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HIV/AIDS and Infection Control

While it’s not making headlines like it did in the previous decades, HIV/AIDS  is still a global epidemic that also hits close to home.  Today, many dental professionals have no recollection of the ‘Acer’ story that brought dentistry into the realm of disease and HIV transmission. It has changed the way we are required to practice. It was a turning point for infection control practices in dentistry and public awareness and concerns. The media was filled with stories of potential cross contamination, waterline biofilmsevacuation suck-back, handpieces,  ‘experts still baffled’patient fear .

Despite the lapsed time, many still remain confused by the misinformation out there. The Dr. Acer case is the only apparent known transmission of HIV clinician to patient.  Infection control guidelines continue to be updated and mandated across the country. Overkill? We don’t yet have a ‘national standard’. Alberta and Ontario saw major changes in recent years. British Columbia is in the process of updating it’s guidelines with dental and hygiene members recently receiving the latest ‘draft’ copy of the guidelines for input. Are these changes long past due? Overkill? Or designed simply to meet the publics ill informed cry for more stricter measures? The UK is considering allowing HIV+ individuals to practice once again. Have we reached a turning point in understanding and awareness?  Your thoughts?

 World AIDS Day
The week of November 24-December 1st is World AIDS week. December 1st is World AIDS Day. Celebrated since 1988 to raise awareness around the issues relating to HIV/AIDS. Education is key – for professionals and for the public. Oral health needs, rights to treatment, and an understanding of the oral manifestations/treatments as well as a solid understanding of disease transmission is required of all health care professionals.

Is it a Canadian issue? The following are some Canadian statistics:

 HIV/AIDS in Canada by the Numbers

 General HIV & AIDS Statistics
• 65,000 - Estimated number of people living with HIV/AIDS in Canada in 2008. 26% of these individuals were undiagnosed, which means they could unknowingly transmit HIV.

• 21,300 - Number of AIDS cases reported since 1979.

• 2,300 – 4,500 - New cases of HIV reported each year.

HIV and Gay Men and Men Who Have Sex with Men
• 44% - New infections in 2008 attributed to gay men and men who have sex with men, the group most affected by HIV.

Heterosexual Sex
• 36% - Proportion of new cases of HIV attributed to heterosexual sex in 2008.

HIV and Women
• 26.2% - Proportion of new HIV cases attributed to women in 2008. Prior to 1998, women accounted for only 12% of all positive test reports.

• 45% - Proportion of positive HIV tests among women attributed to Aboriginal women, who represent about 4% of the total Canadian female population, in 2007.

• 20% - Proportion of positive HIV tests among women attributed to black women, who represent a little more than 2% of women in Canada.

• 58.3% - Proportion of positive test reports among women attributed to the age category 15 to 19 years in 2008.

HIV and Youth
• 17,453 - Number of positive HIV test reports among youth under the age of 30 years since 1985.

• 494 - Number of cases of HIV attributed to perinatal (mother to infant) transmission since 1984.

HIV and Drug Use
• 19.1% - Proportion of newly reported cases of HIV in 2008 attributed to injection drug use.

HIV in Prisons
• 2% – 8% - Estimate of HIV prevalence in Canadian federal and provincial prisons. Women in prison have higher HIV prevalence rates than men (about 4% compared to 1-2% for men).

Affected Age Groups
• 30 – 39 years - The age group attributed to most new infections of HIV since 1985. Among women, this age group represents 36.9% of new reports, while among men, it represents 39.9% of reports.

• Over 40 years - The age group increasingly affected by HIV. In the period 1985-1997, the over 40 age group represented 26.5% of infections, while in 2008, while it represented 45% of all newly reported cases of HIV in 2008.

• Over 50 years - It is estimated that up to 12% of HIV-positive people in Canada are older than 50. This number is expected to increase by as much as 20% over the next decade.

HIV among Ethnocultural Populations
• 29.4% - Proportion of overall positive test reports attributed to Aboriginal peoples in 2008.

• 14.5% - Proportion of overall positive test reports attributed to black Canadians in 2008.

Top Three Provinces Most Affected by HIV
• 81% - combined proportion of HIV reports attributed to Ontario, Quebec and British Columbia in 2008. On an individual basis, each province represents 42.7%, 24.7% and 13.6% of infections, respectively.

• Saskatchewan, Ontario and British Columbia - provinces with the highest per capita rate of HIV cases reported, while Newfoundland and Labrador, Northwest Territories and Nunavut reported the lowest rates.

 [Statistical data provided via the Canadian Aids Society 613.230.3580 | |]

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The Ultimate Hygiene Exam

We all aspire to provide ‘ideal’ treatment for our clients and feel we can’t because of restrictions placed on us outside our control. If it was your practice, what you your protocol look like?

[Originally posted by Rachel Wall, Inspired Hygiene, Reprinted with permission]

Greet patient by name with a handshake

  • “Hi, Ms. Jones. My name is Rachel and I will be taking care of you.”

Escort patient to treatment room

Ask patient for any questions/concerns they may have

  • “Have you noticed any changes with anything in your mouth? Do you have any questions or concerns before we start today?”
  • Address any specific concerns

Take blood pressure and record in chart

Review medical history

  • “Are you taking any medication, supplements or over-the-counter drugs? Are you taking aspirin daily? Have you had any surgery or new diagnoses since your last visit?”

Take radiographs if necessary

Review radiographs

  • Observe bone level and compare to periodontal probe readings
  • Observe decay visible on x-rays
  • Observe margins of restorations
  • Observe any lesions in the bone

Do extra-oral head/neck oral cancer screening

  • “Ms. Jones, I am going to be my exam by feeling for any unusual lumps or bumps on your face and neck. Is that ok? Have you noticed any lumps or bumps?”

Do intra-oral cancer screening

  • Complete a visual exam
  • Utilize technology for oral cancer screening-Velscope or Vizilite

Complete general intra-oral exam

  • Observe restorations, teeth and gums
  • Calculus detection
  • Decay examination
  • Evaluation of existing restorations
  • Cosmetic evaluation-shade guide analysis
  • Breath Analysis
  • Oral Hygiene Evaluation
  • Occlusal Analysis

Complete 6-point periodontal examination

  • “Ms. Jones, I am now going to do a very thorough exam of your gums. This exam looks for signs of gum disease. I will be taking several measurements on each tooth and you will hear me call out lots of numbers. If you hear numbers that are 1-3 with no bleeding, that indicates that your gums are healthy and normal. Any numbers you hear that are 4 or higher or if you hear me say there are many areas of bleeding, that is a sign of gum infection. I will review all the numbers when the exam is finished”
  • Using a periodontal probe, measure the depth of each pocket.
  • Start on the upper right facial moving around the arch taking 3 measurements on per tooth. Then move to the lingual and take 3 measurements per tooth. Repeat on the lower arch.
  • Say all perio numbers aloud from the upper right to the upper left facial. Then look back at upper facial areas and say aloud any points of bleeding, pus. Repeat on lingual and on lower arch.
  • Measure recession from the CEJ to the gingival margin. Say all numbers aloud with surfaces to be recorded on perio chart.
  • Record mobility and furcation aloud and record on perio chart
  • Read aloud the total number of bleeding sites and pockets over 4mm
  • Print perio chart in color.
  • Highlight infected areas on periodontal chart (4mm or greater).

Determine patient’s periodontal status: healthy, gingivitis, periodontal disease

Share your observations with the patient

  • Share with patient their periodontal status-healthy or infected
  • Share with patients any teeth you are concerned about
  • This is a good time to discuss whitening, fresh breath solutions

Take intra-oral photographs

  • If patient has periodontal disease, take photos of inflamed, bleeding tissues and/or visible calculus.
  • If patient has healthy gums, it is now time to discuss their restorative needs. Take photos of next restorative priority (area of concern).

Create periodontal treatment plan or preliminary restorative plan for doctor approval

Call Doctor for exam (doctor may do exam any time after hygiene exam is complete)

  • Doctor confirms all findings and makes final diagnosis
  • Doctor reinforces need for perio therapy as first priority when there are no emergency restorative needs
  • Doctor reinforces need for restorative treatment when patient’s periodontal status is healthy
  • This may occur immediately following hygiene exam or closer to the end of the appointment depending on doctor’s schedule

Begin hygiene service

You may now begin scaling.

[Reprinted with Permission. Original appeared as a blog post by Rachel Wall, at Inspired Hygiene  April 26th, 2010 Step-by-Step System for the Ultimate Hygiene Exam. Rachel provides office consulting, online programs, books, CDs and host of other valuable practice managment supports for dental/hygiene practice, her specialty, Dental Hygiene Practice]

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Deals in Dental Hygiene?

It seems we’ve become a consumer driven health care system. Is that a good thing? Perhaps in some respects – when we are educating and collaborating with the client with respect to decision making and treatment – yes.

Groupon Dental Deal

But, society has become very ‘deal’ driven – ‘ultimate couponing’, ‘deals of the day’, ‘Groupon’, ‘daily deals’, ‘SwarmJam’, and similar offerings are everywhere. We’re seeing them in the coffee shop, the hair dresser, spa, bakery, cleaning services…they pop up in our email, our newspapers…and yes, I’ve also seen some in the dental industry.

Here in British Columbia, the College of Dental Surgeons has spoken out against the ‘Groupon’ or like offerings:

CDSBC has been asked whether it is acceptable for a dentist to use this approach to gain new patients. The simple answer is no. The way the system works is that the company operating the website takes up to 50 per cent of any money that is paid. This effectively means the dentist is paying the company a commission for the referral. Any scheme that includes paying a third party a fee for the referral is explicitly contrary to the Code of Ethics, and therefore not permitted.

As you can see, they disapprove. Yet, competition in the dental industry is tight, especial within the major centers. The sprouting of independent hygiene probably isn’t helping.

Most of the offers I’ve seen locally and in other areas of Canada and the US, relate to dental hygiene services, typically for new patients. It’s the staff within the practice, not the dentist, that are asked to work harder, see more clients, at a reduced fee to the client. This in my opinion is fueling the dentist/practice view that the hygiene department isn’t ‘producing’ ($) and adding to the push of lower wages. Even more importantly however, it’s not instilling value in the client for the services they are receiving. And, it’s not just dentists that are at fault, the desire for clients has lead hygiene practices down this dangerous road as well. Are ‘deal seakers’ the loyal client base you’re looking for?

This is a problem I’ve always felt existed with our insurance assignment clients – they don’t pay ‘up front’ so they have no concept what dentistry costs, and they fail to value it, or their insurance benefits. Too often I see people who make their first dental visit when they are about to lose their employment – they’ve had dental insurance benefits for years, but simply never bothered to use it.

We need to do more to educate the public and dental practices. There’s a saying, Don’t look for deals in brain surgery, parachutes, or dentistry.”  People don’t like to go to the dentist - those that do go regularly prefer to have things done comfortably, fast and in the best way possible  given the circumstances so that they don’t have to redo it, and pay twice.  My advice, treat people well, make sure they know how much you care, long before they see how much you know and patient flow won’t be a problem. Value will be created as will trust and the rest of the pieces will fall into place.

‘Cheap’ should not be a part of health care. There’s a huge leap between cheap and choice and making care affordable. Dentistry can be made affordable by providing payment options and treatment options. Sometimes that may require referring them to the local dental or hygiene school for care, or seeing them in study club. It may mean occasionally accepting insurance assignment, although you’re a ‘fee-for-service’ office. It shouldn’t mean turning people away. If they’re not happy, and do not value the care you are providing, it doesn’t matter how good that care is. They are paying for ‘care’ not dentistry. Dentistry is a people business, a relationship business. Would you agree?

[the opinions expressed are my personal opinions and not the opinions of CDHA]

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Continuing Education

As health care professionals, we know that dental hygiene/health care is not a static field. The research is constantly evolving, new treatments, protocols and productsbombard us daily. The number of references on MEDLINE for randomised controlled trials in dentistry is continuing to increase above the 3000 level (Figure 1). The picture for references to systematic reviews on the other hand is relatively static at around 1000 per year (Figure 2).  Bastian et. al. highlight this in a recent paper that 75 trials and 11 systematic reviews are published each day! Back in 2001 there were ”over 700 dental journals available worldwide, about 320 are indexed in MEDLINE” and that number has continued to increase as publications have gone electronic and publishing costs subsequently decreased. That’s a lot of new information to keep up on! (12, 3)

We’ve all become consci0us of the importance of peer reviewed, evidence based research, even if that wasn’t the ‘buzz phrase’ back when we were in school. It’s not the basis of science/medicine/health care, or it should be.  So how do we keep up on all this new ‘stuff’?

Generally, “we don’t know, what we don’t know”. By constantly networking with colleagues/peers, educators, regulators, manufacturers, and marketers we expose ourselves to new ideas, share in the experiences of others, become exposed to new products, entertain new ideas and concepts.

Dental hygiene practice can be very isolating. Sometimes we need to step outside our comfort zone, ask questions of others, question ourselves and what we’re doing. Ours is a very dynamic profession interlaced with medicine and oral-systemic connections. No one expects you to know it all. The expectation is, however, that you are open to new ideas and change, and seeking out ‘a better way’ for both you and your client – perhaps something more effective, more efficient, more cost effective, environmentally friendly, . . . the possibilities are endless.

We you see the opportunities for your yourself, your practice, your client and your profession if you stay home hidden away in your operatory? Probably not. You need to seek out the unknown and the best way is by networking with colleagues – in person, on line, at conferences, study clubs, schools etc.

Your professional bodies (licensing and association) have a number of avenues to facilitate this. CDHA provides online communities, online live and archived continuing education programs, avenues for sharing and chat on twitter and facebook, and of course via this blog as well. CDHA is also hosting YOUR  national conference, Advancing Dental Hygiene Practice, to be held 9-11 June 2011 at the Lord Nelson Hotel, Halifax, Nova Scotia. This is another opportunity to connect with peers, colleagues, educators and administrators in the dental profession and ‘flesh out’ some of what you may be missing. Take the opportunity – for yourself, your practice, your patients and the profession!

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Effective Patient Management

FEAR’ is the biggest barrier in dentistry – need to build trust, rapport, and respect. Ms. Sandy Chernoff’s lecture was about communication to build trusting respectful relationships and rapport with clients through effective listening. Problem solving requires critical thinking – apply your knowledge.

Key effective listening techniques are; “peel the onion”-non-judgmental, summarize issue, problem-solve –ask questions. These techniques are achieved by using the tools for effective listening; stop talking, put person at ease, remove distractions, empathize, be patient, watch own emotions, be objective, and ask questions. Let them tell you!  You were given two ears and one mouth…what does that tell you? Need to listen more! Pay attention to the conversation, people talk at 150 words/minute. Everyone’s brain goes somewhere else during a conversation. Try to stay present! Reflective listening is repeating what you heard or paraphrasing.

The road blocks to effective listening are; interrupting, criticizing, reassurances, related stories, avoiding eye contact, and providing advice. Do not get into the ‘ritual dance’ of “he says/she says”-change the dance by stopping to listen takes the other person guard off. Do not assume! What is the definition of ‘assume’? Ass (out of)/U/Me.

How do we motivate people? Compelling reasons that matter to the patient/person will initiate change. What is your plan for patient motivation? Be understanding, create need + value, involve the client, and recognize their sense of identity. Choose the right words for the right message.  ***key concept: repeat important messages 3x’s for the patient to remember the message*** Watch the TV commercials-listen for the key message…is it repeated 3x’s? Listening + building respectful trust relationships + motivation = patient compliance.

Please check the PDC website to download the notes on this seminar.

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