CADHA20X • California Dental Hygienists and Assistants 2020

Table of Contents

CADHA20X • California Dental Hygienists and Assistants 2020

How to Receive Credit

NetCE 5 Hour Course #51390 • Controversial Issues in Dentistry

51390 • Controversial Issues in Dentistry

1. INTRODUCTION

2. DENTAL AMALGAM: IS IT SAFE?

3. COMMUNITY WATER FLUORIDATION

4. ANTIBIOTIC USE IN DENTISTRY

5. TREATING TWO PATIENTS AT ONCE: THE PREGNANT DENTAL PATIENT

6. PERIODONTAL DISEASE AND SYSTEMIC DISEASE

7. TOBACCO USE: IS THERE A SAFE ALTERNATIVE TO SMOKING?

8. HALTING MEDICATIONS PRIOR TO INVASIVE DENTAL PROCEDURES

9. ACCESS TO DENTAL CARE: A MULTIFACTORIAL PROBLEM

10. CONCLUSION

Works Cited

NetCE 3 Hour Course #51952 • Carpal Tunnel Syndrome

51952 • Carpal Tunnel Syndrome

1. INTRODUCTION

2. CARPAL TUNNEL SYNDROME DEFINED

3. CAUSES AND CONTRIBUTING FACTORS

4. CONDITIONS THAT MIMIC CARPAL TUNNEL SYNDROME

5. DIAGNOSING CARPAL TUNNEL SYNDROME

6. TREATMENT OF CARPAL TUNNEL SYNDROME

7. PREVENTION STRATEGIES

8. SIMULATED CASE STUDY

9. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

NetCE 2 Hour Course #58582 • Infection Control for Dental Professionals: The California Requirement

58582 • Infection Control for Dental Professionals: The California Requirement

1. INTRODUCTION

2. OSHA AND CAL/OSHA REGULATIONS

3. MODES OF TRANSMISSION

4. BLOODBORNE PATHOGENS

5. PREVENTION STRATEGIES

6. ENVIRONMENTAL CONTROL MEASURES

7. ENGINEERING AND WORK PRACTICE CONTROLS

8. PROTECTING DENTAL HEALTHCARE WORKERS

9. CONCLUSION

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

Works Cited

NetCE 2 Hour Course #51292 • The California Dental Practice Act

51292 • 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

CADHA20X • California Dental Hygienists and Assistants 2020

Mark J. Szarejko, DDS, FAGD

Charlene H. Grafton, RN, BS, MS, CCM

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

CADHA20X • California Dental Hygienists and Assistants 2020

Expiration Date: 12/31/2020

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.

51390 • Controversial Issues in Dentistry

Mark J. Szarejko, DDS, FAGD

www.netce.com

Copyright © 2020 NetCE, All rights reserved.

Even in the current era, there are controversial issues among dental professionals and among allied health professionals. Perhaps the greatest divide exists between the public's perception of oral health issues and the principles advocated by the dental profession. This course will discuss some of the current controversial issues as they pertain to the concerns of dental professionals, allied health professionals, and the general public. Both sides of each issue will be discussed to provide course participants with the information they need to make informed decisions.

Table of Contents

51390 • Controversial Issues in Dentistry

Course Overview

Audience

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. DENTAL AMALGAM: IS IT SAFE?

3. COMMUNITY WATER FLUORIDATION

4. ANTIBIOTIC USE IN DENTISTRY

5. TREATING TWO PATIENTS AT ONCE: THE PREGNANT DENTAL PATIENT

GENERAL CONSIDERATIONS

FIRST TRIMESTER

SECOND TRIMESTER

THIRD TRIMESTER

6. PERIODONTAL DISEASE AND SYSTEMIC DISEASE

PERIODONTAL DISEASE AND CARDIOVASCULAR DISEASE

PERIODONTAL DISEASE AND DIABETES

7. TOBACCO USE: IS THERE A SAFE ALTERNATIVE TO SMOKING?

SMOKELESS TOBACCO PRODUCTS

ELECTRONIC CIGARETTES (E-CIGARETTES)

HOOKAHS

8. HALTING MEDICATIONS PRIOR TO INVASIVE DENTAL PROCEDURES

ANTICOAGULANTS

ANTIPLATELET MEDICATIONS

9. ACCESS TO DENTAL CARE: A MULTIFACTORIAL PROBLEM

RURAL AREAS AND THE DENTAL WORKFORCE

CHILDREN

ELDERLY PATIENTS

10. CONCLUSION

Works Cited

51390 • Controversial Issues in Dentistry

Education Category. Management

Release Date. 02/01/2020

Expiration Date. 01/31/2023

Course Overview

Even in the current era, there are controversial issues among dental professionals and among allied health professionals. Perhaps the greatest divide exists between the public's perception of oral health issues and the principles advocated by the dental profession. This course will discuss some of the current controversial issues as they pertain to the concerns of dental professionals, allied health professionals, and the general public. Both sides of each issue will be discussed to provide course participants with the information they need to make informed decisions.

Audience

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

Course Objective

The purpose of this course is to provide providing factual information about controversial topics in dentistry, allowing professionals to objectively assess the issue and discuss it with patients and other professionals.

Learning Objectives

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

1. Discuss the relative safety of amalgam restorative material.

2. Outline the issues that surround the use of fluoride in public water supplies.

3. Describe situations that do and do not require the use of antibiotics in dentistry.

4. List dental procedures and medications that are safe for pregnant patients.

5. Evaluate the data that suggest a link between periodontal disease and certain systemic illnesses.

6. Identify dental concerns related to alternatives to smoking, such as e-cigarettes, hookahs, and smokeless tobacco.

7. Evaluate issues related to access to dental care within the United States.

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.

Division Planner

William E. Frey, DDS, MS, FICD

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

Dentistry is a profession in which exacting measurements can dictate procedural success or failure. The margin of a crown that is open by only 0.1 mm will allow for bacterial ingress and the development of recurrent caries and the ultimate failure of the restoration. Minute errors in the angulation of the placement of implants can compromise prosthetic function and aesthetics. Periodontal pathology and the success of periodontal treatment are measured by millimeters.

However, there are many controversial issues in the dental profession that are more subjective in nature and for which definitive answers are not available. This course will highlight issues that are of current interest and that have differing views among members of the dental profession, members of other allied health professions, and/or the general public. Course participants will be provided with an analysis of the underlying elements of these controversial issue, which should allow them to make an informed decision about each.

2. DENTAL AMALGAM: IS IT SAFE?

The use of restorative materials to repair carious lesions predates modern times. As early as 1578, Li Shizhen recorded the use of a dental formulation, the composition of which was 100 parts mercury coupled with 45 parts silver and 900 parts tin [1]. In 1826, Taveau mixed melted silver coins and mercury to produce a silver paste that was used as a filling material [2]. G.V. Black, the first dentist to develop the scientific principles of cavity design, advanced the use of an alloy composed of 68.5% silver, 25.5% tin, 5% gold, and 1% zinc that could be combined with mercury to form the premier dental restorative material of its time [3]. While the composition of these alloys may seem rudimentary, they are indeed the predecessors of modern-day dental amalgam alloys.

The current composition of dental amalgam is 40% to 70% silver, 12% to 30% tin, and 12% to 24% copper, with the quantitative ranges reflecting variations in the manufacturing processes. Trace amounts of indium, palladium, and zinc may also be included in the mixture [4]. The combination of these metals is useless as a restorative dental material unless they are combined with mercury, which creates a pliable restorative material that can be condensed into cavity preparations and that hardens soon after its placement. Mercury comprises about 42% to 45% of the total weight of the combined amalgam alloy [5].

Amalgam has been used to restore millions of carious lesions on several generations of patients. It is a versatile material that is easy to place, can withstand the cumulative load-bearing forces of occlusion for an extended duration, and has been the most cost-effective among all dental restorative materials. Dental amalgam restorations have often been called "silver fillings," because when they are polished after placement, the amalgam surface has a luster that is similar to silver. However, oxidation reactions of amalgam cause the amalgam surface to darken over time and acquire a gray-to-black appearance that can be cosmetically displeasing. The retention of an amalgam restoration depends on adherence to the modern conservative principles of cavity design and by internal retention features, such as the judicious placement of slots and grooves. Ignoring these principles will compromise the longevity of an amalgam restoration and will jeopardize the integrity and strength of the remaining tooth structure.

The placement of an amalgam restoration can require the removal of healthy tooth structure beyond the boundaries of the carious lesion, which impairs the strength of the tooth by decreasing its fracture resistance. All restorative dental materials have advantages and disadvantages related to the physical properties of the material, the ease of placement of the material, and cost. However, the controversy surrounding dental amalgam restorations is detached from these issues; rather, it is focused on concerns of the potential for systemic toxicity due to the inclusion of mercury in its formulation.

Mercury is in its elemental form in dental amalgam restorations and should not be confused with methylmercury, which is found in fish and is absorbed through the digestive tract. Elemental mercury is the least potentially toxic form of mercury, unlike the highly toxic methylmercury. The elemental form is minimally absorbed by the body, while methylmercury is readily absorbed and accumulates within the body tissues [6].

At one time, the elemental mercury in dental amalgam was believed to be bound within the restorative matrix and rendered inert. However, research has revealed that minute amounts of mercury vapor are released from dental amalgam restorations when they wear and when old restorations are removed from teeth [7]. It is this release of minute amounts of mercury vapor over time that some groups have proposed may be the cause of several systemic illnesses [8]. Other groups consider the mercury vapor released from amalgam restorations as inconsequential and unrelated to the development of any systemic illness [8].

The debate about the safety of dental amalgam restorations is a global one. Norway, Denmark, and Sweden have all banned the use of dental amalgam due to their concerns about the impact of mercury on patients and have labeled it an environmental toxin [9]. It is unclear if the actions of these countries will set a precedent for other countries (such as the United States) to enact similar legislation and ban the use of dental amalgam as a restorative material.

Numerous independent studies have been conducted over many years to explore the possible relationship between the mercury in dental amalgam and adverse systemic health. These studies have addressed the concerns that mercury vapor from dental amalgam restorations is implicated in the development of systemic illnesses such as Alzheimer disease, autism, multiple sclerosis, Parkinson disease, renal disease, and lupus [10]. However, the results of scientific studies and reviews to date have not supported these claims.

In 1993, the U.S. Public Health Service (USPHS) conducted a review of the available literature about the safety of mercury used in dental amalgam restorations. The conclusion was that the current scientific evidence demonstrated that exposure to mercury released from dental amalgam restorations does not pose a serious health risk [11]. The USPHS updated this report in 1997. The U.S. Food and Drug Administration (FDA) reviewed about 60 studies published in peer-reviewed scientific literature and cited by citizens groups as a basis to petition the FDA for stringent regulations against the use of dental amalgam [12]. Analysis of the data did not support claims that dental amalgam restorations were the cause of adverse neural, renal, or developmental effects.

The independent nonprofit organization Life Sciences Research Organization (LSRO) uses scientists from a broad spectrum of disciplines to investigate issues related to a variety of areas, including health care and biomedicine. In 2004, the LSRO was commissioned by the National Institutes of Health (NIH), the FDA, and the U.S. Department of Health and Human Services (HHS) to review in excess of 950 scientific articles and research studies about the safety of dental amalgam. These studies and articles were derived from many sources, including the USPHS, the World Health Organization, the European Commission, and Health Canada [13]. The LSRO concluded there was inadequate evidence to establish a definitive link between dental amalgam and kidney disease, Parkinson disease, multiple sclerosis, neurodegenerative diseases (e.g., Alzheimer disease), and autoimmune diseases [14].

In 2009, the FDA published a white paper entitled FDA Update/Review of Potential Adverse Health Risks Associated with Exposure to Mercury in Dental Amalgam [15]. That same year, the FDA issued a final rule on encapsulated dental amalgam in which the powder alloy and the elemental mercury were classified as a class II medical device [16]. The FDA also reiterated its position that dental amalgam remains a safe restorative material for patient use. Classification as a class II medical device means that the FDA can impose controls on dental amalgam [17]. In 2020, the FDA updated its guidance related to the use of mercury-containing dental amalgam [137]. In these guidelines, the FDA states that certain groups may be at greater risk for potential harmful health effects of mercury vapor released from these amalgams. As a result, it now recommends that certain high-risk groups avoid getting dental amalgam whenever possible and appropriate, including [137]:

- Pregnant women and their developing fetuses

- Women who are planning to become pregnant

- Nursing women and their newborns and infants

- Children, especially those younger than 6 years of age

- People with pre-existing neurologic disease (e.g., multiple sclerosis, Alzheimer disease, Parkinson disease)

- People with impaired kidney function

- People with known heightened sensitivity (allergy) to mercury or other components of dental amalgam

The guideline panel stressed that while the majority of evidence suggests exposure to mercury vapor from dental amalgam fillings does not lead to harmful health effects for most people, there may be some effects in specific subpopulations.

The Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR), one of the European Commission's leading scientific authorities, issued a report in 2008 concluding there was no scientific evidence that dental amalgam caused any adverse systemic effects and that its use did not pose a risk for the development of systemic disease. In 2014, the SCHENIR reaffirmed its position but also suggested that studies about its use should be continued [18]. As recently as 2015, the FDA indicated that there was no change in their position about the use of dental amalgam. The FDA also indicated that they would continue to evaluate the safety of dental amalgam and that further actions would be taken if warranted [19].

There is no doubt that the debate about the safety of dental amalgam will continue. To date, studies have not found scientific evidence demonstrating the use of dental amalgam is a precipitating factor in the development of systemic disease, but research is ongoing. Dentists should be forthright in discussing the use of dental amalgam as a restorative material with their patients. Alternative restorative materials, such as composites, gold, and porcelain, also have their limitations, advantages, and disadvantages. Patients should be informed that these alternatives are more expensive than dental amalgam and that insurance reimbursement is variable. An open exchange of scientifically based information about the safety of dental amalgam among members of the dental profession, the allied health professions, and the public is in the best interest of all.

3. COMMUNITY WATER FLUORIDATION

In 1945, the city of Grand Rapids, Michigan, began to add low amounts of fluoride to its community water system [20]. This practice began after dentists in some regions of the United States observed that the teeth of many of their patients appeared stained or mottled yet also protected from tooth decay. Today, approximately 75% of people in the United States are served by fluoridated community water systems [21]. The decision of whether or not to fluoridate municipal water systems is not made by the federal government but by local and state governments.

Fluoridated water works both topically and systemically to reduce the potential for teeth to develop carious lesions. Systemic fluorides are ingested directly through the consumption of fluoridated water, foods, or beverages. Fluoride dietary supplements in pill, tablet, or liquid form are also considered systemic fluorides.

Developing enamel is strengthened and is more resistant to the development of carious lesions when it incorporates systemic fluoride. Systemic fluorides also exert a topical effect, as residual amounts of the ingested fluoride ions remain in the saliva, the dental plaque, and the gingival crevicular fluids. These ions inhibit the demineralization of enamel, promote the remineralization of demineralized enamel, and alter the metabolism of cariogenic bacteria [22]. Systemic fluorides are distinct from dental fluorides, which are strictly topical in nature (e.g., fluoride-containing toothpastes, mouth rinses, fluoride applied in a professional setting).

The initial target concentration of fluoride in community water systems was established in 1962 as a range of 0.7–1.2 mg per liter of water [23]. At the time, it was assumed that people who lived in warmer climates would have a higher fluid intake and would consequently ingest fluoride more than those who lived in cooler regions of the country with assumed lower fluid intake and an overall lower consumption of fluoride. Thus, higher levels of fluoride were added to community water systems in cooler regions of the country, while lower levels of fluoride were added to those in warmer regions of the country.

These recommendations were not re-evaluated until 2010, when the HHS reviewed the most current information about fluoride intake from community water and other sources [23]. Variables considered included fluid intake relative to regional temperature differences, sources of fluoride that were unavailable in 1962, trends in patterns of the staining or mottling of enamel due to excess fluoride consumption (dental fluorosis), and the prevalence of and trends in dental caries.

As a result of their analysis, the HHS changed its recommendation to a target concentration of 0.7 mg per liter of water for all fluoridated water supplies across the United States [24]. This level of fluoride was deemed sufficient to reduce the incidence of dental caries while minimizing the risk of dental fluorosis.

Fluoridation of community water supplies has been a major factor in the reduction of dental caries in the United States [23]. It is a cost-effective way to provide all members of a community with fluoride. The benefits of fluoridation apply to both deciduous and permanent teeth not only during their formation but for their duration in the oral cavity. However, there are several groups that oppose the fluoridation of community water sources. They believe that when fluoridated community water sources are combined with fluorides in toothpaste, foods, and beverages, adverse systemic health effects, such as bone fractures, skeletal fluorosis, cancer, neurologic effects, and endocrine problems, may occur [23].

It is nearly impossible to determine the amount of fluoride each person ingests daily. Fluoride from community water systems, processed food and beverages, and fluoridated toothpastes or mouth rinses all contribute to daily intake. The national standard of 0.7 mg/liter in community water reflects these additional sources of fluoride ingestion.

As with any ingested substance, there are levels at which chronic fluoride ingestion can be associated with adverse effects. The maximum allowable concentration of fluoride in community water systems, also known as the maximum contaminant level (MCL), is 4.0 mg/liter [24]. This level is nearly six times the recommended level for community water systems. Ingestion of fluoride at the MCL for a long period of time can lead to the development of dental and skeletal fluorosis [25]. The most common adverse effect associated with the long-term ingestion of fluoride in excess of 2 mg/liter is dental fluorosis [30]. Mild forms of dental fluorosis feature small white spots or streaks in the dental enamel (i.e., mottled enamel). Severe forms of dental fluorosis feature brown or black pits in the enamel. These are not carious lesions but may require composite restorations, as surface pitting will enhance the retention of plaque and increase the potential for the development of caries. In more severe cases, all the enamel may be damaged [26]. A study published by the Centers for Disease Control and Prevention found that approximately 23% of the U.S. population between 6 and 49 years of age had some form of dental fluorosis; 16.0% had very mild fluorosis, 4.8% had mild fluorosis, 2.0% had moderate fluorosis, and less than 1% had severe fluorosis [27]. An additional 16.5% were classified as having questionable or possible dental fluorosis. This same study found that the rates of dental fluorosis among adolescents (12 to 15 years of age) significantly increased between 1986–1987 and 1999–2004. Skeletal fluorosis is characterized by pain and stiffness in major joints and an increased risk for fractures. This condition is extremely rare in the United States.

The National Research Council did not find any evidence to substantiate a relationship between fluoride concentrations of 2–4 mg/liter and the occurrence of adverse systemic effects [28]. Furthermore, an analysis of peer-reviewed scientific evidence does not support a correlation between community water fluoridation of 0.7–1.2 mg/liter of water and illnesses such as heart disease, cancer, osteoporosis, renal disorders, Alzheimer disease, and bone fractures [29]. Based on this information, the current fluoride concentration of 0.7 mg/liter of water (and the previously recommended range) was considered a safe way reduce the risk of caries. The use of fluoride in its appropriate concentrations in community water systems should be considered an adjunct in achieving and maintaining optimal oral health.

Another possible area of controversy is the link between fluoride exposure and intelligence quotient (IQ). Several studies have explored this relationship, and patients may have questions about the safety of fluoride, especially for children or while pregnant. A 2019 Canadian study of 512 mother-child pairs compared IQ in offspring of women living in areas with fluoridated water to those living in areas with non-fluoridated water. In this study, a 1-mg higher daily intake of fluoride among pregnant women was associated with a 3.66 lower IQ score in offspring at 3 to 4 years of age [31]. These findings were consistent with findings from other studies in India and Mexico [32,33]. However, several other studies found no impact of fluoride consumption or exposure at recommended levels on IQ [34]. Even in studies finding a relationship, other factors (e.g., nutrition, exposure to high-fluoride coal smoke) could be contributing to differences in IQ.

To date, the American Dental Association and the American Academy of Pediatrics continue to recommend fluoridated water as a means to protect children from caries and tooth decay, based on decades of research supporting the safety of fluoride and the effectiveness in improving oral health [35,36]. However, studies are ongoing, and changes in recommendations may be considered based on evolving evidence.

4. ANTIBIOTIC USE IN DENTISTRY

Sir Alexander Fleming's observation in 1928 that the mold Penicillium notatum inhibited a circumferential zone of bacterial growth in a petri dish ultimately led to the development and mass production of penicillin for medical use in 1943—the beginning of the wide use of antibiotic therapy [37]. Today, a myriad of antibiotics are used to treat infections of bacterial origin, some of which are odontogenic.

The indiscriminate use of antibiotics among the allied health professions has led to increasing antibiotic resistance and to an increasing difficulty in the eradication of bacterial infections that were once easily eliminated with empiric therapy. This section will highlight the general principles of conservative and efficacious use of antibiotics.

Bacterial ingress from necrotic pulpal tissues and from periodontal pockets is the usual source of odontogenic infections. Empiric antibiotic therapy should be used when a patient with an odontogenic infection develops an elevated body temperature, lymphadenopathy, trismus (i.e., difficulty opening the mouth), dysphagia (i.e., difficulty swallowing), and/or cellulitis (the extension of the infection into the contiguous tissues, the borders of which are ill-defined and the surface texture indurated). Other indications for empiric antibiotic therapy are periodontal abscesses, pericoronitis, and acute necrotizing ulcerative gingivitis [38]. This is not an all-inclusive list, as the patient's overall medical history, immune status, and age should also be considered when making the decision to prescribe an antibiotic.

Perhaps the greatest issue and challenge to the appropriate use of antibiotics in dentistry arises from patient demands and expectations. Inflammation is the basis for most dental pain, and definitive treatment of dental disease (e.g., restorative dentistry, oral surgery, endodontics, periodontal therapy) is usually the proper treatment—not empiric antibiotic therapy. Antibiotics are not a typical part of the treatment of a carious lesion or pulpitis without swelling. Restoring, extracting, or performing endodontic therapy is the treatment of choice in these cases, with nonsteroidal anti-inflammatory drugs (NSAIDs) used for analgesic purposes, if necessary. Dental clinicians should not prescribe antibiotics as a substitute for definitive treatment. Patients may have received antibiotics from dental clinicians for these situations in the past and may expect or demand them when dental problems arise. It is important that antibiotics not be prescribed to assuage a patient. Instead, clinicians should take time to educate patients about the underlying causes of dental conditions and to explain why antibiotics will be of no use.

Gingivitis and periodontal disease are chronic inflammatory conditions treated by definitive therapy, such as increasing the frequency of recall appointments, root planing and curettage, patient education and instructions tailored to the patient's individual periodontal needs, and periodontal surgery. Traditional approaches to periodontal therapy, whether surgical or nonsurgical (i.e., scaling and root planing), have been shown to significantly reduce the bacterial population in treated sites without the use of supplemental antimicrobial agents. In an attempt to enhance the effect due to mechanical therapy, antibiotics such as penicillin, members of the tetracycline family, and metronidazole have all been given systemically. The members of the tetracycline family (e.g., tetracycline, doxycycline, minocycline) are good candidates for use as these drugs concentrate in the gingival crevicular fluid by a factor of four to eight, depending on the agent employed. Thus, every systemic application of a member of the tetracycline family will produce a topical application of the agent within the periodontal pocket in a concentration several times greater than that produced in the serum. Clinical studies have failed, however, to demonstrate any significant benefit of the routine use of systemic antibiotics alone or in combination with mechanical therapy over mechanical therapy alone for patients diagnosed with adult periodontitis [39,40,41,42,43]. Additionally, the use of antibiotics to treat periodontitis is controversial due to the wider context of the overprescribing of antibiotics and the rise of antimicrobial resistance [44]. The use of supplemental systemic antibiotics seems indicated, however, in the treatment of patients diagnosed with aggressive manifestations of periodontal disease, such as those associated with juvenile and refractory periodontitis [45,46,47,48].

The use of antibiotics in conjunction with oral surgical procedures has also been a subject of controversy. Some patients may believe that the only way to prevent alveolar osteitis ("dry sockets") or to heal properly is to take antibiotics after oral surgery. Acute alveolar osteitis is an acute inflammatory condition caused by the loss of the protective blood clot that covers the alveolar bone of the extraction site. The intense pain associated with this condition arises from an inflammatory response of the exposed bone and is not the result of an infection. As such, the treatment of choice is gentle irrigation and debridement of the socket and the placement of an obtundent dressing; antibiotics are not appropriate [49].

The prophylactic use of antibiotics prior to the extractions of third molars ("wisdom teeth") also remains controversial. A meta-analysis of 24 studies related to this issue found that the data do not support the use of adjunctive antibiotics in the prevention of infection after third-molar surgery [50].

Antibiotics will always have their place as an adjunct to dental treatment. However, clinicians should prescribe these medications judiciously, in the best interest of the oral and general health of their patients. They should also educate patients that the indiscriminate use of antibiotics will continue to cause the emergence of bacterial strains resistant to all known antibiotics, potentially precipitating a public health crisis.

5. TREATING TWO PATIENTS AT ONCE: THE PREGNANT DENTAL PATIENT

Perhaps one of the most controversial issues in dentistry is treating the pregnant patient. The concern for harming the developing fetus and/or the mother has led many in the general public to believe that only dental problems of a dire or emergent nature should be treated during pregnancy. One of the ethical foundations of the dental profession is to "do no harm," and this applies to the pregnant patient and the developing fetus. However, treatment modifications during pregnancy can promote optimal oral health in a safe and efficacious manner. Before treating a pregnant patient, dentists should consult with the patient's obstetrician to determine if routine dental treatment is appropriate or if there are comorbidities that mandate the deferral of elective dental treatment until the completion of the pregnancy.

GENERAL CONSIDERATIONS

Nausea

Nausea and vomiting of pregnancy ("morning sickness") occurs in about 75% of pregnancies [51]. It usually begins between the fourth and eighth week of pregnancy and though it usually resolves before 20 weeks, it may continue through the duration of the pregnancy for some women [52]. The long-term regurgitation of acidic gastric contents can lead to the erosion and loss of enamel. Patients who have this problem should be instructed to first rinse their mouths with a neutralizing solution of 1 teaspoon of baking soda to 8 ounces of water to remove any acidic residue from the teeth. Patients who do not rinse before brushing their teeth with toothpaste will essentially be burnishing the acidic residue onto the enamel surface, enhancing the erosive effects. Continued erosion of enamel can lead to exposure of dentin, with subsequent development of tooth sensitivity. Patients may be prone to avoid brushing and flossing sensitive areas, with a consequent accumulation of plaque that can increase the risk of caries and periodontal problems. Desensitizing toothpastes or fluoride varnishes can relieve this sensitivity for minor areas of exposed dentine, but larger areas of erosion will require restoration.

Some patients will develop a heightened gag reflex during pregnancy and may be especially sensitive to the accumulation of intraoral fluids (e.g., from high-speed hand pieces and ultrasonic scaling units). Staff members should use high-speed suction to minimize the accumulation of fluids. Impressions may be deferred until after the pregnancy, as the flow of these materials toward the soft palate can stimulate the gag reflex.

Medication Use

Prescribing and administering medications for pregnant patients should be done with concern for both maternal and fetal safety. The FDA has established pregnancy drug risk categories according to drugs' effects on reproduction and pregnancy [53]. The safest medications that have been tested in pregnant women are category A drugs. However, due to possible risks to maternal and fetal health, drug trials rarely include pregnant women, and there are only a few medications that fall into this category. Category B medications have been found to have no fetal risk in animal studies, or more rarely, have been proven safe in women despite evidence of increased risks in animal studies. Medications for which increased risk of harm to mother or fetus cannot be ruled out are referred to as category C, while medications with evidence of negative effects are category D. Any medications that are contraindicated during pregnancy are considered category X.

The drug risk categories have been in effect since 1979 and were substantially updated in 2006 under the FDA's Physician Labeling Rule (PLR). Effective June 2015, the Pregnancy and Lactation Labeling Rule (PLLR) replaced the product letter categories with three detailed labeling subsections [54,55,56,57]:

- The pregnancy subsection must provide information relevant to use of the drug in pregnant women (e.g., dosing, potential risk to fetus); it must also provide information about whether a registry exists that collects/maintains date on the drug's effect on pregnant women.

- The lactation subsection must provide information about use of the drug during breastfeeding (e.g., amount of drug in breast milk, potential effect/s on the child).

- The females/males of reproductive potential subsection must include information about pregnancy testing, contraception, and infertility as it relates to the drug.

The PLLR is intended to provide a more consistent way to include relevant information about the risks and benefits for the mother, the fetus, and the breastfeeding child. It will apply to all "newly approved" drug and biologic product applications. The labeling of previously approved products that contain the product letter categories will be phased in gradually [57].

When prescribing medications to pregnant women before, during, and after dental treatment, these guidelines should be taken into consideration. In addition, the patient's unique medical history, medication use, and current condition should be considered. If there is any doubt as to which medication, dose, or frequency of administration to use, consultation with the patient's obstetrician is advisable.

FIRST TRIMESTER

Rapid cell division and organ development occurs between the second and eighth week of pregnancy. During this time, the fetus is most susceptible to the effects of stress and teratogens. Approximately 50% to 75% of all spontaneous abortions (miscarriages) occur during this period [58]. Dental treatment should be limited to basic periodontal prophylaxis, if needed, and emergency treatment of traumatic injuries, acute odontogenic infections, and/or pain of dental origin. Radiographs should only be done if required for diagnosis of an emergent dental problem. This is also an excellent time to educate patients about the importance of oral hygiene and the challenges that they may face during pregnancy.

A number of changes in the oral cavity have been associated with pregnancy, including caries, perimylolysis, tooth mobility, xerostomia, pregnancy granuloma, and ptyalism/sialorrhea [60]. Perhaps most commonly, the hormonal changes that occur during pregnancy have been linked with gingivitis. Approximately 60% to 75% of women will develop pregnancy gingivitis [59]. This can range from mild to severe gingival inflammation that can develop despite meticulous oral hygiene and the absence of chronic irritants such as plaque and calculus. Shifts in hormone levels may cause changes in the established microbiota, with overgrowth of certain bacteria species, increases in the ratio of bacterial anaerobes to aerobes, and changes in the proportions of Prevotella intermedia, Prevotella melaninogenicus, and Porphyromonas gingivalis [60,61,62]. Pre-existing subclinical gingivitis may become exacerbated during pregnancy to the point that clinical signs become apparent, including swelling, redness, bleeding, and tenderness [63]. These signs may begin to be noticeable in the second trimester and peak around the eighth month. Anterior teeth may be more apparently involved than the posterior. Mouth breathing is a potential exacerbating factor. A woman who has poor oral hygiene runs the risk of even greater gingival problems, although gingivitis can develop in women with no changes in their plaque-management behavior. Postpartum studies have shown that after delivery, the mother's level of gingivitis decreases as the constituency of the microbiota changes back to approximate its prepregnancy status. With the inflammation comes an increase in tooth mobility. Xerostomia is also reported in a high percentage of patients.

In a study published in 2010, researchers evaluated the way in which changing hormone levels influenced the gingival tissues in 48 pregnant and 28 nonpregnant women. In analyses of the subjects clinically and microbiologically, the researchers found that the proportions of the subgingival pathogens did not differ during pregnancy but did differ significantly after delivery. Patients who were P. gingivalis-positive presented with increased gingival inflammation that was not related to plaque [62]. Receptors for female sex hormones are located on human gingiva. The presence of progesterone, for example, may lead to greater gingival exudate. The inflammatory response also appears to be triggered as levels of estrogen and progesterone rise [61,64,65,66].

In addition to generalized gingival changes, a solitary, tumor-like growth, frequently referred to as a "pregnancy tumor" or "pregnancy granuloma," may appear. This lesion is often found associated with anterior interdental areas and has a histologic appearance similar to a pyogenic granuloma. Often, the lesion will regress after delivery, so decisions about surgical removal are best delayed until some time postpartum. Also, removal of the lesion during pregnancy may result in a recurrence [60].

SECOND TRIMESTER

By the second trimester, fetal organ formation is complete, so some elective dental procedures may be performed at this time. The increasing fetal size and weight during the second trimester can place pressure on the inferior vena cava and compromise the return of blood to the heart when the patient is in a supine position. This can lead to maternal hypotension, decreased cardiac output, and loss of consciousness. Turning the patient on her left side will relieve the fetal weight against the inferior vena cava and allow the resumption of the appropriate blood flow. Radiographs should only be taken if absolutely necessary.

THIRD TRIMESTER

While dental treatment poses a minimal risk to the fetus in the third trimester, increasing fetal size and weight can make the mother feel uncomfortable in any position for dental treatment. Appointment duration should be kept to a minimum and should address basic oral hygiene procedures and emergent dental issues. Contact in this period presents an opportunity to educate the mother about the oral hygiene needs of young children and the need for the child to see a dentist or pedodontist early in life so a preventive regimen can be instituted to promote optimal oral health. Pregnant patients should be provided with information about the importance of proper brushing techniques of deciduous teeth and about whether or not fluoride supplements are recommended for the child.

6. PERIODONTAL DISEASE AND SYSTEMIC DISEASE

Since the late 20th century, there has been a resurgence of interest about the association between oral health, specifically periodontal disease, and various systemic diseases. However, this is not a new theory. In 1891, a publication entitled The Human Mouth as a Focus of Infection theorized that poor oral health could be detrimental to systemic health, postulating that the extraction of all teeth could be a means of safeguarding overall health [67]. Today, the areas of greatest interest are the potential relationships between periodontal disease and cardiovascular disease and diabetes. Because this is an area of continuing research, there is some disagreement.

PERIODONTAL DISEASE AND CARDIOVASCULAR DISEASE

In 1989, studies by Mattila and colleagues determined that there was a higher rate of caries, periodontitis, periapical lesions, and pericoronitis among patients with recent myocardial infarctions [68]. Syrjanen and colleagues noted poor oral hygiene among patients who had experienced a recent stroke compared with a control group that had not experienced a stroke [9]. Since then, many studies exploring the relationship between periodontal disease and cardiovascular health have been published, suggesting factors that may constitute the basis of this relationship.

Researchers have hypothesized both direct and indirect pathways by which the pathogenic bacteria associated with periodontal disease may cause damage to the vascular endothelium, with the subsequent development of atherosclerosis. Atherosclerosis is the primary cause of myocardial infarction, stroke, and peripheral vascular disease. While research in this area continues, a direct cause-and-effect relationship between periodontal disease and cardiovascular disease has not yet been established [69].

Direct Pathways

Periodontal disease is inflammatory in nature, and Actinobacillus actinomycetemcomitans, P. gingivalis, Tannerella forsythia, and Treponema denticola are among the most common pathogenic bacteria [70]. Inflammation in the periodontal pockets creates a highly vascular environment, which allows periodontal pathogens direct access to the systemic circulation.

Atheromas are small, patchy thickenings that develop on the inner lining of arteries and subsequently protrude into the arterial lumen. These plaques can impede and ultimately stop the flow of blood. Platelets can collect on these atheromatous lesions and further impede the flow of blood by forming a thrombus (a stationary blood clot). If the thrombus detaches and travels through the bloodstream, it can lodge anywhere in the vascular network. Studies show that 40% of atheromatous lesions contain antigens produced in response to periodontal pathogens [71]. P. gingivalis can stimulate platelet aggregation, a component of atheromas and thrombi [72]. It has also been suggested that these periodontal pathogens can infiltrate the vascular endothelium and directly cause dysfunction, inflammation, and atherosclerosis [73].

Indirect Pathways

Periodontal disease is a chronic inflammatory disease, and in patients with this disease, chemical mediators of inflammation are released systemically. These mediators have been theorized as an indirect pathway by which periodontal disease may influence the development of cardiovascular disease. Circulating inflammatory mediators produced and released in association with periodontal disease include cytokines, such as tumor necrosis factor-alpha (TNF-a) and interleukin-1 (IL-1). These cytokines can increase the low-density lipoprotein (LDL) level and decrease the high-density lipoprotein (HDL) level while also elevating the triglyceride level, all of which contribute to the development of cardiovascular disease [74].

The soluble blood protein fibrinogen, which is converted to fibrin during the coagulation process, is also elevated in patients with periodontal disease [75]. The release of fibrinogen can lead to localized clot (thrombus) formation, with the potential for a stroke or myocardial infarction. C-reactive protein (CRP), an acute-phase protein, is elevated in patients with periodontal disease. CRP is a strong indicator of cardiovascular risk. Elevated CRP levels coupled with the ratio of total cholesterol to HDL are used to identify persons at high risk for the development of a myocardial infarction [76]. When definitive periodontal treatment is performed, with a subsequent decrease in gingival inflammation, the serum levels of these inflammatory mediators also decrease [77].

PERIODONTAL DISEASE AND DIABETES

Periodontal disease is unequivocally a major complication of diabetes, and poorly controlled diabetes and periodontal disease are closely linked [78,79,80]. Susceptibility to periodontitis is increased by approximately threefold in people with diabetes. [80]. Individuals with diabetes frequently complain of oral changes, including diminished salivary flow and/or xerostomia, altered saliva composition, inflammation, loss of sensation, changes in taste perception, numbness, burning mouth syndrome, and lesions of the oral mucosa and tongue [81]. Although these are not all symptoms of periodontitis, the oral changes can predispose an individual for the development of gingivitis and periodontitis. There is evidence of a relationship between periodontal disease severity and diabetes (particularly poorly controlled diabetes), but the exact mechanism by which one might influence the other has not been definitively determined [80]. Emerging evidence suggests the existence of a two-way relationship between diabetes and periodontitis, with diabetes increasing the risk for periodontitis and periodontal inflammation negatively affecting glycemic control [80]. Many believe that the host of oral changes evidenced in patients with diabetes may act synergistically to predispose these individuals for periodontitis [82].

Both diabetes and periodontal disease share a common pathogenesis that involves enhanced inflammatory response at the local and systemic levels. This inflammatory response is mainly caused by the chronic effects of hyperglycemia and specifically the formation of biologically active glycated proteins and lipids [80,83]. Patients with diabetes, especially uncontrolled diabetes, are at an increased risk for impaired healing, and the periodontal pocket can experience persistent inflammation and bacterial infection in patients with periodontal disease, which can be made worse by this impaired healing [82,85]. Loss of teeth because of aggressive periodontitis may also occur [85].

The pathophysiology of endothelial dysfunction and inflammation is the root cause of much of the microvascular and macrovascular deterioration associated with diabetes [80,85]. The normal metabolic response to a glucose load is an increase in free fatty acids and insulin. These changes result in a transient decrease in endothelium-derived nitric oxide production and in endothelium-mediated vasoconstriction. In the presence of normal glucose tolerance, endothelial nitric oxide production and vasodilation return to normal within two hours. However, in patients with diabetes, endothelium-mediated vasoconstriction continues for hours [84]. This impaired blood flow can affect collagen synthesis, maturation, and homeostatic turnover, all of which can result in impaired healing and the development of periodontal disease [82].

In addition to vasoconstriction, endothelial dysfunction is correlated with aggregation of platelets, a proinflammatory state characterized by the accumulation of leukocytes and coagulation products on the endothelium. Fibrinolysis is decreased, and thrombosis is increased. As the secretion of prostacyclin and nitric oxide induce vasoconstriction, plasma cytokine and prothrombin factors levels increase. This makes the plasma markedly procoagulant and antifibrinolytic, promoting atherosclerosis [85]. The Insulin Resistance Atherosclerosis Study also demonstrated that chronic hyperglycemia was positively associated with increased intimal-medial wall thickness [83]. These changes in both the microvascular and macrovascular systems lead to reduced vascular reactivity and increased production of glycation end products [84]. The accumulation of advanced glycation end products in the gingival tissues is generally responsible for the oral complications of diabetes. In fact, individuals with poorly controlled diabetes have a two- to three-fold increase in the prevalence of oral lesions and periodontal disease.

7. TOBACCO USE: IS THERE A SAFE ALTERNATIVE TO SMOKING?

Tobacco was the first export of the New World and was marketed in Europe as a remedy for stress, ulcers, headaches, asthma, and even rheumatism. In contrast to strict regulations found elsewhere in the world, tobacco was brought to the United States as a cash crop. Though medical concerns were suggested, the first tobacco prohibition movements in the United States were primarily driven by religious and moral motivations [86].

Associations between smoking and cancer were not published in the United States until the 1950s and 1960s. The 1964 publication Smoking and Health: Report of the Advisory Committee to the Surgeon General led to immediate political notice of the tobacco issue and the advent of programs and policies to reduce smoking [87]. Anti-tobacco policies have included taxation on tobacco products, increased insurance premiums, warning labels, public health campaigns, and restrictions on tobacco sales to minors, smoking in public areas, and tobacco marketing. Prior to 1964, there were few if any laws regulating involuntary secondhand smoke exposure. Studies revealing the detrimental effects of secondhand smoke to nonsmokers led to new anti-smoking legislation. Today, nearly all 50 states have laws restricting smoking in places such as schools, public transportation, government buildings, elevators, and restaurants. In accordance with federal law, smoking is prohibited on buses, trains, and domestic airline flights. Such laws have decreased cigarette consumption by making smoking less socially acceptable and more inconvenient [86].

Despite the seemingly well-known and highly publicized health consequences of smoking, 13.9% of the U.S. population 18 years of age or older are current cigarette smokers [88]. Approximately 480,000 Americans die each year as a result of active and/or passive smoking-related health consequences [89].

With the adverse effects of smoking known and increasing social pressures to limit or ban smoking in many public places, smokers have begun to seek alternatives to cigarette smoking that can satisfy the physiologic and psychologic cravings for nicotine but without the deleterious health effects and stigma of cigarettes. Although the prevalence of cigarette smoking continues to decline, there is some evidence that this decline is a reflection of a migration to non-cigarette products, especially e-cigarettes [90,91]. In addition to a rise in the use of smokeless tobacco, people across the United States (especially youth) are using e-cigarettes, cigars, cigarillos (small cigars), hookahs, kreteks, pipes, and bidis (or beedis) [92,93]. Unfortunately, each of these products is just as dangerous (if not more so) as use of cigarettes, despite public perception.

SMOKELESS TOBACCO PRODUCTS

Smokeless tobacco by definition is non-pyrolytic (not burned or combustible), and there may be an erroneous belief that because it is not smoked, this tobacco is safe. However, this is demonstrably untrue.

Smokeless tobacco is also known as dip, chew, snuff, or chewing tobacco and generally exists in two forms. Snuff is finely ground tobacco that can be moist, dry, or placed in pouches. Moist snuff comprises about 81% of the smokeless tobacco market. With this product, a pinch (or "dip") is placed between the gingival tissues and the cheek or lip [94]. Expectoration is required. More rarely, finely ground snuff may be sniffed or inhaled through the nose. Chewing tobacco exists in the form of loose leaves, as tobacco leaves condensed together as a plug or as tobacco leaves that are twisted together like a rope. The loose leaf form of chewing tobacco accounts for about 18% of the smokeless tobacco market [95]. In 2016, approximately 3.4% of adults, or about 9 million individuals 18 years of age and older, in the United States currently used a smokeless tobacco product [96].

While smokeless tobacco eliminates the risks of secondhand and thirdhand smoke to bystanders, it remains highly addictive and harmful to users. Nicotine from smokeless tobacco is absorbed more slowly through the oral mucosa, compared with the rapid systemic absorption and distribution from cigarette smoke [97]. However, the effects of nicotine absorbed through the oral mucosa are more protracted. Although the route of absorption varies, the potential for addiction remains the same.

Smokeless tobacco contains 28 carcinogens and is a known cause of oral and pancreatic cancers [98]. The extended contact time of smokeless tobacco products on the oral mucosa allows these carcinogens ample time to begin changing the cells of the mouth and esophagus. Smokeless tobacco users may develop squamous cell carcinoma, smokeless tobacco keratosis (also known as snuff pouch lesion or snuff dipper's lesion), and/or verrucous carcinoma. Potential adverse effects to the periodontium include gingival recession, periodontal disease, and necrotizing ulcerative gingivitis [52].

ELECTRONIC CIGARETTES (E-CIGARETTES)

The rise of e-cigarettes in the past decade has introduced new variables in the prevention and treatment of nicotine addiction. Originally marketed as a smoking cessation tool, e-cigarettes are electronic products that typically deliver nicotine in the form of an aerosol [91]. Most e-cigarettes consist of a cartridge (which holds a liquid solution containing varying amounts of nicotine, flavorings, and other chemicals), a heating device (vaporizer), and a power source (usually a battery) [99]. In many e-cigarettes, puffing activates the battery-powered heating device, which vaporizes the liquid in the cartridge. The resulting aerosol or vapor is then inhaled (called "vaping") [99]. It is unclear if this delivery method decreases the risks seen with conventional tobacco smoking; however, it does introduce the risks of toxicity associated with consumption of the potent e-liquid.

In 2017, 2.8% of adults were current e-cigarette users. Adults 25 to 44 years of age have the highest rate of e-cigarette use (22.5%), followed by those 45 to 64 years of age (21.3%), 18 to 24 years of age (18.3%), and older than 65 (11%) [91]. Use is much higher among men (24.8%) than women (14.2%).

Adolescent use of e-cigarettes has skyrocketed from 1.5% in 2011 to 20.8% in 2018, making it the number one form of tobacco used among youth [100,101]. In 2018, the FDA issued more than 1,300 warnings and fines to retailers who illegally sold e-cigarette products to minors [102]. In 2020, the FDA banned mint- and fruit-flavored e-cigarette cartridges in an effort to halt uptake among children [13].

Because e-cigarettes have been used in the United States for a relatively short period, the long-term effects on oral and systemic health are not totally clear. Elimination of exposure to tar is a benefit for e-cigarette use. However, the chemicals that are inhaled while using e-cigarettes are associated with known health hazards. Nicotine remains a highly addictive compound regardless of its source. People who use e-cigarettes can experience nicotine withdrawal symptoms if they discontinue the use of the device. One study demonstrated that formaldehyde, a known carcinogen, can be produced during the vaping process, with the potential for the user and bystanders to inhale vapor that contains the carcinogen [103]. In general, e-cigarettes cannot be considered a safe alternative to cigarette smoking.

HOOKAHS

A hookah is a type of waterpipe comprised of a head or bowl, plate, body, jar, hose, and mouthpiece. The body of the hookah fits down into the jar, which is partially filled with water, although any liquid (e.g., alcohol, juice) can be used. Tobacco is placed in the bowl at the head of the body and covered with a filter, such as perforated tin foil, and then burning embers or charcoal is placed above it (and sometimes covered by a cap). The hot air from the charcoal roasts the tobacco and the ensuing smoke is passed down into the liquid in the jar, where it is partially filtered, diluted, and cooled. The smoke then bubbles up and passes through the hose and mouthpiece for inhalation. Repeated inhalation is required to keep the tobacco burning. The plate stores dead coals/embers. The types of tobacco used for hookah are ajami or tumbak, which is a pure, dark tobacco paste; "honeyed" tobamel or maassel, containing 70% honey or molasses and featuring flavors (e.g., apple, mango, banana); or jurak, which may be sweetened or contain fruits or oils. It is commonplace to use 10–20 g at a time, and these tobaccos may be mixed with other drugs [104]. Smoking sessions last up to an hour or longer, and it has been reported that the nicotine content of the tobacco used for hookah is higher than that in cigarettes [105]. Thus, the smoker is exposed to a higher volume of smoke for longer periods (not to mention those in the vicinity). A report from the World Health Organization states that a hookah user may inhale as much smoke in one session as a cigarette smoker would after consuming at least 100 cigarettes [106].

Contrary to popular belief, waterpipe smoking is not safer or less addictive than cigarette smoking [107]. The FDA began regulating the manufacture, import, packaging, labeling, advertising, promotion, sale, and distribution of tobacco mixtures used for hookah in 2016 [108]. Hookah smoke contains higher concentrations of carbon monoxide, nicotine, tar, heavy metals, and carcinogens, likely because of its method of use (i.e., tobacco mixtures heated by quick-burning charcoal or wood embers and inhalation through use of a plastic hose for an hour or longer) [109,110]. It is also common to share a hookah, so users are also at risk of exposure to infections (e.g., herpes due to sharing of the mouthpiece) [111]. Hookah pipe smoking may be a gateway to cigarette smoking and other drug use. Although policies are in place to ban smoking in many public places, many times, hookah use is exempt because it is done in places which identify themselves as "tobacco bars," waterpipe smoking areas are set up outside, or the smoking is done in places where tobacco is sold.

8. HALTING MEDICATIONS PRIOR TO INVASIVE DENTAL PROCEDURES

The ability to achieve hemostasis after invasive dental procedures can be challenged by various coagulopathies and by the patient's use of anticoagulant and antiplatelet medications. A literature review of thromboembolic risks upon discontinuance of anticoagulant therapy prior to invasive dental procedures revealed serious embolic complications, including four deaths, among 493 patients [112]. Whether or not it is necessary to temporarily hold these medications before invasive dental treatment has been the source of confusion. In essence, this decision is based on an individualized assessment of risk.

ANTICOAGULANTS

Prior to initiating invasive dental treatment for any patient who is using an anticoagulant medication, the first step is to identify the underlying condition. A variety of conditions require anticoagulation, including venous thrombosis, pulmonary embolism, and prevention of recurrent myocardial infarction or stroke. In many cases, patients with these conditions have additional comorbidities, such as hypertension and diabetes. A patient's entire medical history should be considered before dental treatment is initiated, and consultation with the patient's physician should be sought if there is concern about proceeding with treatment. It is important to note that only a physician should make the decision to withhold anticoagulant therapy.

Anticoagulants reduce vitamin K-dependent synthesis of coagulation factors II, VII, IX, and X in the liver. Warfarin has been the most commonly prescribed anticoagulant in the United States, although other agents (e.g., apixaban, dabigatran) are growing in popularity [113]. The therapeutic effects of warfarin can be monitored using the international normalized ratio (INR), which is a ratio of the patient's prothrombin time against a laboratory control. The INR of a person whose blood clots normally and is not taking an anticoagulant would be 1. Values greater than 1 indicate a lengthened time to coagulation. The therapeutic range of INR depends on the medical problem for which it is prescribed. Laboratory values obtained within the last 48 hours are the most accurate [114]. An INR of 3 or less generally indicates it is safe to perform minor oral surgery without a temporary discontinuance of the warfarin [115]. However, INR values should only serve as a guide, because there is no universally accepted value at which a patient on warfarin is guaranteed to achieve hemostasis after an invasive dental procedure. Other factors that can adversely affect hemostasis include hepatic disease, alcoholism, thrombocytopenia (low platelets), renal failure, and the nature and the extent of the planned surgical procedure.

As noted, while warfarin is the most common anticoagulant, other agents are commonly used, including dabigatran (a potent inhibitor of free thrombin) and the selective factor Xa inhibitors rivaroxaban and apixaban. INR is not useful for these medications, and evidence-based guidelines are lacking for the dental management of patients using these agents, so consultation with the patient's physician is advisable prior to the initiation of any invasive dental procedure.

Patients who remain on anticoagulant therapy during invasive dental treatment should not use NSAIDs (e.g., naproxen, ibuprofen), as these medications can inhibit platelet aggregation. When this action is coupled with the actions of an anticoagulant medication, the potential for postprocedural bleeding increases.

ANTIPLATELET MEDICATIONS

Antiplatelet medications act by inhibiting platelet aggregation; aspirin and clopidogrel are popular examples. The most common indications for antiplatelet medications are the prevention of arterial and venous thrombosis in patients with ischemic heart disease, the prevention of platelet aggregation in patients who have cardiac stents or heart valve implants, and prevention of recurrent stroke in patients who have experienced one in the past [116]. These medications have no impact on coagulation factors. In most cases, patients who use aspirin for antiplatelet therapy do not experience more postsurgical bleeding than patients who do not take aspirin [117]. Similarly, studies have demonstrated that the use of clopidogrel is not equated with excessive bleeding during or after minor oral surgery procedures [118].

As with patients who use anticoagulants, the underlying condition necessitating antiplatelet therapy should be documented. Consultation with the patient's physician is advisable to understand the current status and prognosis of the patient's cardiovascular or cerebrovascular problem and to determine if any other co-existing systemic illnesses complicate the ability to provide dental care for the patient.

Platelets are not actually cells but are fragments of a larger progenitor cell called a megakaryocyte. These fragments lack a nucleus but contain a host of chemicals that are essential to the clotting process. Because antiplatelet medications interrupt varied phases of the process by which platelets adhere to a damaged blood vessel and to each other, there is a concern about the ability to achieve hemostasis after an invasive dental procedure. The risk of bleeding during or after an invasive dental procedure if a patient remains on antiplatelet medications should be weighed against the risk of an adverse cardiovascular or cerebrovascular event if these medications are held temporarily.

The American Heart Association, the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, the American College of Surgeons, and the American Dental Association have published a consensus opinion about drug-eluting stents and antiplatelet therapy [119]. It stresses the importance of maintaining antiplatelet medications to minimize the risk of stent thrombosis and recommends that the patient's cardiologist should be consulted to discuss the patient's antiplatelet regimen and the optimal management of the patient for invasive dental procedures [120]. A decision to temporarily discontinue aspirin, clopidogrel, or any other antiplatelet medication is made by the cardiologist.

While studies indicate that patients who continue antiplatelet therapy during invasive dental procedures are not likely to experience excessive bleeding, it remains a possibility. The nature and extent of the procedure, hepatic disease, alcohol abuse, and/or any coagulopathy should be considered. If the medications are continued and intra-operative or postsurgical bleeding is a concern, the procedure may need to be completed in a hospital or an outpatient treatment center.

The use of NSAIDs for analgesic relief of pain adjunctive to dental treatment is common, and these medications can inhibit platelet aggregation and prolong the bleeding times in some patients [121]. If antiplatelet therapy and NSAIDs are taken concurrently, the risk of bleeding will increase. Therefore, an alternative analgesic, such as acetaminophen, should be considered.

9. ACCESS TO DENTAL CARE: A MULTIFACTORIAL PROBLEM

Although the link between oral health and general health is well-established, the divide between the two fields is great. Many healthcare professionals have not received formal training in oral health, but collaborative care with dental professionals is an essential aspect of improving dental care. A discussion of all the underlying causes of poor access to dental care for people in the United States is beyond the scope of this course. However, a brief exploration of major contributing factors will be provided.

RURAL AREAS AND THE DENTAL WORKFORCE

As compared to decades ago, dental health has improved across the United States, which is primarily attributed to fluoridation of water and toothpaste and greater awareness of optimal oral hygiene. However, rural areas have a variety of factors that continue to contribute to poorer oral health in this population [122]:

- Geographic isolation

- Lack of adequate transportation

- Higher rate of poverty compared to metro areas

- Large elderly population (with limited insurance coverage of oral health services)

- Acute provider shortages

- State-by-state variability in scope of practice

- Difficulty finding providers willing to treat Medicaid patients

- Lack of fluoridated community water

- Poor oral health education

Dental care is a problem largely because of a lack of practicing dentists and insufficient dental insurance. There are fewer rural dentists (per capita) available to address oral disease than in urban settings, and the majority of dental health professional shortage areas lacking access to dental services are rural [124]. An estimated 8,600 additional dentists will be required nationally to meet care needs by 2025 [124]. To address this problem, areas with fewer dental professionals may qualify for a federal dental health professional shortage area designation. Having this designation can qualify the area to receive financial aid or recruitment aid from the government [125,126].

It is estimated that 49 million people in the United States live in areas in which access to dental care is limited [127]. Rural areas and areas in which there is a chronic high rate of unemployment can have difficulty in attracting dentists to these areas due to the high cost of maintaining a practice.

A shortage of dental practitioners in rural and micropolitan areas has resulted in emergency departments becoming the alternative for evaluation and treatment of dental conditions [123]. To address this problem, states have passed laws intended to expand the dental care workforce. In Minnesota, for example, additional license types (dental therapists and advanced dental therapists) have been added to help meet the need for dental professionals qualified to provide preventive and restorative dental care, in some cases with less direct supervision [128,129]. In this case, at least half of a dental therapist's patients must be considered underserved—that is, on public assistance, uninsured, or living in an area with a shortage of dentists [130]. Several states permit new dental profession types to provide dental care under varying levels of supervision by dentists, allowing these providers to meet dental care needs in nontraditional, tribal, school-based, and community settings [128]. In Alaska, where the majority of land is classified as rural, some clinics have sent out dental health aide therapists to distant rural sites to deliver routine restorative care. As a result of this initiative, many recipients were able to have regular access to dental care for the first time [130].

Aside from government actions to increase workforce numbers and to expand the scope of practice, dental care workforce capacity can be built using teledentistry. In California, dental hygienists use teledentistry to improve dental care access for the young and disabled. Dental hygienists go to community settings such as schools, Head Start public programs, and nursing homes, where patients are screened and data are transmitted digitally back to the dentist, who creates a treatment plan for the hygienist to implement [130]. These solutions have potential to mitigate dental disease in rural underserved communities.

CHILDREN

Dental caries are the most common chronic childhood disease and are five times more common than asthma [131]. However, studies indicate that many children have not received even the most basic of dental care. A study of third-grade children in New York revealed that 54% had dental caries, with 33% lacking treatment [132]. In 2009, 17 million low-income children received no dental care [133]. There are many underlying reasons for this disparity of dental care among children, including lack of transportation, lack of insurance, poor understanding of the importance of deciduous teeth, and difficulty finding a pedodontist.

As compared with the general population and other racial/ethnic groups, American Indian/Alaska Native (AI/AN) children are disproportionately affected by dental disease, and oral health for school-aged AI/AN children 6 to 9 years of age did not change significantly between 2012 and 2017 [134]. The compromised health of this population is believed to be rooted in historic economic adversity and poor social conditions [135].

The Indian Health Services Early Childhood Caries Initiative provides AI/AN children with oral assessments and interventions to mitigate early childhood dental disease, giving public health nurses the opportunity to be part of a collaborative team effort improving oral health. The Indian Health Services Early Childhood Caries Initiative involves multiple stakeholders, including dental and medical staff and other programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). WIC is a social program for low-income women, infants, and children up to 5 years of age to provide healthy foods and referrals [136].

ELDERLY PATIENTS

Numerous socioeconomic issues can present obstacles for patients of any age who wish to obtain dental care. However, geriatric patients may experience additional barriers in their attempts to maintain dental health.

Financing of dental care is the primary obstacle for many older adults. Most patients older than 65 years of age are retired and therefore no longer have dental insurance as an employee benefit. Without this option and income limited to retirement savings, social security income, and any pension plan benefits, the costs associated with dental treatment may not be easily accommodated. Funding from federal, state, and county sources is often limited, both in available funds and treatment coverage.

Available financial resources among the geriatric population vary considerably. Unfortunately, many older adults live near or even below the poverty level and have difficulty in affording basic preventive dental care.

Medical problems can also present a major obstacle in the provision of dental care for geriatric patients. As discussed, many older adults are afflicted with at least one chronic disease and most have experienced medical problems. Even with Medicare insurance, the cumulative costs of medical treatment and medications can escalate and contribute to budgetary concerns, making it difficult to afford dental care.

Coping with serious medical problems may leave older adults without the motivation and ability to seek dental care. Some medical problems may also lead to one spouse assuming the role of caretaker for the other. If this is the case, both can have difficulties in obtaining dental care. The caregiver spouse may have difficulty setting aside time for a dental appointment, while the morbidity of the medical problem and transport issues make dental appointments difficult for the infirmed. Patients in long-term care facilities may also face obstacles in obtaining dental care [96]. The cost of long-term care is often a strain and may limit patients' ability to afford dental treatment. Difficulties with transportation, especially to an outside dental office, may also be a barrier to seeking dental care. In order to overcome this barrier, some long-term care facilities may contract with a private dentist to provide care within the facility. However, the fees associated with this level of service are prohibitive to many.

While there are other barriers in the provision of dental treatment of geriatric patients, including the availability of clinicians specializing in treating older patients, financial and transportation issues are the most frequently encountered. Because oral health is such an important component to overall health and quality of life, efforts should be made toward the improvement of access to dental care for all within the geriatric population.

10. CONCLUSION

This course has presented several controversial issues that arise in dental practice. In some cases, these can be divisive issues, but ideally they can be a means of beginning and maintaining progress toward long-term solutions and improved care and patient education. Clinicians who are well-informed about these multifaceted issues will be in the best position to inform patients and to provide treatment that will enhance their quality of their life.

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137. U.S. Food and Drug Administration. FDA Issues Recommendations for Certain High-Risk Groups Regarding Mercury-Containing Dental Amalgam. Available at https://www.fda.gov/news-events/press-announcements/fda-issues-recommendations-certain-high-risk-groups-regarding-mercury-containing-dental-amalgam. Last accessed January 5, 2021.

51952 • Carpal Tunnel Syndrome

Charlene H. Grafton, RN, BS, MS, CCM

www.netce.com

Copyright © 2018 NetCE, All rights reserved.

This course will be applicable to dental professionals who are at risk for carpal tunnel syndrome. An evaluation of available treatments for a diagnosis of computer-related injury will be provided. According to the Bureau of Labor and Occupational Safety and Health Association, certain professions are at risk for overuse injuries of the hand, fingers, and wrist. Identifying these occupations and other risk factors will be reviewed. Numerous research studies regarding the importance of ergonomics will be cited. This will include identification of available alternative devices and training methods to reduce the incidence of carpal tunnel syndrome. Finally, office safety programs and work claims will be reviewed in order to reduce these types of injuries.

Table of Contents

51952 • Carpal Tunnel Syndrome

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

About the Sponsor

Disclosure Statement

1. INTRODUCTION

PURPOSE OF THE COURSE

2. CARPAL TUNNEL SYNDROME DEFINED

3. CAUSES AND CONTRIBUTING FACTORS

HEALTH CONDITIONS

OCCUPATION/ACTIVITY

PERSONAL/PHYSICAL FACTORS

4. CONDITIONS THAT MIMIC CARPAL TUNNEL SYNDROME

HAND-ARM VIBRATION SYNDROME

OTHER MEDIAN NERVE COMPRESSION SYNDROMES

CERVICAL SPONDYLOSIS

CUBITAL TUNNEL SYNDROME

TENOSYNOVITIS

5. DIAGNOSING CARPAL TUNNEL SYNDROME

PHYSICAL EXAMINATION

ELECTROPHYSIOLOGIC STUDIES AND IMAGING

6. TREATMENT OF CARPAL TUNNEL SYNDROME

TREATMENT GOALS AND ASSESSMENT TOOLS

NON-SURGICAL TREATMENT

SURGICAL TREATMENT

7. PREVENTION STRATEGIES

NON-ENGLISH-PROFICIENT PATIENTS

8. SIMULATED CASE STUDY

9. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

51952 • Carpal Tunnel Syndrome

Education Category. Community Health

Release Date. 07/01/2018

Expiration Date. 06/30/2021

Course Overview

This course will be applicable to dental professionals who are at risk for carpal tunnel syndrome. An evaluation of available treatments for a diagnosis of computer-related injury will be provided. According to the Bureau of Labor and Occupational Safety and Health Association, certain professions are at risk for overuse injuries of the hand, fingers, and wrist. Identifying these occupations and other risk factors will be reviewed. Numerous research studies regarding the importance of ergonomics will be cited. This will include identification of available alternative devices and training methods to reduce the incidence of carpal tunnel syndrome. Finally, office safety programs and work claims will be reviewed in order to reduce these types of injuries.

Audience

This course is designed for dental professionals who may encounter patients with carpal tunnel syndrome or who are at risk for carpal tunnel syndrome themselves.

Course Objective

The purpose of this course is to provide dental professionals with awareness of carpal tunnel syndrome, based on specific signs and symptoms and appropriate diagnostic tests, and of interventions available to treat and/or prevent the condition.

Learning Objectives

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

1. Define carpal tunnel syndrome, and identify the causes and contributing factors.

2. Identify conditions that may mimic carpal tunnel syndrome.

3. Describe the methods and tools currently used to diagnose carpal tunnel syndrome.

4. Discuss the recommended treatment options for carpal tunnel syndrome.

5. Discuss potential prevention strategies for patients who may be at risk for developing carpal tunnel syndrome, including considerations for non-English-proficient patients.

Faculty

Charlene H. Grafton, RN, BS, MS, CCM, is licensed in two states as a Registered Nurse and was nationally certified as a Case Manager. She has worked as a Qualified Rehabilitation Provider and an Independent Nurse Case Manager. She was selected as Who's Who by American Colleges and Universities, American Nursing and also by the International Tennis Federation. Also, she is a Veteran of the Army Nurse Corps, First Lieutenant. Ms. Grafton has demonstrated her natural leadership style through volunteer work and participation on various Boards of Directors, such as the Jaycee Jaynes, Nevada Community Enrichment Program, Southern Nevada Continuity of Care Association, Florida's Governor's Council on Fitness and Sports, Nevada Tennis Association, National Senior Women's Tennis Association, Health Insight (Medicare and Medicaid) and the Executive Women's Golf League. In addition, she has presented papers and shown her teaching abilities by speaking at local, state, regional, national and international forums on a variety of subjects, including teaching techniques, lateral dominance, fitness and case management. As a writer, she has published two books about dominance and researched in areas of coordination, laterality, and sidedness from gifted to learning disabilities/problems and functional independence. Her work has also appeared in trade magazines.

Faculty Disclosure

Contributing faculty, Charlene H. Grafton, RN, BS, MS, CCM, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

William E. Frey, DDS, MS, FICD

Division Planner Disclosure

The division planner 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.

1. INTRODUCTION

While carpal tunnel syndrome is possibly the most common nerve disorder diagnosed today, it is not a new condition born of the information technology age [1]. Compression of the median nerve of the hand was first reported in 1854 by Sir James Paget. In 1880, James Putnam reported on a series of patients who were experiencing pain and paresthesia in the median nerve of the hand. In 1913, Pierre Marie and Charles Foix offered a description of the pathology of median nerve compression, and in 1933, Sir James Learmonth reported the first release treatment for median nerve compression [2].

Determining the causes of carpal tunnel syndrome remains an area of ongoing research, discussion, and disagreement among healthcare professionals. Historically, some have concluded that carpal tunnel syndrome is purely an occupational disorder with clear-cut associations to repetitive manual movements or work tasks. Others have concluded that the causes of carpal tunnel syndrome are unknown, unproven, or based on multiple factors.

Despite the ongoing disagreement about its causes, the U.S. Department of Labor Bureau of Labor Statistics reports that carpal tunnel syndrome exacts a significant toll each year on the health and productivity of the U.S. workforce. The rate of reported cases, while declining in recent years, accounts for the second highest number of days away from work among all work-related musculoskeletal disorders [12,13,14]. Approximately 5,650 cases of occupational injury or illness resulting from carpal tunnel syndrome and involving time away from work (median: 28 days) are reported each year, resulting in lost wages, increased healthcare costs in local communities, and added costs to state workers' compensation programs.

PURPOSE OF THE COURSE

The purpose of this course is to provide information about the causes of carpal tunnel syndrome and to review current methods of diagnosis and treatment and recommended prevention strategies. It begins by defining carpal tunnel syndrome, which includes a discussion of common symptoms, causes and contributing factors, and conditions that mimic carpal tunnel syndrome. Current diagnostic methods and tools are reviewed, and current treatment options and recommended prevention strategies are discussed. The course concludes with a simulated case study that describes the course of treatment for a patient who presents with chronic symptoms of carpal tunnel syndrome.

2. CARPAL TUNNEL SYNDROME DEFINED

Carpal tunnel syndrome is generally associated with such umbrella terms as repetitive stress injuries, work-related upper extremity disorders, musculoskeletal disorders, entrapment neuropathies, and cumulative trauma disorders [16,18]. Specifically, carpal tunnel syndrome is a painful disorder of the wrist and hand that occurs when the median nerve (which runs from the hand to the forearm) becomes compressed [1,19].

The carpal tunnel is a narrow passageway on the palm side of the wrist. Surrounded by bones and ligaments, the carpal tunnel houses and protects the tendons of the hand and the median nerve, which controls sensations to the thumb and fingers (Figure 1). When the median nerve becomes pinched or compressed (due to swelling or irritation in adjacent tissues or tendons), the result can be pain, numbness, hand weakness, and in extreme cases, loss of hand function. Cases of bilateral carpal tunnel syndrome have been reported, but typically only one hand is affected [1,20,21]. Carpal tunnel syndrome is rare in children; it usually occurs only in adults [9].

Figure 1: CARPAL TUNNEL ANATOMY

Source : Author

The symptoms of carpal tunnel syndrome typically appear gradually and may include [9,20]:

- Numbness, burning, or tingling in the fingers and palm of the hand

- Pain in the wrist, palm, or forearm, especially during use

- Decreased grip strength

- Weakness in the thumb

- Sensation of swollen fingers, whether or not swelling is apparent

- Difficulty distinguishing between hot and cold

Symptoms may cause waking during the night with the urge to "shake out" the hand or wrist. Symptoms may occur with activities that require prolonged grasping and/or flexing of the wrist (e.g., driving, holding a book). Left untreated, carpal tunnel syndrome can progress to persistent numbness and permanent loss of hand function. In severe and chronic cases, irreversible muscle damage or atrophy may occur [1,9,23]. Complete sensory loss in the hand has also been reported.

3. CAUSES AND CONTRIBUTING FACTORS

Researchers have identified a variety of factors that may cause or contribute to the development of carpal tunnel syndrome. These factors include the presence of other health conditions, engagement in an occupation or activity that involves repetitive use of the hand, and the presence of a range of personal/physical factors that may indicate a predisposition to carpal tunnel syndrome [1,3,9,13,19,20,26,28,30]. There is general agreement that carpal tunnel syndrome is multifactorial and that the exact cause is unknown [31]. Also, the role of individual contributing factors in the development and prognosis of carpal tunnel syndrome is uncertain. In some instances, no cause can be identified [9]. However, the pathophysiology seems to involve alterations of fluid balance (e.g., fluid retention), hormonal changes, and accompanying peripheral tissue edema, which may be precipitated by a variety of disorders and bodily changes [47].

HEALTH CONDITIONS

Several health conditions are associated with the presence of carpal tunnel syndrome and may be contributing factors in its development. The most commonly noted co-occurring health conditions are noninflammatory synovial fibrosis, metabolic syndrome, diabetes, thyroid disorders, rheumatoid arthritis, pregnancy, and menopause.

Noninflammatory Synovial Fibrosis

Noninflammatory synovial fibrosis is the most common pathologic finding in patients with idiopathic carpal tunnel syndrome [32,33]. This finding supports the belief that chronic or repetitive injury to the median nerve, resulting in tissue swelling, compression of the nerve, or injury to the outside layers of the nerve, is a primary factor in the development of carpal tunnel syndrome [9,19,32,34,35,36]. Studies of patients with idiopathic carpal tunnel syndrome have revealed alterations in the material properties of the synovial tissue, irregular patterns of tendon movement, and an absence of the normal interconnections between tissue layers that surround the median nerve [32,36,37]. The long-term effect of these altered properties is unknown.

Metabolic Syndrome

Metabolic disorders have a well-documented association with carpal tunnel syndrome [1,19,28,39,40,41]. This is particularly true of disorders that directly affect the nerves of the body by increasing their susceptibility to compression [9]. Metabolic syndrome, which is characterized by abdominal obesity, hypertension, hyperlipidemia, and insulin resistance, is frequently associated with the presence of carpal tunnel syndrome [1,19,28,39]. The incidence of metabolic syndrome has been found to be higher in patients with carpal tunnel syndrome. Also, in patients with metabolic syndrome, the symptoms may be more severe [39].

Diabetes

Diabetes has been linked with several debilitating musculoskeletal disorders of the hand, including carpal tunnel syndrome [20,40]. The incidence of carpal tunnel syndrome is higher in individuals with diabetes than in those without. Some studies have found that presence of the syndrome appears to be related more to the duration of the diabetes than to the patient's gender or age [40,41]. A 2014 case-controlled retrospective analysis of nearly 1,600 patient records found that type 2 diabetes was not an independent risk factor for carpal tunnel syndrome, despite the increased prevalence of diabetes in the carpal tunnel group [4]. In this analysis, the prevalence of carpal tunnel syndrome was not influenced by duration of diabetes, glycemic control, or microvascular complications.

Thyroid Disease

Studies conducted to determine the prevalence of musculoskeletal problems with respect to thyroid function have indicated that musculoskeletal disorders, including carpal tunnel syndrome, frequently accompany thyroid conditions; however, a 2014 meta-analysis found evidence of publication bias and poor control in many studies investigating this association [5,9,28,44]. Symptoms of carpal tunnel syndrome commonly appear in hypothyroid patients (40% higher compared to healthy controls), including patients with normally functioning thyroid glands [5,28]. The combination of hypothyroidism and carpal tunnel syndrome appears to be more prevalent in the elderly [46]. It is important to note that the risk of developing carpal tunnel syndrome increases when thyroid disease is untreated [47]. It is clear that more well-controlled studies are needed to elucidate the effect of thyroid disease on carpal tunnel compression.

Tophaceous gout, characterized by deposits of sodium urate (tophi) in the joints and external ear, is another health condition associated with carpal tunnel syndrome [38,48]. Patients (particularly men) with a history of gout are at increased risk for developing carpal tunnel syndrome, even when appropriate medical treatment is given [38].

Hemodialysis

Carpal tunnel syndrome has become an increasingly recognized problem in patients who undergo long-term hemodialysis [50,51]. A strong correlation has been noted between the duration of hemodialysis and the appearance of carpal tunnel syndrome. Arteriovenous fistula and amyloidosis have been identified as possible causes for the development of the syndrome in this patient population [50,52,53].

Rheumatoid Arthritis

Rheumatoid arthritis has also been associated with carpal tunnel syndrome [9,54]. Patients with rheumatoid arthritis and carpal tunnel syndrome reportedly have a significantly higher incidence of enlarged areas of the median nerve than do arthritic patients and healthy persons without carpal tunnel syndrome. However, whether rheumatoid arthritis has a role in the development of carpal tunnel syndrome is uncertain, and in 2015, one study reported a similar rate of carpal tunnel syndrome in individuals with rheumatoid arthritis and those without the disorder [8,55].

Pregnancy and Menopause

Female gender is an independent risk factor for carpal tunnel syndrome, and fluid retention during pregnancy or menopause is frequently associated with development of the disease [1,19,39,47,54,56]. As many as 62% of women experience symptoms of carpal tunnel syndrome during pregnancy, although the rate varies considerably in the available literature [47,57]. Reduced pain tolerance associated with psychologic distress, depression, and/or anhedonia during pregnancy may further exacerbate uncomfortable sensations [47]. When onset is during pregnancy, symptoms usually appear in both hands and during the third trimester. Previous pregnancy does not increase the risk for carpal tunnel syndrome, but patient weight gain during pregnancy does. Pregnancy-induced carpal tunnel syndrome usually resolves spontaneously within 6 to 12 weeks following delivery, with significant improvement noted between weeks 6 and 12 postpartum [20,56].

OCCUPATION/ACTIVITY

Carpal tunnel syndrome has been reported among a variety of occupations, including clerical workers (e.g., cashiers, data entry workers, typists), assembly line workers (manufacturing, sewing, finishing, cleaning, meat packing), computer workers, and some healthcare professionals [3,9,10,20,25,26,27,59,60]. Information about the association of carpal tunnel syndrome with repetitive activity is now so widely available and easily obtained that many workers self-diagnose before obtaining a medical assessment.

Although a causal relationship between specific work activities and carpal tunnel syndrome has not been firmly established, studies have shown that intensive (i.e., greater than 4 kg of hand force), repetitive motion (at intervals less than 10 seconds), vibration, and extreme postures of the hand and wrist during job performance may contribute to the development of carpal tunnel syndrome by temporarily increasing pressure in the carpal tunnel, which threatens the viability of the median nerve and affects normal hand function [3,27,54,59,61,67]. However, many researchers feel that assigning work as the cause of carpal tunnel syndrome makes it easier for individuals to ignore their responsibility to address correctable lifestyle factors that may contribute to development of the syndrome. Furthermore, to date there is no solid evidence that computer operators are at risk, but the prevalence of self-reported carpal tunnel syndrome among this cohort is greater than 10% [25,26].

PERSONAL/PHYSICAL FACTORS

Obesity and Fitness

Obesity and lack of physical fitness (particularly no activities involving wrist strain) are considered to be primary risk factors in the development of carpal tunnel syndrome [1,7,8,40,67,68,69,70,106]. Obese individuals are more likely than non-obese individuals to have chronic health conditions, including diabetes, hypertension, and osteoarthritis [73]. The presence of these conditions, rather than excess body weight alone, may be the reason for a higher prevalence of carpal tunnel syndrome in obese individuals [74].

Gender

As noted, women are much more likely than men to develop carpal tunnel syndrome [7,9,67]. The dominant hand is usually affected first and produces the most severe pain [7]. The increased incidence in women may be partly due to hormonal factors, but in general, it is believed to be related to a propensity to and higher frequency of musculoskeletal problems among women [75]. The type of work performed may also be a contributing factor. Women who perform unskilled or semiskilled work (e.g., assembly work) appear to have a higher incidence of carpal tunnel syndrome than women who perform in higher-skilled jobs (e.g., computer work) [26,76]. Women with carpal tunnel syndrome also have a higher absence rate from work and a longer duration of disability than men.

Heredity

Inherited variations in the size and shape of the hand and wrist, or in the size of the carpal tunnel and its contents, may predispose some individuals to carpal tunnel syndrome [20,31,77]. Individuals with bilateral disease reportedly also have a greater incidence of familial disease than those with either unilateral disease or no carpal tunnel syndrome [78].

Age

The incidence of carpal tunnel syndrome increases with age. This is believed to be a result of median sensory latency and more severe compression of the median nerve [79]. The disability duration also reportedly increases with age, with a peak incidence between 45 and 60 years of age [40,68,80].

Smoking and Alcohol Consumption

Smoking and alcohol consumption are believed to be two of the many personal lifestyle choices that may contribute to an increased risk for carpal tunnel syndrome [18,54,56]. However, their respective roles in its development are unclear.

4. CONDITIONS THAT MIMIC CARPAL TUNNEL SYNDROME

There are many conditions with presenting symptoms that may mimic carpal tunnel syndrome. Consideration of these conditions during the assessment process will ensure accurate diagnosis and effective treatment.

HAND-ARM VIBRATION SYNDROME

Hand-arm vibration syndrome (HAVS) is often misdiagnosed as carpal tunnel syndrome due to similar symptoms and causes. Further complicating diagnosis is the fact that the two syndromes may coexist. HAVS consists of an array of injuries to the nerves, muscles, and tendons of the wrist and hand and commonly afflicts occupational groups who use handheld vibrating tools. The symptoms of HAVS include tenderness or pain and swelling of the fingers; numbness, weakness, or tingling in the fingers; reduced sensitivity to heat and cold; and loss of dexterity and coordination in the fingers [81].

OTHER MEDIAN NERVE COMPRESSION SYNDROMES

Pronator syndrome and anterior interosseous nerve syndrome are median nerve compressions that may cause pain, tenderness, aching in the wrist, difficulty moving the index and middle fingers, a feeling of poor coordination, and paresthesia that extends into the hand. These syndromes are rare but should be suspected if a patient with carpal tunnel syndrome fails to respond to treatment [82].

CERVICAL SPONDYLOSIS

Cervical spondylosis is a disorder caused by abnormal wear on the cervical vertebrae, resulting in chronic degeneration of the cervical spine and eventually weakness, compression of one or more nerve roots, and pain in the neck and arm [83]. Hand paresthesia is common. Because this symptom is also common in carpal tunnel syndrome, additional symptoms should be evaluated to properly distinguish between cervical spondylosis and carpal tunnel syndrome. Patients with cervical spondylosis generally have a higher incidence of neck and lower limb pain than patients with carpal tunnel syndrome [84].

CUBITAL TUNNEL SYNDROME

Cubital tunnel syndrome is caused by pressure on the ulnar nerve at the elbow. When the pressure increases enough to disturb normal nerve function, pain, numbness, and tingling may occur in the forearm or hand. Most often this pain is present in the ring and little fingers. Other symptoms that mirror carpal tunnel syndrome include decreased grip strength, weakness while pinching, and a feeling of clumsiness [1,9,85]. Individuals with cubital tunnel syndrome are more likely than individuals with carpal tunnel syndrome to present with muscle atrophy [23].

TENOSYNOVITIS

Tenosynovitis involves inflammation of the tendon and tendon sheath and is also known as de Quervain tenosynovitis of the wrist [86]. When the tendons at the base of the thumb become irritated or inflamed this causes the tunnel around the tendon to swell and results in pain and difficulty grasping and holding objects. Overuse is the most common cause [86]. New repetitive activity, hormonal fluctuations associated with pregnancy and breastfeeding, and wrist fractures also are possible causes of de Quervain tenosynovitis [87].

Stenosing tenosynovitis, also referred to as "trigger finger," occurs when the pulley/tendon relationship between the hand and fingers is restricted by thickening or swelling at the base of the fingers. This creates pain and a distinctive catching, popping, or locking action in the finger or thumb. A cycle of triggering, inflammation, and swelling is common. Like carpal tunnel syndrome, stenosing tenosynovitis has been associated with other health conditions, such as gout, diabetes, and rheumatoid arthritis. In many cases, the actual cause is not clear [88].

5. DIAGNOSING CARPAL TUNNEL SYNDROME

Early diagnosis of carpal tunnel syndrome is important to prevent muscle atrophy or damage to the median nerve that cannot be reversed by treatment [1,9]. Early diagnosis, including a physical examination, medical history, routine laboratory tests, and imaging, can also help to identify or rule out other health conditions that may present with similar signs and symptoms and require specialized treatment [89,90]. The physical examination should include specific testing, such as Phalen's maneuver or Tinel's sign, that can produce the symptoms of carpal tunnel syndrome [9,20]. In elderly patients, particular attention should be given to the objective evidence of carpal tunnel syndrome rather than subjective complaints [91].

PHYSICAL EXAMINATION

Several tests are available to assess the nerves and tendons of the hand. While these tests are a vital step in diagnosing carpal tunnel syndrome, additional testing is necessary to confirm any findings.

During Phalen's maneuver (wrist-flexion test), tingling or numbness may be produced by asking the patient to flex the wrists while extending the fingers. If symptoms occur within one minute, the presence of carpal tunnel syndrome is suggested [9,23]. A positive result with Phalen's maneuver may indicate severe carpal tunnel syndrome [92]. The test is not a reliable indicator of carpal tunnel syndrome in the diabetic population [93].

Tinel's sign, also referred to as Tinel's test, consists of pressing or tapping on the median nerve in the patient's wrist. If tingling in the fingers or a shock-like sensation occurs, the presence of carpal tunnel syndrome is suggested [9,23]. A positive result on Tinel's sign is not an indication of the syndrome's severity [92]. A new test, the scratch collapse test, has shown higher sensitivity (64%) than Tinel's sign for carpal tunnel syndrome and a positive predictive value of 99% [94,95]. With this test, the examiner lightly scratches the patient's skin over the area of nerve compression as the patient performs resisted shoulder external rotation bilaterally. Momentary loss of resistance on the affected side is considered a positive test.

Other tests that may be part of the physical examination include the flick sign and the hand elevation test. In testing for the flick sign, the patient flicks the hand and wrist as if shaking a thermometer. If tingling or a shock-like sensation occurs, the presence of carpal tunnel syndrome is suggested; however, this test has been found to be of limited usefulness [96]. During the hand elevation test, the patient elevates the hand above the head as high as comfortably possible for about one minute. Symptoms of tingling and numbness indicate the presence of carpal tunnel syndrome. The hand elevation test has been found to be more specific than Phalen's maneuver and Tinel's sign, but overall, no statistically significant differences are apparent between the three tests, which all possess low sensitivity and low specificity compared to electrodiagnostics and/or neuromuscular ultrasound [7,97].

ELECTROPHYSIOLOGIC STUDIES AND IMAGING

After the diagnosis of carpal tunnel syndrome is suggested, it should be confirmed with additional testing [1,6,7,9,89]. Available methods include electrodiagnostic (electrophysiologic) studies, ultrasonography, magnetic resonance imaging (MRI), computed tomography (CT), and pressure-specified sensorimotor devices (PSSDs). The efficacy of each method and combinations of methods for confirming the diagnosis of carpal tunnel syndrome is an area of ongoing research and discussion. Following are descriptions of these methods as well as guidelines and recommendations for their use. A summary of recommendations is provided in Table 1.

Table 1: SUMMARY OF RECOMMENDATIONS FOR DIAGNOSING CARPAL TUNNEL SYNDROME

Test

Recommendations

Phalen's maneuver

Reliable diagnostic test; useful to determine severity of CTS.

Ultrasonography

Useful, accurate; able to define cause of nerve compression and estimate symptom severity. Comparable to EDX but not accurate enough to replace NCS. Useful to support diagnosis of CTS. May be used as an initial screening test. Color Doppler more accurate than gray-scale.

Electrodiagnostic testing

Optional when surgery is not considered; suggested when surgery is considered. Use for patients with suspected or mild-to-moderate cases to determine treatment or if US is negative. Use only in conjunction with symptom analysis, history, and physical exam. Testing protocol should follow recommended guidelines.

Electrophysiologic studies

More useful than US in diagnosing idiopathic CTS

Tinel's sign

Not always useful

Scratch collapse test

Higher sensitivity than Tinel's sign; very high positive predictive value of CTS.

Flick sign

Limited usefulness; use to reproduce symptoms of CTS and to confirm EDX diagnosis.

Hand elevation test

Diagnostic results comparable to Phalen's maneuver and Tinel's sign.

Wrist x-ray

May help to rule out other diagnoses. Limited usefulness for carpal tunnel diagnosis.

History/physical exam

Recommended for all patients to determine severity and rule out other diagnoses. Use in conjunction with sensory testing.

Other

MRI, CT, PSSDs not recommended. NDE, NS not recommended as substitute for EDX studies.

CTS = carpal tunnel syndrome; EDX = electrodiagnostic; NCS = nerve conduction study; US = ultrasonography; MRI = magnetic resonance imaging; CT = computed tomography; PSSDs = pressure-specified sensorimotor devices; NDE = nervepace digital electroneurometer; NS = neurosentinel.

Source: [6,9,56,82,89,92,93,96,97,98,100,101,102,103,104,105,106,107,108]

Electrodiagnostic Study

The electrodiagnostic (EDX) study is a two-part electrical test that includes a nerve conduction study (NCS) and electromyography. The EDX study is conducted to assess nerve health in patients with complaints of pain, weakness, numbness, or tingling. During the nerve conduction portion of the carpal tunnel syndrome test, an electrode placed near the elbow side of the tunnel generates a mild electrical current. The impulse travels in the nerve through the carpal tunnel to the hand. The time it takes the impulse to travel to the hand indicates the health of the nerve; a delayed impulse indicates nerve damage. The electromyography portion of the test consists of placing small needles into a sampling of muscles that are supplied by the median nerve. The electrical impulses of the muscles are measured both at rest and upon contraction. Poor or abnormal muscle performance indicates severe nerve compression [1,48].

Evidence Based Practice Recommendation

The American College of Occupational and Environmental Medicine recommends quality electrodiagnostic studies to assist in securing a firm diagnosis for patients without a clear diagnosis of carpal tunnel syndrome. An electrodiagnostic study is also recommended as one of two methods to attempt to objectively secure a diagnosis of carpal tunnel syndrome prior to surgical release.

https://www.acoem.org/PracticeGuidelines.aspx

Last Accessed: June 19, 2018

Level of Evidence: C (Limited evidence of at least one study of moderate quality)

Many researchers and clinicians have concluded that for diagnosing carpal tunnel syndrome, EDX studies are most effective when used in conjunction with other diagnostic methods, when the diagnosis of carpal tunnel syndrome is uncertain, or when surgical treatment is being considered [89,109]. In its published guideline on the diagnosis of carpal tunnel syndrome, the American Academy of Orthopaedic Surgeons (AAOS) recommends that EDX studies be conducted only when clinical and other provocative test results are positive or when surgery is being considered. The AAOS finds little evidence to support EDX studies for other purposes, such as differentiating among diagnoses [101].

In its published practice parameter for EDX studies in carpal tunnel syndrome patients, the American Academy of Neurology, the American Academy of Physical Medicine and Rehabilitation, and the American Association of Electrodiagnostic Medicine (AAEM), now the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) Task Force, concluded that EDX studies are highly effective for the diagnosis of carpal tunnel syndrome. The AANEM Task Force made the following recommendations to confirm a clinical diagnosis [102]:

- Perform median sensory NCS across the wrist with a conduction distance of 13 to 14 cm. Compare abnormal results to the result of adjacent nerve NCS in the symptomatic limb.

- Perform one of the following additional studies when results are normal and conduction distance is greater than 8 cm:

- Compare median sensory or mixed nerve conduction across the wrist (conduction distance: 7 to 8 cm) with ulnar sensory nerve conduction across the wrist (same conduction distance).

- Compare median sensory conduction across the wrist with radial or ulnar sensory conduction across the wrist in the same limb.

- Compare median sensory or mixed nerve conduction through the carpal tunnel to sensory or mixed NCS of forearm or digits of median nerve in same limb.

- Perform motor conduction study of median nerve and one other nerve in the symptomatic limb.

The AANEM Task Force has also recommended the following optional studies [102]:

- Perform median motor nerve conduction between wrist and palm.

- Compare median motor nerve distal latency to ulnar motor nerve distal latency.

- Perform median motor nerve terminal latency index.

- Conduct electromyography of a sample of muscles, including a thenar muscle innervated by median nerve of symptomatic limb.

The AANEM Task Force did not recommend sympathetic skin response tests or investigational studies for the diagnosis of carpal tunnel syndrome [102].

A 2015 review concluded that the ideal initial electromyography tests for confirming the clinical diagnosis of carpal tunnel syndrome are median sensory peak distal latency (SDL) and median motor distal latency (MDL) [7]. Considering the multitude of possible EDX methods, the reviewers' objectives were to identify the best-validated tests with the greatest specificity and sensitivity and to create a flow chart of the recommended EDX approaches in a simplified, logical order. According to the flow chart, one (or more) comparison study of median NCS with proximal nerves in the same limb is suggested if the results of median SDL and MDL are normal or ambiguous despite clinical symptoms of carpal tunnel syndrome [7].

Ultrasonography

Ultrasonography is a method in which high frequency sound waves (ultrasonic echoes) produce images or photographs of organs and tissues. Ultrasonography can reveal impaired movement of the median nerve. Doppler ultrasonography changes the sound waves into images that can be viewed on a monitor and measures the direction and velocity of the object being studied. Gray-scale ultrasonography measures the strength of ultrasound echoes and records the strongest echoes as white and the weakest echoes in shades of gray [48]. Color Doppler ultrasonography is believed to be more accurate than gray-scale in diagnosing carpal tunnel syndrome due to the increased perception of the circulatory status of the median nerve [103].

Studies comparing ultrasonography to other methods for diagnosing carpal tunnel syndrome have yielded a variety of conclusions regarding its usefulness. For example, some researchers have concluded that ultrasonography is comparable to EDX, with the positive predictive value of ultrasound 100% in one study, and that it should be considered the initial diagnostic test of choice [6,110,111]. Other researchers have concluded that while ultrasonography is somewhat useful (e.g., when diagnosing idiopathic carpal tunnel syndrome), it is not an ideal method for estimating the severity of symptoms and nerve damage [82,104,105,110,112,113,114,115].

Magnetic Resonance Imaging

Magnetic resonance imaging has been used in the development of a biomechanical model of the wrist and carpal tunnel, which can help during evaluation of median nerve health [116,117]. Although MRI is less accurate than EDX studies for confirming a diagnosis of carpal tunnel syndrome, it has proved to be useful in grading the severity of the disorder in patients with idiopathic symptoms, in explaining persistent symptoms following surgery, and in predicting whether a patient will benefit from surgery [118,119,120]. The routine use of MRI is not recommended for diagnosing patients with suspected carpal tunnel syndrome [56,101].

Computed Tomography

Computed tomography uses x-rays to produce detailed, cross-sectional images of selected structures inside the body [48]. In the diagnosis of carpal tunnel syndrome, CT imaging provides a view of any structural abnormalities of the carpal tunnel and median nerve [121,122]. The routine use of CT technology is not recommended for diagnosing patients with suspected carpal tunnel syndrome [101].

Pressure-Specified Sensorimotor Device

A pressure-specified sensorimotor device is an electromechanical device that measures motor function and sensory loss. The use of PSSDs has been favorably compared to EDX studies for diagnosing carpal tunnel syndrome, but current research supporting PSSDs as diagnostic tools is lacking [122,123]. The routine use of PSSD technology for diagnosing patients with suspected carpal tunnel syndrome is not recommended [101].

6. TREATMENT OF CARPAL TUNNEL SYNDROME

Surgery, corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), diuretics, wrist splints, exercise, ultrasound therapy, laser therapy, and yoga are among the methods that have been recommended for the treatment of carpal tunnel syndrome [72,99,124,125,126]. Although no single treatment method has been universally accepted, there is agreement that the treatment of carpal tunnel syndrome should begin as early as possible and should include attention to underlying causes, such as diabetes or rheumatoid arthritis. There is also agreement that successful treatment depends on patient compliance with the treatment program [9,106].

In its 2016 practice guideline for the management of carpal tunnel syndrome (Table 2), the AAOS recommended that treatment decisions be based on [106]:

- Communication between the patient and the physician, with active patient participation and physician input based on the physician's experience and skill

- Evaluation of the patient's current quality of life with carpal tunnel syndrome

- Discussion of applicable and available non-surgical options and procedures

Patients will present with a wide variety of needs, choices, and access to non-operative alternatives. Even when well informed about available non-operative therapies, patients may opt for surgical treatment.

Table 2: AAOS RECOMMENDATIONS FOR TREATMENT OF CARPAL TUNNEL SYNDROME

Treatment Method (For)

Strength of Recommendationa

Surgical release of the transverse carpal ligament

★★★★

Surgical treatment of carpal tunnel syndrome should have a greater treatment benefit at 6 and 12 months versus splinting, NSAIDs, and a single steroid injection

★★★★

Simultaneous bilateral or staged endoscopic carpal tunnel release might be performed based on patient and surgeon preference.

★★

Benefit of endoscopic (versus open) carpal tunnel release

★★

Use of buffered lidocaine rather than plain lidocaine for local anesthesia to reduce injection pain

★★★

Use of local anesthesia rather than intravenous regional anesthesia (Bier block) may offer longer pain relief after carpal tunnel release

★★

Wrist immobilization (e.g., brace, splint, orthosis) rather than or prior to surgery

★★★★

Local steroid injections

★★★★

Oral steroids

★★★

Ketoprofen phonophoresis for pain reduction

★★★

Therapeutic ultrasound

★★

Laser therapy

★★

Perioperative use of aspirin

★★

Treatment Method (Against)

Strength of Recommendationa

No benefit of oral treatments (diuretic, gabapentin, astaxanthin capsules, NSAIDs, or pyridoxine) compared to placebo

★★★

No benefit of magnet therapy

★★★★

No benefit of prescription of pre-operative antibiotics

★★

No benefit to routine use of adjunctive techniques, including epineurotomy, neurolysis, flexor tenosynovectomy, and lengthening/reconstruction of the flexor retinaculum (transverse carpal ligament)

★★★

No benefit to routine supervised therapy versus home programs in the immediate postoperative period

★★★

No benefit to routine postoperative immobilization after carpal tunnel release

★★★★

aStrength of Recommendation Descriptions

Strength Visual

Evidence Quality

★★★★

Evidence from two or more "high" quality studies with consistent findings for recommending for or against the intervention.

★★★

Evidence from two or more "moderate" quality studies with consistent findings, or evidence from a single "high" quality study for recommending for or against the intervention

★★

Evidence from two or more "low" quality studies with consistent findings or evidence from a single "moderate" quality study recommending for against the intervention or diagnostic or the evidence is insufficient or conflicting and does not allow a recommendation for or against the intervention.

★

There is no supporting evidence. In the absence of reliable evidence, the guideline development group is making a recommendation based on their clinical opinion. Consensus statements are published in a separate, complimentary document.

aLevels of Evidence

Strength Visual

Overall Strength of Evidence

★★★★

Strong

★★★

Moderate

★★

Low strength evidence or conflicting evidence

★

No evidence

Source: [106]

TREATMENT GOALS AND ASSESSMENT TOOLS

Before deciding on a course of treatment, healthcare professionals and patients should discuss the desired outcome. Is the goal symptom improvement only? Is it a permanent modification of leisure time and/or work activity? Is it surgery followed by a return to work? Establishing goals prior to treatment allows healthcare professionals and patients to measure success and track progress [20].

In addition to discussing desired outcomes, patient response to treatment should be assessed by one or more of the following instruments [64,65,66,71]:

- Boston Carpal Tunnel Questionnaire: A disease-specific, patient-based outcome questionnaire measuring symptom severity and functional status of patients with carpal tunnel syndrome

- Disabilities of the arm, shoulder, and hand (DASH) tool: A region-specific outcome measure of upper limb function

- Michigan Hand Outcomes Questionnaire (MHQ): A region-specific (hand/wrist) instrument designed to evaluate patients prior to and after hand surgery

- Patient Evaluation Measure (PEM): A patient-completed questionnaire

- Short Form Health Survey (SF-36 or SF-12): The SF-36 is a generic measure of overall physical health used to assess the health of general populations; the SF-12 is a shorter alternative of the SF-36 frequently used in large population health surveys

NON-SURGICAL TREATMENT

Non-surgical treatments for carpal tunnel syndrome are typically offered to patients with mild-to-moderate symptoms and to those who are waiting to undergo surgery [63,72]. Non-surgical treatment methods are generally considered successful in treating carpal tunnel syndrome when they have produced measurable improvement in the patient's symptoms and functional ability within two to seven weeks. The AAOS suggests that surgery or additional non-surgical treatment be considered if improvement is not seen within this or another patient/physician determined timeframe [127].

Local corticosteroid injections and splinting have demonstrated short-term benefit and symptomatic relief in patients with mild or moderate carpal tunnel syndrome [60,62,63,106,127]. Based on patient preference and clinical judgment, the use of local steroid injections should be considered before surgery is considered. Oral steroids are somewhat effective in the treatment of carpal tunnel syndrome but are not considered as effective as local injections [106].

Evidence Based Practice Recommendation

According to the American Academy of Orthopaedic Surgeons, strong evidence supports that the use of steroid (methylprednisolone) injection should improve patient-reported outcomes.

https://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/guidelines/CTS%20CPG_2.29.16.pdf

Last Accessed: June 19, 2018

Strength of Recommendation: Strong (Evidence from two or more "high" strength studies with consistent findings for recommending for or against the intervention)

Corticosteroid injection has been found to improve patient satisfaction, symptoms, and function when measured at intervals of 2, 4, 8, and 12 weeks. As noted, it demonstrates a more significant overall improvement in the symptoms of carpal tunnel syndrome than oral corticosteroids, but does not appear to provide a better long-term outcome (greater than six months) than splinting or NSAIDs. Two treatment injections do not appear to provide any added benefit when compared to one treatment injection [63,125].

Splinting has been found to improve patient satisfaction, symptoms, and function when measured at intervals of 2, 4, and 12 weeks. The AAOS suggests that splinting be considered before surgery. This may be particularly helpful when weighing the risks of surgery versus the benefits. Splinting is not recommended for use after routine carpal tunnel release surgery. The benefit of splinting for postoperative rehabilitation is undetermined [63,106,127].

NSAIDs are used to treat a variety of acute and chronic pain conditions, including carpal tunnel syndrome, but opinion varies as to their effectiveness and safety for long-term use [48,58,62]. Specifically, NSAIDs have been associated with gastrointestinal and cardiovascular risks and toxicity with long-term use [107].

Diuretics and vitamin B6 (pyridoxine) may also help with temporary relief of symptomatic carpal tunnel syndrome, but their long-term benefits are unproven [56,62,63]. Acupuncture, yoga, exercise, laser therapy, activity modification, and ergonomic workplace modifications also have been mentioned as non-surgical treatment alternatives, but most experts agree that further research is needed to determine the viability and efficacy of these methods [9,17,49,62,63,106,125].

SURGICAL TREATMENT

Carpal tunnel release is the preferred treatment for patients with chronic or severe carpal tunnel syndrome. It is achieved by either an open or endoscopic procedure [9,99,106,127]. Both types of surgery are generally performed on an outpatient basis under local anesthesia. Open release surgery involves making an incision of up to 2 inches at the base of the palm of the hand and cutting the transverse carpal ligament, which releases pressure on the median nerve [9,45]. Endoscopic surgery involves making a small, one-half inch incision at the wrist and introducing an arthroscope beneath the transverse carpal ligament. Using the scope as a guide, the ligament is cut, relieving pressure on the median nerve [9,17,45].

The choice of open or endoscopic surgery is generally guided by the surgeon's and patient's preferences [124]. The two methods have shown comparable complication and return-to-work rates [43]. Surgical outcomes in the elderly (70 years of age and older) can be less predictable than in younger patients; however, surgical treatment in this group has been associated with better symptom relief and improvement in function than non-surgical treatments [42,126].

Patients with bilateral carpal tunnel syndrome may require surgical release in both hands. When compared to consecutive release, simultaneous release has been shown to offer comparable disability durations and substantial cost savings [21].

7. PREVENTION STRATEGIES

Although the number of cases of carpal tunnel syndrome among U.S. workers has been declining, the resulting number of reported days away from work remains high [13]. This lost work time and decreased employee productivity have led employers to develop organizational approaches to managing employee health, safety, and productivity, with an emphasis on prevention and returning employees to work as quickly as possible [29,30]. Rising healthcare costs and the focus on preventing carpal tunnel syndrome have led researchers to study and recommend a variety of prevention strategies, including the application of ergonomic principles to job and workstation design, the use of ergonomically sound equipment (including ergonomic keyboards and dual numeric keyboards), the development of predictive models, and the use of exercise regimens and patient education and safety programs [17,22,24].

The concept of work-related carpal tunnel syndrome, though unproven, has had a significant societal impact in the United States [11]. The U.S. Department of Labor Occupational Safety and Health Administration (OSHA) has developed a four-point approach designed to reduce and prevent illness and injury resulting from musculoskeletal disorders (MSDs) in the workplace. OSHA's four-point approach includes [15]:

- Guidelines designed to prevent/reduce workplace MSDs

- Enforcement designed to prosecute serious ergonomic violations in the workplace

- Outreach and assistance designed to assist businesses with the management of ergonomic issues

- A National Advisory Committee on Ergonomics, created to advise OSHA on ergonomic guidelines and identify gaps in research

OSHA's research component may be the most important point in its approach to carpal tunnel syndrome, as none of the prevention strategies studied to date have conclusively demonstrated that they prevent carpal tunnel syndrome [9,106]. Despite this, there are a multitude of recommendations that apply to many types of workers and work environments [17]:

- Take multiple "microbreaks" (about three minutes each) from work throughout the work day that include stretches (e.g., wrist, fingers, hand, forearm, shoulders, neck) and breathing exercises. These are good times to incorporate exercises aimed at reducing eye fatigue.

- Maintain a good posture relative to the type of work being performed. For computer workers, this means sitting with the spine against the back of the chair with the shoulders relaxed, neck flexible, and head upright, with the work at eye level.

- For computer users and other types of workers, wrist position is critical. Wrists should not remain flexed, greatly extended, or deviate from side to side for prolonged periods of time.

- Workspaces and furniture should be designed to be comfortable for the worker. Specially designed chairs and desks can promote correct posture and potentially save money by decreasing healthcare expenditures and worker absences.

- The grip and force used on tools, implements, and controls (including pencils and keyboards) should be as light as possible.

There are many examples of specific exercises to help prevent carpal tunnel. One example of wrist exercise instructs the individual to hold the second and third fingers up while the others remain closed; draw five clockwise circles in the air with the two fingertips; draw five more counterclockwise circles; and then repeat with the other hand [17].

NON-ENGLISH-PROFICIENT PATIENTS

As a result of the evolving racial and immigration demographics in the United States, interaction with patients for whom English is not a native language is inevitable. Because patient history is such a vital aspect of the assessment of carpal tunnel syndrome, it is each practitioner's responsibility to ensure that information and instructions are explained in such a way that allows for patient understanding. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient's lack of proficiency in the English language, an interpreter is required.

In this multicultural landscape, interpreters are a valuable resource to help bridge the communication and cultural gap between clients/patients and practitioners. Interpreters are more than passive agents who translate and transmit information back and forth from party to party. When they are enlisted and treated as part of the interdisciplinary clinical team, they serve as cultural brokers, who ultimately enhance the clinical encounter. In any case in which information regarding diagnostic procedures, treatment options and medication/treatment measures are being provided, the use of an interpreter should be considered.

8. SIMULATED CASE STUDY

Patient A is a woman, 54 years of age, who has been employed for 17 years in the manufacturing industry. She has missed little work and continues to perform her regular duties, which include spending many hours each day at an assembly station. Patient A also spends time each day at her home computer. The patient presents to her physician's office with chronic pain, tingling, and numbness in her right hand and wrist as well as pain, tingling, and numbness in her neck and shoulders. Patient A indicates that she is unable to take anti-inflammatory medication due to a peptic ulcer and that she has had no success alleviating symptoms with other medications. She also reports a history of hypertension and recent-onset arthritis.

Comments and rationale: Patient A's gender, age, medical history, and symptoms are positive risk factors for carpal tunnel syndrome. A physical examination including laboratory tests and imaging should be conducted to confirm the medical history of hypertension and rheumatoid arthritis.

Phalen's maneuver is performed and reveals significant weakness in Patient A's right hand. Ultrasound and a two-part EDX study are ordered, which confirm the initial diagnosis of carpal tunnel syndrome. A single cortisone injection at the right wrist is recommended while the patient considers further treatment options. The injection provides Patient A with temporary symptom relief (for four weeks). The patient then elects to undergo outpatient endoscopic carpal tunnel release. Postoperative instructions include no computer or other repetitive hand use for a minimum of four weeks. The patient demonstrates significant symptom improvement three weeks postoperatively and reports being pain-free six weeks postoperatively. Patient A relates that she is able to cook and play tennis with no related pain. A follow-up examination at one year shows no recurrence of symptoms.

9. CONCLUSION

Carpal tunnel syndrome is possibly the most common nerve disorder diagnosed today. Determining the causes of carpal tunnel syndrome remains an area of ongoing research and may be a synergy between genetics, co-existing health conditions, and personal lifestyle factors. Researchers continue to study the clinical course of carpal tunnel syndrome. By identifying the biomechanical factors related to pain, researchers hope to better understand, treat, and prevent carpal tunnel syndrome and to find new ways to limit or prevent its occurrence.

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76. Bongers FJM, Schellevis FG, van den Bosch WJHM, van der Zee J. Carpal tunnel syndrome in general practice (1987 and 2001): incidence and the role of occupational and nonoccupational factors. Br J Gen Pract. 2007;57(534):36-39.

77. Kamolz LP, Beck H, Haslik W, et al. Carpal tunnel syndrome: a question of hand and wrist configurations? J Hand Surg Br. 2004;29(4):321-324.

78. Alford JW, Weiss APC, Akelman E. The familial incidence of carpal tunnel syndrome in patients with unilateral and bilateral disease. Am J Orthop. 2004;33(8):397-400.

79. Bodofsky EB, Campellone JV, Wu KD, Greenberg WM. Age and the severity of carpal tunnel syndrome. Electromyogr Clin Neurophysiol. 2004;44(4):195-199.

80. Ashworth NL. Carpal Tunnel Syndrome. Available at https://emedicine.medscape.com/article/327330-overview. Last accessed June 5, 2018.

81. Weir E, Lander L. Hand-arm vibration syndrome. CMAJ. 2005;172(8):1001-1002.

82. Lee MJ, LaStayo PC. Pronator syndrome and other nerve compressions that mimic carpal tunnel syndrome. J Orthop Sports Phys Ther. 2004;34(10):601-609.

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84. Chow CS, Hung LK, Chiu CP, et al. Is symptomatology useful in distinguishing between carpal tunnel syndrome and cervical spondylosis? Hand Surg. 2005;10(1):1-5.

85. American Society for Surgery of the Hand. Cubital Tunnel Syndrome. Available at http://www.assh.org/handcare/hand-arm-conditions/cubital-tunnel. Last accessed June 5, 2018.

86. Norvell JG. Carpal Tunnel Syndrome in Emergency Medicine. Available at https://emedicine.medscape.com/article/822792-overview. Last accessed June 5, 2018.

87. American Society for Surgery of the Hand. de Quervain's Tendonitis. Available at http://www.assh.org/handcare/Anatomy/Details-Page/ArticleID/27956/de-Quervain-syndrome. Last accessed June 5, 2018.

88. American Society for Surgery of the Hand. Trigger Finger. Available at http://www.assh.org/handcare/hand-arm-conditions/trigger-finger. Last accessed June 5, 2018.

89. Cartwright MS, Hobson-Webb LD, Boon AJ, et al. Evidence-based guideline: neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. Muscle Nerve. 2012;46(2):287-293.

90. Washington State Department of Labor and Industries. Work-Related Carpal Tunnel Syndrome Diagnosis and Treatment Guideline. Olympia, WA: Washington State Department of Labor and Industries; 2014.

91. Blumenthal S, Herskovitz S, Verghese J. Carpal tunnel syndrome in older adults. Muscle Nerve. 2006;34(1):78-83.

92. Priganc VW, Henry SM. The relationship among five common carpal tunnel syndrome tests and the severity of carpal tunnel syndrome. J Hand Ther. 2003;16(3):225-236.

93. Edwards A. Phalen's test with carpal compression: testing in diabetics for the diagnosis of carpal tunnel syndrome. Orthopedics. 2002;25(5):519-520.

94. Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch collapse test for evaluation of carpal and cubital tunnel syndrome. J Hand Surg Arm. 2008;33(9):1518-1524.

95. Douglas R. Scratch collapse test for the evaluation of carpal and cubital tunnel syndrome. J Hand Ther. 2009;22(4):384.

96. Hansen PA, Micklesen P, Robinson LR. Clinical utility of the flick maneuver in diagnosing carpal tunnel syndrome. Am J Phys Med Rehabil. 2004;83(5):363-367.

97. Ma H, Kim I. The diagnostic assessment of hand elevation test in carpal tunnel syndrome. J Korean Neurosurg Soc. 2012;52(5):472-475.

98. Amirfeyz R, Gozzard C, Leslie IJ. Hand elevation test for assessment of carpal tunnel syndrome. J Hand Surg. 2005;30(4):361-364.

99. Verdugo RJ, Salinas RA, Castillo JL, Cea JG. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database Syst Rev. 2008;(4):CD001552.

100. Homan MM, Franzblau A, Werner RA, Albers JW, Armstrong TJ, Bromberg MB. Agreement between symptom surveys, physical examination procedures and electrodiagnostic findings for the carpal tunnel syndrome. Scand J Work Environ Health. 1999;25(2):115-124.

101. American Academy of Orthopaedic Surgeons. Clinical Guideline on Diagnosis of Carpal Tunnel Syndrome. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007.

102. Jablecki CK, Andary MT, Floeter MK, et al. Practice parameter: electrodiagnostic studies in carpal tunnel syndrome: report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2002;58(11):1589-1592.

103. Mallouhi A, Pülzl P, Trieb T, Piza H, Bodner G. Predictors of carpal tunnel syndrome: accuracy of gray-scale and color Doppler sonography. Am J Roentgenol. 2006;186(5):1240-1245.

104. El Miedany YM, Aty SA, Ashour S. Ultrasonography versus nerve conduction study in patients with carpal tunnel syndrome: substantive or complementary tests? Rheumatology (Oxford). 2004;43(7):887-895.

105. Kaymak B, Ozçakar L, Cetin A, Candan Cetin M, Akinci A, Hasçelik Z. A comparison of the benefits of sonography and electrophysiologic measurements as predictors of symptom severity and functional status in patients with carpal tunnel syndrome. Arch Phys Med Rehabil. 2008;89(4):743-748.

106. American Academy of Orthopaedic Surgeons. Clinical Practice Guideline on the Management of Carpal Tunnel Syndrome. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2016.

107. Hegmann KT. Hand, wrist, and forearm disorders not including carpal tunnel syndrome. In: Hegmann KT (ed). Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. 3rd ed. Elk Grove Village, IL: American College of Occupational and Environmental Medicine; 2011: 1-188.

108. Blebea JS, Lott KE, Daffner RH, et al. ACR Appropriateness Criteria: Chronic Wrist Pain. Reston, VA: American College of Radiology; 2009.

109. Bland JD. Carpal tunnel syndrome. Curr Opin Neurol. 2005;18(5):581-585.

110. Wong SM, Griffith JF, Hui AC, Lo SK, Fu M, Wong KS. Carpal tunnel syndrome: diagnostic usefulness of sonography. Radiology. 2004;232(1):93-99.

111. Mondelli M, Filippou G, Gallo A, Frediani B. Diagnostic utility of ultrasonography versus nerve conduction studies in mild carpal tunnel syndrome. Arthritis Rheum. 2008;59(3):357-366.

112. Iannicelli E, Almberger M, Chianta GA, et al. High resolution ultrasonography in the diagnosis of carpal tunnel syndrome. Radiol Med (Torino). 2005;110(5-6):623-629.

113. Yesildag A, Kutluhan S, Sengul N, et al. The role of ultrasonographic measurements of the median nerve in the diagnosis of carpal tunnel syndrome. Clin Radiol. 2004;59(10):910-915.

114. Kwon BC, Jung KI, Baek GH. Comparison of sonography and electrodiagnostic testing in the diagnosis of carpal tunnel syndrome.J Hand Surg. 2008;33(1):65-71.

115. Naranjo A, Ojeda S, Mendoza D, Francisco F, Quevedo JC, Erqusquin C. What is the diagnostic value of ultrasonography compared to physical evaluation in patients with idiopathic carpal tunnel syndrome? Clin Exp Rheumatol. 2007;25(6):853-859.

116. Mogk JP, Keir PJ. Evaluation of the carpal tunnel based on 3-D reconstruction from MRI. J Biomech. 2007;40(10):2222-2229.

117. Keir PJ. Magnetic resonance imaging as a research tool for biomechanical studies of the wrist. Semin Musculoskelet Radiol. 2001;5(3):241-250.

118. Jarvik JG, Comstock BA, Heagerty PJ, et al. Magnetic resonance imaging compared with electrodiagnostic studies in patients with suspected carpal tunnel syndrome: predicting symptoms, function, and surgical benefit at 1 year. J Neurosurg. 2008;108(3):541-550.

119. Martins RS, Siqueira MG, Simplicio H, Agapito D, Medeiros M. Magnetic resonance imaging of idiopathic carpal tunnel syndrome: correlation with clinical findings and electrophysiological investigation. Clin Neurol Neurosurg. 2008;110(1):38-45.

120. Wilder-Smith EP, Seet RCS, Lim ECH. Diagnosing carpal tunnel syndrome—clinical criteria and ancillary tests. Nat Clin Pract Neurol. 2006;2(7):366-374.

121. Lee CH, Kim TK, Yoon ES, Dhong ES. Correlation of high-resolution ultrasonographic findings with the clinical symptoms and electrodiagnostic data in carpal tunnel syndrome. Ann Plast Surg. 2005;54(1):20-23.

122. Weber RA, Schuchmann JA, Albers JH, Ortiz J. A prospective blinded evaluation of nerve conduction velocity versus Pressure-Specified Sensory Testing in carpal tunnel syndrome. Ann Plast Surg. 2000;45(3):252-257.

123. Tassler PL, Dellon AL. Correlation of measurements of pressure perception using the pressure-specified sensory device with electrodiagnostic testing. J Occup Environ Med. 1995;37(7):862-866.

124. Scholten RJPM, Mink van der Molen A, Uitdehaag BMJ, Bouter LM, de Vet HCW. Surgical treatment options for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007;(4):CD003905.

125. Marshall SC, Tardif G, Ashworth NL. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007;(2):CD001554.

126. Ettema AM, Amadio PC, Cha SS, Harrington JR, Harris AM, Offord KP. Surgery versus conservative therapy in carpal tunnel syndrome in people aged 70 years and older. Plast Reconstr Surg. 2006;118(4):947-958.

127. American Academy of Orthopaedic Surgeons. Carpal Tunnel Syndrome. Available at https://orthoinfo.aaos.org/en/diseases--conditions/carpal-tunnel-syndrome. Last accessed June 5, 2018.

Evidence-Based Practice Recommendations Citations

1. Carpal tunnel syndrome. In: Hegmann KT (eds). Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. 3rd ed. Elk Grove Village, IL: American College of Occupational and Environmental Medicine; 2011. Available at https://www.acoem.org/PracticeGuidelines.aspx. Last accessed June 19, 2018.

2. American Academy of Orthopaedic Surgeons. Management of Carpal Tunnel Syndrome: Evidence-Based Clinical Practice Guideline. Available at https://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/guidelines/CTS%20CPG_2.29.16.pdf. Last accessed June 19, 2018.

58582 • Infection Control for Dental Professionals: The California Requirement

William E. Frey, DDS, MS, FICD

www.netce.com

Copyright © 2019 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

58582 • Infection Control for Dental Professionals: The California Requirement

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

About the Sponsor

Disclosure Statement

1. INTRODUCTION

2. OSHA AND CAL/OSHA REGULATIONS

BLOODBORNE PATHOGENS STANDARD

CALIFORNIA AEROSOL TRANSMISSIBLE DISEASE STANDARD

3. MODES OF TRANSMISSION

AEROSOLS, DROPLETS, AND SPLATTER

FOMITE TRANSMISSION

4. BLOODBORNE PATHOGENS

HEPATITIS B VIRUS

HEPATITIS C VIRUS

HIV/AIDS

5. PREVENTION STRATEGIES

STANDARD PRECAUTIONS

RESPIRATORY HYGIENE

ASEPTIC TECHNIQUE

SAFE INJECTION PRACTICES

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT

6. ENVIRONMENTAL CONTROL MEASURES

ENVIRONMENTAL CLEANING

MEDICAL WASTE MANAGEMENT

DENTAL UNIT WATERLINES, BIOFILM, AND WATER QUALITY

7. ENGINEERING AND WORK PRACTICE CONTROLS

CLEANING, DISINFECTION, AND STERILIZATION

8. PROTECTING DENTAL HEALTHCARE WORKERS

OCCUPATIONAL EXPOSURES

TUBERCULOSIS PREVENTION

VACCINATION

TRAINING AND EDUCATION

9. CONCLUSION

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

Works Cited

58582 • Infection Control for Dental Professionals: The California Requirement

Education Category. Infection Control / Internal Medicine

Release Date. 02/01/2019

Expiration Date. 01/31/2022

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.

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 the use of precautions, 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 professionals, including vaccination, education, and exposure responses.

Faculty

William E. Frey, DDS, MS, FICD, graduated from the University of California School of Dentistry, San Francisco, California, in 1966. In 1975, he completed residency training in Periodontics and received a Master's degree from George Washington University.
Dr. Frey retired from the United States Army Dental Corps in 1989 after 22 years of service. Throughout the course of his professional career, he has continuously practiced dentistry, the first 7 years as a general dentist and the past more than 40 as a periodontist. His military experience included the command of a networked Dental Activity consisting of five dental clinics. In his last assignment, he was in charge of a 38-chair facility. Colonel Frey was selected by the Army to serve on two separate occasions as the Chair of the Periodontal Department in Army General Dentistry Residency Training Programs.
Dr. Frey is the founder and president of Perio Plus, a practice management firm specializing in creating individually-designed hygiene and periodontal care programs for general dentists. He is also the creator of the Inspector Gum patient education series.

Faculty Disclosure

Contributing faculty, William E. Frey, DDS, MS, FICD, 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.

1. INTRODUCTION

More than 690,000 people work in the dental profession in the United States [1]. In California alone there are approximately 91,000 dental healthcare professionals (DHCPs), including dentists, dental hygienists, and dental assistants. 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. In California, there are three regulatory agencies involved in infection control in the dental healthcare setting: the Dental Board of California (DBC), which sets the minimum standards, the California Division of Occupational Safety and Health (Cal/OSHA), which publishes the Bloodborne Pathogens Standard, and the California Department of Public Health, which established the Waste Management Act.

To address the issue of infection control and reduce the potential for harm, the DBC established a requirement that dental healthcare licensees in California complete a course on infection control and prevention. DBC regulations also require that licensees comply with and enforce precautions and workplace practices that minimize the transmission of pathogens in dental settings. "Standard Precautions" is the DBC term for infection control measures that encompasses both "Universal Precautions"—a term the Occupational Safety and Health Administration (OSHA) uses—and the Cal/OSHA mandate for bloodborne pathogen transmission. The DBC mandates that Standard Precautions must be practiced in the care of all patients. The same infection control precautions apply to all patients, and all body fluids, except sweat, are considered potentially infectious. Universal Precautions are measures taken when exposed to blood, while Standard Precautions apply to all potentially infectious materials. While most elements of Standard Precautions evolved from Universal Precautions, developed for protection of healthcare personnel, additional elements of Standard Precautions focus on protection of patients. Contact Precautions are used to prevent transmission of an infectious agent associated with environmental contamination (e.g., treating all environmental surfaces as potentially contaminated) that is not interrupted by Standard Precautions alone.

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 [2]. The DBC Standard Precaution guidelines are reviewed annually. Current guidelines may be downloaded at https://govt.westlaw.com/calregs/Document/I3F75D9A0B95D11E0A3CAA6663E6464AA and are found at the conclusion of this course. Significant changes in the 2011 revision include application of the guidelines to all dental healthcare professionals (not just "registered" professionals) and specific steps for disinfection [2]. The goal of these guidelines is to reduce the number of healthcare-associated infections in California dental practice settings.

2. OSHA AND CAL/OSHA 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]. The OSHA Standard requires employers whose employees have exposure to blood or other potentially infectious material to implement safe work practices, education, and barriers to exposure. The Standard was later amended to cover the safe use of sharps.

BLOODBORNE PATHOGENS STANDARD

The OSHA Bloodborne Pathogens Standard requires that every healthcare worker who may have contact on the job with blood or other bodily fluids (referred to as other potentially infectious material or OPIM) 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 Contact Precautions.

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 healthcare employers to develop exposure control procedures and train employees to follow those procedures [4,15]. 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.

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 [4,10,21]:

- 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 Centers for Disease Control and Prevention (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.

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 Contact Precautions are designed to interrupt the mode of transmission.

The most common modes of transmission in the healthcare setting are the hands of healthcare workers and items that move from patient to patient, both of which are examples of indirect transmission (Table 1). Items moving between patients should be cleaned and sterilized after each use to avoid indirect transmission of pathogens. Because it addresses the weakest link in the chain of transmission, hand hygiene is still the single most important procedure for preventing the spread of infection.

Table 1: Common Modes of Infection Transmission

Category

Definition

Direct

Person-to-person transmission of pathogens

Indirect

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

Fomites

Contact with soiled objects, such as used gloves, pens, used tissues, and soiled laundry

Source: Compiled by Author

AEROSOLS, DROPLETS, AND SPLATTER

Aerosols, droplets (produced by the respiratory tract), and splatter contaminated with blood and bacteria are produced during many dental procedures [9]. 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.

Several studies have shown that aerosol 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. 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.

The American Dental Association recommends that in addition to using standard barriers, such as masks, gloves, and eye protection, 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 [6].

Diseases known to spread by aerosols or droplet include:

- TB

- Pneumonic Yersinia pestis infection (plague)

- Influenza

- Legionellosis (Legionnaires disease)

- Severe acute respiratory syndrome (SARS)

Procedures or equipment aimed at eliminating the means of transmission include [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

- Gloves to minimize contamination of hands, discarded after each patient

- 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 personal protective equipment (PPE) may become contaminated with potential pathogens after care of a patient colonized or infected with an infectious agent [7].

Contaminated clothing and laboratory coats can potentially transmit infectious agents to successive patients. A 2007 study in a Maryland teaching hospital revealed that 27% of the white coats worn by 109 physicians and other healthcare professionals were colonized with Staphylococcus aureus and 6% were colonized with methicillin-resistant S. aureus (MRSA). In a follow-up questionnaire, 65% of the healthcare workers reported they had last washed their white coat more than a week ago and nearly 16% had last washed their coat more than 30 days ago [8]. A study presented at the American Society of Microbiology Conference in 2012 identified clothing and household linens (e.g., cotton towels) as a significant transmission source of infectious pathogens [30]. However, evidence linking clothing to hospital infection rates is lacking, and additional research is necessary to determine the actual extent of this risk [31].

Dental equipment and dental unit waterlines are both potential sources of transmission and potential reservoirs. Routine cleaning and sterilization and adherence to the American Dental Association's recommended procedures for treating dental unit waterlines have been shown to be effective in eliminating transmission of infectious organisms via these devices. 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. In addition, a new infection control standard that took effect on January 1, 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. This requirement is 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 [39].

4. 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 human immunodeficiency virus (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 Be antigen status of the source individual [9,11]. 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 [9].

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% [11]. 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 [11]. 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 [9]. 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.

The prevalence of hepatitis C virus infection among dentists and surgeons is similar to that among the general population, approximately 1% to 2% [11]. No studies of transmission from hepatitis C virus-infected dental healthcare personnel 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 HlV-infected blood is 0.3%; 99.7% of needlestick or cut exposures do not lead to infection [9,11]. 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) [9,11].

In the United States, the risk of HIV transmission in dental settings is extremely low. According to the most recent data, a total of 57 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]. Transmission of HIV to 6 patients of a single dentist with AIDS has been reported, but the mode of transmission could not be determined [13].

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 [14]. The risk was also increased if the exposure was to blood from patients with terminal illnesses, possibly reflecting the higher titer of HIV in late-stage AIDS patients.

5. PREVENTION STRATEGIES

In 1986, California became the first state to pass a comprehensive bloodborne pathogen standard [6]. The California standard provided a model for federal legislation, and in 1991, OSHA published its Bloodborne Pathogens Standard. Since then, regulatory and legislative activity has focused on implementing a hierarchy of prevention and control measures to improve infection control in healthcare settings. Respiratory hygiene, safe injection practices, aseptic technique, hand hygiene, and the use of PPE are now accepted as essential components of an effective infection prevention strategy. The Cal/OSHA ATD standard passed into law in 2009 was expected to be a blueprint for federal standards addressing aerosol transmissible diseases, but this has not come to fruition [6,15].

STANDARD PRECAUTIONS

The gradual acceptance of various infection prevention standards has changed the way we work in the provision of dental care. 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

- All bodily fluids, secretions, and excretions (except sweat), regardless of whether they contain blood

- Intact or nonintact skin

- Mucous membranes

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.

When adhering to Standard Precautions, always:

- Use good hand hygiene.

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

- Use a gown any time your clothing is soiled and if a patient has uncontained bodily fluids (e.g., blood, saliva).

- Use a mask and eye protection if you may be splashed or be exposed to droplets; glasses do not adequately protect you.

- 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.

- Reuse gowns, even for repeated contacts with the same patient.

- Contaminate the environment with dirty gloves.

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

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 professionals 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.

ASEPTIC TECHNIQUE

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 other potentially infectious material should be kept separate from medications.

SAFE INJECTION PRACTICES

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 [16]. Guidelines on the design, implementation, and evaluation of a sharps injury prevention program have been developed by CDC.

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. 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.

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 administered from the same syringe to more than one patient, even if the needle is changed.

Dental professionals 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.

Cases of bloodborne pathogen transmission as a result of improper injection practices have common themes [16]. 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.

HAND HYGIENE

Despite the simplicity and effectiveness of hand hygiene in preventing the spread of infectious disease, adherence to hand hygiene practice remains unacceptably low [35]. Adherence varies among professional categories of healthcare workers but is usually estimated as less than 50%, a rate that has not changed in more than a decade [17,35,38]. For dental healthcare workers, strict adherence to hand hygiene protects both the patient and the worker. Hand hygiene should be done when you first come to work, before you touch your first patient or clean equipment, and before and after every patient contact—including after touching intact skin. In addition, perform hand hygiene:

- 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 dental healthcare professionals from participating in direct patient care. These include weeping dermatitis, exudative lesions, or any hand conditions that increase the risk of disease transmission.

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. Such handwashing removes the oils that harbor the organisms. 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 [35]. 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. 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.

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 [28,29]. In addition, antiseptics may be added to alcohol-based handrubs in order to achieve persistent germicidal activity [10]. 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.

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.

PERSONAL PROTECTIVE EQUIPMENT

PPE is defined as "specialized clothing or equipment worn by an employee for protection against infectious materials" [18]. Cal/OSHA regulations require use of PPE in dental care settings to protect personnel from exposure to bloodborne pathogens. 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 [18]. 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 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, protective eyewear, face shields, and protective clothing.

Procedures that 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 other potentially infectious material 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.

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

Dental personnel should wear gloves to prevent contamination of their hands when touching mucous membranes, blood, saliva, or other potentially infectious material. 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 professionals should always use gloves when [19]:

- Anticipating direct contact with blood or bodily fluids, mucous membranes, nonintact skin, and other potentially infectious material

- Engaging in direct contact with patients who are colonized or infected with pathogens transmitted by the contact route, such as vancomycin-resistant enterococci or 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 [19].

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 [10].

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].

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 [19].

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 [19]. When processing contaminated sharp instruments, needles, and devices, heavy utility gloves should be used to prevent puncture injuries.

Cover Garb

Gowns are intended to protect the arms and exposed body areas and prevent contamination of clothing with blood, bodily fluids, and other potentially infectious material. 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. Laboratory coats or jackets worn over personal clothing for comfort or purposes of identity are not considered PPE [19].

California regulations require that dental personnel wear reusable or disposable protective attire when their clothing or skin is likely to be soiled with blood or other potentially infectious material. Gowns must be changed daily or between patients if they become moist or visibly soiled. Protective attire must be removed when leaving laboratories or areas of patient care activities. Reusable gowns should be laundered in accordance with Cal/OSHA Bloodborne Pathogens Standards [2].

Masks, Protective Eyewear, and Face Shields

In California, dental professionals 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 or other potentially infectious material. After each patient and during patient treatment (if applicable), masks must be changed if moist or contaminated. After each patient, face shields and protective eyewear shall be cleaned and disinfected, if contaminated [2].

Masks should fit snuggly 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 other potentially infectious material. 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 snuggly 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, ear pieces, 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 [19].

6. ENVIRONMENTAL CONTROL MEASURES

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 [20].

ENVIRONMENTAL CLEANING

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 other potentially infectious material.

If items or surfaces likely to be contaminated are difficult to clean and disinfect, they must be protected with disposable impervious barriers. Clean and disinfect all clinical contact surfaces that are not protected by impervious barriers using a California Environmental Protection Agency (Cal/EPA)-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 Cal/EPA-registered, hospital-grade disinfectant. Chemical-resistant utility gloves should be worn when handling hazardous chemicals.

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. Regulated medical waste is defined as [10]:

- Liquid or semi-liquid blood or other potentially infectious materials

- Contaminated items that would release blood or other potentially infectious material in a liquid or semi-liquid state if compressed

- Items that are caked with dried blood or other potentially infectious material capable of releasing these materials during handling

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

- Pathologic and microbiologic wastes containing blood or other potentially infectious material

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].

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 [20].

DENTAL UNIT WATERLINES, BIOFILM, AND WATER QUALITY

The following information is taken from the Centers for Disease Control and Prevention publication Guidelines for Infection Control in Dental Health-Care Settings[10].

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.

In 1993, the CDC recommended that dental waterlines be flushed at the beginning of the clinic day to reduce the microbial load. Dental unit water that remains untreated or unfiltered is unlikely to meet drinking water standards.

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. 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 [2].

Patient material, such as oral micro-organisms, blood, and saliva, can enter the dental water system during treatment. Devices connected to the dental water system that enter the patient's mouth should be flushed to discharge water and air for a minimum of 20 to 30 seconds after each patient to remove patient material that might have entered the turbine, air, or waterlines.

Manufactured dental units are now engineered to prevent retraction of oral fluids, but some older units are equipped with antiretraction valves that require periodic maintenance. Users should consult the owner's manual or contact the manufacturer to determine whether testing or maintenance of antiretraction valves or other devices is required. Even with antiretraction valves, flushing devices for a minimum of 20 to 30 seconds after each patient is recommended. The DBC standards require that, at the beginning of each work day, dental lines and devices must be purged with air or flushed with water for at least two minutes prior to attaching handpieces, scales, air/water syringe tips, or other devices [2].

7. ENGINEERING AND WORK PRACTICE CONTROLS

The following information is taken from the OSHA Bloodborne Pathogens Standard, 1910.1030.

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:

- 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

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 other potentially infectious material is present.

All procedures involving blood or other potentially infectious material 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 other potentially infectious material 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.

CLEANING, DISINFECTION, AND STERILIZATION

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) [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 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: [10]

Cleaning is defined as the removal of visible soil (organic and inorganic material) from objects and surfaces; normally, it is accomplished manually or mechanically using water with detergents or enzymatic products. 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:

- 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 months on dry surfaces [32]. 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 [32]. 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. These items pose the greatest risk of transmitting infection and require sterilization.

Semicritical items touch intact mucous membranes and have a lower risk of transmission. 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 [10,21].

Noncritical items pose the least risk of transmission of infection, contacting only intact skin, an effective barrier to most micro-organisms. In the majority of cases, cleaning and disinfection with an EPA-registered hospital disinfectant is adequate. When the item is visibly contaminated with blood or other potentially infectious material, an EPA-registered hospital disinfectant with a tuberculocidal claim (i.e., intermediate-level disinfectant) should be used [10].

High-speed dental hand pieces, low-speed hand piece components used intraorally, and other dental unit attachments (e.g., reusable air or water syringe tips and ultrasonic scaler tips) must be heat-sterilized between patients. Single-use disposable instruments such as prophylaxis angles, cups, brushes, tips for high-speed evacuators, saliva ejectors, and air and water syringe tips must be used for one patient only and discarded. Proper functioning of the sterilization cycle must be verified at least weekly through the use of a biologic indicator (such as a spore test). Test results should be maintained for 12 months [2].

Dental unit water lines must be anti-retractive. At the beginning of each workday, dental unit lines should be purged with air or flushed with water for at least two minutes prior to attaching handpieces, scalers, and other devices. The dental unit line must be flushed between each patient for a minimum of 20 seconds [2]. Single-use barriers may be used on those environmental surfaces that are difficult to clean and disinfect.

Laboratory Areas

According to California regulations, splash shields and equipment guards must be used on dental laboratory lathes. Fresh pumice and a disinfected, 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 [2].

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 [2].

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.

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].

8. PROTECTING DENTAL HEALTHCARE WORKERS

Protecting dental professionals is an integral part of every dental organization's general program for infection prevention and control. The objectives usually include [23,24]:

- 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 other potentially infectious material, most commonly a needlestick injury. The risk of infection depends on several factors, including:

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

- Whether the exposure was to nonintact 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 estimated to be 0.3% [11]. There are no documented cases of a dental healthcare professional contracting HIV from an occupational exposure.

OSHA's final rule for occupational exposure to bloodborne pathogens requires dental employers 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 other potentially infectious material. 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 infection.

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.

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; there is no PEP recommended for hepatitis C virus as of 2019 [36]. 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. 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 [36].

TUBERCULOSIS PREVENTION

California has one of the highest incidence rates of TB in the country, primarily because of its large immigrant and other high-risk populations (e.g., homeless persons) [37]. The TB infection rate is 10 times higher among foreign-born individuals than among those born in the United States and is particularly high among those originating in Asia. 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 [25]. In addition, the California Department of Public Health requires that healthcare facilities in California perform initial and annual TB screening of employees [34].

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.

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 ADA's 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 [26].

VACCINATION

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 [27].

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 [33]. 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 [5].

TRAINING AND EDUCATION

Dental professionals 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 other potentially infectious material, 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. 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 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. Engineering controls help to make the workplace safer, while administrative controls ensure that written protocols are in place and followed. Lastly, ensuring that dental professionals are immune or vaccinated can help decrease the availability of potential hosts.

10. 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/I3F75D9A0B95D11E0A3CAA6663E6464AA.

Works Cited

1. U.S. Bureau of Labor Statistics. Occupational Outlook Handbook: Dentists. Available at https://www.bls.gov/ooh/Healthcare/Dentists.htm. Last accessed December 12, 2018.

2. California Code of Regulations. Section 1005: Minimum Standards for Infection Control. Available at https://govt.westlaw.com/calregs/Document/I3F75D9A0B95D11E0A3CAA6663E6464AA. Last accessed December 12, 2018.

3. Occupational Safety and Health Administration. Bloodborne Pathogens Standards, 1910.1030. Available at https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030. Last accessed December 12, 2018.

4. California Department of Industrial Regulation. Code of Regulations: Aerosol Transmissible Diseases. Available at https://www.dir.ca.gov/Title8/5199.html. Last accessed December 12, 2018.

5. Centers for Disease Control and Prevention. Seasonal Influenza Vaccination Resources for Health Professionals. Available at https://www.cdc.gov/flu/professionals/vaccination/index.htm. Last accessed December 12, 2018.

6. Harrel SK, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications.J Am Dent Assoc. 2004;135(4):429-437.

7. Siegel JD, Rhinehart E, Jackson M, Chiarello L, the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Available at https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf. Last accessed December 12, 2018.

8. Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich EN. Methicillin-resistant Staphylococcus aureus (MRSA) and white coats of healthcare workers. Am J Infect Control. 2009;37(2):101-105.

9. Centers for Disease Control and Prevention. Exposure to Blood: What Healthcare Personnel Need to Know. Available at https://www.cdc.gov/HAI/pdfs/bbp/Exp_to_Blood.pdf. Last accessed December 12, 2018.

10. Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM. Guidelines for infection control in dental health-care settings—2003. MMWR. 2003;52(RR17):1-61.

11. Centers for Disease Control and Prevention. Infection Control in Dental Settings: FAQs Bloodborne Pathogens Occupational Exposure. Available at https://www.cdc.gov/oralhealth/infectioncontrol/bloodborne_exposures.htm. Last accessed December 12, 2018.

12. Centers for Disease Control and Prevention. Surveillance of Occupationally Acquired HIV/AIDS in Healthcare Personnel, as of December 2010. Available at https://www.cdc.gov/HAI/organisms/hiv/Surveillance-Occupationally-Acquired-HIV-AIDS.html. Last accessed December 12, 2018.

13. Centers for Disease Control and Prevention. Epidemiologic notes and reports update: transmission of HIV infection during invasive dental procedures—Florida. MMWR. 1991;40(23):377-381.

14. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med. 1997;337(21):1485-1490.

15. California Department of Public Health. Cal/OSHA's Aerosol Transmissible Disease Standards and Local Health Departments. Available at https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/OHB/CDPH%20Document%20Library/ATD-Guidance.pdf. Last accessed December 12, 2018.

16. Occupational Safety and Health Administration. Frequently Asked Questions: Needlestick. Available at http://www.osha.gov/needlesticks/needlefaq.html. Last accessed December 12, 2018.

17. Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis. 2001;7(2):1818-1865.

18. Centers for Disease Control and Prevention. Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings. Available at https://www.cdc.gov/HAI/pdfs/ppe/PPEslides6-29-04.pdf. Last accessed December 12, 2018.

19. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-166.

20. Sehulster L, Chinn RYW. Guidelines for environmental infection control in health-care facilities, 2003. MMWR. 2003;52(RR10):1-42.

21. Rutala WA, Weber DJ, the Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Available at https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines.pdf. Last accessed December 12, 2018.

22. U.S. Food and Drug Administration. Reprocessing of Single-Use Devices. Available at https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ReprocessingofReusableMedicalDevices/default.htm. Last accessed December 12, 2018.

23. Bolyard EA, Tablan OC, Williams WW, et al. Guidelines for infection control in healthcare personnel, 1998. Infect Control Hosp Epidemiol. 1998;19(6):407-463.

24. Occupational Safety and Health Administration. Personal Protective Equipment. Available at https://www.osha.gov/SLTC/personalprotectiveequipment/. Last accessed December 12, 2018.

25. Jensen PA, Lambert LA, Iademarco MF, Ridzon R. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Available at https://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf. Last accessed December 12, 2018.

26. American Dental Association. Tuberculosis. Available at https://www.ada.org/en/member-center/oral-health-topics/tuberculosis-overview-and-dental-treatment-conside. Last accessed December 12, 2018.

27. California Department of Industrial Relations. California Code of Regulations: Title 8, Subchapter 7.16.109. Available at https://www.dir.ca.gov/title8/5193.html. Last accessed December 12, 2018.

28. Estrela C, Ribeiro RG, Estrela CR, Pécora JD, Sousa-Neto MD. Antimicrobial effect of 2% sodium hypochlorite and 2% chlorhexidine tested by different methods. Braz Dent J. 2003;14(1):58-62.

29. Hübner NO, Handrup S, Meyer G, Kramer A. Impact of the "Guidelines for infection prevention in dentistry" (2006) by the Commission of Hospital Hygiene and Infection Prevention at the Robert Koch-Institute (KRINKO) on hygiene management in dental practices—analysis of a survey from 2009. GMS Krankenhhyg Interdiszip. 2012;7(1):Doc14.

30. Simmons College. Press Release: Superbug Transmitted by Textiles: Research Cites Clothing as Key Link in Spread of Infection. Available at http://www.hospitalinfection.org/PDF/Dr.%20Liz%20Scott%20PR.pdf. Last accessed December 12, 2018.

31. American Medical Association. AMA Meeting: Hand-Washing Trumps Dress Codes in Preventing Infections. Available at https://www.amednews.com/article/20100628/profession/306289923/7/. Last accessed December 12, 2018.

32. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review.BMC Infectious Diseases. 2006;6:130.

33. Mast EE, Weinbaum CM, Fiore AM, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part II: immunization of adults. MMWR. 2006;55(RR16):1-25.

34. California Department of Public Health. CCR, Title 22, Section 72535 (b). Available at https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/Title-22-for-Use-of-TST.aspx. Last accessed December 12, 2018.

35. Pfoh E, Dy S, Engineer C. Interventions to Improve Hand Hygiene Compliance: Brief Update Review. In: Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality; 2013.

36. 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 Recomm Rep. 2001;50(RR-11):1-52.

37. California Department of Public Health. TB Fact Sheet 2017. Available at https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/TBCB-TB-Fact-Sheet-2017.pdf. Last accessed December 12, 2018.

38. Centers for Disease Control and Prevention. Hand Hygiene in the Healthcare Setting. Available at https://www.cdc.gov/handhygiene/science. Last accessed December 12, 2018.

39. California Dental Association. New Infection Control Standard for Procedures that Expose Dental Pulp. Available at https://www.cda.org/news-events/new-infection-control-standard-for-procedures-that-expose-dental-pulp. Last accessed December 12, 2018.

51292 • The California Dental Practice Act

William E. Frey, DDS, MS, FICD

www.netce.com

Copyright © 2019 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

51292 • The California Dental Practice Act

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

About the Sponsor

Disclosure Statement

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

51292 • The California Dental Practice Act

Education Category. Management

Release Date. 02/01/2019

Expiration Date. 01/31/2022

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.

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

William E. Frey, DDS, MS, FICD, graduated from the University of California School of Dentistry, San Francisco, California, in 1966. In 1975, he completed residency training in Periodontics and received a Master's degree from George Washington University.
Dr. Frey retired from the United States Army Dental Corps in 1989 after 22 years of service. Throughout the course of his professional career, he has continuously practiced dentistry, the first 7 years as a general dentist and the past more than 40 as a periodontist. His military experience included the command of a networked Dental Activity consisting of five dental clinics. In his last assignment, he was in charge of a 38-chair facility. Colonel Frey was selected by the Army to serve on two separate occasions as the Chair of the Periodontal Department in Army General Dentistry Residency Training Programs.
Dr. Frey is the founder and president of Perio Plus, a practice management firm specializing in creating individually-designed hygiene and periodontal care programs for general dentists. He is also the creator of the Inspector Gum patient education series.

Faculty Disclosure

Contributing faculty, William E. Frey, DDS, MS, FICD, 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.

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 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, 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]. It is the Board's mission to protect the health and safety of dental care consumers.

In addition, the practice of dental hygiene is regulated by the Dental Hygiene Committee 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/or treatment (nonsurgical, surgical, or related procedures) of diseases, disorders, and/or conditions of the oral cavity, maxillofacial area, and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her 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, or in any other way advertises himself or represents himself 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 he will perform by himself or his agents or servants any operation upon the human teeth, alveolar process, gums, jaws, or associated structures, or in any way indicates that he 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 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. 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.

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). The processing times for coronal polishing course approval are set forth in section 1069.
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.) The processing times for ultrasonic scaler course approval are set forth in section 1069.

(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.

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 nine governor-appointed positions: four public members, four dental hygienists, and one practicing dentist [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). 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 Dental Board/California Department of Justice (DOJ) or if records no longer exist [21]. Fingerprinting must be conducted using the DOJ Live Scan system; fingerprint records from other institutions (e.g., Department of Motor Vehicles) are not suitable. 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 Committee 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 Committee 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.dhcc.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 profession 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.dhcc.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 intake, complaint analysis, inspection, investigation, and probation [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 section. The Board's Enforcement Unit may be contacted at (916) 274-6326. Violations of the Act by hygienists are handled by the Hygiene Committee's Complaint Unit, which operates in a similar manner and can be contacted at (866) 810-9899.

According to CCR Section 490.(b), 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 the business or profession for which the licensee's license was issued" [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 he or she is licensed to practice, in advertising or in any other manner indicating that he or she 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.

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

(k) The advertising in violation of Section 651 regarding fraudulent advertising.

(l) The advertising to guarantee any dental service, or to perform any dental operation painlessly.

(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: (A) the death of his or her patient during the performance of any dental or dental hygiene procedure; (B) the discovery of the death of a patient whose death is related to a dental or dental hygiene procedure performed by him or her; or (C) except for a scheduled hospitalization, the removal to a hospital or emergency center for medical treatment for a period exceeding 24 hours 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 his or her practice with a copy sent to the Dental Hygiene Committee 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 Committee 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 Committee of California to establish a consensus. The committee 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.

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 conscious 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 conscious sedation or general anesthesia.

(b) Any dentist with patients recovering from conscious 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 conscious 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 conscious sedation to fail to have these patients continuously monitored during the dental procedure with a pulse oximeter or similar or superior monitoring equipment required by the board.

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

(e)

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

2. The written informed consent, in the case of a minor, shall include, but not be limited to, the following information:
"The administration and monitoring of 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 his or her dental treatment, and consult with your dentist or pediatrician as needed."

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

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 a conspicuous place in his or her office the name of each and every person employed there in the practice of 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. 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:

(a) 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.

(b) 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.

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

(d) 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.

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

(f) 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.

(g) 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.

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 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/pubs/manuals/pract. The California Uniform Controlled Substances Act (part of the California Health and Safety Code) can be found at https://leginfo.legislature.ca.gov/faces/codesTOCSelected.xhtml?tocCode=HSC. 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 sections of the Act addresses the facilitation of abuse by prescribing practices, including the new CURES reporting requirements.

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.

Section 11150.2. (a) Notwithstanding any other law, if cannabidiol is 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 cannabidiol 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 his or her 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 cannabidiol 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 cannabidiol 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 provision of 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. All prescriptions for Schedule II, Schedule III, and Schedule IV 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) Pharmacies may dispense prescriptions for Schedule III, Schedule IV, and Schedule V controlled substances from out-of-state prescribers pursuant to Section 4005 of the Business and Professions Code and Section 1717 of Title 16 of the California Code of Regulations.

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, and Schedule IV 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, and Schedule IV 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 of Justice, 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 of Justice, for educational, peer review, statistical, or research purposes, provided that patient information, including any information that may identify the patient, is not compromised. Further, data disclosed to any individual or agency as described in this subdivision shall not be disclosed, sold, or transferred to any third party, unless authorized by, or pursuant to, state and federal privacy and security laws and regulations. The Department of Justice 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. 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 is provided and keep 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, or Schedule IV controlled substance, as defined in the controlled substances schedules in federal law and regulations, specifically Sections 1308.12, 1308.13, and 1308.14, 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 of Justice as soon as reasonably possible, but not more than seven days after the date a controlled substance is dispensed, in a format specified by the Department of Justice:

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 any 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. International Statistical Classification of Diseases, 9th revision (ICD-9) or 10th revision (ICD-10) Code, 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. Date of origin of the prescription.

10. Date of dispensing of the prescription.

(e) The Department of Justice 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. All prescriber and dispenser invitees 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 of Justice 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 of Justice may establish a process to educate authorized subscribers of the CURES PDMP on how to access and use the CURES PDMP.

Section 11165.1. (a)

1. A health care practitioner authorized to prescribe, order, administer, furnish, or dispense Schedule II, Schedule III, or Schedule IV controlled substances pursuant to Section 11150 shall, before July 1, 2016, or upon receipt of a federal Drug Enforcement Administration (DEA) registration, whichever occurs later, 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 the electronic history of controlled substances dispensed to an individual under his or her care based on data contained in the CURES Prescription Drug Monitoring Program (PDMP).

2. A pharmacist shall, before July 1, 2016, or upon licensure, whichever occurs later, 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 pharmacist the electronic history of controlled substances dispensed to an individual under his or her care based on data contained in the CURES PDMP.

2. An application may be denied, or a subscriber may be suspended, for reasons which 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 his or her federal DEA registration suspended or revoked.

4. Violating a law governing controlled substances or any other 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 his or her patients, or to document compliance with the law.

3. An authorized subscriber shall notify the department within 30 days of any changes to the subscriber account.

4. Commencing no later than October 1, 2018, an approved health care practitioner, pharmacist, and any 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. Commencing no later than October 1, 2018, 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 can certify 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, or Schedule IV 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, or Schedule IV 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, and 1308.14 of Title 21 of the Code of Federal Regulations.

(f) A health care practitioner, pharmacist, and any 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 any false, incomplete, inaccurate, or misattributed information submitted to, reported by, or relied upon in the CURES database or for any 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:

"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.

1. "Department" means the Department of Justice.

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

3. "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.

4. "User-initiated basis" means an authorized health care practitioner or pharmacist has taken an action to initiate the query to the CURES database, such as clicking a button, issuing a voice command, or taking some other action that can be attributed to a specific health care practitioner or pharmacist.

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 CURES database to review a patient's controlled substance history before prescribing a Schedule II, Schedule III, or Schedule IV controlled substance to the patient for the first time and at least once every four months thereafter if 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 CURES database the first time he or she prescribes, orders, administers, or furnishes a controlled substance to a patient, he or she shall consult 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 four months thereafter if the substance remains part of the treatment of the patient.

2. For purposes of this paragraph, "first time" means the initial occurrence in which a health care practitioner, in his or her 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 obtain a patient's controlled substance history from the CURES database no earlier than 24 hours, or the previous business day, before he or she 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 is admitted to any of the following facilities or during an emergency transfer between any of the following facilities 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.

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 a controlled substance to a patient as part of the patient's treatment for a surgical procedure and the quantity of the controlled substance does not exceed a nonrefillable five-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.

4. If a health care practitioner prescribes, orders, administers, or furnishes a controlled substance to a patient currently receiving hospice care, as defined in Section 1339.40.

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 five-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 he or she did not consult the database in the patient's medical record.

6. If the CURES database is not operational, as determined by the department, or when it 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 any cause of the temporary technological or electrical failure that is reasonably within his or her control.

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

8. 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 five-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) This section is not operative until six months after the Department of Justice certifies that the CURES database is ready for statewide use and that the department has adequate staff, which, at a minimum, shall be consistent with the appropriation authorized in Schedule (6) of Item 0820-001-0001 of the Budget Act of 2016 (Chapter 23 of the Statutes of 2016), user support, and education. The department shall notify the Secretary of State and the office of the Legislative Counsel of the date of that certification.

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

(g) 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.

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 Section 11166.05, a mandated reporter shall make a report to an agency specified in Section 11165.9 whenever the mandated reporter, in his or her professional capacity or within the scope of his or her 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 to the agency immediately or as soon as is practicably possible by telephone and the mandated reporter shall prepare and send, fax, or electronically transmit a written follow-up report thereof 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 (CDA) have published useful guidelines regarding the identification of the orofacial signs of abuse and particular injuries of concern. According to these guidelines, possible signs of abuse include [6,7]:

- 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.

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 CDA's Dental Professionals Against Violence Reference Manual is a useful resource for dental professionals and includes the acronym RADAR to assist in the routine abuse screening of patients [7]:

- Recognize signs and symptoms of abuse/neglect, routinely screen

- Ask direct, non-judgmental questions with compassion

- Document your findings

- Assess patient safety

- 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 data [8]. Identify the medical problem, document the suspected abuse, 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 $1000 or, in cases of serious injury/death following a failure to report, 12 months in jail, and/or a fine of $5000.

ELDER AND DEPENDENT ADULT ABUSE AND NEGLECT

Abusive injuries to the mouth and oral cavity of elder or dependent 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 [11,12]. 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 a steady increase in reporting over the last few decades [14]. Contrary to popular belief, the overwhelming majority of abuse and neglect occurs in domestic, rather than institutional (e.g., residential care), settings [12,14]. 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 the one of the most common causes of elder injury reporting (roughly 500,000 cases per year in the United States) [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]. In the United States in 2011, 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) had been experienced by an estimated 22.3% of women and 14.0% of men during their lifetimes [17].

Dental professionals should be vigilant in recognizing signs of abuse among adolescent and adult patients. Facial injuries occur in 94% of intimate partner violence cases and are similar to those already discussed [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 injuries through the use of nonjudgmental questions. The CDA recommends the following line of indirect questioning for use with most age groups [7]:

- "I am concerned that your symptoms/injuries may have been caused by someone hurting you."

- "I don't know if this is (or has ever been) a problem for you, but many of the patients I see are dealing with abuse/abusive relationships. Some are too afraid or uncomfortable to bring it up themselves, so I have started asking about it routinely."

The CDA also offers these examples of direct questioning [7]:

- "Did someone cause these injuries? Was it your parent/caretaker/partner/husband?"

- "Are you in a relationship with (or do you live with) someone who physically hurts or threatens you?"

- "Is it safe for you to go home?"

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.

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 [7]. 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

Dental Professionals Against Violence Reference Manual

https://www.cdafoundation.org

Works Cited

1. Dental Board of California. Dental Practice Act. Available at https://www.dbc.ca.gov/lawsregs/laws.shtml. Last accessed December 13, 2018.

2. American Dental Association. General Dentistry. Available at https://www.ada.org/en/education-careers/careers-in-dentistry/general-dentistry. Last accessed December 13, 2018.

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 December 13, 2018.

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.

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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 December 13, 2018.

12. National Center on Elder Abuse. Abuse of Adults Aged 60+: 2004 Survey of Adult Protective Services. Available at http://www.napsa-now.org/wp-content/uploads/2012/09/2-14-06-FINAL-60+REPORT.pdf. Last accessed December 13, 2018.

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/Data. Available at https://ncea.acl.gov/whatwedo/research/statistics.html. Last accessed December 13, 2018.

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 http://leginfo.legislature.ca.gov/faces/codesTOCSelected.xhtml?tocCode=wic. Last accessed December 13, 2018.

17. Centers for Disease Control and Prevention. Prevalence and Characteristics of Sexual Violence, Stalking, and Intimate Partner Violence Victimization: National Intimate Partner and Sexual Violence. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6308a1.htm?s_cid=ss6308a1_e. Last accessed December 13, 2018.

18. Barkley Burnett L, Adler J. Domestic Violence: Clinical Presentation. Available at http://emedicine.medscape.com/article/ 805546-clinical#b4. Last accessed December 13, 2018.

19. California Legislative Code. Business and Professions Code Section 1600-1621. Available at http://leginfo.legislature.ca.gov/ faces/codes_displayText.xhtml?lawCode=BPC&division=2.&title=&part=&chapter=4.&article=1. Last accessed December 13, 2018.

20. Dental Hygiene Committee of California. Home Page. Available at https://www.dhcc.ca.gov/index.shtml. Last accessed December 13, 2018.

21. Dental Board of California. Fingerprint Requirement for License Renewal. Available at https://www.dbc.ca.gov/licensees/fingerprint_faq.shtml. Last accessed December 13, 2018.

22. Dental Board of California. Enforcement Program. Available at https://www.dbc.ca.gov/consumers/enforcement.shtml. Last accessed December 13, 2018.

23. Shouse Law Group. How Criminal Convictions Affect California Dental Board Licenses. Available at https://www.shouselaw.com/dentists.html. Last accessed December 13, 2018.

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 December 13, 2018.

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 December 13, 2018.

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 December 13, 2018.

27. California Dental Association. Mandatory CURES Consultation in Effect Oct 2. Available at https://www.cda.org/news-events/mandatory-cures-consultation-in-effect-oct-2. Last accessed December 13, 2018.