Atient Management Legend: Topic Cards Topic Cards

ATIENT MANAGEMENT LEGEND
Topic Cards Topic Cards

behavioral sciences 1-19 OSHA 51-76
infection control 20-50 public health 77-99
BS
Arrange the following steps of the educational process in correct order.
1. expressing needs
2. stimulating motivation
3. recognizing needs
4. evaluating results
5. reinforcing learning
6. setting goals
7. acting to achieve goals
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•3,1,2,6,7,5,4
Although each learning situation will not fol- Step 4
low these steps in exact sequence, most situa- • setting goals
tions will include all of these seven steps in • short-range or long-range guides to ac-
some form: tivity
• must be meaningful, attractive & at-
• recognizing needs tainable
• expressing needs Step 5
• stimulating motivation • acting to achieve goals
• setting goals • activity is needed for learning
• acting to achieve goals • must be directed at specific goals
• reinforcing learning Step 6
• evaluating results • reinforcing learning
Step 1 • review & repetition aid in learning re-
• recognizing needs tention
• dentist recognizes educational needs as treat- Step 7
ment needs are determined • evaluating results
• dentist helps patient recognize needs • aid in judging what patient has learned
Step 2 • aid in determining how effective
• expressing needs dentist's teaching has been
• dentist records educational needs • can help clarify or redefine goals
• dentist helps patient state needs
Step 3
• stimulating motivation
• motivation arouses & maintains interest
• dentist may appeal to inner needs or use arti-
ficial stimuli
BS
Identify each of the following statements that are true concerning needs and
learning.
• needs are driving forces that prompt a person to act
• the process of learning is continuous
• learning occurs as a person attempts to satisfy needs
• expressing needs helps to pinpoint them for the patient and dentist
• recording educational needs can be as important as recording treatment needs
• all of the above statements are true
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• all of the above statements are true
Needs & Learning Assessment of behavior

• needs & goals may provide motiva- • in order to change behavior, assess-
tion ment of the behavior is needed
• motivation arouses & maintains in- • how to assess behavior
terest - identify problem
• motivation may be artificial or built- - consider motivation
in - consider readiness
• patients rarely learn without motiva- - consider willingness to change
tion - consider ability to change
• learning is continuous and occurs - collect baseline data
when a person attempts to satisfy - reassess behavior after imple-
needs memtation
• motivation stimulates a person to act
on needs
• motivation is a fundamental part of
every learning situation
• short-range goals are less remote &
more easily attained
• goals should be attractive & attain-
able in order to be meaningful
• goal-directed activity is necessary
for learning
BS
Most researchers believe that changes in behavior are a prerequisite to

changes in attitude.
Behavior can be defined as a determined, purposeful unit of activity.
• both statements are true
• both statements are false
• the first statement is true, the second is false
• the first statement is false, the second is true
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Behavior Behavior examples

• changes in behavior are a prerequisite • a common behavior for a dentist is
to changes in attitude to observe that a problem exists
• behavior is defined as a determined, (e.g., tooth decay)
purposeful unit of activity • a common behavior for a patient
is to avoid the dentist even though a
- determined need exists & treatment is required
the assumption that the behavior
is lawful & has determinants both of the above examples meet the
- purposeful criteria of being "determined, pur-
the assumption that the poseful units of human activity"
behavior is goal-oriented, that it
seeks to achieve positive and re- Behavior management
duce negative need or motivated
• as described by the ADA, tech-
states
niques or therapies used to alter or
- unit of activity
control the actions of a patient who
what a person does that can be re-
is receiving dental treatment; exam-
ported or described as discrete
ples include education or anxiety
elements relief techniques
• the means by which the dental
health team effectively and effici-
ently performs treatment for the
patient, and, at the same time, instills
a positive attitude
BS
The principal nonverbal cue that two or more persons can use to regulate ver-
bal communication is:
• posture
• facial expression
• eye contact
• gestures
• proximity
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• eye contact
Communication Listening
• the process by which information is • receiving & understanding messages
exchanged between 2 or more persons • a good listener shows attention &
interest
• communication is essential in the
dentist-patient relationship • listening techniques include
• acceptable verbal & non-verbal - paraphrasing (repeating in own
communication varies with the age, sex, words)
ethnicity and culture of the patient - interpretation (identifying the
• communication is both verbal & underlying reason)
non-verbal; also includes listening - preparation (allowing time for dis-
cussion & eliminating distractions)
Verbal communication
• involves use of language Eye contact
• choice of words is important • is the principle non-verbal cue used to
• delivery of speech is important regulate verbal communication
(fast vs. slow, loud vs. soft) • when listening to a patient, a dentist
should maintain eye contact
Non-verbal communication • a dentist should engage the patient's
• involves use of body language eyes as often as is comfortable for both
• conveyed by eye contact, posture, body parties
movement, hand gestures & expressions
Facilitative skills
Empathy & Rapport • facilitative skills make communication
• empathy is the ability to experience the easier and help to develop trust
feelings of another person • include encouraging patient questions,
• rapport is a mutual sense of trust and answering questions, responding to re-
openness between individuals quests & communicating with warmth
BS
Which term describes a behavioral response that operates by the simple

process of association of one stimulus with another?
• operant conditioning
• classical conditioning
• observational learning
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• classical conditioning
Classical conditioning Observational learning
• a stimulus leads to a response • or modeling, is a type of learning that
• a.k.a. pavlovian or respondent condi- occurs as a function of observing, re-
tioning taining and replicating behavior exe-
• a process of behavior modification by cuted by others in a social context
which a subject comes to respond in a • two phases: acquisition of the behavior
desired manner to a previously neutral & performance of the behavior
stimulus that has been repeatedly pre-
sented along with an unconditioned Example
stimulus that elicits the desired response Classical conditioning
• before conditioning, a painful injection
Operant conditioning (unconditioned stimulus) would elicit a
• process of behavior modification in fear reaction (unconditioned response)
which the likelihood of a specific be- • during conditioning, the dentist with
havior is increased or decreased through syringe (neutral stimulus) is linked
positive or negative reinforcement each with the painful injection and elicits a
time the behavior is exhibited, so that fear reaction
the subject comes to associate the pleas- • after conditioning, the dentist with a
ure or displeasure of the reinforcement syringe (conditioned stimulus) will en-
with the behavior courage a fear reaction (conditioned
• four types: positive reinforcement, response)
negative reinforcement, punishment
& extinction
BS
Which type of aggression is an act of hostility unnecessary for self-protection
or preservation that is directed toward an external object or person?
• destructive aggression
• inward aggression
• constructive aggression
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• destructive aggression
Destructive aggression Aggressive personality
• act of hostility • personality with behavior patterns
• unnecessary for self-protection or characterized by irritability,
preservation tantrums, destructiveness or vio-
• directed toward external object or lence in response to frustration
person • aggressive personalities are individ-
uals whose overall "style" of inter-
Constructive aggression acting involves considerable, per-
• act of self-assertiveness sistent, maladaptive aggression
• in response to a threatening action expressed in a variety of ways and
• for purpose of self-protection and in a wide range of circumstances
preservation • characteristics include the
following:
Inward aggression - seek a superior position in any
• destructive behavior directed relationship or encounter
against oneself - abhor submission
- self-advancing at expense of
others
- have disdain for truth
- lack internal "brakes"
BS
Match the type of question on the left to the correct example on the right.
direct 1. You're not afraid of needles, are you?

probing 2. How are you doing with brushing & flossing?
laundry list 3. How are you?
open-ended 4. Is it easier to hold the brush this way?
leading 5. What else did you notice about your gums?
facilitating 6. Is the pain sharp, dull, or throbbing?
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•4,5,6,2,1,3
# Type Example
4 direct Is it easier to hold the brush this way?

question direct questions asked for a specific bit of information
C probing What else did you notice about your gums?

question probing questions ask for more specific information that the
Patient offers spontaneously
6 laundry list Is the pain sharp, dull, or throbbing?
question laundry list questions give the patient a list of choices
2 open-ended How are you doing with brushing & flossing?

question open-ended questions request information in the patient's
own words and specify a content area
1 leading You're not afraid of needles, are you?

question leading questions entice a patient to answer in a specific way;
leading questions should not he used with patients
3 facilitating How are you?
question facilitating questions encourage the patient to say more
without specifying an area or topic
Communication hints
• ask questions/never presume
• carefully inquire/never interrogate
• be specific/avoid being vague or abstract
• provide information & educate/instead of giving advice
• provide accurate information/fully discuss concerns & offer support
• exhibit professionalism/it is an essential component of dentist-patient relationships
• exhibit confidence, care & warmth
BS
Which one of the following types of patients is usually considered to be the

most difficult?
• the "know-it-all" patient
• the anxious patient
• the shy patient
• the talkative patient
• the stubborn patient
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• the anxious patient
Anxious patient Management of the anxious patient
• is the most difficult patient to manage • be friendly
in dentistry • be calm & patient
• anxiety is defined as unpleasant nega- • build trust; use empathy & respect
tive emotional state without identifi- • create a relaxing environment
able cause • make the patient feel welcome
• anxiety is the feeling of apprehension, • convey a sincere concern for patient's
uneasiness, agitation or uncertainty re- well-being
sulting from the anticipation of a threat • explain procedures before doing them
of danger whose source is unknown • encourage the patient to ask questions
• most anxious patients have had a trau- • use understandable words
matic experience in a healthcare setting • pay attention to what the patient is
• anxiety causes patients to avoid dental saying and how it is said
treatment & interferes with treatment • forewarn patient about possible pain
• anxiety may cause problems with pain • watch a patient's eyes & eyebrows to
see if the patient is feeling pain
Indicators of anxiety • give patient control by giving option
• affective — patient is emotional, talks a to "raise your hand if you feel any-
lot, talks fast thing"
• cognitive — patient is not listening & • provide moral support during proce-
does not follow instructions dure
• motor — increase in body movement • use headphones or TV as a distraction
& muscle tension • use SUDS (the subjective unit of dis-
• psychological — increase in heart rate, tress scale) to assess the level of pat-
respiration, sweating & dry mouth ient anxiety throughout treatment; ask
the patient to rate their level of anxiety
from 0 (none) to 10 (highest level)
BS
Which type of parent has an excessively demanding attitude?
• neglectful parent
• overprotective parent
• manipulative parent
• hostile parent
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• manipulative parent
Manipulative parent Hostile parent
• is demanding • questions the necessity of treatment
• demands usually start with appoint- • questions stem from distrust and not
ment times curiosity
• may try to provide diagnosis and di-
rect the course of treatment Neglectful parent
• fails to keep appointments
Overprotective parent • misses recall visits
• insists on remaining with child in • does not oversee oral hygiene of
operatory regardless of situation or child
age of child
• usually has a child who is shy, the uncooperative child
docile and manageable • may be described as stubborn or
• by pointing out the lack of appre- spoiled & is usually a child with
hension of the child and the impor- defiant behavior
tance of establishing a one-on-one • may be hostile or angry; with this
relationship between the dentist and child, the dentist must try to iden-
child, this will usually satisfy most tify the underlying source of these
overprotective parents emotions
BS
Dental fear is an unpleasant mental, emotional or physiologic sensation de-

rived from a specific dental related stimulus.
Someone who experiences fear will not necessarily be anticipating a negative

event, their response will occur at the moment the unpleasant event (e.g.,
pain) occurs.
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Dental fear Stress
• refers to the fear of dentistry and • is defined as the body's reaction to a
receiving dental care change that requires a physical, men-
• is defined as an unpleasant mental, tal or emotional adjustment or
emotional or physiologic sensation response
derived from a specific dental-re- • stress can be caused by physical, emo-
lated stimulus tional or psychological influences
• elements common to all fears
- fear of unknown Stress, anxiety, & fear
- fear of pain/bodily injury • of stress, fear & anxiety --- stress is
- fear of loss of control associated with a response
- fear of helplessness & dependency • stress is the body's response to danger
• understanding the above elements of • fear is a feeling of uneasiness in
fear allows for effective planning for response to imminent danger
the treatment of fearful & anxious • anxiety is a feeling of uneasiness when
patients no danger is present
• when evaluating a patient's dental • the interaction of the intensity of an
fear, take note of what the patient emotional response with threat appraisal
says and how the patient behaves & determines the behavior that will follow
appears while in the dental office --- whether to show up to a dental
appointment, submit to an injection,
Dental anxiety accept the need for extraction etc.
• is defined as a non-specific uneasiness,
apprehension or negative thoughts about
what may happen during a dental
appointment
• patients who are fearful or anxious
avoid dental appointments
BS
A 32-year-old woman visits the dental office for a routine dental cleaning. The
dental hygienist discovers that the patient has not been following the home
care program that was recommended six months ago. The hygienist believes
that the problem is not a skills deficiency but a management deficiency in-
stead. What is the best course of action for the hygienist?
• accept that the patient might never change her habits
• provide the patient with a pamphlet on periodontal disease
• collaborate with the dentist to determine the course of action
• go over brushing & flossing techniques
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• collaborate with the dentist to determine course of action
Motivating the patient Motivating patients

• reviewing home care instructions will • use good communication techniques
not solve the problem, since this is not • express empathy and engage the
a skills deficiency; a plan must be patient
determined to motivate this patient • identify the patient's current oral
• if the patient knows what to do, and hygiene status and the agree on
how to do it, members of the dental achievable goals for improvement
team must collaborate and find a way to • avoid arguing; gently challenge the
motivate the patient to embrace the thought that underlies the behavior
recommended home care regimen • support self-efficacy; encourage the
patient to believe that they can change
Stages of change model (SCM) the behavior and they will achieve their
1 — pre-contemplation (no admission of desired goals
problem ) • develop a partnership with the patient
2 contemplation (considering problem • consult your patient & elicit their
& change) views , the patient will feel that their
3 — preparation (getting ready to change) voice is heard & their needs are
4 — action / willpower (changing considered
behavior) • ultimately, the patient must believe
5 — maintenance (maintain behavior that the decision to follow a partic-
change) ular course of action is theirs
6 — relapse (abandon change)
BS
Behavior shaping is also called:
• aversive conditioning
• successive approximation
• restraining
• hypnodontics
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• successive approximation
Behavior shaping Aversive conditioning
• a.k.a. successive approximation • using a punishment or something u
• shaping is used when an existing pleasant to stop an unwanted behavior
behavior needs to be changed into a • like all forms of punishment, it may
more appropriate or new behavior work but is less effective than reinforc-
• the strategy involves use of reinforce- ement
ment of successive approximations of • an example is the HOME technique
a desired behavior (Hand-Over-Mouth)
• immediate positive reinforcement
includes verbal praise and nonverbal Hypnodontics
indications of approval • the application of hypnosis and
• each approximate desired behavior that controlled suggestion in dentistry
is demonstrated is reinforced, while
behaviors that are not approximations of Restraining
the desired behavior are not reinforced • a dental restraint is defined as any
• examples of behavior shaping methods form of restriction of movement by a
include tell-show-do and modeling patient in the dental environment
• a dental restraint includes the following
characteristics :
- short duration
- limits movement of head & body
- prevents injury to the patient and/or
dental staff during the procedure
- provides physical control to allow
dental staff to complete treatment
- is usually well tolerated by patient
• an example is papoose board
BS
Which one of the following is a conceptual framework that describes a per-

son's health behavior as an expression of his or her health beliefs?
• health maintenance model
• health role model
• health belief model
• leading circle model
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• health belief model
Health belief model (HBM) • developed in response to the failure
• is a psychological model that a of a free tuberculosis (TB) health
attempts to explain and predict screening program
health behaviors by focusing on • has been adapted to explore a
the attitudes& beliefs of indivi- variety of long- and short-term
duals health behaviors, including sexual
• developed in the 1950s by social risk behaviors and the transmission
psychologists working in the U.S. of HIV/AIDS
Public Health Services • suggests that individuals act to
prevent disease only when they are
susceptible to it
INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTION
Age, sex, ethnicity Perceived bene Its

Personality versus
So do-economics
barriers to behavioural
Knowledge change
1
Likelihood of be
Perceived susceptibilty/ Perceived threat of
change
seriousness of disease disease
Cues to action
• education
• s yrrpto rrts
• media into ration
BS
Behavior modification is also known as:
• behavior evaluation
• behavior therapy
• behavior shaping
• behavior training
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• behavior therapy
Behavior modification operant conditioning
• a.k.a. behavior therapy • a.k.a. instrumental conditioning
• type of psychotherapy that attempts to • a method of learning that occurs
modify observable, maladjusted patterns through rewards & punishments for
of behavior by the substitution of a new behavior
response to a given stimulus • positive & negative reinforcement
• mostly used in pediatric dentistry strengthen behavior
• punishment & extinction weaken
Techniques behavior
for modifying behavior
• classical conditioning aversive conditioning
• operant conditioning • using a punishment or something
• aversive conditioning unpleasant to stop unwanted behavior
• modeling • is less effective than reinforcement
• systemic desensitization • an example is the HOME technique
(Hand-Over-Mouth)
classical conditioning
• a.k.a. pavlovian or respondent condition- modeling
ing • form of learning where individuals
• a naturally occurring stimulus is paired ascertain how to act by observing
with a response another individual
- next, a previously neutral stimulus is
paired with the naturally occurring systemic desensitization
stimulus • therapy for phobias, fears & aversions
- eventually, the previously neutral stim- • premise is to reduce a person's anxiety
ulus comes to evoke the response with responses through counter conditioning
out the presence of the naturally occur- • teaches a person to replace the feelings
ring stimulus of anxiety with feelings of relaxation
• the two elements are known as condi- when the object or behavior is present
tioned stimulus & conditioned response
BS
Five techniques are used to facilitate patient dialogue: empathy, respect, re-
flection, interpretation and silence.
Reflection is the explanation and understanding of the patient's comments.
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Facilitation reflection
Five techniques are used to facilitate patient • is a response that restates or
dialogue: empathy, respect, reflection, in- repeats a segment of the patient's
terpretation and silence. statement
• reflection encourages the patient to
empathy continue communicating
• is the ability to accurately understand • reflection is a subtle way of asking a
the patient's feelings question and is less intimidating than
• empathy also involves being able to asking a direct question
communicate this understanding
• when properly done, empathy increases interpretation
rapport, encourages expression and • is the dentist's explanation and
promotes trust understanding of the patient's
• the dentist must actively listen and con- comments
centrate on what the patient is trying to • an interpretation may stimulate dialogue
say both verbally and nonverbal ly by requiring the patient to agree or to
• when communicating empathically, it disagree with the statement
is helpful to respond with the same • an interpretation does not need to be
feeling as the patient's statement correct in order to stimulate dialogue
respect silence
• respect promotes rapport, open • is used to facilitate dialogue by
expression & trust stimulating the patient to comment
• respect is communicated via the way and therefore break the silence
the dentist works with the patient • when using silence, it is very important
• communicate respect by regarding each to communicate interest by nodding the
patient as an individual head "yes", leaning toward the patient,
and/or maintaining eye contact
BS
Each of the following are ways to communicate effectively with patients

EXCEPT one. Which one is the EXCEPTION?
• describe
• evaluate
• be specific
• be responsive
• pay attention
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• evaluate
Communications Effectively
with Patients
Do Don't
Describe Evaluate
Be specific Be general
Be responsive Be evasive
Pat attention Be distracted
Suggestions
Listen carefully Interrupt
from Patients
Make eye contact Let eyes wander
Use lay terms Use jargon How to Reduce Anxiety
Lean forward Lean back
Prevent pain
Use gestures Fold arms
Be reassuring
Use expression Show disinterest
Have a calm demeanor
Ask questions Presume Provide moral support
Work efficiently
Be friendly
BS
Each of the following are considered to be aversive conditions of interaction

between the dentist arid patient EXCEPT one. Which one is the EXCEPTION?
• psychophysiological reactions
• stress, anxiety & fear
• preventive oral health behavior
• pain
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• preventive oral health behavior
Aversive conditions Dental fear, anxiety & pain
• any negative condition to which a per- • dental fear is an unpleasant emotional
son will learn to make a response to or physiologic sensation derived from a
avoid it specific dental-related stimulus
• the dentist-patient interaction seeks to • dental anxiety is a non-specific uneasi-
minimize conditions that are perceived ness, apprehension or negative thoughts
as aversive about what may happen during dental
• aversive conditions treatment
- psychophysiological reactions • dental phobia is when dental treatment
- stress, anxiety & fear is avoided or endured with intense
- pain anxiety
• dental fear & anxiety can come from
Non-aversive conditions different sources
• non-aversive conditions • dental fear & anxiety are often from a
- preventive oral health behavior previous bad experience, or, from
- communication hearing of a bad experience , or a gen-
- gathering information eral fear of needles
- identifying problems • dental fear happens during childhood
- giving information or adolescence in approximately 50-
85% of cases
• the dentist-patient interaction seeks to • dental fear, anxiety & pain are all
maximize the conditions that arc interrelated
perceived as non-aversive • fear may cause a person to endure pain
and not seek treatment
• pain & anxiety
- as pain increases, anxiety increases
- as anxiety increases, pain is enhanced
& is less tolerable
BS
Which of the following suggests that change does not happen in one step and
people tend to progress through different stages on their way to successful
change.
• ABC model (behavior theory model)
• stages of change model (SCM)
• social cognitive theory
• contemporary public health model
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• stages of change model (SCM)
Stages of change model (SCM) Social cognitive theory
• behavior change does not happen in • behaviors are learned through obser-
one step vation, modeling & motivation such
• a person will progress through dif- as positive reinforcement
ferent stages on the way to successful • learning is strengthened if the observer
change identifies with their "model
• each person will progress at their own • learning is strengthened if someone
rate models a behavior he or she has seen
rewarded; this motivates the person
Stages of change to model the behavior to get a reward
1 — pre-contemplation
not acknowledging there is a prob- ABC model (behavior theory)
lem that needs to be changed • behavior has 3 components :
2 — contemplation A= antecedents (trigger)
acknowledging problem but not B = behaviors
ready or sure of wanting to make a C = consequences
change • "B" comes between "A" and "C"
3 — preparation • rather than occurring in isolation,
getting ready to change behavior is preceded by an antecedent
4 — action/willpower that sets off the behavior and is
changing behavior followed by a consequence
5 — maintenance
maintaining behavior change Contemporary community (public)
6 — relapse health model
abandoning change, returning to old • a prevention model that considers so-
behavior cial, cultural, economical & enviro-
nmental factors as having significant
influence on a person's health behaviors
BS
Which of the following is an essential part of risk management?
• veracity
• documentation
• autonomy
• negligence
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•documentation
Risk management Documentation
• refers to the policies and procedures the • is essential to risk management
dentist should follow in order to reduce • dental records must be thorough, con-
the chance that a patient will file legal sistent & complete
action against him or her • must include actual visits, missed visits
• includes issues of legal competence, & evidence of noncompliance
informed consent, liability, confiden-
tiality and documentation Documentation tips
• inform the insurance carrier if an
Informed consent incident with a patient occurs
• informed consent (written or oral) • remember that everything written in
must he obtained by the dentist from the record can be used in court
adult patients prior to treatment • always document informed consent
• informed consent components • never change any written entry - add
- WHO will render treatment an addendum / separate entry instead
- WHAT are the treatment options • if a mistake is made - draw a single
- WHAT treatment will be done line through the error, mark it "error"
- WHEN will the treatment occur and initial & date it
- WHERE (if referring the patient) • be specific - write facts only, not opinions
- WHY purpose of the procedure and • be objective - avoid personal charac-
risks versus benefits terizations, state behaviors
- QUESTIONS the opportunity for the • be complete
patient to ask questions & obtain info • be timely
• write legibly
Patient record • maintain integrity of the patient record
• the patient record is the property of the • never sign a patient record entry for
dentist and must be retained by the dentist someone else, or vice versa
• countersign carefully - you are as
responsible as original person who signed
IC
Identify which one of the following is a false statement concerning personal
protective equipment (PPE):
1. protective clothing must be worn by dental professionals when contact with

blood or other bodily fluids is anticipated
2. gloves must be worn to prevent contact with blood, saliva or mucous membranes
3. wearing gloves replaces the need for handwashing
4. protective clothing must be removed before leaving the dental office
5. masks must be changed between patients
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• wearing gloves replaces the need for hand washing
Protective clothing Gloves

• protective clothing includes gowns, • wearing gloves does not replace the
lab coats & jackets need for handwashing
• may be disposable • dental professionals must wear gloves
• is worn over existing clothing (street to prevent skin contact with blood,
clothes or scrubs) saliva or mucous membranes
• is used to prevent skin & mucous • new gloves must be worn for each
membrane exposure when contact patient
with blood or other body fluids is • gloves must be worn when touching
anticipated contaminated items or surfaces
• must be changed daily or more often • non-sterile gloves are recommended
if visibly soiled for examinations & nonsurgical
• protective clothing must be removed procedures
before leaving the dental office • sterile gloves are recommended for
all surgical procedures
Masks & protective eyewear • utility gloves are recommended for
• if spatter & aerosolized sprays are cleaning and instrument processing
likely, surgical masks & protective • gloves must be changed whenever
eyewear, or chin-length plastic face they are torn, cut or punctured during
shields must be used treatment
• a mask must be changed between • gloves should never be washed
patients or more often if it becomes before use, or, disinfected for reuse
wet or moist
• face shields & protective eyewear
must be washed/disinfected with
appropriate cleaning agents
IC
Identify each of the following that is a true statement regarding the launder-
ing of contaminated laundry in the dental setting:
1. contaminated laundry must be handled as little as possible
2. the dentist may choose to use an outside laundry service
3. the dentist or assigned office personnel may launder the clothes on-site
4. contaminated laundry should be bagged at the location of use
5. contaminated laundry should be handled with appropriate PPE
6. if contaminated laundry is transported to a laundromat, the employee must be

trained in the handling of contaminated laundry
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• all statements are true
Protective clothing Laundry choices

• for optimal protection — gowns, jackets • in the dental office — contaminated
or coats are required to be long laundry includes protective clothing
sleeved and high necked that is used to cover street clothes or
• such clothin g, minimizes the potential scrubs
for exposed skin to contact blood, • the dentist may choose to use an out-
saliva or other potentially infectious side laundry service
material • the dentist or assigned office personnel
may launder the clothes in a washer
Disposable gowns and dryer on-site
• if used, eliminates the need to launder • if contaminated laundry is trans-
contaminated protective clothing ported to a laundromat— the
employee or dentist must use PPE, be
Contaminated laundry trained in handling of contaminated
• defined as laundry that has been laundry and transport the laundry in a
soiled with blood or OPIM (other red/orange bag that is labelled with a
potentially infectious material) biohazard symbol
• a dentist who is unincorporated and is
• handling of contaminated laundry the owner may take laundry home; if
includes the following: the owner is unincorporated, the owner
- handle as little as possible is not subject to OSHA regulations
- handle with appropriate PPE
- bag at location of use
- do not sort or rinse at location of use
- label transport bags with a biohazard
sign
IC
Match each term with the correct definition:
clinical contact surface 1. a disinfectant that makes the label claim

'tuberculocidal'
disinfectant
2. a germicide effective against HIV and HBV
disinfection 3. an agent capable of inactivating Mycobac-
terium tuberculosis
hospital disinfectant 4. any surface directly contaminated from
patient materials, gloved hands, blood, or OPIM
intermediate level disinfectant
5. a process which destroys a majority of, but
low level disinfectant not all, microorganisms
6. a chemical agent used to destroy recognized
tuberculocidal pathogens; kills some but not all microorgan-
isms
7. a germicide effective against Salmonella
choleraesuis, Staphylococcal aureus and
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• 4, 6, 5, 7, 1, 2, 3
Clinical contact surface Intermediate level disinfectant

• any surface directly contaminated from • disinfectant that makes the label claim
patient materials, gloved hands, blood `tuberculocidaP
or OPIM (other potentially infectious
material) Low level disinfectant
• these surfaces can then cross contam- • germicide effective against HIV &
inate other instruments, devices, hands, HBV
gloves & other items
Tuberculocidal
Disinfectant • agent capable of inactivating Mycobac-
• chemical agent used to destroy recog- terium tuberculosis
nized pathogens; kills some but not all
microorganisms Disinfectant selection
factors to consider
Disinfection • ability to inactivate TB, HIV and Hepa-
• a process which destroys a majority of, titis B
but not all, microorganisms • suitability for use as a cleaner and disin-
• while disinfection is lethal to some fectant
organisms, only sterilization kills all • health hazards and precautions
organisms • contact time requirements
• compatibility with equipment, devices
Hospital disinfectant and materials
• germicide effective against Salmonella • shelf life and storage
choleraesuis, Staphylococcal aureus • sensitivity to temperature
and Pseudomonas aeruginosa on non-
living objects
IC
1. pathogens present in blood that cause disease

antiseptic in humans
asepsis 2. includes protective attire, gloves, mask and

eyewear
bloodborne pathogens 3. involves contact with blood or other poten-
tially infectious materials and that results from
exposure incident dental procedures
infectious waste 4. the absence of disease-causing microorgan-

isms
personal protective equipment 5. measures designed to protect operators & pa-
tients from pathogens spread by blood or any
standard precautions other body fluid, excretion, or secretion
6. a substance that inhibits the growth of bacte-

ria
7. waste that consists of blood, blood products,

contaminated sharps or other microbiologic 23
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• 6, 4, 1, 3, 7, 2, 5
Basic terminology • infectious waste

an understanding of the terminology related waste that consists of blood, blood
to infection control is important for the den- products, contaminated sharps, or other
tal professional microbiologic products
• antiseptic • occupational exposure
a substance that inhibits the growth of contact with blood or other infectious
bacteria materials that involves the skin, eye, or
• asepsis mucous membranes and that results
the absence of pathogens, or disease- from procedures performed by the den-
causing microorganisms tal professional
• bloodborne pathogens • parenteral exposure
pathogens present in blood that cause exposure to blood or other infectious
disease in humans materials that results from piercing or
• disinfect puncturing the skin barrier
the use of a chemical or physical proce- • personal protective equipment (PPE)
dure to inhibit or destroy pathogens; protective attire, gloves, mask and eye
highly resistant bacterial and mycotic wear
spores are not killed during disinfection • sharp
• disinfection any object that can penetrate skin, in-
the act of disinfecting cluding, but not limited to, needles and
• exposure incident scalpels
a specific incident that involves contact • standard precautions
with blood or other potentially infec- measures designed to protect health care
tious materials that results from proce-
dures performed by the dental profes-
sional
IC
The interpretation of the Centers for Disease Control & Prevention (CDC) rec-
ommended infection control practices in dental healthcare settings varies
from state to state; not all guidelines apply in all states.
The CDC recommended infection control practices in dental healthcare set-

tings are stand-alone guidelines and are not required to be used in conjunc-
tion with OSHA practices & procedures.
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CDC recommended infection control Recommendations

practices in dental health care set- • vaccination of dental professionals
tings • use of protective attire and barrier
• primary purpose of infection control techniques
procedures is to prevent the trans- • hand washing and care of hands
mission of infectious diseases • proper use and care of sharps
• infectious diseases may be trans- (instruments and needles)
mitted • sterilization of instruments
- from patient to dental professional • cleaning & disinfection of the
- from dental professional to patient dental unit and environmental
- from one patient to another patient surfaces
• use of recommended infection con- • disinfection of the dental laboratory
trol guidelines greatly reduces the • use and care of hand pieces, anti-
transmission of infectious diseases retraction valves, and other devices
• recommended infection control attached to air & water lines of dental
practices are applicable to all set- units
tings in which dental treatment is • single use of disposable instruments
provided and must be observed • proper handling of biopsy specimens
in conjunction with required • proper use of extracted teeth in
OSHA (Occupational Safety and dental educational settings
Health Administration) practices • proper disposal of waste materials
and procedures for worker protec- • implementation of recommendations
tion
IC
Instruments in the dental practice can all be classified as either critical or non-
critical.
For infection to occur, these three conditions must be present:

a susceptible host, a pathogen with sufficient infectivity and numbers to
cause infection, and, a portal of entry through which the pathogen may enter
the host.
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PATIENT MANAGEMENT
Disease transmission critical instruments

• for an infection to occur by one of • penetrate soft tissue or bone
these routes of transmission, the fol- • must be sterilized after each use
lowing three conditions must be • examples include forceps, scalpels,
present: bone chisels, scalers and surgical
- a susceptible host burs
- a pathogen with sufficient infecti- semicritical instruments
vity and numbers to cause infection • contact but do not penetrate soft
- a portal of entry through which the tissue or bone
pathogen may enter the host • must be sterilized after each use
• effective infection control practices • if the instrument can be damaged by
are intended to alter one of these heat and sterilization is not feasible,
three conditions and prevent disease a disposable one-use item is
transmission required
• examples include x-ray beam align-
Classification ment devices, mirrors, amalgam
• all instruments in the dental practice condensers and burs
can be classified as critical, semi- noncritical instruments
critical or noncritical • do not come in contact with mu-
• instruments are classified depend- cous membranes
ing on the risk of transmitting infec- • because there is little risk of trans-
tion & the need to sterilize between mitting infection, an intermediate
uses level or low-level disinfectant is
required between uses in different
patients
IC
pasteurization 1. pathogens present in blood that cause disease

in humans
sanitization 2. an agent that prevents further growth of bac-
teria
antiseptic
3. an agent capable of killing bacteria
disinfectant 4. to expose food to an elevated temperature for
a period of time sufficient to destroy certain dis-
bacteriostatic ease-causing microorganisms
bactericidal 5. a chemical agent used on inanimate objects to

destroy or inhibit the growth of harmful organ-
isms
6. treatment of water to reduce microbial counts
to safe levels
7. an antimicrobial agent that can be safely
applied to living tissues
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PATIENT MANAGEMENT
• 4, 6, 7, 5, 2, 3
Definitions • disinfectant
• antiseptic a chemical agent used on inanimate
an antimicrobial agent that can objects to destroy or inhibit the
be safely applied to living tissues growth of harmful organisms; not
(e.g., alcohol); inhibits but does not considered safe for use on human
necessarily destroy microorganisms tissues (e.g., bleach); a disinfec-
tant kills some, but not all microor-
• bactericidal ganisms
an agent that is capable of killing
bacteria; bactericidal agents are • pasteurization
preferable over those which are to expose food to an elevated tem-
bacteriostatic perature for a period of time suffi-
cient to destroy certain disease-
• bacteriostatic causing microorganisms; the target
an agent that prevents the further of pasteurization is the destruction
growth of bacteria of Mycobacterium tuberculosis
• sanitization
treatment of water supplies to
reduce microbial counts to safe
public health levels
IC
Identify each of the following that is a true statement regarding the pur-
pose of cleaning prior to disinfection:
1. cleaning destroys all pathogens
2. cleaning reduces the concentration of pathogens
3. cleaning removes blood and debris which can interfere with disinfection
4. cleaning is optional prior to disinfection
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• 2, 3
Cleaning Cleaning
• is defined as the physical removal Results in
of debris • a reduction in the number of
• with aseptic technique, you must microorganisms present
clean before you disinfect • the removal of blood, tissue biobur-
• the cleaning step is not optional, it den and other debris that can
is required interfere with disinfection
• all disinfectant products include
specific instructions for cleaning
prior to disinfection
IC
Identify the term that BEST describes the complete destruction of all forms
of microbial life, including heat-resistant bacterial spores:
• pasteurization
• sanitization
• sterilization
• disinfection
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PATIENT MANAGEMENT
• sterilization
Sterilization Biological monitoring
• defined as the destruction of all forms • sterilizers must be monitored for
of microbial life proper functioning. this is done via
• limiting requirement is the inactiva- the use of biological indicators (BI) or
tion of bacterial spores spore tests
• proof of such destruction is the ultimate • both the CDC and ADA recommend
criteria for sterilization because spores weekly spore testing of all sterilizers
are the most heat-resistant microbial
forms
• per the Centers for Disease Control and Other definitions
Prevention (CDC), sterilization is • disinfection
required for all instruments and the inhibition or killing of pathogens;
items that are placed in the patient's spores are not killed during disinfection
mouth
• if an item cannot withstand heat sterili- • pasteurization
zation, a disposable (one-time use) to expose food to an elevated tempera-
item should be used instead ture for a period of time sufficient to
• heat is the most efficient and depend destroy certain disease-causing
able physical mode of achieving microorganisms; the target of pasteur-
sterilization of dental instruments; ization is the destruction of
the heat may be moist or dry Mycobacterium tuberculosis
• three equipment options for heat
sterilization include the autoclave, the • sanitization
chemical vapor sterilizer and the dry treatment of water supplies to reduce
heat oven microbial counts to safe public health
levels
IC
Identify the type of pathogen that provides the ultimate test for efficacy of
sterilization:
• fungal organisms
• HIV
• hepatitis B virus
• bacterial spores
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PATIENT MANAGEMENT
• bacterial spores
Biological monitoring Spore testing

• involves the processing of highly • after a spore strip is processed in a
resistant bacterial spores to determine sterilizer, it is mailed to a monitoring
if they have been killed service
• a biological indicator (BI) or spore • in a laboratory setting, the spore strip
strip contains the spores used in is aseptically placed in a test tube of
biological monitoring culture media for 7 days
• a spore strip is a small piece of paper • for each of the 7 days, the tube of
that contains one or more types of culture media is inspected for cloudi-
spores — Bacillus atrophaes spores are ness
used for testing dry heat oven units and • if spores are viable & have not been
Geobacillus stearothermophilus killed, the culture media appears
spores are used for testing steam and cloudy
chemical vapor units • if no cloudiness is noted in the culture
• the spore strip is enclosed in a media, then sterilization is confirmed
protective glassine envelope • cloudiness in the culture media indi-
cates a failed test (spores were not
killed), also known as a positive biolog-
ical spore test
• to rule out contamination during testing,
a Gram stain is prepared to identify the
bacteria in the failed test
• when the gram-positive Bacillus
organism is observed on the test slide,
sterilization failure is confirmed
IC
For a steam autoclave, identify each of the following that lists the correct tem-
perature, pressure and time that must be used for sterilization.
• 250° F, 15 psi, 20 minutes
• 270° F, 30 psi, 08 minutes
• 270° F, 20 psi, 20 minutes
• 320° F, 20 psi, 20 minutes
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PATIENT MANAGEMENT
• 250° F, 15 psi, 20 minutes — or — 270° F, 30 psi, 8 minutes
Autoclave Advantages & Disadvantages
• the use of steam heat under pre • advantages
sure remains the oldest, most com- - a short efficient cycle time
mon and most acceptable method - good penetration
for instrument sterilization - a wide range of materials can he
• the typical autoclave uses processed without destruction
- a temperature of 121 °C (250 °F) • disadvantages
- a pressure of 15 psi - corrosion of unprotected carbon
- cycle time of 20 minutes steel instruments
or - dulling of unprotected cutting edges
- a temperature of 132 °C (270 °F) - packages may remain wet at the
- a pressure of 30 psi end of a cycle
- cycle time of 8 minutes - use of hard water may leave
deposits
- possible destruction of heat-
sensitive materials
Autoclave problems
that may result in a failed spore test
• faulty temperature gauge
• faulty pressure gauge
• faulty timer
• faulty or dirty gasket / seal
• faulty heating coil, exhaust line
• faulty or clogged bleeder valve
• mineral deposit build-up
IC
For a dry heat oven, identify the correct temperature and time that must be
used for sterilization.
• 375° F, 60 minutes
• 375° F, 120 minutes
• 320° F, 60 minutes
• 320° F, 120 minutes
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• 320° F, 120 minutes
Dry heat oven Advantages & Disadvantages
• in the absence of moisture, destruction • advantages
of all forms of microbial life requires - no dulling of cutting edges
conditions very different from the auto- - no corrosion of metal instruments
clave • disadvantages
• dry heat sterilizes much less - the long cycle time
efficiently than moist heat - poor penetration
• a HIGHER TEMPERATURE & - may discolor or char items
LONGER CYCLE TIME is required - destroys heat-labile items
for sterilization to occur - cannot sterilize liquids
- not suitable for hand pieces
• the typical dry heat oven uses
- a temperature of 160 °C (320 °F) Forced air convection ovens
- cycle time of 120 minutes • a.k.a. rapid heat transfer ovens
Or • another option for dry heat sterilization
- a temperature of 170 °C (340 °F) • use a HIGHER TEMPERATURE \
- cycle time of 60 minutes and a CONTROLLED INTERNAL
AIRFLOW
• the use of a commercial cooking oven • uses a temperature of 190 °C (375°F)
is not a substitute for an FDA-app- and a cycle time of 12 minutes for
proved sterilizer wrapped items and 6 minutes for
unwrapped items
Dry heat oven problems

• faulty timer
IC
For a chemical vapor sterilizer, identify the correct temperature, pressure and
time that must be used for sterilization.
• 250° F, 20 psi, 20-40 minutes
• 250° F, 30 psi, 40-60 minutes
• 270° F, 15 psi, 40-60 minutes
• 270° F, 20 psi, 20-40 minutes
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PATIENT MANAGEMENT
• 270° F, 20 psi, 20-40 minutes
Chemical vapor sterilizer Advantages & Disadvantages
• requires the use of organic solvents • advantages
(chemicals) instead of water to - no corrosion of metal instruments
produce the sterilizing vapor including carbon steel
- no dulling of cutting edges
• the typical chemical vapor sterilizer - suitable for orthodontic stainless
uses wires
- a temperature of 132 °C (270 °F) • disadvantages
- a pressure of 20 psi - instruments must be completely
- cycle time of 20-40 minutes dried before processing
- special chemical solutions must be
• instead of distilled water (used in used
steam autoclaves), a solution of - destroys heat sensitive plastics
alcohol, formaldehyde, ketone, - produces a strong chemical odor in
acetone and water is used to produce poorly ventilated areas
the sterilizing vapor - cannot sterilize liquids
Chemical vapor sterilizer problems

• faulty timer
• faulty or dirty gasket/seal
• faulty or clogged metering valve
IC
How many hours are required to kill bacterial spores when a dental instru-
ment is placed in a 2% solution of glutaraldehyde?
• 8 hours
• 10 hours
• 12 hours
• 24 hours
33
PATIENT MANAGEMENT
• 10 hours
Glutaraldehyde 2% Advantages & Disadvantages
• is a liquid chemical sterilant • advantages
• capable of killing spores if - most potent category of chemical
sufficient contact time is provided germicide
and there is absence of extraneous - EPA registered as chemical
organic material required contact sterilant
time is 10 hours • disadvantages
• a.k.a. "cold sterilization" - long time period required for
• if this method is used to sterilized sterilization
an instrument, after 10 hours, it - allergenic
must be rinsed with sterile water, - highly toxic to tissues
dried and placed in a sterile - no way to monitor efficacy
container (if not used immediately)
Reminders
Important note • CDC refers to heat sterilization as
• use of a chemical sterilant in the method of choice when
dentistry is no longer considered sterilizing instruments and devices
appropriate for sterilizing heat- • dental instruments must be
stable instruments appropriately cleaned, packaged &
sterilized between uses with a heat-
based, biologically monitored
process
• if heat sensitive, a heat-stable
alternative or disposable item
must be used
IC
Identify which one of the following is the most efficient way to kill microbes:
• cold sterilization
• heat sterilization
• glutaraldehyde
• all of the above
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• heat sterilization
Heat sterilization • heat sterilization as the method of
• use of heat has long been recog- choice when sterilizing instruments
nized as the most efficient and and devices
reliable method of sterilization
• using a steam autoclave, chemical • dental instruments must be appro-
vapor sterilizer or dry heat oven— priately cleaned, packaged & steril-
cell death is accomplished via ized between uses with a heat-
heat inactivation of critical based, biologically monitored
enzymes and other proteins process
within cells
• moist heat destroys bacteria by • if heat sensitive, it is preferable to
denaturation; the denaturation use a heat-stable alternative or
process is quickened by the use of disposable item
pressure
• dry heat destroys microorganisms
by causing coagulation of proteins
IC
Identify which one of the following is a false statement concerning infection
control in the dental setting:
• exposure is not synonymous with infection
• do not disinfect what you can sterilize
• environmental surfaces must be sterilized between patients
• all dental patients can be treated using standard bloodborne precautions
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• environmental surfaces must be sterilized
• it is not possible to sterilize the

environmental surfaces that
become contaminated during
patient care
• thorough cleaning of the
surfaces is sufficient to break the
cycles of cross-contamination and
cross-infection
• chemical disinfectants used on sur-
faces should:
- kill as many microbes as possible
in the shortest time possible
- not damage the surface being
decontaminated
- not be harmful to humans or
animals
- not be affected by presence of
organic material
- be compatible with soap,
detergents and other chemicals
- be inexpensive
- be stable during storage
is
Identify which one of the following is a false statement regarding potential
operator errors that may cause the failure of a spore test:
• the sterilizer was overloaded
• the sterilizer cycle was interrupted
• improper packaging was used
• inadequate time, temperature and/or pressure was used
• inadequate warm up time was completed
• mineral deposit build up
36
PATIENT MANAGEMENT
• mineral deposit build up
Operator errors Errors & Problems
• overloading A number of conditions may cause a
• interrupting sterilization cycle spore test to fail - overloading the steril-
• using inadequate time izer, inadequate temperature and/or pres-
• using inadequate wane up time sure, inadequate time, or improper
• using inadequate temperature packaging of instruments.
• using inadequate pressure
• using improper packaging In the majority of cases, OPERATOR
• using expired chemical solution ERROR is responsible for the failure.
Equipment problems Of all the errors listed in the question,

• faulty temperature gauge only one is not an operator error — it
• faulty pressure gauge is an EQUIPMENT PROBLEM —
• faulty timer "mineral deposit build up".
• faulty or dirty gasket/seal
• faulty heating coil, exhaust line
• faulty or clogged bleeder valve
• mineral deposit build-up
• faulty or clogged metering valve
IC
Identify which one of the following is a true statement concerning chemical

monitoring:
• chemical monitoring is a definitive means of determining sterilization
• chemical monitoring determines if critical pressure has been reached
• chemical monitoring uses heat sensitive chemicals
• when a chemical indicator changes color, sterilization is complete
• a chemical indicator is part of the spore strip glassine envelope
37
PATIENT MANAGEMENT
• chemical monitoring uses heat sensitive chemicals
Chemical monitoring • weekly testing of the sterilizer via

• uses heat sensitive chemicals (not biological indicators is the ONLY
spores) to assess the physical condi- definitive way to verify steriliza-
tions during the sterilization process tion success
• involves the use of indicators that • a chemical indicator can serve as a
change color when exposed to routine check for all item proce-
certain temperatures ssed in the sterilizer
• examples include autoclave tape, • provides immediate feedback
special markings on bags and concerning the critical steriliza-
pouches, chemical indicator tion temperature; identifies if the
strips, tabs or packets sterilizer does not reach critical
• a color change only indicates that temperature
the sterilizer reached the proper • chemical indicators should be
temperature but does not indicate placed inside each sterilizer pouch
how long the temperature was or wrapped cassette to verify the
maintained or what pressure was sterilizing parameter for that indica-
reached and maintained tor has been satisfied internally
• confusion often exists between • these indicators should also be
biological monitoring (spore test- placed on the outside of the
ing) & chemical monitoring package
IC
Identify which one of the following is a false statement concerning the use
of alcohol hand gels in the dental setting:
• the convenience of alcohol hand gel use helps to increase compliance with hand
washing guidelines
• hand washing with an alcohol product takes less time than using soap & water
• alcohol hand gels can save busy practitioners valuable time between patients
• studies have shown that alcohol hand gels reduce microorganisms significantly
better than soap & water
• alcohol hand gels cause more dryness than soap & water hand washing
38
PATIENT MANAGEMENT
• hand gels cause more dryness than soap & water washing
Hand gels • there is a misguided belief that

• the convenience of alcohol hand gel alcohol-based hand gels will dry
use helps to increase compliance out the skin, particularly with
with hand washing guidelines frequent use
• increasing popularity of hand gels is • alcohol hand gels on the market
due to flexibility & convenience today contain moisturizers specifi-
• hand washing with an alcohol cally to prevent such dryness
product takes less time than water • studies have shown that this new
washing and does not require a sink, generation of gels cause less dryness
water or paper towels for drying and irritation than the traditional
• for the busy practitioner who has to soap and water method of hand
clean their hands often, the quickness washing
of hand sanitizers can save valuable
time between patients
• studies have also confirmed that alco-
hol hand gels kill more germs; hand
gels with 60% - 70% alcohol reduce
microorganisms including bacteria,
fungi and viruses significantly better
than soap and water
IC
Identify which one of the following is a false statement concerning when to

use hand hygiene techniques in the dental setting:
• before touching a patient
• before aseptic procedures
• after donning gloves
• after touching a patient
• after touching patient surroundings
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• after donning gloves
Hand hygiene recommendations Techniques

• soap & water hand washing • soap & water hand washing
should be used when hands are - wet hands
dirty or visibly soiled with blood or - apply amount of soap recom-
other bodily fluids, before eating, mended by the manufacturer
after using a restroom, and, if hands - rub hands together for at least 15
come in contact with spores seconds
• in all other cases, alcohol based - rinse with water and dry thoro-
hand gel can be used for routine ughly with a disposable towel
decontamination of hands - use towel to turn off faucet
• once gloves are placed on the - avoid use of HOT water
hands, hand gel or soap & water • alcohol based hand gel
should not be used on the gloves - apply the amount of gel recom-
mended by the manufacturer to
When to clean hands... one palm
• before touching a patient - rub hands together, covering all
• before aseptic procedures surfaces
• after body fluid exposure or risk - continue rubbing hands together
• after touching a patient until all surfaces are dry
• after touching patient surroundings - if hands feel dry after 10 seconds
or less of rubbing, too little prod-
uct has been used
IC
Identify which one of the following is a false statement concerning the use of
disinfectants in the dental setting:
• the disinfectant used must be registered by the EPA
• each practice must maintain a written schedule for surface disinfection
• PPE must be used when using disinfectants
• when using a disinfectant, the use of vinyl exam gloves is recommended
40
PATIENT MANAGEMENT
• when using a disinfectant, the use of vinyl exam gloves is recommended
Surface disinfection Housekeeping surface
• surfaces without barriers must be • reusable pails, bins and containers
cleaned and disinfected with an must be regularly inspected,
intermediate-level disinfectant cleaned and disinfected
• housekeeping surfaces contaminated
Manufacturer instructions with body fluids must be cleaned and
• disinfecting solutions must be disinfected with an EPA-registered
prepared following manufacturer intermediate level disinfectant
guidelines
• disinfecting solutions must be EPA Cleaning schedule
registered • the office must have a cleaning
• manufacturer instructions for schedule based on the type and
pre-cleaning surfaces must be degree of contamination and location
followed before disinfection
• the disinfectant must be applied to Surface disinfection & OSHA
the surface for the contact time • the office must have a written
designated on the product label schedule for disinfection of surfaces
as required by OSHA
Personal protection equipment
• puncture and chemical resistant
utility gloves must be used when
cleanin g and disinfecting surfaces
• in addition to gloves, protective
clothing, eye protection & mask
must be worn when cleaning and
disinfecting surfaces
IC
Between patients, all surfaces without protective coverings must be cleaned

and disinfected with an intermediate-level disinfectant.
Between patients, all protective coverings used in place of surface disinfec-

tion must be changed/replaced.
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Protective coverings
• the use of protective covers on
disinfected surfaces and non-critical
equipment is acceptable
• covers (barriers) must be resistant

to fluids and puncture in order to
protect surfaces from contamination
• these coverings may be used instead

of surface disinfection between patients
• coverings must be replaced/

changed between patients
• protective covers eliminate the

need to disinfect the covered
areas between patients
• areas covered with barriers during

the treatment day should be
disinfected at the end of the day
is
The Occupational Safety and Health Administration's (OSHA) Bloodborne
Pathogens Standard mandates that all dental healthcare professionals re-
ceive, at a minimum, the Hepatitis B vaccination series.
The Centers for Disease Control and Prevention (CDC) mandates all other vac-
cinations.
42
PATIENT MANAGEMENT
Immunizations
• the Occupational Safety and Health Administra-
tion's (OSHA) Bloodborne Pathogens Standard
mandates that all dental healthcare profess-
ionals receive, at a minimum, the Hepatitis B
vaccination series
• OSHA defers to the Centers for Disease

Control and Prevention (CDC) for all other
required vaccinations and screenings
• the CDC recommends the following

vaccinations for dental healthcare professionals:
- influenza
- mmr
- varicella
- tdap
- hepatitis b
IC
All employees with potential exposure to bloodborne pathogens are required

to have the Hepatitis B vaccination.
The vaccination record of each employee must be kept for 30 years beyond
the employee's last day of employment in the practice.
43
PATIENT MANAGEMENT
In the dental setting, who needs the What Hepatitis B vaccination documenta-
Hepatitis B vaccination? tion is required?
• all employees with potential exposure • according to OSHA, a vaccination
to bloodborne pathogens record is part of the employee's
• front office and housekeeping staff medical record, and is required to be
should be assessed as to their exposure kept for 30 years beyond the employ-
level; if the answer to the following ees last date of employment
questions is "yes", the vaccination • all part- time and temporary employ-
is needed ees are required to provide documenta-
- do they handle contaminated laundry? tion of Hep B vaccination which must
- do they enter patient treatment areas be kept for the same amount of time,
where there is potential for exposure? 30 years
- are they designated to perform first • according to the CDC and OSHA 29
aid or CPR? CFR 1910.1030 (h) (1) (ii) (B), employ-
ers are required to keep accurate
When should the dentist employer offer copies of each employees Hep B
Hepatitis B vaccinations to employees? vaccination status, including the date
• employers are required to provide of each dose
Hep B vaccinations to all new
employees free of charge after train- Is a post vaccination titer required?
ing and within 10 days of working in • post vaccination titer testing must be
a position where there is potential done 1 - 2 months after the original
exposure to bloodborne pathogens vaccine series is completed
• the only exception is if the employee • documentation is treated like an
has previously received the vaccine employee medical record and kept for
series, and, antibody testing has 30 years from last date of employment
revealed the worker is immune
IC
A booster dose of the Hepatitis B vaccine is required.
The Hepatitis B vaccine series requires that at least 16 weeks elapse between
dose 1 and dose 3.
44
PATIENT MANAGEMENT
What if a new employee has been previously What if a titer, administered within the
vaccinated but has no documentation? proper amount of time, showed the
• check with employee's previous employee status to be negative?
employers — per OSHA requirements, a • repeat the three dose series and test for
copy of the vaccination records should be anti-HBs one to two months after dose 3
part of the medical record and retained • if the employee is still negative after a
• if all attempts are unsuccessful, OSHA second vaccine series, the employee is
requires documentation verifying the considered a non-responder and should be
employers attempt to obtain the record tested for chronic HBV infection
and should include a written statement • if results are positive for infection, the
from the employee about vaccination person should receive appropriate
status and approximate dates of the counseling and medical management
vaccinations • if the person is not infected, they should
• if original documents cannot be obtained be counseled on how to protect themselves
then the Hep B vaccination must be made from infection and the need to obtain Hep
available unless the employee has titer B immune globulin prophylaxis for any
documentation known or likely exposure to a Hep B
positive individual
What if an employee started, but did not
complete the three doses of the vaccine? Is a booster for Hep B vaccine required?
• if the vaccine series was interrupted after • no
dose I, the Hep B vaccine series should be • there are currently no guidelines requiring
continued where it left off a booster
• at least 16 weeks must elapse between
doses 1 & 3
• at least 8 weeks must elapse between
doses 2 & 3
• if only dose 3 is delayed, it should be
administered as soon as possible
IC
Identify which one of the following is the most common form of a glove-as-
sociated reaction seen on the hands of health care professionals:
• irritant contact dermatitis
• latex allergy /type I immediate hypersensitivity
• allergic contact dermatitis/type IV delayed hypersensitivity
• fungal infection of the cuticles
45
PATIENT MANAGEMENT
• irritant contact dermatitis
Contact dermatitis Latex allergy
• contact dermatitis can develop from • type I hypersensitivity to latex
frequent and repeated use of hand proteins
hygiene products, exposure to • a more serious systemic allergic
chemicals and glove use reaction
• contact dermatitis is classified as • begins within minutes of exposure
either irritant or allergic but can sometimes occur hours
later
Irritant contact dermatitis • produces varied symptoms, which
• is common & nonallergic include runny nose, sneezing, itchy
• develops as dry, itchy, irritated areas eyes, scratchy throat, hives & itchy
on the skin around the area of contact burning sensations
• may involve more severe symptoms
Allergic contact dermatitis including difficult breathing, cough-
• type IV hypersensitivity ing spells, and wheezing; cardiovas-
• can result from exposure to accelera- cular and gastrointestinal ailments
tors and other chemicals used in the • in rare cases, anaphylaxis & death
manufacture of rubber gloves may occur
• can result from exposure to other
chemicals found in the dental practice
setting
• often manifests as a rash beginning
hours after contact
• like irritant dermatitis, is usually
confined to the areas of contact
IC
Identify each of following that is a true statement concerning providing safe

treatment for patients with possible or documented latex allergy:
1. be aware of common predisposing conditions (e.g., allergies to avocados, kiwis,

nuts, or bananas)
2. be familiar with the different types of hypersensitivity immediate and delayed
3. frequently clean all working areas contaminated with latex powder/dust
4. frequently change ventilation filters and vacuum bags used in latex-contaminated

areas
5. have latex-free kits (e.g., dental treatment and emergency kits) available at all
times
6. be aware that allergic reactions can be provoked from indirect contact as well as
direct contact
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PATIENT MANAGEMENT
• all of the statements are true
Considerations for patients with
latex allergy
• screen all patients for latex allergy • to minimize exposure to airborne latex
• be aware of common predisposing particles, schedule patient as the first
conditions (e.g., allergies to avocados, appointment of the day
kiwis, nuts or bananas) • frequently clean all working areas
• be familiar with the different types of contaminated with latex powder
hypersensitivity • frequently change filters and vacuum
• consider sources of latex other than bags used in latex-contaminated areas
gloves; prophy cups, rubber dams and • have latex-free kits (e.g., dental treat-
ortho elastics ment and emergency kits) available
• provide an alternative treatment area at all times
free of latex in which no patient contact • be aware that allergic reactions can be
occurs with any latex devices, materials provoked from indirect contact as well
and products as direct contact (e.g., being touched by
• remove all latex-containing products someone who has worn latex gloves)
from the patient's vicinity and • communicate latex allergy procedures
adequately cover/isolate any latex- (e.g., verbal instructions, written
containing devices that cannot be protocols, posted signs) to other
removed from the treatment personnel
environment • if latex-related complications occur,
• be aware that allergens in the ambient manage the reaction and seek
air can cause respiratory and or anaphy- emergency assistance as indicated
lactic symptoms in people with latex • follow medical emergency response
allergies recommendations for anaphylaxis
IC
Identify each of following that is a true statement concerning hepatitis C virus
(HCV) infection:
1. injection drug users are at risk for HCV infection
2. HCV infection is the leading indication for liver transplants in the United States
3. HCV infection signs and symptoms may include fever, fatigue, dark urine, loss of
appetite, nausea, vomiting and jaundice
4. 70-80% of persons with HCV infection are asymptomatic
5. there is no cure for HCV infection
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PATIENT MANAGEMENT
• all of the statements are true
Hepatitis C Virus (HCV) Infection At Risk

• is a contagious disease that ranges for HCV Infection
in severity from a mild illness last- • current injection drug users
ing a few weeks to a serious, life- • past injection drug users
long illness that attacks the liver • blood, blood products & organ
• results from infection with the Hep- recipients
atitis C virus which is spread • hemodialysis patients
through contact with the blood of • persons who received body
an infected person piercing or tattoos done with
non-sterile instruments
• may be "acute" or "chronic" • persons with known exposures to
the HCV
• acute HCV infection - health care workers injured by
- is a short-term illness needle sticks
- occurs within the first 6 months - recipients of blood or organs from
after someone is exposed to HCV a donor who tested positive for
- often leads to chronic infection HCV
• HIV-infected persons
• chronic HCV infection • children born to mothers with HCV
- is a long-term illness
- occurs when the HCV remains in a
person's body
- can last a lifetime and lead to
serious liver problems, including
cirrhosis or liver cancer
IC
Identify which one of the following is an option for treating a patient with a
confirmed latex allergy:
• wear vinyl or nitrile gloves
• wear hypoallergenic latex gloves
• do not wear any gloves
• refuse to treat the patient
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PATIENT MANAGEMENT
• wear vinyl or nitrile gloves
Common glove materials Glove types

• natural rubber latex (NRL) • the type of glove used should be
• nitrile based upon the type of procedure to
• polyvinyl chloride (vinyl) & other be performed (non-sterile vs.
synthetics sterile vs. utility)
• polyethylene (plastic) • both non-sterile examination gloves
• combinations of latex and/or and sterile surgical gloves are
synthetics medical devices regulated by FDA
• sterile surgical gloves are used for
Non-latex glove options all surgical procedures & must meet
• a wide variety of non-latex items FDA standards for sterility
are available for use in the dental assurance
practice • utility gloves are used for house
• vinyl or nitrile gloves can be used keeping procedures (cleaning &
to treat patients with latex allergies; disinfecting) and are not FDA
these gloves do no cross-react with regulated because they are not
latex allergens promoted for medical use
• hypoallergenic gloves are no
longer labeled as latex alternatives
as they contain latex with a
chemical coating over the latex
IC
An infection caused by normally non-pathogenic microorganisms in a host

whose resistance has been decreased or compromised is known as:
• a nosocomial infection
• a secondary infection
• an opportunistic infection
• a recurrent infection
49
PATIENT MANAGEMENT
• an opportunistic infection
Infection Nosocomial infection
• invasion by and multiplication of • a hospital acquired infection
pathogenic microorganisms in a • nosocomial means originating or
bodily part or tissue, which may taking place in a hospital,
produce subsequent tissue injury especially in reference to an
and progress to overt disease infection
through a variety of cellular or toxic • the term "nosocomial" comes from
mechanisms two Greek words "nosus" meaning
• instance of being infected "disease" + "komeion" meaning
• an agent or a contaminated "to take care of;" "nosocomial"
substance responsible for one's refers to any disease contracted by a
becoming infected patient while under medical care
• the pathological state resulting
from having been infected
Opportunistic
• an infection by a microorganism
that normally does not cause
disease but becomes pathogenic
when the body's immune system is
impaired and unable to fight off
infection
IC
Identify which one of the following that is not a vaccine preventable disease:
• hepatitis A infection
• hepatitis B infection
• hepatitis C infection
• VZV (varicella zoster virus) infection
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PATIENT MANAGEMENT
• hepatitis C infection
List of * recommended vaccines
Vaccine preventable diseases for all health care professionals
• Anthrax • Mumps*
• Cervical Cancer • Pertussis (Whooping Cough)*
• Diphtheria* • Pneumococcal
• Hepatitis A • Poliomyelitis (Polio)
• Hepatitis B* • Rabies Rotavirus
• Haemophilus influenzae type b (Hib) • Rubella (German Measles)*
• Human Papillomavirus (HPV) • Shingles (Herpes Zoster)
• HIN1 Flu (Swine Flu) • Smallpox
• Influenza (Seasonal Flu)* • Tetanus*
• Japanese Encephalitis (JE) Lyme Disease • Tuberculosis
• Measles* • Typhoid Fever
• Meningococcal • Varicella (Chickenpox)*
• Monkeypox • Yellow Fever
OSHA
What does OSHA stand for?
• Occupational Safety & Health Administration
• Occupational Safety & Hazard Administration
• Occupational Standards & Health Administration
• Occupational Standards & Hazard Administration
51
PATIENT MANAGEMENT
• Occupational Safety & Health Administration (OSHA)
Occupational Safety & Employer responsibilities under OSHA

Health Administration law
• OSHA is a federal agency • employers have the responsibility to pro-
• created in 1970 vide a safe workplace
• protects workers from hazards in the • employers must provide their work-
work place ers with a workplace that does not have
• under the Occupational Safety & serious hazards and must follow all OSHA
Health Act of 1970 (OSH Act), safety and health standards
employers are responsible for • employers must find and correct safety
providing a safe and healthful work and health problems
place for their workers • employers must first try to eliminate or
reduce hazards by making feasible changes
in working conditions rather than relying
on personal protective equipment
OSHA and its state partners
• visit ww k os ha.gov for more informat-
have dramatically improved
ion
workplace safety, reducing
work-related deaths and injuries
by more than 65 percent since
1970
OSHA
The Occupational Safety & Health Administration (OSHA) is a federal agency
that develops and enforces regulations designed to protect the:
• patient
• employer
• employee
52
PATIENT MANAGEMENT
• employee
Occupational Safety &

Health Administration
Occupational rules & regulations
• is a federal agency
• a division of the U.S. Department of • OSHA standards are rules that de-
Labor scribe the methods that employers
• protects employees from hazards in must use to protect their employees
the work place through standards or from hazards
regulations • there are OSHA standards for const-
• employers must provide their ruction work, agriculture, maritime
workers with a workplace that does operations, and general industry
not have serious hazards and must • standards limit the amount of hazar-
follow all OSHA safety and health dous chemicals workers can be exposed
standards to, require the use of certain safe pract-
ices and equipment, and require employ-
ers to monitor hazards and keep records
of workplace injuries and illnesses
• examples of OSHA standards include
General Safety, Hazard Communica-
tion & Bloodborne Pathogens
OSHA
Identify which one of the following is considered to be "infectious" and "reg-
ulated" medical waste:
• gowns
• plastic barriers
• extracted teeth
• cotton rolls
53
PATIENT MANAGEMENT
• extracted teeth
Regulated medical waste Regulated medical waste containers

• comprises 1%-2% of waste in dental set- • regulated medical waste must be placed
ting in a biohazard container that is closable
• requires special handling, storage & dis- • constructed to contain all contents and
posal prevent leakage of fluids during handling,
• in the dental setting, defined as storage, transport or shipping
- liquid or semi-liquid blood or OPIM • puncture resistant if discarding
- contaminated items that would release contaminated sharps
blood or OPIM in a liquid or semi-liq- • marked with
uid state if compressed fluorescent
- items that are caked with dried blood or orange or
OPIM and are capable of releasing these orange-red
materials during handling labels
- contaminated sharps with lettering
and BIOHAZARD
Types of regulated medical waste symbols in a
• hulk (in liquid or semi-liquid form) blood contrasting color
or OPIM, including saliva • closed prior to removal to prevent
• items that would release blood or OPIM spillage or protrusion of contents during
in a liquid or semi-liquid state if compressed handling, storage, transport or shipping
• items that arc caked with dried blood or
OPIM and are capable of releasing these ma- Non-regulated medical waste
terials during handling • examples include used gloves, masks,
• contaminated sharps gowns, lightly soiled gauze or cotton
• pathological including extracted teeth rolls, disposable plastic barriers
• can be disposed of in regular trash
OSHA
Each one of the following is considered regulated waste EXCEPT one. Which
one is the EXCEPTION?
• blood soaked gauze
• contaminated needles
• surgically removed tissue
• gloves
54
PATIENT MANAGEMENT
• gloves
Non-regulated vs. Regulated medical Regulated medical waste

waste • bulk (in liquid or semi-liquid form)
• studies have compared microorganisms blood or OPIM, including saliva
in residential waste with waste from • items that would release blood or
multiple health-care settings — general OPIM in a liquid or semi-liquid state if
waste from hospitals or dental prac- compressed
tices is no more infective than residen- • items that are caked with dried blood
tial waste or OPIM and are capable of releasing
• the majority of soiled items in dental these materials during handling
offices arc general medical waste and • contaminated sharps
thus can be disposed of with ordinary • pathological including extracted teeth
waste
• although any item that has had contact Non-Regulated medical waste
with blood, exudates, or secretions might • examples include used gloves, masks,
be infective, treating all as infective is gowns, lightly soiled gauze or cotton
neither necessary nor practical rolls, disposable plastic barriers
• waste that carries a substantial risk • can be disposed of in regular trash
of causing infection during handling
and disposal is regulated medical
waste
OSHA
Identify which one of the following is a true statement from the American
Dental Association's Best Management Practices for Amalgam Waste?
• use bleach to flush waste water lines in order to minimize the dissolution of amalgam
• dispose of teeth with amalgam restorations in biohazard or sharps containers
• salvage amalgam pieces from restoration removal and recycle with amalgam waste
• stock bulk elemental mercury in addition to precapsulated alloys
55
PATIENT MANAGEMENT
• salvage amalgam pieces from restoration removal
and recycle with amalgam
American Dental Association
Best Management Practices for Amalgam Waste
Do Do not
• use precapsulated alloys & stock var- • use bulk mercury
ious sizes • put used disposable amalgam cap-
• recycle used disposable amalgam sules in biohazard containers, infec-
capsules tious waste containers or regular
• salvage, store & recycle scrap amal- garbage
gam • put scrap amalgam in biohazard con-
• salvage, store & recycle amalgam tainers, infectious waste containers or
pieces from restorations after removal regular garbage
& recycle the amalgam waste • put removed amalgam pieces from
• use chair-side traps, vacuum pump restorations in biohazard containers, in-
filters and amalgam separators to retain fectious waste containers or regular
amalgam & recycle contents garbage
• do recycle teeth that contain amalgam • rinse devices containing amalgam
restorations over drains or sinks
• manage amalgam waste through as • dispose of teeth with amalgam
much recycling as possible restorations in biohazard containers, in-
• use line cleaners that minimize disso- fectious waste containers or regular
lution of amalgam garbage
• flush amalgam waste down the drain
or toilet
• use bleach or chlorine-containing
cleaners to flush wastewater lines
OSHA
Identify each one of the following that is a true statement regarding what
must be included in the training of employees as detailed by the OSHA Blood-
borne Pathogens Standard:
• information on the hepatitis B vaccine
• explanation of biohazard labels used in the office
• a copy of the standard and explanation of its contents
• opportunity for interactive questions & answers with the person conducting the training
session
• explanation of the basis for selection of PPE
• general explanation of the epidemiology & symptoms of bloodborne diseases
• explanation of the modes of transmission of bloodborne pathogens
• instructions on disposal of amalgam waste

56
PATIENT MANAGEMENT
• information on the hepatitis B vaccine
• explanation of biohazard labels used in the office
• a copy of the standard and explanation of its contents
• opportunity for interactive questions & answers with the person
conducting the training session
• explanation of the basis for selection of PPE
• general explanation of the epidemiology & symptoms of
bloodborne diseases
• explanation of the modes of transmission of bloodborne pathogens
OSHA Bloodborne Pathogens Standard • explanation of basis for selection of PPE
• requires that all employees with occupational • info on types, proper use, location, removal,
exposure receive training at the time of initial handling, decontamination & disposal of PPE
assignment & at least annually thereafter • info on hepatitis B vaccine, including efficacy,
• employees must receive additional training safety, method of administration, benefits & that
when changes or procedures affect the em- it will be offered at no cost
ployee's exposure • info on actions to take & who to contact in an
emergency involving blood or OPIM
Employee training must include: • explanation of the procedure to follow if an ex-
• copy of the current standard & explanation posure incident occurs, including the method of
of contents reporting & what medical follow-up will be made
• general explanation of the epidemiology & available
symptoms of bloodborne diseases • info on post-exposure evaluation & follow - up
• explanation of the modes of transmission of that will be provided following an exposure inci-
bloodborne pathogens dent
• explanation of the employer's exposure control • explanation of the biohazard signs & labels
plan & how the employee can obtain a copy of and/or color coding required
the written plan
• explanation of how to recognize tasks that may Trainer must:
involve exposure to blood & OPIM • provide an opportunity for interactive ques-
• explanation of how to prevent or reduce expo- tions & answers
sure including engineering controls, work prac- • be knowledgeable in the subject matter & how
tices & PPE the info relates to that workplace
OSHA
Identify which one of the following is a false statement regarding the OSHA
Bloodborne Pathogens Standard training of employees:
• training must be provided at no cost to the employee
• training must be conducted during normal working hours
• training must be reviewed twice per year
• training must take place as soon as the employee is hired
57
PATIENT MANAGEMENT
• training must be reviewed twice per year
OSHA
Bloodborne Pathogens Standard
Employee Training
• requires that all employees with occupational exposure receive training at the
time of initial assignment
• training should take place as soon as possible for all new hires
• training must be reviewed and take place annually thereafter
• employer must provide the training at no cost to the employee
• employer must provide the training during normal working hours
• employer must document attendance of the employee and maintain attendance

records for a minimum of 3 years
OSHA
The OSHA Bloodborne Pathogens Standard requires that a written exposure
control plan (ECP) be reviewed:
• biannually
• annually
• quarterly
• none of the above
58
PATIENT MANAGEMENT
• annually
Exposure Control Plan (ECP)

• the employer shall ensure that a • provisions for the initial reporting of
written copy of the ECP is accessible exposure incidents
to all employees • hepatitis B vaccination series for un-
• the ECP shall be reviewed & updated vaccinated employees
at least annually and whenever nec- • effective procedures for
essary to reflect new or modified - evaluating the circumstances surr-
tasks and procedures which affect oc- ounding exposure incidents
cupational exposure, and, to reflect - work practice controls
new or revised employee positions - gathering sharps injury log info
with occupational exposure - making periodic determinations of
• the ECP shall reflect changes in the frequency of use & types/brands
technology that eliminate or reduce of sharps involved in exposure inci-
exposure to bloodborne pathogens dents
- identifying & selecting currently
ECP Elements available engineering control devices
• exposure determinations - actively involving employees in the
• schedule & method of implementa- review & update of the ECP for the
tion which includes: procedures they perform
- methods of compliance
- hepatitis b vaccination
- post exposure ev aluation/follow up
- communication of hazards
- recordkeeping
OSHA
Which of the following diseases prompted OSHA to adopt the Bloodborne
Pathogens Standard for dentistry:
• tuberculosis
• HIV disease
• HBV/hepatitis B
• HCV/hepatitis C
59
PATIENT MANAGEMENT
• HIV disease
OSHA Bloodborne Pathogens Standard

• HIV disease prompted the OSHA reg- • all of the requirements of the OSHA
ulatory action Bloodborne Pathogens Standard can be
- in 1986, unions representing health found in Title 29 of the Code of Fed-
care workers (HCW) petitioned eral Regulations at 29 CFR 1910.1030
OSHA for an emergency rule to pro- • the standard's requirements state what
tect workers from work place expos- employers must do to protect workers
ure to HIV and HBV who are occupationally exposed to
- the petition was denied but OSHA blood or OPIM (other potentially in-
created a permanent rule on exposure fectious materials)
to bloodborne pathogens; it took 5 • the standard protects workers who
years to develop this rule can reasonably be anticipated to come
• bloodborne pathogens are infectious into contact with blood or OPIM as a re-
microorganisms present in blood that sult of doing their job duties
can cause disease in humans
• pathogens include, but are not limited
to, HBV, HCV and HIV
• workers exposed to bloodborne
pathogens are at risk for serious or
life-threatening illnesses
OSHA
The OSHA Bloodborne Pathogens Standard is a comprehensive set of rules
and regulations that have been created to prevent the transmission of blood-
borne diseases:
• to patients
• to employers
• to employees
• to all of the above
60
PATIENT MANAGEMENT
• to employees
Bloodborne Pathogens Standard Bloodborne Pathogens Standard

Overview Requirements for Employers
• bloodborne pathogens are infectious • establish an exposure control plan
microorganisms present in blood that • update the plan annually
can cause disease in humans • implement standard precautions
• workers exposed to bloodborne • identify & use engineering controls
pathogens are at risk for serious or • identify & ensure use of work practice
life-threatening illnesses controls
• the standard's requirements state what • provide PPE
employers must do to PROTECT • make hepatitis B vaccinations avail-
EMPLOYEES who are occupation- able to all employees with occupational
ally exposed to blood or OPIM (other exposure
potentially infectious materials) • make post-exposure evaluation avail-
• all of the requirements of OSHA's able to any employee who experiences
Bloodborne Pathogens Standard can be an exposure incident
found in Title 29 of the Code of Fed- • use labels & signs to communicate
eral Regulations at 29 CFR 1910.1030 hazards
• provide information & training to em-
ployees
• maintain employee medical & training
records
OSHA
As defined by OSHA, an exposure incident is a specific eye, mouth, other mu-
cous membrane, non-intact skin or parenteral contact with blood or other po-
tentially infectious materials (OPIM) which results from the performance of a
worker's duties.
An example of an exposure incident is a needle stick.
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PATIENT MANAGEMENT
Exposure incident Exposure incident report

Is a specific eye, mouth, other mucous Each of the following must be included in
membrane, non-intact skin or parenteral the exposure incident report, the exposed
contact with blood or OPIM that results person's confidential medical record & pro-
from the performance of an employee's vide to the qualified HCP:
• date & time of exposure
duties
• details of the procedure being performed,
• an example of an exposure incident is a
including where & how exposure occurred
needle stick
• if involving a sharp device, the type of
• the employee must report the expos-
device & how/when during its handling
ure incident to the designated person in
the exposure occurred
the practice as soon as possible
• details of the exposure, including the type
• when an exposure incident occurs, the
and amount of fluid or material and the
steps to follow include:
severity of the exposure
- immediately report exposure
• for percutaneous injury depth of the
- administer basic first aid
wound, gauge of the needle & whether
- ensure the device involved is not
fluid was injected
reused on the patient
• for a skin or mucous membrane expos-
- refer to an appropriate HCP as
ure - estimated volume of material, contact
soon as possible for evaluation & fol-
duration & skin condition
low-up
• details about the exposure source —
- create exposure incident report
whether the source material contained HBV,
HCV or HIV
• if the source patient has HIV, the stage
of disease, history of therapy & viral load
• vaccination info of exposed person
• details about counseling, postexposure
management & follow-up
OSHA
Unless the employer can establish that identification of the source individual
is infeasible or prohibited by state or local law, following an exposure inci-
dent — the source individual must be identified and the HBV and HIV status
must be determined.
If the source individual does not consent, the employer must establish that
legally required consent cannot be obtained.
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PATIENT MANAGEMENT
Evaluation & Follow-up

Source testing
• the employer must make immediate confi-
• follow-up includes identifying the
dential medical evaluation & follow-up
source individual, unless the employer
available to the employee
can establish that identification is infeasi-
• must be at no cost to the employee and at
ble or prohibited by stat or local law, and,
a reasonable time & place
determining the source's HBV & HIV
• performed by a licensed physician or other
status
licensed HCP
• if the status of the source individual is
• provided according to recommendations of
not already known, the employer is re-
the U.S. Public Health Service
quired to test the source's blood as soon
• tests must be conducted by an accredited
as feasible, provided the source individ-
laboratory at no cost to the employee
ual consents
• the employee may consent to have blood
• if the source individual does not con-
drawn for infection status, but may withhold
sent, the employer must establish that
consent for HIV testing at that time; in such
legally required consent cannot be ob-
cases, the employer must ensure that the
tained
blood sample is preserved for at least 90
• if state or local law allows testing with-
days in case the employee changes decision
out the source individual's consent, the
• post-exposure prophylaxis for HIV, HBV
employer must test the individual's blood,
& HCV, when medically indicated, must be
if it is available
offered to the employee
• the results of these tests must be made
• must include counseling about the possible
available to the exposed employee & the
implications of the exposure & infection sta-
employee must be informed of the laws &
tus, including the results, interpretation of all
regulations about disclosing the source's
tests & how to protect personal contacts
identity and infectious status
• must include evaluation of reported ill-
nesses that may be related to the exposure
OSHA
In 1996, Universal Precautions were revised and renamed:
• mandatory precautions
• hazard precautions
• standard precautions
• OSHA precautions
63
PATIENT MANAGEMENT
• standard precautions
Standard Precautions
• the practice of considering that all • although the OSHA Bloodborne
blood & body fluids might be con- Pathogens Standard still uses the term
taminated with blood and should be universal precautions — in 1996 the
treated as infectious CDC expanded the concept of universal
• all patients must be treated with the precautions and changed the term to
same infection control procedures standard precautions
because patients with bloodborne in- • elements of standard precautions
fections can be asymptomatic or un- - hand washing
aware they are infected - using PPE
• standard precautions must be used - proper handling of contaminated
for all patient encounters items
• standard precautions apply to con- - cleaning & disinfecting of surfaces
tact with 1) blood; 2) all body fluids, - using engineering & work practice
secretions, and excretions (except controls
sweat), regardless of whether they con- - using appropriate respiratory hyg-
tain blood; 3) non-intact skin; and 4) iene/cough etiquette
mucous membranes - using safe injection practices
• although standard precautions apply to
all patient encounters, the application
of standard precautions during pa-
tient care is determined by the task
being performed & the anticipated
exposure to pathogens
OSHA
According to the CDC, which of the following are common infection control
violations observed in the dental office:
• improper disposal of biohazardous waste
• improper biological monitoring of sterilizer
• improper disposal of sharps
• improper hand hygiene
• improper storage of dental instruments
• improper flushing of dental water lines
• improper disinfection of environmental surfaces
• improper instrument debridement

64
PATIENT MANAGEMENT
• improper disposal of biohazardous waste
• improper biological monitoring of sterilizer
• improper storage of dental instruments
• improper flushing of dental water lines
• improper disinfection of environmental surfaces
Common Violations Observed in

Dental Offices
• lack of written protocol for instrument
• improper disposal of biohazardous
processing & sterilization
waste
• lack of verification of employee hepa-
• improper biological monitoring of
sterilizer titis B vaccination
• inability to verify instrument steriliza-
tion
• repeated use of single use disposables
• improper storage of dental instru-
ments • cross contamination of surfaces
• failure to use surgical gloves when
• improper flushing of dental water
providing surgical services
lines
• failure to use utility gloves when han-
• improper disinfection of surfaces
dling contaminated items in sterilization
• lack of PPE area
• failure to separate contaminated areas
• lack of written exposure control plan
from non-contaminated areas in the
• failure to sterilize handpieces
sterilization area
OSHA
Identify each one of the following that is a true statement concerning the use
of a face mask in the dental setting:
• a new mask should be used for each patient
• a mask should have a 95% filter efficiency for small particle aerosols
• a mask is required when spatter of blood or body fluids is likely
• a mask is used to protect nose & mouth from spatter
• a mask that is damp is still effective as a barrier
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• a new mask should be used for each patient
• a mask should have a 95% filter efficiency for small particle aerosols
• a mask is required when spatter of blood or body fluids is likely
• a mask is used to protect nose & mouth from spatter
Surgical mask Tips on Choosing a Mask
• the function is to protect the wearer from • filtration
large droplets or spatter that may contact mu- - must meet the requirements for bacterial
cous membranes of nose, lip & mouth filtration efficiency(BFE)
• face masks also protect the patient from - look for 95% BFE
health-care worker oral or nasal respiratory • comfort & fit
secretions - coverage of both nose & chin
• masks should fit the face well, creating a light - comfortable nosepiece that easily conforms
seal over the nose and mouth & stays in place
• because they only cover the nose and mouth, - snug fit over nose helps eliminate fogging
face masks should always be worn with proof protective eyewear
tective eyewear - carloop bands, ties, or elastic backs that
• change the face mask between patients, and provide a close fit yet do not pull or apply
sooner if it becomes moist pressure
Wet masks - comfort & fit with protective eyewear in
• condensation from the wearer's breath adds place
moisture to the mask material - mask design & quality of construction
• when wet, resistance to the airflow through • breathability
the mask increases which causes more air to - good airflow reduces moisture build-up
pass through & around the edges of the mask, within the mask
weakening the seal between mask & face • cost-effectiveness
• wet masks also may collapse against the - consider overall value in terms of comfort,
skin; direct contamination quickly results, fit, quality, and protection
making the mask an ineffective protective bar-
OSHA
OPIM stands for .
• other possibly irritating materials
• only potential infectious matter
• only potently infectious matter
• other potentially infectious materials
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• other potentially infectious materials
Other Potentially Infectious Materials

(OPIM)
• is a term used by OSHA • includes HIV-containing cell or tissue
• includes human body fluids cultures, organ cultures, and HIV- or
—semen, vaginal secretions, cerebro- HBV-containing culture medium or
spinal fluid, synovial fluid, pleural other solutions
fluid, pericardial fluid, peritoneal • includes blood, organs, or other tis-
fluid, amniotic fluid sues from experimental animals in-
—saliva in dental procedures fected with HIV or HBV
— any body fluid that is visibly cont- • includes blood and tissues of experi-
aminated with blood mental animals infected with blood-
— all body fluids in situations where it borne pathogens
is difficult or impossible to differ- • includes any pathogenic microorgan-
entiate between body fluids ism
• includes any unfixed tissue or organ • includes human cell lines
(other than intact skin) from a human
(living or dead)
OSHA
Documents that contain information concerning hazardous chemicals are
called
• MDDS
• MSSD
• MSDS
• MDSD
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• MSDS
Material Safety Data Sheets • MSDS should be obtained directly

• are an important component of prod- from the manufacturer or product
uct & workplace safety distributor; to obtain the MSDS you
• intended to provide employees & may contact the manufacturer or dist-
emergency personnel with procedures ributor directly or online
for handling a substance in a safe • OSHA does not require that MSDS be
manner provided to purchasers of household con-
• includes information such as physical sumer products when the products are
data (melting point, boiling point, flash used in the workplace in the same
point, etc.), toxicity, health effects, first manner that a consumer would use
aid, reactivity, storage, disposal, prot- them (16r example — Windex or White
ective equipment & spill-handling Out); this exemption in OSHA's regula-
procedures tion is based, however, not upon the
• MSDS formats can vary from source to chemical manufacturer's intended use
source within a country depending on of his product, but upon how it actually
national requirements is used in the workplace
• OSHA requires that MSDS be read- • employees who are required to work
ily available to employees for all pot- with hazardous chemicals in a manner
entially harmful substances handled that results in a duration and frequency
in the workplace under the Hazard of exposure greater than what a normal
Communication Standard consumer would experience have a right
to know about the properties of those
hazardous chemicals
• the American Dental Association of-
fers MSDS information, resources, and
materials including manuals
OSHA
Material Safety Data Sheets (MSDS) must be readily available to employees
for all potentially hazardous chemicals used in the dental practice.
Identify each one of the following that is found on the MSDS:
• fire & explosion data
• hazardous ingredients
• dental office contact information
• chemical & common names
• protection information
• reactivity data
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• fire & explosion data
• chemical & common names
• protection information
• reactivity data
Material Safety Data Sheets
include the following information:
• product identification • health hazard data
— product name • reactivity data
commercial or marketing name • spill, leak & disposal procedures
— synonym • protection info
approved chemical name or • handling & storage precautions
synonym • emergency & first aid procedures
— chemical family • date of MSDS preparation
group of chemicals with related • name & address of manufacturer
physical and chemical properties
— formula
chemical formula, if applicable
• physical data
— boiling point, vapor pressure, etc.
• tire and explosion hazard data
OSHA
Which one of the following is regulated by OSHA?
• all sharps
• contaminated sharps
• non-contaminated sharps
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• contaminated sharps
Sharps
• objects that can penetrate a worker's • recapping, bending, or removing needles
skin is permissible only if there is no feasible al-
• includes, but not limited to — needles, ternative or if such actions are required for
scalpels, broken glass, capillary tubes a specific medical or dental procedure
& the exposed ends of dental wires • if recapping, bending, or removal is
• if blood or OPIM are present or may necessary, employers must ensure that
be present on the sharp, it is a contamin- workers use either a mechanical device or
ated sharp & PPE must be worn a one-handed technique; the cap must not
• a contaminated sharp can result in an be held in one hand while guiding the sharp
employee being infected with HIV, HBV, into it or placing it over the sharp
HCV or other bloodborne pathogens • one-handed "scoop" technique uses the
• careful handling of contaminated sharps needle itself to pick up the cap, and then the
can prevent injury & reduce risk of inf- cap is pushed against a hard surface to en-
ection sure a tight fit onto the device; the cap may
• employers must ensure that contami- be held with tongs or forceps and placed
nated sharps are disposed of in sharps over the needle
disposal containers immediately or as • contaminated broken glass must not be
soon as feasible after use picked up by hand, but must be cleaned up
• sharps disposal containers must be using mechanical means, such as a brush
readily accessible & located as close as and dust pan, tongs or forceps
feasible to the area where sharps are used
• contaminated sharps must never be
sheared or broken
OSHA
Identify each one of the following that is a true statement concerning sharps
containers.
• must be puncture-resistant
• must have sides & bottom that are leak proof
• must be labeled or color-coded as hazardous
• must be a reusable containers
• must be closable
• must be kept upright
• must be replaced routinely and not be overfilled
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• must be puncture-resistant
• must have sides & bottom that are leak proof
• must be labeled or color-coded as hazardous
• must be closable
• must be kept upright
• must be replaced routinely and not be overfilled
Sharps containers Handling containers

• must be puncture-resistant • employers must ensure that reusable
• sides and the bottom must be leakproof sharps that are contaminated are not
• must be labeled or color-coded red to stored in a manner that requires workers
warn that the contents are hazardous to reach by hand into the containers where
• must be closable these sharps have been placed
• must be kept upright to keep the • before sharps disposal containers are re-
sharps & any liquids from spilling out moved or replaced, they must be closed
• must be replaced routinely & not to prevent spilling the contents
overfilled • if there is a chance of leakage from the
• disposal containers that are reusable disposal container, the employer must en-
must not be opened, emptied, or sure that it is placed in a secondary con-
cleaned manually or in any other man- tainer that is closable, appropriately
ner that would expose workers to the risk labeled or color-coded red, and con-
of injury structed to contain all contents and pre-
vent leakage during handling, storage,
transport or shipping
OSHA
Engineering controls are controls that are intended to isolate or remove haz-
ards in the workplace.
Work place controls are controls that are intended to reduce the likelihood of
exposure by altering the manner in which a task is performed.
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Percutaneous Injuries (PIs) Engineering Controls

• PIs pose the single greatest risk of • technology-based
transmission of a bloodborne infection • used to remove or isolate hazards in
to a dental healthcare worker the workplace
• result from injuries by contaminated • examples include rubber dams (mini-
needles, burs, scalpels, broken glass, ex- mize exposure to oral fluids by creating a
posed ends of dental wires or other dry field), needle recappers (place con-
sharps that penetrate or break skin taminated ends of the needles away from
• prevention of PIs is influenced by DHCW hands) and sharps containers
equipment design and technology as well (isolate & contain contaminated sharps
as worker knowledge, training & skill in a puncture-resistant receptacle)
• action strategies to prevent PIs in-
clude the use of appropriate administra- Work Practice Controls
tive controls, engineering controls and • behavior-based
work practice controls • subject to human error & non-compli-
ance
Administrative Controls • used to change or alter a task or pro-
• safety rules implemented by the em- cedure in order to reduce the likeli-
ployer to help assure a safe work envi- hood of an exposure
ronment • greatly influences the success of other
• examples include written programs, control measures
exposure control plan, education and • example is using the one-handed
training, as well as task-specific Stan- scoop technique to recap dental needles
dard Operating Procedures designed to & prohibiting the recapping of needles
minimize exposure by a two-handed technique
OSHA
For each employee whose job involves occupational exposure to blood and
OPIM, what must be maintained in the employee medical record by the den-
tist employer?
• occupational exposure/incident records
• test results pertaining to exposure incident
• hepatitis B vaccine record
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Employee Medical Records Maintaining Employee Medical Records

• the employer must maintain a med- • medical records must be maintained
ical record for each employee whose for the duration of the employment
job involves occupational exposure to plus 30 years
blood or OPIM • the record must be kept confidential
• the employee medical record must
include: Transferring Employee
- hepatitis B vaccine documentation Medical Records
- details concerning exposure incid- • when selling a dental practice, the em-
ents ployee medical records must be trans-
- medical evaluations & opinions (referred to the new owner
garding exposure incidents) • in cases where there is no new owner
- test results (regarding exposure in- of the dental practice, you must notify
cidents) the director of NIOSH (National Insti-
• each employee is entitled to review tute for Occupational Safety & Health)
his or her own medical record at least 3 months prior to closing the
dental practice and offer to
transmit/transfer the employee records
to NIOSH
OSHA
Per the current CDC guidelines, dental unit water lines should be flushed at
the beginning of the day for how long?
• 30 seconds
• 45 seconds
• 60 seconds
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• 30 seconds
Flushing of Dental Unit Water Lines Dental Unit Water Lines

• flush water lines at the beginning of • obtain & follow the dental unit manu-
the day for 30 seconds (may tem- facturer's recommendations for treating
porarily reduce the level of microbes dental unit waterlines
in the water) • if recommended by manufacturer, in-
• flush air/water through handpieces stall & maintain antiretraction valves to
for 20-30 seconds after each patient prevent oral fluids from being drawn
(helps reduce any patient-borne mi- into dental waterlines
crobes that may have entered the • avoid heating dental unit water;
handpiece and were "sucked hack" warming the water may amplify biofilm
down the dental unit line) formation
• consider using a separate water reser-
voir system to eliminate the inflow of
municipal water into the dental unit
• use sterile solutions for surgical irri-
gations
• educate & train oral healthcare work-
ers on effective treatment measures
• monitor scientific & technological de-
velopments to identify improved ap-
proaches as they become available
• ensure that any sterile water system
or device marketed to improve dental
water quality has FDA approval
OSHA
Per OSHA guidelines, what is the minimum amount of time required for em-
ployers to keep employee training records?
• 2 years
• 3 years
• 5 years
• 7 years
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• 3 years
Employee Training Records

• training records are completed for each employee upon completion of training
• documents must be kept for at least three years
• training records include:
- the dates of the training sessions
- the contents or a summary of the training sessions
- the names and qualifications of persons conducting the training
- the names and job titles of all persons attending the training sessions
• employee training records are provided upon request to the employee or the em-
ployee's authorized representative
OSHA
Per OSHA guidelines, what is the minimum amount of time required for em-
ployers to keep a sharps injury log?
• 2 years
• 3 years
• 5 years
• 7 years
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• 5 years
Sharps Injury Log

• all percutaneous injuries resulting from contaminated sharps must be recorded in a
Sharps Injury Log
• all incidences must include at least:
- date of the injury
- type and brand of the device involved (syringe, suture needle)
- department or work area where the incident occurred
- explanation of how the incident occurred
• this log must be reviewed as part of the annual program evaluation
• must be maintained for at least five years following the end of the calendar year
covered
• if a copy is requested by anyone, any personal identifiers must be removed from
the report
OSHA
Per OSHA guidelines,, no employee in the dental practice may decline the hep-
atitis B vaccination.
The hepatitis B vaccination is non-infectious and there is no risk of develop-

ing HBV from the vaccine.
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PATIENT MANAGEMENT
Declining the Hepatitis B Vaccine Statement for Declination Form

• any employee may decline the hep- I understand that due to my occupa-
atitis B vaccine tional exposure to blood or other po-
• employers must ensure that workers tentially infectious materials that I may
who decline the vaccination sign a dec- be at risk of acquiring hepatitis B virus
lination form (HBV) infection.
• the purpose of the form is to encour-
age greater participation in the vac- I have been given the opportunity to be
cination program by stating that a vaccinated with hepatitis B vaccine, at
worker declining the vaccination re- no charge to myself. However, I decline
mains at risk of acquiring hepatitis B hepatitis B vaccination at this time.
infection
• the form also states that if a worker I understand that by declining this vac-
initially declines to receive the vaccine, cine, I continue to be at risk of acquir-
but at a later date decides to accept it, ing hepatitis B, a serious disease. If in
the employer is required to make it the future I continue to have occupa-
available, at no cost, provided the tional exposure to blood or other po-
worker is still occupationally ex- tentially infectious materials and I
posed want to be vaccinated with hepatitis B
vaccine, I can receive the vaccination
series at no charge to me.
employee signature date

PH
Identify which one of the following is the organization that maintains records
on all diseases that occur in the United States.
• CDC (Centers for Disease Control & Prevention)
• OSHA (Occupational Safety & Health Administration)
• FDA (Food & Drug Administration)
• EPA (Environmental Protection Agency)
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• CDC (Centers for Disease Control & Prevention)
DHHS CMS
Department of Health & Human Services Centers for Medicare & Medicaid Services
• principal agency of U.S. government for pro- • administers Medicare & Medicaid programs
tecting the health of Americans that provide health services to roughly 25% of
• provides essential human services Americans
• involved with the delivery, funding and re-
search aspects of oral health HRSA
Health Resources & Services Administration
CDC • provides access to essential health care serv-
Centers for Disease Control & Prevention ices for people who are low-income, uninsured
• 1 of 13 major components of the DHHS or who live in rural or urban areas where health
• monitors & maintains records of all diseases care is limited
found in U.S. & develops recommendations to
protect the health of the population IHS
• formulates health care worker guidelines & Indian Health Service
recommendations for prevention of infectious • focuses on raising the health status of Native
diseases Americans & Native Alaskans
FDA NIH
• promotes & protects public health by helping National Institutes of Health
safe & effective products reach the market in a • premier medical research organization
timely way • NIDCR (National Institute of Dental &
• monitors products for continued safety after in Craniofacial Research) is part of NIH
use
• provides public with accurate, science-based AHRQ
info needed to improve health Agency for Healthcare Research & Quality
• supports research on health care systems,
ACF health care quality and cost issues
Administration for Children & Families • supports research on access to health care, &
• responsible for federal programs that promote effectiveness of medical treatments
the economic & social well-being of families,
children, individuals & communities
• responsible for the Head Start program
PH
Identify which one of the following is the test result that erroneously assigns
an individual to a specific diagnostic or reference group, due to insufficient
exact methods of testing:
• a false negative test
• a true negative test
• a false positive test
• a true positive test
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PATIENT MANAGEMENT
• a false positive test
Types of errors Categories of tested individuals

• a false positive result • true positives
means that the test indicates presence those who test positive for a condition
of the disease when it is absent and are positive (have the condition)
• false negative result • false positives

means that the test indicates absence those who test positive for a condition
of the disease when it is present but are negative (do not have condi-
tion)
• true negatives
those who test negative and are nega-
tive
• false negatives
those who test negative but are positive
PH
Identify which one of the following is defined as the percent of persons with-
out the disease who are correctly classified as not having the disease:
• specificity
• sensitivity
• reliability
• validity
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PATIENT MANAGEMENT
• specificity
Definitions
Validity p value
• refers to whether questions asked by the • is a probability
study are answered by the method • answer calculated by a statistical test of a hy-
• a valid test is sensitive, specific & unbiased pothesis (Ho or null hypothesis)
• its magnitude informs the researcher as to the
Reliability validity of the hypothesis
• is the repeatability & reproducibility of test
< .05 (5%), reject the H0
• produces very similar results when used to
results are statistically significant
measure a variable at different times
> .05 (5%), accept the H0
Sensitivity results are not statistically significant
• percent of persons with the disease who are
correctly classified as having the disease Correlation/correlation coefficient (r)
- true positive (TP) those who have the dis- • quantifies relationship between variables
ease (x and y)
- false negative (FN) those who incorrectly Multiple regression
are classified as not having the disease
• provides a mathematical model of linear re-
Specificity lationship between a dependent & two or more
• percent of persons without the disease who independent or predictor variables
are correctly classified as not having disease Chi - square
- true negative (TN) those who do not have • a test commonly used to compare observed
the disease data with data we would expect to obtain ac-
- false positive (FP) those who have the dis- cording to a specific hypothesis
ease but not identified by the test
T- test
Inferential statistics • used to analyze the statistical difference be-
• used to make claims about the populations tween two means
that give rise to the data collected
• allow generalizations to be made from sample
data to a larger group
PH
Identify which one of the following is defined as the measure of quality of
care provided in a particular setting:
• quality assurance
• quality control
• quality assessment
• quality inspection
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PATIENT MANAGEMENT
• quality assessment
Quality assessment Informed consent

• is limited to the appraisal of whether or • in the informed consent process for den-
not standards of quality have been met tal treatment, legally there are three com-
ponents that must be addressed:
Quality assurance
- explanation of a procedure
• includes the action to take the necessary
so that a competent adult understands
corrective steps to improve the situation in
- explanation & assessment
the future
of risks & benefits of the procedure, or
• is the measurement of the quality of care
the consequences if no procedure is per-
PLUS the implementation of any neces-
formed
sary changes to either maintain or improve
- discussion of alternative choices
the quality of care rendered
• the interaction between dentist and pa-
tient is the foundation of informed consent,
Quality assurance concepts
• structure not the written word
• obtaining informed consent should be
refers to the layout and equipment of a
facility viewed as good dental practice
• there is a moral duty not to act against
• process
a patient's will; a patient should not be co-
involves the actual services that the dentist
erced into, unduly influenced to, receive in-
and assistant perform for the patients &
ducements to or be intimidated into having
how well they perform
• outcome a procedure
is the change in health status that occurs as
a result of the care delivered
PH
Identify which TWO of the following indices were developed in an attempt to
provide a standardized method of measuring periodontal disease, and, are
criticized because they combine gingivitis and periodontitis measures into a
common score?
• PDI (periodontal disease index)
• OHI-S (simplified oral hygiene index)
• PI (periodontal index)
• GI (gingival index)
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• PDI (periodontal disease index)
• PI (periodontal index)
PI & PDI Gingival index (GI)

• neither is considered the best method to • introduced in 1960's by Loe & Sillness
measure periodontal disease • only measures gingival inflammation
• both developed in an attempt to provide a • widely accepted index for gingivitis
standardized method of measuring periodon- • allows for clear distinction between the loca-
tal disease among groups of people in epi- tion/quantity of gingivitis & the severity/
demiologic studies quality of gingivitis
• both combine gingivitis & periodontitis into • applies a four-category qualitative assess-
a single tooth score or average score for the ment (normal, mild, moderate or severe in-
individual or group flammation) to four sites (mesial, distal, buccal
and lingual surfaces) on each examined tooth
PI • each area is scored on a 0 to 3 ordinal scale;
• identifies two levels of gingivitis based on values can then be averaged to yield a score for
extent and two levels of periodontitis based an individual
on severity of destruction
• total score is achieved by averaging the in- Other Indices
dividual tooth scores • P-M-A(Papillary-Marginal-Attached) meas-
urements confined to within gingiva
PDI • Plaque Index (PI)
• a modification of PI to determine plaque accumulation
• distinguishes three levels of gingivitis based • Sulcus Bleeding Index (SBI)
on the extent of the inflammation & sever- to determine bleeding & gingival health
ity of the inflammation • OHI & OHI-S are debris indices
• quantitatively measures periodontitis by • DMFS & DMFT are caries indices
loss of attachment with a periodontal probe
& defines degrees of periodontitis severity
based on the amount of attachment lost
• total score is achieved by averaging the in-
dividual tooth scores
PH
If the major purpose of an epidemiologist's study is to determine caries sus-
ceptibility instead of immediate treatment needs, the best caries index to use
is:
• TSIF
• PSR
• DMFT
• CPITN
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• DMFT
DMFT Dental Caries

• way to define dental caries in a population • • caries prevalence in U.S. declined substan-
measures either the number of teeth (DMFT) tially in the 1970s & 1980s due to fluorida-
or the number of tooth surfaces (DMFS) tion, the use of fluorides and other preventive
that are decayed, missing or filled due to measures
caries • in the 1970's, the mean DMFS for U.S. chil-
• with the permanent dentition, acronyms dren ages 5 to 17 was 7.1; in the late1980's
DMFT and DMFS are used the value dropped to 2.5 ( a 65% reduction)
• with the primary dentition, acronyms deft • the proportion of DMFS that is either un-
and defs are used, with e referring to a tooth treated caries or missing surfaces also dra-
that is indicated for extraction matically decreased during this period
• is an irreversible index • baby bottle tooth decay affects approxi-
• results of this index indicate a group's caries mately 5% of U.S. infants; ethnic minority &
susceptibility low socioeconomic children are at the great-
• widely accepted & best known dental index est risk
• coronal caries prevalence has declined
DMFT Limitations among U.S. adults under age 45
• values are not related to the number of • nearly all dentate U.S. adults have at least
teeth at risk one decayed or filled tooth
• index can be invalid in older adults be-
cause teeth can become lost for reasons other
than caries
• index can be misleading in children whose
teeth have been extracted for orthodontic rea-
sons
• cannot be used for root caries
• cannot account for sealed teeth
PH
According to the plaque index (PI) of Sillness & Loe, tooth #14 would have what
PI score?
• 1.0
Tooth #14
• 1.5 surface scores
• 2.0 buccal 2
lingual 1
• 2.5
menial 2
distal 3
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PATIENT MANAGEMENT
• 2.0
Plaque Index for tooth #14: Scores Criteria for Plaque Index
• 2+1+2+3 / 4 = 2.
0 no plaque
Plaque Index (PI) 1 film of plaque adhering to free gingival

• developed by Sillness Loe to be used margin & adjacent area of tooth; plaque
may be seen only after application of
with the Gingival Index (GI) disclosing solution or by running a probe
• same surfaces of same teeth are scored across tooth surface.
as in the GI and a 0 to 3 scale is used 2 moderate accumulation of soft deposits
• used extensively;not universally ac- within the gingival pocket and/or on the
tooth & gingival margin which can be seen
cepted
with the naked eye.
• PI scores the plaque present according
3 abundance of soft matter within the
to thickness at the gingival margin rather gingival pocket and/or on the tooth &
than its coronal extent as seen with the gingival margin.
OHI-S
Periodontal Disease
• some studies suggest 80-90% of chil-
dren have inflammatory periodontal
disease (gingivitis or periodontitis) by
age of 15
• localized acute gingivitis is the most
common form
• studies show the strongest relation-
ship between prevalence & severity of
periodontal disease is with oral hy-
giene & age
PH
Identify which one of the following describes the gingival index (GI):
• reversible index
• irreversible index
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• reversible index
Dental Index Common Indices (continued)
• a data collection instrument • PI
• numerically expresses the oral health status of - periodontal index
a population - reversible index
• may be reversible or irreversible - combines gingivitis & periodontitis into a
- irreversible index measures conditions that single tooth score or average score for the
cannot be reversed; example is dental caries individual or group
- reversible index measures conditions that • PDI
can be changed; examples are plaque & bleed- - periodontal disease index
ing - reversible index
- combines gingivitis & perodontitis into a
Common Indices single tooth score or average score for the
• DMFT individual or group
- decayed-missing-filled teeth index • CPITN
- irreversible index - community periodontal index of treatment
- determines total dental caries experience, past needs
and present - reversible index
- only used on permanent teeth - provides conclusions about the incidence of
- almost universally accepted periodontitis in a population, as well as
- best known of all dental indices treatment needs
• GI • OHI-S
- gingival index - simplified oral hygiene index
- reversible index - reversible index
- measures inflammation of the gingiva - used to measure OH status by using a debris
- distinguishes between location/quantity of index & calculus index; both are combined
gingivitis and the severity/quality of the gin- for a single score
givitis • PI/plaque index
• P-M-A - reversible index
- papillary-marginal-attached - used to assess thickness of plaque at the
- oldest reversible index gingival margin
- precursor to the GI
PH
Identify which one of the following is a system where a provider of coverage
contracts to pay for some of the patient's dental treatment:
• first-party dentistry
• second-party dentistry
• third-party dentistry
• fourth-party dentistry
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•third-party dentistry
Third-Party Reimbursement
• usual, customary & reasonable (UCR) fee • Capitation
- reimbursement based on the dentist's usual - dentist is paid a fixed amount, usually on
charge, unless the charge exceeds certain pa- a monthly basis, directly by the capitation
rameters plan
- in order to determine UCR fees, a dentist - for this fixed payment, the dentist agrees to
must become a participating provider with a provide specified dental services for patients
plan & agree to file fees periodically who present and who are assigned to the
practice by the capitation plan
• Table of allowances
- a third-party payer determines what fees it
will pay for each procedure Panel of providers
- a participating dentist agrees to charge plan • closed panel - dental services provided by
members these pre-negotiated fees as pay- salaried dentists at specified locations only
ment in full • open panel - dental services provided by
any dentist willing to accept third party pay-
• Fee schedules
ment
- a list of fees established by a dentist for de-
livery of specific dental services
- fee schedule usually presents payment in Fee-for-service
• dentistry is financed mainly through fee-
full, whereas table of allowances may not
for-service self-pay
- example is Medicaid
• 56% of all dental expenses are paid out-
• Reduced fee for service of- pocket by the patient
- commonly associated with Preferred • third-party payers represented by private
Provider Organization (PPO) plans insurance pay approximately 33% of total
- participating dentist agrees to provide care dental expenses, followed by government-
for fees usually lower than other dentists in a financed or public programs (Medicaid,
particular geographic area Veterans Affairs)
PH
The major objective of public health programs is:
• prevention
• cost efficiency
• teamwork
86
PATIENT MANAGEMENT
• prevention
Prevention Fluoridation of community water
• is major objective of PH programs • single most effective & efficient way to pre-
• more ethical to prevent disease than cure it vent dental caries regardless of age, race or in-
• teamwork is necessary to handle large come
groups efficiently • defined as adjusting fluoride concentration
• cost efficiency plays a major role because in community water for optimal oral health
prevention is cheaper than a cure • recommended level ranges from 0.7 to 1.2
• may be primary, secondary or tertiary ppm of fluoride depending on the mean max-
- primary prevention is preventing disease imum daily air temperature over a 5-year pe-
before it occurs; is the most effective way riod
to improve health & control costs; examples • most communities are fluoridated at 1 ppm
include water fluoridation & sealants = 1.0 mg fluoride / liter of water
- secondary prevention is controlling the • at this level fluoridated water is odorless, col-
disease after it occurs; example is placing an orless and tasteless
amalgam restoration • effectiveness of community water fluorida-
- tertiary prevention is limiting a disability tion is 20% to 40%
from disease, or rehabilitating an individual
with disability; example is providing den- Fluoridation of school water
tures • developed & tested in 1960's for use in rural
schools with an independent water supply
Education • recommended concentration for school water
• plays an important role in public health fluoridation is 4.5 times the fluoride concen-
• it decreases need for government interven- tration for community water
tion; when people learn why regulations are • higher concentrations needed to compensate
of value they comply for part-time exposure because children spend
limited time at school
• caries is reduced 20% to 30% when children
consume fluoridated water at school for 12
years
PH
Fluoride supplements are available by prescription only.
Fluoride mouth rinses are the most popular school-based fluoride regimen in
the United States.
87
PATIENT MANAGEMENT
Topical Fluoride Office-Based Methods
• the application of topical fluoride to teeth in- • sealants
creases tooth resistance to caries - most decay in children occurs on the chewing
• fluoride can be delivered either brushed on as a surfaces
varnish or in a tray as a gel - use of fluorides & pit and fissure sealants is
• fluoride varnish needed to prevent caries
- a vehicle for holding fluoride in close contact - effectiveness of dental sealants has been re-
with tooth for a period of time ported as 51% to 67%
- way to use high fluoride concentrations in
small amounts of material • fluoride gels
- useful to prevent root surface caries in older - most common fluoride used is acidulated
adults with gingival recession phosphate fluoride (APF)
- useful in patients with disabilities - APF has a pH of about 3.0
- most common concentration is 1.23%, usually
Fluoride Supplements as NaF, in orthophosphoric acid
• available by prescription only
• intended for use by children living in non-flu-
oridated areas; daily supplements should be used Home-Based Methods
from 6 months to 16 years • brushing
• tablets - use a fluoride toothpaste
- chew for 30 seconds, swish for 30 seconds, - use a pea-sized amount of toothpaste
then swallow - brush 2 times per day
- provides systemic & topical benefits • fluoride gels
- studies show a 30% reduction in caries with - contain stannous fluoride (0.4%) or sodium
daily use of fluoride tablets on school days fluoride (1.0%)
• mouth rinse - formulated in a nonaqueous gel base without
- most popular school-based regimen abrasives
- studies show 25%-28% reduction in caries by - gel should remain in the mouth for 4 minutes
rinsing daily or weekly in school with dilute so- and then spit out
lutions of fluoride
- rinsing weekly with 0.2% neutral sodium flu-
oride (NaF) is more common than using a
0.05% NaF solution
PH
In regards to reporting child abuse, a dentist is:
• morally obligated to report suspected cases
• ethically obligated to report suspected cases
• legally obligated to report suspected cases
88
PATIENT MANAGEMENT
Reporting Child Abuse Mandatory Reporting
• a dentist is morally, ethically and legally ob- • dentists are obligated to be well versed
ligated to report a suspected case of child in the mandatory reporting procedures in
abuse the state in which they practice
• from ADA Principles of Ethics and Code of • each state has its own guidelines that
Professional Conduct "dentists shall be must be followed when reporting cases of
obliged to become familiar with the signs of suspected abuse
abuse and neglect and to report suspected • in all states, however, it is standard that
cases to the proper authorities, consistent with once abuse is suspected against a child,
state laws" (Section 3. e. Abuse and Neglect) elderly or disabled patient, it must be re-
• once an injury of a suspicious nature is ob- ported to the appropriate agency
served, the dentist's first and immediate re- • dentists must identify the appropriate
sponsibility is the protection of the child agencies within their state in which they
• child abuse most commonly involves new- practice and ensure that this information
borns and children up to age three is readily available should the need arise
• physical indicators
Reporting Domestic Violence
- fractured teeth • a dentist is ethically obligated to iden-
- oral lacerations tify and refer cases of domestic violence
- fractures of the jaw • a dentist must be familiar with the phys-
- bruising of the face ical signs of domestic violence
• behavioral indicators • domestic violence injuries
- watchfulness and fearfulness - 68% involve the face
- sullen and withdrawn demeanor - 45% involve the eyes
- cowering at adult displeasure - 12% involve the neck
- extreme anxiousness or nervousness
- excessive need to please
- aggressive or out of control behavior
PH
Identify which one of the following describes the proportion of existing cases
of disease in a population at one point in time, or, during a specified time:
• incidence
• prevalence
• epidemiology
• frequency
69
PATIENT MANAGEMENT
• prevalence
Prevalence Oral Cancer

• is the proportion of a population with • most oral & pharyngeal cancers are squa-
a problem at a designated time mous cell carcinoma (SCC)
• it depends on both the incidence and the • SCC is twice as common in males as in fe-
duration of the problem males
• prevalence is more relevant than incidence • SCC causes nearly twice as many deaths in
when assessing the impact of a problem within males as in females
a community & to assess the needs • SCC is closely related to advanced age, alco-
• expressed as percentage of the population hol consumption and smoking
Incidence • SCC of the lip and oral cavity account for
• a.k.a. cumulative incidence 2/3 of all new oral & pharyngeal cancers
• is the number of new cases of a disease that • the tongue is the most common site of can-
occurs in a population at risk of the disease cers of the oral cavity
during a specific time period • survival rates vary depending on the cancer
• expressed as a rate site, gender and race
• 5-year survival rate for oral & pharyngeal
Frequency cancers is about 50%
• is a count • 5-year survival rates for cancer of the lip are
Epidemiology about 90%; of the tongue it is about half that
• study of the distribution & cause of disease • erythroplakia, rather than leukoplakia, may
• groups are studied to answer questions about be the first sign of cancerous change in a le-
etiology of diseases, prevention, disease pat- sion
terns & allocation of resources
• communicable disease is one that is trans-
mitted from one to another
• non-communicable disease is one that is
not transmitted from one to another; usually
caused by one's own normal flora or an envi-
ronmental reservoir
PH
Random assignment and blinding are methods used in clinical trials to en-
hance study validity and
• increase bias
• decrease bias
• have no change on bias
90
PATIENT MANAGEMENT
• decrease bias
Definitions Randomized & blinded study

• when a study is both randomized &
Randomized study blinded, subjects have no say in their
• all subjects have an equal chance of
choice of experimental treatment nor
being assigned to either study or con- do they have information about what
trol group
experimental treatment they are receiv-
• researchers prefer the random as-
ing
signment method for placing subjects
• randomized & blinded studies require
into either the study or control group
justification
because any uncontrolled variables in-
fluencing the outcome are likely to af- Dependent variable
fect subjects in both groups equally • a variable whose value depends on
those of others
Blind study • in the formula x = 3y + z
• subjects are unaware of whether x is the dependent variable
they are in a test or control group; one
way to achieve a blinded study is with Independent variable
the use of placebos • variable whose value determines that
of others
Double blind study • in the formula x = 3y + z
• neither participants nor examiners y & z are the independent variables
know the group allocations (test or
control groups)
PH
The most important concept of public health as defined by C.E.A. Winslow is:
• to encourage mental and physical efficiency
• promotion of health through organized community effort
• individuals acting alone can solve any problem
• the science and art of preventing disease
91
PATIENT MANAGEMENT
• promotion of health through organized community effort
Public Health Dental Public Health

• definition • definition
- as defined by C.E.A. Winslow - as defined by the American B oard
- the science & art of preventing dis- of Dental Public Health
ease, prolonging life and promoting - the science and art of preventing
physical health and efficiency through and controlling dental diseases and
organized community efforts promoting dental health through
organized community efforts
• principles of public health
- a problem exists • form of dental practice which serves
- solutions to the problem exist the community as a patient rather
- the solutions to the problem are applied than the individual
• a public health problem must meet the • is concerned with the dental health
following criteria: education of the public, with applied
- a condition or situation that is wide- dental research, with administra-
spread and has an actual or potential tion of group dental care programs
cause of morbidity or mortality as well as the prevention and control
- there is a perception on the part of the of dental disease on a community
public, government, or public health au- basis
thorities that the condition is a public
health problem
PH
As used in epidemiology, the term MORTALITY refers to:
• disease
• life span
• death
• birth
92
PATIENT MANAGEMENT
• death
Definitions • attack rate is the proportional number

• mortality (death rate) reflects the of cases developing in the population
number of deaths caused by a specific that was exposed to the infectious agent
disease; it is the ratio of the number of • endemic is a disease or other occur-
deaths caused by the disease to the total rence that is constantly present in a pop-
number of cases of the disease at a spe- ulation
cific time • epidemic is a disease or other occur-
• morbidity (illness) is the incidence rence whose incidence is higher than ex-
of a specific disease within a given pected
population • index case is the first identified case
• natality is the birth rate; ratio of of a disease in an outbreak or epidemic
births to the general population • outbreak is a cluster of cases occur-
• birth-death ratio (vital index) is the ring during a brief time interval and af-
number of births in a given year di- fecting a specific population; an out-
vided by the number of deaths in a may be the onset of an epidemic
given year. It is an indication of the • pandemic is a worldwide epidemic
population growth, stability or reduc- • portal of entry is a surface or orifice
tion through which a disease-causing agent
• crude death rate is the ratio of the enters the body
number of deaths occurring within a • portal of exit is a surface or orifice
given time period and population to the from which a disease-causing agent
total population during that time exits and disseminates
• reservoir is the natural habitat of a
disease-causing organism
PH
A method of payment for dental services in which the provider is paid a fixed
amount without regard to the actual number or nature of services provided
to each patient is called a:
• capitation fee
• fixed fee
• contractual fee
• managed fee
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PATIENT MANAGEMENT
• capitation fee
Dental Managed Care Capitation Fee

• an arrangement whereby a third-party payer • payment to the dentist for these managed-
(insurance company, federal government or cor- care programs (D-HMO, D-PPO, D-IPA) is
poration) mediates between doctors & pa- usually made on a capitation basis
tients, negotiating fees for services & oversees • capitation fee is usually a fixed monthly
the types of treatment given payment paid by a carrier to a dentist based
• examples include D-HMO, D-PPO & D-IPA on the number of patients assigned to the
dentist for treatment
D-HMO
• fee is the same regardless of how much or
• Dental Health Maintenance Organization
how little care is delivered
• plan most commonly associated with dental
managed care Delivery Model
• usually a self-contained staff model practice
• staff model usually has one or more den-
where no distinction is made between providers
tal offices that use salaried staff dentists
of insurance and providers of care
• network model uses multiple dental of-
• also called a capitation dental plan
fices in various locations and is the most
• participants are limited in dentist selection
common method of delivering dental bene-
D-PPO & D-IPA fits in managed dental care
• Dental Preferred Provider Organization • closed model (a.k.a. Exclusive Provider
Dental Individual Practice Association Organization) is where the patients have a
• represent groups of doctors who practice in the limited choice of offices where they can go
community and are distinct from the insurance to obtain dental care
provider
• an insurance agency contracts with the provid-
ers for discounted rates and may refer patients
to these providers exclusively
• typically involve contracts between insurers
and a number of dentists; patients can choose
from list of dentists
PH
Identify which one of the following is NOT a fundamental principle defined in
the American Dental Association Code of Professional Conduct:
• justice
• autonomy
• beneficence
• maleficence
• veracity
94
PATIENT MANAGEMENT
• maleficence
ADA Code The dental profession holds a special

includes three main components position of TRUST within society.
• The Principles of Ethics
• The Code of Professional Conduct As a consequence, society affords the
• The Advisory Opinions profession certain privileges, in return,
the profession makes a commitment to
ADA Code society that its members will adhere to
includes five fundamental principles high ethical standards of conduct.
1. justice or "fairness" - the dentist has
a duty to treat people fairly These standards are embodied in the
2. autonomy or "self-governance" - the ADA Principles of Ethics and Code of
dentist has a duty to respect a patient's Professional Conduct.
rights to self-determination and confi-
dential ity The ADA CODE is a written expres-
3. beneficence or "do good" - the den- sion of the obligations arising from the
tist has the duty to be kind and to give the implied contract between the dental
highest quality of care that one is capab- profession and society.
le of
4. nonmaleficence or "do no harm" - Members of the ADA voluntarily agree
the dentist has a duty to refrain from to abide by the code as a condition of
harming the patient membership. They recognize that con-
5. veracity or "truthfulness" - the den- tinued public trust in the dental pro-
tist has a duty to communicate truthfully fession is based on the commitment of
individual dentists to high ethical stan-
dards of conduct.
PH
All of the following are true concerning the ADA (Americans with Disabilities
Act) EXCEPT one. Which one is the EXCEPTION?
• a dentist cannot deny anyone care due to a disability
• dental offices must structurally allow access for the disabled
• a dentist cannot dismiss an employee due to a disability
• a person with HIV is not protected by the ADA
95
PATIENT MANAGEMENT
• a person with HIV is not protected by the ADA
Americans with Disabilities Act (ADA) Definition

• signed into law in 1990 a person with a disability is legally defin-
• applies to all private and state-run busi- ed as anyone who:
nesses, employment agencies and unions • has a physical or mental impairment
with more than fifteen employees that substantially limits one or more
• gives federal civil rights protections major life activities
to individuals with disabilities similar • has a record of such an impairment is
to those provided on the basis of race, regarded as having such an impairment
color, sex, national origin, age and relig-
ion ADA and HIV
• guarantees equal opportunity for indi- • persons with HIV disease, both symp-
viduals with disabilities in public accom- tomatic & asymptomatic, have physical
modations, employment, transportation, impairments that substantially limit one
state and local government services and or more major life activities and are pro-
telecommunications tected by the ADA
• public accommodations such as a doc- • persons who are discriminated against
tor's office may not discriminate on the because they are regarded as having HIV
basis of disability disease are also protected by the ADA
• reasonable changes in policies, pract- • persons who are discriminated against
ices, and procedures must be made to because they have a known association
avoid discrimination or relationship with an individual who
ADA Goal has HIV are also protected by the ADA
• to make sure that no qualified person
with any kind of disability is turned
down for a job or promotion, or re-
fused entry to a public access area
PH
A descriptive epidemiological study helps to define the of disease
in a population.
• cause
• cure
• extent
• mortality
96
PATIENT MANAGEMENT
• extent
Epidemiological Studies can be organized into - cross-sectional study - looks at both the ex-
three categories posure of interest & disease outcome at the
• descriptive epidemiology - used to quantify same point in time
disease status in the community: major param- - case - control study - identifies subjects on
eters of interest are prevalence and incidence the basis of whether disease of interest is pres-
ent and then, by a history, looks for association
- prevalence is the proportion of existing cases between the disease and one or more past ex-
of a disease in a population at one point in time posures
or during a specified period of time; expressed - cohort study - identifies subjects according
as percentage from 0 % -100% to if they have a particular exposure of interest
Prevalence = # of people with disease & then follows them over time to see if an as-
total # of people at risk sociation exists between exposure & develop-
ment of disease
- incidence is the number of new cases of a dis-
ease that occur in a population at risk of the • experimental epidemiology - used in inter-
disease during a specified time period vention studies; once etiology is established, re-
Incidence = # of new cases of disease searchers determine effectiveness of a program
total # of people at risk of prevention; may be clinical or community tri-
als
• analytical epidemiology - also called "obser- - clinical trials - conducted to test new pre-
vational epidemiology", is used to assess the re- ventive or therapeutic agents, with subjects as-
lationship between exposures and disease by signed by the investigator to different treatment
observing exposure-disease associations as they groups, usually by random assignment; well-
naturally occur in the population under study; designed clinical trials use a double - blind de-
the three main types are as follows: cross - sec- sign
tional study, case-control study and cohort - community trials - in situations in which an
study intervention can be practically evaluated only
at the community level, a community trial can
be conducted; group as a whole is studied
rather than the individuals in it
PH
Identify which one of the following is the part of a published research study
that includes the statement of intent, theory and hypothesis:
• abstract
• introduction & literature review
• methods
• results
• discussion
• summary & conclusion
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copyright CI 2013-2014 - Dental Decks
PATIENT MANAGEMENT
• introduction & literature review
Format of a Research Study

I. Title
- topic and focus of study
2. Abstract
- research focus
- method
- summary of results
- concluding statement
- key words
3. Introduction & literature review
- importance
- literature review
- statement of intent, theory and hypothesis
4. Methods
- sampling strategy
- measurement strategies & instruments
- experimental design
- statistical analytical procedures
5. Results
6. Discussion
- review and summary of results
- discussion of results
- comparison to theoretic presentation or hypotheses
7. Summary & Conclusion
R. Bibliography & References
PH
Identify which one of the following is described as the presentation, organi-
zation and summarization of data:
• inferential statistics
• descriptive statistics
• informative statistics
• reliability statistics
98
PATIENT MANAGEMENT
• descriptive statistics
Definitions
• biostatistics is the mathematics of collec- • skewed distribution is symmetrical with
tion, organization, and interpretation of nu- dispersion skewed to the left or right of the
meric data having to do with living organisms median; dispersion skewed to the right is said
• statistics is the practice, study, or result of to be positive with the mean being greater
the application of mathematical functions than the mode and median
to collections of data in order to summa- • mean or average is the value obtained by
rize or extrapolate the data adding all the measurements and dividing by
• statistics can be used to describe data and the number of measurements
to make inferences from them • median is the middle measurement in a set
• descriptive statistics is a way of summa- of data where half the data is above and half
rizing data or letting one number stand for a the data is below the number
group of numbers; three ways we can sum- • mode is the most frequent measurement in
marize data: a set of data
- tabular representation of data • range is the difference between the highest
- graphical representation of data and lowest value in the distribution
- numerical representation of data • variance & standard deviation measure
variability within a distribution
• inferential statistics allow someone to gen- • standard deviation is a number that indi-
eralize from the sample of data to a larger cates how much on average each value in the
group of subjects distribution deviates from the mean of the dis-
• frequency distributions is a tabulation of
tribution
values that one or more variables take in a • variance measures the same thing as stan-
sample dard deviation (dispersion of scores in a dis-
• normal distribution is a random variation tribution); variance is the square of the
that conforms to a particular probability dis- standard deviation
tribution; is the most commonly observed
probability distribution; the shape resembles a
bell and is referred to as a "bell curve"
PH
The portion of covered dental care costs for which the covered person has a
financial responsibility, usually a fixed percentage is called:
• copayment
• coinsurance
• deductible
• balance billing
99
PATIENT MANAGEMENT
• coinsurance
Definitions
• deductible is the amount of eligible expenses a • reasonable & customary (R & C) is a term used
covered person or family must pay each year from to refer to the commonly charged fees for dental
his/her own pocket before the plan will make pay- services within a geographic area; a fee is generally
ment for eligible expenses; on family policies, de- considered to be reasonable if it falls within the pa-
ductibles are typically per person and usually have rameters of the commonly charged fee for the par-
a maximum of 2 or 3 family members that will need ticular service within that specific community
to meet the deductible • preferred provider organization (PPO) is a den-
• copayment is a cost-sharing arrangement in tal care delivery arrangement which offers access
which an insured pays a specified charge for a spec- to participating providers at reduced costs; PPOs
ified service, such as $25 for an office visit; the in- provide insured incentives, such as lower de-
sured is usually responsible for payment at the time ductibles and copayments, to use providers in the
the service is rendered; if a plan has copayments on network; network providers agree to negotiated fees
dental office visits, this charge typically does not in exchange for their preferred provider status
count toward coinsurance and deductible payments • point-of-service plan (POS) is a dental insurance
because the service is covered before the deductible plan that offers members options for different de-
and coinsurance livery systems such as DMO &, PPO
• coordination of benefits (COB) is a provision in • participating provider is a provider who has
the contract that applies when a person is covered been contracted to render dental services to the in-
under more than one dental plan; it requires that sured at a pre-negotiated fee
payment of benefits be coordinated by all plans to • out-of-network provider is a dental care provider
eliminate over-insurance or duplication of benefits with whom a managed care organization does not
• coinsurance is the portion of covered dental care have a contract to provide dental care services; be-
costs for which the covered person has a financial cause the beneficiary must pay either all of the costs
responsibility, usually a fixed percentage; coinsur- of care from an out-of-network provider or their
ance usually applies after the insured meets his/her cost-sharing requirements are greatly increased
deductible • network is a list of dentists who provide dental
• balance billing is the (usually) illegal practice of care services to the beneficiaries of a specific man-
dental offices and other medical facilities billing pa- aged care organization
tients for the balance between what they want to
charge their patients for services and what the in-
surance company has already reimbursed them

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ATIENT MANAGEMENT LEGEND

Topic Cards Topic Cards

Arrange the following steps of the educational process in correct order.

7. acting to achieve goals

• needs are driving forces that prompt a person to act

• the process of learning is continuous

• learning occurs as a person attempts to satisfy needs

• recording educational needs can be as important as recording treatment needs

• all of the above statements are true

Needs & Learning Assessment of behavior

Most researchers believe that changes in behavior are a prerequisite to

Behavior can be defined as a determined, purposeful unit of activity.

• both statements are true

• both statements are false

• the first statement is true, the second is false

• the first statement is false, the second is true

Behavior Behavior examples

Which term describes a behavioral response that operates by the simple

direct 1. You're not afraid of needles, are you?

4 direct Is it easier to hold the brush this way?

C probing What else did you notice about your gums?

2 open-ended How are you doing with brushing & flossing?

1 leading You're not afraid of needles, are you?

Which one of the following types of patients is usually considered to be the

• the "know-it-all" patient

• the anxious patient

• the shy patient

• the talkative patient

• the stubborn patient

Dental fear is an unpleasant mental, emotional or physiologic sensation de-

Someone who experiences fear will not necessarily be anticipating a negative

• both statements are true

• both statements are false

• the first statement is true, the second is false

• the first statement is false, the second is true

• accept that the patient might never change her habits

• provide the patient with a pamphlet on periodontal disease

• collaborate with the dentist to determine the course of action

• go over brushing & flossing techniques

Motivating the patient Motivating patients

Which one of the following is a conceptual framework that describes a per-

• health maintenance model

• health role model

• health belief model

• leading circle model

Age, sex, ethnicity Perceived bene Its

Behavior modification is also known as:

Reflection is the explanation and understanding of the patient's comments.

• both statements are true

• both statements are false

• the first statement is true, the second is false

• the first statement is false, the second is true

Each of the following are ways to communicate effectively with patients

Each of the following are considered to be aversive conditions of interaction

• stress, anxiety & fear

• preventive oral health behavior

• ABC model (behavior theory model)

• stages of change model (SCM)

• social cognitive theory

• contemporary public health model

Which of the following is an essential part of risk management?

1. protective clothing must be worn by dental professionals when contact with

3. wearing gloves replaces the need for handwashing