the Dental Hygiene Board of California. All other licensure, including that for RDAs/RDAEFs, is handled by the Dental Board (despite the existence of the Dental Assisting Council, whose purpose is to consider matters related to dental assisting practice and make recommendations to the board). Complaints, investigations, and enforcement are handled by either the Dental Hygiene Board or the Dental Board, according to profession, but the governing regulations and laws set forth in the California Dental Practice Act pertain to all dental professionals. Information about application for licensure to practice as a dentist or dental auxiliary can be found in CCR Section 1028 and CCR Sections 1076–1079.3, respectively. Specific information about the licensure application requirements and process for dentists and dental assistants can be found at https://www.dbc.ca.gov/applicants and for hygienists at https://www.dhbc.ca.gov/applicants.

Effective July 2012, application for licensure may be denied based on delinquent state tax payments [1]. Similarly, current licenses/certifications/registrations may be revoked for failure to pay taxes.

LICENSE RENEWAL

Licenses for all dental professions must be renewed every two years before the last day of the professional's birth month. Practicing without renewing after this date is considered practicing without a license [1]. It is required that dentists have completed 50 hours of continuing education and dental auxiliaries (excluding RDHAPs) have completed 25 hours of continuing education (maximum of 25 hours and 12.5 hours of home study, respectively) upon renewal submission. The continuing education requirement is 35 hours for RDHAPs. Coursework regarding the Dental Practice Act, infection control, and basic life support is mandatory every two years for all licensees. To receive credit, all courses must be from Board-approved providers. In addition, the Board has identified topics that may only constitute a portion of the full continuing education requirement or that are not acceptable at all. A complete listing of allowable and non-allowable courses is available on the Board website.

Links to information regarding license renewal for dentists and dental assistants can be found at https://www.dbc.ca.gov/licensees, and renewal information for hygienists can be found at https://www.dhbc.ca.gov/licensees/renewals.

ACTS LEADING TO SUSPENSION OF A LICENSE AND IN VIOLATION OF THE DENTAL PRACTICE ACT

Violations of the Act by Board licensees are grounds for suspension of a license/certification and are handled by the Board's Enforcement Program, which is composed of five sections: Complaint and Compliance Unit; Inspections/Probation Section; Investigation Unit: Sworn Investigators; Investigation Analysis Unit; and Discipline Coordination Unit [22]. Complaints originate from many sources, including dental professionals, healthcare providers, insurance companies, law enforcement agencies, and patients. Complaint intake specialists route these to the appropriate section; for example, an allegation of an unsafe or unsanitary office condition is routed to the inspection section, whereby Board enforcement inspectors may be sent out and are authorized to issue citations and fines. In addition to Board enforcement action, other law enforcement or regulatory agencies are involved when indicated [1]. Dental professionals placed on probation status by the Board for violations of the Act are monitored by the Enforcement Program's Probation Unit. The Board's Enforcement Unit may be contacted by phone at (916)263-2300 or by e-mail at DentalBoardComplaints@dca.ca,gov. Violations of the Act by hygienists are handled by the Hygiene Board's Complaint Unit, which operates in a similar manner and can be contacted at (866) 810-9899 or by email at DHBCEnforcement@dca.ca.gov.

According to CBPC Section 1670.1, conviction of crimes committed by dental professionals outside of the workplace may also be grounds for Board discipline and can impact licensure status if the crime is "substantially related to the qualifications, functions, or duties of a dentist or dental assistant licensed under this chapter" [1]. These vary considerably on a case-by-case basis. Various lesser convictions, for example, driving under the influence (DUI), illicit drug possession, and prescription drug diversion, may not necessarily lead to license revocation provided the proper steps are taken toward remediation (e.g., entering the Board diversion program, submitting to periodic drug testing) [23]. In general, convictions for assaults, sex crimes, multiple misdemeanors (e.g., second DUI/controlled substance charge), and other egregious violations constitute a basis for denial or revocation of licenses or certifications. In addition to violations outside the workplace, unprofessional conduct, in its many forms, is grounds for Board Enforcement action. Acts and omissions that characterize unprofessional conduct are covered extensively in CBPC Sections 1680, 1681, and 1682 and CCR Section 1018.05.

CBPC Section 1680. Unprofessional conduct by a person licensed under this chapter is defined as, but is not limited to, any one of the following:

(a) The obtaining of any fee by fraud or misrepresentation.

(b) The employment directly or indirectly of any student or suspended or unlicensed dentist to practice dentistry as defined in this chapter.

(c) The aiding or abetting of any unlicensed person to practice dentistry.

(d) The aiding or abetting of a licensed person to practice dentistry unlawfully.

(e) The committing of any act or acts of sexual abuse, misconduct, or relations with a patient that are substantially related to the practice of dentistry.

(f) The use of any false, assumed, or fictitious name, either as an individual, firm, corporation, or otherwise, or any name other than the name under which the person is licensed to practice, in advertising or in any other manner indicating that the person is practicing or will practice dentistry, except that name as is specified in a valid permit issued pursuant to Section 1701.5.

(g) The practice of accepting or receiving any commission or the rebating in any form or manner of fees for professional services, radiograms, prescriptions, or other services or articles supplied to patients.

(h) The making use by the licensee or any agent of the licensee of any advertising statements of a character tending to deceive or mislead the public.

(i) The advertising of either professional superiority or the advertising of performance of professional services in a superior manner. This subdivision shall not prohibit advertising permitted by subdivision (h) of Section 651.

(j) The employing or the making use of solicitors.

(k) The advertising in violation of Section 651.

(l) The advertising to guarantee any dental service, or to perform any dental operation painlessly. This subdivision shall not prohibit advertising permitted by Section 651.

(m) The violation of any of the provisions of law regulating the procurement, dispensing, or administration of dangerous drugs, as defined in Chapter 9 (commencing with Section 4000) or controlled substances, as defined in Division 10 (commencing with Section 11000) of the Health and Safety Code.

(n) The violation of any of the provisions of this division.

(o) The permitting of any person to operate dental radiographic equipment who has not met the requirements of Section 1656.

(p) The clearly excessive prescribing or administering of drugs or treatment, or the clearly excessive use of diagnostic procedures, or the clearly excessive use of diagnostic or treatment facilities, as determined by the customary practice and standards of the dental profession. Any person who violates this subdivision is guilty of a misdemeanor and shall be punished by a fine of not less than one hundred dollars ($100) or more than six hundred dollars ($600), or by imprisonment for a term of not less than 60 days or more than 180 days, or by both a fine and imprisonment.

(q) The use of threats or harassment against any patient or licensee for providing evidence in any possible or actual disciplinary action, or other legal action; or the discharge of an employee primarily based on the employee's attempt to comply with the provisions of this chapter or to aid in the compliance.

(r) Suspension or revocation of a license issued, or discipline imposed, by another state or territory on grounds that would be the basis of discipline in this state.

(s) The alteration of a patient's record with intent to deceive.

(t) Unsanitary or unsafe office conditions, as determined by the customary practice and standards of the dental profession.

(u) The abandonment of the patient by the licensee, without written notice to the patient that treatment is to be discontinued and before the patient has ample opportunity to secure the services of another dentist, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions and provided the health of the patient is not jeopardized.

(v) The willful misrepresentation of facts relating to a disciplinary action to the patients of a disciplined licensee.

(w) Use of fraud in the procurement of any license issued pursuant to this chapter.

(x) Any action or conduct that would have warranted the denial of the license.

(y) The aiding or abetting of a licensed dentist, dental assistant, registered dental assistant, registered dental assistant in extended functions, dental sedation assistant permitholder, orthodontic assistant permitholder, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions to practice dentistry in a negligent or incompetent manner.

(z)

1. The failure to report to the board in writing within seven days any of the following:

1. the death of the licensee's patient during the performance of any dental or dental hygiene procedure;

2. the discovery of the death of a patient whose death is related to a dental or dental hygiene procedure performed by the licensee; or

3. except for a scheduled hospitalization, the removal to a hospital or emergency center for medical treatment of any patient to whom oral conscious sedation, conscious sedation, or general anesthesia was administered, or any patient as a result of dental or dental hygiene treatment. With the exception of patients to whom oral conscious sedation, conscious sedation, or general anesthesia was administered, removal to a hospital or emergency center that is the normal or expected treatment for the underlying dental condition is not required to be reported. Upon receipt of a report pursuant to this subdivision the board may conduct an inspection of the dental office if the board finds that it is necessary. A dentist shall report to the board all deaths occurring in the licensee's practice with a copy sent to the Dental Hygiene Board of California if the death was the result of treatment by a registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions. A registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions shall report to the Dental Hygiene Board of California all deaths occurring as the result of dental hygiene treatment, and a copy of the notification shall be sent to the board.

2. The report required by this subdivision shall be on a form or forms approved by the board. The form or forms approved by the board shall require the licensee to include, but not be limited to, the following information for cases in which patients received anesthesia: the date of the procedure; the patient's age in years and months, weight, and sex; the patient's American Society of Anesthesiologists (ASA) physical status; the patient's primary diagnosis; the patient's coexisting diagnoses; the procedures performed; the sedation setting; the medications used; the monitoring equipment used; the category of the provider responsible for sedation oversight; the category of the provider delivering sedation; the category of the provider monitoring the patient during sedation; whether the person supervising the sedation performed one or more of the procedures; the planned airway management; the planned depth of sedation; the complications that occurred; a description of what was unexpected about the airway management; whether there was transportation of the patient during sedation; the category of the provider conducting resuscitation measures; and the resuscitation equipment utilized. Disclosure of individually identifiable patient information shall be consistent with applicable law. A report required by this subdivision shall not be admissible in any action brought by a patient of the licensee providing the report.

3. For the purposes of paragraph (2), categories of provider are: General Dentist, Pediatric Dentist, Oral Surgeon, Dentist Anesthesiologist, Physician Anesthesiologist, Dental Assistant, Registered Dental Assistant, Dental Sedation Assistant, Registered Nurse, Certified Registered Nurse Anesthetist, or Other.

4. The form shall state that this information shall not be considered an admission of guilt, but is for educational, data, or investigative purposes.

5. The board may assess a penalty on any licensee who fails to report an instance of an adverse event as required by this subdivision. The licensee may dispute the failure to file within 10 days of receiving notice that the board had assessed a penalty against the licensee.

(aa) Participating in or operating any group advertising and referral services that are in violation of Section 650.2.

(ab) The failure to use a fail-safe machine with an appropriate exhaust system in the administration of nitrous oxide. The board shall, by regulation, define what constitutes a fail-safe machine.

(ac) Engaging in the practice of dentistry with an expired license.

(ad) Except for good cause, the knowing failure to protect patients by failing to follow infection control guidelines of the board, thereby risking transmission of bloodborne infectious diseases from dentist, dental assistant, registered dental assistant, registered dental assistant in extended functions, dental sedation assistant permitholder, orthodontic assistant permitholder, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions to patient, from patient to patient, and from patient to dentist, dental assistant, registered dental assistant, registered dental assistant in extended functions, dental sedation assistant permitholder, orthodontic assistant permitholder, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions. In administering this subdivision, the board shall consider referencing the standards, regulations, and guidelines of the State Department of Public Health developed pursuant to Section 1250.11 of the Health and Safety Code and the standards, guidelines, and regulations pursuant to the California Occupational Safety and Health Act of 1973 (Part 1 (commencing with Section 6300) of Division 5 of the Labor Code) for preventing the transmission of HIV, hepatitis B, and other blood-borne pathogens in health care settings. The board shall review infection control guidelines, if necessary, on an annual basis and proposed changes shall be reviewed by the Dental Hygiene Board of California to establish a consensus. The Board shall submit any recommended changes to the infection control guidelines for review to establish a consensus. As necessary, the board shall consult with the Medical Board of California, the California Board of Podiatric Medicine, the Board of Registered Nursing, and the Board of Vocational Nursing and Psychiatric Technicians, to encourage appropriate consistency in the implementation of this subdivision.

The board shall seek to ensure that all appropriate dental personnel are informed of the responsibility to follow infection control guidelines, and of the most recent scientifically recognized safeguards for minimizing the risk of transmission of bloodborne infectious diseases.

(ae) The utilization by a licensed dentist of any person to perform the functions of any registered dental assistant, registered dental assistant in extended functions, dental sedation assistant permitholder, orthodontic assistant permitholder, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions who, at the time of initial employment, does not possess a current, valid license or permit to perform those functions.

(af) The prescribing, dispensing, or furnishing of dangerous drugs or devices, as defined in Section 4022, in violation of Section 2242.1.

(ag) Using water, or other methods used for irrigation, that are not sterile or that do not contain recognized disinfecting or antibacterial properties when performing dental procedures on exposed dental pulp.

(ah) The failure by the treating dentist, prior to the initial diagnosis and correction of malpositions of human teeth or initial use of orthodontic appliances, to perform an examination pursuant to subdivision (b) of Section 1684.5, including the review of the patient's most recent diagnostic digital or conventional radiographs or other equivalent bone imaging suitable for orthodontia. New radiographs or other equivalent bone imaging shall be ordered if deemed appropriate by the treating dentist.

Section 1681. In addition to other acts constituting unprofessional conduct within the meaning of this chapter, it is unprofessional conduct for a person licensed under this chapter to do any of the following:

(a) Obtain or possess in violation of law, or except as directed by a licensed physician and surgeon, dentist, or podiatrist, administer to himself, any controlled substance, as defined in Division 10 (commencing with Section 11000) of the Health and Safety Code, or any dangerous drug as defined in Article 8 (commencing with Section 4211) of Chapter 9.

(b) Use any controlled substance, as defined in Division 10 (commencing with Section 11000) of the Health and Safety Code, or any dangerous drug as defined in Article 8 (commencing with Section 4211) of Chapter 9, or alcoholic beverages or other intoxicating substances, to an extent or in a manner dangerous or injurious to himself, to any person, or the public to the extent that such use impairs his ability to conduct with safety to the public the practice authorized by his license.

(c) The conviction of a charge of violating any federal statute or rules, or any statute or rule of this state, regulating controlled substances, as defined in Division 10 (commencing with Section 11000) of the Health and Safety Code, or any dangerous drug, as defined in Article 8 (commencing with Section 4211) of Chapter 9, or the conviction of more than one misdemeanor, or any felony, involving the use or consumption of alcohol or drugs, if the conviction is substantially related to the practice authorized by his license. The record of conviction or certified copy thereof, certified by the clerk of the court or by the judge in whose court the conviction is had, shall be conclusive evidence of a violation of this section; a plea or verdict of guilty or a conviction following a plea of nolo contendere is deemed to be a conviction within the meaning of this section; the board may order the license suspended or revoked, or may decline to issue a license, when the time for appeal has elapsed or the judgment of conviction has been affirmed on appeal, or when an order granting probation is made suspending imposition of sentence, irrespective of a subsequent order under any provision of the Penal Code, including, but not limited to, Section 1203.4 of the Penal Code, allowing such person to withdraw his plea of guilty and to enter a plea of not guilty, or setting aside the verdict of guilty, or dismissing the accusation, information or indictment.

Section 1682. In addition to other acts constituting unprofessional conduct under this chapter, it is unprofessional conduct for:

(a) Any dentist performing dental procedures to have more than one patient undergoing moderate sedation, deep sedation, or general anesthesia on an outpatient basis at any given time unless each patient is being continuously monitored on a one-to-one ratio while sedated by either the dentist or another licensed health professional authorized by law to administer moderate sedation, deep sedation, or general anesthesia.

(b) Any dentist with patients recovering from moderate sedation, deep sedation, or general anesthesia to fail to have the patients closely monitored by licensed health professionals experienced in the care and resuscitation of patients recovering from moderate sedation, deep sedation, or general anesthesia. If one licensed professional is responsible for the recovery care of more than one patient at a time, all of the patients shall be physically in the same room to allow continuous visual contact with all patients and the patient to recovery staff ratio should not exceed three to one.

(c) Any dentist with patients who are undergoing deep sedation, general anesthesia, or moderate sedation to fail to have these patients continuously monitored during the dental procedure with a pulse oximeter or similar or superior monitoring equipment and ventilation continuously monitored using at least two of the three following methods:

1. Auscultation of breath sounds using a precordial stethoscope.

2. Monitoring for the presence of exhaled carbon dioxide with capnography.

3. Verbal communication with a patient under moderate sedation. This method shall not be used for a patient under deep sedation or general anesthesia.

(d) Any dentist with patients who are undergoing moderate sedation to have dental office personnel directly involved with the care of those patients who are not certified in basic cardiac life support (CPR) and recertified biennially.

(e)

1. Any dentist to fail to obtain the written informed consent of a patient prior to administering moderate sedation, deep sedation, general anesthesia. In the case of a minor, the consent shall be obtained from the child's parent or guardian.

2. The written informed consent for general anesthesia, in the case of a minor, shall include, but not be limited to, the following information:
"The administration and monitoring of deep sedation or general anesthesia may vary depending on the type of procedure, the type of practitioner, the age and health of the patient, and the setting in which anesthesia is provided. Risks may vary with each specific situation. You are encouraged to explore all the options available for your child's anesthesia for their dental treatment, and consult with your dentist, family physician, or pediatrician as needed."

3. Nothing in this subdivision shall be construed to establish the reasonable standard of care for administering or monitoring oral moderate sedation, moderate sedation, deep sedation, or general anesthesia.

Section 1683. (a) Every dentist, dental health professional, or other licensed health professional who performs a service on a patient in a dental office shall identify himself or herself in the patient record by signing his or her name, or an identification number and initials, next to the service performed and shall date those treatment entries in the record. Any person licensed under this chapter who owns, operates, or manages a dental office shall ensure compliance with this requirement.

(b) Repeated violations of this section constitute unprofessional conduct.

Section 1683.1 (a) Any individual, partnership, corporation, or other entity that provides dental services through telehealth shall make available the name, telephone number, practice address, and California state license number of any dentist who will be involved in the provision of services to a patient prior to the rendering of services and when requested by a patient.

(b) A violation of this section shall constitute unprofessional conduct.

Section 1684. In addition to other acts constituting unprofessional conduct under this chapter, it is unprofessional conduct for a person licensed under this chapter to perform, or hold himself or herself out as able to perform, professional services beyond the scope of his or her license and field or fields of competence as established by his or her education, experience, training, or any combination thereof. This includes, but is not limited to, the use of any instrument or device in a manner that is not in accordance with the customary standards and practices of the dental profession. This section shall not apply to research conducted by accredited dental schools or colleges, or to research conducted pursuant to an investigational device exemption issued by the United States Food and Drug Administration.

(a)

1. A licensee who fails or refuses to comply with a request for the dental records of a patient, that is accompanied by written authorization of the patient or the patient’s representative, as defined in subdivision (e) of Section 123105 of the Health and Safety Code, for release of record to the board, within 15 days of receiving the request and authorization, shall pay to the board a civil penalty of two hundred fifty dollars ($250) per day for each day that the documents have not been produced after the 15th day, up to a maximum of five thousand dollars ($5,000) unless the licensee is unable to provide the documents within this time period for good cause.

2. A health care facility shall comply with a request for the dental records of a patient that is accompanied by that patient’s written authorization for release of records to the board together with a notice citing this section and describing the penalties for failure to comply with this section. Failure to provide the patient’s dental records to the board within 30 days of receiving this request, authorization, and notice shall subject the health care facility to a civil penalty, payable to the board, of up to two hundred fifty dollars ($250) per day for each day that the documents have not been produced after the 30th day, up to a maximum of five thousand dollars ($5,000), unless the health care facility is unable to provide the documents within this time period for good cause. This paragraph shall not require health care facilities to assist the board in obtaining the patient’s authorization. The board shall pay the reasonable cost of copying the dental records.

(b)

1. A licensee who fails or refuses to comply with a court order, issued in the enforcement of a subpoena, mandating the release of records to the board shall pay to the board a civil penalty of one thousand dollars ($1,000) per day for each day that the documents have not been produced after the date by which the court order requires the documents to be produced, unless it is determined that the order is unlawful or invalid. Any statute of limitations applicable to the filing of an accusation by the board shall be tolled during the period the licensee is out of compliance with the court order and during any related appeals.

2. Any licensee who fails or refuses to comply with a court order, issued in the enforcement of a subpoena, mandating the release of records to the board is guilty of a misdemeanor punishable by a fine payable to the board not to exceed five thousand dollars ($5,000). The fine shall be added to the licensee’s renewal fee if it is not paid by the next succeeding renewal date. Any statute of limitations applicable to the filing of an accusation by the board shall be tolled during the period the licensee is out of compliance with the court order and during any related appeals.

3. A health care facility that fails or refuses to comply with a court order, issued in the enforcement of a subpoena, mandating the release of patient records to the board, that is accompanied by a notice citing this section and describing the penalties for failure to comply with this section, shall pay to the board a civil penalty of up to one thousand dollars ($1,000) per day for each day that the documents have not been produced, up to ten thousand dollars ($10,000), after the date by which the court order requires the documents to be produced, unless it is determined that the order is unlawful or invalid. Any statute of limitations applicable to the filing of an accusation by the board against a licensee shall be tolled during the period the health care facility is out of compliance with the court order and during any related appeals.

4. Any health care facility that fails or refuses to comply with a court order, issued in the enforcement of a subpoena, mandating the release of records to the board is guilty of a misdemeanor punishable by a fine payable to the board not to exceed five thousand dollars ($5,000). Any statute of limitations applicable to the filing of an accusation by the board against a licensee shall be tolled during the period the health care facility is out of compliance with the court order and during any related appeals.

(c) Multiple acts by a licensee in violation of subdivision (b) shall be punishable by a fine not to exceed five thousand dollars ($5,000) or by imprisonment in a county jail not exceeding six months, or by both that fine and imprisonment. Multiple acts by a health care facility in violation of subdivision (b) shall be punishable by a fine not to exceed five thousand dollars ($5,000) and shall be reported to the State Department of Health Care Services and shall be considered as grounds for disciplinary action with respect to licensure, including suspension or revocation of the license or certificate.

(d) A failure or refusal to comply with a court order, issued in the enforcement of a subpoena, mandating the release of records to the board constitutes unprofessional conduct and is grounds for suspension or revocation of the licensee’s license.

(e) Imposition of the civil penalties authorized by this section shall be in accordance with the Administrative Procedure Act (Chapter 5 (commencing with Section 11500) of Division 3 of Title 2 of the Government Code).

(f) For the purposes of this section, a “health care facility” means a clinic or health care facility licensed or exempt from licensure pursuant to Division 2 (commencing with Section 1200) of the Health and Safety Code.

1684.5. (a) In addition to other acts constituting unprofessional conduct under this chapter, it is unprofessional conduct for any dentist to perform or allow to be performed any treatment on a patient who is not a patient of record of that dentist. A dentist may, however, after conducting a preliminary oral examination, require or permit any dental auxiliary to perform procedures necessary for diagnostic purposes, provided that the procedures are permitted under the auxiliary's authorized scope of practice. Additionally, a dentist may require or permit a dental auxiliary to perform all of the following duties prior to any examination of the patient by the dentist, provided that the duties are authorized for the particular classification of dental auxiliary pursuant to Article 7 (commencing with Section 1740):

1. Expose emergency radiographs upon direction of the dentist.

2. If the dental auxiliary is a registered dental assistant in extended functions, a registered dental hygienist, or a registered dental hygienist in alternative practice, determine and perform radiographs for the specific purpose of aiding a dentist in completing a comprehensive diagnosis and treatment plan for a patient using telehealth, as defined by Section 2290.5, for the purpose of communication with the supervising dentist pursuant to Sections 1753.55, 1910.5, and 1926.05. A dentist is not required to review patient records or make a diagnosis using telehealth.

3. Perform extra-oral duties or functions specified by the dentist.

4. Perform mouth-mirror inspections of the oral cavity, to include charting of obvious lesions, malocclusions, existing restorations, and missing teeth.

(b) For purposes of this section, "patient of record" refers to a patient who has been examined, has had a medical and dental history completed and evaluated, and has had oral conditions diagnosed and a written plan developed by the licensed dentist.

(c) For purposes of this section, if dental treatment is provided to a patient by a registered dental assistant in extended functions, a registered dental hygienist, or a registered dental hygienist in alternative practice pursuant to the diagnosis and treatment plan authorized by a supervising dentist, at a location other than the dentist's practice location, it is the responsibility of the authorizing dentist that the patient or the patient's representative receive written notification that the care was provided at the direction of the authorizing dentist and that the notification include the authorizing dentist's name, practice location address, and telephone number. This provision shall not require patient notification for dental hygiene preventive services provided in public health programs as specified and authorized in Section 1911, or for dental hygiene care when provided as specified and authorized in Section 1926.

(d) A dentist shall not concurrently supervise more than a total of five registered dental assistants in extended functions, registered dental hygienists, or registered dental hygienists in alternative practice providing services pursuant to Sections 1753.55, 1910.5, and 1926.05.

(e) This section shall not apply to dentists providing examinations on a temporary basis outside of a dental office in settings including, but not limited to, health fairs and school screenings.

(f) This section shall not apply to fluoride mouth rinse or supplement programs administered in a school or preschool setting.

Section 1685. In addition to other acts constituting unprofessional conduct under this chapter, it is unprofessional conduct for a person licensed under this chapter to require, either directly or through an office policy, or knowingly permit the delivery of dental care that discourages necessary treatment or permits clearly excessive treatment, incompetent treatment, grossly negligent treatment, repeated negligent acts, or unnecessary treatment, as determined by the standard of practice in the community.

CCR Section 1018.05 Unprofessional Conduct Defined. In addition to those acts detailed in Business and Professions Code Sections 1670, 1680, 1681 and 1682, the following shall also constitute unprofessional conduct:

(a) Failure to provide records requested by the Board within 15 days of the date of receipt of the request or within the time specified in the request, whichever is later, unless the licensee is unable to provide the documents within this time period for good cause. For the purposes of this section, "good cause" includes physical inability to access the records in the time allowed due to illness or travel.

(b) Failure to report to the Board, within 30 days, any of the following:

1. The bringing of an indictment or information charging a felony against the licensee.

2. The conviction of the licensee, including any verdict of guilty, or pleas of guilty or no contest, of any felony or misdemeanor.

3. Any disciplinary action taken by another professional licensing entity or authority of this state or of another state or an agency of the federal government or the United States military.

4. For the purposes of this section, "conviction" means a plea or verdict of guilty or a conviction following a plea of nolo contendere or "no contest" and any conviction that has been set aside or deferred pursuant to Sections 1000 or 1203.4 of the Penal Code, including infractions, misdemeanors, and felonies. "Conviction" does not include traffic infractions with a fine of less than one thousand dollars ($1,000) unless the infraction involved alcohol or controlled substances.

4. VIOLATIONS AND PENALTIES

As discussed, various acts or omissions can be cause for revocation or suspension of a license. Violation of any section of the Dental Practice Act can also lead to civil and criminal prosecution, including [1]:

Section 1700. Any person, company, or association is guilty of a misdemeanor, and upon conviction thereof shall be punished by imprisonment in the county jail not less than 10 days nor more than one year, or by a fine of not less than one hundred dollars ($100) nor more than one thousand five hundred dollars ($1,500), or by both fine and imprisonment, who:

(a) Assumes the degree of "doctor of dental surgery," "doctor of dental science," or "doctor of dental medicine" or appends the letters "DDS," or "DDSc" or "DMD" to his or her name without having had the right to assume the title conferred upon him or her by diploma from a recognized dental college or school legally empowered to confer the same.

(b) Assumes any title, or appends any letters to his or her name, with the intent to represent falsely that he or she has received a dental degree or license.

(c) Engages in the practice of dentistry without causing to be displayed in an area that is likely to be seen by all patients who use the facility, the original or copy of the current license, permit, or registration of each person employed at the facility to practice dentistry.

(d) Within 10 days after demand is made by the executive officer of the board, fails to furnish to the board the name and address of all persons practicing or assisting in the practice of dentistry in the office of the person, company, or association, at any time within 60 days prior to the demand, together with a sworn statement showing under and by what license or authority this person, company, or association and any employees are or have been practicing dentistry. This sworn statement shall not be used in any prosecution under this section.

(e) Is under the influence of alcohol or a controlled substance while engaged in the practice of dentistry in actual attendance on patients to an extent that impairs his or her ability to conduct the practice of dentistry with safety to patients and the public.

Section 1700.5. Notwithstanding Section 1700, any person who holds a valid, unrevoked, and unsuspended certificate as a dentist under this chapter may append the letters "DDS" to his or her name, regardless of the degree conferred upon him or her by the dental college from which the licensee graduated.

Section 1701. (a) Any person is for the first offense guilty of a misdemeanor and shall be punishable by a fine of not less than two hundred dollars ($200) or more than three thousand dollars ($3,000), or by imprisonment in a county jail for not to exceed six months, or both, and for the second or a subsequent offense is guilty of a felony and upon conviction thereof shall be punished by a fine of not less than two thousand dollars ($2,000) nor more than six thousand dollars ($6,000), or by imprisonment pursuant to subdivision (h) of Section 1170 of the Penal Code, or by both such fine and imprisonment, who:

1. Sells or barters or offers to sell or barter any dental degree or any license or transcript made or purporting to be made pursuant to the laws regulating the license and registration of dentists.

2. Purchases or procures by barter any such diploma, license or transcript with intent that the same shall be used in evidence of the holder's qualification to practice dentistry, or in fraud of the laws regulating such practice.

3. With fraudulent intent, makes or attempts to make, counterfeits or alters in a material regard any such diploma, certificate or transcript.

4. Uses, attempts or causes to be used, any such diploma, certificate or transcript which has been purchased, fraudulently issued, counterfeited or materially altered, either as a license to practice dentistry, or in order to procure registration as a dentist.

5. In an affidavit, required of an applicant for examination, license or registration under this chapter, willfully makes a false statement in a material regard.

6. Practices dentistry or offers to practice dentistry as it is defined in this chapter, either without a license, or when his license has been revoked or suspended.

7. Under any false, assumed or fictitious name, either as an individual, firm, corporation or otherwise, or any name other than the name under which he is licensed, practices, advertises or in any other manner indicates that he is practicing or will practice dentistry, except such name as is specified in a valid permit issued pursuant to Section 1701.5.

(b) The board may post an administrative citation issued pursuant to Section 148 on the board's internet website for an offense described in subdivision (a).

Section 1701.1. (a) Notwithstanding Sections 1700 and 1701, a person who willfully, under circumstances or conditions that cause or create risk of bodily harm, serious physical or mental illness, or death, practices or attempts to practice, or advertises or holds himself or herself out as practicing dentistry without having at the time of so doing a valid, unrevoked, and unsuspended certificate, license, registration, or permit as provided in this chapter, or without being authorized to perform that act pursuant to a certificate, license, registration, or permit obtained in accordance with some other provision of law, is guilty of a public offense, punishable by a fine not exceeding ten thousand dollars ($10,000), by imprisonment pursuant to subdivision (h) of Section 1170 of the Penal Code, by imprisonment in a county jail not exceeding one year, or by both the fine and either imprisonment.

(b) A person who conspires with or aids and abets another to commit any act described in subdivision (a) is guilty of a public offense and subject to the punishment described in subdivision (a).

(c) The board may post an administrative citation issued pursuant to Section 148 on the board's internet website for an offense described in subdivisions (a) and (b).

(d) The remedy provided in this section shall not preclude any other remedy provided by law.

5. LAWS GOVERNING THE PRESCRIPTION OF DRUGS

The California Dental Practice Act states that only doctors of dentistry are permitted to prescribe drugs, including analgesics, sedatives, and antibiotics, although prescription of oral conscious sedation to children younger than 13 years of age requires a permit. Dental assistants and dental hygienists are not permitted to write prescriptions [1]. There are many federal and state laws and regulations pertaining to prescribing. It is the responsibility of each Drug Enforcement Administration (DEA)-registered prescriber (or those exempted) to be familiar with and maintain knowledge of all applicable laws and regulations. Pertinent citations of federal laws governing the prescription of controlled substances are included in the DEA Practitioner's Manual, available at https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-071)(EO-DEA226)_Practitioner's_Manual_(final).pdf. The California Uniform Controlled Substances Act (part of the California Health and Safety Code) can be found at https://leginfo.legislature.ca.gov/faces/codes_displayexpandedbranch.xhtml?tocCode=HSC&division=10.&title=&part=&chapter=&article. The Substances Act begins at Section 11000, and information regarding prescriptions begins in Section 11150.

There must be careful consideration when prescribing to addicts or suspected addicts, particularly when patients are requesting specific drugs. As of 2016, California legislation requires that all prescribers of controlled substances register to access CURES, the state prescription drug monitoring program database intended to aid prescribers and dispensers in identifying fraudulent activity, thereby reducing prescription drug abuse and diversion without affecting legitimate medical practice or patient care. As of October 2018, all licensees authorized to prescribe, order, administer, furnish or dispense controlled substances in California must, with some exceptions, check a patient's prescription history in CURES 2.0 before prescribing a Schedule II, III, or IV substance [27].

The following section of the California Business and Professional Code addresses unprofessional conduct related to furnishing prescription drugs and excessive prescribing.

Section 725. (a) Repeated acts of clearly excessive prescribing, furnishing, dispensing, or administering of drugs or treatment, repeated acts of clearly excessive use of diagnostic procedures, or repeated acts of clearly excessive use of diagnostic or treatment facilities as determined by the standard of the community of licensees is unprofessional conduct for a physician and surgeon, dentist, podiatrist, psychologist, physical therapist, chiropractor, optometrist, speech-language pathologist, or audiologist.

(b) Any person who engages in repeated acts of clearly excessive prescribing or administering of drugs or treatment is guilty of a misdemeanor and shall be punished by a fine of not less than one hundred dollars ($100) nor more than six hundred dollars ($600), or by imprisonment for a term of not less than 60 days nor more than 180 days, or by both that fine and imprisonment.

(c) A practitioner who has a medical basis for prescribing, furnishing, dispensing, or administering dangerous drugs or prescription controlled substances shall not be subject to disciplinary action or prosecution under this section.

(d) No physician and surgeon shall be subject to disciplinary action pursuant to this section for treating intractable pain in compliance with Section 2241.5.

The following sections of the Uniform Controlled Substances Act addresses the facilitation of abuse by prescribing practices, including the new CURES reporting requirements.

Section 11150.2. (a) Notwithstanding any other law, if cannabinoids are excluded from Schedule I of the federal Controlled Substances Act and placed on a schedule of the act other than Schedule I, or if a product composed of cannabinoids is approved by the federal Food and Drug Administration and either placed on a schedule of the act other than Schedule I, or exempted from one or more provisions of the act, so as to permit a physician, pharmacist, or other authorized healing arts licensee acting within their scope of practice, to prescribe, furnish, or dispense that product, the physician, pharmacist, or other authorized healing arts licensee who prescribes, furnishes, or dispenses that product in accordance with federal law shall be deemed to be in compliance with state law governing those acts.

(b) For purposes of this chapter, upon the effective date of one of the changes in federal law described in subdivision (a), notwithstanding any other state law, a product composed of cannabinoids may be prescribed, furnished, dispensed, transferred, transported, possessed, or used in accordance with federal law and is authorized pursuant to state law.

(c) This section does not apply to any product containing cannabinoids that is made or derived from industrial hemp, as defined in Section 11018.5 and regulated pursuant to that section.

Section 11153. (a) A prescription for a controlled substance shall only be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his or her professional practice. The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription. Except as authorized by this division, the following are not legal prescriptions: (1) an order purporting to be a prescription which is issued not in the usual course of professional treatment or in legitimate and authorized research; or (2) an order for an addict or habitual user of controlled substances, which is issued not in the course of professional treatment or as part of an authorized narcotic treatment program, for the purpose of providing the user with controlled substances, sufficient to keep him or her comfortable by maintaining customary use.

(b) Any person who knowingly violates this section shall be punished by imprisonment pursuant to subdivision (h) of Section 1170 of the Penal Code, or in a county jail not exceeding one year, or by a fine not exceeding twenty thousand dollars ($20,000), or by both that fine and imprisonment.

(c) No provision of the amendments to this section enacted during the second year of the 1981–82 Regular Session shall be construed as expanding the scope of practice of a pharmacist.

Section 11164.1. (a)

1. Notwithstanding any other law, a prescription for a controlled substance issued by a prescriber in another state for delivery to a patient in another state may be dispensed by a California pharmacy, if the prescription conforms with the requirements for controlled substance prescriptions in the state in which the controlled substance was prescribed.

2. A prescription for Schedule II, Schedule III, Schedule IV, or Schedule V controlled substances dispensed pursuant to this subdivision shall be reported by the dispensing pharmacy to the Department of Justice in the manner prescribed by subdivision (d) of Section 11165.

(b) A pharmacy may dispense a prescription for a Schedule III, Schedule IV, or Schedule V controlled substance from an out-of-state prescriber pursuant to Section 4005 of the Business and Professions Code and Section 1717 of Title 16 of the California Code of Regulations.

(c) This section shall become operative on January 1, 2021.

Section 11165. (a) To assist health care practitioners in their efforts to ensure appropriate prescribing, ordering, administering, furnishing, and dispensing of controlled substances, law enforcement and regulatory agencies in their efforts to control the diversion and resultant abuse of Schedule II, Schedule III, Schedule IV, and Schedule V controlled substances, and for statistical analysis, education, and research, the Department of Justice shall, contingent upon the availability of adequate funds in the CURES Fund, maintain the Controlled Substance Utilization Review and Evaluation System (CURES) for the electronic monitoring of, and Internet access to information regarding, the prescribing and dispensing of Schedule II, Schedule III, Schedule IV, and Schedule V controlled substances by all practitioners authorized to prescribe, order, administer, furnish, or dispense these controlled substances.

(b) The Department of Justice may seek and use grant funds to pay the costs incurred by the operation and maintenance of CURES. The department shall annually report to the Legislature and make available to the public the amount and source of funds it receives for support of CURES.

(c)

1. The operation of CURES shall comply with all applicable federal and state privacy and security laws and regulations.

1. CURES shall operate under existing provisions of law to safeguard the privacy and confidentiality of patients. Data obtained from CURES shall only be provided to appropriate state, local, and federal public agencies for disciplinary, civil, or criminal purposes and to other agencies or entities, as determined by the department, for the purpose of educating practitioners and others in lieu of disciplinary, civil, or criminal actions. Data may be provided to public or private entities, as approved by the department, for educational, peer review, statistical, or research purposes, if patient information, including information that may identify the patient, is not compromised. The University of California shall be provided access to identifiable data for research purposes if the requirements of subdivision (t) of Section 1798.24 of the Civil Code are satisfied. Further, data disclosed to an individual or agency as described in this subdivision shall not be disclosed, sold, or transferred to a third party, unless authorized by, or pursuant to, state and federal privacy and security laws and regulations. The department shall establish policies, procedures, and regulations regarding the use, access, evaluation, management, implementation, operation, storage, disclosure, and security of the information within CURES, consistent with this subdivision.

2. Notwithstanding subparagraph (A), a regulatory board whose licensees do not prescribe, order, administer, furnish, or dispense controlled substances shall not be provided data obtained from CURES.

3. The department shall, no later than January 1, 2021, adopt regulations regarding the access and use of the information within CURES. The department shall consult with all stakeholders identified by the department during the rulemaking process. The regulations shall, at a minimum, address all of the following in a manner consistent with this chapter:

1. The process for approving, denying, and disapproving individuals or entities seeking access to information in CURES.

2. The purposes for which a health care practitioner may access information in CURES.

3. The conditions under which a warrant, subpoena, or court order is required for a law enforcement agency to obtain information from CURES as part of a criminal investigation.

4. The process by which information in CURES may be provided for educational, peer review, statistical, or research purposes.

4. In accordance with federal and state privacy laws and regulations, a health care practitioner may provide a patient with a copy of the patient's CURES patient activity report as long as no additional CURES data are provided and the health care practitioner keeps a copy of the report in the patient's medical record in compliance with subdivision (d) of Section 11165.1.

(d) For each prescription for a Schedule II, Schedule III, Schedule IV, or Schedule V controlled substance, as defined in the controlled substances schedules in federal law and regulations, specifically Sections 1308.12, 1308.13, 1308.14, and 1308.15, respectively, of Title 21 of the Code of Federal Regulations, the dispensing pharmacy, clinic, or other dispenser shall report the following information to the department or contracted prescription data processing vendor as soon as reasonably possible, but not more than one working day after the date a controlled substance is released to the patient or patient's representative, in a format specified by the department:

1. Full name, address, and, if available, telephone number of the ultimate user or research subject, or contact information as determined by the Secretary of the United States Department of Health and Human Services, and the gender, and date of birth of the ultimate user.

2. The prescriber's category of licensure, license number, national provider identifier (NPI) number, if applicable, the federal controlled substance registration number, and the state medical license number of a prescriber using the federal controlled substance registration number of a government-exempt facility.

3. Pharmacy prescription number, license number, NPI number, and federal controlled substance registration number.

4. National Drug Code (NDC) number of the controlled substance dispensed.

5. Quantity of the controlled substance dispensed.

6. The International Statistical Classification of Diseases (ICD) Code contained in the most current ICD revision, or any revision deemed sufficient by the State Board of Pharmacy, if available.

7. Number of refills ordered.

8. Whether the drug was dispensed as a refill of a prescription or as a first-time request.

9. Prescribing date of the prescription.

10. Date of dispensing of the prescription.

11. The serial number for the corresponding prescription form, if applicable.

(e) The department may invite stakeholders to assist, advise, and make recommendations on the establishment of rules and regulations necessary to ensure the proper administration and enforcement of the CURES database. A prescriber or dispenser invitee shall be licensed by one of the boards or committees identified in subdivision (d) of Section 208 of the Business and Professions Code, in active practice in California, and a regular user of CURES.

(f) The department shall, prior to upgrading CURES, consult with prescribers licensed by one of the boards or committees identified in subdivision (d) of Section 208 of the Business and Professions Code, one or more of the boards or committees identified in subdivision (d) of Section 208 of the Business and Professions Code, and any other stakeholder identified by the department, for the purpose of identifying desirable capabilities and upgrades to the CURES Prescription Drug Monitoring Program (PDMP).

(g) The department may establish a process to educate authorized subscribers of the CURES PDMP on how to access and use the CURES PDMP.

(h)

1. The department may enter into an agreement with an entity operating an interstate data sharing hub, or an agency operating a prescription drug monitoring program in another state, for purposes of interstate data sharing of prescription drug monitoring program information.

2. Data obtained from CURES may be provided to authorized users of another state's prescription drug monitoring program, as determined by the department pursuant to subdivision (c), if the entity operating the interstate data sharing hub, and the prescription drug monitoring program of that state, as applicable, have entered into an agreement with the department for interstate data sharing of prescription drug monitoring program information.

3. An agreement entered into by the department for purposes of interstate data sharing of prescription drug monitoring program information shall ensure that all access to data obtained from CURES and the handling of data contained within CURES comply with California law, including regulations, and meet the same patient privacy, audit, and data security standards employed and required for direct access to CURES.

4. For purposes of interstate data sharing of CURES information pursuant to this subdivision, an authorized user of another state's prescription drug monitoring program shall not be required to register with CURES, if the authorized user is registered and in good standing with that state's prescription drug monitoring program.

5. The department shall not enter into an agreement pursuant to this subdivision until the department has issued final regulations regarding the access and use of the information within CURES as required by paragraph (3) of subdivision (c).

(j) If the dispensing pharmacy, clinic, or other dispenser experiences a temporary technological or electrical failure, it shall, without undue delay, seek to correct any cause of the temporary technological or electrical failure that is reasonably within its control. The deadline for transmitting prescription information to the department or contracted prescription data processing vendor pursuant to subdivision (d) shall be extended until the failure is corrected. If the dispensing pharmacy, clinic, or other dispenser experiences technological limitations that are not reasonably within its control, or is impacted by a natural or manmade disaster, the deadline for transmitting prescription information to the department or contracted prescription data processing vendor shall be extended until normal operations have resumed.

Section 11165.1. (a)

1. A health care practitioner authorized to prescribe, order, administer, furnish, or dispense Schedule II, Schedule III, Schedule IV, or Schedule V controlled substances pursuant to Section 11150 shall, upon receipt of a federal Drug Enforcement Administration (DEA) registration, submit an application developed by the department to obtain approval to electronically access information regarding the controlled substance history of a patient that is maintained by the department. Upon approval, the department shall release to that practitioner or their delegate the electronic history of controlled substances dispensed to an individual under the practitioner's care based on data contained in the CURES Prescription Drug Monitoring Program (PDMP).

2. A pharmacist shall, upon licensure, submit an application developed by the department to obtain approval to electronically access information regarding the controlled substance history of a patient that is maintained by the department. Upon approval, the department shall release to the pharmacist or their delegate the electronic history of controlled substances dispensed to an individual under the pharmacist's care based on data contained in the CURES PDMP.

3. A licensed physician and surgeon who does not hold a DEA registration may submit an application developed by the department to obtain approval to electronically access information regarding the controlled substance history of the patient that is maintained by the department. Upon approval, the department shall release to the physician and surgeon or their delegate the electronic history of controlled substances dispensed to a patient under their care based on data contained in the CURES PDMP.

4. The department shall implement its duties described in clauses (i), (ii), and (iii) upon completion of any technological changes to the CURES database necessary to support clauses (i), (ii), and (iii), or by October 1, 2022, whichever is sooner.

2. The department may deny an application or suspend a subscriber, for reasons that include, but are not limited to, the following:

1. Materially falsifying an application to access information contained in the CURES database.

2. Failing to maintain effective controls for access to the patient activity report.

3. Having their federal DEA registration suspended or revoked.

4. Violating a law governing controlled substances or another law for which the possession or use of a controlled substance is an element of the crime.

5. Accessing information for a reason other than to diagnose or treat a patient, or to document compliance with the law.

3. An authorized subscriber shall notify the department within 30 days of a change to the subscriber account.

4. An approved health care practitioner, pharmacist, or a person acting on behalf of a health care practitioner or pharmacist pursuant to subdivision (b) of Section 209 of the Business and Professions Code may use the department's online portal or a health information technology system that meets the criteria required in subparagraph (E) to access information in the CURES database pursuant to this section. A subscriber who uses a health information technology system that meets the criteria required in subparagraph (E) to access the CURES database may submit automated queries to the CURES database that are triggered by predetermined criteria.

5. An approved health care practitioner or pharmacist may submit queries to the CURES database through a health information technology system if the entity that operates the health information technology system certifies all of the following:

1. The entity will not use or disclose data received from the CURES database for any purpose other than delivering the data to an approved health care practitioner or pharmacist or performing data processing activities that may be necessary to enable the delivery unless authorized by, and pursuant to, state and federal privacy and security laws and regulations.

2. The health information technology system will authenticate the identity of an authorized health care practitioner or pharmacist initiating queries to the CURES database and, at the time of the query to the CURES database, the health information technology system submits the following data regarding the query to CURES:

1. The date of the query.

2. The time of the query.

3. The first and last name of the patient queried.

4. The date of birth of the patient queried.

5. The identification of the CURES user for whom the system is making the query.

3. The health information technology system meets applicable patient privacy and information security requirements of state and federal law.

4. The entity has entered into a memorandum of understanding with the department that solely addresses the technical specifications of the health information technology system to ensure the security of the data in the CURES database and the secure transfer of data from the CURES database. The technical specifications shall be universal for all health information technology systems that establish a method of system integration to retrieve information from the CURES database. The memorandum of understanding shall not govern, or in any way impact or restrict, the use of data received from the CURES database or impose any additional burdens on covered entities in compliance with the regulations promulgated pursuant to the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations.

6. No later than October 1, 2018, the department shall develop a programming interface or other method of system integration to allow health information technology systems that meet the requirements in subparagraph (E) to retrieve information in the CURES database on behalf of an authorized health care practitioner or pharmacist.

7. The department shall not access patient-identifiable information in an entity's health information technology system.

8. An entity that operates a health information technology system that is requesting to establish an integration with the CURES database shall pay a reasonable fee to cover the cost of establishing and maintaining integration with the CURES database.

9. The department may prohibit integration or terminate a health information technology system's ability to retrieve information in the CURES database if the health information technology system fails to meet the requirements of subparagraph (E), or the entity operating the health information technology system does not fulfill its obligation under subparagraph (H).

2. A health care practitioner authorized to prescribe, order, administer, furnish, or dispense Schedule II, Schedule III, Schedule IV, or Schedule V controlled substances pursuant to Section 11150 or a pharmacist shall be deemed to have complied with paragraph (1) if the licensed health care practitioner or pharmacist has been approved to access the CURES database through the process developed pursuant to subdivision (a) of Section 209 of the Business and Professions Code.

(b) A request for, or release of, a controlled substance history pursuant to this section shall be made in accordance with guidelines developed by the department.

(c) In order to prevent the inappropriate, improper, or illegal use of Schedule II, Schedule III, Schedule IV, or Schedule V controlled substances, the department may initiate the referral of the history of controlled substances dispensed to an individual based on data contained in CURES to licensed health care practitioners, pharmacists, or both, providing care or services to the individual.

(d) The history of controlled substances dispensed to an individual based on data contained in CURES that is received by a practitioner or pharmacist from the department pursuant to this section is medical information subject to the provisions of the Confidentiality of Medical Information Act contained in Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code.

(e) Information concerning a patient's controlled substance history provided to a practitioner or pharmacist pursuant to this section shall include prescriptions for controlled substances listed in Sections 1308.12, 1308.13, 1308.14, and 1308.15 of Title 21 of the Code of Federal Regulations.

(f) A health care practitioner, pharmacist, or a person acting on behalf of a health care practitioner or pharmacist, when acting with reasonable care and in good faith, is not subject to civil or administrative liability arising from false, incomplete, inaccurate, or misattributed information submitted to, reported by, or relied upon in the CURES database or for a resulting failure of the CURES database to accurately or timely report that information.

(g) For purposes of this section, the following terms have the following meanings:

1. "Automated basis" means using predefined criteria to trigger an automated query to the CURES database, which can be attributed to a specific health care practitioner or pharmacist.

2. "Department" means the Department of Justice.

3. "Entity" means an organization that operates, or provides or makes available, a health information technology system to a health care practitioner or pharmacist.

4. "Health information technology system" means an information processing application using hardware and software for the storage, retrieval, sharing of or use of patient data for communication, decisionmaking, coordination of care, or the quality, safety, or efficiency of the practice of medicine or delivery of health care services, including, but not limited to, electronic medical record applications, health information exchange systems, or other interoperable clinical or health care information system.

(h) This section shall become operative on July 1, 2021, or upon the date the department promulgates regulations to implement this section and posts those regulations on its Internet website, whichever date is earlier.

Section 11165.2. (a) The Department of Justice may conduct audits of the CURES Prescription Drug Monitoring Program system and its users.

(b) The Department of Justice may establish, by regulation, a system for the issuance to a CURES Prescription Drug Monitoring Program subscriber of a citation which may contain an order of abatement, or an order to pay an administrative fine assessed by the Department of Justice if the subscriber is in violation of any provision of this chapter or any regulation adopted by the Department of Justice pursuant to this chapter.

(c) The system shall contain the following provisions:

1. Citations shall be in writing and shall describe with particularity the nature of the violation, including specific reference to the provision of law or regulation of the department determined to have been violated.

2. Whenever appropriate, the citation shall contain an order of abatement establishing a reasonable time for abatement of the violation.

3. In no event shall the administrative fine assessed by the department exceed two thousand five hundred dollars ($2,500) for each violation. In assessing a fine, due consideration shall be given to the appropriateness of the amount of the fine with respect to such factors as the gravity of the violation, the good faith of the subscribers, and the history of previous violations.

4. An order of abatement or a fine assessment issued pursuant to a citation shall inform the subscriber that if the subscriber desires a hearing to contest the finding of a violation, a hearing shall be requested by written notice to the CURES Prescription Drug Monitoring Program within 30 days of the date of issuance of the citation or assessment. Hearings shall be held pursuant to Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code.

5. In addition to requesting a hearing, the subscriber may, within 10 days after service of the citation, request in writing an opportunity for an informal conference with the department regarding the citation. At the conclusion of the informal conference, the department may affirm, modify, or dismiss the citation, including any fine levied or order of abatement issued. The decision shall be deemed to be a final order with regard to the citation issued, including the fine levied or the order of abatement which could include permanent suspension to the system, a monetary fine, or both, depending on the gravity of the violation. However, the subscriber does not waive its right to request a hearing to contest a citation by requesting an informal conference. If the citation is affirmed, a formal hearing may be requested within 30 days of the date the citation was affirmed. If the citation is dismissed after the informal conference, the request for a hearing on the matter of the citation shall be deemed to be withdrawn. If the citation, including any fine levied or order of abatement, is modified, the citation originally issued shall be considered withdrawn and a new citation issued. If a hearing is requested for a subsequent citation, it shall be requested within 30 days of service of that subsequent citation.

6. Failure of a subscriber to pay a fine within 30 days of the date of assessment or comply with an order of abatement within the fixed time, unless the citation is being appealed, may result in disciplinary action taken by the department. If a citation is not contested and a fine is not paid, the subscriber account will be terminated:

1. A citation may be issued without the assessment of an administrative fine.

2. Assessment of administrative fines may be limited to only particular violations of law or department regulations.

(d) Notwithstanding any other provision of law, if a fine is paid to satisfy an assessment based on the finding of a violation, payment of the fine shall be represented as a satisfactory resolution of the matter for purposes of public disclosure.

(e) Administrative fines collected pursuant to this section shall be deposited in the CURES Program Special Fund, available upon appropriation by the Legislature. These special funds shall provide support for costs associated with informal and formal hearings, maintenance, and updates to the CURES Prescription Drug Monitoring Program.

(f) The sanctions authorized under this section shall be separate from, and in addition to, any other administrative, civil, or criminal remedies; however, a criminal action may not be initiated for a specific offense if a citation has been issued pursuant to this section for that offense, and a citation may not be issued pursuant to this section for a specific offense if a criminal action for that offense has been filed.

(g) Nothing in this section shall be deemed to prevent the department from serving and prosecuting an accusation to suspend or revoke a subscriber if grounds for that suspension or revocation exist.

Section 11165.4. (a)

1. A health care practitioner authorized to prescribe, order, administer, or furnish a controlled substance shall consult the patient activity report or information from the patient activity report obtained from the CURES database to review a patient's controlled substance history for the past 12 months before prescribing a Schedule II, Schedule III, or Schedule IV controlled substance to the patient for the first time and at least once every six months thereafter if the prescriber renews the prescription and the substance remains part of the treatment of the patient.

2. If a health care practitioner authorized to prescribe, order, administer, or furnish a controlled substance is not required, pursuant to an exemption described in subdivision (c), to consult the patient activity report from the CURES database the first time the health care practitioner prescribes, orders, administers, or furnishes a controlled substance to a patient, the health care practitioner shall consult the patient activity report from the CURES database to review the patient's controlled substance history before subsequently prescribing a Schedule II, Schedule III, or Schedule IV controlled substance to the patient and at least once every six months thereafter if the prescriber renews the prescription and the substance remains part of the treatment of the patient.

3. A health care practitioner who did not directly access the CURES database to perform the required review of the controlled substance use report shall document in the patient's medical record that they reviewed the CURES database generated report within 24 hours of the controlled substance prescription that was provided to them by another authorized user of the CURES database.

2. For purposes of this paragraph, "first time" means the initial occurrence in which a health care practitioner, in their role as a health care practitioner, intends to prescribe, order, administer, or furnish a Schedule II, Schedule III, or Schedule IV controlled substance to a patient and has not previously prescribed a controlled substance to the patient.

2. A health care practitioner shall review a patient's controlled substance history that has been obtained from the CURES database no earlier than 24 hours, or the previous business day, before the health care practitioner prescribes, orders, administers, or furnishes a Schedule II, Schedule III, or Schedule IV controlled substance to the patient.

(b) The duty to consult the CURES database, as described in subdivision (a), does not apply to veterinarians or pharmacists.

(c) The duty to consult the CURES database, as described in subdivision (a), does not apply to a health care practitioner in any of the following circumstances:

1. If a health care practitioner prescribes, orders, or furnishes a controlled substance to be administered to a patient while the patient in any of the following facilities or during an emergency transfer between any of the following facilities, or for use while on facility premises:

1. A licensed clinic, as described in Chapter 1 (commencing with Section 1200) of Division 2.

2. An outpatient setting, as described in Chapter 1.3 (commencing with Section 1248) of Division 2.

3. A health facility, as described in Chapter 2 (commencing with Section 1250) of Division 2.

4. A county medical facility, as described in Chapter 2.5 (commencing with Section 1440) of Division 2.

5. Another medical facility, including, but not limited to, an office of a health care practitioner and an imaging center.

6. A correctional clinic, as described in Section 4187 of the Business and Professions Code, or a correctional pharmacy, as described in Section 4021.5 of the Business and Professions Code.

2. If a health care practitioner prescribes, orders, administers, or furnishes a controlled substance in the emergency department of a general acute care hospital and the quantity of the controlled substance does not exceed a nonrefillable seven-day supply of the controlled substance to be used in accordance with the directions for use.

3. If a health care practitioner prescribes, orders, administers, or furnishes buprenorphine or other controlled substance containing buprenorphine in the emergency department of a general acute care hospital.

4. If a health care practitioner prescribes, orders, administers, or furnishes a controlled substance to a patient as part of the patient's treatment for a surgical, radiotherapeutic, or diagnostic procedure and the quantity of the controlled substance does not exceed a nonrefillable seven-day supply of the controlled substance to be used in accordance with the directions for use, in any of the following facilities:

1. A licensed clinic, as described in Chapter 1 (commencing with Section 1200) of Division 2.

2. An outpatient setting, as described in Chapter 1.3 (commencing with Section 1248) of Division 2.

3. A health facility, as described in Chapter 2 (commencing with Section 1250) of Division 2.

4. A county medical facility, as described in Chapter 2.5 (commencing with Section 1440) of Division 2.

5. A place of practice, as defined in Section 1658 of the Business and Professions Code.

6. Another medical facility where surgical procedures are permitted to take place, including, but not limited to, the office of a health care practitioner.

5. If a health care practitioner prescribes, orders, administers, or furnishes a controlled substance to a patient who is terminally ill, as defined in subdivision (c) of Section 11159.2.

1. If all of the following circumstances are satisfied:

1. It is not reasonably possible for a health care practitioner to access the information in the CURES database in a timely manner.

2. Another health care practitioner or designee authorized to access the CURES database is not reasonably available.

3. The quantity of controlled substance prescribed, ordered, administered, or furnished does not exceed a nonrefillable seven-day supply of the controlled substance to be used in accordance with the directions for use and no refill of the controlled substance is allowed.

2. A health care practitioner who does not consult the CURES database under subparagraph (A) shall document the reason they did not consult the database in the patient's medical record.

7. If the CURES database is not operational, as determined by the department, or cannot be accessed by a health care practitioner because of a temporary technological or electrical failure. A health care practitioner shall, without undue delay, seek to correct the cause of the temporary technological or electrical failure that is reasonably within the health care practitioner's control.

8. If the CURES database cannot be accessed because of technological limitations that are not reasonably within the control of a health care practitioner.

9. If consultation of the CURES database would, as determined by the health care practitioner, result in a patient's inability to obtain a prescription in a timely manner and thereby adversely impact the patient's medical condition, provided that the quantity of the controlled substance does not exceed a nonrefillable seven-day supply if the controlled substance were used in accordance with the directions for use.

(d)

1. A health care practitioner who fails to consult the CURES database, as described in subdivision (a), shall be referred to the appropriate state professional licensing board solely for administrative sanctions, as deemed appropriate by that board.

2. This section does not create a private cause of action against a health care practitioner. This section does not limit a health care practitioner's liability for the negligent failure to diagnose or treat a patient.

(e) All applicable state and federal privacy laws govern the duties required by this section.

(f) The provisions of this section are severable. If any provision of this section or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application.

(g) This section shall become operative on July 1, 2021, or upon the date the department promulgates regulations to implement this section and posts those regulations on its internet website, whichever date is earlier.

6. REPORTING OF ABUSE AND NEGLECT

In accordance with California Penal Code Section 11165.7, dentists, dental assistants, and dental hygienists are mandated reporters of child abuse and neglect [3]. Reporting suspected abuse is not only an ethical duty but is also a legal obligation.

CHILD ABUSE AND NEGLECT REPORTING LAW

Section 11164. (a) This article shall be known and may be cited as the Child Abuse and Neglect Reporting Act.

(b) The intent and purpose of this article is to protect children from abuse and neglect. In any investigation of suspected child abuse or neglect, all persons participating in the investigation of the case shall consider the needs of the child victim and shall do whatever is necessary to prevent psychological harm to the child victim.

Section 11166. (a) Except as provided in subdivision (d), and in Section 11166.05, a mandated reporter shall make a report to an agency specified in Section 11165.9 whenever the mandated reporter, in the mandated reporter's professional capacity or within the scope of the mandated reporter's employment, has knowledge of or observes a child whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect. The mandated reporter shall make an initial report by telephone to the agency immediately or as soon as is practicably possible, and shall prepare and send, fax, or electronically transmit a written follow-up report within 36 hours of receiving the information concerning the incident. The mandated reporter may include with the report any nonprivileged documentary evidence the mandated reporter possesses relating to the incident.

Section 11165.9. Reports of suspected child abuse or neglect shall be made by mandated reporters, or in the case of reports pursuant to Section 11166.05, may be made, to any police department or sheriff's department, not including a school district police or security department, county probation department, if designated by the county to receive mandated reports, or the county welfare department. Any of those agencies shall accept a report of suspected child abuse or neglect whether offered by a mandated reporter or another person, or referred by another agency, even if the agency to whom the report is being made lacks subject matter or geographical jurisdiction to investigate the reported case, unless the agency can immediately electronically transfer the call to an agency with proper jurisdiction. When an agency takes a report about a case of suspected child abuse or neglect in which that agency lacks jurisdiction, the agency shall immediately refer the case by telephone, fax, or electronic transmission to an agency with proper jurisdiction. Agencies that are required to receive reports of suspected child abuse or neglect may not refuse to accept a report of suspected child abuse or neglect from a mandated reporter or another person unless otherwise authorized pursuant to this section, and shall maintain a record of all reports received.

IDENTIFYING, DOCUMENTING, AND REPORTING ABUSE AND NEGLECT

Preventing serious morbidity and mortality involves intervening at the first suspicion or indication of abuse and/or neglect. Dentists and dental hygienists are often the healthcare professionals who have the most frequent interactions with children and should be attentive to any signs of neglect and physical abuse—as abusive injuries commonly involve the face, jaw, mouth, teeth, and tongue [4]. One study found that orofacial trauma was concurrent with 49% of documented cases of child physical abuse [5]. Other studies show that craniofacial and neck injuries occur in 50% to 65% of child abuse victims and that the lips are a site for abusive injury in 54% of cases [6,7].

Clinical Signs of Abuse

The American Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect and the California Dental Association have published useful articles regarding the identification of the orofacial signs of abuse and particular injuries of concern. According to these sources, possible signs of abuse include [6,7,12]:

- Forced feeding injuries caused by eating utensils, bottles, hands, fingers, and other objects; scalding liquids; or caustic substances. These may be responsible for burns, contusions, or lacerations of the lips, tongue, buccal mucosa, gingival alveolar mucosa, frenum, or palate (soft and hard). Objects forced into the face/mouth may also cause facial bone and jaw fractures and avulsed, displaced, or fractured teeth.

- Mouth gagging injuries resulting in bruises, lichenification, or scarring at the corners of the mouth

- Strangulation injuries resulting in bruising, a hoarse or raspy voice, and difficulty breathing

- Discolored teeth from previous trauma

- Serious trauma (e.g., retropharyngeal abscesses, posterior pharyngeal injuries) resulting from caregivers with factitious disorder (i.e., Münchausen syndrome) by proxy

- Injury to the petechiae of the palate (particularly at the junction of soft and hard palate) resulting from forced oral sex

- Sexually transmitted oral/perioral infections (e.g., gonorrhea, human papillomavirus warts), although these can be transmitted by other means as well

- Bite marks or bruises on the head or face, strangulation marks, or black eyes

- Missing hair from hair pulling

- Welts in the shape of objects (e.g., belt buckle, clothes iron)

- Other suspicious trauma/bruises indicative of abuse (e.g., rope marks)

During examination, excessive caries, gingivitis, and oral infections/diseases should be noted as possible signs of neglect. (Parents or caretakers with an ignorance of proper oral care, who have no perceived value of oral health, with limited access to health care or insurance, and/or geographic isolation should be differentiated from those with a willful disregard for the child's health [6].) Perioral and intraoral injuries and infections in various stages of healing, especially those that seem inappropriate for the child's developmental age, should be documented. Additionally, abuse and neglect are more prevalent (up to four times more common) in individuals with developmental or physical disability [12].

Although accidental injuries are common in pediatric patients, the history of trauma, including mechanism and timing, must be weighed against the injury features. Characteristics of the injury that do not seem to match the reported history should spur suspicion of abuse. The acronym RADAR is commonly used to assist in the routine abuse screening of patients [29]:

- Routinely screen for signs and symptoms of abuse/neglect

- Ask direct, non-judgmental questions with compassion

- Document your findings

- Assess patient safety before the patient leaves the medical setting

- Review, refer, report

A parent or primary caretaker may be genuinely unaware of the abuse or injuries and may not be able to offer information relevant to the history. It is important not to make judgments of family members (either innocent or guilty), apportion blame, or attempt to personally undertake a criminal investigation. The scope of dental practice does not include these actions, and they may interfere with a law enforcement investigation. The AAP notes that the dental professional's role in a criminal investigation is to interpret medical information for nonmedical professionals in an understandable manner that accurately reflects the medical evidence [8]. Identify the medical problem, document the suspected abuse (e.g., names, photos, body map, preserve evidence), treat the injuries, and offer honest, factual medical information to parents, families, law enforcement, and justice officials.

Reporting Abuse

As noted in the California Dental Practice Act, dental healthcare professionals have a legal and ethical responsibility to report suspected child abuse to the proper authorities, not to punish perpetrators of abuse but to protect the abuse victims. One author writes, "The dentist must view himself as a child advocate. Simply treating dental and facial injuries of abused children while ignoring the social needs of the child and family is unacceptable" [9].

Nonetheless, the decision of whether or not to report suspected abuse is ethically challenging. Although healthcare professionals are obligated to report suspected abuse, suspicion of abuse is somewhat of a judgment call and certain biases may influence the decision to report. It has been noted that well-intentioned professionals in all fields are swayed by both negative and positive social biases (e.g., sex, race, socioeconomic status, physical appearance, job status), and it is advisable to challenge personal biases and weigh only the facts of the case. A 2008 prospective, observational AAP study found that, "clinicians did not report 27% of injuries considered likely or very likely caused by child abuse and 76% of injuries considered possibly caused by child abuse" because of various biases and experiences [10]. However, patients who had an injury that was not a laceration, who had more than one family risk factor, who had a serious injury, who had a child risk factor other than an inconsistent injury, who had a parental history of substance abuse, or who were unfamiliar to the clinician were more likely to be reported.

Professionally mandated reporters are protected from civil or criminal prosecution in consequence of a good-faith report of abuse, and no clinician in the aforementioned AAP study was sued for malpractice as a result of reporting abuse [7,10]. However, it is possible for dental professionals to be sued, and a state petition for up to $50,000 in recompensatory legal fees is available for dentists having to defend themselves in court [7]. On the other hand, civil or criminal penalties for willfully not reporting abuse or impeding a report when abuse has been found to have occurred include 6 months in jail and/or a fine of $1,000 or, in cases of serious injury/death following a failure to report, 12 months in jail, and/or a fine of $5,000.

ELDER AND DEPENDENT ADULT ABUSE AND NEGLECT

Abusive injuries to the mouth and oral cavity of elder or dependent (e.g., developmentally or physically disabled) adults are similar in type and causation to those sustained by pediatric patients, including trauma from forced feeding, object insertion, mouth gagging, and being slapped, hit, or strangled, but also include damage to and from prostheses. The number of new elder and dependent adult abuse cases is usually about 18,000 per month in California alone, with family members constituting two-thirds of perpetrators [11,26]. However, researchers estimate that for each incident of reported abuse there are at least five (and perhaps up to 14) unreported incidents [11]. Studies have shown that dental professionals are reluctant to report elder or dependent abuse/neglect and that they have a low index of suspicion of this category of abuse [13].

The national frequency of elder abuse is estimated at up to 10%, with some research indicating that the number may be as high as 1 in 6 [14]. The overwhelming majority of abuse and neglect occurs in domestic, rather than institutional (e.g., residential care) settings, largely due to the shift in care in the 20th century from state institutions to the home (particularly for younger disabled individuals) [12,14]. However, with an increasing aging population and longer life expectancies, it is projected that by 2030 there will be a 50% increase in the number of older adults who require nursing home care [14]. Women are the victims of elder abuse two-thirds of the time.

Elder and dependent adults are also at risk for poor oral health due to caretaker neglect. In fact, neglect is one of the most common causes of elder injury reporting [14]. These populations are also at a high risk for self-neglect, accounting for more than 500,000 additional reported cases in the United States per year. A 2010 study revealed that 40% of individuals 65 years of age or older suffer from some form of neglect [15].

Elder and Dependent Adult Abuse Laws

Laws pertaining to mandatory elder and dependent adult abuse reporting are found in the California Welfare and Institutions Code Sections 15600 to 15632 [16].

Section 15600. (a) The Legislature recognizes that elders and dependent adults may be subjected to abuse, neglect, or abandonment and that this state has a responsibility to protect these persons.

(i) Therefore, it is the intent of the Legislature in enacting this chapter to provide that adult protective services agencies, local long-term care ombudsman programs, and local law enforcement agencies shall receive referrals or complaints from public or private agencies, from any mandated reporter submitting reports pursuant to Section 15630, or from any other source having reasonable cause to know that the welfare of an elder or dependent adult is endangered, and shall take any actions considered necessary to protect the elder or dependent adult and correct the situation and ensure the individual's safety.

Section 15630. (a) Any person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not he or she receives compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter.

(b) (1) Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced behavior, including an act or omission, constituting physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known or suspected instance of abuse by telephone or through a confidential Internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an Internet report shall be made through the confidential Internet reporting tool established in Section 15658, within two working days.

INTIMATE PARTNER VIOLENCE

Intimate partner violence is defined as violence directed at a "spouse, former spouse, cohabitant, former cohabitant, or person with whom the suspect has had a child or is having or has had a dating or engagement relationship" [7]. According to a 2016 to 2017 survey by the Centers for Disease Control and Prevention, severe physical violence by an intimate partner (including acts such as being hit with something hard, being kicked or beaten, or being burned on purpose) has been experienced by an estimated 32.5% of women and 24.6% of men during their lifetimes [17].

Dental professionals should be vigilant in recognizing signs of abuse among adolescent and adult patients. Up to 50% of abusive injuries occur to the head (particularly areas covered with hair) and neck, and facial injuries occur in 94% of intimate partner violence cases and are similar to those already discussed [7,18]. Again, dental visits may be a patient's only contact with healthcare professionals, making identification of abuse an important part of dental visits [7]. A history of intimidation, fear, isolation, and dependency is often present in victims of abuse, so it is especially important to determine the origin of orofacial or craniofacial injuries through the use of nonjudgmental questions. The Stanford School of Medicine recommends the following lines of indirect questioning for most age groups [31]:

- How are things going at home?

- What about stress levels? How are things going at work? At home?

- How do you feel about the relationships in your life?

- How does your partner treat you?

- Are you having any problems with your partner?

Alternately, lines of direct questioning may be used [31]:

- Did someone kick, hit, hurt, or threaten to hurt you? Was it your parent/caretaker or partner/husband?

- Are you in a relationship with (or do you live with) someone who hits, kicks, or threatens to hurt you?

- Have you ever been slapped, pushed, or shoved by your parent/partner?

- Have there been times when you felt afraid at home being around another person?

- Have you been hit or scared since the last time I saw you?

- Has anyone at home hit you or tried to injure you in any way?

- What kinds of experiences with violence have you had in your life?

- Do you feel controlled or isolated by your partner?

- Does your partner ever try to control you by threatening to hurt you or your family?

- Has anyone close to you ever threatened or hurt you?

- Does your partner ever hit, kick, hurt or threaten you?

- Have you ever been slapped, pushed or shoved by your partner?

- Have you ever been touched in a way that made you feel uncomfortable?

- Has anyone ever made you to do something sexual when you did not want to?

- Has your partner ever refused to practice safe sex?

It is up to the practitioner's judgment which line of questioning to employ. Remember that the objectives are to advocate for and protect the patient. The questions can be framed in a way that does not cause a patient to feel singled out [31]:

- Because unfortunately violence is so common in our society, I have started asking all of my patients about it.

- Because domestic violence has so many effects on health, I now ask all my patients about it.

- From past experience with other patients, I’m concerned that some of your medical problems may be the result of someone hurting you. Is that happening?

- I don’t know if this is a problem for you, but many of my patients are dealing with abusive relationships. Some are too afraid or uncomfortable to bring it up themselves, so I’ve started asking about it routinely.

- Violence affects many families. Violence in the home may result in physical and emotional problems for you and your child. We are offering services to anyone who may be concerned about violence in their home.

When working cross-culturally, it is helpful to learn the colloquialisms used to describe abuse. For example, in some Latino cultures "disrespected me" refers to intimate partner violence or sexual assault [30]. If abuse is suspected and there is a cultural disconnect, consider the assistance of a knowledgeable co-worker, who may be able to act as a cultural broker.

7. CONCLUSION

Although its primary objective is to safeguard the public, the California Dental Practice Act is an excellent resource for dental professionals to ensure compliance with state law. Dental professionals with a good knowledge of the Dental Practice Act and its effects on dental care will practice legally and safely.

8. RESOURCES

California Dental Practice Act

https://www.dbc.ca.gov/about_us/lawsregs/laws.shtml

California Dental Association

https://www.cda.org

Dental Hygiene Board of California

https://dhbc.ca.gov

Works Cited

1. Dental Board of California. Dental Practice Act. Available at https://www.dbc.ca.gov/about_us/lawsregs/laws.shtml. Last accessed January 7, 2025.

2. American Dental Association. High School and College Students. Available at https://www.ada.org/resources/careers/high-school-and-college-students. Last accessed January 7, 2025.

3. California Legislative Information. CA Penal Code Section 11164-11174.3. Available at https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=PEN&division=&title=1.&part=4.&chapter=2.&article=2.5. Last accessed January 7, 2025.

4. American Academy of Pediatrics. Oral and dental aspects of child abuse and neglect. Pediatrics. 1999;104(2 Pt 1):348-350.

5. Becker DB, Needleman HL, Kotelchuck M. Child abuse and dentistry: orofacial trauma and its recognition by dentists. J Am Dent Assoc. 1978;97(1):24-28.

6. Kellogg N, American Academy of Pediatrics Committee on Child Abuse and Neglect. Oral and dental aspects of child abuse and neglect. Pediatrics. 2005;116(6):1565-1568.

7. Spencer DE. Child abuse: dentists' recognition and involvement. J Calif Dent Assoc. 2004;32(4):299-303.

8. Christian CW, Block R, Committee on Child Abuse and Neglect, American Academy of Pediatrics. Abusive head trauma in infants and children. Pediatrics. 2009;123(5):1409-1411.

9. Bernat JE. Child abuse and neglect: dentistry's role. N Y State Dent J. 1989;55(3):34-37.

10. Flaherty EG, Sege RD, Griffith J, et al. From suspicion of physical child abuse to reporting: primary care clinician decision-making. Pediatrics. 2008;122(3):611-619.

11. California State Legislature. Assembly Bill 2435. Available at http://www.leginfo.ca.gov/pub/09-10/bill/asm/ab_2401-2450/ab_2435_cfa_20100405_092058_asm_comm.html. Last accessed January 7, 2025.

12. Glassman P, Miller C, Ingraham R, Woolford E. The extraordinary vulnerability of people with disabilities: guidelines for oral health professionals. J Calif Dent Assoc. 2004;32(5):379-386.

13. Johnson TE, Boccia AD, Strayer MS. Elder abuse and neglect: detection, reporting, and intervention. Spec Care Dentist. 2001;21(4):141-146.

14. National Center on Elder Abuse. Research: Statistics and Data. Available at https://ncea.acl.gov/researchstatisticsanddata#gsc.tab=0. Last accessed January 7, 2025.

15. Mattoo KA, Shalabh K, Khan A. Geriatric forensics: a dentist's perspective and contribution to identify existence of elder abuse among his patients. J Forensic Dent Sci. 2010;2(2):81-85.

16. California Legislative Information. California Welfare and Institutions Code. Available at https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=15600&lawCode=WIC. Last accessed January 7, 2025.

17. Centers for Disease Control and Prevention. The National Intimate Partner and Sexual Violence Survey: 2016/2017 Report on Intimate Partner Violence. Available at https://www.cdc.gov/nisvs/documentation/NISVSReportonIPV_2022.pdf. Last accessed Janaury 7, 2025.

18. Barkley Burnett L, Adler J. Domestic Violence: Clinical Presentation. Available at http://emedicine.medscape.com/article/805546-clinical#b4. Last accessed January 7, 2025.

19. California Legislative Code. Business and Professions Code Section 1600-1621. Available at https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=BPC&division=2.&title=&part=&chapter=4.&article=1. Last accessed January 7, 2025.

20. Dental Hygiene Board of California. Laws and Regulations. Available at https://dhbc.ca.gov/lawsregs/index.shtml. Last accessed January 7, 2025.

21. Dental Board of California. Fingerprint Requirement for License Renewal. Available at https://www.dbc.ca.gov/licensees/fingerprint_faq.shtml. Last accessed January 7, 2025.

22. Dental Board of California. Enforcement Program. Available at https://www.dbc.ca.gov/consumers/enforcement.shtml. Last accessed January 7, 2025.

23. Shouse Law Group. How Criminal Convictions Affect California Dental Board Licenses. Available at https://www.shouselaw.com/dentists.html. Last accessed January 7, 2025.

24. California Legislative Code. Business and Professions Code Section 1625–1636.6. http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=BPC&division=2.&title=&part=&chapter=4.&article=2. Last accessed January 7, 2025.

25. California Legislative Code. Business and Professions Code Section 1648.10–1648.20. Available at http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=BPC&division=2.&title=&part=&chapter=4.&article=2.9. Last accessed January 7, 2025.

26. California Department of Social Services. Adult Protective Services and County Block Grant Monthly Statistical Report. Available at https://www.cdss.ca.gov/inforesources/Research-and-Data/Disability-Adult-Programs-Data-Tables/SOC-242 . Last accessed January 7, 2025.

27. California Dental Association. Mandatory CURES Consultation in Effect Oct 2. Available at https://www.cda.org/Home/Practice/Practice-Support/Regulatory-Compliance/CURES-and-Opioid-Pain-Management. Last accessed January 7, 2025.

28. Westlaw. California Code of Regulations. Available at https://govt.westlaw.com/calregs/Browse/Home/California/CaliforniaCodeofRegulations?transitionType=Default&contextData=%28sc.Default%29. Last accessed January 7, 2025.

29. County of Orange Social Services Agency. RADAR: A Domestic Violence Intervention. Available at https://www.factoc.org/radar-a-domestic-violence-intervention. Last accessed January 7, 2025.

30. U.S. Department of Justice Office for Victims of Crime. Existe Ayuda (Help Exists) Toolkit. Available at https://ovc.ojp.gov/sites/g/files/xyckuh226/files/pubs/existeayuda/index.html. Last accessed January 7, 2025.

31. Stanford Medicine. Domestic Abuse: How to Ask. Available at https://domesticabuse.stanford.edu/screening/how.html. Last accessed January 7, 2025.

58584 • Infection Control for Dental Professionals: The California Requirement

Mark J. Szarejko, DDS, FAGD

www.netce.com

Copyright © 2025 NetCE, All rights reserved.

Effective infection control techniques are critical to reducing the incidence of infections in dental facilities. Antiseptic techniques and antibiotics will kill micro-organisms, while proper hand hygiene will block their transmission. Gloves, gowns, and masks remove dental professionals from the transmission cycle by protecting them from contact with micro-organisms. Contact Precautions and isolation techniques help patients avoid being vectors of transmission. Lastly, ensuring that dental professionals are immune or vaccinated can help decrease the availability of potential hosts.

Table of Contents

58584 • Infection Control for Dental Professionals: The California Requirement

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. INFECTION CONTROL REGULATIONS

BLOODBORNE PATHOGENS STANDARD

CALIFORNIA AEROSOL TRANSMISSIBLE DISEASE STANDARD

3. MODES OF TRANSMISSION

DIRECT AND INDIRECT CONTACT

AEROSOLS, DROPLETS, AND SPLATTER

FOMITE TRANSMISSION

WATER TRANSMISSION

4. STANDARD PRECAUTIONS

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT

RESPIRATORY HYGIENE

ENGINEERING AND WORK PRACTICE CONTROLS (SHARPS SAFETY)

SAFE INJECTION PRACTICES (ASEPTIC TECHNIQUE)

STERILIZATION AND DISINFECTION OF PATIENT-CARE ITEMS AND DEVICES

CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES

5. TRANSMISSION-BASED PRECAUTIONS

CONTACT PRECAUTIONS

DROPLET PRECAUTIONS

AIRBORNE PRECAUTIONS

6. PROTECTING DENTAL HEALTHCARE WORKERS

OCCUPATIONAL EXPOSURES

TUBERCULOSIS PREVENTION

VACCINATION

TRAINING AND EDUCATION

7. CONCLUSION

8. DENTAL BOARD OF CALIFORNIA GENERAL PROVISIONS: SECTION 1005. MINIMUM STANDARDS FOR INFECTION CONTROL

Works Cited

58584 • Infection Control for Dental Professionals: The California Requirement

Education Category. Infection Control / Internal Medicine

Release Date. 02/01/2025

Expiration Date. 01/31/2028

Course Overview

Effective infection control techniques are critical to reducing the incidence of infections in dental facilities. Antiseptic techniques and antibiotics will kill micro-organisms, while proper hand hygiene will block their transmission. Gloves, gowns, and masks remove dental professionals from the transmission cycle by protecting them from contact with micro-organisms. Contact Precautions and isolation techniques help patients avoid being vectors of transmission. Lastly, ensuring that dental professionals are immune or vaccinated can help decrease the availability of potential hosts.

Audience

This course is designed for all dentists, dental hygienists, and dental assistants in all practice settings, particularly those practicing in California.

Accreditations & Approvals

NetCE Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement. 10/1/2021 to 9/30/2027 Provider ID #217994. NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. NetCE is approved as a provider of continuing education by the Florida Board of Dentistry, Provider #50-2405. NetCE is a Registered Provider with the Dental Board of California. Provider Number RP3841. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

NetCE designates this activity for 2 continuing education credits. AGD Subject Code 148. This course meets the Dental Board of California's requirements for 2 unit(s) of continuing education. Dental Board of California course #02-3841-26452. NetCE is authorized by IACET to offer 0.2 CEU(s) for this program.

Special Approvals

This course fulfills the California requirement for 2 hours of infection control education.

Course Objective

The purpose of this course is to familiarize dental professionals with infection control techniques in order to minimize the risks of microbial transmission in the dental healthcare setting.

Learning Objectives

Upon completion of this course, you should be able to:

1. Outline OSHA and Cal/OSHA regulations that impact the provision of dental care.

2. Analyze potential modes of transmission and pathogens that can result in infection in dental facilities.

3. Discuss potential prevention strategies for infection control, including hand hygiene, and personal protective equipment.

4. Describe effective environmental control measures that should be applied in dental care.

5. Identify steps that should be taken to protect dental healthcare personnel, including vaccination, education, and exposure responses.

Faculty

Mark J. Szarejko, DDS, FAGD, received his dental degree from the State University of New York at Buffalo in 1985. He received fellowship from the Academy of General Dentistry in 1994.

Faculty Disclosure

Contributing faculty, Mark J. Szarejko, DDS, FAGD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

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Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

In 2023, there were more than 751,000 jobs in dental occupations in the United States[1]. In California alone there are approximately 104,000 dental healthcare professionals, including dentists, dental hygienists, and dental assistants [29]. Most of these dental workers come in daily contact with a variety of infectious diseases in their workplace and are at risk for both transmitting and contracting these diseases.

Universal Precautions were originally developed and recommended by the Centers for Disease Control and Prevention (CDC) in the 1980s as an infection control approach to protect healthcare professionals from bloodborne pathogens. Under Universal Precaution recommendations, all human blood and certain bodily fluids are treated as if they are infectious, regardless of patient or setting. In 1996, the CDC expanded these recommendations and introduced Standard Precautions, not only to protect healthcare workers from pathogens in human blood and body fluids but also from pathogens present in bodily fluids that are not covered under Universal Precautions, including saliva during dental procedures. Standard Precautions are the minimum standard of care applied to all patients, and include hand hygiene, use of specific types of personal protective equipment (PPE) based on anticipated exposure, safe injection practices, and management of contaminated environmental items. In addition to Standard Precautions, Transmission-Based Precautions (i.e., Contact Precautions, Droplet Precautions, and Airborne Precautions) are used to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone. The type of Transmission-Based Precaution used is based on what is known or suspected about a patient's infection.

In California, to address the issue of infection control and reduce the potential for harm, the Dental Board of California (DBC) established a requirement that licensed dental healthcare professionals in California complete a course on infection control and prevention, further expanding the requirement to all dental health personnel (DHCP), defined as [9]:

...all paid and non-paid personnel in the dental healthcare setting who might be occupationally exposed to infectious materials, including body substances and contaminated supplies, equipment, environmental surfaces, water, or air. DHCP includes dentists, dental hygienists, dental assistants, dental laboratory technicians (in-office and commercial), students and trainees, contractual personnel, and other persons not directly involved in patient care but potentially exposed to infectious agents (e.g., administrative, clerical, housekeeping, maintenance, or volunteer personnel).

The DBC Infection Control standards require that DHCP comply with and enforce the minimum precautions to minimize the transmission of pathogens in healthcare settings, as set forth by Cal/OSHA. These standards are reviewed by the DBC and Dental Hygiene Committee of California to obtain a consensus on infection control standards. A written protocol should be developed for proper instrument processing, operatory cleanliness, and management of injuries, and a copy of infection control regulations should be conspicuously posted in each dental office [9].

2. INFECTION CONTROL REGULATIONS

Legal issues first began to impact infection control practices at the beginning of the acquired immunodeficiency syndrome (AIDS) epidemic in the early 1980s. The need to protect healthcare workers from bloodborne exposures resulted in the publication of the Bloodborne Pathogens Standard by OSHA in 1991 [3].

BLOODBORNE PATHOGENS STANDARD

The OSHA Standard requires employers whose employees have exposure to blood or other potentially infectious material (OPIM) to implement safe work practices, education, and barriers to exposure. OPIM includes saliva in dental procedures and all bodily fluid in situations where it is difficult or impossible to differentiate between bodily fluids; any unfixed tissue or organ (other than intact skin) from a human (living or dead); human immunodeficiency virus (HIV)-containing cell or tissue cultures, organ culture and blood, or other tissues from experimental animals [9]

The OSHA Bloodborne Pathogens Standard requires that all DHCP who may have contact on the job with blood or other bodily fluids must receive specific annual education, which includes instruction in the basics of infection control and prevention. Training must also cover bloodborne pathogens, modes of transmission, the proper use of needles, and Transmission-Based Precautions [2,3].

CALIFORNIA AEROSOL TRANSMISSIBLE DISEASE STANDARD

In 2009, Cal/OSHA adopted the nation's first aerosol transmissible disease (ATD) standard, which remains in effect today. The standard is designed to protect healthcare workers from diseases spread by an airborne or droplet route. The ATD standard requires employers in health care to develop exposure control procedures and train employees to follow those procedures [4]. Basic exposure precautions, such as source screening, infection control, hand hygiene, and cleaning and decontamination procedures, are a fundamental part of the standard. Employees must be included in the periodic review and assessment of these procedures.

According to the California ATD Standard, California dental offices whose patients have suspected or confirmed illnesses that require Airborne or Droplet Precautions, such as tuberculosis (TB) or other respiratory illnesses, must comply with the ATD standards [4]. Key points include:

- Dental employees must be trained to screen patients for ATDs.

- The screening process must be described in a written office procedure.

- Screening must be consistently implemented.

- Elective dental treatment should be deferred until the patient is non- infectious for TB or other diseases requiring Airborne or Droplet Precautions.

A simple screening procedure can be done by the first person who comes in contact with a patient. For example, the patient may be asked "How are you feeling today?" or "Do you have any coughs, fever, or flu-like symptoms?" If the patient is not feeling well or gives a positive answer to any part of the second question, the dental treatment should be rescheduled.

Outpatient dental clinics or offices are not required to comply with this standard if they meet all of the following conditions [4,21]:

- Dental procedures are not performed on patients identified as ATD cases or suspected ATD cases (e.g., persons with TB or other respiratory illnesses).

- The clinic's injury and illness prevention program includes a written procedure for screening patients for ATDs that is consistent with the CDC guidelines for infection control in dental settings. This procedure must be followed before performing any dental work on a patient.

- Employees have been trained in the screening procedure in accordance with state law.

- Aerosol-generating dental procedures are not performed on a patient identified through the screening procedure as presenting a possible ATD exposure risk unless a licensed physician determines that the patient does not currently have an ATD.

As of 2024, California remains the only state with such a permanent standard; however, the coronavirus disease (COVID) pandemic of 2019–2022 highlighted the need for a standard addressing infectious pathogens spread by aerosols or droplets. During the pandemic, OSHA did issue interim guidance for safe workplaces, and some states issued emergency temporary standards. Experts have called for these requirements to be codified in order to ensure the safety of professions and patients, but this has not yet been accomplished [15]. Full guidance on aerosol-transmissible diseases can be found in the 2023 California Workplace Guide to Aerosol Transmissible Diseases at https://www.dir.ca.gov/dosh/dosh_publications/ATD-Guide.pdf [4].

3. MODES OF TRANSMISSION

Almost all pathogens are transmitted by being carried from one place to another. The mode or means of transmission is the weakest link in the chain of infection, and it is the only link that can be eliminated entirely. Most infection control efforts are aimed at preventing transmission of pathogens from a reservoir to a susceptible host. Both Standard and Transmission-Based Precautions are designed to interrupt the mode of transmission. Table 1 details the most common modes of infection transmission in dentistry [5,6,8].

Table 1: COMMON MODES OF INFECTION TRANSMISSION

Category

Definition

Direct contact

Person-to-person transmission of pathogens (e.g., through skin, blood, or body fluid contact)

Indirect contact

An intermediate person or item acts as a transport between the portal of exit in one person and the portal of entry to the next person (e.g., via unwashed hands, shared equipment, needlesticks)

Dropletsa

Large respiratory droplets propelled by an infected person coughing, sneezing, talking, or breathing heavily. Droplets settle rapidly within 6 feet of the individual on surfaces and in the upper airway of individuals exposed via the eyes, nose, or mouth.

Airborne (aerosols)a

Small particles or micro-droplets are released into the air by an infected person coughing, sneezing, talking, or breathing heavily. Airborne pathogens can linger for long periods of time and travel longer distances, landing on surfaces and being breathed in by other individuals into the lower airway.

Fomites

Contact with a contaminated inanimate object (e.g., used gloves, pens, used tissues, soiled laundry, keyboards, furniture).

Water

Water may be contaminated by micro-organisms in dental water unit lines, causing patient contamination as well as dispersing infected airborne particles and droplets.

aIn 2024, a global consensus was reached to replace the terms droplet, airborne, and aerosol with a general umbrella term of "through the air transmission," regardless of infected respiratory particle size and/or distance traveled.

Source: [5,6,8]

DIRECT AND INDIRECT CONTACT

The most common modes of transmission in the healthcare setting are through contact, both direct and indirect. Because it addresses the weakest link in the chain of transmission, hand hygiene is the single most important procedure for preventing the spread of infection. Items moving between patients should be cleaned and sterilized after each use to avoid indirect transmission of pathogens. Standard Precautions in conjunction with identified Contact Precautions are often used in the dental setting.

Bloodborne Pathogens

Healthcare employees can be exposed to blood through needlestick and other sharps injuries, damaged mucous membranes, and broken skin exposures. The pathogens of primary concern to dental professions are HIV, hepatitis B virus, and hepatitis C virus.

Hepatitis B Virus

Healthcare personnel who have received the hepatitis B vaccine and developed immunity to the virus are at virtually no risk for infection. For a susceptible person, the risk from a single needlestick or cut exposure to hepatitis B-infected blood ranges from 6% to 30%, depending on the hepatitis B antigen status of the source individual. While there is a risk for hepatitis B infection from exposures of mucous membranes or nonintact skin, there is no known risk for infection from exposure to intact skin [5,10].

Hepatitis C Virus

Hepatitis C is transmitted primarily through percutaneous exposure to infected blood. The average risk for infection after a needlestick or cut exposure to hepatitis C virus-infected blood is approximately 1.8%. The risk following a blood exposure to the eye, nose, or mouth is unknown but is believed to be very small; however, hepatitis C virus infection from blood splashes to the eye has been reported. There also has been a report of hepatitis C virus transmission that may have resulted from exposure to nonintact skin, but there is no known risk from exposure to intact skin. Documented transmission of hepatitis C or hepatitis B virus has resulted from using the same syringe or vial to administer medication to more than one patient, even if the needle was changed [5,10].

The prevalence of hepatitis C virus infection among dentists and surgeons is similar to that among the general population, approximately 1% to 2% [5]. No studies of transmission from hepatitis C virus-infected DHCP to patients have been reported, and the risk for such transmission appears limited [10].

HIV/AIDS

The average risk of HIV infection after a needlestick or cut exposure to HIV-infected blood is 0.3%; 99.7% of needlestick or cut exposures do not lead to infection. The risk after exposure of the eye, nose, or mouth to HIV-infected blood is estimated to be 0.1%. There have been no documented cases of HIV transmission due to an exposure involving a small amount of blood on intact skin (i.e., a few drops of blood on skin for a short period of time) [5,10].

In the United States, the risk of HIV transmission in dental settings is extremely low. According to surveillance data from 1981 to 2013, a total of 58 cases of HIV seroconversion had been documented among healthcare personnel after occupational exposure to a known HIV-infected source, but none were among dental care personnel [12].

Certain factors affect the risk of HIV transmission after an occupational exposure. Laboratory studies have determined if needles that pass through latex gloves are solid rather than hollow-bore or are of small gauge (e.g., anesthetic needles), less blood is transferred. In a retrospective, case-control study of healthcare personnel, an increased risk for HIV infection was associated with exposure to a relatively large volume of blood, as with a deep injury with a device that was visibly contaminated with the patient's blood or a procedure that involved a needle placed in a vein or artery [12]. The risk was also increased if the exposure was to blood from patients with terminal illnesses, possibly reflecting the higher titer of HIV in patients with late-stage AIDS.

AEROSOLS, DROPLETS, AND SPLATTER

Aerosols, droplets (produced by the respiratory tract), and splatter contaminated with blood and bacteria are produced during many dental procedures. Devices such as dental handpieces, ultrasonic and sonic scalers, air polishers, air-water syringes, and air abrasion units produce visible aerosol clouds and possible airborne contamination. Splatter generated by dental procedures such as drilling is a primary risk for transmission of bloodborne pathogens. In general, because of their smaller size, aerosols pose the greatest risk for airborne infection [9].

Several studies have shown that airborne or droplet nuclei may extend up to 6 feet away from the source and can remain airborne for up to 30 minutes after a procedure. Tuberculosis (TB) is of special concern because it is a large particle that can remain airborne or can dry on a surface and become airborne again as part of a dust particle.

In 2024, the World Health Organization (WHO) and the Centers for Disease Control and Prevention from the United States, China, Europe, and Africa, published a global consensus of the terminology for pathogens that transmit through the air. Key changes include [8]:

- Any infected particles that are expelled from an individual through nose or mouth are referred to as "infectious respiratory particles" (IRPs).

- IRPs exist on a spectrum of sizes and should no longer be distinguished as "small" (aerosol) or "large" (droplet).

- The descriptor "through the air transmission" should be used to characterize any transmission that involves a pathogen moving through the air or being suspended in the air. Two further descriptors can be used:

- Airborne transmission or inhalation: IRPs are expelled into the air and inhaled by another person. This can occur at short or long distances, dependent on various factors (e.g., airflow, humidity, temperature, ventilation).

- Direct deposition: IRPs are expelled into the air and directly deposited on the exposed mouth, nose, or eyes of another person.

Due to the existing research and recommendations primarily using the terms and definitions of "aerosol" and "droplet," these terms will continue to be used throughout this course, unless otherwise noted.

The American Dental Association recommends that in addition to using Universal and Standard Precautions, such as masks, gloves, and eye protection, Transmission-Based Precautions, including the proper sterilization of instruments and treatment of dental unit waterlines is necessary to reduce or eliminate this source of potentially contaminated dental aerosols. Preprocedural rinsing with an antimicrobial mouthwash such as chlorhexidine is also recommended, although it is only effective for oral bacteria found in saliva and those adhering to mucous membranes. It does not penetrate subgingivally and likely has no effect on bacteria in the nasopharynx [5,6].

Diseases known to spread by aerosols or droplet include:

- TB

- Pneumonic Yersinia pestis infection (plague)

- Influenza

- Legionellosis (Legionnaires disease)

- Measles

- Chickenpox

- Disseminated shingles

- Severe acute respiratory syndrome and coronavirus (SARS and COVID)

Procedures or equipment aimed at eliminating the means of transmission include [5,6]:

- Universal preprocedural rinses

- Dental dams for certain procedures

- High-volume evacuator (HVE) at the treatment site (An HVE can only remove airborne contamination if it removes a large volume of air. A saliva ejector does not remove enough air to be classified as an HVE.)

- High-efficiency particulate arresting and ultraviolet filters in the ventilation system

- Disposable PPE discarded after each patient (e.g., gloves, masks, gowns)

- Cleaning, disinfection, and sterilization of equipment used by more than one patient

- Environmental cleaning and disinfection, especially of high-touch surfaces

FOMITE TRANSMISSION

Devices can transmit pathogens if they are contaminated with blood or bodily fluids or are shared without cleaning, disinfecting, and sterilizing between patients; these are classified as fomites. Surgical instruments that are inadequately cleaned between patients or that have manufacturing defects that interfere with the effectiveness of reprocessing may transmit bacterial, fungal, and viral pathogens. Clothing, uniforms, laboratory coats, or gowns used as PPE may become contaminated with potential pathogens after care of a patient colonized or infected with an infectious agent [5,6,10].

WATER TRANSMISSION

Dental water units and dental unit waterlines are both potential sources of transmission and potential reservoirs. Routine cleaning and sterilization and adherence to the CDC's recommended procedures for treating dental unit waterlines have been shown to be effective in eliminating transmission of infectious organisms via these devices. Infections known to be caused by dental-related water transmission include Pseudomonas aeruginosa, Mycobacterium avium, and Legionella pneumophila [5,7].

4. STANDARD PRECAUTIONS

In 1986, California became the first state to pass a comprehensive bloodborne pathogen standard. The California standard provided a model for federal legislation, and in 1991, OSHA published its Bloodborne Pathogens Standard [3,30]. Since then, regulatory and legislative activity has focused on implementing a hierarchy of prevention and control measures to improve infection control in healthcare settings.

The gradual acceptance of various infection prevention standards has changed the way we work in the provision of dental care. The DBC defines Standard Precautions as "a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered" [9]. The DBC mandates that Standard Precautions must be practiced in the care of all patients, and all body fluids, except sweat, are considered potentially infectious [9]. The use of Standard Precautions reduces the risk of infection to staff and patients and ensures that the right precautions are used with both known and unknown carriers of diseases due to bloodborne pathogens. Standard Precautions apply to contact with blood, intact or nonintact skin, mucous membranes, and all bodily fluids, secretions, and excretions (except sweat), regardless of whether they contain blood. A central tenet of Standard Precautions is to consider all patients to be potentially infected with a bloodborne pathogen. Saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between Universal Precautions and Standard Precautions. For organisms other than bloodborne pathogens, early identification and prompt isolation are critical.

As noted, Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of health or dental care setting, and include [5]:

- Utilization of effective hand hygiene

- Use of PPE (e.g., gloves, masks, eyewear)

- Respiratory hygiene, including cough/ sneeze etiquette

- Sharps safety (engineering and work practice controls)

- Safe injection practices (aseptic technique)

- Cleaning, sterilization, and disinfection of instruments and devices

- Cleaning and disinfection of environmental surfaces

HAND HYGIENE

Despite the simplicity and effectiveness of hand hygiene in preventing the spread of infectious disease, adherence to hand hygiene practice remains low. Adherence varies among professional categories of healthcare workers but is usually estimated at less than 50%. Healthcare providers may be required to clean their hands as many as 100 times in a 12-hour shift, depending on the number of patients and intensity of care [14,17]. For dental healthcare workers, strict adherence to proper hand hygiene is the most important prevention strategy to protect both the patient and the worker. In one study, adherence rates to hand hygiene among postgraduate-year dentists found that overall handwashing compliance rate was 34.7%, with higher rates of compliance noted in oral surgery services (92.8%) than during work in general clinical practice (34.2%) [13]. The World Health Organization has designed the guidelines 5 Moments for Hand Hygiene as a reminder of when proper hand hygiene should be completed [11]:

1. Before touching a patient

2. Before a procedure

3. After a procedure or exposure to body fluids

4. After touching a patient

5. After touching a patient's surroundings

In general, perform hand hygiene [14]:

- After contact with any bodily fluids, including your own

- Before any non-invasive or invasive procedure

- Each time you remove your gloves

- When your hands feel or look dirty

- After contact with contaminated things or environments, such as charts

- After handling used equipment or linen

- After using the bathroom

- Before contact with any portal of entry, your patient's or your own

- Before and after eating

A number of conditions restrict DHCP from participating in direct patient care. These include weeping dermatitis, exudative lesions, or any hand condition that increases the risk of disease transmission [9].

Good handwashing is difficult to practice, is rarely known or taught, and is one of the single most effective ways to prevent transmission of many diseases, including influenza. Everyone knows to wash their hands before eating and after using the restroom. However, few do little more than remove obvious dirt. Good handwashing involves removing the skin oils where organisms can remain even when the hands look clean. A quick pass under the water faucet and fast dry with a towel may remove visible dirt, but the oils and organisms remain.

To effectively remove the oils and organisms, the process should take at least 20 seconds, or the amount of time it takes to sing "Twinkle, Twinkle Little Star." The hands should be soaped and rubbed vigorously for 15 seconds to create a good lather and to assure that all parts of each hand are soaped and rubbed well. Then, the hands should be rinsed thoroughly and dried, preferably with a paper towel. The towel should be used to turn off the water faucet and then properly thrown away. However, 20 seconds is a long time in the busy life of a healthcare provider, and this 20 seconds has been identified as a major barrier to handwashing, particularly among those who consider themselves "too busy" to wash their hands. If there is no visible dirt or contamination, a waterless hand sanitizer with at least 60% alcohol can be used between patients. However, nothing is as good as washing well with soap and water. Further, some organisms are not eliminated through the use of hand sanitizers alone (e.g., Clostridioides difficile spores). Hands should be thoroughly dried before donning gloves and washed again immediately after glove removal [9].

Some mistakenly think that hot water must be used to kill the organisms. Water hot enough to kill organisms would be too hot to touch. Warm water softens oils but mainly adds to comfort and encourages better washing technique (i.e., longer duration). Careful attention to handwashing and cleansing may result in chapped skin, so the dental professional must find effective lotions to care for his/her hands [14,17].

Certain soaps contain stronger antiseptic compounds, such as chlorhexidine, and these soaps may be considered in cases in which exposure to potentially infectious material is likely. Antiseptic soaps or surgical preparation liquids have been found more effective than plain soap in removing bacteria from healthcare workers hands both pre- and postprocedure. In addition, antiseptics may be added to alcohol-based handrubs in order to achieve persistent germicidal activity. Possible side effects associated with frequent use of antiseptic hand scrubs include skin irritation, dermatitis, allergic reactions, and potential development of microbial resistances. Chlorhexidine products are considered safe for regular use in dental practice; however, if associated side effects are bothersome, they may result in decreased hand hygiene compliance [10,14].

In summary, start and end each work day using an antibacterial soap. Gloves provide a breeding ground for microbial growth, and washing before and after use is encouraged. If hands are not visibly soiled, a waterless hand sanitizer (at least 60% alcohol) may be used. For surgical procedures, wash hands with antimicrobial soap prior to gowning and gloving [5].

PERSONAL PROTECTIVE EQUIPMENT

PPE is defined as special coverings designed to protect healthcare personnel from exposure to or contact with infectious agents [18]. Cal/OSHA regulations require use of PPE in dental care settings to protect personnel from exposure to bloodborne pathogens and other OPIM [9]. Under OSHA's General Duty Clause, PPE is also required for any potential infectious disease exposure. Employers must provide their employees with appropriate PPE and ensure its proper disposal. If reusable, it must be properly cleaned or laundered, repaired, and stored after use [19]. PPE must fit the individual user, and it is up to the employer to ensure that PPE is available in sizes appropriate for all their workers. Employees are prohibited from taking PPE home to launder.

In addition to the familiar gloves, masks, and gowns, PPE includes a variety of barriers and respirators used alone or in combination to protect skin, mucous membranes, and airways from contact with infectious agents. The selection of PPE is based on the nature of the patient/provider interaction and the likely mode of transmission. Primary PPE used in oral healthcare settings includes gloves, surgical masks, respiratory devices, protective eyewear, face shields, and protective shoes and clothing.

Procedures that can generate splashes or sprays of blood, bodily fluids, secretions, excretions, or chemical agents require either a face shield (disposable or reusable) or mask and goggles. The wearing of masks, eye protection, and face shields in specified circumstances (when blood or OPIM exposures are likely to occur) is mandated by the OSHA Bloodborne Pathogens Standard. Sterile barriers for invasive procedures and masks or respirators for the prevention of droplet contamination are also required [2].

The use of PPE is not a substitute for safe work practices. Avoid contaminating yourself by keeping your hands away from your face and not touching or adjusting equipment. PPE is a potential means of transmission if not changed between patients. All PPE should be removed when leaving patient care areas.

Gloves

DHCP should wear medical exam gloves to prevent contamination of their hands when touching mucous membranes, blood, saliva, or OPIM [9]. Gloves reduce the likelihood that micro-organisms present on the hands will be transmitted to patients during surgical or other patient-care procedures. Gloves used in the healthcare setting are subject to U.S. Food and Drug Administration (FDA) evaluation and clearance. Nonsterile, disposable medical gloves made of latex or nitrile should be available for routine patient care. Dental personnel should always use gloves when [18]:

- Anticipating direct contact with blood or bodily fluids, mucous membranes, nonintact skin, and OPIM

- Engaging in direct contact with patients who are colonized or infected with pathogens transmitted by the contact route, such as vancomycin-resistant enterococci or methicillin-resistant Staphylococcus aureus (MRSA)

- Handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces

Studies have repeatedly shown that vinyl gloves have higher failure rates than latex or nitrile gloves. For this reason, either latex or nitrile gloves are preferable for clinical procedures that require manual dexterity or those involving more than brief patient contact. Heavier, reusable utility gloves should be used for non-patient-care activities, such as handling or cleaning contaminated equipment or surfaces, handling chemicals, or disinfecting contaminated tools [9,18].

During dental procedures, patient examination gloves commonly contact multiple types of chemicals and materials, such as disinfectants and antiseptics, composite resins, and bonding agents, and these materials can compromise the integrity of latex, nitrile, and other synthetic glove materials. In addition, latex gloves can interfere with the setting of vinyl polysiloxane impression materials. Given the diverse selection of dental materials on the market, dental practitioners should consult glove manufacturers regarding the chemical compatibility of glove materials [5,18].

Wearing sterile surgeon's gloves during surgical procedures has a strong theoretical rationale. Sterile gloves minimize transmission of micro-organisms from the hands of surgical personnel to patients and prevent contamination of the hands of surgical personnel with the patient's blood and bodily fluids. In addition, sterile surgeon's gloves are more rigorously regulated by the FDA and may provide an increased level of protection for the provider if exposure to blood is likely [10,18].

Gloves should be removed and replaced if torn or punctured and discarded between patients to prevent transmission of infectious material. They should never be washed and reused, as micro-organisms cannot be removed reliably from glove surfaces. Glove reuse has been associated with transmission of MRSA and gram-negative bacilli [9,10].

When gloves are worn in combination with other PPE, they should be put on last. Gloves that fit snugly around the wrist are preferred for use with a gown because they will cover the gown cuff and provide a more reliable continuous barrier for the arms, wrists, and hands. Removing gloves properly also prevents hand contamination. Hand hygiene following glove removal ensures that the hands will not carry potentially infectious material that might have penetrated through unrecognized tears or contaminated the hands during glove removal. When processing contaminated sharp instruments, needles, and devices, heavy utility gloves should be used to prevent puncture injuries [10,18].

When adhering to Standard Precautions, always [5]:

- Use good hand hygiene.

- Use gloves for contact with blood, bodily fluids, nonintact skin (including rashes), mucous membranes, used equipment, linens, and trash.

- Change gloves if they become heavily soiled when working on a patient or if you must go from a potentially more infective area to a lesser one.

In addition, never:

- Wear artificial fingernails.

- Touch a second patient with the same pair of gloves used on the first patient.

- Contaminate the environment with dirty gloves.

- Wear gloves outside the treatment area unless you can say why you are wearing them.

Protective Clothing

Gowns are intended to protect the arms and exposed body areas and prevent contamination of clothing with blood, bodily fluids, and OPIM. The type of gown selected is based on the nature of the patient/provider interaction, including the anticipated degree of contact with infectious material and potential for blood and bodily fluid penetration of the barrier. General work clothes (e.g., uniforms, scrubs, laboratory coats, jackets) are not considered PPE. Dental personnel should change protective clothing when it becomes visibly soiled or as soon as possible if penetrated by blood or other possibly infectious fluid [18].

California regulations require that all DHCP wear reusable or disposable protective attire when their clothing or skin is likely to be exposed to aerosol spray or splashing or spattering of blood, OPIM, or chemicals and germicidal agents. Gowns must be changed daily or between patients if they become moist or visibly soiled. All PPE used during patient care shall be removed when leaving laboratories or areas of patient care activities. Reusable gowns should be laundered in accordance with Cal/OSHA Bloodborne Pathogens Standards. In addition, gowns should be worn for disinfection, sterilization, and housekeeping procedures involving the use of germicides or handling contaminated items [9].

Masks, Protective Eyewear, and Face Shields

In California, DHCP are required to wear surgical masks that cover both the nose and mouth, in combination with either chin-length plastic face shields or protective eyewear when there is potential for splashing or spattering of blood, droplets, chemical, or germicidal agents, or OPIM. After each patient, masks should be changed and disposed of properly. After each patient treatment, face shields and protective eyewear shall be disposed or cleaned and disinfected [9,18].

Masks should fit snugly and fully cover the nose and mouth to prevent fluid penetration. For this reason, masks that have a flexible nose piece and can be secured to the head with string ties or elastic are preferable. Surgical masks protect against micro-organisms generated by the wearer and also protect dental personnel from large-particle droplet spatter that might contain bloodborne pathogens or OPIM. If the mask becomes wet or contaminated, it should be changed between patients or even during patient treatment. For employees at increased risk of exposure to ATDs, such as those working in endemic areas (e.g., Southeast Asia) or in areas designated for isolation or quarantine, the employer must provide a respirator at least as effective as an N95 respirator.

Most surgical masks are not National Institute for Occupational Safety and Health (NIOSH)-certified as respirators, do not protect the user adequately from exposure to TB, and do not satisfy OSHA requirements for respiratory protection. However, certain surgical masks (i.e., N95 respirators) do meet the requirements and are certified by NIOSH. The level of protection a respirator provides is determined by the efficiency of the filter material for incoming air (e.g., 95% for N95) and how well the face piece fits or seals to the face. N95 respirators are required to be labeled as such on the device.

Respirators are used when treating patients with diseases requiring Airborne Precautions and should be used in the context of a complete respiratory protection program. This program should include training and fit testing to ensure an adequate seal between the edges of the respirator and the wearer's face.

Goggles with side shields provide barrier protection for the eyes and should fit snugly over and around the eyes or personal prescription lenses. Personal prescription lenses do not provide optimal eye protection and should not be used as a substitute for goggles. If goggles or face shields are reusable, they must be placed in a designated receptacle for subsequent reprocessing. If they are not reusable, they may be discarded in a designated waste receptacle.

Face shields extending from chin to crown provide better face and eye protection from splashes and sprays than goggles. Shields that wrap around the sides may reduce splashes around the edge. Removal of a face shield, goggles, and mask can be performed safely after gloves have been removed and hand hygiene performed. The ties, earpieces, or headband used to secure the equipment to the head are considered clean and therefore safe to touch with bare hands. The front of the face shield is considered contaminated [10,18].

RESPIRATORY HYGIENE

If dental clinics and offices comply with state regulations for screening of patients with ATDs, they are not required to comply with the new standards for prevention of transmission of ATDs [4]. However, because no screening process is universally effective, dental personnel should be aware of the potential dangers associated with transmission of pathogens via the airborne and droplet routes.

Respiratory droplets can transmit infection when they travel directly from the respiratory tract of the infected individual to the mucosal surfaces of the recipient, generally over short distances (i.e., 6 feet or less). Airborne transmission occurs with only a few organisms that can survive the drying of respiratory droplets. When the droplets evaporate, they leave behind droplet nuclei, which are so small they remain suspended in the air and can travel over longer distances. Respiratory droplets and droplet nuclei are generated when an infected person coughs, sneezes, or talks during procedures. Facial masks or shields generally provide direct protection from droplet transmission. Some pathogens transmitted via the airborne route (e.g., TB) require the use of an N95 respirator or better (e.g., N99, N100) due to the small particle size [5].

Measures to contain respiratory secretions in symptomatic patients and accompanying adults may include [5,18]:

- Post signs to instruct patients with known or suspected respiratory infection to cover mouth and nose when sneezing or coughing, use and properly dispose of tissues, and wash hands after sneezing or coughing.

- Provide tissues and no-touch receptacles.

- Have handwashing stations or hand sanitizer available in waiting areas.

- Offer masks to patients and accompanying adults.

- Provide ample space in waiting areas, or consider placing symptomatic patients in a separate waiting area.

ENGINEERING AND WORK PRACTICE CONTROLS (SHARPS SAFETY)

Most percutaneous injuries among DHCP involve scalers, burs, needles, wires, and sharp instruments. In 2000, the Federal Needlestick Safety and Prevention Act authorized OSHA to revise its Bloodborne Pathogens Standard to require the use of safety-engineered sharp devices in healthcare settings [2,3,16]. Guidelines on the design, implementation, and evaluation of a sharps injury prevention program have been developed by the CDC, and outline engineering controls and work practice controls as primary methods to prevent such occurrences. Engineering controls, such as sharps disposal containers, self-sheathing needles, and safer medical devices (e.g., sharps with engineered sharps injury protections and needleless systems) isolate or remove the bloodborne pathogens hazard from the workplace. On the other hand, work practice controls reduce the likelihood of exposure by specifying the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).

Engineering and work practice controls are intended to work synergistically to eliminate or minimize employee exposure. These controls must be examined and maintained or replaced on a regular basis to ensure their effectiveness. To maintain a safe workplace, employers must provide handwashing facilities that are readily accessible to employees.

Contaminated needles and other contaminated sharps should not be bent, recapped, or removed unless the employer can demonstrate that there is no alternative or that such action is required by a specific procedure. Necessary bending, recapping, or needle removal must be accomplished through the use of a mechanical device or a one-handed scoop technique. Shearing or breaking of contaminated needles is prohibited. Immediately, or as soon as possible after use, contaminated reusable sharps (e.g., scalpels, dental knives) must be placed in appropriate containers until properly reprocessed. These containers must be [9,10]:

- Puncture resistant

- Labeled or color-coded

- Leak-proof on the sides and bottom

- Maintained in accordance with OSHA requirements for reusable sharps

- Designed so personnel are not required to reach by hand into the container

- Located as close as possible to the point of use

SAFE INJECTION PRACTICES (ASEPTIC TECHNIQUE)

Safe injection practices are designed to prevent disease transmission within the healthcare setting. The absence of visible blood or other signs of contamination in a used syringe does not mean the item is free from potentially infectious agents. Bacteria and other microbes can be present without any visible evidence of contamination. All used injection supplies and materials should be considered potentially contaminated and should be discarded.

To ensure safe injection practices, use aseptic technique throughout all aspects of injection preparation and administration. Aseptic technique involves the handling, preparation, and storage of medications in a manner that prevents microbial contamination. It also applies to the handling of all supplies used for injections and infusions. To avoid contamination, medications should be drawn in a clean medication preparation area. Any item that may have come in contact with blood or OPIM should be kept separate from medications. In addition, eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure. Food and drink should not be kept in refrigerators, freezers, shelves, or cabinets or on countertops where blood or OPIM is present.

A new, sterile syringe and needle should be used to draw up medications while preventing contact between the injection materials and the nonsterile environment. Practice proper hand hygiene before handling medications, and discard medication vials upon expiration or any time there are concerns regarding the sterility of the medication [5].

Never leave a needle or other device inserted into a vial or bottle for multiple uses. This provides a direct route for micro-organisms to enter the vial and contaminate the fluid. Medications should never be combined between vials or administered from the same syringe to more than one patient, even if the needle is changed. Multidose vials should be used on a single patient whenever possible and should never enter the immediate patient treatment area [5].

Dental personnel should follow proper technique when using and handling needles, cannulae, and syringes. Whenever possible, use sharps with engineered sharps injury protections (e.g., non-needle or needle devices with built-in safety features or mechanisms that effectively reduce the risk of an exposure incident). Do not disable or circumvent the safety feature on devices [5].

Cases of bloodborne pathogen transmission as a result of improper injection practices have common themes. Often, aseptic technique and Standard Precautions were not carefully followed. Infection control programs may be lacking or responsibilities unclear. In several instances, failure to recognize an infection control breach has led to prolonged transmission and a growing number of infected patients. In all cases, investigations were time-consuming and costly and required the notification, testing, and counseling of hundreds and sometimes thousands of patients [5,16].

STERILIZATION AND DISINFECTION OF PATIENT-CARE ITEMS AND DEVICES

Application of accepted infection control principles helps maintain a safe environment for both patients and dental care workers. This includes proper use of Standard Precautions and application of approved techniques for cleaning, disinfection, sterilization, and reprocessing of dental equipment. Healthcare policies must identify—primarily on the basis of an item's intended use—whether cleaning and disinfection or sterilization is indicated (Table 2) [9,10,21].

Table 2: METHODS FOR STERILIZING AND DISINFECTING PATIENT-CARE ITEMS AND ENVIRONMENTAL SURFACES

Process

Result

Method

Examples

Patient Care Items

Environmental Surfaces

Sterilization

Destroys all forms of viable micro-organisms, including bacterial spores.

Heat-automated, high temperature

Steam, dry heat, unsaturated chemical vapor

Heat-tolerant critical and semicritical

NA

Heat-automated, low temperature

Ethylene oxide gas, plasma sterilization

Heat-sensitive critical and semicritical

Liquid immersiona

Glutaraldehyde, glutaraldehydes with phenols, hydrogen peroxide, hydrogen peroxide with peracetic acid, peracetic acid

High-level disinfection

Destroys all micro-organisms, but not necessarily high numbers of bacterial spores.

Heat-automated

Washer disinfector

Heat-sensitive semicritical

NA

Liquid immersiona

Glutaraldehyde, glutaraldehydes with phenols, hydrogen peroxide, hydrogen peroxide with peracetic acid, ortho-phthalaldehyde

Intermediate-level disinfection

Destroys vegetative bacteria and most fungi and viruses. Inactivates Mycobacterium bovisb. Not necessarily capable of killing bacterial spores.

Liquid contact

EPA-registered hospital disinfectant with label claim of tuberculocidal activity (e.g., chlorine-containing products, quaternary ammonium compounds with alcohol, phenolics, bromides, iodophors, EPA-registered chlorine-based product)

Noncritical with visible blood

Clinical contact surfaces, blood spills on housekeeping surfaces

Low-level disinfection

Destroys most vegetative bacteria and certain fungi and viruses. Does not inactivate Mycobacterium bovis.

Liquid contact

EPA-registered hospital disinfectant with no label claim regarding tuberculocidal activity. OSHA also requires label claim of HIV and HBV potency for use of low-level disinfectant for use on clinical contact surfaces (e.g., quaternary ammonium compounds, some phenolics, some iodophors)

Noncritical without visible blood

Clinical contact surfaces, housekeeping surfaces

aContact time is the single critical variable distinguishing the sterilization process from high-level disinfection with FDA-cleared liquid chemical sterilants. High-level disinfection uses shorter submersion times.

bInactivation of the more resistant Mycobacterium bovis is used as a benchmark to measure germicidal potency.

Source: [9,10,21]

Cleaning is defined as the removal of visible soil (organic and inorganic material) debris and OPIM from objects and surfaces; normally, it is accomplished manually or mechanically using water with detergents or enzymatic products [9]. Cleaning must precede any disinfection or sterilization process.

Decontamination reduces the number of pathogenic micro-organisms on objects, usually with a 0.5% chlorine solution [21]. Thorough cleaning and decontamination are essential before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes.

Disinfection is a process that eliminates many or all pathogenic micro-organisms, except bacterial spores, on inanimate objects. In healthcare settings, objects are usually disinfected using liquid chemicals or wet pasteurization (i.e., the use of hot water to destroy micro-organisms). There are three levels of disinfection [9,10]:

- High-level disinfection: Used to disinfect patient-care equipment that touches mucous membranes or blood.

- Intermediate-level disinfection: Used mainly to disinfect items that have contact with intact skin, but is appropriate for certain semicritical items (e.g., chair arms).

- Low-level disinfection: Used to disinfect the healthcare environment or items that touch intact skin.

Surface disinfection is an important part of environmental cleaning. Most bacteria and mycobacteria (e.g., TB) survive for several months on dry surfaces [20]. Respiratory viruses, such as coxsackie or influenza, can persist on surfaces for a few days. Hepatitis viruses and HIV can persist for more than one week, and herpes viruses have been shown to persist from only a few hours up to seven days [20]. All surfaces in patient care areas should be cleaned then disinfected according to the manufacturer's instructions and allowed to dry completely.

Sterilization is a process that destroys or eliminates all forms of microbial life and is carried out in healthcare facilities by physical or chemical methods. Sterile and nonsterile are absolute concepts. If a sterile item is touched by anything nonsterile, the formerly sterile item is contaminated.

The sterilization area should be separate from any patient care or staff break areas. The sterilization section of the processing area should include the sterilizers and related supplies, with adequate space for loading, unloading, and cool down [10]. The area can also include incubators for analyzing spore tests and enclosed storage for sterile items and single-use items. Manufacturer and local building code specifications will determine placement and room ventilation requirements.

According to the CDC guideline, heat-tolerant dental instruments usually are sterilized by steam under pressure (autoclaving), dry heat, or unsaturated chemical vapor [10]. All sterilization should be performed by using medical sterilization equipment cleared by the FDA. The sterilization times, temperatures, and other operating parameters recommended by the manufacturer of the equipment used, as well as instructions for correct use of containers, wraps, and chemical or biological indicators, should always be followed [10]. Sterilization most often fails due to overloading.

Devices being sterilized should first be cleaned, as debris interferes with the sterilization process. If an ultrasonic unit is utilized, it should be covered while actively in use. Instruments should be fully dry prior to packaging and storage.

Storage practices for wrapped sterilized instruments can be either date- or event-related. Packages containing sterile supplies should be inspected before use to verify barrier integrity and dryness. Although some facilities continue to date every sterilized package and use shelf-life practices, other facilities have switched to event-related practices [10]. This approach recognizes that the product should remain sterile indefinitely, unless an event causes it to become contaminated (e.g., torn or wet packaging). Even for event-related packaging, the date of sterilization should be placed on the package, and if multiple sterilizers are used in the facility, the sterilizer used should be indicated on the outside of the packaging material to facilitate the retrieval of processed items in the event of a sterilization failure [10]. If packaging is compromised, the instruments should be re-cleaned, sterilized again, and packaged in new wrap.

Categorizing Patient-Care Items

Patient-care items (e.g., dental instruments, devices, and equipment) are categorized using the Spaulding classification system as critical, semicritical, or noncritical, depending on the potential risk for infection associated with their intended use.

Critical items are those items that enter sterile spaces, such as soft tissue or bone, or items that come into contact with the bloodstream. These items pose the greatest risk of transmitting infection and require sterilization. Examples of critical dental instruments include surgical instruments, periodontal scalers, scalpel blades, and surgical dental burs [9,10]. Critical instruments, items, and devices should be discarded or pre-cleaned, packaged or wrapped, and sterilized after each use. Methods of sterilization include steam under pressure (autoclaving), chemical vapor, and dry heat. If a critical item is heat-sensitive, it should, at minimum, be processed with high-level disinfection and packaged or wrapped after disinfection. These instruments, items, and devices shall remain sealed and stored in a manner so as to prevent contamination and shall be labeled with the date of sterilization and the specific sterilizer used if more than one sterilizer is utilized in the facility [9].

Semicritical items touch intact mucous membranes or nonintact skin and have a lower risk of transmission. Examples of semicritical dental instruments include mouth mirrors, amalgam condensers, reusable dental impression trays, and dental handpieces. Because the majority of semicritical items in dentistry are heat-tolerant, they should be sterilized using heat. If a semicritical item is heat-sensitive, it should, at a minimum, be processed with high-level disinfection, which kills all microbial life except spores [9,10,21]. Semi-critical instruments, items, and devices should be pre-cleaned, packaged or wrapped, and sterilized after each use. Methods of sterilization include autoclaving, chemical vapor, and dry heat. If a semi-critical item is heat sensitive, it should, at minimum, be processed with high-level disinfection and packaged or wrapped upon completion of the disinfection process. These packages or containers shall remain sealed, shall be stored in a manner so as to prevent contamination, and shall be labeled with the date of sterilization and the specific sterilizer used if more than one sterilizer is utilized in the facility [9].

Noncritical items pose the least risk of transmission of infection and include devices, equipment, and surfaces that come in contact with soil, debris, saliva, blood, OPIM, and intact skin, but not mucous membranes [9]. Noncritical items include radiograph heads/cones, blood pressure cuffs, facebows, and pulse oximeters. In the majority of cases, cleaning and disinfection with a California Environmental Protection Agency (CalEPA)-registered hospital low-level disinfectant labeled effective against HBV and HIV is adequate. When the item is visibly contaminated with blood or OPIM, a CalEPA-registered hospital intermediate-level disinfectant with a tuberculocidal claim (i.e., intermediate-level disinfectant) should be used [9,10].

High-speed dental hand pieces, low-speed hand pieces, rotary components and dental unit attachments (e.g., reusable air or water syringe tips and ultrasonic scaler tips) shall be packaged and heat-sterilized in a manner consistent with the same sterilization practices as a semi-critical instrument or item [9]. Single-use disposable items such as prophylaxis angles, cups, brushes, tips for high-speed evacuators, saliva ejectors, air and water syringe tips, and gloves must be used for one patient only and discarded. California requires proper functioning of the sterilization cycle of all sterilization devices be verified at least weekly through the use of a biologic indicator (such as a spore testing monitor). Test results should be documented and maintained for 12 months [9]. Studies have demonstrated variability among dental practices in meeting sterilization standards. In one study, 49% of respondents did not challenge autoclaves with biological indicators. Other studies using biologic indicators found a high proportion (15% to 65%) of positive spore tests after assessing the efficacy of sterilizers used in dental offices [21].

Laboratory Areas

According to California regulations, splash shields and equipment guards should be used on dental laboratory lathes. Fresh pumice and a sterilized or new ragwheel should be used for each patient. Devices used to polish, trim, or adjust contaminated intraoral devices must be disinfected or sterilized and stored in a manner so as to prevent contamination [9].

All intraoral items, such as impressions, bite registrations, and prosthetic or orthodontic appliances, must be cleaned and disinfected with an intermediate-level disinfectant before manipulation in the laboratory and before placement in the patient's mouth. Such items should be thoroughly rinsed prior to placement in the patient's mouth [9].

Reprocessing Reusable Medical Equipment

Reusable instruments, medical devices, and equipment should be managed and reprocessed according to recommended and appropriate methods. Industry guidelines as well as equipment and chemical manufacturer recommendations should be used to develop and update reprocessing policies and procedures. Written instructions should be available for each instrument, medical device, and equipment reprocessed. The FDA has issued guidance on ensuring the safety of reusable medical devices [23].

All procedures involving blood or OPIM must be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances. Splatter shields should be used on medical equipment associated with risk-prone procedures.

Equipment that may become contaminated with blood or OPIM must be examined before servicing or shipping and should be decontaminated as necessary, unless the employer can demonstrate that decontamination of such equipment or portions of such equipment is not feasible. A readily observable label should be attached to the equipment stating which portions remain contaminated. The employer must ensure that this information is conveyed to all affected employees, the servicing representative, and the manufacturer before handling, servicing, or shipping, so appropriate precautions may be taken.

Single-Use Devices

A single-use device is a device that is intended for use on a single patient during a single procedure. An unused single-use device is referred to as an original device. A reprocessed single-use device is an original device that has previously been used on a patient and has been subjected to additional processing and manufacturing for the purpose of an additional single use on a patient [22].

Dental Unit Waterlines, Biofilm, and Water Quality

Studies have shown that dental unit waterlines, such as narrow-bore plastic tubing that carries water to high-speed handpieces, air/water syringes, and ultrasonic scalers, can become colonized with micro-organisms, including bacteria, fungi, and protozoa. Protected by a polysaccharide layer known as a glycocalyx, these micro-organisms colonize and replicate on the interior surfaces of the tubing and form a biofilm. This biofilm serves as a reservoir that can increase the number of micro-organisms in the water used during dental treatment [10].

California regulations require that dental unit water lines be anti-retractive, to prevent patient material, such as oral micro-organisms, blood, and saliva, from entering a dental water system during treatment. These dental unit lines and devices should be purged with air or flushed with water at the beginning of the clinic day for at least two minutes prior to attaching handpieces, scalers, air water syringe tips, or other devices [9]. The dental unit lines and devices should be flushed between each patient for a minimum of 20 seconds [9]. Commercial devices and procedures shown to improve the quality of water used in dental treatment include self-contained water systems with chemical treatment, in-line microfilters, and combinations of these treatments. Simply using tap, distilled, or sterile water will not eliminate bacterial contamination in treatment water if biofilms in the system are not controlled. Microbial load should be less than or equal to 500 colony-forming units of heterotrophic bacteria per milliliter (≤500 CFU/mL) of water, the standard set for drinking water by the EPA [7]. Removal or inactivation of dental waterline biofilms requires use of chemical germicides. California law defines "germicide" as a chemical agent that can be used to disinfect items and surfaces based on the level of contamination. All germicides must be used in accordance with intended use and label instructions [9].

Regarding irrigation, if a surgical procedure involves soft tissue or bone, California regulations require the use of sterile coolants or irrigants, delivered using a sterile delivery system [9]. In addition, a new infection control standard that took effect in 2019, requires that water or other methods for irrigation must be sterile or contain recognized disinfecting or antibacterial properties when performing procedures on exposed dental pulp. Appropriate oral irrigants include chlorhexidine, BioPure MTAD, and sodium hypochlorite [33]. This requirement was in response to a 2016 outbreak of mycobacterial infection from a Southern California dental clinic that led to the hospitalization of more than 60 children. The cause was determined to be bacteria introduced through water during pulpotomies [33].

CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES

As discussed, contaminated surfaces and objects can serve as the means of transmission for potential pathogens. The transfer of a micro-organism from an environmental surface to a patient is largely via hand contact with the surface. Although hand hygiene is important to minimize the impact of this transfer, cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of infections [10].

All work areas, including contact surfaces and barriers, must be maintained in a clean and sanitary condition. Employers are required to determine and implement a written schedule for cleaning and disinfection based on the location, type of surface to be cleaned, type of soil present, and tasks or procedures being performed. All equipment and environmental and working surfaces must be properly cleaned and disinfected after contact with blood or OPIM.

If non-critical items or surfaces likely to be contaminated are manufactured in a manner preventing cleaning and disinfection, they should be protected with disposable impervious barriers. Disposable barriers should be changed when visibly soiled or damaged and between patients. Products used to clean items or surfaces prior to disinfection procedures shall be clearly labeled and follow all material safety data sheet (MSDS) handling and storage instructions. Clean and disinfect all clinical contact surfaces that are not protected by impervious barriers using a CalEPA-registered, hospital grade low- to intermediate-level disinfectant after each patient. The low-level disinfectants used must be labeled effective against hepatitis B virus and HIV. Use disinfectants in accordance with the manufacturer's instructions. Clean all housekeeping surfaces (e.g., floors, walls, sinks) with a detergent and water or a CalEPA-registered, hospital-grade disinfectant. Chemical-resistant utility gloves should be worn when handling hazardous chemicals [9].

Medical Waste Management

Federal, state, and local guidelines and regulations specify the categories of medical waste subject to regulation and outline the requirements associated with treatment and disposal [9]. Regulated medical waste is defined as [10]:

- Liquid or semi-liquid blood or OPIM

- Contaminated items that would release blood or OPIM in a liquid or semi- liquid state if compressed

- Items that are caked with dried blood or OPIM capable of releasing these materials during handling

- Contaminated sharps (e.g., needles, burs, scalpel blades, endodontic files)

- Pathologic and microbiologic wastes containing blood or OPIM

Regulated medical waste accounts for only 9% to 15% of total waste in hospitals and 1% to 2% of total waste in dental offices [10]. Examples of regulated waste found in dental practice settings are solid waste soaked or saturated with blood or saliva (e.g., gauze saturated with blood after surgery), extracted teeth, surgically removed hard and soft tissues, and contaminated sharp items, such as needles, scalpel blades, and wires [10]. General medical waste, including used gloves, masks, gowns, and lightly soiled gauze or cotton rolls, may be disposed of with ordinary waste.

Regulated medical waste requires careful disposal and containment before collection and consolidation for treatment. A single, leak-resistant biohazard bag is usually adequate for containment of regulated medical wastes, provided the bag is sturdy and the waste can be discarded without contaminating the bag's exterior. Contamination or puncturing of the bag requires placement into a second biohazard bag. All bags should be securely closed for disposal.

Medical waste requiring storage should be kept in labeled, leak-proof, puncture-resistant containers under conditions that minimize or prevent foul odors. The storage area should be well-ventilated and inaccessible to pests. Any facility that generates regulated medical waste should have a regulated medical waste management plan to ensure health and environmental safety in accordance with federal, state, and local regulations [10,21].

5. TRANSMISSION-BASED PRECAUTIONS

As discussed, Transmission-Based Precautions are used in addition to Standard Precautions for patients that require additional precautions to prevent infection transmission. The three categories of Transmission-Based Precautions are Contact, Droplet, and Airborne Precautions; these categories may overlap, and more than one category may be used at a time [25].

CONTACT PRECAUTIONS

Contact Precautions are utilized for patients with known or suspected infections that represent an increased risk for contact transmission. Contact Precautions require that practitioners [24]:

- Ensure appropriate patient placement to lessen risk for other patients or employees.

- Use PPE appropriately, including gloves and a gown. Donning PPE upon room entry and properly discarding before exiting the patient room is recommended to contain pathogens.

- Use disposable or dedicated patient-care equipment such as blood pressure cuffs. If common equipment must be used for multiple patients, thoroughly clean and disinfect.

- Prioritize cleaning and disinfection of patient rooms and contact surfaces, focusing on frequently touched surfaces and equipment and objects in the immediate vicinity of the patient.

DROPLET PRECAUTIONS

Use Droplet Precautions for patients that are known or suspected to be infected with pathogens transmitted by respiratory droplets. Droplet Precautions requires that one [24]:

- Source control by putting a mask on the patient to prevent respiratory droplets from spreading.

- Ensure appropriate patient placement to lessen risk for other patients or employees.

- Use PPE appropriately, including gloves and a gown. Donning PPE upon rom entry and properly discarding before exiting the patient room is recommended to contain pathogens.

- Limit transport and movement of patients outside of the room, and if movement is necessary, instruct patient to wear a mask and follow Respiratory Hygiene/Cough Etiquette.

AIRBORNE PRECAUTIONS

Airborne Precautions are used when patients are known or suspected to be infected with pathogens transmitted by airborne or aerosol route. Airborne pathogens include TB, measles, chickenpox, and herpes zoster. Airborne Precautions require [24]:

- Source control by putting a mask on the patient to prevent respiratory droplets from spreading.

- Ensure appropriate patient placement in an airborne infection isolation room (AIIR) constructed according to the CDC's Guideline for Isolation Precautions. In settings where Airborne Precautions cannot be implemented due to limited engineering resources, masking the patient and placing the patient in a private room with the door closed will reduce the likelihood of airborne transmission until the patient is either transferred to a facility with an AIIR or returned home.

- Restrict susceptible healthcare personnel from entering the room of patients known or suspected to have measles, chickenpox, disseminated zoster, or smallpox if other immune healthcare personnel are available.

- Use PPE appropriately, including a fit- tested NIOSH-approved N95 or higher level respirator for healthcare personnel.

- Limit transport and movement of patients outside of the room, and if movement is necessary, instruct patient to wear a surgical mask and observe Respiratory Hygiene/Cough Etiquette. Healthcare personnel transporting patients who are on Airborne Precautions do not need to wear a mask or respirator during transport if the patient is wearing a mask and infectious skin lesions are covered.

- Immunize susceptible persons as soon as possible following unprotected contact with vaccine-preventable infections (e.g., measles, varicella, or smallpox).

6. PROTECTING DENTAL HEALTHCARE WORKERS

Protecting DHCP is an integral part of every dental organization's general program for infection prevention and control. The objectives usually include [5]:

- Educating personnel about the principles of infection control and emphasizing individual responsibility

- Providing care to personnel for work-related illnesses or exposures

- Identifying work-related infection risks and implementing appropriate preventive measures

- Containing costs by preventing infectious diseases that result in absenteeism and disability

OCCUPATIONAL EXPOSURES

An occupational exposure is defined as a percutaneous injury or contact of mucous membrane or nonintact skin with blood, tissue, or OPIM, most commonly a needlestick injury. The risk of infection depends on several factors, including [27]:

- Whether the exposure was from a hollow-bore needle or other sharp instrument

- Whether the exposure was to non- intact skin or mucous membranes

- The amount of blood involved

- The amount of contagion present in the source person's blood

If a sharps injury occurs, wash the exposed area with soap and water. Do not "milk" or squeeze the wound. There is no evidence that using antiseptics will reduce the risk of transmission for any bloodborne pathogens; however, the use of antiseptics is not contraindicated. In the event that the wound needs suturing, emergency treatment should be obtained. The risk of contracting HIV from this type of exposure is extremely rare. There are no documented cases of a dental healthcare professional contracting HIV from an occupational exposure.

OSHA requires dental employers of an individual with an occupational exposure to a bloodborne pathogen to arrange a confidential medical evaluation and follow-up for any employee reporting an exposure incident [3]. An exposure incident is any eye, mouth, mucous membrane, nonintact skin, or other parenteral contact with blood or OPIM. Saliva in dental procedures is treated as potentially infectious material.

Following an exposure, the dental employer must refer the exposed employee to a licensed healthcare professional who can provide information and counseling and discuss how to prevent further spread of a potential infection. The exposed employee is entitled to appropriate follow-up and evaluation of any reported illness to determine if the symptoms may be related to HIV or hepatitis B or C infection [27].

Prompt response is necessary whenever an occupational exposure occurs. If possible, the patient should be interviewed to determine if any risk factors or bloodborne pathogens not previously disclosed are present. The patient may be tested along with the employee, if he or she agrees, in order to obtain the most information possible. Testing and postexposure prophylaxis may be conducted at an occupational injury clinic. All events leading up to and after the exposure should be documented in a written report [27].

Postexposure Prophylaxis

Postexposure prophylaxis (PEP) involves the provision of medications to someone who has had a substantial exposure, usually to blood, in order to reduce the likelihood of infection. PEP is available for HIV and hepatitis B virus. Although there is no PEP recommended for hepatitis C virus, limited data indicate that antiviral therapy might be beneficial when started early in the course of infection [28]. For employees who have not received the hepatitis B vaccine series, the vaccine (and in some circumstances hepatitis B immunoglobulin) should be offered as soon as possible (within seven days) after the exposure incident. The effectiveness of hepatitis B immunoglobulin administered more than seven days after exposure is unknown. PEP has been the standard of care for healthcare providers with substantial occupational exposures since 1996 and must be provided in accordance with the recommendations of the U.S. Public Health Service [28].

TUBERCULOSIS PREVENTION

California has one of the highest incidence rates of TB in the country, primarily because of its large population of persons born outside of the United States [31]. In 2023, the TB infection rate in California was 13 times higher among non-U.S.-born individuals than among those born in the United States. The rates of TB among Asian and Black individuals born outside the United States were 43 and 28 times higher, respectively, than that of U.S.-born White persons [31].

To prevent the transmission of Mycobacterium tuberculosis in dental care settings, infection-control policies should be developed based on the community TB risk assessment and reviewed annually. The policies should include appropriate screening for latent or active TB disease in dental care providers, education about the risk for TB transmission, and provisions for detection and management of patients who have suspected or confirmed TB disease.

The CDC recommends that all dental care providers be screened for TB upon hire, using either a tuberculin skin test or blood test [10]. The California Department of Public Health recommends an initial skin or blood test; positive reactions or results should be followed up by chest x-ray. Annual testing thereafter is recommended for dental personnel, although local and/or employer policies and methods of testing (e.g., questionnaire or skin or blood test) may differ [32].

Patients with symptoms of TB should be identified by screening; dental treatment should be deferred until active TB has been ruled out or the patient is no longer infectious following treatment. The potentially active TB patient should be promptly referred to an appropriate medical setting for evaluation of possible infectiousness and should be kept in the dental care setting only long enough to arrange for referral. Standard Precautions are not sufficient to prevent transmission of active TB [24].

A diagnosis of active respiratory TB should be considered for any patient with the following symptoms:

- Coughing for more than three weeks

- Loss of appetite

- Unexplained weight loss

- Night sweats

- Bloody sputum or hemoptysis

- Hoarseness

- Fever

- Fatigue

- Chest pain

A person with latent TB (positive skin test and no symptoms) can be treated in a dental office using standard infection control precautions [26]. This person has no symptoms and cannot transmit TB to others as there are no spores in his or her sputum.

The American Dental Association recommends that all patients be asked about any history of TB or exposure to TB, including signs and symptoms and medical conditions that increase their risk for TB disease. The Health History Form, developed by the U.S. Department of Health and Human Services, can be used to ask these questions.

If a patient with suspected or confirmed infectious TB disease requires urgent dental care, that care should be provided in a setting that meets the requirements for California ATD standards and airborne infection isolation. Respiratory protection (with a fitted N95 disposable respirator) should be used while performing procedures on such patients. Standard surgical masks are not designed to protect against TB transmission [4,26].

VACCINATION

Due to increased risk of occupational exposure, the CDC strongly recommends that all healthcare workers, including dental care providers, receive immunizations as a preventive measure. While these are the recommendations from the CDC, state and local legislation and workplace regulations may or may not require these immunizations.

Hepatitis B

Cal/OSHA guidelines require that healthcare workers who perform tasks that may involve exposure to blood or bodily fluids must have hepatitis B vaccination made available to them within 10 working days of initial assignment. The employee must also be given free information about the efficacy, safety, and benefits of vaccination [30].

The hepatitis B vaccine is given in a series of three injections at 0, 1, and 6 months. If one of the injections is missed, the series does not need to be restarted. The CDC recommends if the series is interrupted, the second or third dose should be administered as soon as possible; the second and third doses should be separated by an interval of at least eight weeks [24]. No booster is necessary. Follow-up serologic testing two months after vaccination (to ensure efficacy) is recommended. The provision of employer-supplied hepatitis B vaccination may be delayed until after probable exposure for employees whose sole exposure risk is the provision of first aid.

The high risk of hepatitis B virus exposure among healthcare personnel makes it imperative that clinical dental personnel be vaccinated. Vaccination can protect both workers and patients from hepatitis B virus infection and, whenever possible, should be completed when dentists or other dental care personnel are in training [10].

Influenza

Influenza is primarily transmitted from person to person via large, virus-laden droplets generated when infected persons cough or sneeze. These large droplets can settle on the mucosal surfaces of the upper respiratory tracts of susceptible persons who are within 3 feet of infected persons. Transmission may also occur through direct contact or indirect contact with respiratory secretions, such as when touching surfaces contaminated with influenza virus and then touching the eyes, nose, or mouth. The CDC strongly recommends that all healthcare personnel, especially those who have contact with patients at high risk, who have high-risk medical conditions, or who are older than 50 years of age, receive an annual (seasonal) influenza vaccination [24].

Measles, Mumps, and Rubella (MMR)

Vaccination for measles, mumps, and rubella is typically given in a single combination vaccine. The CDC notes that, regardless of birth year, individuals should receive two doses of measles, two doses of mumps, and one dose of rubella live-virus vaccine to be considered protected. MMR is given in a series of two injections, at least 28 days apart. Because the vaccine is often combination, most individuals will receive two doses of rubella-containing vaccine, with no adverse effect [24].

Tetanus and Diphtheria (Toxoids) and Acellular Pertussis (Tdap)

Vaccination for tetanus is recommended for all DHCP, regardless of age. The CDC recommends receiving the vaccine as soon as feasible if Tdap has not already been received, and regardless of interval from the last tetanus and diphtheria (Td) immunization. Routine boosters are recommended every 10 years thereafter [24].

Varicella

The varicella-zoster virus is responsible for chickenpox and shingles. The CDC recommends the varicella-zoster vaccine for all DHCP who do not have evidence of immunity, defined as: written documentation of two doses of varicella vaccine; laboratory evidence of immunity or confirmation of disease; diagnosis or verification of acute disease by a health-care provider; or diagnosis or verification of herpes zoster by a healthcare provider. While the varicella vaccine is recommended, the CDC does note that serologic testing before vaccination is likely to be cost-effective, as 71% to 93% of adults without a history of varicella are immune [24]. Immunization is considered complete after a series of two doses, spaced four to eight weeks apart [24].

TRAINING AND EDUCATION

Dental personnel should also fulfill all federal and state requirements for infection control training. New employees, or employees being transferred into jobs involving tasks or activities with potential exposure to blood or OPIM, must receive bloodborne pathogen training before assignment to tasks in which an occupational exposure may occur. Retraining is required annually or when changes in procedures or tasks affecting occupational exposure occur. Employees should be provided access to a qualified trainer to answer questions during the training session [9,10].

7. CONCLUSION

Effective infection control techniques are critical to reducing the incidence of infections in dental facilities. Antiseptic techniques and antibiotics will kill micro-organisms, while proper hand hygiene will block their transmission. Gloves, gowns, and masks remove DHCP from the transmission cycle by protecting them from contact with micro-organisms. Transmission-Based Precautions and isolation techniques help patients avoid being vectors of transmission. Engineering controls help to make the workplace safer, while administrative controls ensure that written protocols are in place and followed. Lastly, ensuring that all DHCP are immune or vaccinated can help decrease the availability of potential hosts.

8. DENTAL BOARD OF CALIFORNIA GENERAL PROVISIONS: SECTION 1005. MINIMUM STANDARDS FOR INFECTION CONTROL

The Dental Board of California General Provisions: Section 1005. Minimum Standards for Infection Control is available online at https://govt.westlaw.com/calregs/Document/IDB85BD734C8111EC89E5000D3A7C4BC3.

Works Cited

1. U.S. Bureau of Labor Statistics. Occupational Outlook Handbook: Dentists and Similar Occupations. Available at https://www.bls.gov/ooh/healthcare/dentists.htm. Last accessed December 15, 2024.

2. Occupational Safety and Health Administration. Worker Protections Against Occupational Exposure to Infectious Diseases. Available at https://www.osha.gov/bloodborne-pathogens/worker-protections. Last accessed December 15, 2024.

3. Occupational Safety and Health Administration. Standard 1910.1030: Bloodborne Pathogens. Available athttps://www.osha.gov/ laws-regs/regulations/standardnumber/1910/1910.1030. Last accessed December 15, 2024.

4. California Department of Industrial Relations. The California Workplace Guide to Aerosol Transmissible Diseases. Available at https://www.dir.ca.gov/dosh/dosh_publications/ATD-Guide.pdf. Last accessed December 15, 2024.

5. Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Available at https://www.cdc.gov/dental-infection-control/hcp/summary/index.html. Last accessed December 15, 2024.

6. Centers for Disease Control and Prevention. Infection Control Basics. Available at https://www.cdc.gov/infection-control/hcp/ basics/index.html. Last accessed December 15, 2024.

7. Mills SE, Porteous N, Zawada J. Dental unit water quality: Organization for Safety, Asepsis and Prevention white paper and recommendations. 2018;(1)1:1-27.

8. World Health Organization. Global Technical Consultation Report on Proposed Terminology for Pathogens that Transmit Through the Air. Geneva: World Health Organization; 2024.

9. 9.California Code of Regulations. Section 1005: Minimum Standards for Infection Control. Available at https://govt.westlaw.com/calregs/Document/IDB85BD734C8111EC89E5000D3A7C4BC3. Last accessed December 15, 2024.

10. Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings—2003. MMWR. 2003;52(RR17):1-72.

11. World Health Organization. Five Moments for Hand Hygiene. Available at https://www.who.int/publications/m/item/five-moments-for-hand-hygiene. Last accessed December 15, 2024.

12. Centers for Disease Control and Prevention. Occupationally acquired HIV infection among health care workers–United States, 1985–2013. MMWR. 2015;63(53):1245-246.

13. Cheng HC, Peng BY, Lin ML, Chen SL. Hand hygiene compliance and accuracy in a university dental teaching hospital. J Int Med Res. 2019;47(3):1195-1201.

14. Centers for Disease Control and Prevention. Clinical Safety: Hand Hygiene for Healthcare Workers. Available at https://www.cdc.gov/handhygiene/science. Last accessed December 15, 2024.

15. Boles C, Parker J, Hallett L, Henshaw J. Current understanding and future directions for an occupational infectious disease standard. Toxicology and Industrial Health. 2020;36(9):703-710.

16. Occupational Safety and Health Administration. Bloodborne Pathogens and Needlestick Prevention: General Guidance. Available at https://www.osha.gov/bloodborne-pathogens/general. Last accessed December 15, 2024.

17. Armstrong-Novak J, Juan HY, Cooper K, et al. Healthcare personnel hand hygiene compliance: are we there yet? Curr Infect Dis Rep. 2023;25:23-129.

18. Centers for Disease Control and Prevention. Dental Infection Prevention and Control: Best Practices for Personal Protective Equipment. Available at https://www.cdc.gov/dental-infection-control/hcp/dental-ipc-faqs/personal-protective-equipment.html. Last accessed December 15, 2024.

19. United States Department of Labor. Occupational Safety and Health Administration. 1910.132—General Requirements, Personal Protective Equipment. Available at https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.132. Last accessed December 15, 2024.

20. Porter L, Sultan O, Mitchell B, Kiernan M, et al. How long do nosocomial pathogens persist on inanimate surfaces? A scoping review. J Hosp Infect. 2024;147:25-31.

21. Rutala WA, Weber DJ, the Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 (Update: June 2024). Available at https://www.cdc.gov/infection-control/media/pdfs/Guideline-Disinfection-H.pdf. Last accessed December 15, 2024.

22. U.S. Food and Drug Administration. Reprocessing of Single-Use Devices. Available at https://www.fda.gov/medical-devices/products-and-medical-procedures/reprocessing-single-use-medical-devices-information-health-care-facilities. Last accessed December 15, 2024.

23. U.S. Food and Drug Administration. Reprocessing of Reusable Medical Devices in Health Care Settings. Available at https://www.fda.gov/medical-devices/products-and-medical-procedures/reprocessing-reusable-medical-devices. Last accessed December 15, 2024.

24. Shefer A, Atkinson W, Friedman C, et al. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2011:60(RR07):1-45.

25. Centers for Disease Control and Prevention. Transmission-Based Precautions. Available at https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html. Last accessed December 15, 2024.

26. American Dental Association. Tuberculosis. Available at https://www.ada.org/resources/ada-library/oral-health-topics/tuberculosis-overview-and-dental-treatment-conside. Last accessed December 15, 2024.

27. Centers for Disease Control and Prevention. Best Practices for Occupational Exposure to Blood. Available at https://www.cdc.gov/dental-infection-control/hcp/dental-ipc-faqs/occupational-exposure.html. Last accessed December 15, 2024.

28. U.S. Public Health Service. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR. 2001;50(RR11):1-52.

29. Dental Board of California. Dental Board of California. Available at https://www.dbc.ca.gov. Last accessed January 1, 2025.

30. California Department of Industrial Relations. California Code of Regulations: Title 8, Subchapter 7.16.109, Section 5193. Bloodborne Pathogens. Available at https://www.dir.ca.gov/title8/5193.html. Last accessed January 1, 2025.

31. California Department of Public Health. TB in California: 2023 Snapshot. Available at https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/TB-in-California-2023-Snapshot.aspx. Last accessed January 1, 2025.

32. California Department of Public Health. California Tuberculosis (TB) Testing Regulations for Health Care Facilities. Available at https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/California-TB-Testing-Regulations.aspx#. Last accessed January 1, 2025.

33. California Dental Association. New Infection Control Standard for Procedures that Expose Dental Pulp. Available at https://www.cda.org/newsroom/newsroom-archives/new-infection-control-standard-for-procedures-that-expose-dental-pulp/. Last accessed January 1, 2025.

57001 • Implicit Bias in Health Care

Alice Yick Flanagan, PhD, MSW

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

The role of implicit biases on healthcare outcomes has become a concern as some cite that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This course will explore definitions of implicit and explicit bias, the nature and dynamics of implicit biases, and how they can affect health outcomes. Because implicit biases are unconscious, strategies will be reviewed to assist in raising professionals' awareness of and interventions to reduce them.

Table of Contents

57001 • Implicit Bias in Health Care

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. DEFINITIONS OF IMPLICIT BIAS AND OTHER TERMINOLOGIES

IMPLICIT VS. EXPLICIT BIAS

OTHER COMMON TERMINOLOGIES

3. MEASUREMENT OF IMPLICIT BIAS: A FOCUS ON THE IAT

EXTENT OF IMPLICIT BIASES AND RISK FACTORS

4. THEORETIC EXPLANATIONS AND CONTROVERSIES

SOCIAL PSYCHOLOGICAL AND COGNITIVE THEORETICAL FRAMEWORKS

BEHAVIORAL OR FUNCTIONAL PERSPECTIVES

NEUROSCIENTIFIC PERSPECTIVES

STRUCTURAL OR CRITICAL THEORY

5. CONSEQUENCES OF IMPLICIT BIASES

HEALTH DISPARITIES

CLINICAL DECISIONS AND PROVIDER-PATIENT INTERACTIONS

PATIENTS' PERCEPTIONS OF CARE

6. DEVELOPMENTAL MODEL TO RECOGNIZING AND REDUCING IMPLICIT BIAS

7. CREATING A SAFE ENVIRONMENT

8. STRATEGIES TO PROMOTE AWARENESS OF IMPLICIT BIAS

9. INTERVENTIONS TO REDUCE IMPLICIT BIASES

PERSPECTIVE TAKING

EMPATHY INTERVENTIONS

INDIVIDUATION

MINDFULNESS

COUNTER-STEREOTYPICAL IMAGING

EFFECTIVENESS OF IMPLICIT BIAS INTERVENTIONS

10. ROLE OF INTERPROFESSIONAL COLLABORATION AND PRACTICE AND IMPLICIT BIASES

11. CONCLUSION

12. RESOURCES

MINDFULNESS RESOURCES

Works Cited

57001 • Implicit Bias in Health Care

Education Category. Ethics - Human Rights

Release Date. 11/01/2024

Expiration Date. 10/31/2027

Course Overview

The role of implicit biases on healthcare outcomes has become a concern as some cite that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This course will explore definitions of implicit and explicit bias, the nature and dynamics of implicit biases, and how they can affect health outcomes. Because implicit biases are unconscious, strategies will be reviewed to assist in raising professionals' awareness of and interventions to reduce them.

Audience

This course is designed for dental professionals working in all practice settings.

Accreditations & Approvals

NetCE Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement. 10/1/2021 to 9/30/2027 Provider ID #217994. NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. NetCE is approved as a provider of continuing education by the Florida Board of Dentistry, Provider #50-2405. NetCE is a Registered Provider with the Dental Board of California. Provider Number RP3841. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type.

Designations of Credit

NetCE designates this activity for 3 continuing education credits. AGD Subject Code 558. This course meets the Dental Board of California's requirements for 3 unit(s) of continuing education. Dental Board of California course #03-3841-26439.

Course Objective

The purpose of this course is to provide dental professionals with an overview of the impact of implicit biases on clinical interactions and decision making.

Learning Objectives

Upon completion of this course, you should be able to:

1. Define implicit and explicit biases and related terminology.

2. Evaluate the strengths and limitations of the Implicit Association Test.

3. Describe how different theories explain the nature of implicit biases, and outline the consequences of implicit biases.

4. Discuss strategies to raise awareness of and mitigate or eliminate one's implicit biases.

Faculty

Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.

Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.

Faculty Disclosure

Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Mark J. Szarejko, DDS, FAGD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

In the 1990s, social psychologists Dr. Mahzarin Banaji and Dr. Tony Greenwald introduced the concept of implicit bias and developed the Implicit Association Test (IAT) as a measure. In 2003, the Institute of Medicine published the report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care highlighting the role of health professionals' implicit biases in the development of health disparities [1]. Today, some states have passed legislation requiring certain health professionals to take implicit bias training. This ultimately sends a message that biases, racial inequities, and disparities continue to exist in the healthcare system and should be addressed [39]. The phenomenon of implicit bias is premised on the assumption that while well-meaning individuals may deny prejudicial beliefs, these implicit biases negatively affect their clinical communications, interactions, and diagnostic and treatment decision-making [2,3].

One explanation is that implicit biases are a heuristic, or a cognitive or mental shortcut. Heuristics offer individuals general rules to apply to situations in which there is limited, conflicting, or unclear information. Use of a heuristic results in a quick judgment based on fragments of memory and knowledge, and therefore, the decisions made may be erroneous. If the thinking patterns are flawed, negative attitudes can reinforce stereotypes [4]. In health contexts, this is problematic because clinical judgments can be biased and adversely affect health outcomes. The Joint Commission provides the following example [3]:

A group of physicians congregate to examine a child's x-rays but has not been able to reach a diagnostic consensus. Another physician with no knowledge of the case is passing by, sees the x-rays, and says "Cystic fibrosis." The group of physicians was aware that the child is African American and had dismissed cystic fibrosis because it is less common among Black children than White children.

The purpose of this course is to provide health professionals an overview of implicit bias. This includes an exploration of definitions of implicit and explicit bias. The nature and dynamics of implicit biases and how they can affect health outcomes will be discussed. Finally, because implicit biases are unconscious, strategies will be reviewed to assist in raising professionals' awareness of and interventions to reduce them.

2. DEFINITIONS OF IMPLICIT BIAS AND OTHER TERMINOLOGIES

IMPLICIT VS. EXPLICIT BIAS

In a sociocultural context, biases are generally defined as negative evaluations of a particular social group relative to another group. Explicit biases are conscious, whereby an individual is fully aware of his/her attitudes and there may be intentional behaviors related to these attitudes [5,101]. These individuals are generally uninterested in changing their biases [102]. For example, an individual may openly endorse a belief that women are weak and men are strong. This bias is fully conscious and is made explicitly known. The individual's ideas may then be reflected in his/her work as a manager.

FitzGerald and Hurst assert that there are cases in which implicit cognitive processes are involved in biases and conscious availability, controllability, and mental resources are not [6]. The term "implicit bias" refers to the unconscious attitudes and evaluations held by individuals. These individuals do not necessarily endorse the bias, but the embedded beliefs/attitudes can negatively affect their behaviors [2,7,8,9,102]. They are automatically activated, and an individual may not even be aware that these biases affect their behaviors and communication patterns [101]. Some have asserted that the cognitive processes that dictate implicit and explicit biases are separate and independent [9].

Implicit biases can start as early as 3 years of age. As children age, they may begin to become more egalitarian in what they explicitly endorse, but their implicit biases may not necessarily change in accordance to these outward expressions [10]. Because implicit biases occur on the subconscious or unconscious level, particular social attributes (e.g., skin color) can quietly and insidiously affect perceptions and behaviors [11]. According to Georgetown University's National Center on Cultural Competency, social characteristics that can trigger implicit biases include [12]:

- Age

- Disability

- Education

- English language proficiency and fluency

- Ethnicity

- Health status

- Disease/diagnosis (e.g., HIV/AIDS)

- Insurance

- Obesity

- Race

- Socioeconomic status

- Sexual orientation, gender identity, or gender expression

- Skin tone

- Substance use

For example, studies have shown that implicit biases regarding pain experiences of Black patients and treatment adherence by patients with obesity continue to exist in health care. In one study, health professionals demonstrated less respect for patients with higher body mass index (BMI) [102]. These implicit biases affect how clinicians interact with patients, manage conditions, structure treatment protocols, and express empathy [103].

An alternative way of conceptualizing implicit bias is that an unconscious evaluation is only negative if it has further adverse consequences on a group that is already disadvantaged or produces inequities [6,13]. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages [13].

When the concept of implicit bias was introduced in the 1990s, it was thought that implicit biases could be directly linked to behavior. Despite the decades of empirical research, many questions, controversies, and debates remain about the dynamics and pathways of implicit biases [2].

OTHER COMMON TERMINOLOGIES

In addition to understanding implicit and explicit bias, there is additional terminology related to these concepts that requires specific definition.

Cultural Competence

Cultural competence is broadly defined as practitioners' knowledge of and ability to apply cultural information and appreciation of a different group's cultural and belief systems to their work [14]. It has also been defined as a process between the patient and practitioner based on how patients identify and respond to their experiences based on their worldviews and cultural values when they seek help and then receive care [104]. The acquisition of cultural competence is a dynamic process, meaning that there is no endpoint to the journey to becoming culturally aware, sensitive, and competent. Some have argued that cultural curiosity is a vital aspect of this approach.

Cultural Humility

Cultural humility refers to an attitude of humbleness, acknowledging one's limitations in the cultural knowledge of groups. Practitioners who apply cultural humility readily concede that they are not experts in others' cultures and that there are aspects of culture and social experiences that they do not know. From this perspective, patients are considered teachers of the cultural norms, beliefs, and value systems of their group, while practitioners are the learners [15]. Cultural humility is a lifelong process involving reflexivity, self-evaluation, and self-critique [16]. Experts have identified five attributes of cultural humility: openness, self-awareness, egoless, supportive interaction, and self-reflection and critique [105].

Discrimination

Discrimination has traditionally been viewed as the outcome of prejudice [17]. It encompasses overt or hidden actions, behaviors, or practices of members in a dominant group against members of a subordinate group [18,106]. Discrimination has also been further categorized as lifetime discrimination, which consists of major discreet discriminatory events, or everyday discrimination, which is subtle, continual, and part of day-to-day life and can have a cumulate effect on individuals [19].

Diversity

Diversity "encompasses differences in and among societal groups based on race, ethnicity, gender, age, physical/mental abilities, religion, sexual orientation, and other distinguishing characteristics" [20]. Diversity is often conceptualized into singular dimensions as opposed to multiple and intersecting diversity factors [21].

Intersectionality

Intersectionality is a term to describe the multiple facets of identity, including race, gender, sexual orientation, religion, sex, and age. These facets are not mutually exclusive, and the meanings that are ascribed to these identities are inter-related and interact to create a whole [22].

Prejudice

Prejudice is a generally negative feeling, attitude, or stereotype against members of a group [23]. It is important not to equate prejudice and racism, although the two concepts are related. All humans have prejudices, but not all individuals are racist. The popular definition is that "prejudice plus power equals racism" [23]. Prejudice stems from the process of ascribing every member of a group with the same attribute [24].

Race

Race is linked to biology. Race is partially defined by physical markers (e.g., skin or hair color) and is generally used as a mechanism for classification [25]. It does not refer to cultural institutions or patterns. In modern history, skin color has been used to classify people and to imply that there are distinct biologic differences within human populations [26]. Historically, the U.S. Census has defined race according to ancestry and blood quantum; today, it is based on self-classification [26].

There are scholars who assert that race is socially constructed without any biological component [27]. For example, racial characteristics are also assigned based on differential power and privilege, lending to different statuses among groups [28].

Stereotype

A stereotype is a general association of particular attributes or characteristics to a collective or social group [106]. Positive and negative stereotypes exist related to most individual attributes.

Racism

Racism is the "systematic subordination of members of targeted racial groups who have relatively little social power…by members of the agent racial group who have relatively more social power" [29]. Racism is perpetuated and reinforced by social values, norms, and institutions.

There is some controversy regarding whether unconscious (implicit) racism exists. Experts assert that images embedded in our unconscious are the result of socialization and personal observations, and negative attributes may be unconsciously applied to racial minority groups [30]. These implicit attributes affect individuals' thoughts and behaviors without a conscious awareness.

Structural racism refers to the laws, policies, and institutional norms and ideologies that systematically reinforce inequities resulting in differential access to services such as health care, education, employment, and housing for racial and ethnic minorities [31,32].

3. MEASUREMENT OF IMPLICIT BIAS: A FOCUS ON THE IAT

Project Implicit is a research project sponsored by Harvard University and devoted to the study and monitoring of implicit biases. It houses the Implicit Association Test (IAT), which is one of the most widely utilized standardized instruments to measure implicit biases. The IAT is based on the premise that implicit bias is an objective and discreet phenomenon that can be measured in a quantitative manner. Developed and first introduced in 1998, it is an online test that assesses implicit bias by measuring how quickly people make associations between targeted categories with a list of adjectives [33]. For example, research participants might be assessed for their implicit biases by seeing how rapidly they make evaluations among the two groups/categories career/family and male/female. Participants tend to more easily affiliate terms for which they hold implicit or explicit biases. So, unconscious biases are measured by how quickly research participants respond to stereotypical pairings (e.g., career/male and family/female). The larger the difference between the individual's performance between the two groups, the stronger the degree of bias [34; 35; 107]. Since 2006, more than 4.6 million individuals have taken the IAT, and results indicate that the general population holds implicit biases [3]. By late 2023, more than 80 million study sessions had been conducted and more than 40 million IATs completed at the Project Implicit website [107].

Interactive Activity

Visit https://implicit.harvard.edu/implicit and complete an assessment.

Measuring implicit bias is complex, because it requires an instrument that is able to access underlying unconscious processes. While many of the studies on implicit biases have employed the IAT, there are other measures available. They fall into three general categories: the IAT and its variants, priming methods, and miscellaneous measures, such as self-report, role-playing, and computer mouse movements [36]. This course will focus on the IAT, as it is the most commonly employed instrument. It is also important to note that the IAT is more a procedure and less a discrete measurement, because there is not a single IAT. Instead, each specific dimension (e.g., race, gender, age, disability) has its own set of items. After completing the IAT, respondents are provided with results regarding their measured preference such as: "Your responses suggested a strong automatic preference for White people over Black people" [108]. The key term here is "preferences," which does not necessarily mean implicit bias or negativity.

The IAT is not without controversy. One of the debates involves whether IAT scores focus on a cognitive state or if they reflect a personality trait. If it is the latter, the IAT's value as a diagnostic screening tool is diminished [37]. There is also concern with its validity in specific arenas, including jury selection and hiring [37]. Some also maintain that the IAT is sensitive to social context and may not accurately predict behavior [37]. Essentially, a high IAT score reflecting implicit biases does not necessarily link to discriminating behaviors, and correlation should not imply causation. A meta-analysis involving 87,418 research participants found no evidence that changes in implicit biases affected explicit behaviors [38].

EXTENT OF IMPLICIT BIASES AND RISK FACTORS

Among the more than 40 million participants who have completed the IAT at the Project Implicit website, individuals generally exhibited implicit preference for White faces over Black or Asian faces. In addition, there is a general preference for heterosexual people over gay individuals, young over old individuals, thin over obese people, and cisgender over gender and sexual minorities (LGBTQ+) [107]. The Pew Research Center also conducted an exploratory study on implicit biases, focusing on the extent to which individuals adhered to implicit racial biases [40]. A total of 2,517 IATs were completed and used for the analysis. Almost 75% of the respondents exhibited some level of implicit racial biases. Only 20% to 30% did not exhibit or showed very little implicit bias against the minority racial groups tested. Approximately half of all single-race White individuals displayed an implicit preference for White faces over Black faces. For single-race Black individuals, 45% had implicit preference for their own group. For biracial White/Black adults, 23% were neutral. In addition, 22% of biracial White/Asian participants had no or minimal implicit racial biases. However, 42% of the White/Black biracial adults leaned toward a pro-White bias.

In another interesting field experiment, although not specifically examining implicit bias, resumes with names commonly associated with African American or White candidates were submitted to hiring officers [41]. Researchers found that resumes with White-sounding names were 50% more likely to receive callbacks than resumes with African American-sounding names [41]. The underlying causes of this gap were not explored.

Implicit bias related to sex and gender is also significant. A survey of emergency medicine and obstetrics/gynecology residency programs in the United States sought to examine the relationship between biases related to perceptions of leadership and gender [42]. In general, residents in both programs (regardless of gender) tended to favor men as leaders. Male residents had greater implicit biases compared with their female counterparts. In a scoping review of studies around the world, researchers identified 87 studies that assessed unconscious biases among healthcare professionals [109]. Racial implicit biases were most frequently studied. Physicians and nurses were included in the majority of the studies. Analysis of the included studies indicates that implicit biases remain prevalent among healthcare providers.

Other forms of implicit bias can affect the provision of health and mental health care. One online survey examining anti-fat biases was provided to 4,732 first-year medical students [43]. Respondents completed the IAT, two measures of explicit bias, and an anti-fat attitudes instrument. Nearly 75% of the respondents were found to hold implicit anti-fat biases. Interestingly, these biases were comparable to the scope of implicit racial biases. Male sex, non-Black race, and lower BMI predicted holding these implicit biases.

Certain conditions or environmental risk factors are associated with an increased risk for certain implicit biases, including [44,45,106]:

- Stressful emotional states (e.g., anger, frustration)

- Uncertainty

- Low-effort cognitive processing

- Time pressure

- Lack of feedback

- Feeling behind with work

- High patient caseload

- Lack of guidance

- Long hours

- Patient overcrowding

- High-crises environments

- Mentally taxing tasks

- High cognitive load

- Juggling competing tasks

4. THEORETIC EXPLANATIONS AND CONTROVERSIES

A variety of theoretical frameworks have been used to explore the causes, nature, and dynamics of implicit biases. Each of the theories is described in depth, with space given to explore controversies and debates about the etiology of implicit bias.

SOCIAL PSYCHOLOGICAL AND COGNITIVE THEORETICAL FRAMEWORKS

One of the main goals of social psychology is to understand how attitudes and belief structures influence behaviors. Based on frameworks from both social and cognitive psychology, many theoretical frameworks used to explain implicit bias revolve around the concept of social cognition. One branch of cognitive theory focuses on the role of implicit or nondeclarative memory. Experts believe that this type of memory allows certain behaviors to be performed with very little conscious awareness or active thought. Examples include tooth brushing, tying shoelaces, and even driving. To take this concept one step farther, implicit memories may also underlie social attitudes and stereotype attributions [46]. This is referred to as implicit social cognition. From this perspective, implicit biases are automatic expressions based on belonging to certain social groups [47]. The IAT is premised on the role of implicit memory and past experiences in predicting behavior without explicit memory triggering [48].

Another branch of cognitive theory used to describe implicit biases involves heuristics. When quick decisions are required under conditions of uncertainty or fatigue, and/or when there is a tremendous amount of information to assimilate without sufficient time to process, decision-makers resort to heuristics [49]. Heuristics are essentially mental short cuts that facilitate (usually unconscious) rules that promote automatic processing [50]. However, these rules can also be influenced by socialization factors, which could then affect any unconscious or latent cognitive associations about power, advantage, and privilege. Family, friends, media, school, religion, and other social institutions all play a role in developing and perpetuating implicit and explicit stereotypes, and cognitive evaluations can be primed or triggered by an environmental cue or experience [51]. When a heuristic is activated, an implicit memory or bias may be triggered simultaneously [47]. This is also known as the dual-process model of information processing [50].

BEHAVIORAL OR FUNCTIONAL PERSPECTIVES

Behavioral or functional theorists argue that implicit bias is not necessarily a latent or unconscious cognitive structure. Instead, this perspective recognizes implicit bias as a group-based behavior [52]. Behavior is biased if it is influenced by social cues indicating the social group to which someone belongs [52]. Social cues can occur rapidly and unintentionally, which ultimately leads to automatic or implicit effects on behavior. The appeal of a behavioral or functional approach to implicit bias is that it is amoral; that is, it is value- and judgment-free [52]. Rather than viewing implicit bias as an invisible force (i.e., unconscious cognitive structure), it is considered a normal behavior [53].

NEUROSCIENTIFIC PERSPECTIVES

Implicit bias has neuroscientific roots as well and has been linked to functions of the amygdala [2,54]. The amygdala is located in the temporal lobe of the brain, and it communicates with the hypothalamus and plays a large role in memory. When situations are emotionally charged, the amygdala is activated and connects the event to memory, which is why individuals tend to have better recall of emotional events. This area of the brain is also implicated in processing fear. Neuroscientific studies on implicit biases typically use functional magnetic resonance imaging (fMRI) to visualize amygdala activation during specific behaviors or events. In experimental studies, when White research subjects were shown photos of Black faces, their amygdala appeared to be more activated compared to when they viewed White faces [55]. This trend toward greater activation when exposed to view the faces of persons whose race differs from the viewer starts in adolescence and appears to increase with age [54]. This speaks to the role of socialization in the developmental process [54].

It may be that the activation of the amygdala is an evolutionary threat response to an outgroup [56]. Another potential explanation is that the activation of the amygdala is due to the fear of appearing prejudiced to others who will disapprove of the bias [56]. The neuroscientific perspective of implicit bias is controversial. While initial empirical studies appear to link implicit bias to amygdala activation, many researchers argue this relationship is too simplistic [2].

STRUCTURAL OR CRITICAL THEORY

Many scholars and policymakers are concerned about the narrow theoretical views that researchers of implicit bias have taken. By focusing on unconscious cognitive structures, social cognition and neuroscientific theories miss the opportunity to also address the role of macro or systemic factors in contributing to health inequities [9,57,106]. By focusing on the neurobiology of implicit bias, for example, racism and bias is attributed to central nervous system function, releasing the individual from any control or responsibility. However, the historical legacy of prejudice and bias has roots in economic and structural issues that produce inequities [58,106]. Larger organizational, institutional, societal, and cultural forces contribute, perpetuate, and reinforce implicit and explicit biases, racism, and discrimination. Psychological and neuroscientific approaches ultimately decontextualize racism [9,57].

In response to this conflict, a systems-based practice has been proposed [59]. This type of practice emphasizes the role of sociocultural determinants of health outcome and the fact that health inequities stem from larger systemic forces. As a result, medical and health education and training should focus on how patients' health and well-being may reflect structural vulnerabilities driven in large part by social, cultural, economic, and institutional forces. Health and mental health professionals also require social change and advocacy skills to ensure that they can effect change at the organizational and institutional levels [59].

Implicit bias is not a new topic; it has been discussed and studied for decades in the empirical literature. Because implicit bias is a complex and multifaceted phenomenon, it is important to recognize that there may be no one single theory that can fully explain its etiology.

5. CONSEQUENCES OF IMPLICIT BIASES

HEALTH DISPARITIES

Implicit bias has been linked to a variety of health disparities [1]. Health disparities are differences in health status or disease that systematically and adversely affect less advantaged groups [60]. These inequities are often linked to historical and current unequal distribution of resources due to poverty, structural inequities, insufficient access to health care, and/or environmental barriers and threats [61]. Healthy People 2030 defines a health disparity as [62]:

…a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.

As noted, in 2003, the Institute of Medicine implicated implicit bias in the development and continued health disparities in the United States [1]. Despite progress made to lessen the gaps among different groups, health disparities continue to exist. One example is racial disparities in life expectancy among Black and White individuals in the United States. Life expectancy for Black men is 4.4 years lower than White men; for Black women, it is 2.9 years lower compared with White women [63]. Hypertension, diabetes, and obesity are more prevalent in non-Hispanic Black populations compared with non-Hispanic White groups (25%, 49%, and 59% higher, respectively) [64]. In one study, African American and Latina women were more likely to experience cesarean deliveries than their White counterparts, even after controlling for medically necessary procedures [65]. This places African American and Latina women at greater risk of infection and maternal mortality.

One of the most salient statistics that highlights racial health disparities is in maternal morbidity and mortality rates. In the United States, Black patients are 212% more likely than White patients to die from pregnancy- or childbirth-related causes [110]. In addition, during the COVID-19 pandemic, evidence of racial health disparities was widespread. People of color were hospitalized for COVID at 4.7 to 5.3 times the rate of White Americans [110].

Gender health disparities have also been demonstrated. Generally, self-rated physical health (considered one of the best proxies to health) is poorer among women than men. Depression is also more common among women than men [66]. Lesbian and bisexual women report higher rates of depression and are more likely than non-gay women to engage risk behaviors such as smoking and binge drinking, perhaps as a result of LGBTQ+-related stressors. They are also less likely to access healthcare services [67].

Socioeconomic status also affects health care engagement and quality. In a study of patients seeking treatment for thoracic trauma, those without insurance were 1.9 times more likely to die compared with those with private insurance [68].

CLINICAL DECISIONS AND PROVIDER-PATIENT INTERACTIONS

In an ideal situation, health professionals would be explicitly and implicitly objective and clinical decisions would be completely free of bias. However, healthcare providers have implicit (and explicit) biases at a rate comparable to that of the general population [6,69]. It is possible that these implicit biases shape healthcare professionals' behaviors, communications, and interactions, which may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions [69]. For example, physicians have been shown to minimize Black patients' pain, ignore their complaints, and spend less time in examination rooms with them [111]. In a 2021 study, physicians were more likely to expect Black patients would not adhere to an HIV pre-exposure prophylaxis medication compared with White patients [112]. As a result, physicians were less likely to discuss available regimens with Black patients.

They may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up [7]. The adverse consequences of implicit biases between patients and practitioners emerge in the following areas [106]:

- Communication

- Relationship

- Patient satisfaction and patient's view toward provider's patient-centeredness

- Treatment adherence and practitioners' views of patient's likelihood to adhere to treatment

- Practitioners' clinical decision-making

In a landmark 2007 study, a total of 287 internal medicine physicians and medical residents were randomized to receive a case vignette of an either Black or White patient with coronary artery disease [70]. All participants were also administered the IAT. When asked about perceived level of cooperativeness of the White or Black patient from the vignette, there were no differences in their explicit statements regarding cooperativeness. Yet, the IAT scores did show differences, with scores showing that physicians and residents had implicit preferences for the White patients. Participants with greater implicit preference for White patients (as reflected by IAT score) were more likely to select thrombolysis to treat the White patient than the Black patient [70]. This led to the possible conclusion that implicit racial bias can influence clinical decisions regarding treatment and may contribute to racial health disparities. However, some argue that using vignettes depicting hypothetical situations does not accurately reflect real-life conditions that require rapid decision-making under stress and uncertainty.

PATIENTS' PERCEPTIONS OF CARE

It has been hypothesized that providers' levels of bias affect the ratings of patient-centered care [34]. Patient-centered care has been defined as patients' positive ratings in the areas of perception of provider concern, provider answering patients' questions, provider integrity, and provider knowledge of the patient. Using data from 134 health providers who completed the IAT, a total of 2,908 diverse racial and ethnic minority patients participated in a telephone survey. Researchers found that for providers who scored high on levels of implicit bias, African American patients' ratings for all dimensions of patient-centered care were low compared with their White patient counterparts. Latinx patient ratings were low regardless of level of implicit bias.

A 2013 study recorded clinical interactions between 112 low-income African American patients and their 14 non-African American physicians for approximately two years [71]. Providers' implicit biases were also assessed using the IAT. In general, the physicians talked more than the patients; however, physicians with higher implicit bias scores also had a higher ratio of physician-to-patient talk time. Patients with higher levels of perceived discrimination had a lower ratio of physician-to-patient talk time (i.e., spoke more than those with lower reported perceived discrimination). A lower ratio of physician-patient talk time correlated to decreased likelihood of adherence.

Another study assessed 40 primary care physicians and 269 patients [72]. The IAT was administered to both groups, and their interactions were recorded and observed for verbal dominance (defined as the time of physician participation relative to patient participation). When physicians scored higher on measures of implicit bias, there was 9% more verbal dominance on the part of the physicians in the visits with Black patients and 11% greater in interactions with White patients. Physicians with higher implicit bias scores and lower verbal dominance also received lower scores on patient ratings on interpersonal care, particularly from Black patients [72].

In focus groups with racially and ethnically diverse patients who sought medical care for themselves or their children in New York City, participants reported perceptions of discrimination in health care [73]. They reported that healthcare professionals often made them feel less than human, with varying amounts of respect and courtesy. Some observed differences in treatment compared with White patients. One Black woman reported [73]:

When the doctor came in [after a surgery], she proceeded to show me how I had to get up because I'm being released that day "whether I like it or not"…She yanked the first snap on the left leg…So I'm thinking, 'I'm human!' And she was courteous to the White lady [in the next bed], and I've got just as much age as her. I qualify on the level and scale of human being as her, but I didn't feel that from the doctor.

Another participant was a Latino physician who presented to the emergency department. He described the following [73]:

They put me sort of in the corner [in the emergency department] and I can't talk very well because I can't breathe so well. The nurse comes over to me and actually says, "Tu tiene tu Medicaid?" I whispered out, "I'm a doctor…and I have insurance." I said it in perfect English. Literally, the color on her face went completely white…Within two minutes there was an orthopedic team around me…I kept wondering about what if I hadn't been a doctor, you know? Pretty eye opening and very sad.

These reports are illustrative of many minority patients' experiences with implicit and explicit racial/ethnic biases. Not surprisingly, these biases adversely affect patients' views of their clinical interactions with providers and ultimately contribute to their mistrust of the healthcare system.

6. DEVELOPMENTAL MODEL TO RECOGNIZING AND REDUCING IMPLICIT BIAS

There are no easy answers to raising awareness and reducing health providers' implicit bias. Each provider may be in a different developmental stage in terms of awareness, understanding, acceptance, and application of implicit bias to their practice. A developmental model for intercultural sensitivity training has been established to help identify where individuals may be in this developmental journey [74,75]. It is important to recognize that the process of becoming more self-aware is fluid; reaching one stage does not necessarily mean that it is "conquered" or that there will not be additional work to do in that stage. As a dynamic process, it is possible to move back and forth as stress and uncertainty triggers implicit biases [74]. This developmental model includes six stages:

- Denial: In this stage, the individual has no awareness of the existence of cultural differences between oneself and members of other cultural groups and subgroups. Individuals in this stage have no awareness of implicit bias and cannot distinguish between explicit and implicit biases.

- Defense: In this stage, the person may accept that implicit biases exist but does not acknowledge that implicit biases exist within themselves.

- Minimization: An individual in this stage acknowledges that implicit biases may exist in their colleagues and possibly themselves. However, he or she is uncertain of their consequences and adverse effects. Furthermore, the person believes he or she is able to treat patients in an objective manner.

- Acceptance: In the acceptance stage, the individual recognizes and acknowledges the role of implicit biases and how implicit biases influence interactions with patients.

- Adaptation: Those in the adaptation stage self-reflect and acknowledge that they have unrecognized implicit biases. Not only is there an acknowledgement of the existence of implicit bias, these people begin to actively work to reduce the potential impact of implicit biases on interactions with patients.

- Integration: At this stage, the health professional works to incorporate change in their day-to-day practice in order to mitigate the effects of their implicit biases on various levels—from the patient level to the organization level.

7. CREATING A SAFE ENVIRONMENT

Creating a safe environment is the essential first step to exploring issues related to implicit bias. Discussions of race, stereotypes, privilege, and implicit bias, all of which are very complex, can be volatile or produce heightened emotions. When individuals do not feel their voices are heard and/or valued, negative emotions or a "fight-or-flight" response can be triggered [76]. This may manifest as yelling, demonstrations of anger, or crying or leaving the room or withdrawing and remaining silent [76]. Some experts have recommended an exercise involving index cards on which "honest inquiry" is written on one side and "honest response" is written on the other [113]. Learners can then hold up the side of the index card to facilitate questions and seek responses from everyone.

Creating and fostering a sense of psychological safety in the learning environment is crucial. Psychological safety results when individuals feel that their opinions, views, thoughts, and contributions are valued despite tension, conflict, and discomfort. This allows the individual to feel that their identity is intact [76]. When psychological safety is threatened, individuals' energies are primarily expended on coping rather than learning [76]. As such, interventions should not seek to confront individuals or make them feel guilty and/or responsible [77].

When implicit bias interventions or assessments are planned, facilitators should be open, approachable, non-threatening, and knowledgeable; this will help create a safe and inclusive learning environment [77]. The principles of respect, integrity, and confidentiality should be communicated [77]. Facilitators who demonstrate attunement, authenticity, and power-sharing foster positive and productive dialogues about subjects such as race and identity [76]. Attunement is the capacity of an individual to tacitly comprehend the lived experiences of others, using their perspectives to provide an alternative viewpoint for others. Attunement does not involve requiring others to talk about their experiences if they are not emotionally ready [76]. Authenticity involves being honest and transparent with one's own position in a racialized social structure and sharing one's own experiences, feelings, and views. Being authentic also means being vulnerable [76]. Finally, power-sharing entails redistributing power in the learning environment. The education environment is typically hierarchical, with an expert holding more power than students or participants. Furthermore, other students may hold more power by virtue of being more comfortable speaking/interacting [76]. Ultimately, promoting a safe space lays a foundation for safely and effectively implementing implicit bias awareness and reduction interventions.

8. STRATEGIES TO PROMOTE AWARENESS OF IMPLICIT BIAS

As discussed, the IAT can be used as a metric to assess professionals' level of implicit bias on a variety of subjects, and this presupposes that implicit bias is a discrete phenomenon that can be measured quantitatively [79]. When providers are aware that implicit biases exist, discussion and education can be implemented to help reduce them and/or their impact.

Another way of facilitating awareness of providers' implicit bias is to ask self-reflective questions about each interaction with patients. Some have suggested using SOAP (subjective, objective, assessment, and plan) notes to assist practitioners in identifying implicit biases in day-to-day interactions with patients [80]. Integrating the following questions into charts and notes can stimulate reflection about implicit bias globally and for each specific patient interaction:

- Did I think about any socioeconomic and/or environmental factors that may contribute to the health and access of this patient?

- How was my communication and interaction with this patient? Did it change from my customary pattern?

- How could my implicit biases influence care for this patient?

When reviewing the SOAP notes, providers can look for recurring themes of stereotypical perceptions, biased communication patterns, and/or types of treatment/interventions proposed and assess whether these themes could be influenced by biases related to race, ethnicity, age, gender, sexuality, or other social characteristics.

Experts have also formulated questions for each of the three stages of reflection to help increase awareness when guiding nursing students through learning about implicit biases [114,115]:

- Awareness: Recall a patient who you considered challenging, difficult, or uncomfortable to be around.

- Critical analysis: Do I or did I have an automatic feeling or judgment about this person? Am I being reminded of someone? What is this person triggering in my background?

- New perspective: How might I consciously intervene to mitigate the impact of this bias? What can I do differently when similar thoughts, feelings, or emotions arise?

A review of empirical studies conducted on the effectiveness of interventions promoting implicit bias awareness found mixed results. At times, after a peer discussion of IAT scores, participants appeared less interested in learning and employing implicit bias reduction interventions. However, other studies have found that receiving feedback along with IAT scores resulted in a reduction in implicit bias [81]. Any feedback, education, and discussions should be structured to minimize participant defensiveness [81].

9. INTERVENTIONS TO REDUCE IMPLICIT BIASES

Interventions or strategies designed to reduce implicit bias may be further categorized as change-based or control-based [58]. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors [58]. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically. In a similar vein, interventions targeted on implicit biases may be categorized as either those that "de-bias" or neutralize or that raise awareness [116].

PERSPECTIVE TAKING

Perspective taking is a strategy of taking on a first-person perspective of a person in order to control one's automatic response toward individuals with certain social characteristics that might trigger implicit biases [82; 117]. The goal is to increase psychological closeness and empathy, anticipate others' feelings and reactions, and facilitate connection with members of the group [4; 117]. Engaging with media that presents a perspective (e.g., watching documentaries, reading an autobiography) can help promote better understanding of the specific group's lives, experiences, and viewpoints. In one study, participants who adopted the first-person perspectives of African Americans had more positive automatic evaluations of the targeted group [83]. However, one of the critiques to perspective taking is that instead of highlighting similarities, differences can be emphasized and could result in reinforced stereotypes [117].

Interactive Activity

Consuming media that presents a viewpoint and life experience different from your own can help minimize implicit biases. Visit the following sites and consider how they might challenge or expand your perception of each group. Internet searches can help identify many more options for various social groups.

Think Out Loud Podcast

Young Black people share their experiences growing up in Portland, Oregon.

https://www.opb.org/article/2020/10/30/young-black-people-share-their-experiences-growing-up-in-portland

George Takei: Growing Up Asian-American

This PBS clip is a brief introduction, and the subject can be further explored in Takei's book They Called Us Enemy.

https://www.pbs.org/wnet/pioneers-of-television/video/george-takei-growing-up-asian-american

Seattle Public Library LGBTQ Staff Picks

A reading list including books and films focusing on LGBTQ+ life, culture, history, and politics.

https://www.spl.org/programs-and-services/social-justice/lgbtq/lgbt-staff-picks

EMPATHY INTERVENTIONS

Promoting positive emotions such as empathy and compassion can help reduce implicit biases. This can involve strategies like perspective taking and role playing [77]. In a study examining analgesic prescription disparities, nurses were shown photos of White or African American patients exhibiting pain and were asked to recommend how much pain medication was needed; a control group was not shown photos. Those who were shown images of patients in pain displayed no differences in recommended dosage along racial lines; however, those who did not see the images averaged higher recommended dosages for White patients compared with Black patients [84]. This suggests that professionals' level of empathy (enhanced by seeing the patient in pain) affected prescription recommendations.

In a study of healthcare professionals randomly assigned to an empathy-inducing group or a control group, participants were given the IAT to measure implicit bias prior to and following the intervention. Level of implicit bias among participants in the empathy-inducing group decreased significantly compared with their control group counterparts [85].

INDIVIDUATION

Individuation is an implicit bias reduction intervention that involves obtaining specific information about the individual and relying on personal characteristics instead of stereotypes of the group to which he or she belongs [4,82]. The key is to concentrate on the person's specific and unique experiences, achievements, personality traits, qualifications, and other personal attributes rather than focusing on gender, race, ethnicity, age, ability, and other social attributes, all of which can activate implicit biases [118]. Teaching individuals to pause and take time to ask questions instead of relying on assumptions is vital [118]. When providers lack relevant information, they are more likely to fill in data with stereotypes, in some cases unconsciously. Time constraints and job stress increase the likelihood of this occurring [69].

MINDFULNESS

Mindfulness requires stopping oneself and deliberately emptying one's mind of distractions or allowing distractions to drift through one's mind unimpeded, focusing only on the moment; judgment and assumptions are set aside. This approach involves regulating one's emotions, responses, and attention to return to the present moment, which can reduce stress and anxiety [86]. There is evidence that mindfulness can help regulate biological and emotional responses and can have a positive effect on attention and habit formation [4]. A mindfulness activity assists individuals to be more aware of their thoughts and sensations. This focus on deliberation moves the practitioner away from a reliance on instincts, which is the foundation of implicit bias-affected practice [4,87]. Research indicates that there are two main types of mindfulness practice [119]. The first is general mindful practice, which includes interventions that promote awareness to the individual in the present moment through current body sensation and emotional states. The second type is loving-kindness meditation, which entails individuals thinking of another person (from out-group or in-group) and sending love to them and to the self. The goal of this type of practice is to promote empathy and compassion to another person or persons.

Mindfulness approaches include yoga, meditation, and guided imagery. Additional resources to encourage a mindfulness practice are provided later in this course.

An approach to mindfulness using the acronym STOPP has been developed as a practical exercise to engage in mindfulness in any moment. STOPP is an acronym for [88]:

- Stop

- Take a breath

- Observe

- Pull back

- Practice

Interactive Activity

Visit the following website to view a short, animated video on the STOPP technique. After viewing the video, consider how you can incorporate the technique into your work.

https://www.youtube.com/watch?v=tStXi7f7Vgk

Mindfulness practice has been explored as a technique to reduce activation or triggering of implicit bias, enhance awareness of and ability to control implicit biases that arise, and increase capacity for compassion and empathy toward patients by reducing stress, exhaustion, and compassion fatigue [89]. One study examined the effectiveness of a loving-kindness meditation practice training in improving implicit bias toward African Americans and unhoused persons. One hundred one non-Black adults were randomized to one of three groups: a six-week loving-kindness mindfulness practice, a six-week loving-kindness discussion, or the waitlist control. The IAT was used to measure implicit biases, and the results showed that the loving-kindness meditation practice decreased levels of implicit biases toward both groups [90].

There is also some novel evidence that mindfulness may have neurologic implications. For example, one study showed decreased amygdala activation after a mindfulness meditation [91]. However, additional studies are required in this area before conclusions can be reached.

COUNTER-STEREOTYPICAL IMAGING

Counter-stereotypical imaging approaches involve presenting an image, idea, or construct that is counter to the oversimplified stereotypes typically held regarding members of a specific group [120]. In one study, participants were asked to imagine either a strong woman (the experimental condition) or a gender-neutral event (the control condition) [92]. Researchers found that participants in the experimental condition exhibited lower levels of implicit gender bias. Similarly, exposure to female leaders was found to reduce implicit gender bias [93]. Whether via increased contact with stigmatized groups to contradict prevailing stereotypes or simply exposure to counter-stereotypical imaging, it is possible to unlearn associations underlying various implicit biases. If the social environment is important in priming positive evaluations, having more positive visual images of members in stigmatized groups can help reduce implicit biases [94]. Inviting speakers whose demographic background is different from staff or other invited presenters is also a good practice [120]. Some have suggested that even just hanging photos and having computer screensavers reflecting positive images of various social groups could help to reduce negative associations [94].

EFFECTIVENESS OF IMPLICIT BIAS INTERVENTIONS

The effectiveness of implicit bias trainings and interventions has been scrutinized. In a 2019 systematic review, different types of implicit bias reduction interventions were evaluated. A meta-analysis of empirical studies published between May 2005 and April 2015 identified eight different classifications of interventions [13]:

- Engaging with others' perspectives, consciousness-raising, or imagining contact with outgroup: Participants either imagine how the outgroup thinks and feels, imagine having contact with the outgroup, or are made aware of the way the outgroup is marginalized or given new information about the outgroup.

- Identifying the self with the outgroup: Participants perform tasks that lessen barriers between themselves and the outgroup.

- Exposure to counter-stereotypical exemplars: Participants are exposed to exemplars that contradict negative stereotypes of the outgroup.

- Appeal to egalitarian values: Participants are encouraged to activate egalitarian goals or think about multiculturalism, cooperation, or tolerance.

- Evaluative conditioning: Participants perform tasks to strengthen counter-stereotypical associations.

- Inducing emotion: Emotions or moods are induced in participants.

- Intentional strategies to overcome biases: Participants are instructed to implement strategies to over-ride or suppress their biases.

- Pharmacotherapy

Interventions found to be the most effective were, in order from most to least, [13]:

- Intentional strategies to overcome biases

- Exposure to counter-stereotypical exemplars

- Identifying self with the outgroup

- Evaluative conditioning

- Inducing emotions

For implicit bias interventions to be effective, they must be grounded in social psychological theories and incorporate perspective taking, building partnerships, and emotional regulation (e.g., mindfulness) to help reduce stress [39].

In general, the sample sizes were small. It is also unclear how generalizable the findings are, given many of the research participants were college psychology students. The 30 studies included in the meta-analysis were cross-sectional (not longitudinal) and only measured short-term outcomes, and there is some concern about "one shot" interventions, given the fact that implicit biases are deeply embedded. Would simply acknowledging the existence of implicit biases be sufficient to eliminate them [95,96]? Or would such a confession act as an illusion to having self-actualized and moved beyond the bias [95]? Others have questioned the effectiveness interventions to reduce implicit biases on a long-term basis and suggest that institutional strategies to identify and address biases may be more effective [121]. One example is the University of Washington's School of Medicine's online reporting mechanism, which allows individuals who are either third-party observers or who are targets to report issues. When necessary, follow-up to reported incidents are conducted by human resources.

Optimally, implicit bias interventions involve continual practice to address deeply habitual implicit biases or interventions that target structural factors [95,96].

10. ROLE OF INTERPROFESSIONAL COLLABORATION AND PRACTICE AND IMPLICIT BIASES

The study of implicit bias is appropriately interdisciplinary, representing social psychology, medicine, health psychology, neuroscience, counseling, mental health, gerontology, LGBTQ+ studies, religious studies, and disability studies [13]. Therefore, implicit bias empirical research and curricula training development lends itself well to interprofessional collaboration and practice (ICP).

One of the core features of ICP is sharing—professionals from different disciplines share their philosophies, values, perspectives, data, and strategies for planning of interventions [97]. ICP also involves the sharing of roles, responsibilities, decision making, and power [98]. Everyone on the team employs their expertise, knowledge, and skills, working collectively on a shared, patient-centered goal or outcome [98,99].

Another feature of ICP is interdependency. Instead of working in an autonomous manner, each team member's contributions are valued and maximized, which ultimately leads to synergy [97]. At the heart of this are two other key features: mutual trust/respect and communication [99]. In order to share responsibilities, the differing roles and expertise are respected.

ICP is a powerful tool to mitigate implicit biases. The inherent characteristics of ICP—enhanced communications, trust, and shared decision making—should help reduce implicit biases in the team. At the heart of ICP is also the promotion of equity, which builds in accountability and can facilitate learning about and increased awareness of members' implicit biases [122].

Experts have recommended that a structural or critical theoretical perspective be integrated into core competencies in healthcare education to teach students about implicit bias, racism, and health disparities [100]. This includes [100]:

- Values/ethics: The ethical duty for health professionals to partner and collaborate to advocate for the elimination of policies that promote the perpetuation of implicit bias, racism, and health disparities among marginalized populations.

- Roles/responsibilities: One of the primary roles and responsibilities of health professionals is to analyze how institutional and organizational factors promote racism and implicit bias and how these factors contribute to health disparities. This analysis should extend to include one's own position in this structure.

- Interprofessional communication: Ongoing discussions of implicit bias, perspective taking, and counter-stereotypical dialogues should be woven into day-to-day practice with colleagues from diverse disciplines.

- Teams/teamwork: Health professionals should develop meaningful contacts with marginalized communities in order to better understand whom they are serving.

Adopting approaches from the fields of education, gender studies, sociology, psychology, and race/ethnic studies can help build curricula that represent a variety of disciplines [78]. Students can learn about and discuss implicit bias and its impact, not simply from a health outcomes perspective but holistically. Skills in problem-solving, communication, leadership, and teamwork should be included, so students can effect positive social change [78].

11. CONCLUSION

In the more than three decades since the introduction of the IAT, the implicit bias knowledge base has grown significantly. It is clear that most people in the general population hold implicit biases, and health professionals are no different. While there continue to be controversies regarding the nature, dynamics, and etiology of implicit biases, it should not be ignored as a contributor to health disparities, patient dissatisfaction, and suboptimal care. Given the complex and multifaceted nature of this phenomenon, the solutions to raise individuals' awareness and reduce implicit bias are diverse and evolving.

12. RESOURCES

American Bar Association Diversity and Inclusion Center

Toolkits and Projects

https://www.americanbar.org/groups/diversity/resources/toolkits

National Implicit Bias Network

https://implicitbias.net/resources/resources-by-category

The Ohio State University

The Women's Place: Implicit Bias Resources

https://womensplace.osu.edu/resources/implicit-bias-resources

The Ohio State University

Kirwan Institute for the Study of Race and Ethnicity

http://kirwaninstitute.osu.edu

University of California, Los Angeles

Equity, Diversity, and Inclusion: Implicit Bias

https://equity.ucla.edu/know/implicit-bias

University of California, San Francisco, Office of Diversity and Outreach

Unconscious Bias Resources

https://diversity.ucsf.edu/resources/unconscious-bias-resources

Unconscious Bias Project

https://unconsciousbiasproject.org

Health Care Access Now

https://healthcareaccessnow.org/implicit-bias-resources

MINDFULNESS RESOURCES

University of California, San Diego Center for Mindfulness

https://cih.ucsd.edu/mindfulness

University of California, Los Angeles Guided Meditations

https://www.uclahealth.org/marc/mindful-meditations

Mindful: Mindfulness for Healthcare Professionals

https://www.mindful.org/mindfulhome-mindfulness-for-healthcare-workers-during-covid

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51914 • Dental Care for Patients with Disabilities

Mark J. Szarejko, DDS, FAGD

www.netce.com

Copyright © 2025 NetCE, All rights reserved.

The ability to maintain optimal oral health requires daily attention to oral hygiene and regular dental evaluations. The oral environment has a complex composition of microbial organisms and any alteration in this environment, from systemic illness, treatments, or poor oral hygiene, can result in short- and long-term oral effects. Even patients with ideal physical and mental health can be challenged in their pursuit of optimal oral health. Patients with complicated medical and/or mental health problems have a greater incidence of acute and chronic oral health problems because many are unable to perform the basic tasks necessary for fundamental oral hygiene. This is compounded by the fact that some systemic diseases and medications used in their treatment have a higher predilection for adverse oral effects. Immunosuppression, whether the result of diseases such as human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) or pharmacologic induction via chemotherapy or immunosuppressive therapy, can allow resident oral microflora to achieve pathogenic status. This course will highlight the systemic diseases and mental health issues with direct and/or indirect influence on the oral and maxillofacial complex. Suggestions to improve oral hygiene and to facilitate dental appointments will also be included.

Table of Contents

51914 • Dental Care for Patients with Disabilities

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. AUTOIMMUNE DISEASES

SJÖGREN DISEASE

LUPUS ERYTHEMATOSUS

3. IMMUNOSUPPRESSIVE CONDITIONS

HIV/AIDS

ORGAN AND BONE MARROW TRANSPLANTATION

4. DISEASES AND CONDITIONS AFFECTING NEUROMUSCULAR COORDINATION

PARKINSON DISEASE

CEREBRAL PALSY

SPINAL CORD INJURIES

STROKE

5. CONDITIONS CAUSING COGNITIVE IMPAIRMENT

DOWN SYNDROME

ALZHEIMER DISEASE

6. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

51914 • Dental Care for Patients with Disabilities

Education Category. Community Health

Release Date. 05/01/2025

Expiration Date. 04/30/2028

Course Overview

The ability to maintain optimal oral health requires daily attention to oral hygiene and regular dental evaluations. The oral environment has a complex composition of microbial organisms and any alteration in this environment, from systemic illness, treatments, or poor oral hygiene, can result in short- and long-term oral effects. Even patients with ideal physical and mental health can be challenged in their pursuit of optimal oral health. Patients with complicated medical and/or mental health problems have a greater incidence of acute and chronic oral health problems because many are unable to perform the basic tasks necessary for fundamental oral hygiene. This is compounded by the fact that some systemic diseases and medications used in their treatment have a higher predilection for adverse oral effects. Immunosuppression, whether the result of diseases such as human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) or pharmacologic induction via chemotherapy or immunosuppressive therapy, can allow resident oral microflora to achieve pathogenic status. This course will highlight the systemic diseases and mental health issues with direct and/or indirect influence on the oral and maxillofacial complex. Suggestions to improve oral hygiene and to facilitate dental appointments will also be included.

Audience

This course is designed for dental professionals involved in assessing and promoting optimum oral care for special needs patients.

Accreditations & Approvals

NetCE Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement. 10/1/2021 to 9/30/2027 Provider ID #217994. NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. NetCE is approved as a provider of continuing education by the Florida Board of Dentistry, Provider #50-2405. NetCE is a Registered Provider with the Dental Board of California. Provider Number RP3841. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type.

Designations of Credit

NetCE designates this activity for 5 continuing education credits. AGD Subject Code 750. This course meets the Dental Board of California's requirements for 5 unit(s) of continuing education. Dental Board of California course #05-3841-26465.

Course Objective

The purpose of this course is to focus awareness upon the difficult oral health issues that patients with disabilities face on a daily basis and to provide healthcare professionals with the necessary information to improve patients' oral and systemic health.

Learning Objectives

Upon completion of this course, you should be able to:

1. Outline the chronic oral health issues caused by Sjögren disease.

2. Describe the oral health issues associated with the systemic and discoid forms of lupus erythematosus.

3. Discuss the diverse variety of opportunistic oral infections that occur in patients with

4. Outline how immunosuppression for patients with organ and bone marrow transplants and from chemotherapy affects short-term and long-term oral health care.

5. Review oral health considerations for patients with Parkinson disease, cerebral palsy, and spinal cord injuries, and describe treatment modifications for home care and in-office dental care.

6. Identify the varying degrees of physical impairment experienced by stroke victims and techniques that allow them to maintain oral hygiene.

7. Describe the special oral health issues encountered by cognitively impaired patients, particularly those with Down syndrome or Alzheimer disease.

Faculty

Mark J. Szarejko, DDS, FAGD, received his dental degree from the State University of New York at Buffalo in 1985. He received fellowship from the Academy of General Dentistry in 1994.

Faculty Disclosure

Contributing faculty, Mark J. Szarejko, DDS, FAGD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

In dentistry, patients with disabilities include those for whom a medical, physical, developmental, mental, or cognitive condition complicates their ability to maintain optimal levels of oral hygiene. As a result, these patients are at increased risk for caries and periodontal disease; the overall health of the oral mucosal tissues and the oral and maxillofacial complex can also deteriorate. According to some estimates, there are nearly 44.2 million people in the United States who are considered to have one or more disabilities [1]. Some of the conditions associated with patients with disabilities are also associated with the chronic health issues of the aging process. Because the older population in the United States is expected to grow from about 57.8 million in 2022 to 88.9 million by 2060, this is an area of particular concern [2].

Because a complete discussion of all debilitating conditions is not possible in this course, representative conditions with diverse origins will be described. This includes autoimmune, immunosuppressive, neurologic, and cognitive conditions. Autoimmune conditions such as Sjögren disease can decrease salivary production and cause a long-term challenge to oral health. Immunosuppression, caused by human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) or resulting from the use of certain medications, can cause opportunistic infections of bacterial, fungal, or viral origin. Patients who have Parkinson disease, cerebral palsy, or spinal cord injuries may develop neuromuscular control problems that preclude their ability to maintain basic oral hygiene. Developmental disabilities, such as Down syndrome, and acquired cognitive problems, such as Alzheimer disease, pose an ongoing challenge when maintaining oral hygiene, and caretaker assistance is usually required. Anticoagulant therapies used in the treatment of cardiovascular disease require special management when oral or periodontal surgery is required.

This course will discuss the oral effects associated with these conditions and the indirect and direct complications associated with the medications used in their treatment. Approaches to maintaining oral health, including at-home and in-office modifications, will also be outlined.

2. AUTOIMMUNE DISEASES

SJÖGREN DISEASE

Sjögren disease is a common autoimmune disorder that occurs in two different forms. Primary Sjögren disease involves the lacrimal glands (keratoconjunctivitis sicca) and the salivary glands (xerostomia). The secondary form presents with these problems and a diagnosed systemic connective tissue disease such as rheumatoid arthritis or fibromyalgia. Sjögren disease develops slowly over many years, and diagnosis is made an average of 2.8 years after the onset of symptoms [3]. It is estimated that as many as 4 million individuals in the United States have this disease, and women are nine times more likely to be affected than men [4]. While Sjögren disease can occur at any age, patients in their fourth and fifth decades of life are most frequently affected. The etiology of this autoimmune disorder is not well understood. Histopathologic examination reveals an infiltration of lymphocytes that causes chronic inflammation within the salivary glands and the lacrimal glands [5]. The secreting capacity of the salivary glands is diminished at rates that vary among patients. Similarly, the lymphocytic infiltration and subsequent proliferative epithelial response constricts the ducts. Decreased salivary production and flow results in xerostomia (dry mouth). The initiation of the syndrome is believed to be triggered by environmental factors, possibly viruses [4]. Because women are more likely to be affected, it is hypothesized that female sex hormones may influence the onset or presentation of the disease. The changes are irreversible, and with no current cure for Sjögren disease, patients are affected by numerous long-term problems of the oral and maxillofacial complex originating from xerostomia.

Problems Associated with Xerostomia

Saliva plays a critical role in the health and maintenance of the oropharyngeal region. A sustained reduction of salivary production in patients afflicted with Sjögren disease increases the risk for dental caries and opportunistic infections, such as candidiasis, and causes problems with the oral mucosa such as mucositis and glossitis. Speaking, swallowing, and eating can become difficult tasks under these circumstances.

The adequate production of saliva is an essential component in the self-cleansing action of teeth, as cariogenic bacteria are less adherent to the surfaces of teeth when a salivary layer is present, which minimizes their physical retention. Saliva also has a buffering capacity that raises the oral pH and creates a less acidic oral environment. When salivary production decreases, its buffering ability is also diminished and the oral pH is lower. The acidic oral environment that develops is more favorable to the proliferation of cariogenic bacteria [6,7].

Patients with secondary Sjögren disease who have diseases such as rheumatoid arthritis or fibromyalgia can have additional problems with the proper maintenance of their oral hygiene. Musculoskeletal conditions such as arthritis can interfere with the dexterity and coordination necessary for basic oral hygiene techniques, such as brushing and flossing. Patients with gingival recession and circumferentially exposed root surfaces have a greater surface area of vulnerable tooth surfaces exposed to this caries-prone environment.

Miscellaneous Oral Problems

The reduction of salivary production for patients with Sjögren disease causes a commensurate reduction in the salivary immunoglobulins and enzymes that act to decrease the pathogenicity of organisms of the oral microflora. Among these, overgrowth of the fungal organism Candida albicans causes candidiasis in many of these patients. This fungal organism thrives in an oral environment that is less lubricated and more acidic. Antifungal rinses such as nystatin are usually effective to treat candidiasis in patients with Sjögren disease. Cases that are unresolved require systemic antifungal therapy with agents such as fluconazole [8]. Antifungal troches that must be dissolved by the patient's saliva may be difficult for these patients to use.

In addition, it is important to remember that the acrylic bases of prostheses (e.g., partial or complete dentures) contain microscopic porosities and surface irregularities that can harbor candidal organisms. These appliances should also undergo antifungal treatment that is compatible with the materials of which they are composed. This is important to prevent reinoculation of the tissue-bearing mucosal surfaces with fungal organisms. Candidal infections recur in these patients because the oral conditions conducive to the initial outbreak do not resolve.

Dental Treatment Considerations

Dental treatment for patients with Sjögren disease involves both a proactive and preventive approach. These patients require more frequent recall appointments to evaluate their home care and to restore carious lesions that may develop between recall appointments. Oral hygiene instructions tailored to the patient's individual needs should be provided. Patients with arthritis or fibromyalgia may benefit from toothbrushes with modified handles or grips and special flossing aids to provide basic oral home care in the presence of compromised dexterity. Patients should also receive nutritional counseling that emphasizes a low-sugar diet to decrease the risk of extensive caries.

Evidence Based Practice Recommendation

The Sjögren's Foundation asserts that chlorhexidine administered by varnish, gel, or rinse may be considered in patients with Sjögren disease with dry mouth and a high root caries rate.

https://www.sjogrens.org/sites/default/files/inline-files/SF_PCG-Oral_0.pdf

Last Accessed: April 25, 2025

Strength of Recommendation: Strong

Concentrated preparations of 5,000 ppm sodium fluoride that can be applied directly to the teeth with a toothbrush or delivered via custom fluoride trays are an essential part of caries reduction; over-the-counter fluoride rinses do not provide the protection required to manage the increased risk. Sodium fluoride is preferred over stannous fluoride as the latter has a metallic taste, may cause a burning sensation, and can stain enamel [9]. Antimicrobial mouth rinses such as 0.12% chlorhexidine gluconate may be used to decrease the bacterial growth associated with caries and periodontal disease. Chlorhexidine has substantivity, the ability to adhere to the gingiva, mucosal tissues, and teeth for prolonged periods of time, which differentiates it from other commercial preparations. Patients should be advised that chlorhexidine will stain teeth and existing bonded (composite) restorations. A prophylaxis will remove the stains from the unrestored surfaces of the teeth, but stains in the bonded restorations may require their replacement.

Patients who wear complete or partial dentures may experience discomfort resulting from the decreased amount of saliva. The mucosal tissues that form the foundation for the prosthesis can become ulcerated, which can minimize or preclude their use. Commercial salivary substitutes may provide some relief, but their effects are temporary. Medications such as pilocarpine and cevimeline are cholinergic agonists and can stimulate salivary flow but only in the exocrine tissue and ducts that have not been destroyed by the autoimmune process [10]. Soft reline material may help to reduce the trauma to the desiccated oral mucosa.

In addition to the effects of the disease process, patients with Sjögren disease may be taking medications for other chronic illnesses, and many of these can cause xerostomia. Clinicians should determine if an alternative medication may be prescribed for which the side effect of xerostomia can be eliminated or reduced.

Treatment and Prognosis

As noted, there is no cure for Sjögren disease [11]. Patients with the condition will display varying degrees of morbidity and a spectrum of oral and maxillofacial complications. Among the most serious complication associated with primary Sjögren disease is the development of certain types of lymphomas [12]. Dental treatment should be centered on a preventative and proactive approach that mandates more frequent recall appointments and intensive patient involvement with their daily oral hygiene regimen. All clinicians involved in the oral health and overall physical health of these patients should strive to provide a continuity of care that minimizes the discomfort and complications of the disease and improves patients' quality of life [7].

LUPUS ERYTHEMATOSUS

Lupus occurs in several forms, the two most common being discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE). DLE affects the skin and mucosa, usually without systemic involvement. SLE can affect multiple organs and systems and is the more serious form of the disease. The underlying basis for lupus is the formation of autoantibodies, especially to DNA and other nuclear material. The precise antigenic stimulus that initiates the formation of these autoantibodies is unknown. The deposition of the antigen-antibody complex into varied tissues and the resultant inflammatory response is the pathophysiologic basis of SLE [13].

The lesions of DLE usually occur on the face, scalp, ears, and hands. These lesions can feature an erythematous area and scales that extend into hair follicles, causing follicular plugging. Although oral lesions are not a strict identifying feature of DLE, when they do occur the buccal mucosa and palate are areas of predilection. Oral lesions associated with DLE can feature irregular white borders and telangiectasia peripheral to a small atrophic area that contains white papules [14]. A biopsy may be required to differentiate the oral lesions of DLE from malignant lesions such as squamous cell carcinoma.

As noted, SLE is more virulent than the discoid form of this disease. It primarily occurs in women of childbearing age, with a 9:1 female-to-male ratio [15]. Improved treatment modalities have increased the 10-year survival rate to greater than 85%, and the survival rate at five years is 95% [16,70]. Complications from infections, renal failure, and cardiovascular and pulmonary pathology are among the leading cause of death for these patients [17,18].

A classic cutaneous manifestation of lupus, which occurs in approximately 30% to 40% of patients, is a butterfly-shaped (malar) rash that extends over the bridge of the nose and the cheeks. The degree of erythema accompanying this rash can range considerably. Oral lesions can be non-specific and can include ulcerations, petechiae, and erythematous lesions of varied morphology.

Dental Treatment Considerations

Patients with SLE have varying degrees of systemic involvement. Necessary modifications to dental treatment and the ability of the patient to maintain good oral hygiene will depend upon the systems affected and the degree of their involvement.

As with Sjögren disease, arthritis affects many patients with SLE and may compromise the dexterity needed for brushing and flossing. Toothbrushes with modified handles and flossing aids can improve the ability of these patients to maintain proper oral hygiene. More frequent recall appointments may be needed if patients with SLE afflicted with arthritis experience persistent difficulty in basic oral hygiene techniques.

Hematologic problems may also occur with SLE. Thrombocytopenia, a condition of decreased platelet count, may be present and is a concern for oral and periodontal surgery patients. Before these procedures are initiated, the patient's most recent complete blood count values should be assessed. If the platelet count is less than 50,000/mm3, hemostasis can be compromised, and serious bleeding can occur [19].

Medications utilized in the treatment of SLE can have systemic ramifications and can require modifications for dental treatment. The salicylates and nonsteroidal anti-inflammatory drugs (NSAIDs) used to provide analgesia can also prolong the bleeding time. The degree to which this occurs may be clinically insignificant, but the synergistic effect can be a concern when considering oral or periodontal surgery for patients with SLE who experience thrombocytopenia. If an invasive dental procedure is indicated, it should be coordinated with the patient's physician.

Immunosuppressive medications such as azathioprine and cyclophosphamide are used in patients with SLE to decrease the autoimmune response that causes organ and system damage. Azathioprine can cause bone marrow suppression and decrease production of platelets and granular and agranular leukocytes [20]. If a patient with SLE takes these medications, his or her physician must be consulted before any oral or periodontal surgical procedure is begun. Concerns about postsurgical hemostasis and infections should be discussed. The dosage of this medication may need to be adjusted pending the laboratory values as determined in the complete blood count. Hepatotoxicity is also a potential effect of azathioprine. Many medications utilized in dentistry are metabolized in the liver, and their metabolism may be diminished in patients taking azathioprine, with the potential for toxic accumulation [21]. Laboratory values for liver enzymes and a liver biopsy may be required if there is any concern about diminished hepatic function. Cyclophosphamide can also cause diminished production of platelets and leukocytes, with associated concerns about hemostasis and postsurgical infections. Mucositis may also occur in some patients for whom cyclophosphamide is prescribed [22].

Systemic corticosteroid oral medications, such as prednisone and methylprednisolone, as well as injectable medications, such as dexamethasone and triamcinolone, are used in SLE patients to decrease the systemic inflammatory response and to suppress the cellular basis for the autoimmune dysfunction. Prolonged use of these medications can extend the healing time of surgical sites, increase the difficulty of detecting oral infections, and cause suppression of adrenal gland secretions. These are significant considerations before any oral or periodontal surgery is contemplated. Further, because many patients consider any dental treatment as a stressor, prolonged pharmacotherapeutic adrenal gland suppression can preclude the ability of this endocrine organ to secrete the appropriate hormones necessary for the physiologic adaptation to stress. A dose adjustment of these medications prior to dental treatment may be necessary to prevent an adrenocortical crisis. When used in conjunction with systemic corticosteroids, analgesics used for odontogenic pain, such as NSAIDs, can increase the risk of gastric ulceration. Another classification of analgesics may be needed [21].

Treatment and Prognosis

Currently, there is no cure for lupus erythematosus. Although there is no cure, there are several types of drugs available to aid in the treatment and management of secondary symptoms. Among these drug classes are NSAIDs, corticosteroids, antimalarials, and immunosuppressives. In cases of lupus-related severe kidney disease not helped by pharmacologic intervention or dialysis, kidney transplant may be necessary. The medications used to treat both forms of lupus can have numerous interactions with medications used for dental treatment and can adversely affect immunocompetence, hemostasis, and the ability to withstand stress.

3. IMMUNOSUPPRESSIVE CONDITIONS

HIV/AIDS

The oral complications discussed in this section are mainly evident when the progression of HIV infection has reached the level at which designated opportunistic illnesses and infections fulfill the criteria for the diagnosis of AIDS. Patients with AIDS encounter unique oral problems, and special considerations for their dental treatment are often necessary.

The defining characteristic of HIV disease is the immune deficiency state caused by ongoing viral replication and cell-to-cell transmission within lymphoid tissue. With chronicity of infection there is a progressive depletion of CD4 (helper-inducer) lymphocytes, the very T lymphocyte cohort whose function it is to direct other cells in the immune system, and to orchestrate the inactivation of virus antigen. The result is a depressed T lymphocyte functional capacity, characterized by depletion of helper T cells (T4), impaired killer T cell activity, and increased suppressor T cells (T8). In persons with intact lymphocyte immune systems, the normal number of CD4 T cells ranges from 600–1,200 cells/mcL.

Symptomatic illness can be expected to supervene as the CD4 count declines to a level less than 200 cells/mcL, as this correlates with severe immunodeficiency. The Centers for Disease Control and Prevention defines late-stage HIV infection as AIDS on the basis of two criteria: CD4 count less than 200 cells/mcL or a characteristic AIDS-defining illness such as pneumonia, central nervous system toxoplasmosis, or other opportunistic infections or tumors (Kaposi sarcoma). The natural history and the prognosis for the patient with chronic HIV infection have been dramatically altered by antiretroviral therapy, especially by the use of combination antiretroviral therapy (cART).

Evidence Based Practice Recommendation

According to the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America, oral fluconazole at 100 mg once per day is considered the drug of choice to treat oropharyngeal candidiasis in patients with HIV/AIDS, except during pregnancy. One to two weeks of therapy is recommended for oropharyngeal candidiasis; two to three weeks of therapy is recommended for esophageal disease.

https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-oi/guidelines-adult-adolescent-oi.pdf

Last Accessed: April 25, 2025

Strength of Recommendation/Level of Evidence: AI (Strong recommendation based on one or more randomized trials with clinical outcomes and/or validated laboratory endpoints)

Oral candidiasis is the most frequent opportunistic oral infection in patients with HIV/AIDS, with a very high occurrence in this population [23]. When C. albicans becomes an opportunistic oral pathogen, the extent and virulence of the infection increase as the CD4+ lymphocyte count decreases. Candidiasis can extend to the pharynx and esophagus and ultimately result in a fatal septic termination. Oral or intravenous antifungal medications such as fluconazole and itraconazole are used when advanced fungal infections occur. Caution must be exercised when other medications are prescribed, as antifungal medications can have numerous problematic drug-drug interactions. Invasive dental treatment should be avoided during an outbreak of oral candidiasis as surgical sites can become a means of systemic fungal dissemination.

Periodontal disease can manifest aggressively in patients with HIV/AIDS, especially those who are extremely immunocompromised. Most forms of periodontal disease progress slowly and asymptomatically. As the immunocompetence of patients with HIV/AIDS deteriorates, periodontal pathogens can accelerate the loss of soft tissue attachment and of the alveolar bone. Necrotizing gingivitis and periodontitis (previously called HIV-associated gingivitis and periodontitis) can be of such severity that loss of alveolar bone support requires the extraction of the involved teeth. Extension of the periodontal pathogens into the adjacent mucosa and bone can cause a necrotizing stomatitis, which can destroy these tissues and advance to a life-threatening infection [24]. It is critical for all HIV patients to maintain regular recall appointments during the entire course of their illness. Initial periodontal problems that can be treated conservatively with an early diagnosis will become increasingly difficult to treat and potentially refractory to periodontal treatment during the progression of the disease.

Before treatment such as oral or periodontal surgery and root planing and curettage is started, the overall health status of the patient should be assessed. The most recent laboratory results, including complete blood count, CD4+ levels, and viral load, must be known before any invasive treatment is attempted. Some patients with AIDS develop thrombocytopenia, and postsurgical hemostasis becomes an issue. Similarly, patients may develop neutropenia, in which the production of neutrophils and their role in a healthy immune system decreases. These patients can be at an increased risk of postoperative infections. The infections can become life-threatening even after basic surgical procedures. Invasive procedures may require postponement until the appropriate hematologic values are attained. Antibiotics used prophylactically and postsurgically, by oral or parenteral means, are further considerations.

As HIV progresses, there will be a point, determined by the CD4+ and viral load levels, when the patient is placed on cART. Medications from different classes of the antiretroviral drugs are combined to decrease the viral load and increase the CD4+ level; some of these medications can interact with those used in the scope of dental practice.

Acetaminophen, alone or in combination with narcotics such as codeine or hydrocodone, is frequently used to control dental and postsurgical pain. If acetaminophen is combined with zidovudine, a nucleoside reverse transcriptase inhibitor that may be included in the cART regimen, there is potential to accentuate the neutropenia and anemia caused by zidovudine. NSAIDs such as ibuprofen and naproxen are also commonly utilized to control postprocedural dental pain. These medications can alter the metabolism of the nucleotide tenofovir and can also increase the risk for renal complications [25]. When medications are prescribed for systemic diseases, clinicians have the responsibility to be cognizant of their potential interactions with medications utilized for dental treatment. Hepatic and renal diseases can alter the clearance of many medications.

Treatment and Prognosis

There is no cure for HIV/AIDS at the present time. Proactive use of cART has been successful in increasing the lifespan for these patients; however, these medications can have multiple side effects and require a significant number of pills be taken daily, which can decrease patient compliance. Dental treatment should be initiated in the earliest known stage of HIV infection, during which time dental caries, periodontal problems, and oral pathology can be treated while the patient's immune system is capable of withstanding such treatment. The frequency of recall appointments should reflect the oral health concerns and the degree of complications associated with advancing HIV disease.

ORGAN AND BONE MARROW TRANSPLANTATION

Solid organ and bone marrow transplants are being done with increasing frequency. These are complex procedures with initial and long-term challenges. Potent immunosuppressive medications are prescribed for these patients to decrease the risk of rejection of the transplant. These medications can have pronounced oral effects and can subject the patient to opportunistic oral infections, which can have significant morbidity and even result in death.

Cyclosporine (modified and nonmodified) is a commonly used immunosuppressive agent prescribed for organ transplant patients. Systemically, it can induce changes in neural, renal, and hepatic function and can cause hypertension [26,72]. Potential oral effects include gingival hyperplasia, oral ulcers, xerostomia, and increased susceptibility to opportunistic oral infections. Gingival enlargement usually occurs within the first three months of cyclosporine administration and can be potentiated by the coadministration of medications such as the calcium channel blocker nifedipine, used to treat hypertension. The hyperplasia can involve the interdental papillae and the marginal and papillary tissues [27]. These tissue changes can complicate patients' ability to maintain ideal oral hygiene and increase the incidence of periodontal disease.

Another potent immunosuppressive medication that is used for organ transplant patients is tacrolimus. The increased risk for opportunistic infections associated with cyclosporine is also a potential problem with tacrolimus. Renal toxicity, anemia, and hyperkalemia are among the other potential side effects [28]. However, the associated gingival hyperplasia and hypertension that may occur with cyclosporine are not encountered with tacrolimus.

Acute periodontal infections develop more readily, as pharmacologically induced immunosuppression can decrease the host response to periodontal pathogens. The opportunistic infections that occur with the use of medications such as cyclosporine may last longer and be more virulent than those in non-immunocompromised patients. C. albicans is a common cause of candidiasis in many post-transplant patients. Systemic antifungal agents such as ketoconazole and voriconazole are used when extensive or refractory candidiasis is not resolved with topical agents such as nystatin. These medications may increase the serum concentrations of cyclosporine and tacrolimus, so they should be only used with caution after medical consultation.

Aspergillus is another fungal species that can demonstrate a virulent and even lethal course in the immunosuppressed transplant patients. This fungal pathogen is seen in 5% of liver, lung, and heart transplant patients but is less common in kidney transplant patients [29]. Systemic antifungal medications that are effective against Aspergillus spp. include itraconazole, posaconazole, voriconazole, caspofungin, and micafungin [28,30]. The use of these medications may increase the serum levels of cyclosporine; blood levels of the immunosuppressive agent should be monitored carefully.

Oral and maxillofacial viral infections also can occur more frequently and require an extended healing period for post-transplant patients. Herpes simplex virus 1 (HSV-1) causes outbreaks of recurrent herpes labialis (cold sores). These lesions can become more expansive in immunocompromised patients and can even cause herpetic keratoconjunctivitis, which can lead to blindness. The combination of stress associated with ongoing medical issues and medically induced immunosuppression contributes to these recurrent outbreaks.

The varicella zoster virus, which causes chickenpox in children and young adults, can also be reactivated in the adult years as the herpes zoster virus, which causes shingles. Oral and maxillofacial involvement follows the distribution of the mandibular, maxillary, and ophthalmic divisions of the trigeminal nerve. These vesicular lesions can be cutaneous or intraoral and are much more extensive then than those of HSV-1. Immunosuppressed patients may have prolonged and more aggressive outbreaks of shingles. Intraoral involvement can progress to necrosis of the mucosa and alveolar bone, with tooth loss as a potential sequela.

Topical or oral antiviral agents such as acyclovir or valacyclovir can expedite the healing of recurrent herpes labialis lesions. Extensive shingles lesions may require intravenous acyclovir to promote healing. Because the immunosuppressed status of transplant patients will continue for life, viral outbreaks are likely to recur. Many patients with shingles develop a painful condition called postherpetic neuralgia (PHN) at the area where the lesions occurred. Narcotic analgesics and antidepressants are prescribed for this chronic, painful condition. If a patient has PHN and is taking these medications, prescribing additional narcotic analgesics for odontogenic pain or postsurgical analgesia should be avoided.

A special concern for transplant recipients is the increasing chance for the development of certain malignancies over time [31]. Squamous cell carcinoma (particularly occurring on the lip), basal cell carcinomas, and Kaposi sarcoma occur with increasing incidence post-transplantation [26]. The range of incidence extends from 10% 10 years after the transplant to 40% after 20 years [32]. The viral DNA of human papillomavirus (HPV) has been isolated from some of these lesions. The chronic immunosuppressive state of transplant patients may allow the HPV to have a role in the development of these lesions [33]. This potential for oral malignancies mandates that patients who have received transplants be educated regarding the necessity for regular, comprehensive oral examinations including oral and maxillofacial cancer screenings.

The first bone marrow transplant was performed in 1958 [34]. This procedure is utilized for patients afflicted with myeloproliferative disorders, including aplastic anemia, chronic myelogenous leukemia, and acute leukemia that has been refractory to chemotherapy treatment. Prior to the transplant, procedures in varied combinations such as chemotherapy, total body irradiation, and the use of immunosuppressive medications are used to kill cancer cells and to decrease the immune response that can cause rejection of the transplanted tissues. This rigorous pretreatment regimen can reactivate the herpes simplex virus in as many as 80% of patients [35]. Acyclovir is used prophylactically for bone marrow transplant patients who test positive for antibodies to herpes simplex virus.

Chemotherapy is used in conjunction with surgery and radiotherapy for varied systemic and organ-based malignancies. These medications have a low margin of safety and target rapidly dividing cells, which includes both the malignant cells and healthy cells of many tissues. The cells of the oral mucosa are rapidly dividing and may be damaged during chemotherapy. The resulting oral mucositis features painful mucosal ulcerations that can also serve as a means of systemic dissemination for oral pathogens. The alteration of the ability of the bone marrow to produce an adequate quality and quantity of platelets, erythrocytes, and granular and agranular leukocytes can make these patients prone to opportunistic infections and bleeding problems. Fortunately, these problems resolve after the cessation of chemotherapy.

Dental Treatment Considerations

A proactive course of dental treatment prior to transplant surgery and chemotherapy is mandatory to maintain optimal oral health and to prevent dental pathology from developing into problems that can become life-threatening. Patients who require an organ or a bone marrow transplant are chronically ill and may wait years before a transplant is available. The patient's physician should be consulted before any treatment is initiated; these patients are usually on several medications that can interact with those used for dental treatment. Patients with compromised liver and kidney function will have an altered ability to metabolize and excrete certain medications, such as local anesthetics, analgesics, and antibiotics. Decreased hepatic function can alter the production of coagulation factors, which can affect hemostasis for surgical procedures. Cardiac patients who are awaiting a heart transplant may be placed on anticoagulant therapy with medications such as warfarin, clopidogrel, or aspirin. NSAIDs can potentiate the anticoagulant effects of these medications and may cause internal bleeding. Alternative analgesics compatible with the patient's medical history and current medications should be utilized. When any dental procedure is planned in which hemostasis is a concern, clinicians should consult the patient's physician to obtain the most recent prothrombin time (PT) and international normalized ratio (INR).

Dental treatment should be designed to restore carious teeth or to extract those that cannot be restored or that the patient will not maintain upon their restoration. Similarly, teeth with periodontal problems that cannot be treated and maintained should be extracted. The long-term immunosuppressive concerns of transplant patients must be addressed before any invasive dental treatment is started. It is essential that surgical procedures are completed as far in advance as possible of the transplant surgery and subsequent immunosuppressive therapy. The frequency of recall appointments should reflect the patient's ability to maintain optimal oral hygiene via home care. Antibacterial mouth rinses such as 0.12% chlorhexidine gluconate can be an excellent supplement for an oral hygiene regimen that seeks to promote optimal periodontal health. Management of the patient before and after any transplant procedure should consist of patient education, motivation, and treatment that will allow the patient to achieve and maintain oral health as much as possible.

Treatment and Prognosis

Many factors can influence the survival rates of organ transplant patients. Unfortunately, many patients die waiting for a transplanted organ. The five-year survival rates for kidney and heart transplant patients are approximately 85% and 80%, respectively [36,73]. Immunosuppressive therapy can subject the patient to many systemic complications with serious and even fatal consequences. Local infections that would not be a health threat to an immunocompetent patient may be the source of a fatal septicemia for a transplant patient. The allied healthcare professionals involved in the care of these patients should promote oral and systemic health and optimize a successful convalescence and long-term survival.

4. DISEASES AND CONDITIONS AFFECTING NEUROMUSCULAR COORDINATION

PARKINSON DISEASE

Parkinson disease is a progressive neurodegenerative condition that affects more than 1 million Americans [37]. The mean age at diagnosis is 60 years. In these patients, the neurons in the substantia nigra of the brain that store and release the neurotransmitter dopamine undergo a 60% to 70% depletion. The result is impaired motor function and poorly coordinated bodily movements [38]. The extent of impairment may be staged/measured using the Hoehn and Yahr scale, which describes five stages of Parkinson disease. The categories range from stage 1, which indicates mild tremors and minimal, unilateral functional impairment, to stage 5, which is characterized by incapacitating motor symptoms that require restriction to bed or dependence upon a wheelchair for ambulation [39]. However, this staging system has been criticized for its over-reliance on physical (rather than psychologic or behavioral) symptoms. The interference with normal motor function can have varied orofacial manifestations that progressively detract from optimal oral function.

Evidence Based Practice Recommendation

The National Institute for Health and Care Excellence recommends that pharmacologic management for drooling of saliva in people with Parkinson disease should only be considered if nonpharmacologic management (e.g., speech and language therapy) is not available or has not been effective.

https://www.nice.org.uk/guidance/ng71

Last Accessed: April 25, 2025

Level of Evidence: Expert Opinion/Consensus Statement

Approximately half of patients with Parkinson disease have chronic problems with drooling [40]. Parkinson disease can affect the pharyngeal muscles and those of the tongue and the floor of the mouth, causing dysphagia (difficulty in swallowing). This condition combined with the head flexed in an anterior plane can make swallowing saliva difficult and drooling a chronic problem.

Saliva laden with the oral fungal organism C. albicans can inoculate the corners of the lips to cause angular cheilitis. This localized fungal infection can cause the lips and adjacent skin to remain cracked and inflamed for extended periods of time with subsequent pain during basic movements of the tissues. Antifungal preparations such as nystatin ointment may provide temporary relief, but angular cheilitis usually recurs in patients with Parkinson disease because its origin, chronic drooling, remains.

The progressive neurodegeneration and commensurate loss of motor skills can make wearing dentures very difficult. The maxillary denture can develop retention problems when the musculature of the soft palate, upon whose termination an adequate suction seal is dependent, undergoes tremors and spasms that destabilize the area. The mandibular denture can present as more of a challenge to the patient with Parkinson disease when the musculature of the tongue, lips, cheeks, and floor of the mouth cannot operate in unison as balancing forces. Zinc-free denture adhesives may offer some additional retention but are not able to totally counter the progressive loss of motor skills necessary for successful prosthetic function. The placement of implants for additional denture retention may be an option in the early stage of the disease. The increasing morbidity associated with advancing Parkinson disease precludes their placement during later stages. Patients who possess all or some of their teeth will face oral hygiene challenges as the disease advances and swallowing a bolus of food becomes more challenging. The cumulative effect of the extended contact time between the teeth and the food increases the risk of caries development. Tremors to the fingers decrease patients' ability to maintain optimal oral hygiene and increase the incidence of both caries and periodontal disease. An increasing frequency of recall appointments may be necessary to monitor the degree of oral hygiene impairment and implement strategies for improvement. Caregiver involvement for basic oral hygiene procedures such as brushing and flossing is usually required as the disease progresses.

Pharmacologic management of Parkinson disease includes medications that replace the depleted dopamine, potentiate the action of dopamine that is produced, or increase dopamine availability as it crosses the blood-brain barrier. The medication levodopa is transformed into dopamine by the neurons of the substantia nigra. The benefit of this medication can decrease after prolonged administration, so its use is reserved for adjunctive treatment as the disease advances. A side effect of this medication is orthostatic hypotension; after dental treatment, patients should be raised incrementally from the reclined position to an upright position to minimize the chances of postprocedural syncope. Assistance to and from the chair may be necessary. Entacapone and carbidopa are utilized for patients with Parkinson disease to increase the bioavailability of levodopa, and both can also cause orthostatic hypotension. Selegiline is also prescribed with levodopa. Because selegiline is metabolized in the liver into l-methamphetamine and l-amphetamine, its combination with other sympathomimetic substances, such as epinephrine or levonordefrin, could cause an increase in blood pressure [41]. The patient's blood pressure should be recorded before any procedure, and vasoconstrictors should be used sparingly or avoided completely.

Treatment and Prognosis

Parkinson disease is incurable, and its progression can vary considerably among patients. The illness generally progresses to complete disability and contributes to the death of affected patients despite long-term pharmacologic intervention. Preventive and interceptive dental treatment should be initiated as early as is possible for patients with Parkinson disease. Advancing disease can preclude the ability of the patient to cooperate for basic dental treatment. Cognitive impairment in the latter stages of the disease can require that consent for dental procedures be obtained from a designated representative.

CEREBRAL PALSY

It is estimated that 1 million individuals in the United States have cerebral palsy [42]. In 2006, the International Workshop on the Definition and Classification of Cerebral Palsy updated its definition of the condition, which is recognized as a group of activity-limiting disorders affecting the development of movement and posture [43]. Non-progressive disturbances that occur in the developing fetal or infant brain cause motor disorders; these can be accompanied by disorders that impair sensation, cognition, behavior, and communication [43]. Cerebral palsy is not associated with specific oral or maxillofacial lesions or abnormalities. However, several oral conditions occur within this patient population.

Periodontal disease is common in patients with cerebral palsy. The motor skills required for brushing and flossing are compromised to varying degrees, especially if cognitive and sensation disturbances accompany the motor problems, and optimal oral hygiene can be difficult to achieve and maintain. Caregivers may not be able to brush and floss the patient's teeth to a degree that allows for effective and consistent removal of bacterial plaque; the cumulative accretion of plaque may lead to gingivitis and ultimately periodontal disease. Some patients with cerebral palsy take medications to control seizures, such as phenytoin. Gingival hyperplasia has been identified as a side effect of this medication and may be exacerbated by plaque accumulation. When the surfaces of the teeth are covered by more gingival tissue, the ability to maintain plaque control becomes even more of a challenge. A gingivectomy can remove the hyperplastic tissue but recurrence with the continued use of phenytoin remains an issue.

Dental caries are more prevalent among patients with cerebral palsy as a result of the same factors that predispose patients to periodontal problems. Bacteria within accumulated plaque maintain prolonged contact with tooth surfaces and induce the development of dental caries. When the muscles of mastication and swallowing are compromised by cerebral palsy, the teeth have a prolonged exposure time to the bolus of food. This can result in an increased risk for caries. This problem is amplified when it is coupled with a patient's inability to maintain optimal oral hygiene. The irregular surfaces of unrestored carious lesions favor further accumulation of plaque and debris that perpetuate dental caries and periodontal issues.

An estimated 59% to 92% of patients with cerebral palsy have malocclusions, many of which are categorized as Angle's Class II ("buck teeth") classification [44]. Malocclusions decrease the efficiency of mastication and complicate oral hygiene, both of which can increase the risk of periodontal problems and caries. Further, protrusive teeth are more subject to traumatic dental injuries that require expensive endodontic and restorative procedures or extractions. Cerebral palsy is not an absolute contraindication to orthodontic correction for the varied malocclusions. However, an already challenging oral hygiene regimen will become even more difficult.

Dental Treatment Considerations

Dental treatment considerations for patients with cerebral palsy begin with a preventive approach early in the disease process. These patients can have considerable variation in motor and cognitive skills, which will influence maintenance of optimal oral hygiene. Patients for whom adequate brushing and flossing is a challenge must rely on a caregiver to provide adjunctive or complete oral hygiene care. Demonstrations of the appropriate methods of oral hygiene unique to the patient should be demonstrated to the caregiver in the dental office.

Special care must be used in brushing and flossing for these patients as variability in the control of oromotor function can complicate basic oral hygiene procedures. Expectoration of toothpaste and mouth rinses may be difficult for some patients, and the ingestion of excessive amounts of fluoride is a consideration. Only a small amount of toothpaste should be used and only for one quadrant at a time. If mouth rinses are used as an adjunct for oral care, they should be alcohol free.

The frequency of prophylaxis appointments will be determined by the ability of the patient or caregiver to maintain adequate plaque control. Each appointment should include an examination for caries whose prompt restoration is essential for good long-term oral health. Some patients may have muscle spasms and uncontrolled movements that can compromise the ability to provide dental care. These patients will require sedation and may need treatment at an outpatient hospital center.

Treatment and Prognosis

The treatment and prognosis of cerebral palsy is as variable as the patients afflicted with the disease. There is no cure, but advances in medicine and physical therapy techniques have improved the quality of life for many patients. Professionals must strive to provide adequate access to care, including dental care, for patients with cerebral palsy.

SPINAL CORD INJURIES

In the United States, there are approximately 18,000 new spinal cord injuries each year [45]. The extent of sensory and motor function impairment these patients experience will depend upon the level at which the spinal cord was injured. The more superior the location of the injury, the greater the motor and sensory deficit. Because these injuries are usually the result of sudden, traumatic accidents, the oral health status and needs of the patients will span a considerable spectrum. Patients with higher level spinal cord injuries who are quadriplegic will be dependent upon caregiver assistance for all of their oral health needs. Lower spinal cord injuries causing paraplegia allow patients to use their arms and hands; these patients are often able to maintain oral health independently. As noted, any specific dental considerations for patients with spinal cord injury relate to the level of injuries, the degree of presenting periodontal and carious involvement, and ability to provide adequate long-term maintenance of the teeth and soft tissues.

The patient's physician should be consulted before any dental treatment is begun. Quadriplegic patients may have difficulty with adequate ventilation as well as an impaired gag and cough reflex and problems with the control of oral fluids that can accumulate during dental procedures [46]. Paraplegics usually do not have these difficulties but will require assistance upon transfer from the wheelchair to the dental chair. An accompanying caregiver may assist with the transfer in a manner that will not cause injury to the patient. Dental team members who wish to assist with chair transfers should obtain the proper training.

The sustained pressure on weight-bearing areas common among individuals who use wheelchairs or who are bedridden can cause localized ischemia and the development of decubitus (pressure) ulcers of the skin. If longer appointments are required, a change of the position of the legs can decrease the occurrence of this problem. If they develop, skin ulcerations of this nature can become infected locally and provide a portal of systemic dissemination for pathogenic organisms, potentially resulting in sepsis. Quadriplegic patients may require some of their dental or oral care treatment in a hospital setting.

There is an increased risk of aspirating solids or liquids into the lungs with quadriplegia, and aspiration pneumonia is a possibility [47]. The rapid removal of water from high speed handpieces used for restorative dentistry or during hygiene procedures is mandatory to prevent the aspiration of accumulated fluids. Rubber dam isolation of the area to be treated may not be possible for quadriplegic patients with ventilation issues. Complex treatment for these patients can require a concerted effort of the general dentist and dental specialists. Both quadriplegic and paraplegic patients may have anticoagulants such as warfarin, dipyridamole, or aspirin prescribed to reduce the chance of thrombosis. Procedures in which hemostasis is a concern, including oral surgery, periodontal surgery, and root planing and curettage, should not be undertaken without physician consultation.

Quadriplegic patients who wear dentures or partial dentures will require a caregiver to insert, remove, and clean these prostheses. Some partial dentures can be difficult to insert or remove, so caregivers should receive education regarding appropriate placement and removal techniques. Partial dentures placed or removed with excessive force can traumatize the teeth and oral mucosa and damage the partial denture clasps and framework. Partial and complete dentures must be relined or remade periodically in response to changes of the alveolar bone and overlying oral mucosa. Prostheses that conform to the oral tissues and provide the appropriate occlusion will be an essential component in the oral and overall health of these patients.

Treatment and Prognosis

Today, there is no cure for spinal cord injuries. Those who provide home care for quadriplegic patients must be able to provide adequate oral care on a daily basis. Periodic dental examinations and prophylaxis procedures are also necessary. During dental examinations, the oral health status of patients with spinal cord injuries may be monitored and interventional treatment provided as required.

STROKE

The American Heart Association estimates that every 40 seconds someone in the United States has a stroke [48]. As such, stroke is the fifth leading cause of death in the United States, after heart disease, cancer, accidents, and chronic lower respiratory diseases [49]. Strokes are the result of interruption of the blood supply to the brain via ischemic or hemorrhagic means. Ischemic strokes are more common and develop from the thrombosis of a cerebral vessel or from a distant embolus that has become lodged in a cerebral vessel. Hemorrhagic strokes involve bleeding within the brain; this type of stroke accounts for approximately 10% to 20% of all stroke cases [48,74].

The residual motor and sensory deficits associated with a stroke will depend upon the area of the brain in which the affected cerebral vessel was located. Strokes that involve the patient's dominant side can reduce the neuromuscular coordination that is essential for proper oral hygiene techniques. The hand of the unaffected, non-dominant side can be used in attempt to brush the teeth, and a flosser may be used to floss with only one hand. Physical therapy can help, but not all patients will regain use of the affected side. Stroke patients will depend upon healthcare professionals, while hospitalized, or home caregivers to provide basic oral hygiene procedures. Some stroke patients may require this assistance for the remainder of their lives. Because the oral hygiene of these patients can undergo demise after a stroke, it is essential that periodic dental examinations and prophylaxis appointments be maintained. Oral care should be deferred until the patient is stabilized and elective surgical procedures should be deferred for at least six months after the occurrence of a stroke [9]. The patient's physician should be consulted before any treatment is initiated.

Underlying conditions such as diabetes, hypertension, and cardiovascular disease may have been instrumental in causing the stroke. Medications prescribed for these and other chronic conditions may affect the selection of local anesthetics, analgesics, and antibiotics that are used for dental treatment. In addition, anticoagulant medications such as warfarin, clopidogrel, or aspirin are usually prescribed to decrease the chance of another stroke. Anticoagulants' intended effects can be potentiated with the coadministration of many medications used in dentistry, including NSAIDs (e.g., ibuprofen, naproxen), penicillin, and amoxicillin [50]. Patients on anticoagulant therapy should not have any invasive procedure without collaboration with their physician. A temporary hold on anticoagulants may be necessary unless the risk of another stroke or other cardiovascular event precludes the temporary discontinuance. Patients should never discontinue anticoagulant therapy unless it is under the guidance of a physician. If use of anticoagulants must be continued, laboratory values such as INR and PT can provide the clinician with necessary information regarding the patient's ability to achieve hemostasis. Further considerations for patients on anticoagulant therapy will be discussed later in this course.

Dental Treatment Considerations

Dental treatment considerations vary considerably among stroke survivors according to the initial amount of cerebral damage and the level of long-term disability. Even patients for whom minimal damage has occurred and who appear to have minimal motor and sensory deficits should not undergo dental treatment until physician approval has been granted. Unfortunately, many stroke victims do retain long-term or permanent sensory, motor, and cognitive problems that impact oral health and function and the ability to undergo dental treatment.

Dysphagia can occur when strokes cause neural and muscular compromise to the floor of the mouth, the tongue, and the pharynx. Eating and drinking can become a challenge with this condition, and patients may select foods of softer consistency that facilitate swallowing but compromise proper nutrition. The same neural and muscular issues can make partial dentures difficult to wear and the use of complete dentures nearly impossible. Partial dentures are retained by teeth and only partially reliant upon a balance of muscular forces for their retention. A complete maxillary (upper) denture depends upon a functioning musculature, especially at the junction of the hard and soft palates, for its retention. A complete mandibular (lower) denture relies on a balance between the muscles of the cheeks, tongue, chin, and floor of the mouth for retention. When stroke-related involvement of one or more of these muscles occurs, the stability and retention of prostheses are compromised. Patients may also feel that it is difficult to re-establish the proper occlusal pattern needed for proper mastication. The use of implant-retained dentures or denture adhesives (zinc-free) may be of assistance. However, surgery for implant placement should only be done with physician approval.

Cognitive impairment may remain for the patient's lifetime. Matters related to treatment options and informed consent may be beyond the comprehension of some post-stroke patients and will be delegated to their legally appointed representative.

Because many stroke patients are also being treated for hypertension, the use of vasoconstrictors, such as epinephrine and levonordefrin, which are combined with most local anesthetics, should be kept to an absolute minimum or avoided. Appointments should be kept short and as stress-free as possible, with vital signs monitored throughout. Patients should be kept in a position that accommodates unilateral weakness or paralysis and protects them from the accumulation of fluids and debris in the mouth. Many stroke patients develop dysarthria, a condition in which the muscles used for proper speaking are weakened, resulting in slurred speech. Clinicians will need to spend more time to communicate effectively with patients when this occurs.

Approximately 30% of stroke survivors have depression [51,71]. This can decrease patients' desire for recovery and can result in an overall decline in oral hygiene. Some antidepressants used in the treatment of depression can cause xerostomia. As discussed, xerostomia decreases the cleansing action of saliva and increases the retention of plaque on teeth and within the gingival sulcus, resulting in an increased risk of caries and periodontal problems. Tricyclic antidepressants such as amitriptyline can potentiate the vasopressor effects of both epinephrine and levonordefrin [51]. The concurrent use of these agents can raise the blood pressure to levels that endanger stroke survivors, and their use should be avoided.

Treatment and Prognosis

Treatment and prognosis vary among stroke survivors. The underlying medical condition(s) that precipitated the stroke require continuing treatment to decrease the risk of recurrence of stroke. Patients should be evaluated on an individual basis to determine their ability to maintain adequate oral hygiene and optimal oral health. Careful attention to the medical issues that confront stroke patients will allow necessary dental treatment to be accomplished in a safe manner.

Considerations for Patients on Anticoagulant Therapy

Many stroke patients are initiated on anticoagulant therapy as a secondary prevention measure. Anticoagulant medications influence the synthesis of clotting factors. Antiplatelet therapy is used to decrease the risk of adverse cardiovascular events in patients with arterial or venous thrombosis, ischemic heart disease, coronary artery stents, or a history of an ischemic cerebrovascular accident [52]. Aspirin and clopidogrel, used individually or in combination, are among the most common of these agents. Aspirin inhibits the formation of thromboxane A2, a platelet product necessary for platelet adhesion. This inhibitory effect lasts for the 7- to 10-day lifespan of the platelet; the production of new platelets overcomes the inhibitory effects [53]. Clopidogrel inhibits the activation of platelets and ultimately the fibrinogen binding that is required for platelet adhesion.

Among the coumarin derivative class of anticoagulant medications, warfarin is the most commonly prescribed. Warfarin inhibits the synthesis of Factors VII, IX, and X and prothrombin, all of which are vitamin K-dependent coagulation proteins. The efficacy of warfarin therapy is monitored using the INR, the values of which reflect the therapeutic range of anticoagulant therapy. This ratio is determined by dividing the PT of the patient by the mean normal PT of the laboratory. The latter is determined by using the International Sensitivity Index [54]. A value of 1.0 reflects normal PT, while higher values indicate an extended PT. The goals of anticoagulant therapy are determined by the nature and extent of the medical problem involved. Prescribed and over-the-counter medications used in the treatment of oral conditions must not potentiate the intended therapeutic range of anticoagulant therapy, as internal bleeding can result. When procedures such as periodontal surgery or root planing and curettage are planned, verifying the patient's ability to attain and maintain hemostasis is essential. When extensive treatment such as multiple or full-mouth extractions is planned, postoperative bleeding can be significant and the procedure may need to be performed in a hospital setting. Patients who use either clopidogrel or aspirin for antiplatelet therapy have a lower risk of postoperative bleeding compared to those on combination therapy. As discussed, patients must be advised never to discontinue their anticoagulant or antiplatelet therapy unless it is approved by their physician.

NSAIDs, some antibiotics, and certain antifungal medications can increase the risk of postoperative bleeding when they are combined with anticoagulant or antiplatelet medications. Whenever possible, alternative medications should be utilized. The duration of anticoagulant and antiplatelet therapy is usually for the lifetime of the patient. Dental clinicians must be cognizant of the patient's current regimen and note any difficulties in internal or occult bleeding that would indicate potential problems in the achievement of postoperative hemostasis. Recent INR value and PT and consultation with the patient's physician can provide guidance for the course of dental treatment that is the safest for the patient.

5. CONDITIONS CAUSING COGNITIVE IMPAIRMENT

DOWN SYNDROME

Down syndrome is a genetic disorder resulting from an aberration of the 21st autosomal chromosome. Nearly 95% of those affected have a complete extra chromosome (trisomy 21) while the remaining 5% have other chromosomal abnormalities, including mosaic trisomy 21 [55,56]. In the United States, more than 400,000 individuals are living with Down syndrome [56]. The development of mental and physical features progresses more slowly for individuals with Down syndrome compared with those without it. The development of motor and language skills is delayed, and the degree to which they are ultimately impaired varies considerably among these individuals, as does intellectual capacity. Most patients with Down syndrome have some degree of intellectual disability that will challenge their cognitive development. Common anomalies and trends in the oral and maxillofacial region can challenge the ability of patients with Down syndrome to maintain optimal oral health.

The presence of an underdeveloped maxillary arch is typical among patients with Down syndrome. This coupled with a mandibular arch of normal dimensions establishes a Class III jaw relationship (mandibular prognathism or underbite) [57]. Abnormal morphology of the teeth, such as shorter and smaller clinical crowns, coupled with a Class III malocclusion can cause compromised occlusal function and difficulties with the proper mastication of food. The delayed eruption sequence of teeth and a higher incidence of congenitally missing teeth among these patients can further prevent the development of a stable occlusion [58]. The occurrence and severity of periodontal disease are both more prevalent among individuals with Down syndrome. The aforementioned problems with congenitally missing or late erupting teeth can cause teeth to drift and incline in a fashion that does not facilitate optimal oral hygiene. Deficiencies in the immune system among these individuals will diminish the response against pathogenic bacteria. Leukocytes such as granulocytes and lymphocytes are the primary cells involved with defense against bacterial infections [59,60]. Nearly half of patients with Down syndrome have chemotactic defects in their neutrophils that prevent the proper migration of these leukocytes towards the pathogenic bacteria [61]. The function of T-lymphocytes is also compromised among many patients with Down syndrome. A combination of decreases in both mitotic activity and the response to an antigenic challenge and an increase in the production of immature T-lymphocytes diminishes the appropriate immune response to periodontal pathogens [62].

When loss of alveolar bone results from this combination of factors, patients with Down syndrome are at a greater risk of tooth loss due to root anatomy variances. Shorter roots and the fusion of molar roots that are usually separate and divergent mean these teeth have less attached alveolar bone at the onset [63]. Therefore, bone loss that would not threaten the retention of teeth in patients without Down syndrome may cause advanced mobility and a poor prognosis for retention among this patient population. The ability for patients with Down syndrome to brush and floss properly will be commensurate with the degree to which their motor skills and cognitive ability have developed. Given these circumstances it is imperative that oral home care and recall appointments combine to create as healthy an oral environment as possible. It may be necessary for caretakers to assist in basic hygiene techniques.

The prevalence of dental caries varies among patients with Down syndrome. The delayed eruption of both the deciduous and permanent dentition common among patients with this disorder decreases the time of exposure to cariogenic bacteria. Clinical crowns that are smaller than average can create spaces between the teeth and can actually facilitate their cleansing. Smaller nasal passages and increased tonsillar volume can cause congestion of the upper respiratory tract. Open-mouthed breathing is a compensatory mechanism for this problem [64]. This breathing pattern has a drying effect on dental plaque and can increase the incidence of both dental caries and periodontal disease. If this pattern is noted, increased frequency of brushing and flossing combined with shorter intervals between dental recall appointments must be enacted.

Treatment and Prognosis

Medical advances have increased the life expectancy of patients with Down syndrome. While these patients have a higher tendency for diverse medical problems, including cardiac issues and seizure disorders, many live past 55 years of age and some outlive their parents. Arrangements for a succeeding caretaker may involve another family member, or in some cases, institutionalization. In either case, access to dental care should remain a steadfast commitment. Most patients with Down syndrome can be treated by a general dentist in a traditional office setting. Patients with moderate-to-severe intellectual disability may require sedation in office or at an outpatient hospital setting. Consistent recall appointments and evaluation of the patient's daily oral hygiene regimen are both proactive practices that can positively impact oral health and quality of life.

ALZHEIMER DISEASE

Approximately 6.9 million people in the United States are living with Alzheimer disease, a major cause of dementia [65]. Alzheimer-type dementia occurs in 10.9% of Americans older than 65, and as many as 33.4% of patients 85 years of age or older [66]. Alzheimer disease is the most common form of dementia and is responsible for 60% to 80% of all new dementia cases [67]. It is a slowly progressing disease that causes memory loss, cognitive impairment, changes in personality, and ultimately, functional impairment and inability to carry out activities of daily living. The initial stage features minimal cognitive impairment and memory loss. Progression to the middle stage features language impairment and the loss of abstract reasoning skills. These problems along with delusions, paranoia, and marked personality changes are seen in the late stage of the disease. Patients in the end-stage of Alzheimer disease become rigid, incontinent, and bedridden. These patients usually succumb to cardiac problems, pulmonary embolisms, or opportunistic infections (e.g., aspiration pneumonia) [68].

Dental Treatment Considerations

There are no oral lesions that are unique to Alzheimer disease. The dental considerations for these patients involve proactive and preventive care in the early stages of the disease while patients are most cooperative and are able to provide a reasonable level of basic oral hygiene by themselves. The ability of the patient to cooperate during dental treatment will decrease during the later stages of this disease. Thus, addressing dental problems as soon as possible after a diagnosis of Alzheimer disease has been confirmed as essential.

The interaction of medications prescribed for Alzheimer disease and systemic illnesses with those utilized for dental treatment are an additional concern. Patients with Alzheimer disease for whom periodontal problems have been controlled and carious lesions have been restored will require recall appointments, the frequency of which is determined by the patient's or caregiver's ability to maintain adequate home care. As this disease progresses, patients may forget to brush and floss their teeth on a regular basis (or forget what a toothbrush is) and may not be cooperative when a caregiver attempts to provide this service. This can potentiate existing periodontal problems or cause new problems to develop. Similarly, new and recurrent carious lesions can develop when the ability to maintain oral hygiene declines.

Because cognitive ability can vary considerably among patients with Alzheimer disease, even in the initial stages, it may be necessary to obtain consent for treatment from an accompanying caregiver or family member. Some patients with Alzheimer disease will not seek routine dental care, and advanced periodontal problems and multiple carious lesions can develop. An attempt to resolve these periodontal issues and to restore the carious lesions is the ideal treatment plan. However, maintenance of these teeth will become more difficult as the disease progresses. The patient, caregiver, and allied healthcare team must discuss optimal treatment options. Patients who did not practice good oral care prior to the diagnosis of Alzheimer disease are unlikely to improve these skills. Extractions of periodontally involved teeth and those with extensive carious lesions can be a practical option for these patients. As the patient's ability to cooperate during dental treatments declines, procedures that require longer appointments and are more complex must be done as early in the disease progression as possible. If partial or complete dentures are made, the patient's name should be incorporated into the acrylic of each prosthesis. This identifying feature will facilitate the return to the appropriate patient if the prosthesis is misplaced. Partial dentures should have a simplified design to facilitate their insertion and removal, and caregivers should be taught these techniques and appropriate home care.

Treatment and Prognosis

Depletion of the cerebral neurotransmitter acetylcholine is a contributing factor in the development of Alzheimer disease, and medications such as donepezil, rivastigmine, galantamine, and memantine are used to reduce the degradation of acetylcholine by the enzyme acetyl cholinesterase [69]. These medications can stimulate the secretion of gastric acid and increase the risk of the development of peptic ulcers [9]. Concurrent use with NSAIDs can increase this risk, so alternative medications compatible with the patient's medical history should be utilized.

Antidepressant and psychotropic medications may also be prescribed for patients with Alzheimer disease. Narcotic analgesics and sedatives can potentiate the effects of these medications and may need to be avoided. Medications for concurrent chronic disease(s) can also influence the selection of analgesics, antibiotics, local anesthetics, and sedatives used for dental problems and treatment. A consultation with the patient's physician should be completed prior to the initiation of dental treatment and updated as the disease progresses. The late and end stages of the disease may require that necessary dental care is performed via sedation or under general anesthesia in a hospital setting. Maintaining the oral comfort and dignity of the patient should be the primary goal of dental treatment.

6. CONCLUSION

This course has highlighted a diverse group of acquired and congenital diseases and syndromes that can significantly impact the lives of patients. All diseases and syndromes discussed are incurable and will impact the patient's and/or caretaker's ability to maintain optimal oral hygiene and the clinician's ability to provide dental treatment. Similarly, medications used to treat these conditions may interact with medications involved in dental or oral care; the use of alternative medications may be necessary. Although each of the diseases/conditions has been discussed singularly, many patients have concurrent illnesses that synergistically complicate their oral and overall health. Furthermore, the aging process can increase the morbidity associated with these diseases.

Dental treatment should be an integral part of the overall health care of any patient with disability. Early preventive treatment can minimize the potential for the development of carious lesions and periodontal problems. Frequent recall appointments reflecting each patient's ability to maintain ideal oral hygiene will also serve to identify new carious lesions and emerging periodontal problems. When these issues are discovered in their initial phases, treatment is less complicated and less expensive compared to treatment attempted when the issues are advanced. Patients with cognitive impairment and neuromuscular degeneration may have difficulty withstanding longer appointments that are required for complex dental treatment. Thus, early identification of dental problems and a proactive approach for their treatment is in the best interest of all. Meticulous attention to the details of a patient's medical problem(s) and prescribed medications allows oral home care and dental treatment to be performed in a unified approach that promotes ideal oral health as a part of an optimum quality of life.

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