The Patient with Diabetes Mellitus










The Patient with Diabetes
Mellitus
Linda D. Boyd, RDH, RD, EdD and Kathryn R. Davis, RDH, MS, DMD
DIABETES MELLITUS
I. Definition
II. Diabetes Impact
ORAL HEALTH IMPLICATIONS OF DIABETES
MELLITUS
I. Relationship Between Diabetes and Periodontal
Disease
II. Dental Caries
III. Endodontic Infections
IV. Dental Implants
BASICS ABOUT INSULIN
I. Definition
II. Description
III. Functions
IV. Effects of Absolute Insulin Deficiency (Type 1
Diabetes)
V. Effects of Impaired Secretion or Action of Insulin
(Type 2 Diabetes)
VI. Insulin Complications
CLASSIFICATION OF DIABETES MELLITUS
I. Type 1 Diabetes Mellitus
II. Type 2 Diabetes Mellitus
III. Gestational Diabetes Mellitus
IV. Other Specific Types of Diabetes Mellitus
DIAGNOSIS OF DIABETES
I. Diabetes Symptoms
II. Diagnostic Tests
IDENTIFICATION OF INDIVIDUALS AT RISK
FOR DEVELOPMENT OF DIABETES
I. Risk Factors
II. Prediabetes
STANDARDS OF MEDICAL CARE FOR
DIABETES MELLITUS
I. Early Diagnosis
II. Management of Prediabetes
III. Diabetes Self-management Education
IV. Medical Nutrition Therapy
V. Physical Activity
VI. Habits
PHARMACOLOGICAL THERAPY
I. Insulin Therapy
II. Oral Antidiabetic Medications
COMPLICATIONS OF DIABETES
I. Infection
II. Neuropathy
III. Nephropathy
IV. Retinopathy
V. Cardiovascular Disease
VI. Amputation
VII. Pregnancy Complications
VIII. Psychosocial Aspects
DENTAL HYGIENE CARE PLAN
I. Appointment Planning
II. Patient History
III. Consultation with Primary Care Provider
IV. Dental Hygiene Assessment and Treatment
V. Continuing Care
DOCUMENTATION
EVERYDAY ETHICS
FACTORS TO TEACH THE PATIENT
REFERENCES
CHAPTER OUTLINE
69
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1164 SECTION IX | Patients with Special Needs
maintaining health and preventing infections and
emergencies.
Understand the presence of infection, including peri-
odontitis, may make it more difficult to control the
blood glucose levels in diabetes.
Identify and treat acute emergencies.
Key words and abbreviations used in this chapter are
found in Boxes 69-1 and 69-2, respectively.
Dental professionals have a significant responsibility to:
Recognize signs and symptoms of diabetes to promote
early diagnosis, significantly reduce life-threatening
complications of the disease, and improve quality of life.
Assess the management and control of diabetes to de-
termine the impact on treatment and oral health of the
patient.
Work with the patient and other healthcare pro-
fessionals to provide preventive oral care aimed at
LEARNING OBJECTIVES
After studying this chapter, the student will be able to:
1. Describe the types of diabetes mellitus and major
characteristics of each.
2. Explain current knowledge about the oral health-diabetes
connection.
3. Describe risk factors and criteria used for diagnosis of diabetes.
4. Summarize lifestyle modifications and medications used to
prevent and manage diabetes.
5. Identify key messages dental hygienist need to convey to
patients with diabetes.
Beta cells: insulin-producing cells of the islets of Langerhans
in the pancreas.
Brittle diabetes: term formerly used to describe very unstable
type 1 diabetes; characterized by unexplained oscillation
between hypoglycemia and diabetic ketoacidosis (DKA).
Casual plasma glucose: blood glucose level at any time of
day with no regard to time of eating.
Charcot’s joints: a joint that is deprived of any pain or posi-
tion sense due to severe osteoarthritis or as a result of
disease such as diabetic neuropathy.
Exocrine: secreting externally via a duct.
Exogenous insulin: insulin from source outside patient.
Gastroparesis: delayed gastric emptying. Occurs when the
vagus nerve is damaged or stops functioning normally
and movement of food is slowed or stopped.
Gestational diabetes: diabetes that occurs during pregnancy.
Gluconeogenesis: synthesis of glucose from noncarbohy-
drate sources, such as amino acids and glycerol; can occur
in the liver and kidneys when the carbohydrate intake is
insufficient to meet the body’s needs.
Glycated or glycosylated hemoglobin (HbA1c): the primary
assay for assessing long-term glycemic control. Indicates
blood glucose levels for the previous 2–3 months.
Glycemia: presence of glucose in blood.
Hyperglycemia: high blood glucose: opposite of
hypoglycemia.
Hyperpnea: abnormal increase in depth and rate of
respiration.
Hypogeusia: abnormally diminished acuteness of the sense
of taste.
Hypoglycemia: an abnormally low level of glucose in the
blood.
Insulin: a powerful hormone secreted by the beta cells
in the islets of Langerhans of the pancreas; the major
fuel-regulating hormone; enters the blood in response to
a rise in concentration of blood glucose and is transported
immediately to bind with cell surface receptors through-
out the body.
Ketoacidosis: diabetic coma; too little insulin; accumulation
of ketone bodies in the blood. Occurs primarily in type 1
diabetes mellitus.
Ketone bodies: normal metabolic products of lipid (fat)
within the liver; excess production leads to urinary excre-
tion of these acidic chemicals.
Ketonuria: excess concentration of ketone bodies in the urine.
Oral glucose tolerance test: a test of the body’s ability to
utilize carbohydrates; aid to the diagnosis of diabetes
mellitus. After ingestion of a specific amount of glucose
solution, the fasting blood glucose rises promptly in a
nondiabetic person, then falls to normal within an hour. In
diabetes mellitus, the blood glucose rise is greater and the
return to normal is prolonged.
Oral hypoglycemic agent: synthetic drug that lowers the
blood sugar level; stimulates the synthesis and release of
insulin from the beta cells of the islets of Langerhans in
the pancreas; used to treat patients with type 2 diabetes
mellitus.
Polydipsia: excessive thirst.
Polyphagia: excessive ingestion of food.
Polyuria: excessive excretion of urine.
Postprandial: after a meal.
Prediabetes: IFG (impaired fasting glucose) and IGT (im-
paired glucose tolerance) are risk factors for future diabe-
tes and cardiovascular disease.
Pruritus: itching.
Retinopathy: noninflammatory degenerative disease of the
retina; called diabetic retinopathy when it occurs with
diabetes of long standing.
BOX 69-1 KEY WORDS: Diabetes Mellitus
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CHAPTER 69 | The Patient with Diabetes Mellitus 1165
A1c (A One C): common abbreviation for glycosylated he-
moglobin (HbA1c)
DKA: Diabetes ketoacidosis
EMS: emergency medical service
FPG: fasting plasma glucose
GDM: gestational diabetes mellitus
HbA1c: glycosylated hemoglobin
HDL: high-density lipoprotein
IDDM: insulin-dependent diabetes mellitus
IFG: impaired fasting glucose
IGT: impaired glucose tolerance
LDL: low-density lipoprotein
NIDDM: noninsulin-dependent diabetes mellitus
OGTT: oral glucose tolerance test
PCOS: polycystic ovarian syndrome
PP: postprandial
SMBG: self-monitoring of blood glucose
WHO: World Health Organization
Key of Abbreviations: Diabetes Mellitus
BOX 69-2
Hypoglycemia Hyperglycemia
Mental confusion Polyuria
Sweating Polydipsia
Irritability Weight loss
Palpitations Polyphagia
Shakiness Blurred vision
Pallor
Headache
Seizure
Coma and death
(if untreated)
Increased susceptibility
to infections
Impaired growth
Ketoacidosis
Symptoms of Low and High Blood Glucose
BOX 69-3
ORAL HEALTH IMPLICATIONS
OF DIABETES MELLITUS
Infection that does not respond to treatment and/or
healing may be signs of undiagnosed diabetes.
The patient needs to be referred to a primary care pro-
vider for evaluation and diagnosis.
Oral findings associated with diabetes can be found in
Table 69-1.
I. Relationship Between Diabetes and
Periodontal Disease
4
The association of diabetes mellitus with periodontal
disease is hypothesized to be related to the inflammatory
process involved in the pathogenesis of both diseases.
A. Diabetes as a Risk Factor for Periodontitis
Systematic reviews suggest patients with diabetes are
at a 2–4 times greater risk for more severe periodontal
disease than individuals without diabetes.
4
B. Effect of Periodontitis on Glycemic Control
Evidence indicates individuals with diabetes had more
severe periodontal disease and a higher A1c than
healthy individuals.
4
C. Effect of Periodontal Treatment on
Diabetes
Nonsurgical periodontal therapy and management of
periodontal disease has resulted in an average decrease
in A1c of 0.6%.
• This is roughly equivalent to decreases seen in physi-
cal activity and weight loss intervention studies.
DIABETES MELLITUS
I. Definition
1
Diabetes mellitus is a group of metabolic diseases asso-
ciated with hyperglycemia (high blood glucose). Symp-
toms of hypo- and hyperglycemia are listed in Box 69-3.
Hyperglycemia results from an insulin deficiency, resis-
tance to insulin action, or both.
People with poorly controlled diabetes mellitus are at
risk of complications including:
• Blindness
• Kidney failure
• Heart disease
• Stroke
• Amputation of toes, feet, and legs.
II. Diabetes Impact
2,3
In the United States, 29 million people (9.3% of the
population) have diabetes. Approximately 8 million
or1 in 4 people with diabetes are undiagnosed.
• Globally, 347 million adults (9.8% of men and 9.2%
of women) have diabetes.
4
• In the United States, 86 million people, more than 1
in 3 adults, have prediabetes.
As the population ages and with increases in obesity,
diabetes has become more prevalent.
Medical costs and lost work and wages for those with dia-
betes is 245 billion dollars annually in the United States.
The risk of death is 50% higher for individuals with
diabetes compared to those without diabetes.
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1166 SECTION IX | Patients with Special Needs
reduced likelihood of success of endodontic treatment
in cases with preoperative periradicular lesions.
IV. Dental Implants
7
A meta-analysis found the failure rate for dental im-
plants was similar between individuals with and with-
out diabetes.
• Well-controlled diabetes is not a contraindication to
placement of a dental implant.
BASICS ABOUT INSULIN
I. Definition
Insulin is a hormone produced by the beta cells in the
pancreas.
Insulin directly or indirectly affects every organ in
the body.
II. Description
The beta cells of the pancreas are responsible for re-
leasing insulin when stimulated by nutrients, primarily
glucose.
8
Insulin acts like a key to unlock the cell to allow uptake
of glucose to use as energy.
Figure 69-1A shows the healthy pancreas and the
action of insulin as it is taken up by the body cells.
III. Functions
The functions of insulin are listed in Box 69-4. Without
insulin, glucose accumulates in the blood, resulting in
hyperglycemia.
Normal blood glucose levels in healthy individuals
range from 60 to 100 mg/dL and the hemoglobin A1c
is less than 5.7%.
1
IV. Effects of Absolute Insulin Deficiency
(Type 1 Diabetes)
9
Glucose increases in the circulating blood (hyperglyce-
mia) until a threshold is reached and glucose spills over
into the urine (glycosuria).
Increased glycosuria induces osmotic diuresis with ex-
cretion of large amounts of urine (polyuria). Water and
electrolytes are lost.
Fluid loss signals excessive thirst to the brain
(polydipsia).
Cells starving for glucose may cause the patient to in-
crease food intake (polyphagia), but weight loss may
still occur.
Without glucose to use for energy, the body metabolizes
fat for energy.
• Management of periodontitis along with lifestyle
changes may have an additive effect on lowering A1c.
II. Dental Caries
5
There is inadequate evidence for a direct relationship
between diabetes and risk for coronal or root caries, but
there is a reduction in salivary flow which puts the pa-
tient at risk for dental caries.
III. Endodontic Infections
6
Patients with diabetes have increased periodontal
disease in teeth involved endodontically and have a
TABLE 69-1 Extraoral/Intraoral Findings
Associated with Diabetes
LOCATION FINDINGS
Gingiva Increased gingival inflammation
Periodontium Periodontitis: more frequent, severe, longer
duration
Attachment loss: more frequent, more extensive
Probing depths: more teeth with deep pockets
Alveolar bone loss: more
Tooth mobility and migration: increased
Healing: delayed, increased infection after
surgery
Teeth Poorly controlled diabetes: increased risk of caries
related to decreased saliva, diet, and less
successful resolution of endodontic therapy
related to decreased resistance to infection
Well-controlled diabetes: decreased caries
related to low sugar, regular eating habits,
dental maintenance appointments
Saliva Glucose in sulcular fluid
Xerostomia: contributes to opportunistic
infection such as oral candidiasis
Mucosa Edematous and red color
Oral candidiasis
Burning mouth and/or tongue, burning mouth
syndrome
Poor tolerance for removable prostheses
Delayed healing
May have increased prevalence of lichen
planus and aphthous stomatitis
Taste Hypogeusia, diminished taste perception
Neck Acanthosis negricans is a skin condition that
has a light brown to black appearance in
the creases on the neck and in other areas.
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CHAPTER 69 | The Patient with Diabetes Mellitus 1167
VI. Insulin Complications
Earlier diagnosis, improved treatment, and better in-
formed patient, family, and friends have reduced the
occurrence of emergency insulin complications.
Constant verbal and visual contact is maintained with
a patient to identify early behavioral and physical
changes indicative of a developing crisis.
A. Hypoglycemia/Insulin Shock
Too much insulin (hyperinsulinism), which lowers
level of blood glucose (hypoglycemia).
Hypoglycemia is the emergency more likely to occur
in the dental setting. See Box 69-3 and Table 69-2 for
symptoms of hypoglycemia.
• End products of fat metabolism are harmful ketones
that accumulate in the blood.
• Ketones are acidic, and when they accumulate, they
are usually neutralized in the blood.
• When large quantities of ketones are present the
neutralizing effect of the blood is depleted rapidly
and an acidic condition (metabolic acidosis) results.
• Metabolic acidosis leads to diabetic coma (ketoaci-
dosis) if not treated promptly.
Figure 69-1B shows changes in pancreas function that
occur in type 1 diabetes.
V. Effects of Impaired Secretion or Action
of Insulin (Type 2 Diabetes)
Deficient insulin action results from inadequate in-
sulin secretion and/or diminished tissue responses to
insulin.
1
• Cell surface insulin receptors develop defects, and
glucose cannot be transmitted into the cell.
• Blood glucose level increases as the insulin resis-
tance of the cells increases. This stimulates more
insulin to be released.
Over time, insulin secretion may also decline and lead
to both decrease of insulin in the blood as well as in-
creased insulin resistance of cells.
Figure 69-1C shows the effects of decreased insulin and
action of insulin that can occur in type 2 diabetes. Note
the defective receptor on the body cell.
FIGURE 69-1 Pancreas and Action of Insulin on Body Cell in Health, and type 1 and 2 Diabetes. A: Healthy pancreas excretes insulin into bloodstream that enables glucose
uptake by body cell. B: Type 1 diabetes shows no insulin produced by pancreas and no glucose uptake by cell. C: Type 2 diabetes shows normal, increased, or decreased insulin
production by pancreas and the defective receptor on cell that hampers insulin uptake.
1. Facilitates glucose uptake from blood into tissues, which
lowers blood glucose level.
2. Speeds the oxidation of glucose within the cells to use
for energy.
3. Speeds the conversion of glucose to glycogen to store
in the liver and skeletal muscles and to prevent the con-
version of glycogen back to glucose.
4. Facilitates conversion of glucose to fat in adipose tissue.
Functions of Insulin
BOX 69-4
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1168 SECTION IX | Patients with Special Needs
Individuals with a longer duration of diabetes and his-
tory of severe hypoglycemia are more likely to experi-
ence hypoglycemic events.
9
B. Hyperglycemic Reaction/Diabetic Coma
(Ketoacidosis)
Too little insulin (hypoinsulinism) with increased lev-
els of blood glucose (hyperglycemia).
Table 69-2 lists a comparison of the characteristics of
hyperglycemic and hypoglycemic reactions, along with
the respective treatment procedures.
CLASSIFICATION OF DIABETES MELLITUS
Classification is based on the etiology of the disease.
TABLE 69-2 Comparison of Hypoglycemia (Insulin Shock) and Hyperglycemia (Diabetic Coma)
HYPOGLYCEMIA/INSULIN SHOCK DIABETIC COMA/KETOACIDOSIS
History/
predisposing
factors
Too much insulin
Too little food: omitted or delayed
Excessive exercise
Stress
Too little insulin: omission of dose or failure to
increase dose when requirements increased
Too much food
Less exercise than planned
Infection, illness of any sort
Trauma, drugs, alcohol abuse
Stress
Occurrence More common complication than ketoacidosis, especially
with less stable type 1 diabetes
Type I diabetes especially if poorly controlled,
unstable
Onset Sudden Develops slowly over hours/days
Behavioral
changes
Confusion, stupor
Drowsy, restless
Anxious, irritable, agitated
Incoordination, weakness
Any hypoglycemia behavioral change
Physical findings Skin: moist, sweaty, perspiration
Hunger
Headache
Tremor, shakiness, weakness
Pallor
Dilated pupils, blurry vision
Dizziness, staggering gait
Skin: flushed, dry
Abdominal pain
Nausea, vomiting
Lack of appetite
Dry mouth, thirst
Fruity smelling breath
Increased urination
Vital signs Temperature: Normal or below
Respiration: Normal
Pulse: Fast, irregular
Blood Pressure: Normal or slightly elevated
Temperature: Elevated when infection
Respiration: Hyperpnea, rapid, and labored with
acetone or fruity smelling breath
Pulse: Rapid, weak
Blood Pressure: Lowered, person may go into shock
If left untreated Possible convulsions, eventual coma and death Eventual coma and death
Treatment Glucose gel (15–20 g) is the preferred treatment for the conscious
individual with hypoglycemia
After 15 min of treatment, if SMBG shows continued hypoglycemia,
the treatment should be repeated. Once SMBG returns to normal,
the individual should consume a meal or snack to prevent
recurrence of hypoglycemia
If unconscious/unresponsive: injection of glucagon or intravenous glucose
Immediate professional care
Activate EMS, hospitalize
Monitor vital signs
Keep patient warm
Fluids for conscious patient
Insulin injection after medical assessment
Prevention Monitoring and regulation of blood sugar and frequent blood glucose
monitoring
Monitoring and regulation of blood sugar and
frequent blood glucose monitoring
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CHAPTER 69 | The Patient with Diabetes Mellitus 1169
The type of diabetes is based on the circumstances at
the time of diagnosis, such as gestational diabetes dur-
ing pregnancy.
1
• Patients often do not fit into a single classification of
diabetes so the focus needs to be on the pathogenesis
and management of the hyperglycemia.
1
A comparison of type 1 and 2 diabetes is found in
Table69-3.
I. Type 1 Diabetes Mellitus
1
A. Description
Figure 69-1B illustrates the changes in type 1 diabetes.
Results from the destruction of insulin-producing
beta cells in the pancreas for one of the following
reasons:
• Autoantibodies
• No known etiology.
An absolute insulin deficiency requires exogenous insu-
lin to sustain life.
Patients are prone to ketoacidosis.
Typically arises in childhood or adolescence.
Individuals with other autoimmune disorders such as
Graves’ disease or Hashimoto’s thyroiditis are prone to
development of type 1 diabetes.
Accounts for 5%–10% of those with diabetes.
TABLE 69-3 Comparison of Type I and Type 2 Diabetes Mellitus
CHARACTERISTIC TYPE 1 TYPE 2
Age of onset Young, usually before or during puberty, but may
appear later
Adult, usually after 30 years, but may occurring with
increasing frequency in children and adolescents
Body weight Normal or thin Most are obese, body fat particularly in abdominal area
Ethnicity More common in Caucasians More common in African Americans, Asian Americans,
Hispanics, Native Americans, Pacific Islanders
Hereditary Yes, but less frequent occurrence than type 2 Much more frequent occurrence in families
Lifestyle Restrictions very difficult for young patients More frequent in sedentary individuals with high-fat diets
Onset of symptoms Rapid, abrupt symptoms of hyperglycemia Slow, insidious progression over years, frequently goes
undiagnosed for years
Symptoms Weight loss, weakness
Polyuria
Frequent/recurrent infections
Polydipsia slow healing
Polyphagia
Tingling/numb extremities
Blurred vision
Fatigue
Mimic flu
Eye/kidney/cardiovascular problems
Any type 1 symptom
Severity Severe, life threatening Early mild but progressively serious
Complications Acute hypoglycemic/hyperglycemic emergencies
and chronic long-term complications common
Acute complications rare, chronic long-term complications
common
Ketoacidosis Common Rare
Stability Unstable, difficult and much effort to control More stable, easier to manage
Insulin No insulin production, exogenous insulin required Insulin levels normal, elevated, or low; exogenous insulin
needed by some
Prevention None, due to multiple genetic predispositions and
unclear environmental factors
May be possible to prevent or delay with lifestyle changes,
increased activity, and weight loss
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1170 SECTION IX | Patients with Special Needs
B. Former Names
Insulin-dependent diabetes mellitus (IDDM), juvenile
diabetes, or juvenile-onset diabetes.
II. Type 2 Diabetes Mellitus
1
A. Description
Figure 69-1C shows changes that occur in Type 2 diabetes.
Most prevalent type of diabetes, accounts for 90%–95%
of all patients with diabetes.
Pancreatic insulin secretion may be low, normal, or
even higher than normal, but the patient exhibits an
insulin resistance that impairs the use of insulin.
• Insulin resistance is the inability of the peripheral
tissues to respond to insulin.
The risk increases with increased number of risk factors.
Onset typical occurs in adulthood and the risk increases
with age.
However, incidence has increased dramatically in chil-
dren and adolescents due to increases in sedentary life-
style and obesity.
10
• In children the typical age at diagnosis is >10 years
to late adolescence.
B. Screening
6
Type 1 diabetes is usually identified after acute symp-
toms of hyperglycemia (Box 69-3) prompt evaluation.
Screening in asymptomatic adults is recommended for
prediabetes and type 2 diabetes. Basic criteria for test-
ing in healthcare setting:
• Age 45 and above, repeated every 3 years or more
frequently.
• Screening begins earlier and more frequently if the
patient is overweight or obese (body mass index
(BMI) > 25 kg/m
2
) and has other risk factors.
• When tests are normal, they are repeated at least
every 3 years.
C. Former Names
Noninsulin-dependent diabetes mellitus (NIDDM) or
adult-onset diabetes.
III. Gestational Diabetes Mellitus (GDM)
6
The prevalence is as high as 9.2% of pregnancies in the
United States and as high as 15% worldwide.
11,12
Defined as any degree of glucose intolerance first recog-
nized during pregnancy.
Onset is related to genetics, obesity, and hormones
causing insulin resistance.
Insulin adjustment, carefully supervised prenatal care,
and improved obstetric practices have lessened much
of the potential danger for the mother.
Infants are larger; premature births more frequent; high
incidence of congenital malformations and perinatal
death; and lower rate with improved prenatal care.
More than 50% of women with GDM go on to develop
type 2 diabetes within 5–10 years.
11
IV. Other Specific Types of Diabetes Mellitus
1
Other types of diabetes result from genetic defects, dis-
eases, endocrinopathies, surgery, drugs, malnutrition, in-
fections, and injury.
Genetic defects of the beta cell.
Genetic defects in insulin action.
Diseases of the pancreas that injure or destroy beta cells.
• Include pancreatitis, trauma, pancreatectomy, carci-
noma, cystic fibrosis.
Endocrinopathies such as Cushing’s syndrome cause an
increase in hormones that antagonize insulin.
• These hormones include growth hormone, cortisol,
and glucagon.
Drug or chemicals may impair insulin secretion, impair
insulin action, or destroy beta cells, and precipitate
diabetes.
• These drugs include: glucocorticoids, thyroid hor-
mone, dilantin, thiazides.
Certain viruses are associated with destruction of beta
cells.
• These viruses include: congenital rubella, cytomega-
lovirus, and mumps.
Uncommon forms of immune-mediated diabetes.
Other genetic syndromes sometimes associated with
diabetes include Down syndrome, Huntington’s chorea,
Prader–Willi syndrome.
DIAGNOSIS OF DIABETES
I. Diabetes Symptoms
Careful review of the medical history with follow-up
questions is used to identify risk factors and symptoms
(Table69-3) of diabetes.
The classic symptoms of diabetes include the 3 P’s:
• Polyphagia (excessive hunger)
• Polydipsia (excessive thirst)
• Polyuria (excessive urination)
II. Diagnostic Tests
1
Criteria for diagnosis of diabetes include the following:
A. Glycated Hemoglobin Assay
(HbA1c or A1c)
The A1c measures the quantity of the end product of
high glucose bound to a hemoglobin molecule (gly-
cated hemoglobin).
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CHAPTER 69 | The Patient with Diabetes Mellitus 1171
• Screening may also include point-of-care A1c
testing using fingersticks or gingival crevicular
bleeding.
14–16
II. Prediabetes
Individuals who have blood glucose levels above nor-
mal, but do not meet the criteria for diagnosis of diabe-
tes are considered to have prediabetes.
• Prediabetes means the individual is at high risk for
developing diabetes.
• Lifestyle changes such as being physically active,
achieving a healthy weight, and making healthy
food choices are recommended.
• The most frequent medication used to manage the
blood glucose level is metformin.
STANDARDS OF MEDICAL CARE FOR
DIABETES MELLITUS
9
Medical management depends on the severity of the
disease and on the individual.
• Consideration is given to individualized needs re-
lated to age, activities, vocation, lifestyle, knowl-
edge, attitudes, personality, culture, emotional and
psychological needs, as well as the health status and
nutritional and weight issues of the patient.
I. Early Diagnosis
Identify individuals with prediabetes and undiagnosed
diabetes.
Assess risk factors and refer for evaluation.
II. Management of Prediabetes
The Diabetes Prevention Program demonstrated life-
style changes including: physical activity, attaining and
maintaining a healthy weight, and making wise food
choices are effective in preventing or delaying the on-
set of diabetes.
17
III. Diabetes Self-management Education
The National Standards for Diabetes Education and
Support guidelines indicate diabetes self-management
education is essential for those at risk for developing
diabetes as well as for those individuals who are newly
diagnosed.
18
Maintain tight glycemic control to reduce the compli-
cations of diabetes through regular self-monitoring of
blood glucose (SMBG) at home.
• Glucose meter (or glucometer) is used at home (and
in the dental office). A fingerstick is used to obtain
a drop of blood for measurement of blood glucose.
A1c value provides an average of blood glucose levels
over a 2–3 months period.
The HbA1c test is used to diagnose prediabetes and
diabetes.
• Prediabetes is diagnosed with an A1c value from 5.7
to 6.4%.
• A1c > 6.5% is used to diagnose diabetes.
The A1c is also used to monitor diabetes control.
• Testing is recommended twice per year for individu-
als with good glycemic control.
• Patients with unstable glycemic control may require
testing every 3 months.
A1c goal may vary slightly for an individual based on
risk for hypoglycemia, but the goal for most nonpreg-
nant adults is <7%.
B. Fasting Plasma Glucose (FPG)
Measurement taken after fasting at least 8 hours.
FPG of 100 to 125 mg/dL is used to diagnose prediabetes.
FPG > 126 mg/dL is the criterion used for diagnosis of
diabetes.
Repeat testing is recommended to confirm a diagnosis.
C. 2-hour Plasma Glucose $200 mg/dL
Typically taken during an oral glucose tolerance test
(OGTT).
Repeat testing is recommended to confirm a diagnosis.
IDENTIFICATION OF INDIVIDUALS AT RISK
FOR DEVELOPMENT OF DIABETES
9
I. Risk Factors
Adults at risk for diabetes include those who are over-
weight with a BMI > 25kg/m
2
and have other risk fac-
tors such as:
• Physical inactivity.
• First degree relative with diabetes.
• High risk race/ethnicity such as African American,
Hispanic, Native American, Asian, Pacific Islander.
• Women who have delivered a baby weight over 9
pounds or had gestational diabetes during pregnancy.
• Hypertension (>140/90 mm Hg) or taking antihy-
pertensive medications.
• Women with polycystic ovarian syndrome (PCOS).
• History of cardiovascular disease.
• A1c > 5.7%, IGT (impaired glucose tolerance), or
IFG (impaired fasting glucose).
Dental visits provide an opportunity to screen patients
for undiagnosed diabetes (see Figure 69-2).
13
• A type 2 diabetes risk test is available on the Ameri-
can Diabetes Association website and could be used
chairside in the dental office for screening.
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1172 SECTION IX | Patients with Special Needs
FIGURE 69-2 Diabetes Risk Test. Are you at risk for type 2 diabetes screening tool. (Source: Copyright 2009 American Diabetes Association. From http://www.diabetes.org.
Reprinted by permission of The American Diabetes Association.)
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CHAPTER 69 | The Patient with Diabetes Mellitus 1173
• Carbohydrate intake needs to be balanced through-
out the day and focus on vegetables, fruits, whole
grains, beans, and low-fat dairy.
• Similar to the Dietary Guidelines for Americans, in-
dividuals with diabetes need to limit or avoid added
sugar and refined carbohydrates.
• Limit intake of saturated fat, trans fat, and cholesterol.
• Recommendations for sodium intake are the same
as for the general population (see section on Dietary
Standards in Chapter 35).
V. Physical Activity
Adults are encouraged to engage in 150 minutes per
week of moderate-intensity physical activity spread
over at least 3 days/week.
Contributes to lowering insulin requirements by in-
creasing the muscle sensitivity to insulin.
VI. Habits
A. Tobacco
Patient must avoid all types of tobacco (see the section
on Tobacco Cessation in Chapter 34).
• Tobacco use increases risk of heart disease, stroke,
myocardial infarction, limb amputations, periodon-
tal disease, and numerous other health problems.
B. Alcohol
Avoid excessive alcohol; alcohol can raise blood pres-
sure and contribute to other health problems.
PHARMACOLOGICAL THERAPY
I. Insulin Therapy
All patients with type 1 diabetes require exogenous insulin
for survival. Type 2 patients may need to use insulin for
control. Insulin available in the United States is manufac-
tured in a laboratory.
A. Types of Insulin
Insulin is classified as rapid acting, regular or short act-
ing, intermediate acting, or long acting based on the on-
set, peak, and duration of action. The types of insulin and
range of peak action are found in Table 69-4.
B. Dosage
Depends on the individual.
Objective: Attain optimum utilization of glucose
throughout each 24 hours.
Factors affecting the need for insulin: Food intake, illness,
stress, variations in exercise, or infections.
“Sick Day Rules: Insulin dose is adjusted if there are
any factors that are affecting the need for insulin.
• Frequency and timing is individualized to patient
needs, but is often recommended before breakfast,
prior to meals, and prior to bedtime.
• More frequent monitoring is associated with better
glycemic control and a lower A1c.
Individuals with type 1 diabetes who are prone to dia-
betic ketoacidosis (DKA) may monitor for urinary ke-
tones with test strips.
• Urinary ketone testing is used during illness, stress,
and vigorous physical activity. It can be performed
by patient at home or analyzed in a laboratory.
A. Interprofessional Healthcare Team
Initial and ongoing individualized education is pro-
vided by the interprofessional team.
• Members include physicians, registered nurses, nurse
practitioners, physician assistant, registered dietitian
nutritionists, pharmacists, mental health profession-
als, dental professionals, and other specialists, such
as endocrinologist, cardiologist, ophthalmologist,
and podiatrist.
B. Educational Resources
Books and journals: A number of excellent books, profes-
sional journals, and other printed materials have been
prepared for the patient and for health professionals.
• Annually the American Diabetes Association pub-
lishes evidence-based Clinical Practice Recommen-
dations in the Diabetes Care journal. These can be
accessed free of charge on www.diabetes.org.
Internet: Access to diabetes education and support re-
sources continues to expand rapidly (review strate-
gies to determine validity of information on websites
in Chapter 2). In addition to static websites, the in-
ternet provides interactive resources that include the
following
19
:
• Interactive behavior change programs.
• Peer support through blogs, email, chat rooms, and
so on.
Technology: Cell phone applications for tracking food in-
take, physical activity, weight, blood glucose, and blood
pressure can be used to assist the individual with self-
monitoring and can be shared with the healthcare team.
20
IV. Medical Nutrition Therapy
9
Medical nutrition therapy is individualized to meet
the needs of the patient to manage and control
diabetes.
The American Diabetes Associations recommends nu-
trition therapy be provided by a registered dietitian/
nutritionist or certified diabetes educator.
Goals for medical nutrition therapy include:
• Energy balance for modest weight loss (5–10 pounds)
and weight maintenance.
Wilkins9781451193114-ch069.indd 1173 07/10/15 11:40 AM

1174 SECTION IX | Patients with Special Needs
• Dual therapy (combination of two antidiabetic med-
ications) for an A1c >7.5%.
• Triple therapy for an A1c >9%.
The take away message for dental professionals is that
when a patient is on multiple medications, it means the
diabetes is not well controlled.
C. Methods for Insulin Administration
Subcutaneous injection with syringe: A syringe is filled
from vial of insulin. Injection sites are rotated usually
on abdomen, thighs, or upper arm.
Insulin pen: Prefilled cartridge of single type of insulin
injected with attached needle. May be disposable or a
reusable type.
Continuous subcutaneous insulin infusion with a battery-
operated insulin pump:
• The insulin pump delivers preprogrammed continu-
ous basal rate of insulin and bolus doses when needed.
• Offers greater flexibility, smoother control of glyce-
mia, but may increase the risk of hypoglycemia.
• The small cellphone-sized pump can be worn in
a pocket or on a belt or waistband, as shown in
Figure69-3.
Inhalable insulin:
21
• Short-acting, “mealtime” insulin is taken through
an inhaler.
• Side effects include lower lung function, cough, dry
mouth, or chest discomfort.
• Brand name Afrezza.
Future modes for insulin administration include an in-
sulin patch, and implantable insulin pumps.
II. Oral Antidiabetic Medications
Oral medications are commonly used to treat type 2 dia-
betes in conjunction with diet, exercise, and possibly the
injection of insulin.
The medications, listed in Table 69-5, may be used in-
dividually or in combinations.
The American Association of Clinical Endocrinolo-
gists (AACE) recommends the following in addition to
lifestyle modifications
22
:
• The most common medications used in prediabetes
is metformin.
• Monotherapy (one antidiabetic medication) for in-
dividuals with an A1c between 6.5% and 7.5%.
TABLE 69-4 Types and Action of Insulin
CLASS OF INSULIN TYPE/NAME PEAK ACTION DURATION
Rapid acting Lispro (Humalog), Aspart (NovoLog) 1 hr 2–4 hr
Regular or short acting Humulin R, Novolin R 2–3 hr 3–6 hr
Intermediate acting NPH (Humulin N, Novolin N) 4–12 hr 12–18 hr
Long acting Detemir (Levemir), Glargine (Lantus) 24 hr 24 hr
Inhaled Afrezza 15 min
FIGURE 69-3 Patient Wearing Insulin Pump. Young boy with active lifestyle wear-
ing an insulin pump. Photo courtesy of Minimed.
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CHAPTER 69 | The Patient with Diabetes Mellitus 1175
TABLE 69-5 Oral Hypoglycemic Agents Used for Treatment of Type 2 Diabetes
AGENT EXAMPLE ACTION/FUNCTION
Biguanides Metformin (Glucophage)
Prevents liver glycogen breakdown to glucose
Increases tissue sensitivity to insulin
Sulfonylureas Glyburide (Diabeta, Mcronase)
Glipizide (Glucotrol)
Stimulates pancreas to release more insulin after a meal
May cause hypoglycemia
Meglitinides Repaglinide (Prandin)
Nateglinide (Starlix)
Stimulates pancreas to release more insulin after a meal
May cause hypoglycemia
Thiazolidinediones Pioglitazone (Actos)
Increases tissue sensitivity to insulin
Dipeptidyl peptidase-4 inhibitors Sitagliptin (Januvia)
Improves insulin level after meals and lowers glucose
production
Alpha-glucosidase inhibitors Acarbose (Precose)
Slows digestion and absorption of glucose into
bloodstream after eating
COMPLICATIONS OF DIABETES
9
Patients with well-controlled blood glucose levels tend to
develop fewer complications later in life than those whose
diabetes is less well controlled.
23
I. Infection
Patients are more susceptible to infections and impaired
healing, which can worsen prognosis.
Presence of stress, trauma, and infection affects blood
glucose levels.
Failure to treat an infection intensifies the symptoms
and increases severity of diabetes; can progress to life-
threatening infections or precipitate diabetic coma.
Insulin requirements may increase with fever, infection,
inflammation, trauma, bleeding, pain, or stress. When
the condition is eliminated, prescribed insulin may be
reduced.
Numerous factors are involved including impaired
immune response, alterations in metabolism of carbo-
hydrate and protein, vascular changes and impaired cir-
culation, and altered nutritional state.
II. Neuropathy
Neuropathy can cause pain, numbness, or tingling of
mouth, face, and extremities.
A. Peripheral Neuropathy
Symptoms vary based on the sensory nerve fibers af-
fected and may result in loss of sensation in the feet,
hands, and fingers.
Numbness in the hands and fingers may make effective
oral self-care difficult.
As many as 50% of people with peripheral neuropathy
may be asymptomatic and not recognize the loss of sen-
sation which can put them at risk for injury and result-
ing infection.
Leads to increased incidence of amputations and Char-
cot’s joints.
B. Autonomic Neuropathy
Manifestations include tachycardia, orthostatic hypoten-
sion, gastroparesis, and an hypoglycemic unawareness.
• Cardiovascular autonomic neuropathy can be symp-
tomatic other than changes in heart rate.
• Gastroparesis is a slowing of digestion and motility
of the gastrointestinal tract.
• Hypoglycemic unawareness can quickly become
an emergency situation because the patient is not
able to recognize the usual symptoms of low blood
glucose.
III. Nephropathy
Diabetes is a leading cause of renal disease, and the most
common cause of end-stage renal disease in the United
States and Europe. Dialysis or kidney transplant is needed.
Patients diagnosed with diabetes are screened for mi-
croalbuminuria (protein in the urine).
IV. Retinopathy
Diabetes is a leading cause of blindness through the
progression of diabetic retinopathy.
Patients are more likely to have glaucoma and cataracts.
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1176 SECTION IX | Patients with Special Needs
DENTAL HYGIENE CARE PLAN
The control of oral infection is vital. Infections can
progress more quickly and can alter the management
of diabetes.
Frequent, thorough oral care requires the patient’s utmost
cooperation and motivation and regular professional care.
The patient with diabetes is prone to life-threatening
emergencies.
Emergency practice drills can help the dental team pre-
vent an emergency, identify early indications of a de-
veloping emergency, and act swiftly and appropriately.
I. Appointment Planning
Stress, including that created during a dental or dental
hygiene appointment, can affect blood sugar levels.
Appointment planning centers around many factors,
including stress prevention.
A. Antibiotic Premedication
Well-controlled diabetes: In general, the patient with
well-controlled diabetes is treated the same as the pa-
tient without diabetes and requires no premedication
related to diabetes.
Uncontrolled, unstable diabetes: Routine dental treat-
ment is deferred until diabetes is stabilized. Only emer-
gency care is given to the uncontrolled patient. Consult
patient’s primary provider to determine if antibiotic
premedication is needed.
B. Time
Treat patient after a meal, preferably with protein and
fat to slow carbohydrate absorption.
Avoid peak insulin level noted in Table 69-4.
Ideal time of appointment varies with individual pa-
tient’s lifestyle and method of insulin intake.
Preferred appointment may be morning, soon after the
patient’s normal breakfast and medication, during the
ascending portion of the blood glucose level curve.
C. Precautions: Prevent/Prepare
for Emergency
Do not keep the patient waiting.
Do not interfere with the patient’s regular meal and
between-meal eating schedule.
Avoid long, stressful procedures; dental and dental hy-
giene care can be divided into short appointments ap-
propriate to the individual’s needs.
Take additional precautions indicated for the patient
with long-term diabetes with complications related to
atherosclerosis and other cardiovascular diseases (see
Chapter 67).
Prevent and treat all infections promptly.
V. Cardiovascular Disease
Individuals with diabetes are at high risk for cardio-
vascular disease, a major cause of morbidity and mor-
tality. Conditions common in people with diabetes
include:
• Hypertension.
• Dyslipidemia (high total cholesterol and low-density
lipoproteins).
• Hypertriglyceridemia (high triglycerides).
May lead to myocardial infarction and stroke.
Owing to the excessive risk of coronary heart disease,
aggressive treatment for dyslipidemia and hypertriglyc-
eridemia is recommended.
Low-dose aspirin therapy may be recommended for the
prevention of cardiovascular disease in patients with di-
abetes. Daily aspirin intake may increase bleeding time.
VI. Amputation
Diabetes is a major cause of limb amputation (usually foot)
from possible complications of neuropathy and vascular
disease.
VII. Pregnancy Complications
Patients with diabetes are at higher risk for spontaneous
miscarriages, having babies with birth defects, and in-
creased weight.
VIII. Psychosocial Aspects
Due to complications of diabetes, the daily life of the
patient as well as those close to the patient is signifi-
cantly affected.
Treatment regimens may be challenging to cope with
and lead to emotional and social problems, including
depression.
A suggestion for the patient to discuss psychosocial is-
sues with the physician may improve patient’s compli-
ance with treatment and daily oral personal care.
TABLE 69-6 Comparison of Average Blood
Glucose and A1c
9
Mean Plasma Glucose
A1c (%) mg/dL mmol/L
6 126 7.0
7 154 8.6
8 183 10.1
9 212 111.8
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CHAPTER 69 | The Patient with Diabetes Mellitus 1177
FIGURE 69-4 Managing Hypoglycemia (Rule of 15s). Flowchart to show steps to take when patient exhibits symptoms of hypoglycemia (insulin shock).
Managing Hypoglycemia (Rule of 15s)
Immediately recognize
symptoms of hypoglycemia
Discontinue treatment
sit patient upright in dental chair
For conscious patient, apply the 15/15 Rule
Have patient consume 15 grams of carbohydrate
Tube of glucose gel (preferred)
3 glucose tablets
Half cup (4 ounces) fruit juice or regular soda
1 tablespoon sugar
Wait 15 minutes and test blood glucose with
glucometer.
If blood glucose still <70 mg/dL, give another
15 grams of carbohydrate.
For unconscious patient, ACTIVATE
EMERGENCY MEDICAL SYSTEM (EMS)
Place in supine position
Provide basic life support
Dentist may administer intramuscular
injection of glucagon from Emergency Kit
EMS transport to hospital
If blood glucose still <70 mg/dL, ACTIVATE
EMERGENCY MEDICAL SYSTEM (EMS)
Wait 15 minutes and test blood glucose with
glucometer.
If the patient has recovered, have the patient eat
a snack with carbohydrate and protein such as:
Crackers and cheese
Crackers and peanut butter
Part of a sandwich
to stabilize the blood glucose until the next meal.
Have you ever been diagnosed with prediabetes, borderline diabetes or diabetes?
Yes No
Have any members of your family ever been diagnosed with diabetes?
Yes No
Do you urinate frequently? How many times per day?
Yes No
Are you frequently thirsty?
Yes No
Does your mouth feel dry?
Yes No
Have you had any unexplained weight loss?
Yes No
Do you experience excessive hunger?
Yes No
Do you had recent blurred vision?
Yes No
Gather detailed information on all current prescribed and over-the-counter medications,
including recommended dose.
Gather information on vitamins, homeopathic, or herbal supplements.
Common Medical History Questions to Screen for Diabetes
BOX 69-5
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1178 SECTION IX | Patients with Special Needs
When was your last visit to your diabetes care healthcare provider?
Answer: It is recommended individuals with stable glycemic control be seen twice/year and those with poor glycemic control
at least quarterly.
What medications and dose have you taken today?
Answer: Medications need to be taken prior to the appointment and patient knowledge about medications suggests per-
sonal responsibility for diabetes self-care.
When did you eat last? What did you eat?
Answer: Foods containing complex carbohydrates and protein and/or fat 1–2 hour before the appointment to prevent hy-
poglycemia is ideal.
Do you monitor your blood sugar at home?
Answer: Yes, SMBG is critical for diabetes self-care.
How often do you monitor your blood glucose?
Answer: Those taking multiple doses of insulin need to check the blood glucose levels 3 or more times daily. Once or twice
daily is typical for those using oral medications.
What is your usual fasting blood sugar in the morning?
Answer: Glucose levels between 90 and 130 mg/dL premeal and below 180 mg/dL 2 hours postmeal.
What is your hemoglobin A1c? How often does your primary care provider check the A1c?
Answer: About <7% and preferably <6.5%; A1c testing recommended twice/year in those with good glycemic control and
quarterly in those with poor control.
(If the patient reports poorly controlled diabetes) Are you experiencing frequent urination?
Answer: Response of “yes” may indicate hyperglycemia and poor diabetes control and requires referral. The patient will not
heal and it is best to postpone treatment as healing will be suboptimal.
Do you have frequent episodes of hypoglycemia (low blood sugar)? Can you tell when your blood sugar is getting low?
Answer: Response of “yes” to the first question and “no to the second identifies a patient at risk for a medical emergency.
Hypoglycemic unawareness occurs as a result of neuropathy and the patient is no longer able to identify when the blood
sugar has dropped to dangerously low levels.
(For those with a history of hypoglycemia, ask this question) What time of day does it usually happen and how do you treat it?
Answer: If the appointment is during a critical time of day for hypoglycemia, precautions need to be taken to prevent and
treat it or the appointment can be rescheduled. Mid-afternoon is typically when some types of insulin and oral medications
reach their peak action and glucose from the midday meal reaches a low resulting in a dangerous combination putting the
patient at risk for hypoglycemia.
Have you been hospitalized for hypoglycemia?
Answer: Response of “yes” indicates extreme risk and preparation needs to be made to rapidly treat hypoglycemia. Place a
glucometer and glucose source near treatment area for quick access.
Are you having problems with your eyes, feet, hands, or legs? If so, what kind of problems are you experiencing?
Answer: A patient experiencing complications may be poorly controlled and a medical consult is advised.
Adapted from Boyd LD. Commentary on survey of diabetes knowledge and practices of dental hygienists. Access. 2008;22(8):40–43.
Questions to Ask a Patient with Diabetes to Gather Additional Information
BOX 69-6
Prepare for hypoglycemia emergency. Keep a package of
glucose gel for the conscious patient as part of the office
emergency supplies.
Monitor for symptoms of hypoglycemia including: diz-
ziness, sweating (diaphoresis), mental confusion, shaki-
ness, pallor, palpitations, and irritability.
D. Emergency Management
Recognize any change in patient behavior that signals a
diabetes emergency.
• If in doubt, it is safer to treat for hypoglycemia since
it will only cause a brief increase in blood glucose.
• Follow the Rule of 15s (see the flowchart in
Figure69-4 for management of hypoglycemia).
9
II. Patient History
A. Refer for Early Diagnosis
Questions regarding signs and symptoms of diabetes are
included in a standard medical history questionnaire.
Appropriate questions to ask are listed in Box 69-5.
• The American Diabetes Association Diabetes Risk
Test (Figure 69-2) can also be used to identify
those at risk.
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CHAPTER 69 | The Patient with Diabetes Mellitus 1179
V. Continuing Care
Appointment for supervision and examination on regu-
lar 3- to 6-month basis as needed. Effectiveness of daily
oral self-care is evaluated.
Probe carefully to detect early bleeding on probing and
evidence of pocket formation.
Assess soft tissue with attention to areas of irritation
related to fixed and removable prostheses.
Identify any changes requiring consultation or refer-
ral to patient’s primary care provider, dietitian, mental
health professional, or other specialist.
Check for dental biofilm control and review control
with the patient at each appointment. Gingival health
is of major importance. Keep the patient motivated.
DOCUMENTATION
Record status of blood glucose control, includ-
ing most recent HbA1c and other daily monitoring
such as fasting blood glucose levels the patient has
performed.
Update current medications and doses.
Confirm compliance of medication intake and food
consumption.
If an unexplained positive response is present suggest-
ing symptoms of diabetes, the patient is referred to a
primary care provider for evaluation.
B. Medical History
Supplement the basic medical history with additional
questions to obtain information about diabetes (sug-
gested questions along with answers can be found in
Box 69-6).
Ask about exercise and tobacco use; review effect on
health.
Update medical history at each appointment.
Identify health problems or complications of diabetes
that may influence dental treatment. Refer to specialist
when indicated.
III. Consultation with Primary Care Provider
Consultation with the primary care provider to obtain A1c
values can be initiated either prior to or at the first visit.
• Table 69-6 provides a conversion for the A1c to av-
erage blood glucose levels.
Further consultation may be necessary in more advanced
periodontal disease to obtain clearance for treatment.
IV. Dental Hygiene Assessment and Treatment
A. Extraoral/Intraoral Examination
Acanthosis negricans appears as a light brown to black
discoloration of the skin in the creases of the neck and
can indicate risk for diabetes (Figure 69-5).
B. Dental Biofilm Control Instruction
Because of the impact of diabetes on periodontal health
and the effect of oral infection on diabetes status, daily
meticulous oral self-care is crucial.
Disclosing the biofilm and individualized self-care mea-
sures for biofilm control are reviewed continuously.
C. Tobacco Cessation
Refer to the information on Tobacco Cessation Pro-
grams in Chapter 34.
D. Instrumentation
Nonsurgical periodontal therapy: Definitive nonsurgical
periodontal therapy reduces the possibility of periodon-
tal abscess formation. Allow several short appointments
if needed for stress management.
Healing: Avoid undue trauma to tissues to minimize the
risk for complications associated with healing
E. Fluoride Application
Fluoride treatments, varnishes, and home use of fluo-
ride are encouraged, particularly with xerostomia.
Methods for daily self-fluoride application are described
in Chapter 36.
FIGURE 69-5 Acanthosis Negricans. This skin condition is seen in patients at risk
for diabetes and typically appears on the creases in the neck as a light brown to black
discoloration.
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1180 SECTION IX | Patients with Special Needs
Example Documentation: Patient with
Diabetes Mellitus
S A 66-year-old Hispanic female who presents for a peri-
odontal maintenance. She reports bleeding when she
flosses for the last couple weeks. She was recently diag-
nosed with type 2 diabetes and is taking Metformin and
Glipizide. Her initial HbA1c was 8.5 and she will have a
follow-up test next month. She reports checking her
blood glucose when she gets up in the morning and be-
fore dinner. Her fasting blood glucose this morning was
120. Patient reports taking her medications this morning.
O Blood pressure: 131/79. Pulse: 88. Respirations 24. Risk as-
sessment for caries was moderate, periodontal disease
was high, and oral cancer was moderate. Periodontal
examination reveals localized bleeding on probing and
1–2 mm pocket depth increases primarily in maxillary
molar areas. Biofilm score: 30%. No new dental caries.
A Moderate localized chronic periodontitis, complicated
by poorly controlled diabetes mellitus.
P Discussed the association of periodontal infection with
diabetes and need for meticulous oral self-care and
regular professional periodontal maintenance appoint-
ments. Reviewed use of interdental brushes for molar
areas where biofilm was located. Patient had difficulty
removing biofilm on the lingual line angles of the molars
so careful wrapping of the floss was also reviewed. Com-
plete periodontal debridement was performed. Applied
5% sodium fluoride varnish and provided a prescription
for 0.12% chlorhexidine gluconate mouthrinse to use
twice a day for 2 weeks to assist with healing.
Signed: _____________________________________, RDH
Date: _______________________________________
BOX 69-7
Ed, a 45-year-old restaurant owner, presents for an ap-
pointment with Susan, the dental hygienist. She has
treated this patient before but he has not had an ap-
pointment for more than 2 years. The review of his medi-
cal history determines he is obese, complains of a dry
mouth, has excessive thirst, gets up at night multiple
times to urinate, and has not seen his primary care pro-
vider in several years. An intraoral examination reveals
candidiasis on his hard palate. Susan suggests that he
see his physician, but he refuses to even talk about it. He
insists that he just wants clean teeth for his daughter’s
upcoming wedding.
Questions for Consideration
1. Describe how each of the dental hygiene ethical core
values (Table II-1, Section II) apply to this scenario.
2. In what ways will Susan be violating the patient’s rights if
she agrees to Ed’s request that she focus only on clean-
ing” his teeth at this appointment? How may she be vio-
lating his rights if she refuses to clean his teeth unless he
first has an examination with his primary care provider?
3. Explain choices or alternative actions Susan can con-
sider as she decides how to continue treatment during
Ed’s appointment.
EVERYDAY ETHICS
Factors to Teach Patients with Diabetes
Importance of regular medical and dental care, eye
examinations, blood pressure checks, blood tests for
cholesterol, lipids, and kidney readings, and prac-
tice self-examination, particularly of feet, for nerve
involvement or delayed healing visits to prevent
complications.
Connection between oral health and diabetes and need
for meticulous oral self-care.
The patient’s role in self-management of diabetes with
an emphasis on the need to be compliant with lifestyle
modifications including healthy eating, physical activity,
weight management, glucose monitoring, tobacco ces-
sation, good oral self-care, limiting or avoiding alcohol,
stress management, and use of prescribed medications.
The value of seeking immediate medical attention for
any signs of complications from diabetes.
Factors to Teach Patients Not Diagnosed
with Diabetes
Need for regular medical examinations and screening
for diabetes.
How to recognize the early warning signs of diabetes
and seek medical consult.
Factors that affect a healthy lifestyle, including healthy
diet, daily exercise, no tobacco products, avoid alcohol,
and maintain ideal weight.
How to practice meticulous oral hygiene to prevent
dental caries and periodontal disease.
Stress reduction techniques.
Factors To Teach The Patient
Record discussion about relationship between oral health
status, oral hygiene status, risk factors, and diabetes.
Box 69-7 contains an example progress note for a pa-
tient with diabetes.
References
1. American Diabetes Association. Diagnosis and classifica-
tion of diabetes mellitus. Diabetes Care. 2014;37 (Suppl 1):
S81–S90.
2. Centers for Disease Control and Prevention. National Diabe-
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pubs/statsreport14.htm. Accessed November 23, 2014.
3. Danaei G, Finucane MM, Lu Y, et al. National, regional, and
global trends in fasting plasma glucose and diabetes preva-
lence since 1980: systematic analysis of health examination
surveys and epidemiological studies with 370 country-years
and 2.7 million participants. Lancet. 2011;378(9785):31–40.
4. Boyd LD, Giblin L, Chadbourne D. Bidirectional relation-
ship between diabetes mellitus and periodontal disease: state
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186–188, 190.
6. Fouad AF. Diabetes mellitus as a modulating factor of end-
odontic infections. J Dent Educ. 2003;67(4):459–467.
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and oral implant failure: a systematic review. J Dent Res.
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9. American Diabetes Association. Standards of medical
care in diabetes—2014. Diabetes Care. 2014;37 (Suppl 1):
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10. Reinehr T. Obesity and diabetes in young adults. MMW
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11. DeSisto CL, Kim SY, Sharma AJ. Prevalence estimates of
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12. Linnenkamp U. IDF diabetes atlas reveals high burden of hy-
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http://www.diabetes.org/are-you-at-risk/diabetes-risk-test/.
Accessed November 23, 2014.
14. Gupta A, Gupta N, Garg R, et al. Developing a chair side,
safe and non-invasive procedure for assessment of blood
glucose level using gingival crevicular bleeding in dental
clinics. J Nat Sci Biol Med. 2014;5(2):329–332.
15. Strauss SM, Russell S, Wheeler A, et al. The dental office
visit as a potential opportunity for diabetes screening: an
analysis using NHANES 2003–2004 data. J Public Health
Dent. 2010;70(2):156–162.
16. Strauss SM, Tuthill J, Singh G, et al. A novel intraoral dia-
betes screening approach in periodontal patients: results of a
pilot study. J Periodontol. 2012;83(6):699–706.
17. The Diabetes Prevention Program Research Group. The
10-year cost-effectiveness of lifestyle intervention or met-
formin for diabetes prevention: an intent-to-treat analysis of
the DPP/DPPOS. Diabetes Care. 2012;35(4):723–730.
18. Haas L, Maryniuk M, Beck J, et al. National standards for
diabetes self-management education and support. Diabetes
Care. 2014;37 (Suppl 1):S144–S153.
19. Brouwer W, Kroeze W, Crutzen R, et al. Which interven-
tion characteristics are related to more exposure to internet-
delivered healthy lifestyle promotion interventions? A sys-
tematic review. J Med Internet Res. 2011;13(1):e2.
20. Kaufman N. Internet and information technology use in treat-
ment of diabetes. Int J Clin Pract Suppl. 2010;(166):41–46.
21. Liao ZH, Chen YL, Li FP, et al. Multicenter clinical study
on the efficacy and safety of inhalable insulin aerosol
in the treatment of type 2 diabetes. Chin Med J (Engl).
2008;121:1159–1164.
22. Garber AJ, Abrahamson MJ, Barzilay JI, et al. AACE com-
prehensive diabetes management algorithm 2013. Endocr
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23. Nathan DM; and DCCT/EDIC Research Group. The diabe-
tes control and complications trial/epidemiology of diabetes
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Diabetes Care. 2014;37(1):9–16.
ENHANCE YOUR UNDERSTANDING
DIGITAL CONNECTIONS
(see the inside front cover for access information)
• Audio glossary
• Quiz bank
SUPPORT FOR LEARNING
(available separately; visit lww.com)
• Active Learning Workbook for Clinical Practice
of the Dental Hygienist, 12th Edition
INDIVIDUALIZED REVIEW
(available separately; visit lww.com)
• Adaptive quizzing with prepU for Wilkins’
Clinical Practice of the Dental Hygienist
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Wilkins9781451193114-ch069.indd 1182 07/10/15 11:40 AM

1183
Appendix I
American Dental Hygienists Association Code
of Ethics for Dental Hygienists*
PREAMBLE
As dental hygienists, we are a community of profession-
als devoted to the prevention of disease and the promo-
tion and improvement of the public’s health. We are
preventive oral health professionals who provide educa-
tional, clinical, and therapeutic services to the public.
We strive to live meaningful, productive, satisfying lives
that simultaneously serve us, our profession, our society,
and the world. Our actions, behaviors, and attitudes are
consistent with our commitment to public service. We
endorse and incorporate the Code into our daily lives.
PURPOSE
The purpose of a professional code of ethics is to achieve
high levels of ethical consciousness, decision making, and
practice by the members of the profession. Specific objec-
tives of the Dental Hygiene Code of Ethics are:
To increase our professional and ethical consciousness
and sense of ethical responsibility.
To lead us to recognize ethical issues and choices and
to guide us in making more informed ethical decisions.
To establish a standard for professional judgment and
conduct.
To provide a statement of the ethical behavior the
public can expect from us.
The Dental Hygiene Code of Ethics is meant to influ-
ence us throughout our careers. It stimulates our continuing
study of ethical issues and challenges us to explore our ethi-
cal responsibilities. The Code establishes concise standards
of behavior to guide the public’s expectations of our profes-
sion and supports existing dental hygiene practice, laws, and
regulations. By holding ourselves accountable to meeting the
standards stated in the Code, we enhance the public’s trust on
which our professional privilege and status are founded.
KEY CONCEPTS
Our beliefs, principles, values, and ethics are concepts re-
flected in the Code. They are the essential elements of our
comprehensive and definitive code of ethics and are inter-
related and mutually dependent.
BASIC BELIEFS
We recognize the importance of the following beliefs that
guide our practice and provide context for our ethics:
The services we provide contribute to the health and
well-being of society.
Our education and licensure qualify us to serve the pub-
lic by preventing and treating oral disease and helping
individuals achieve and maintain optimal health.
Individuals have intrinsic worth, are responsible for
their own health, and are entitled to make choices re-
garding their health.
Dental hygiene care is an essential component of over-
all healthcare, and we function interdependently with
other healthcare providers.
All people should have access to healthcare, including
oral healthcare.
We are individually responsible for our actions and the
quality of care we provide.
FUNDAMENTAL PRINCIPLES
These fundamental principles, universal concepts, and gen-
eral laws of conduct provide the foundation for our ethics.
Universality
The principle of universality assumes that if one individual
judges an action to be right or wrong in a given situation,
*Reprinted with permission from The American Dental Hygienists’ Association. http://www.adha.org.
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1184 APPENDIX I | American Dental Hygienists’ Association Code of Ethics for Dental Hygienists
Societal Trust
We value client trust and understand that public trust in
our profession is based on our actions and behavior.
Nonmaleficence
We accept our fundamental obligation to provide services
in a manner that protects all clients and minimizes harm
to them and others involved in their treatment.
Beneficence
We have a primary role in promoting the well-being of in-
dividuals and the public by engaging in health promotion/
disease prevention activities.
Justice and Fairness
We value justice and support the fair and equitable distribu-
tion of healthcare resources. We believe all people should
have access to high-quality, affordable oral healthcare.
Veracity
We accept the obligation to tell the truth and assume that
others will do the same. We value self-knowledge and seek
truth and honesty in all relationships.
STANDARDS OF PROFESSIONAL
RESPONSIBILITY
We are obligated to practice our profession in a manner
that supports our purpose, beliefs, and values in accor-
dance with the fundamental principles that support our
ethics. We acknowledge the following responsibilities:
To Ourselves as Individuals
Avoid self-deception, and continually strive for knowl-
edge and personal growth.
Establish and maintain a lifestyle that supports optimal
health.
Create a safe work environment.
Assert our own interests in ways that are fair and equitable.
Seek the advice and counsel of others when challenged
with ethical dilemmas.
Have realistic expectations of ourselves and recognize
our limitations.
To Ourselves as Professionals
Enhance professional competencies through continu-
ous learning in order to practice according to high stan-
dards of care.
other people considering the same action in the same situ-
ation would make the same judgment.
Complementarity
The principle of complementarity assumes the existence of
an obligation to justice and basic human rights. It requires
us to act toward others in the same way they would act to-
ward us if roles were reversed. In all relationships, it means
considering the values and perspectives of others before
making decisions or taking actions affecting them.
Ethics
Ethics are the general standards of right and wrong that
guide behavior within society. As generally accepted ac-
tions, they can be judged by determining the extent to
which they promote good and minimize harm. Ethics com-
pel us to engage in health promotion/disease prevention
activities.
Community
This principle expresses our concern for the bond between
individuals, the community, and society in general. It leads
us to preserve natural resources and inspires us to show
concern for the global environment.
Responsibility
Responsibility is central to our ethics. We recognize there
are guidelines for making ethical choices and accept respon-
sibility for knowing and applying them. We accept the con-
sequences of our actions or the failure to act and are willing
to make ethical choices and publicly affirm them.
CORE VALUES
We acknowledge these values as general for our choices
and actions.
Individual Autonomy and Respect for Human
Beings
People have the right to be treated with respect. They have
the right to informed consent prior to treatment, and they
have the right to full disclosure of all relevant information
so that they can make informed choices about their care.
Confidentiality
We respect the confidentiality of client information and
relationships as a demonstration of the value we place on
individual autonomy. We acknowledge our obligation to
justify any violation of a confidence.
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APPENDIX I | American Dental Hygienists’ Association Code of Ethics for Dental Hygienists 1185
To Employees and Employers
Conduct professional activities and programs and de-
velop relationships in ways that are honest, responsible,
open, and candid.
Manage conflicts constructively.
Support the right of our employees and employers to
work in an environment that promotes wellness.
Respect the employment rights of our employers and
employees.
To the Dental Hygiene Profession
Participate in the development and advancement of
our profession.
Avoid conflicts of interest and declare them when they
occur.
Seek opportunities to increase public awareness and
understanding of oral health practices.
Act in ways that bring credit to our profession while
demonstrating appropriate respect for colleagues in
other professions.
Contribute time, talent, and financial resources to sup-
port and promote our profession.
Promote a positive image for our profession.
Promote a framework for professional education that
develops dental hygiene competencies to meet the oral
and overall health needs of the public.
To the Community and Society
Recognize and uphold the laws and regulations govern-
ing our profession.
Document and report inappropriate, inadequate, or
substandard care and/or illegal activities by a health-
care provider to the responsible authorities.
Use peer review as a mechanism for identifying inap-
propriate, inadequate, or substandard care provided by
dental hygienists.
Comply with local, state, and federal statutes that pro-
mote public health and safety.
Develop support systems and quality-assurance pro-
grams in the workplace to assist dental hygienists in
providing the appropriate standard of care.
Promote access to dental hygiene services for all, sup-
porting justice and fairness in the distribution of health-
care resources.
Act consistently with the ethics of the global scientific
community of which our profession is a part.
Create a healthful workplace ecosystem to support a
healthy environment.
Recognize and uphold our obligation to provide pro
bono service.
Support dental hygiene peer-review systems and quality-
assurance measures.
Develop collaborative professional relationships and
exchange knowledge to enhance our own lifelong pro-
fessional development.
To Family and Friends
Support the efforts of others to establish and maintain
healthy lifestyles and respect the rights of friends and
family.
To Clients
Provide oral healthcare utilizing high levels of profes-
sional knowledge, judgment, and skill.
Maintain a work environment that minimizes the risk
of harm.
Serve all clients without discrimination, and avoid ac-
tion toward any individual or group that may be inter-
preted as discriminatory.
Hold professional client relationships confidential.
Communicate with clients in a respectful manner.
Promote ethical behavior and high standards of care by
all dental hygienists.
Serve as an advocate for the welfare of clients.
Provide clients with the information necessary to make
informed decisions about their oral health and encourage
their full participation in treatment decisions and goals.
Refer clients to other healthcare providers when their
needs are beyond our ability or scope of practice.
Educate clients about high-quality oral healthcare.
To Colleagues
Conduct professional activities and programs, and de-
velop relationships in ways that are honest, responsible,
and appropriately open and candid.
Encourage a work environment that promotes individ-
ual professional growth and development.
Collaborate with others to create a work environment
that minimizes risk to the personal health and safety of
our colleagues.
Manage conflicts constructively.
Support the efforts of other dental hygienists to com-
municate the dental hygiene philosophy and preven-
tive oral care.
Inform other healthcare professionals about the rela-
tionship between general and oral health.
Promote human relationships that are mutually
beneficial, including those with other healthcare
professionals.
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1186 APPENDIX I | American Dental Hygienists’ Association Code of Ethics for Dental Hygienists
Obtain informed consent from human subjects partici-
pating in research that is based on specification pub-
lished in Title 21 Code of Federal Regulations Part 46.
Respect the confidentiality and privacy of data.
Seek opportunities to advance dental hygiene knowl-
edge through research by providing financial, human,
and technical resources whenever possible. Report re-
search results in a timely manner.
Report research findings completely and honestly,
drawing only those conclusions that are supported by
the data presented.
Report names of investigators fairly and accurately.
Interpret the research and the research of others accurately
and objectively, drawing conclusions that are supported by
the data presented and seeking clarity when uncertain.
Critically evaluate research methods and results before
applying new theory and technology in practice.
Be knowledgeable concerning currently accepted pre-
ventive and therapeutic methods, products, and tech-
nology and their application to our practice.
To Scientific Investigation
We accept responsibility for conducting research accord-
ing to the fundamental principles underlying our ethical
beliefs in compliance with universal codes, governmen-
tal standards, and professional guidelines for the care and
management of experimental subjects. We acknowledge
our ethical obligations to the scientific community:
Conduct research that contributes knowledge that is
valid and useful to our clients and society.
Use research methods that meet accepted scientific
standards.
Use research resources appropriately.
Systematically review and justify research in progress
to ensure the most favorable benefit-to-risk ratio to re-
search subjects.
Submit all proposals involving human subjects to an
appropriate human subject review committee.
Secure appropriate institutional committee approval
for the conduct of research involving animals.
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1187
*
Reprinted with permission from The National Dental Hygienists’ Association Constitution and By-laws. 2012. http://www.ndhaonline.org.
Appendix II
National Dental Hygienists Association Code of Ethics*
enhance the image of dental hygiene. As hygienists, we
are accountable for participating in the development of
education programs and policies. We are also accountable
for interpreting this information for our patients.
Principle III: Commitment to the Profession
We believe that the quality of services the NDHA pro-
vides to its members directly influences the future of the
profession and the patient population served by its mem-
bers. We must exert every effort to raise performance stan-
dards to improve the skills of our members so that they
can exercise the highest level of professional judgment.
These actions should attract individuals who will make
positive contributions to the practice of dental hygiene.
We actively participate in the planning, development and
learning of all members.
Principle IV: Commitment to the Student
We measure our success by the number of underrepresented
minority students entering the dental hygiene profession
and strive to increase the number of underrepresented mi-
nority dental hygienists by eliminating educational and
social barriers. To accomplish this goal, the NDHA will
provide educational and financial assistance to insure the
continued success of underrepresented minorities in the
profession of dental hygiene.
PREAMBLE
We, the members of the National Dental Hygienists’
Association, affirm our belief in dental health education for
the prevention of dental disease and the importance of pre-
ventive treatment. We affirm and accept our responsibility
to practice our profession according to the highest ethical
standards. We hold ourselves, both individually and collec-
tively, accountable for professional conduct in the dental
hygiene profession according to the provision of this code.
Principle I: Commitment to the Patient
Our success is measured by the progress of each patient’s
achievement of maximum dental health. We work to mo-
tivate our patients to become aware of their individual
state of dental health and engage in those practices that
result in optimum dental health. To this end we will:
1. Address each patient with respect, giving consideration
to the individual’s needs.
2. Maintain each patient’s confidentiality.
3. Maintain the highest level of mental, physical and spir-
itual health possible, to be a role model to our patients
and the community.
Principle II: Commitment to the Community
In fulfilling our obligations to the community, we believe
that cooperative relationships in the community will
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1189
Appendix III
Canadian Dental Hygienists Association: Dental Hygienists
Code of Ethics*
PREAMBLE
The CDHA Code of Ethics sets out the ethical principles
and responsibilities which apply to all members of the den-
tal hygiene profession across all practice areas including
clinical care, education, research, administration and any
other role related to the profession of dental hygiene.
Ethics is the study of moral values and moral reasoning.
Ethical codes are formal statements that guide members of
a profession in their obligations to clients, colleagues, the
larger society, and to global health.
The Code of Ethics serves to:
1. Articulate the ethical principles and responsibilities by
which dental hygienists are guided and under which
they are accountable;
2. Provide a professional resource for education, reflec-
tion, self-evaluation, and peer review within dental hy-
giene and the broader health care community;
3. Inform the public about the ethical principles and re-
sponsibilities of the dental hygiene profession.
Dental hygienists’ primary responsibility is to the client. In
this document, “client” refers to a person or persons or a
community with whom dental hygienists are engaged in a
professional relationship. These relationships occur in all
areas of dental hygiene practice including clinical services
(e.g., private dental offices, independent practice, schools,
community/public health clinics, acute and long term
care, corporate environments); education, research, regu-
latory and policy roles; and administration/employment.
Dental hygienists work in an interprofessional collabora-
tive environment. They are accountable to other codes of
ethics/ethical guidelines including those of their provincial/
territorial regulatory authority and their workplace. The
CDHA Code of Ethics is a strong foundational document,
effective on its own, and complementary to other ethical
codes that address more specific situations and behaviours.
Dental hygienists use the Code of Ethics in conjunc-
tion with professional standards, workplace policies, and
laws and regulations that guide practices and behaviours.
In achieving these requirements, they fulfill their contract
with society to meet a high standard of ethical practice.
ETHICAL PRINCIPLES AND
RESPONSIBILITIES
The “Principles” depict the broad ideals to which dental
hygienists aspire and which guide their practice. The “Re-
sponsibilities” outlined on the following pages are more
precise and provide direction for behaviours in ethical
situations.
Principle: Beneficence
Beneficence involves caring about and acting to promote
the good of another. Dental hygienists use their knowledge
and skills to assist clients to achieve and maintain optimal
oral health and overall wellbeing, and to promote fair and
reasonable access to quality oral health services as an inte-
gral part of the healthcare system.
Responsibilities for Beneficence
1. Dental hygienists put the needs, values, and interests
of clients first.
2. Dental hygienists provide services to clients in a caring
manner with respect for their individual needs, values,
culture, safety, and life circumstances, and in recogni-
tion of their inherent dignity.
3. Dental hygienists regard informed choice as a precon-
dition of intervention, and honour a client’s informed
choice including refusal of intervention.
4. Dental hygienists recommend or provide those services
that they believe are necessary for promoting and main-
taining a client’s oral health and its effect on total body
health and wellness, and which are consistent with the
client’s informed choice.
*Revised 2012. Reprinted with permission from The Canadian Dental Hygienists Association. http://www.cdha.ca/
Wilkins9781451193114-appx3.indd 1189 07/10/15 10:43 AM

1190 APPENDIX III | Canadian Dental Hygienists Association: Dental Hygienists’ Code of Ethics
6. Dental hygienists promote workplace practices and pol-
icies that facilitate professional practice in accordance
with the principles, standards, laws and regulations un-
der which they are accountable.
7. Dental hygienists communicate the nature and
costs of professional services fairly and accurately, ad-
hering to guidelines and/or regulations for advertising
as outlined by their jurisdictional regulatory authority.
Principle: Accountability
Accountability pertains to taking responsibility for one’s
actions and omissions in light of relevant principles, stan-
dards, laws, and regulations. It includes the potential to
self evaluate and be evaluated. It involves practising com-
petently and accepting responsibility for behaviours and
decisions in the professional context.
Responsibilities for Accountability
1. Dental hygienists accept responsibility for knowing
and acting consistently with the principles, practice
standards, laws and regulations under which they are
accountable.
2. Dental hygienists practise within the bounds of their
competence, scope of practice, personal and/or profes-
sional limitations.
3. Dental hygienists refer clients who require services out-
side their scope of practice to the appropriate professional.
4. Dental hygienists address issues in the practice environ-
ment that may hinder or impede the provision of care.
5. Dental hygienists inform their employers about the
principles, standards, laws and regulations to which
dental hygienists are accountable and determine
whether employment conditions facilitate safe profes-
sional practice.
6. Dental hygienists inform their employers and/or
appropriate regulatory authority of unethical practice
by a colleague.
7. Dental hygienists inform the appropriate regula-
tory authority in the event of becoming unable to prac-
tise safely and competently.
Principle: Confidentiality
Confidentiality is the duty to hold secret any information
acquired in the professional relationship. Dental hygien-
ists respect a client’s privacy and hold in confidence in-
formation disclosed to them except in certain narrowly
defined exceptions.
Responsibilities for Confidentiality
1. Dental hygienists demonstrate respect for the privacy
of clients.
2. Dental hygienists promote practices, policies and infor-
mation systems that are designed to respect and protect
clients’ privacy and confidentiality.
5. Dental hygienists take appropriate action to ensure a
client’s safety and quality of care when they suspect un-
ethical or incompetent care.
6. Dental hygienists seek to improve the quality of care,
and advance knowledge in the field of oral health
through advocacy and interprofessional practice.
Principle: Autonomy
Autonomy pertains to the right to make one’s own choices.
By communicating relevant information openly and truth-
fully, dental hygienists assist clients to make informed
choices and to participate actively in achieving and main-
taining their optimal oral health.
Responsibilities for Autonomy
1. Dental hygienists actively involve clients in their oral
healthcare and promote informed choice by commu-
nicating relevant information openly, truthfully, and
sensitively in recognition of their needs, values, and
capacity to understand.
2. Dental hygienists involve and promote informed choice
by substitute decision maker(s) in situations where cli-
ents lack the capacity for informed choice.
3. Dental hygienists, in the event of a substitute decision
maker, involve clients to the extent of their capacity.
4. Dental hygienists recognize cultural differences, and as-
sess and plan interventions with individuals and popu-
lations receiving their services relative to the cultural
context.
Principle: Integrity
Integrity relates to consistency of actions, values, methods,
expectations, and outcomes. It includes the promotion of
fairness and social justice with consideration for those
clients more vulnerable. It conveys a sense of wholeness
and strength, and doing what is right with honesty and
truthfulness.
Responsibilities for Integrity
1. Dental hygienists uphold the principles and standards of
the profession with clients, colleagues and others with
whom they are engaged in a professional relationship.
2. Dental hygienists maintain and advance their knowledge
and skills in dental hygiene through lifelong learning.
3. Dental hygienists provide quality of interventions
through ongoing self evaluation and quality assurance.
4. Dental hygienists promote conditions that enable
social, economic, cultural values and institutions com-
patible with meeting basic human rights and dignity.
5. Dental hygienists collaborate with colleagues in a co-
operative, constructive and respectful manner with
the primary goal of providing safe, competent, fair and
high quality interventions to individuals, families and
communities.
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APPENDIX III | Canadian Dental Hygienists Association: Dental Hygienists’ Code of Ethics 1191
• In an emergency situation,
• In situations where disclosure is necessary to prevent
serious harm to others,
• To the client’s guardian or substitute decision maker.
5. Dental hygienists inform clients in advance of treat-
ment of how their information may be shared, in partic-
ular, around any uses or sharing that may occur without
the client’s express consent.
6. Dental hygienists obtain a client’s consent to use or
share information about his/her circumstances for the
purpose of teaching or research.
3. Dental hygienists understand and respect the poten-
tial of compromising confidentiality when connecting
with clients through social networks or other electronic
media.
4. Dental hygienists hold confidential any information
acquired in the professional relationship and do not use
or disclose confidential information to others without a
client’s express consent. Exceptions include:
• As required by law,
• As required by the policy of the practice environ-
ment (e.g., quality assurance),
Wilkins9781451193114-appx3.indd 1191 07/10/15 10:43 AM

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The Patient with Diabetes MellitusLinda D. Boyd, RDH, RD, EdD and Kathryn R. Davis, RDH, MS, DMDDIABETES MELLITUS I. Definition II. Diabetes ImpactORAL HEALTH IMPLICATIONS OF DIABETES MELLITUS I. Relationship Between Diabetes and Periodontal Disease II. Dental Caries III. Endodontic Infections IV. Dental ImplantsBASICS ABOUT INSULIN I. Definition II. Description III. Functions IV. Effects of Absolute Insulin Deficiency (Type 1 Diabetes) V. Effects of Impaired Secretion or Action of Insulin (Type 2 Diabetes) VI. Insulin ComplicationsCLASSIFICATION OF DIABETES MELLITUS I. Type 1 Diabetes Mellitus II. Type 2 Diabetes Mellitus III. Gestational Diabetes Mellitus IV. Other Specific Types of Diabetes MellitusDIAGNOSIS OF DIABETES I. Diabetes Symptoms II. Diagnostic TestsIDENTIFICATION OF INDIVIDUALS AT RISK FOR DEVELOPMENT OF DIABETES I. Risk Factors II. PrediabetesSTANDARDS OF MEDICAL CARE FOR DIABETES MELLITUS I. Early Diagnosis II. Management of Prediabetes III. Diabetes Self-management Education IV. Medical Nutrition Therapy V. Physical Activity VI. HabitsPHARMACOLOGICAL THERAPY I. Insulin Therapy II. Oral Antidiabetic MedicationsCOMPLICATIONS OF DIABETES I. Infection II. Neuropathy III. Nephropathy IV. Retinopathy V. Cardiovascular Disease VI. Amputation VII. Pregnancy Complications VIII. Psychosocial AspectsDENTAL HYGIENE CARE PLAN I. Appointment Planning II. Patient History III. Consultation with Primary Care Provider IV. Dental Hygiene Assessment and Treatment V. Continuing CareDOCUMENTATIONEVERYDAY ETHICSFACTORS TO TEACH THE PATIENTREFERENCESCHAPTER OUTLINE69Wilkins9781451193114-ch069.indd 1163 07/10/15 11:40 AM 1164 SECTION IX | Patients with Special Needsmaintaining health and preventing infections and emergencies. ▶ Understand the presence of infection, including peri-odontitis, may make it more difficult to control the blood glucose levels in diabetes. ▶ Identify and treat acute emergencies.Key words and abbreviations used in this chapter are found in Boxes 69-1 and 69-2, respectively.Dental professionals have a significant responsibility to: ▶ Recognize signs and symptoms of diabetes to promote early diagnosis, significantly reduce life-threatening complications of the disease, and improve quality of life. ▶ Assess the management and control of diabetes to de-termine the impact on treatment and oral health of the patient. ▶ Work with the patient and other healthcare pro-fessionals to provide preventive oral care aimed at LEARNING OBJECTIVESAfter studying this chapter, the student will be able to:1. Describe the types of diabetes mellitus and major characteristics of each.2. Explain current knowledge about the oral health-diabetes connection.3. Describe risk factors and criteria used for diagnosis of diabetes.4. Summarize lifestyle modifications and medications used to prevent and manage diabetes.5. Identify key messages dental hygienist need to convey to patients with diabetes.Beta cells: insulin-producing cells of the islets of Langerhans in the pancreas.Brittle diabetes: term formerly used to describe very unstable type 1 diabetes; characterized by unexplained oscillation between hypoglycemia and diabetic ketoacidosis (DKA).Casual plasma glucose: blood glucose level at any time of day with no regard to time of eating.Charcot’s joints: a joint that is deprived of any pain or posi-tion sense due to severe osteoarthritis or as a result of disease such as diabetic neuropathy.Exocrine: secreting externally via a duct.Exogenous insulin: insulin from source outside patient.Gastroparesis: delayed gastric emptying. Occurs when the vagus nerve is damaged or stops functioning normally and movement of food is slowed or stopped.Gestational diabetes: diabetes that occurs during pregnancy.Gluconeogenesis: synthesis of glucose from noncarbohy-drate sources, such as amino acids and glycerol; can occur in the liver and kidneys when the carbohydrate intake is insufficient to meet the body’s needs.Glycated or glycosylated hemoglobin (HbA1c): the primary assay for assessing long-term glycemic control. Indicates blood glucose levels for the previous 2–3 months.Glycemia: presence of glucose in blood.Hyperglycemia: high blood glucose: opposite of hypoglycemia.Hyperpnea: abnormal increase in depth and rate of respiration.Hypogeusia: abnormally diminished acuteness of the sense of taste.Hypoglycemia: an abnormally low level of glucose in the blood.Insulin: a powerful hormone secreted by the beta cells in the islets of Langerhans of the pancreas; the major fuel-regulating hormone; enters the blood in response to a rise in concentration of blood glucose and is transported immediately to bind with cell surface receptors through-out the body.Ketoacidosis: diabetic coma; too little insulin; accumulation of ketone bodies in the blood. Occurs primarily in type 1 diabetes mellitus.Ketone bodies: normal metabolic products of lipid (fat) within the liver; excess production leads to urinary excre-tion of these acidic chemicals.Ketonuria: excess concentration of ketone bodies in the urine.Oral glucose tolerance test: a test of the body’s ability to utilize carbohydrates; aid to the diagnosis of diabetes mellitus. After ingestion of a specific amount of glucose solution, the fasting blood glucose rises promptly in a nondiabetic person, then falls to normal within an hour. In diabetes mellitus, the blood glucose rise is greater and the return to normal is prolonged.Oral hypoglycemic agent: synthetic drug that lowers the blood sugar level; stimulates the synthesis and release of insulin from the beta cells of the islets of Langerhans in the pancreas; used to treat patients with type 2 diabetes mellitus.Polydipsia: excessive thirst.Polyphagia: excessive ingestion of food.Polyuria: excessive excretion of urine.Postprandial: after a meal.Prediabetes: IFG (impaired fasting glucose) and IGT (im-paired glucose tolerance) are risk factors for future diabe-tes and cardiovascular disease.Pruritus: itching.Retinopathy: noninflammatory degenerative disease of the retina; called diabetic retinopathy when it occurs with diabetes of long standing.BOX 69-1 KEY WORDS: Diabetes MellitusWilkins9781451193114-ch069.indd 1164 07/10/15 11:40 AM CHAPTER 69 | The Patient with Diabetes Mellitus 1165A1c (A One C): common abbreviation for glycosylated he-moglobin (HbA1c)DKA: Diabetes ketoacidosisEMS: emergency medical serviceFPG: fasting plasma glucoseGDM: gestational diabetes mellitusHbA1c: glycosylated hemoglobinHDL: high-density lipoproteinIDDM: insulin-dependent diabetes mellitusIFG: impaired fasting glucoseIGT: impaired glucose toleranceLDL: low-density lipoproteinNIDDM: noninsulin-dependent diabetes mellitusOGTT: oral glucose tolerance testPCOS: polycystic ovarian syndromePP: postprandialSMBG: self-monitoring of blood glucoseWHO: World Health OrganizationKey of Abbreviations: Diabetes MellitusBOX 69-2Hypoglycemia Hyperglycemia ▷ Mental confusion ▷ Polyuria ▷ Sweating ▷ Polydipsia ▷ Irritability ▷ Weight loss ▷ Palpitations ▷ Polyphagia ▷ Shakiness ▷ Blurred vision ▷ Pallor ▷ Headache ▷ Seizure ▷ Coma and death (if untreated) ▷ Increased susceptibility to infections ▷ Impaired growth ▷ KetoacidosisSymptoms of Low and High Blood GlucoseBOX 69-3ORAL HEALTH IMPLICATIONS OF DIABETES MELLITUS ▶ Infection that does not respond to treatment and/or healing may be signs of undiagnosed diabetes. ▶ The patient needs to be referred to a primary care pro-vider for evaluation and diagnosis. ▶ Oral findings associated with diabetes can be found in Table 69-1.I. Relationship Between Diabetes and Periodontal Disease4 ▶ The association of diabetes mellitus with periodontal disease is hypothesized to be related to the inflammatory process involved in the pathogenesis of both diseases.A. Diabetes as a Risk Factor for Periodontitis ▶ Systematic reviews suggest patients with diabetes are at a 2–4 times greater risk for more severe periodontal disease than individuals without diabetes.4B. Effect of Periodontitis on Glycemic Control ▶ Evidence indicates individuals with diabetes had more severe periodontal disease and a higher A1c than healthy individuals.4C. Effect of Periodontal Treatment on Diabetes ▶ Nonsurgical periodontal therapy and management of periodontal disease has resulted in an average decrease in A1c of 0.6%.• This is roughly equivalent to decreases seen in physi-cal activity and weight loss intervention studies.DIABETES MELLITUSI. Definition1 ▶ Diabetes mellitus is a group of metabolic diseases asso-ciated with hyperglycemia (high blood glucose). Symp-toms of hypo- and hyperglycemia are listed in Box 69-3. ▶ Hyperglycemia results from an insulin deficiency, resis-tance to insulin action, or both. ▶ People with poorly controlled diabetes mellitus are at risk of complications including:• Blindness• Kidney failure• Heart disease• Stroke• Amputation of toes, feet, and legs.II. Diabetes Impact2,3 ▶ In the United States, 29 million people (9.3% of the population) have diabetes. Approximately 8 million or1 in 4 people with diabetes are undiagnosed.• Globally, 347 million adults (9.8% of men and 9.2% of women) have diabetes.4• In the United States, 86 million people, more than 1 in 3 adults, have prediabetes. ▶ As the population ages and with increases in obesity, diabetes has become more prevalent. ▶ Medical costs and lost work and wages for those with dia-betes is 245 billion dollars annually in the United States. ▶ The risk of death is 50% higher for individuals with diabetes compared to those without diabetes.Wilkins9781451193114-ch069.indd 1165 07/10/15 11:40 AM 1166 SECTION IX | Patients with Special Needsreduced likelihood of success of endodontic treatment in cases with preoperative periradicular lesions.IV. Dental Implants7 ▶ A meta-analysis found the failure rate for dental im-plants was similar between individuals with and with-out diabetes.• Well-controlled diabetes is not a contraindication to placement of a dental implant.BASICS ABOUT INSULINI. Definition ▶ Insulin is a hormone produced by the beta cells in the pancreas. ▶ Insulin directly or indirectly affects every organ in the body.II. Description ▶ The beta cells of the pancreas are responsible for re-leasing insulin when stimulated by nutrients, primarily glucose.8 ▶ Insulin acts like a key to unlock the cell to allow uptake of glucose to use as energy. ▶ Figure 69-1A shows the healthy pancreas and the action of insulin as it is taken up by the body cells.III. FunctionsThe functions of insulin are listed in Box 69-4. Without insulin, glucose accumulates in the blood, resulting in hyperglycemia. ▶ Normal blood glucose levels in healthy individuals range from 60 to 100 mg/dL and the hemoglobin A1c is less than 5.7%.1IV. Effects of Absolute Insulin Deficiency (Type 1 Diabetes)9Glucose increases in the circulating blood (hyperglyce-mia) until a threshold is reached and glucose spills over into the urine (glycosuria). ▶ Increased glycosuria induces osmotic diuresis with ex-cretion of large amounts of urine (polyuria). Water and electrolytes are lost. ▶ Fluid loss signals excessive thirst to the brain (polydipsia). ▶ Cells starving for glucose may cause the patient to in-crease food intake (polyphagia), but weight loss may still occur. ▶ Without glucose to use for energy, the body metabolizes fat for energy.• Management of periodontitis along with lifestyle changes may have an additive effect on lowering A1c.II. Dental Caries5 ▶ There is inadequate evidence for a direct relationship between diabetes and risk for coronal or root caries, but there is a reduction in salivary flow which puts the pa-tient at risk for dental caries.III. Endodontic Infections6 ▶ Patients with diabetes have increased periodontal disease in teeth involved endodontically and have a TABLE 69-1 Extraoral/Intraoral Findings Associated with DiabetesLOCATION FINDINGSGingiva Increased gingival inflammationPeriodontium Periodontitis: more frequent, severe, longer durationAttachment loss: more frequent, more extensiveProbing depths: more teeth with deep pocketsAlveolar bone loss: moreTooth mobility and migration: increasedHealing: delayed, increased infection after surgeryTeeth Poorly controlled diabetes: increased risk of caries related to decreased saliva, diet, and less successful resolution of endodontic therapy related to decreased resistance to infectionWell-controlled diabetes: decreased caries related to low sugar, regular eating habits, dental maintenance appointmentsSaliva Glucose in sulcular fluidXerostomia: contributes to opportunistic infection such as oral candidiasisMucosa Edematous and red colorOral candidiasisBurning mouth and/or tongue, burning mouth syndromePoor tolerance for removable prosthesesDelayed healingMay have increased prevalence of lichen planus and aphthous stomatitisTaste Hypogeusia, diminished taste perceptionNeck Acanthosis negricans is a skin condition that has a light brown to black appearance in the creases on the neck and in other areas.Wilkins9781451193114-ch069.indd 1166 07/10/15 11:40 AM CHAPTER 69 | The Patient with Diabetes Mellitus 1167VI. Insulin Complications ▶ Earlier diagnosis, improved treatment, and better in-formed patient, family, and friends have reduced the occurrence of emergency insulin complications. ▶ Constant verbal and visual contact is maintained with a patient to identify early behavioral and physical changes indicative of a developing crisis.A. Hypoglycemia/Insulin Shock ▶ Too much insulin (hyperinsulinism), which lowers level of blood glucose (hypoglycemia). ▶ Hypoglycemia is the emergency more likely to occur in the dental setting. See Box 69-3 and Table 69-2 for symptoms of hypoglycemia.• End products of fat metabolism are harmful ketones that accumulate in the blood.• Ketones are acidic, and when they accumulate, they are usually neutralized in the blood.• When large quantities of ketones are present the neutralizing effect of the blood is depleted rapidly and an acidic condition (metabolic acidosis) results.• Metabolic acidosis leads to diabetic coma (ketoaci-dosis) if not treated promptly. ▶ Figure 69-1B shows changes in pancreas function that occur in type 1 diabetes.V. Effects of Impaired Secretion or Action of Insulin (Type 2 Diabetes) ▶ Deficient insulin action results from inadequate in-sulin secretion and/or diminished tissue responses to insulin.1• Cell surface insulin receptors develop defects, and glucose cannot be transmitted into the cell.• Blood glucose level increases as the insulin resis-tance of the cells increases. This stimulates more insulin to be released. ▶ Over time, insulin secretion may also decline and lead to both decrease of insulin in the blood as well as in-creased insulin resistance of cells. ▶ Figure 69-1C shows the effects of decreased insulin and action of insulin that can occur in type 2 diabetes. Note the defective receptor on the body cell.FIGURE 69-1 Pancreas and Action of Insulin on Body Cell in Health, and type 1 and 2 Diabetes. A: Healthy pancreas excretes insulin into bloodstream that enables glucose uptake by body cell. B: Type 1 diabetes shows no insulin produced by pancreas and no glucose uptake by cell. C: Type 2 diabetes shows normal, increased, or decreased insulin production by pancreas and the defective receptor on cell that hampers insulin uptake.1. Facilitates glucose uptake from blood into tissues, which lowers blood glucose level.2. Speeds the oxidation of glucose within the cells to use for energy.3. Speeds the conversion of glucose to glycogen to store in the liver and skeletal muscles and to prevent the con-version of glycogen back to glucose.4. Facilitates conversion of glucose to fat in adipose tissue.Functions of InsulinBOX 69-4Wilkins9781451193114-ch069.indd 1167 07/10/15 11:40 AM 1168 SECTION IX | Patients with Special Needs ▶ Individuals with a longer duration of diabetes and his-tory of severe hypoglycemia are more likely to experi-ence hypoglycemic events.9B. Hyperglycemic Reaction/Diabetic Coma (Ketoacidosis) ▶ Too little insulin (hypoinsulinism) with increased lev-els of blood glucose (hyperglycemia). ▶ Table 69-2 lists a comparison of the characteristics of hyperglycemic and hypoglycemic reactions, along with the respective treatment procedures.CLASSIFICATION OF DIABETES MELLITUS ▶ Classification is based on the etiology of the disease.TABLE 69-2 Comparison of Hypoglycemia (Insulin Shock) and Hyperglycemia (Diabetic Coma)HYPOGLYCEMIA/INSULIN SHOCK DIABETIC COMA/KETOACIDOSISHistory/ predisposing factorsToo much insulinToo little food: omitted or delayedExcessive exerciseStressToo little insulin: omission of dose or failure to increase dose when requirements increasedToo much foodLess exercise than plannedInfection, illness of any sortTrauma, drugs, alcohol abuseStressOccurrence More common complication than ketoacidosis, especially with less stable type 1 diabetesType I diabetes especially if poorly controlled, unstableOnset Sudden Develops slowly over hours/daysBehavioral changesConfusion, stuporDrowsy, restlessAnxious, irritable, agitatedIncoordination, weaknessAny hypoglycemia behavioral changePhysical findings Skin: moist, sweaty, perspirationHungerHeadacheTremor, shakiness, weaknessPallorDilated pupils, blurry visionDizziness, staggering gaitSkin: flushed, dryAbdominal painNausea, vomitingLack of appetiteDry mouth, thirstFruity smelling breathIncreased urinationVital signs Temperature: Normal or belowRespiration: NormalPulse: Fast, irregularBlood Pressure: Normal or slightly elevatedTemperature: Elevated when infectionRespiration: Hyperpnea, rapid, and labored with acetone or fruity smelling breathPulse: Rapid, weakBlood Pressure: Lowered, person may go into shockIf left untreated Possible convulsions, eventual coma and death Eventual coma and deathTreatment Glucose gel (15–20 g) is the preferred treatment for the conscious individual with hypoglycemiaAfter 15 min of treatment, if SMBG shows continued hypoglycemia, the treatment should be repeated. Once SMBG returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemiaIf unconscious/unresponsive: injection of glucagon or intravenous glucoseImmediate professional careActivate EMS, hospitalizeMonitor vital signsKeep patient warmFluids for conscious patientInsulin injection after medical assessmentPrevention Monitoring and regulation of blood sugar and frequent blood glucose monitoringMonitoring and regulation of blood sugar and frequent blood glucose monitoringWilkins9781451193114-ch069.indd 1168 07/10/15 11:40 AM CHAPTER 69 | The Patient with Diabetes Mellitus 1169 ▶ The type of diabetes is based on the circumstances at the time of diagnosis, such as gestational diabetes dur-ing pregnancy.1• Patients often do not fit into a single classification of diabetes so the focus needs to be on the pathogenesis and management of the hyperglycemia.1 ▶ A comparison of type 1 and 2 diabetes is found in Table69-3.I. Type 1 Diabetes Mellitus1A. Description ▶ Figure 69-1B illustrates the changes in type 1 diabetes. ▶ Results from the destruction of insulin-producing beta cells in the pancreas for one of the following reasons:• Autoantibodies• No known etiology. ▶ An absolute insulin deficiency requires exogenous insu-lin to sustain life. ▶ Patients are prone to ketoacidosis. ▶ Typically arises in childhood or adolescence. ▶ Individuals with other autoimmune disorders such as Graves’ disease or Hashimoto’s thyroiditis are prone to development of type 1 diabetes. ▶ Accounts for 5%–10% of those with diabetes.TABLE 69-3 Comparison of Type I and Type 2 Diabetes MellitusCHARACTERISTIC TYPE 1 TYPE 2Age of onset Young, usually before or during puberty, but may appear laterAdult, usually after 30 years, but may occurring with increasing frequency in children and adolescentsBody weight Normal or thin Most are obese, body fat particularly in abdominal areaEthnicity More common in Caucasians More common in African Americans, Asian Americans, Hispanics, Native Americans, Pacific IslandersHereditary Yes, but less frequent occurrence than type 2 Much more frequent occurrence in familiesLifestyle Restrictions very difficult for young patients More frequent in sedentary individuals with high-fat dietsOnset of symptoms Rapid, abrupt symptoms of hyperglycemia Slow, insidious progression over years, frequently goes undiagnosed for yearsSymptoms Weight loss, weaknessPolyuriaFrequent/recurrent infectionsPolydipsia slow healingPolyphagiaTingling/numb extremitiesBlurred visionFatigueMimic fluEye/kidney/cardiovascular problemsAny type 1 symptomSeverity Severe, life threatening Early mild but progressively seriousComplications Acute hypoglycemic/hyperglycemic emergencies and chronic long-term complications commonAcute complications rare, chronic long-term complications commonKetoacidosis Common RareStability Unstable, difficult and much effort to control More stable, easier to manageInsulin No insulin production, exogenous insulin required Insulin levels normal, elevated, or low; exogenous insulin needed by somePrevention None, due to multiple genetic predispositions and unclear environmental factorsMay be possible to prevent or delay with lifestyle changes, increased activity, and weight lossWilkins9781451193114-ch069.indd 1169 07/10/15 11:40 AM 1170 SECTION IX | Patients with Special NeedsB. Former NamesInsulin-dependent diabetes mellitus (IDDM), juvenile diabetes, or juvenile-onset diabetes.II. Type 2 Diabetes Mellitus1A. Description ▶ Figure 69-1C shows changes that occur in Type 2 diabetes. ▶ Most prevalent type of diabetes, accounts for 90%–95% of all patients with diabetes. ▶ Pancreatic insulin secretion may be low, normal, or even higher than normal, but the patient exhibits an insulin resistance that impairs the use of insulin.• Insulin resistance is the inability of the peripheral tissues to respond to insulin. ▶ The risk increases with increased number of risk factors. ▶ Onset typical occurs in adulthood and the risk increases with age. ▶ However, incidence has increased dramatically in chil-dren and adolescents due to increases in sedentary life-style and obesity.10• In children the typical age at diagnosis is >10 years to late adolescence.B. Screening6 ▶ Type 1 diabetes is usually identified after acute symp-toms of hyperglycemia (Box 69-3) prompt evaluation. ▶ Screening in asymptomatic adults is recommended for prediabetes and type 2 diabetes. Basic criteria for test-ing in healthcare setting:• Age 45 and above, repeated every 3 years or more frequently.• Screening begins earlier and more frequently if the patient is overweight or obese (body mass index (BMI) > 25 kg/m2) and has other risk factors.• When tests are normal, they are repeated at least every 3 years.C. Former Names ▶ Noninsulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes.III. Gestational Diabetes Mellitus (GDM)6 ▶ The prevalence is as high as 9.2% of pregnancies in the United States and as high as 15% worldwide.11,12 ▶ Defined as any degree of glucose intolerance first recog-nized during pregnancy. ▶ Onset is related to genetics, obesity, and hormones causing insulin resistance. ▶ Insulin adjustment, carefully supervised prenatal care, and improved obstetric practices have lessened much of the potential danger for the mother. ▶ Infants are larger; premature births more frequent; high incidence of congenital malformations and perinatal death; and lower rate with improved prenatal care. ▶ More than 50% of women with GDM go on to develop type 2 diabetes within 5–10 years.11IV. Other Specific Types of Diabetes Mellitus1Other types of diabetes result from genetic defects, dis-eases, endocrinopathies, surgery, drugs, malnutrition, in-fections, and injury. ▶ Genetic defects of the beta cell. ▶ Genetic defects in insulin action. ▶ Diseases of the pancreas that injure or destroy beta cells.• Include pancreatitis, trauma, pancreatectomy, carci-noma, cystic fibrosis. ▶ Endocrinopathies such as Cushing’s syndrome cause an increase in hormones that antagonize insulin.• These hormones include growth hormone, cortisol, and glucagon. ▶ Drug or chemicals may impair insulin secretion, impair insulin action, or destroy beta cells, and precipitate diabetes.• These drugs include: glucocorticoids, thyroid hor-mone, dilantin, thiazides. ▶ Certain viruses are associated with destruction of beta cells.• These viruses include: congenital rubella, cytomega-lovirus, and mumps. ▶ Uncommon forms of immune-mediated diabetes. ▶ Other genetic syndromes sometimes associated with diabetes include Down syndrome, Huntington’s chorea, Prader–Willi syndrome.DIAGNOSIS OF DIABETESI. Diabetes SymptomsCareful review of the medical history with follow-up questions is used to identify risk factors and symptoms (Table69-3) of diabetes. ▶ The classic symptoms of diabetes include the 3 P’s:• Polyphagia (excessive hunger)• Polydipsia (excessive thirst)• Polyuria (excessive urination)II. Diagnostic Tests1Criteria for diagnosis of diabetes include the following:A. Glycated Hemoglobin Assay (HbA1c or A1c) ▶ The A1c measures the quantity of the end product of high glucose bound to a hemoglobin molecule (gly-cated hemoglobin).Wilkins9781451193114-ch069.indd 1170 07/10/15 11:40 AM CHAPTER 69 | The Patient with Diabetes Mellitus 1171• Screening may also include point-of-care A1c testing using fingersticks or gingival crevicular bleeding.14–16II. Prediabetes ▶ Individuals who have blood glucose levels above nor-mal, but do not meet the criteria for diagnosis of diabe-tes are considered to have prediabetes.• Prediabetes means the individual is at high risk for developing diabetes.• Lifestyle changes such as being physically active, achieving a healthy weight, and making healthy food choices are recommended.• The most frequent medication used to manage the blood glucose level is metformin.STANDARDS OF MEDICAL CARE FOR DIABETES MELLITUS9 ▶ Medical management depends on the severity of the disease and on the individual.• Consideration is given to individualized needs re-lated to age, activities, vocation, lifestyle, knowl-edge, attitudes, personality, culture, emotional and psychological needs, as well as the health status and nutritional and weight issues of the patient.I. Early Diagnosis ▶ Identify individuals with prediabetes and undiagnosed diabetes. ▶ Assess risk factors and refer for evaluation.II. Management of Prediabetes ▶ The Diabetes Prevention Program demonstrated life-style changes including: physical activity, attaining and maintaining a healthy weight, and making wise food choices are effective in preventing or delaying the on-set of diabetes.17III. Diabetes Self-management Education ▶ The National Standards for Diabetes Education and Support guidelines indicate diabetes self-management education is essential for those at risk for developing diabetes as well as for those individuals who are newly diagnosed.18 ▶ Maintain tight glycemic control to reduce the compli-cations of diabetes through regular self-monitoring of blood glucose (SMBG) at home.• Glucose meter (or glucometer) is used at home (and in the dental office). A fingerstick is used to obtain a drop of blood for measurement of blood glucose. ▶ A1c value provides an average of blood glucose levels over a 2–3 months period. ▶ The HbA1c test is used to diagnose prediabetes and diabetes.• Prediabetes is diagnosed with an A1c value from 5.7 to 6.4%.• A1c > 6.5% is used to diagnose diabetes. ▶ The A1c is also used to monitor diabetes control.• Testing is recommended twice per year for individu-als with good glycemic control.• Patients with unstable glycemic control may require testing every 3 months. ▶ A1c goal may vary slightly for an individual based on risk for hypoglycemia, but the goal for most nonpreg-nant adults is <7%.B. Fasting Plasma Glucose (FPG)Measurement taken after fasting at least 8 hours. ▶ FPG of 100 to 125 mg/dL is used to diagnose prediabetes. ▶ FPG > 126 mg/dL is the criterion used for diagnosis of diabetes. ▶ Repeat testing is recommended to confirm a diagnosis.C. 2-hour Plasma Glucose $200 mg/dLTypically taken during an oral glucose tolerance test (OGTT). ▶ Repeat testing is recommended to confirm a diagnosis.IDENTIFICATION OF INDIVIDUALS AT RISK FOR DEVELOPMENT OF DIABETES9I. Risk Factors ▶ Adults at risk for diabetes include those who are over-weight with a BMI > 25kg/m2 and have other risk fac-tors such as:• Physical inactivity.• First degree relative with diabetes.• High risk race/ethnicity such as African American, Hispanic, Native American, Asian, Pacific Islander.• Women who have delivered a baby weight over 9 pounds or had gestational diabetes during pregnancy.• Hypertension (>140/90 mm Hg) or taking antihy-pertensive medications.• Women with polycystic ovarian syndrome (PCOS).• History of cardiovascular disease.• A1c > 5.7%, IGT (impaired glucose tolerance), or IFG (impaired fasting glucose). ▶ Dental visits provide an opportunity to screen patients for undiagnosed diabetes (see Figure 69-2).13• A type 2 diabetes risk test is available on the Ameri-can Diabetes Association website and could be used chairside in the dental office for screening.Wilkins9781451193114-ch069.indd 1171 07/10/15 11:40 AM 1172 SECTION IX | Patients with Special NeedsFIGURE 69-2 Diabetes Risk Test. Are you at risk for type 2 diabetes screening tool. (Source: Copyright 2009 American Diabetes Association. From http://www.diabetes.org. Reprinted by permission of The American Diabetes Association.)Wilkins9781451193114-ch069.indd 1172 07/10/15 11:40 AM CHAPTER 69 | The Patient with Diabetes Mellitus 1173• Carbohydrate intake needs to be balanced through-out the day and focus on vegetables, fruits, whole grains, beans, and low-fat dairy.• Similar to the Dietary Guidelines for Americans, in-dividuals with diabetes need to limit or avoid added sugar and refined carbohydrates.• Limit intake of saturated fat, trans fat, and cholesterol.• Recommendations for sodium intake are the same as for the general population (see section on Dietary Standards in Chapter 35).V. Physical Activity ▶ Adults are encouraged to engage in 150 minutes per week of moderate-intensity physical activity spread over at least 3 days/week. ▶ Contributes to lowering insulin requirements by in-creasing the muscle sensitivity to insulin.VI. HabitsA. Tobacco ▶ Patient must avoid all types of tobacco (see the section on Tobacco Cessation in Chapter 34).• Tobacco use increases risk of heart disease, stroke, myocardial infarction, limb amputations, periodon-tal disease, and numerous other health problems.B. Alcohol ▶ Avoid excessive alcohol; alcohol can raise blood pres-sure and contribute to other health problems.PHARMACOLOGICAL THERAPYI. Insulin TherapyAll patients with type 1 diabetes require exogenous insulin for survival. Type 2 patients may need to use insulin for control. Insulin available in the United States is manufac-tured in a laboratory.A. Types of InsulinInsulin is classified as rapid acting, regular or short act-ing, intermediate acting, or long acting based on the on-set, peak, and duration of action. The types of insulin and range of peak action are found in Table 69-4.B. DosageDepends on the individual. ▶ Objective: Attain optimum utilization of glucose throughout each 24 hours. ▶ Factors affecting the need for insulin: Food intake, illness, stress, variations in exercise, or infections. ▶ “Sick Day Rules:” Insulin dose is adjusted if there are any factors that are affecting the need for insulin.• Frequency and timing is individualized to patient needs, but is often recommended before breakfast, prior to meals, and prior to bedtime.• More frequent monitoring is associated with better glycemic control and a lower A1c. ▶ Individuals with type 1 diabetes who are prone to dia-betic ketoacidosis (DKA) may monitor for urinary ke-tones with test strips.• Urinary ketone testing is used during illness, stress, and vigorous physical activity. It can be performed by patient at home or analyzed in a laboratory.A. Interprofessional Healthcare Team ▶ Initial and ongoing individualized education is pro-vided by the interprofessional team.• Members include physicians, registered nurses, nurse practitioners, physician assistant, registered dietitian nutritionists, pharmacists, mental health profession-als, dental professionals, and other specialists, such as endocrinologist, cardiologist, ophthalmologist, and podiatrist.B. Educational Resources ▶ Books and journals: A number of excellent books, profes-sional journals, and other printed materials have been prepared for the patient and for health professionals.• Annually the American Diabetes Association pub-lishes evidence-based Clinical Practice Recommen-dations in the Diabetes Care journal. These can be accessed free of charge on www.diabetes.org. ▶ Internet: Access to diabetes education and support re-sources continues to expand rapidly (review strate-gies to determine validity of information on websites in Chapter 2). In addition to static websites, the in-ternet provides interactive resources that include the following19:• Interactive behavior change programs.• Peer support through blogs, email, chat rooms, and so on. ▶ Technology: Cell phone applications for tracking food in-take, physical activity, weight, blood glucose, and blood pressure can be used to assist the individual with self-monitoring and can be shared with the healthcare team.20IV. Medical Nutrition Therapy9 ▶ Medical nutrition therapy is individualized to meet the needs of the patient to manage and control diabetes. ▶ The American Diabetes Associations recommends nu-trition therapy be provided by a registered dietitian/ nutritionist or certified diabetes educator. ▶ Goals for medical nutrition therapy include:• Energy balance for modest weight loss (5–10 pounds) and weight maintenance.Wilkins9781451193114-ch069.indd 1173 07/10/15 11:40 AM 1174 SECTION IX | Patients with Special Needs• Dual therapy (combination of two antidiabetic med-ications) for an A1c >7.5%.• Triple therapy for an A1c >9%. ▶ The take away message for dental professionals is that when a patient is on multiple medications, it means the diabetes is not well controlled.C. Methods for Insulin Administration ▶ Subcutaneous injection with syringe: A syringe is filled from vial of insulin. Injection sites are rotated usually on abdomen, thighs, or upper arm. ▶ Insulin pen: Prefilled cartridge of single type of insulin injected with attached needle. May be disposable or a reusable type. ▶ Continuous subcutaneous insulin infusion with a battery-operated insulin pump:• The insulin pump delivers preprogrammed continu-ous basal rate of insulin and bolus doses when needed.• Offers greater flexibility, smoother control of glyce-mia, but may increase the risk of hypoglycemia.• The small cellphone-sized pump can be worn in a pocket or on a belt or waistband, as shown in Figure69-3. ▶ Inhalable insulin:21• Short-acting, “mealtime” insulin is taken through an inhaler.• Side effects include lower lung function, cough, dry mouth, or chest discomfort.• Brand name Afrezza. ▶ Future modes for insulin administration include an in-sulin patch, and implantable insulin pumps.II. Oral Antidiabetic MedicationsOral medications are commonly used to treat type 2 dia-betes in conjunction with diet, exercise, and possibly the injection of insulin. ▶ The medications, listed in Table 69-5, may be used in-dividually or in combinations. ▶ The American Association of Clinical Endocrinolo-gists (AACE) recommends the following in addition to lifestyle modifications22:• The most common medications used in prediabetes is metformin.• Monotherapy (one antidiabetic medication) for in-dividuals with an A1c between 6.5% and 7.5%.TABLE 69-4 Types and Action of InsulinCLASS OF INSULIN TYPE/NAME PEAK ACTION DURATIONRapid acting Lispro (Humalog), Aspart (NovoLog) 1 hr 2–4 hrRegular or short acting Humulin R, Novolin R 2–3 hr 3–6 hrIntermediate acting NPH (Humulin N, Novolin N) 4–12 hr 12–18 hrLong acting Detemir (Levemir), Glargine (Lantus) 24 hr 24 hrInhaled Afrezza 15 minFIGURE 69-3 Patient Wearing Insulin Pump. Young boy with active lifestyle wear-ing an insulin pump. Photo courtesy of Minimed.Wilkins9781451193114-ch069.indd 1174 07/10/15 11:40 AM CHAPTER 69 | The Patient with Diabetes Mellitus 1175TABLE 69-5 Oral Hypoglycemic Agents Used for Treatment of Type 2 DiabetesAGENT EXAMPLE ACTION/FUNCTIONBiguanides Metformin (Glucophage) Prevents liver glycogen breakdown to glucose Increases tissue sensitivity to insulinSulfonylureas Glyburide (Diabeta, Mcronase)Glipizide (Glucotrol) Stimulates pancreas to release more insulin after a meal May cause hypoglycemiaMeglitinides Repaglinide (Prandin)Nateglinide (Starlix) Stimulates pancreas to release more insulin after a meal May cause hypoglycemiaThiazolidinediones Pioglitazone (Actos) Increases tissue sensitivity to insulinDipeptidyl peptidase-4 inhibitors Sitagliptin (Januvia) Improves insulin level after meals and lowers glucose productionAlpha-glucosidase inhibitors Acarbose (Precose) Slows digestion and absorption of glucose into bloodstream after eatingCOMPLICATIONS OF DIABETES9Patients with well-controlled blood glucose levels tend to develop fewer complications later in life than those whose diabetes is less well controlled.23I. Infection ▶ Patients are more susceptible to infections and impaired healing, which can worsen prognosis. ▶ Presence of stress, trauma, and infection affects blood glucose levels. ▶ Failure to treat an infection intensifies the symptoms and increases severity of diabetes; can progress to life-threatening infections or precipitate diabetic coma. ▶ Insulin requirements may increase with fever, infection, inflammation, trauma, bleeding, pain, or stress. When the condition is eliminated, prescribed insulin may be reduced. ▶ Numerous factors are involved including impaired immune response, alterations in metabolism of carbo-hydrate and protein, vascular changes and impaired cir-culation, and altered nutritional state.II. Neuropathy ▶ Neuropathy can cause pain, numbness, or tingling of mouth, face, and extremities.A. Peripheral Neuropathy ▶ Symptoms vary based on the sensory nerve fibers af-fected and may result in loss of sensation in the feet, hands, and fingers. ▶ Numbness in the hands and fingers may make effective oral self-care difficult. ▶ As many as 50% of people with peripheral neuropathy may be asymptomatic and not recognize the loss of sen-sation which can put them at risk for injury and result-ing infection. ▶ Leads to increased incidence of amputations and Char-cot’s joints.B. Autonomic Neuropathy ▶ Manifestations include tachycardia, orthostatic hypoten-sion, gastroparesis, and an hypoglycemic unawareness.• Cardiovascular autonomic neuropathy can be symp-tomatic other than changes in heart rate.• Gastroparesis is a slowing of digestion and motility of the gastrointestinal tract.• Hypoglycemic unawareness can quickly become an emergency situation because the patient is not able to recognize the usual symptoms of low blood glucose.III. Nephropathy ▶ Diabetes is a leading cause of renal disease, and the most common cause of end-stage renal disease in the United States and Europe. Dialysis or kidney transplant is needed. ▶ Patients diagnosed with diabetes are screened for mi-croalbuminuria (protein in the urine).IV. Retinopathy ▶ Diabetes is a leading cause of blindness through the progression of diabetic retinopathy. ▶ Patients are more likely to have glaucoma and cataracts.Wilkins9781451193114-ch069.indd 1175 07/10/15 11:40 AM 1176 SECTION IX | Patients with Special NeedsDENTAL HYGIENE CARE PLAN ▶ The control of oral infection is vital. Infections can progress more quickly and can alter the management of diabetes. ▶ Frequent, thorough oral care requires the patient’s utmost cooperation and motivation and regular professional care. ▶ The patient with diabetes is prone to life-threatening emergencies. ▶ Emergency practice drills can help the dental team pre-vent an emergency, identify early indications of a de-veloping emergency, and act swiftly and appropriately.I. Appointment PlanningStress, including that created during a dental or dental hygiene appointment, can affect blood sugar levels. Appointment planning centers around many factors, including stress prevention.A. Antibiotic Premedication ▶ Well-controlled diabetes: In general, the patient with well-controlled diabetes is treated the same as the pa-tient without diabetes and requires no premedication related to diabetes. ▶ Uncontrolled, unstable diabetes: Routine dental treat-ment is deferred until diabetes is stabilized. Only emer-gency care is given to the uncontrolled patient. Consult patient’s primary provider to determine if antibiotic premedication is needed.B. Time ▶ Treat patient after a meal, preferably with protein and fat to slow carbohydrate absorption. ▶ Avoid peak insulin level noted in Table 69-4. ▶ Ideal time of appointment varies with individual pa-tient’s lifestyle and method of insulin intake. ▶ Preferred appointment may be morning, soon after the patient’s normal breakfast and medication, during the ascending portion of the blood glucose level curve.C. Precautions: Prevent/Prepare for Emergency ▶ Do not keep the patient waiting. ▶ Do not interfere with the patient’s regular meal and between-meal eating schedule. ▶ Avoid long, stressful procedures; dental and dental hy-giene care can be divided into short appointments ap-propriate to the individual’s needs. ▶ Take additional precautions indicated for the patient with long-term diabetes with complications related to atherosclerosis and other cardiovascular diseases (see Chapter 67). ▶ Prevent and treat all infections promptly.V. Cardiovascular Disease ▶ Individuals with diabetes are at high risk for cardio-vascular disease, a major cause of morbidity and mor-tality. Conditions common in people with diabetes include:• Hypertension.• Dyslipidemia (high total cholesterol and low-density lipoproteins).• Hypertriglyceridemia (high triglycerides). ▶ May lead to myocardial infarction and stroke. ▶ Owing to the excessive risk of coronary heart disease, aggressive treatment for dyslipidemia and hypertriglyc-eridemia is recommended. ▶ Low-dose aspirin therapy may be recommended for the prevention of cardiovascular disease in patients with di-abetes. Daily aspirin intake may increase bleeding time.VI. AmputationDiabetes is a major cause of limb amputation (usually foot) from possible complications of neuropathy and vascular disease.VII. Pregnancy ComplicationsPatients with diabetes are at higher risk for spontaneous miscarriages, having babies with birth defects, and in-creased weight.VIII. Psychosocial Aspects ▶ Due to complications of diabetes, the daily life of the patient as well as those close to the patient is signifi-cantly affected. ▶ Treatment regimens may be challenging to cope with and lead to emotional and social problems, including depression. ▶ A suggestion for the patient to discuss psychosocial is-sues with the physician may improve patient’s compli-ance with treatment and daily oral personal care.TABLE 69-6 Comparison of Average Blood Glucose and A1c9Mean Plasma GlucoseA1c (%) mg/dL mmol/L6 126 7.07 154 8.68 183 10.19 212 111.8Wilkins9781451193114-ch069.indd 1176 07/10/15 11:40 AM CHAPTER 69 | The Patient with Diabetes Mellitus 1177FIGURE 69-4 Managing Hypoglycemia (Rule of 15s). Flowchart to show steps to take when patient exhibits symptoms of hypoglycemia (insulin shock).Managing Hypoglycemia (Rule of 15s)Immediately recognizesymptoms of hypoglycemiaDiscontinue treatmentsit patient upright in dental chairFor conscious patient, apply the 15/15 RuleHave patient consume 15 grams of carbohydrate• Tube of glucose gel (preferred)• 3 glucose tablets• Half cup (4 ounces) fruit juice or regular soda• 1 tablespoon sugarWait 15 minutes and test blood glucose withglucometer.If blood glucose still <70 mg/dL, give another15 grams of carbohydrate.For unconscious patient, ACTIVATEEMERGENCY MEDICAL SYSTEM (EMS)• Place in supine position• Provide basic life support• Dentist may administer intramuscular injection of glucagon from Emergency Kit• EMS transport to hospital If blood glucose still <70 mg/dL, ACTIVATEEMERGENCY MEDICAL SYSTEM (EMS)Wait 15 minutes and test blood glucose withglucometer.If the patient has recovered, have the patient eata snack with carbohydrate and protein such as: • Crackers and cheese • Crackers and peanut butter • Part of a sandwichto stabilize the blood glucose until the next meal. ▷ Have you ever been diagnosed with prediabetes, borderline diabetes or diabetes?Yes No ▷ Have any members of your family ever been diagnosed with diabetes?Yes No ▷ Do you urinate frequently? How many times per day?Yes No ▷ Are you frequently thirsty?Yes No ▷ Does your mouth feel dry?Yes No ▷ Have you had any unexplained weight loss?Yes No ▷ Do you experience excessive hunger?Yes No ▷ Do you had recent blurred vision?Yes No ▷ Gather detailed information on all current prescribed and over-the-counter medications, including recommended dose. ▷ Gather information on vitamins, homeopathic, or herbal supplements.Common Medical History Questions to Screen for DiabetesBOX 69-5Wilkins9781451193114-ch069.indd 1177 07/10/15 11:40 AM 1178 SECTION IX | Patients with Special Needs ▷ When was your last visit to your diabetes care healthcare provider?Answer: It is recommended individuals with stable glycemic control be seen twice/year and those with poor glycemic control at least quarterly. ▷ What medications and dose have you taken today?Answer: Medications need to be taken prior to the appointment and patient knowledge about medications suggests per-sonal responsibility for diabetes self-care. ▷ When did you eat last? What did you eat?Answer: Foods containing complex carbohydrates and protein and/or fat 1–2 hour before the appointment to prevent hy-poglycemia is ideal. ▷ Do you monitor your blood sugar at home?Answer: Yes, SMBG is critical for diabetes self-care. ▷ How often do you monitor your blood glucose?Answer: Those taking multiple doses of insulin need to check the blood glucose levels 3 or more times daily. Once or twice daily is typical for those using oral medications. ▷ What is your usual fasting blood sugar in the morning?Answer: Glucose levels between 90 and 130 mg/dL premeal and below 180 mg/dL 2 hours postmeal. ▷ What is your hemoglobin A1c? How often does your primary care provider check the A1c?Answer: About <7% and preferably <6.5%; A1c testing recommended twice/year in those with good glycemic control and quarterly in those with poor control. ▷ (If the patient reports poorly controlled diabetes) Are you experiencing frequent urination?Answer: Response of “yes” may indicate hyperglycemia and poor diabetes control and requires referral. The patient will not heal and it is best to postpone treatment as healing will be suboptimal. ▷ Do you have frequent episodes of hypoglycemia (low blood sugar)? Can you tell when your blood sugar is getting low?Answer: Response of “yes” to the first question and “no” to the second identifies a patient at risk for a medical emergency. Hypoglycemic unawareness occurs as a result of neuropathy and the patient is no longer able to identify when the blood sugar has dropped to dangerously low levels. ▷ (For those with a history of hypoglycemia, ask this question) What time of day does it usually happen and how do you treat it?Answer: If the appointment is during a critical time of day for hypoglycemia, precautions need to be taken to prevent and treat it or the appointment can be rescheduled. Mid-afternoon is typically when some types of insulin and oral medications reach their peak action and glucose from the midday meal reaches a low resulting in a dangerous combination putting the patient at risk for hypoglycemia. ▷ Have you been hospitalized for hypoglycemia?Answer: Response of “yes” indicates extreme risk and preparation needs to be made to rapidly treat hypoglycemia. Place a glucometer and glucose source near treatment area for quick access. ▷ Are you having problems with your eyes, feet, hands, or legs? If so, what kind of problems are you experiencing?Answer: A patient experiencing complications may be poorly controlled and a medical consult is advised.Adapted from Boyd LD. Commentary on survey of diabetes knowledge and practices of dental hygienists. Access. 2008;22(8):40–43.Questions to Ask a Patient with Diabetes to Gather Additional InformationBOX 69-6 ▶ Prepare for hypoglycemia emergency. Keep a package of glucose gel for the conscious patient as part of the office emergency supplies. ▶ Monitor for symptoms of hypoglycemia including: diz-ziness, sweating (diaphoresis), mental confusion, shaki-ness, pallor, palpitations, and irritability.D. Emergency Management ▶ Recognize any change in patient behavior that signals a diabetes emergency.• If in doubt, it is safer to treat for hypoglycemia since it will only cause a brief increase in blood glucose.• Follow the Rule of 15s (see the flowchart in Figure69-4 for management of hypoglycemia).9II. Patient HistoryA. Refer for Early Diagnosis ▶ Questions regarding signs and symptoms of diabetes are included in a standard medical history questionnaire. Appropriate questions to ask are listed in Box 69-5.• The American Diabetes Association Diabetes Risk Test (Figure 69-2) can also be used to identify those at risk.Wilkins9781451193114-ch069.indd 1178 07/10/15 11:40 AM CHAPTER 69 | The Patient with Diabetes Mellitus 1179V. Continuing Care ▶ Appointment for supervision and examination on regu-lar 3- to 6-month basis as needed. Effectiveness of daily oral self-care is evaluated. ▶ Probe carefully to detect early bleeding on probing and evidence of pocket formation. ▶ Assess soft tissue with attention to areas of irritation related to fixed and removable prostheses. ▶ Identify any changes requiring consultation or refer-ral to patient’s primary care provider, dietitian, mental health professional, or other specialist. ▶ Check for dental biofilm control and review control with the patient at each appointment. Gingival health is of major importance. Keep the patient motivated.DOCUMENTATION ▶ Record status of blood glucose control, includ-ing most recent HbA1c and other daily monitoring such as fasting blood glucose levels the patient has performed. ▶ Update current medications and doses. ▶ Confirm compliance of medication intake and food consumption. ▶ If an unexplained positive response is present suggest-ing symptoms of diabetes, the patient is referred to a primary care provider for evaluation.B. Medical History ▶ Supplement the basic medical history with additional questions to obtain information about diabetes (sug-gested questions along with answers can be found in Box 69-6). ▶ Ask about exercise and tobacco use; review effect on health. ▶ Update medical history at each appointment. ▶ Identify health problems or complications of diabetes that may influence dental treatment. Refer to specialist when indicated.III. Consultation with Primary Care Provider ▶ Consultation with the primary care provider to obtain A1c values can be initiated either prior to or at the first visit.• Table 69-6 provides a conversion for the A1c to av-erage blood glucose levels. ▶ Further consultation may be necessary in more advanced periodontal disease to obtain clearance for treatment.IV. Dental Hygiene Assessment and TreatmentA. Extraoral/Intraoral Examination ▶ Acanthosis negricans appears as a light brown to black discoloration of the skin in the creases of the neck and can indicate risk for diabetes (Figure 69-5).B. Dental Biofilm Control Instruction ▶ Because of the impact of diabetes on periodontal health and the effect of oral infection on diabetes status, daily meticulous oral self-care is crucial. ▶ Disclosing the biofilm and individualized self-care mea-sures for biofilm control are reviewed continuously.C. Tobacco Cessation ▶ Refer to the information on Tobacco Cessation Pro-grams in Chapter 34.D. Instrumentation ▶ Nonsurgical periodontal therapy: Definitive nonsurgical periodontal therapy reduces the possibility of periodon-tal abscess formation. Allow several short appointments if needed for stress management. ▶ Healing: Avoid undue trauma to tissues to minimize the risk for complications associated with healingE. Fluoride Application ▶ Fluoride treatments, varnishes, and home use of fluo-ride are encouraged, particularly with xerostomia. ▶ Methods for daily self-fluoride application are described in Chapter 36.FIGURE 69-5 Acanthosis Negricans. This skin condition is seen in patients at risk for diabetes and typically appears on the creases in the neck as a light brown to black discoloration.Wilkins9781451193114-ch069.indd 1179 07/10/15 11:40 AM 1180 SECTION IX | Patients with Special NeedsExample Documentation: Patient with Diabetes MellitusS – A 66-year-old Hispanic female who presents for a peri-odontal maintenance. She reports bleeding when she flosses for the last couple weeks. She was recently diag-nosed with type 2 diabetes and is taking Metformin and Glipizide. Her initial HbA1c was 8.5 and she will have a follow-up test next month. She reports checking her blood glucose when she gets up in the morning and be-fore dinner. Her fasting blood glucose this morning was 120. Patient reports taking her medications this morning.O – Blood pressure: 131/79. Pulse: 88. Respirations 24. Risk as-sessment for caries was moderate, periodontal disease was high, and oral cancer was moderate. Periodontal examination reveals localized bleeding on probing and 1–2 mm pocket depth increases primarily in maxillary molar areas. Biofilm score: 30%. No new dental caries.A – Moderate localized chronic periodontitis, complicated by poorly controlled diabetes mellitus.P – Discussed the association of periodontal infection with diabetes and need for meticulous oral self-care and regular professional periodontal maintenance appoint-ments. Reviewed use of interdental brushes for molar areas where biofilm was located. Patient had difficulty removing biofilm on the lingual line angles of the molars so careful wrapping of the floss was also reviewed. Com-plete periodontal debridement was performed. Applied 5% sodium fluoride varnish and provided a prescription for 0.12% chlorhexidine gluconate mouthrinse to use twice a day for 2 weeks to assist with healing.Signed: _____________________________________, RDHDate: _______________________________________BOX 69-7Ed, a 45-year-old restaurant owner, presents for an ap-pointment with Susan, the dental hygienist. She has treated this patient before but he has not had an ap-pointment for more than 2 years. The review of his medi-cal history determines he is obese, complains of a dry mouth, has excessive thirst, gets up at night multiple times to urinate, and has not seen his primary care pro-vider in several years. An intraoral examination reveals candidiasis on his hard palate. Susan suggests that he see his physician, but he refuses to even talk about it. He insists that he just wants “clean teeth” for his daughter’s upcoming wedding.Questions for Consideration1. Describe how each of the dental hygiene ethical core values (Table II-1, Section II) apply to this scenario.2. In what ways will Susan be violating the patient’s rights if she agrees to Ed’s request that she focus only on “clean-ing” his teeth at this appointment? How may she be vio-lating his rights if she refuses to clean his teeth unless he first has an examination with his primary care provider?3. Explain choices or alternative actions Susan can con-sider as she decides how to continue treatment during Ed’s appointment.EVERYDAY ETHICSFactors to Teach Patients with Diabetes ▷ Importance of regular medical and dental care, eye examinations, blood pressure checks, blood tests for cholesterol, lipids, and kidney readings, and prac-tice self-examination, particularly of feet, for nerve involvement or delayed healing visits to prevent complications. ▷ Connection between oral health and diabetes and need for meticulous oral self-care. ▷ The patient’s role in self-management of diabetes with an emphasis on the need to be compliant with lifestyle modifications including healthy eating, physical activity, weight management, glucose monitoring, tobacco ces-sation, good oral self-care, limiting or avoiding alcohol, stress management, and use of prescribed medications. ▷ The value of seeking immediate medical attention for any signs of complications from diabetes.Factors to Teach Patients Not Diagnosed with Diabetes ▷ Need for regular medical examinations and screening for diabetes. ▷ How to recognize the early warning signs of diabetes and seek medical consult. ▷ Factors that affect a healthy lifestyle, including healthy diet, daily exercise, no tobacco products, avoid alcohol, and maintain ideal weight. ▷ How to practice meticulous oral hygiene to prevent dental caries and periodontal disease. ▷ Stress reduction techniques.Factors To Teach The Patient ▶ Record discussion about relationship between oral health status, oral hygiene status, risk factors, and diabetes. ▶ Box 69-7 contains an example progress note for a pa-tient with diabetes.References1. American Diabetes Association. Diagnosis and classifica-tion of diabetes mellitus. Diabetes Care. 2014;37 (Suppl 1): S81–S90.2. Centers for Disease Control and Prevention. National Diabe-tes Statistics Report: Estimates of Diabetes and Its Burden in the Wilkins9781451193114-ch069.indd 1180 07/10/15 11:40 AM CHAPTER 69 | The Patient with Diabetes Mellitus 1181United States, 2014. Atlanta, GA: US Department of Health and Human Services; 2014. http://www.cdc.gov//diabetes/pubs/statsreport14.htm. Accessed November 23, 2014.3. Danaei G, Finucane MM, Lu Y, et al. National, regional, and global trends in fasting plasma glucose and diabetes preva-lence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. Lancet. 2011;378(9785):31–40.4. Boyd LD, Giblin L, Chadbourne D. Bidirectional relation-ship between diabetes mellitus and periodontal disease: state of the evidence. Can J Dent Hyg. 2012;46(2):93–102.5. Taylor GW, Manz MC, Borgnakke WS. Diabetes, periodon-tal diseases, dental caries, and tooth loss: a review of the literature. Compend Contin Educ Dent. 2004;25(3):179–184, 186–188, 190.6. Fouad AF. Diabetes mellitus as a modulating factor of end-odontic infections. J Dent Educ. 2003;67(4):459–467.7. Chrcanovic BR, Albrektsson T, Wennerberg A. Diabetes and oral implant failure: a systematic review. J Dent Res. 2014;93(9):859–867.8. Newsholme P, Cruzat V, Arfuso F, et al. Nutrient regu-lation of insulin secretion and action. J Endocrinol. 2014;221(3):R105–R120.9. American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37 (Suppl 1): S14–S80.10. Reinehr T. Obesity and diabetes in young adults. MMW Fortschr Med. 2014;156(8):57–60.11. DeSisto CL, Kim SY, Sharma AJ. Prevalence estimates of gestational diabetes mellitus in the united states, pregnancy risk assessment monitoring system (PRAMS), 2007–2010. Prev Chronic Dis. 2014;11:E104.12. Linnenkamp U. IDF diabetes atlas reveals high burden of hy-perglycaemia in pregnancy. Diabetes Voice. 2014;59:55–56.13. American Diabetes Association. Type 2 diabetes risk test. http://www.diabetes.org/are-you-at-risk/diabetes-risk-test/. Accessed November 23, 2014.14. Gupta A, Gupta N, Garg R, et al. Developing a chair side, safe and non-invasive procedure for assessment of blood glucose level using gingival crevicular bleeding in dental clinics. J Nat Sci Biol Med. 2014;5(2):329–332.15. Strauss SM, Russell S, Wheeler A, et al. The dental office visit as a potential opportunity for diabetes screening: an analysis using NHANES 2003–2004 data. J Public Health Dent. 2010;70(2):156–162.16. Strauss SM, Tuthill J, Singh G, et al. A novel intraoral dia-betes screening approach in periodontal patients: results of a pilot study. J Periodontol. 2012;83(6):699–706.17. The Diabetes Prevention Program Research Group. The 10-year cost-effectiveness of lifestyle intervention or met-formin for diabetes prevention: an intent-to-treat analysis of the DPP/DPPOS. Diabetes Care. 2012;35(4):723–730.18. Haas L, Maryniuk M, Beck J, et al. National standards for diabetes self-management education and support. Diabetes Care. 2014;37 (Suppl 1):S144–S153.19. Brouwer W, Kroeze W, Crutzen R, et al. Which interven-tion characteristics are related to more exposure to internet- delivered healthy lifestyle promotion interventions? A sys-tematic review. J Med Internet Res. 2011;13(1):e2.20. Kaufman N. Internet and information technology use in treat-ment of diabetes. Int J Clin Pract Suppl. 2010;(166):41–46.21. Liao ZH, Chen YL, Li FP, et al. Multicenter clinical study on the efficacy and safety of inhalable insulin aerosol in the treatment of type 2 diabetes. Chin Med J (Engl). 2008;121:1159–1164.22. Garber AJ, Abrahamson MJ, Barzilay JI, et al. AACE com-prehensive diabetes management algorithm 2013. Endocr Pract. 2013;19(2):327–336.23. Nathan DM; and DCCT/EDIC Research Group. The diabe-tes control and complications trial/epidemiology of diabetes interventions and complications study at 30 years: overview. Diabetes Care. 2014;37(1):9–16.ENHANCE YOUR UNDERSTANDINGDIGITAL CONNECTIONS(see the inside front cover for access information)• Audio glossary• Quiz bankSUPPORT FOR LEARNING(available separately; visit lww.com)• Active Learning Workbook for Clinical Practice of the Dental Hygienist, 12th EditionINDIVIDUALIZED REVIEW(available separately; visit lww.com)• Adaptive quizzing with prepU for Wilkins’ Clinical Practice of the Dental HygienistWilkins9781451193114-ch069.indd 1181 07/10/15 11:40 AM Wilkins9781451193114-ch069.indd 1182 07/10/15 11:40 AM 1183Appendix IAmerican Dental Hygienists’ Association Code of Ethics for Dental Hygienists*PREAMBLEAs dental hygienists, we are a community of profession-als devoted to the prevention of disease and the promo-tion and improvement of the public’s health. We are preventive oral health professionals who provide educa-tional, clinical, and therapeutic services to the public. We strive to live meaningful, productive, satisfying lives that simultaneously serve us, our profession, our society, and the world. Our actions, behaviors, and attitudes are consistent with our commitment to public service. We endorse and incorporate the Code into our daily lives.PURPOSEThe purpose of a professional code of ethics is to achieve high levels of ethical consciousness, decision making, and practice by the members of the profession. Specific objec-tives of the Dental Hygiene Code of Ethics are: ▶ To increase our professional and ethical consciousness and sense of ethical responsibility. ▶ To lead us to recognize ethical issues and choices and to guide us in making more informed ethical decisions. ▶ To establish a standard for professional judgment and conduct. ▶ To provide a statement of the ethical behavior the public can expect from us.The Dental Hygiene Code of Ethics is meant to influ-ence us throughout our careers. It stimulates our continuing study of ethical issues and challenges us to explore our ethi-cal responsibilities. The Code establishes concise standards of behavior to guide the public’s expectations of our profes-sion and supports existing dental hygiene practice, laws, and regulations. By holding ourselves accountable to meeting the standards stated in the Code, we enhance the public’s trust on which our professional privilege and status are founded.KEY CONCEPTSOur beliefs, principles, values, and ethics are concepts re-flected in the Code. They are the essential elements of our comprehensive and definitive code of ethics and are inter-related and mutually dependent.BASIC BELIEFSWe recognize the importance of the following beliefs that guide our practice and provide context for our ethics: ▶ The services we provide contribute to the health and well-being of society. ▶ Our education and licensure qualify us to serve the pub-lic by preventing and treating oral disease and helping individuals achieve and maintain optimal health. ▶ Individuals have intrinsic worth, are responsible for their own health, and are entitled to make choices re-garding their health. ▶ Dental hygiene care is an essential component of over-all healthcare, and we function interdependently with other healthcare providers. ▶ All people should have access to healthcare, including oral healthcare. ▶ We are individually responsible for our actions and the quality of care we provide.FUNDAMENTAL PRINCIPLESThese fundamental principles, universal concepts, and gen-eral laws of conduct provide the foundation for our ethics.UniversalityThe principle of universality assumes that if one individual judges an action to be right or wrong in a given situation, *Reprinted with permission from The American Dental Hygienists’ Association. http://www.adha.org.Wilkins9781451193114-appx1.indd 1183 07/10/15 10:41 AM 1184 APPENDIX I | American Dental Hygienists’ Association Code of Ethics for Dental HygienistsSocietal TrustWe value client trust and understand that public trust in our profession is based on our actions and behavior.NonmaleficenceWe accept our fundamental obligation to provide services in a manner that protects all clients and minimizes harm to them and others involved in their treatment.BeneficenceWe have a primary role in promoting the well-being of in-dividuals and the public by engaging in health promotion/disease prevention activities.Justice and FairnessWe value justice and support the fair and equitable distribu-tion of healthcare resources. We believe all people should have access to high-quality, affordable oral healthcare.VeracityWe accept the obligation to tell the truth and assume that others will do the same. We value self-knowledge and seek truth and honesty in all relationships.STANDARDS OF PROFESSIONAL RESPONSIBILITYWe are obligated to practice our profession in a manner that supports our purpose, beliefs, and values in accor-dance with the fundamental principles that support our ethics. We acknowledge the following responsibilities:To Ourselves as Individuals ▶ Avoid self-deception, and continually strive for knowl-edge and personal growth. ▶ Establish and maintain a lifestyle that supports optimal health. ▶ Create a safe work environment. ▶ Assert our own interests in ways that are fair and equitable. ▶ Seek the advice and counsel of others when challenged with ethical dilemmas. ▶ Have realistic expectations of ourselves and recognize our limitations.To Ourselves as Professionals ▶ Enhance professional competencies through continu-ous learning in order to practice according to high stan-dards of care.other people considering the same action in the same situ-ation would make the same judgment.ComplementarityThe principle of complementarity assumes the existence of an obligation to justice and basic human rights. It requires us to act toward others in the same way they would act to-ward us if roles were reversed. In all relationships, it means considering the values and perspectives of others before making decisions or taking actions affecting them.EthicsEthics are the general standards of right and wrong that guide behavior within society. As generally accepted ac-tions, they can be judged by determining the extent to which they promote good and minimize harm. Ethics com-pel us to engage in health promotion/disease prevention activities.CommunityThis principle expresses our concern for the bond between individuals, the community, and society in general. It leads us to preserve natural resources and inspires us to show concern for the global environment.ResponsibilityResponsibility is central to our ethics. We recognize there are guidelines for making ethical choices and accept respon-sibility for knowing and applying them. We accept the con-sequences of our actions or the failure to act and are willing to make ethical choices and publicly affirm them.CORE VALUESWe acknowledge these values as general for our choices and actions. Individual Autonomy and Respect for Human BeingsPeople have the right to be treated with respect. They have the right to informed consent prior to treatment, and they have the right to full disclosure of all relevant information so that they can make informed choices about their care.ConfidentialityWe respect the confidentiality of client information and relationships as a demonstration of the value we place on individual autonomy. We acknowledge our obligation to justify any violation of a confidence.Wilkins9781451193114-appx1.indd 1184 07/10/15 10:41 AM APPENDIX I | American Dental Hygienists’ Association Code of Ethics for Dental Hygienists 1185To Employees and Employers ▶ Conduct professional activities and programs and de-velop relationships in ways that are honest, responsible, open, and candid. ▶ Manage conflicts constructively. ▶ Support the right of our employees and employers to work in an environment that promotes wellness. ▶ Respect the employment rights of our employers and employees.To the Dental Hygiene Profession ▶ Participate in the development and advancement of our profession. ▶ Avoid conflicts of interest and declare them when they occur. ▶ Seek opportunities to increase public awareness and understanding of oral health practices. ▶ Act in ways that bring credit to our profession while demonstrating appropriate respect for colleagues in other professions. ▶ Contribute time, talent, and financial resources to sup-port and promote our profession. ▶ Promote a positive image for our profession. ▶ Promote a framework for professional education that develops dental hygiene competencies to meet the oral and overall health needs of the public.To the Community and Society ▶ Recognize and uphold the laws and regulations govern-ing our profession. ▶ Document and report inappropriate, inadequate, or substandard care and/or illegal activities by a health-care provider to the responsible authorities. ▶ Use peer review as a mechanism for identifying inap-propriate, inadequate, or substandard care provided by dental hygienists. ▶ Comply with local, state, and federal statutes that pro-mote public health and safety. ▶ Develop support systems and quality-assurance pro-grams in the workplace to assist dental hygienists in providing the appropriate standard of care. ▶ Promote access to dental hygiene services for all, sup-porting justice and fairness in the distribution of health-care resources. ▶ Act consistently with the ethics of the global scientific community of which our profession is a part. ▶ Create a healthful workplace ecosystem to support a healthy environment. ▶ Recognize and uphold our obligation to provide pro bono service. ▶ Support dental hygiene peer-review systems and quality-assurance measures. ▶ Develop collaborative professional relationships and exchange knowledge to enhance our own lifelong pro-fessional development.To Family and Friends ▶ Support the efforts of others to establish and maintain healthy lifestyles and respect the rights of friends and family.To Clients ▶ Provide oral healthcare utilizing high levels of profes-sional knowledge, judgment, and skill. ▶ Maintain a work environment that minimizes the risk of harm. ▶ Serve all clients without discrimination, and avoid ac-tion toward any individual or group that may be inter-preted as discriminatory. ▶ Hold professional client relationships confidential. ▶ Communicate with clients in a respectful manner. ▶ Promote ethical behavior and high standards of care by all dental hygienists. ▶ Serve as an advocate for the welfare of clients. ▶ Provide clients with the information necessary to make informed decisions about their oral health and encourage their full participation in treatment decisions and goals. ▶ Refer clients to other healthcare providers when their needs are beyond our ability or scope of practice. ▶ Educate clients about high-quality oral healthcare.To Colleagues ▶ Conduct professional activities and programs, and de-velop relationships in ways that are honest, responsible, and appropriately open and candid. ▶ Encourage a work environment that promotes individ-ual professional growth and development. ▶ Collaborate with others to create a work environment that minimizes risk to the personal health and safety of our colleagues. ▶ Manage conflicts constructively. ▶ Support the efforts of other dental hygienists to com-municate the dental hygiene philosophy and preven-tive oral care. ▶ Inform other healthcare professionals about the rela-tionship between general and oral health. ▶ Promote human relationships that are mutually beneficial, including those with other healthcare professionals.Wilkins9781451193114-appx1.indd 1185 07/10/15 10:41 AM 1186 APPENDIX I | American Dental Hygienists’ Association Code of Ethics for Dental Hygienists ▶ Obtain informed consent from human subjects partici-pating in research that is based on specification pub-lished in Title 21 Code of Federal Regulations Part 46. ▶ Respect the confidentiality and privacy of data. ▶ Seek opportunities to advance dental hygiene knowl-edge through research by providing financial, human, and technical resources whenever possible. Report re-search results in a timely manner. ▶ Report research findings completely and honestly, drawing only those conclusions that are supported by the data presented. ▶ Report names of investigators fairly and accurately. ▶ Interpret the research and the research of others accurately and objectively, drawing conclusions that are supported by the data presented and seeking clarity when uncertain. ▶ Critically evaluate research methods and results before applying new theory and technology in practice. ▶ Be knowledgeable concerning currently accepted pre-ventive and therapeutic methods, products, and tech-nology and their application to our practice.To Scientific InvestigationWe accept responsibility for conducting research accord-ing to the fundamental principles underlying our ethical beliefs in compliance with universal codes, governmen-tal standards, and professional guidelines for the care and management of experimental subjects. We acknowledge our ethical obligations to the scientific community: ▶ Conduct research that contributes knowledge that is valid and useful to our clients and society. ▶ Use research methods that meet accepted scientific standards. ▶ Use research resources appropriately. ▶ Systematically review and justify research in progress to ensure the most favorable benefit-to-risk ratio to re-search subjects. ▶ Submit all proposals involving human subjects to an appropriate human subject review committee. ▶ Secure appropriate institutional committee approval for the conduct of research involving animals.Wilkins9781451193114-appx1.indd 1186 07/10/15 10:41 AM 1187*Reprinted with permission from The National Dental Hygienists’ Association Constitution and By-laws. 2012. http://www.ndhaonline.org.Appendix IINational Dental Hygienists’ Association Code of Ethics*enhance the image of dental hygiene. As hygienists, we are accountable for participating in the development of education programs and policies. We are also accountable for interpreting this information for our patients.Principle III: Commitment to the ProfessionWe believe that the quality of services the NDHA pro-vides to its members directly influences the future of the profession and the patient population served by its mem-bers. We must exert every effort to raise performance stan-dards to improve the skills of our members so that they can exercise the highest level of professional judgment. These actions should attract individuals who will make positive contributions to the practice of dental hygiene. We actively participate in the planning, development and learning of all members.Principle IV: Commitment to the StudentWe measure our success by the number of underrepresented minority students entering the dental hygiene profession and strive to increase the number of underrepresented mi-nority dental hygienists by eliminating educational and social barriers. To accomplish this goal, the NDHA will provide educational and financial assistance to insure the continued success of underrepresented minorities in the profession of dental hygiene.PREAMBLEWe, the members of the National Dental Hygienists’ Association, affirm our belief in dental health education for the prevention of dental disease and the importance of pre-ventive treatment. We affirm and accept our responsibility to practice our profession according to the highest ethical standards. We hold ourselves, both individually and collec-tively, accountable for professional conduct in the dental hygiene profession according to the provision of this code.Principle I: Commitment to the PatientOur success is measured by the progress of each patient’s achievement of maximum dental health. We work to mo-tivate our patients to become aware of their individual state of dental health and engage in those practices that result in optimum dental health. To this end we will:1. Address each patient with respect, giving consideration to the individual’s needs.2. Maintain each patient’s confidentiality.3. Maintain the highest level of mental, physical and spir-itual health possible, to be a role model to our patients and the community.Principle II: Commitment to the CommunityIn fulfilling our obligations to the community, we believe that cooperative relationships in the community will Wilkins9781451193114-appx2.indd 1187 07/10/15 10:42 AM Wilkins9781451193114-appx2.indd 1188 07/10/15 10:42 AM 1189Appendix IIICanadian Dental Hygienists Association: Dental Hygienists’ Code of Ethics*PREAMBLEThe CDHA Code of Ethics sets out the ethical principles and responsibilities which apply to all members of the den-tal hygiene profession across all practice areas including clinical care, education, research, administration and any other role related to the profession of dental hygiene.Ethics is the study of moral values and moral reasoning. Ethical codes are formal statements that guide members of a profession in their obligations to clients, colleagues, the larger society, and to global health.The Code of Ethics serves to:1. Articulate the ethical principles and responsibilities by which dental hygienists are guided and under which they are accountable;2. Provide a professional resource for education, reflec-tion, self-evaluation, and peer review within dental hy-giene and the broader health care community;3. Inform the public about the ethical principles and re-sponsibilities of the dental hygiene profession.Dental hygienists’ primary responsibility is to the client. In this document, “client” refers to a person or persons or a community with whom dental hygienists are engaged in a professional relationship. These relationships occur in all areas of dental hygiene practice including clinical services (e.g., private dental offices, independent practice, schools, community/public health clinics, acute and long term care, corporate environments); education, research, regu-latory and policy roles; and administration/employment.Dental hygienists work in an interprofessional collabora-tive environment. They are accountable to other codes of ethics/ethical guidelines including those of their provincial/territorial regulatory authority and their workplace. The CDHA Code of Ethics is a strong foundational document, effective on its own, and complementary to other ethical codes that address more specific situations and behaviours.Dental hygienists use the Code of Ethics in conjunc-tion with professional standards, workplace policies, and laws and regulations that guide practices and behaviours. In achieving these requirements, they fulfill their contract with society to meet a high standard of ethical practice.ETHICAL PRINCIPLES AND RESPONSIBILITIESThe “Principles” depict the broad ideals to which dental hygienists aspire and which guide their practice. The “Re-sponsibilities” outlined on the following pages are more precise and provide direction for behaviours in ethical situations.Principle: BeneficenceBeneficence involves caring about and acting to promote the good of another. Dental hygienists use their knowledge and skills to assist clients to achieve and maintain optimal oral health and overall wellbeing, and to promote fair and reasonable access to quality oral health services as an inte-gral part of the healthcare system.Responsibilities for Beneficence1. Dental hygienists put the needs, values, and interests of clients first.2. Dental hygienists provide services to clients in a caring manner with respect for their individual needs, values, culture, safety, and life circumstances, and in recogni-tion of their inherent dignity.3. Dental hygienists regard informed choice as a precon-dition of intervention, and honour a client’s informed choice including refusal of intervention.4. Dental hygienists recommend or provide those services that they believe are necessary for promoting and main-taining a client’s oral health and its effect on total body health and wellness, and which are consistent with the client’s informed choice.*Revised 2012. Reprinted with permission from The Canadian Dental Hygienists Association. http://www.cdha.ca/Wilkins9781451193114-appx3.indd 1189 07/10/15 10:43 AM 1190 APPENDIX III | Canadian Dental Hygienists Association: Dental Hygienists’ Code of Ethics6. Dental hygienists promote workplace practices and pol-icies that facilitate professional practice in accordance with the principles, standards, laws and regulations un-der which they are accountable.7. Dental hygienists communicate the nature and costs of professional services fairly and accurately, ad-hering to guidelines and/or regulations for advertising as outlined by their jurisdictional regulatory authority.Principle: AccountabilityAccountability pertains to taking responsibility for one’s actions and omissions in light of relevant principles, stan-dards, laws, and regulations. It includes the potential to self evaluate and be evaluated. It involves practising com-petently and accepting responsibility for behaviours and decisions in the professional context.Responsibilities for Accountability1. Dental hygienists accept responsibility for knowing and acting consistently with the principles, practice standards, laws and regulations under which they are accountable.2. Dental hygienists practise within the bounds of their competence, scope of practice, personal and/or profes-sional limitations.3. Dental hygienists refer clients who require services out-side their scope of practice to the appropriate professional.4. Dental hygienists address issues in the practice environ-ment that may hinder or impede the provision of care.5. Dental hygienists inform their employers about the principles, standards, laws and regulations to which dental hygienists are accountable and determine whether employment conditions facilitate safe profes-sional practice.6. Dental hygienists inform their employers and/or appropriate regulatory authority of unethical practice by a colleague.7. Dental hygienists inform the appropriate regula-tory authority in the event of becoming unable to prac-tise safely and competently.Principle: ConfidentialityConfidentiality is the duty to hold secret any information acquired in the professional relationship. Dental hygien-ists respect a client’s privacy and hold in confidence in-formation disclosed to them except in certain narrowly defined exceptions.Responsibilities for Confidentiality1. Dental hygienists demonstrate respect for the privacy of clients.2. Dental hygienists promote practices, policies and infor-mation systems that are designed to respect and protect clients’ privacy and confidentiality.5. Dental hygienists take appropriate action to ensure a client’s safety and quality of care when they suspect un-ethical or incompetent care.6. Dental hygienists seek to improve the quality of care, and advance knowledge in the field of oral health through advocacy and interprofessional practice.Principle: AutonomyAutonomy pertains to the right to make one’s own choices. By communicating relevant information openly and truth-fully, dental hygienists assist clients to make informed choices and to participate actively in achieving and main-taining their optimal oral health.Responsibilities for Autonomy1. Dental hygienists actively involve clients in their oral healthcare and promote informed choice by commu-nicating relevant information openly, truthfully, and sensitively in recognition of their needs, values, and capacity to understand.2. Dental hygienists involve and promote informed choice by substitute decision maker(s) in situations where cli-ents lack the capacity for informed choice.3. Dental hygienists, in the event of a substitute decision maker, involve clients to the extent of their capacity.4. Dental hygienists recognize cultural differences, and as-sess and plan interventions with individuals and popu-lations receiving their services relative to the cultural context.Principle: IntegrityIntegrity relates to consistency of actions, values, methods, expectations, and outcomes. It includes the promotion of fairness and social justice with consideration for those clients more vulnerable. It conveys a sense of wholeness and strength, and doing what is right with honesty and truthfulness.Responsibilities for Integrity1. Dental hygienists uphold the principles and standards of the profession with clients, colleagues and others with whom they are engaged in a professional relationship.2. Dental hygienists maintain and advance their knowledge and skills in dental hygiene through lifelong learning.3. Dental hygienists provide quality of interventions through ongoing self evaluation and quality assurance.4. Dental hygienists promote conditions that enable social, economic, cultural values and institutions com-patible with meeting basic human rights and dignity.5. Dental hygienists collaborate with colleagues in a co-operative, constructive and respectful manner with the primary goal of providing safe, competent, fair and high quality interventions to individuals, families and communities.Wilkins9781451193114-appx3.indd 1190 07/10/15 10:43 AM APPENDIX III | Canadian Dental Hygienists Association: Dental Hygienists’ Code of Ethics 1191• In an emergency situation,• In situations where disclosure is necessary to prevent serious harm to others,• To the client’s guardian or substitute decision maker.5. Dental hygienists inform clients in advance of treat-ment of how their information may be shared, in partic-ular, around any uses or sharing that may occur without the client’s express consent.6. Dental hygienists obtain a client’s consent to use or share information about his/her circumstances for the purpose of teaching or research.3. Dental hygienists understand and respect the poten-tial of compromising confidentiality when connecting with clients through social networks or other electronic media.4. Dental hygienists hold confidential any information acquired in the professional relationship and do not use or disclose confidential information to others without a client’s express consent. Exceptions include:• As required by law,• As required by the policy of the practice environ-ment (e.g., quality assurance),Wilkins9781451193114-appx3.indd 1191 07/10/15 10:43 AM Wilkins9781451193114-appx3.indd 1192 07/10/15 10:43 AM 1193Appendix IVInternational Federation of Dental Hygienists Code of Ethics*hygienists value respect for persons and personal dignity as human beings are unique, in their abilities, strengths, weaknesses and needs. a. Dental hygienists value respect for truthfulness. Truth-fulness is essential when assisting the patient to obtain relevant information about dental hygiene services, diagnosis, treatment and probable out-comes. Truthfulness builds trust. b. Dental hygienists value respect for individual choice. Patients have choices and can decide which services to accept or decline. c. Dental hygienists value respect for patient confidenti-ality. Confidentiality is preserved unless such confi-dentiality could pose substantial risk or serious harm and where that risk or harm is greater than the harm of breaking the confidentiality. d. Dental hygienists respect the natural environment.These values are embedded in the four principle ele-ments of the Code.CODE OF ETHICSThe code of ethics has four principal elements that out-line the standards of ethical conduct. This establishes the standards of behavior of dental hygienists and embodies integrity and respect.1. Dental Hygienists and People/Society2. Dental Hygienists and Practice3. Dental Hygienists and Co-workers4. Dental Hygienists and the ProfessionDental Hygienists and People/Society ▶ The dental hygienist strives to promote an environ-ment in which the human rights, values, customs, and *Reprinted with permission from The International Federation of Dental Hygienists. http://ifdh.org.INTRODUCTIONThe fundamental responsibility of dental hygienists is to promote and restore oral health.Dental hygienists promote oral health by providing clinical, therapeutic remedies, and health education.Dental hygienists serve the public as oral health profes-sionals and thus contribute to the public’s general health and well-being.The need for dental hygiene services is universal and unrestricted by race, color, age, sex, language, religion, po-litical or other opinion, national or social origin, property, birth or other status.Dental hygienists are called upon to deliver care to the individual, the family and the community.In a business relationship in which a dental hygienist is an employee the dental hygienist exhibits competence, loy-alty and fair return of work for compensation. However, em-ployee status does not minimize a dental hygienist’s ethical responsibility to account for a patient’s well-being. Nor does it lessen the dental hygienist’s right to act competently, ac-countably and knowledgably on behalf of the patient.Dental hygiene care is provided with integrity and respect and in collaboration with other health care professionals.Values Embedded in the Code of EthicsDental hygienists value integrity and respect.1. Integrity: moral soundness; uprightness; sincerity; free-dom from corrupting influence or motive a. Dental hygienists value personal integrity and are honest, truthful, and respectful when interacting with other human beings. b. Dental hygienists value professional integrity and prac-tice according to the profession’s standards and values. c. Ethical practice requires both personal integrity and professional integrity.2. Respect: to regard with special attention, to care for, to avoid violation of, or interference with. Dental Wilkins9781451193114-appx4.indd 1193 07/10/15 10:48 AM 1194 APPENDIX IV | International Federation of Dental Hygienists Code of Ethics ▶ The dental hygienist provides timely competent care and charges reasonable fees for professional services. ▶ The dental hygienist, in providing care, ensures that use of technology and scientific advances are compat-ible with the safety, dignity and rights of people.Dental Hygienist and Co-Workers ▶ The dental hygienist sustains a co-operative and col-laborative relationship with co-workers in oral health and other fields. ▶ A dental hygienist recognizes particular skills and ex-pertise of health care personnel working collaboratively in the patient’s care. ▶ A dental hygienist advocates for the patient when another oral health provider is giving inappropriate or incompe-tent care, inconsistent with the patient’s well-being.Dental Hygienists and the Profession ▶ The dental hygienist adheres to and may exceed the standards of dental hygiene practice within the jurisdic-tion of the country of practice. ▶ The dental hygienist is active in developing and pub-lishing a core of research based on the ongoing pursuit of professional knowledge. ▶ The dental hygienist, acting through the professional organization, participates in creating and maintaining equitable social and economic working conditions in oral health. ▶ The dental hygienist promotes respect for human beings ensuring the profession protects their right to health.spiritual beliefs of the individual, family and commu-nity are respected. ▶ The dental hygienist endeavors to ensure that the indi-vidual receives sufficient and appropriate information on which to base consent for care and related dental hygiene treatment. ▶ The dental hygienist provides services consistent with the patient’s needs and requests. ▶ The dental hygienist holds personal information con-fidential and uses professional reasoned judgment in sharing this information. ▶ The dental hygienist protects the environment by respon-sible disposal of all wastes in the dental hygiene practice. ▶ The dental hygienist’s own personal interests, if in con-flict with her/his professional obligation should be de-clared and resolved for the well-being of the client.Dental Hygienists and Practice ▶ The dental hygienist has the qualifications, knowledge, training, skills, judgment and attitudes to practice safely. ▶ The dental hygienist has a thorough knowledge of the profession and its related laws. ▶ The dental hygienist at all times practices with integ-rity and adheres to the standards of practice and per-sonal conduct of her/his legislative jurisdiction. ▶ The dental hygienist is personally responsible for re-maining competent and current in her/his professional knowledge by continual education and training. ▶ The dental hygienist provides a choice of services within a range of safe affordable options consistent with the patient’s needs.Wilkins9781451193114-appx4.indd 1194 07/10/15 10:48 AM 1195Appendix VGuidelines for Infection Control in Dental Health Care Settings*and latex hypersensitivity; and maintenance of records, data management, and confidentiality (IB).5,16–18,222. Establish referral arrangements with qualified health-care professionals to ensure prompt and appropriate provision of preventive services, occupationally related medical services, and postexposure management with medical follow-up (IB, IC).5,13,19,22B. Education and Training1. Provide DHCP (1) on initial employment, (2) when new tasks or procedures affect the employee’s occu-pational exposure, and (3) at a minimum, annually, with education and training regarding occupational exposure to potentially infectious agents and infection- control procedures/protocols appropriate for and spe-cific to their assigned duties (IB, IC).5,11,13,14,16,19,222. Provide educational information appropriate in con-tent and vocabulary to the educational level, literacy and language of DHCP (IB, IC).5,13C. Immunization Programs1. Develop a written comprehensive policy regarding im-munizing DHCP, including a list of all required and rec-ommended immunizations (IB).5,17,182. Refer DHCP to a prearranged qualified healthcare pro-fessional or to their own health care professional to re-ceive all appropriate immunizations based on the latest recommendations as well as their medical history and risk for occupational exposure (IB).5,17D. Exposure Prevention and Postexposure Management1. Develop a comprehensive postexposure management and medical follow-up program (IB, IC).5,13,14,19A. Include policies and procedures for prompt report-ing, evaluation, counseling, treatment, and medical follow-up of occupational exposures.RECOMMENDATIONSEach recommendation is categorized on the basis of existing scientific data, theoretical rationale, and applicability. Rankings are based on the system used by the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Prac-tices Advisory Committee (HICPAC) to categorize recommendations:Category IA: Strongly recommended for implementa-tion and strongly supported by well-designed experi-mental, clinical, or epidemiologic studies.Category IB: Strongly recommended for implementa-tion and supported by experimental, clinical, or epide-miologic studies and a strong theoretical rationale.Category IC: Required for implementation as mandated by federal or state regulation or standard. When IC is used, a second rating can be included to provide the ba-sis of existing scientific data, theoretical rationale, and applicability. Because of state differences, the reader should not assume that the absence of an IC implies the absence of state regulations.Category II: Suggested for implementation and sup-ported by suggestive clinical or epidemiologic studies or a theoretical rationale.Unresolved issue: No recommendation. Insufficient evi-dence or no consensus regarding efficacy exists.I. Personnel Health Elements of an Infection-Control ProgramA. General Recommendations1. Develop a written health program for dental health-care personnel (DHCP) that includes policies, pro-cedures, and guidelines for education and training; immunizations; exposure prevention and postexposure management; medical conditions, work-related illness, and associated work restrictions; contact dermatitis *Excerpted from Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health Care Settings, 2003. MMWR. 2003;52 (RR-17):1–61. http://www.cdc.gov/oralhealth/infectioncontrol/guidelines. Accessed August 31, 2015.Wilkins9781451193114-appx5.indd 1195 07/10/15 10:51 AM 1196 APPENDIX V | Guidelines for Infection Control in Dental Health Care Settings4. DHCP should complete a second 3-dose vaccine series or be evaluated to determine if they are hepatitis B sur-face antigen (HBsAg)-positive if no antibody response occurs to the primary vaccine series (IA, IC).14,195. Retest for anti-HBs at the completion of the second vac-cine series. If no response to the second 3-dose series oc-curs, nonresponders should be tested for HBsAg (IC).14,196. Counsel nonresponders to vaccination who are HBsAg-negative regarding their susceptibility to HBV infection and precautions to take (IA, IC).14,197. Provide employees appropriate education regarding the risks of HBV transmission and the availability of the vaccine. Employees who decline the vaccination should sign a declination form to be kept on file with the employer (IC).13B. Preventing Exposures to Blood and OPIM (Other Potentially Infectious Materials)1. General recommendationsa. Use standard precautions (Occupational Safety and Health Administration’s [OSHA’s]) blood-borne pathogen standard retains the term universal pre-cautions) for all patient encounters (IA, IC).11,13,19,53b. Consider sharp items (e.g., needles, scalers, burs, lab knives, and wires) that are contaminated with pa-tient blood and saliva as potentially infective and establish engineering controls and work practices to prevent injuries (IB, IC).6,13,113c. Implement a written, comprehensive program de-signed to minimize and manage DHCP exposures to blood and body fluids (IB, IC).13,14,19,972. Engineering and work-practice controlsa. Identify, evaluate, and select devices with engi-neered safety features at least annually and as they become available on the market (e.g., safer anes-thetic syringes, blunt suture needle, retractable scalpel, or needleless IV systems) (IC).13,97,110–112b. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers located as close as feasible to the area in which the items are used (IA, IC).2,7,13,19,113,115c. Do not recap used needles by using both hands or any other technique that involves directing the point of a needle toward any part of the body. Do not bend, break, or remove needles before disposal (IA, IC).2,7,8,13,97,113d. Use either a one-handed scoop technique or a me-chanical device designed for holding the needle cap when recapping needles (e.g., between multiple in-jections and before removing from a nondisposable aspirating syringe) (IA, IC).2,7,8,13,14,1133. Postexposure management and prophylaxisa. Follow CDC recommendations after percutaneous, mu-cous membrane, or nonintact skin exposure to blood or other potentially infectious material (IA, IC).13,14,19B. Establish mechanisms for referral to a qualified health-care professional for medical evaluation and follow-up.C. Conduct a baseline tuberculin skin test (TST), pref-erably by using a two-step test, for all DHCP who might have contact with persons with suspected or confirmed infectious TB, regardless of the risk clas-sification of the setting (IB).20E. Medical Conditions, Work-Related Illness, and Work Restrictions1. Develop and have readily available to all DHCP com-prehensive written policies regarding work restriction and exclusion that include a statement of authority de-fining who can implement such policies (IB).5,222. Develop policies for work restriction and exclusion that encourage DHCP to seek appropriate preventive and cu-rative care and report their illnesses, medical conditions, or treatments that can render them more susceptible to opportunistic infection or exposures; do not penalize DHCP with loss of wages, benefits, or job status (IB).5,223. Develop policies and procedures for evaluation, diag-nosis, and management of DHCP with suspected or known occupational contact dermatitis (IB).324. Seek definitive diagnosis by a qualified healthcare pro-fessional for any DHCP with suspected latex allergy to carefully determine its specific etiology and appropriate treatment as well as work restrictions and accommoda-tions (IB).32F. Records Maintenance, Data Management, and Confidentiality1. Establish and maintain confidential medical records (e.g., immunization records and documentation of tests received as a result of occupational exposure) for all DHCP (IB, IC).5,132. Ensure that the practice complies with all applicable federal, state, and local laws regarding medical record-keeping and confidentiality (IC).13,34II. Preventing Transmission of Bloodborne PathogensA. HBV Vaccination1. Offer the hepatitis B virus (HBV) vaccination series to all DHCP with potential occupational exposure to blood or other potentially infectious material (IA, IC).2,13,14,192. Always follow U.S. Public Health Service/CDC recom-mendations for hepatitis B vaccination, serologic test-ing, follow-up, and booster dosing (IA, IC).13,14,193. Test DHCP for hepatitis B surface antibody (anti-HBs) 1–2 months after completion of the 3-dose vaccination series (IA, IC).14,19Wilkins9781451193114-appx5.indd 1196 07/10/15 10:51 AM APPENDIX V | Guidelines for Infection Control in Dental Health Care Settings 1197generate splashing or spattering of blood or other body fluids (IB, IC).1,2,7,8,11,13,1372. Change masks between patients or during patient treat-ment if the mask becomes wet (IB).23. Clean with soap and water, or if visibly soiled, clean and disinfect reusable facial protective equipment (e.g., clinician and patient protective eyewear or face shields) between patients (II).2B. Protective Clothing1. Wear protective clothing (e.g., reusable or disposable gown, laboratory coat, or uniform) that covers personal clothing and skin (e.g., forearms) likely to be soiled with blood, saliva, or OPIM (IB, IC).7,8,11,13,1372. Change protective clothing if visibly soiled134; change immediately or as soon as feasible if penetrated by blood or other potentially infectious fluids (IB, IC).133. Remove barrier protection, including gloves, mask, eyewear, and gown before departing work area (e.g., dental patient care, instrument processing, or laboratory areas) (IC).13C. Gloves1. Wear medical gloves when a potential exists for con-tacting blood, saliva, OPIM, or mucous membranes (IB, IC).1,2,7,8,132. Wear a new pair of medical gloves for each patient, remove them promptly after use, and wash hands immediately to avoid transfer of microorganisms to other patients or environments (IB).1,7,8,1233. Remove gloves that are torn, cut, or punctured as soon as feasible and wash hands before regloving (IB, IC).13,210,2114. Do not wash surgeon’s or patient examination gloves before use or wash, disinfect, or sterilize gloves for reuse (IB, IC).13,138,177,212,2135. Ensure that appropriate gloves in the correct size are readily accessible (IC).136. Use appropriate gloves (e.g., puncture- and chemical-resistant utility gloves) when cleaning instruments and performing housekeeping tasks involving contact with blood or OPIM (IB, IC).7,13,157. Consult with glove manufacturers regarding the chemi-cal compatibility of glove material and dental materials used (II).D. Sterile Surgeon’s Gloves and Double Gloving During Oral Surgical Procedures1. Wear sterile surgeon’s gloves when performing oral sur-gical procedures (IB).2,8,1372. No recommendation is offered regarding the effectiveness of wearing two pairs of gloves to prevent disease transmis-sion during oral surgical procedures. The majority of stud-ies among health care personnel (HCP) and DHCP have demonstrated a lower frequency of inner glove perforation III. Hand HygieneA. General Considerations1. Perform hand hygiene with either a nonantimicrobial or antimicrobial soap and water when hands are visibly dirty or contaminated with blood or other potentially infectious material. If hands are not visibly soiled, an alcohol-based hand rub can also be used. Follow the manufacturer’s instructions (IA).1232. Indications for hand hygiene includea. when hands are visibly soiled (IA, IC);b. after bare-handed touching of inanimate objects likely to be contaminated by blood, saliva, or respi-ratory secretions (IA, IC);c. before and after treating each patient (IB);d. before donning gloves (IB); ande. immediately after removing gloves (IB, IC).7–9, 11,13,113,120–123,125,126,1383. For oral surgical procedures, perform surgical hand antisep-sis before donning sterile surgeon’s gloves. Follow the man-ufacturer’s instructions by using either an antimicrobial soap and water, or soap and water followed by drying hands and application of an alcohol-based surgical hand-scrub product with persistent activity (IB).121–123,127–133,144,1454. Store liquid hand-care products in either disposable closed containers or closed containers that can be washed and dried before refilling. Do not add soap or lotion to (i.e., top off) a partially empty dispenser (IA).9,120,122,149,150B. Special Considerations for Hand Hygiene and Glove Use1. Use hand lotions to prevent skin dryness associated with handwashing (IA).153,1542. Consider the compatibility of lotion and antiseptic products and the effect of petroleum or other oil emol-lients on the integrity of gloves during product selec-tion and glove use (IB).2,14,122,1553. Keep fingernails short with smooth, filed edges to allow thorough cleaning and prevent glove tears (II).122,123,1564. Do not wear artificial fingernails or extenders when hav-ing direct contact with patients at high risk (e.g., those in intensive care units or operating rooms) (IA).123,157–1605. Use of artificial fingernails is usually not recommended (II).157–1606. Do not wear hand or nail jewelry if it makes donning gloves more difficult or compromises the fit and integ-rity of the glove (II).123,142,143IV. PPE (Personal Protective Equipment)A. Masks, Protective Eyewear, and Face Shields1. Wear a surgical mask and eye protection with solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures likely to Wilkins9781451193114-appx5.indd 1197 07/10/15 10:51 AM 1198 APPENDIX V | Guidelines for Infection Control in Dental Health Care Settings10. Inform DHCP of all OSHA guidelines for exposure to chemical agents used for disinfection and steriliza-tion. Using this report, identify areas and tasks that have potential for exposure (IC).15B. Instrument Processing Area1. Designate a central processing area. Divide the instru-ment processing area, physically or, at a minimum, spatially into distinct areas for (1) receiving, cleaning, and decontamination; (2) preparation and packaging; (3) sterilization; and (4) storage. Do not store instru-ments in an area where contaminated instruments are held or cleaned (II).173,247,2482. Train DHCP to employ work practices that prevent contamination of clean areas (II).C. Receiving, Cleaning, and Decontamination Work Area1. Minimize handling of loose contaminated instruments during transport to the instrument processing area. Use work-practice controls (e.g., carry instruments in a cov-ered container) to minimize exposure potential (II). Clean all visible blood and other contamination from dental instruments and devices before sterilization or disinfection procedures (IA).243,249–2522. Use automated cleaning equipment (e.g., ultrasonic cleaner or washer-disinfector) to remove debris to im-prove cleaning effectiveness and decrease worker expo-sure to blood (IB).2,2533. Use work-practice controls that minimize contact with sharp instruments if manual cleaning is necessary (e.g., long-handled brush) (IC).144. Wear puncture- and chemical-resistant/heavy-duty utility gloves for instrument cleaning and decontami-nation procedures (IB).75. Wear appropriate PPE (e.g., mask, protective eyewear, and gown) when splashing or spraying is anticipated during cleaning (IC).13D. Preparation and Packaging1. Use an internal chemical indicator in each package. If the internal indicator cannot be seen from outside the package, also use an external indicator (II).243,254,2572. Use a container system or wrapping compatible with the type of sterilization process used and that has received FDA clearance (IB).243,247,2563. Before sterilization of critical and semicritical instru-ments, inspect instruments for cleanliness, then wrap or place them in containers designed to maintain steril-ity during storage (e.g., cassettes and organizing trays) (IA).2,247,255,256E. Sterilization of Unwrapped Instruments1. Clean and dry instruments before the unwrapped steril-ization cycle (IB).248and visible blood on the surgeon’s hands when double gloves are worn; however, the effectiveness of wearing two pairs of gloves in preventing disease transmission has not been demonstrated (Unresolved issue).V. Contact Dermatitis and Latex HypersensitivityA. General Recommendations 1. Educate DHCP regarding the signs, symptoms, and diagnoses of skin reactions associated with frequent hand hygiene and glove use (IB).5,31,32 2. Screen all patients for latex allergy (e.g., take health history and refer for medical consultation when latex allergy is suspected) (IB).32 3. Ensure a latex-safe environment for patients and DHCP with latex allergy (IB).32 4. Have emergency treatment kits with latex-free prod-ucts available at all times (II).32VI. Sterilization and Disinfection of Patient-Care ItemsA. General Recommendations 1. Use only Food and Drug Administration (FDA)-cleared medical devices for sterilization and follow the manufacturer’s instructions for correct use (IB).248 2. Clean and heat-sterilize critical dental instruments before each use (IA).2,137,243,244,246,249,407 3. Clean and heat-sterilize semicritical items before each use (IB).2,249,260,407 4. Allow packages to dry in the sterilizer before they are handled to avoid contamination (IB).247 5. Use of heat-stable semicritical alternatives is encour-aged (IB).2 6. Reprocess heat-sensitive critical and semicritical in-struments by using FDA-cleared sterilant/high-level disinfectants or an FDA-cleared low-temperature ster-ilization method (e.g., ethylene oxide). Follow manu-facturer’s instructions for use of chemical sterilants/ high-level disinfectants (IB).243 7. Single-use disposable instruments are acceptable al-ternatives if they are used only once and disposed of correctly (IB, IC).243,383 8. Do not use liquid chemical sterilants/high-level disin-fectants for environmental surface disinfection or as holding solutions (IB, IC).243,245 9. Ensure that noncritical patient-care items are barrier-protected or cleaned, or if visibly soiled, cleaned and disinfected after each use with a U.S. Environmental Protection Agency (EPA)-registered hospital disin-fectant. If visibly contaminated with blood, use an EPA-registered hospital disinfectant with a tubercu-locidal claim (i.e., intermediate level) (IB).2,243,244Wilkins9781451193114-appx5.indd 1198 07/10/15 10:51 AM APPENDIX V | Guidelines for Infection Control in Dental Health Care Settings 11999. The following are recommended if the repeat spore test is positive:a. Do not use the sterilizer until it has been inspected or repaired or the exact reason for the positive test has been determined (II).9,243b. Recall, to the extent possible, and reprocess all items processed since the last negative spore test (II).9,243,283c. Before placing the sterilizer back in service, rechal-lenge the sterilizer with biological indicator tests in three consecutive empty chamber sterilization cycles after the cause of the sterilizer failure has been determined and corrected (II).9,243,28310. Maintain sterilization records (i.e., mechanical, chem-ical, and biological) in compliance with state and local regulations (IB).243G. Storage Area for Sterilized Items and Clean Dental Supplies1. Implement practices on the basis of date- or event- related shelf-life for storage of wrapped, sterilized in-struments and devices (IB).243,2842. Even for event-related packaging, at a minimum, place the date of sterilization, and if multiple steril-izers are used in the facility, the sterilizer used, on the outside of the packaging material to facilitate the retrieval of processed items in the event of a steriliza-tion failure (IB).243,2473. Examine wrapped packages of sterilized instruments be-fore opening them to ensure the barrier wrap has not been compromised during storage (II).243,2844. Reclean, repack, and resterilize any instrument package that has been compromised (II).5. Store sterile items and dental supplies in covered or closed cabinets, if possible (II).285VII. Environmental Infection ControlA. General Recommendations1. Follow the manufacturers’ instructions for correct use of cleaning and EPA-registered hospital disinfecting prod-ucts (IB, IC).243–2452. Do not use liquid chemical sterilants/high-level dis-infectants for disinfection of environmental surfaces (clinical contact or housekeeping) (IB, IC).243–2453. Use PPE, as appropriate, when cleaning and disinfecting environmental surfaces. Such equipment might include gloves (e.g., puncture- and chemical-resistant utility), protective clothing (e.g., gown, jacket, or lab coat), and protective eyewear/face shield, and mask (IC).13,15B. Clinical Contact Surfaces1. Use surface barriers to protect clinical contact sur-faces, particularly those that are difficult to clean (e.g., switches 2. Use mechanical and chemical indicators for each un-wrapped sterilization cycle (i.e., place an internal chemical indicator among the instruments or items to be sterilized) (IB).243,2583. Allow unwrapped instruments to dry and cool in the sterilizer before they are handled to avoid contamina-tion and thermal injury (II).2604. Semicritical instruments that will be used immediately or within a short time can be sterilized unwrapped on a tray or in a container system, provided that the instru-ments are handled aseptically during removal from the sterilizer and transport to the point of use (II).5. Critical instruments intended for immediate reuse can be sterilized unwrapped if the instruments are main-tained sterile during removal from the sterilizer and transport to the point of use (e.g., transported in a ster-ile covered container) (IB).2586. Do not sterilize implantable devices unwrapped (IB).243,2477. Do not store critical instruments unwrapped (IB).248F. Sterilization Monitoring1. Use mechanical, chemical, and biological monitors ac-cording to the manufacturer’s instructions to ensure the effectiveness of the sterilization process (IB).248,278,2792. Monitor each load with mechanical (e.g., time, temper-ature, and pressure) and chemical indicators (II).243,2483. Place a chemical indicator on the inside of each pack-age. If the internal indicator is not visible from the out-side, also place an exterior chemical indicator on the package (II).243,254,2574. Place items/packages correctly and loosely into the ster-ilizer so as not to impede penetration of the sterilant (IB).2435. Do not use instrument packs if mechanical or chemical indicators indicate inadequate processing (IB).243,247,2486. Monitor sterilizers at least weekly by using a bio-logical indicator with a matching control (i.e., bio-logical indicator and control from same lot number) (IB).2,9,243,247,278,2797. Use a biological indicator for every sterilizer load that contains an implantable device. Verify results before us-ing the implantable device, whenever possible (IB).243,2488. The following are recommended in the case of a posi-tive spore test:a. Remove the sterilizer from service and review ster-ilization procedures (e.g., work practices and use of mechanical and chemical indicators) to determine whether operator error could be responsible (II).8b. Retest the sterilizer by using biological, mechanical, and chemical indicators after correcting any identi-fied procedural problems (II).c. If the repeat spore test is negative, and mechanical and chemical indicators are within normal limits, put the sterilizer back in service (II).9,243Wilkins9781451193114-appx5.indd 1199 07/10/15 10:51 AM 1200 APPENDIX V | Guidelines for Infection Control in Dental Health Care Settingsimmediately before removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping (IC).2,8,13,113,115c. Pour blood, suctioned fluids, or other liquid waste carefully into a drain connected to a sanitary sewer system, if local sewage discharge requirements are met and the state has declared this an acceptable method of disposal. Wear appropriate PPE while performing this task (IC).7,9,13VIII. Dental Unit Waterlines, Biofilm, and Water QualityA. General Recommendations1. Use water that meets EPA regulatory standards for drinking water (i.e., ≤500 CFU/mL of heterotrophic water bacteria) for routine dental treatment output water (IB, IC).341,3422. Consult with the dental unit manufacturer for appro-priate methods and equipment to maintain the recom-mended quality of dental water (II).3393. Follow recommendations for monitoring water quality provided by the manufacturer of the unit or waterline treatment product (II).4. Discharge water and air for a minimum of 20–30 seconds after each patient, from any device connected to the dental water system that enters the patient’s mouth (e.g., handpieces, ultrasonic scalers, and air/ water syringes) (II).2,311,3445. Consult with the dental unit manufacturer on the need for periodic maintenance of antiretraction mechanisms (IB).2,311B. Boil-Water Advisories1. The following apply while a boil-water advisory is in effect:a. Do not deliver water from the public water system to the patient through the dental operative unit, ul-trasonic scaler, or other dental equipment that uses the public water system (IB, IC).341,342,346,349,350b. Do not use water from the public water system for dental treatment, patient rinsing, or handwashing (IB, IC).341,342,346,349,350c. For handwashing, use antimicrobial-containing products that do not require water for use (e.g., alcohol-based hand rubs). If hands are visibly con-taminated, use bottled water, if available, and soap for handwashing or an antiseptic towelette (IB, IC).13,1222. The following apply when the boil-water advisory is cancelled:a. Follow guidance given by the local water utility regarding adequate flushing of waterlines. If no guidance is provided, flush dental waterlines and faucets for 1–5 minutes before using for patient care (IC).244,346,351,352on dental chairs) and change surface barriers between pa-tients (II).1,2,260,2882. Clean and disinfect clinical contact surfaces that are not barrier-protected, by using an EPA-registered hospital disinfectant with a low- (i.e., human immunodeficiency virus [HIV] and HBV label claims) to intermediate-level (i.e., tuberculocidal claim) activity after each patient. Use an intermediate-level disinfectant if visibly con-taminated with blood (IB).2,243,244C. Housekeeping Surfaces1. Clean housekeeping surfaces (e.g., floors, walls, and sinks) with a detergent and water or an EPA-registered hospital disinfectant/detergent on a routine basis, de-pending on the nature of the surface and type and degree of contamination, and as appropriate, based on the loca-tion in the facility, and when visibly soiled (IB).243,2442. Clean mops and cloths after use and allow to dry before reuse; or use single-use, disposable mop heads or cloths (II).243,2443. Prepare fresh cleaning or EPA-registered disinfecting solutions daily and as instructed by the manufacturer (II).243,2444. Clean walls, blinds, and window curtains in patient-care areas when they are visibly dusty or soiled (II).9,244D. Spills of Blood and Body Substances1. Clean spills of blood or OPIM and decontaminate sur-face with an EPA-registered hospital disinfectant with low-level (i.e., HBV and HIV label claims) to interme-diate-level (i.e., tuberculocidal claim) activity, depend-ing on size of spill and surface porosity (IB, IC).13,113E. Carpet and Cloth Furnishings1. Avoid using carpeting and cloth-upholstered furnish-ings in dental operatories, laboratories, and instrument processing areas (II).9,293–295F. Regulated Medical Waste1. General recommendationsa. Develop a medical waste management program. Disposal of regulated medical waste must follow fed-eral, state, and local regulations (IC).13,301b. Ensure that DHCP who handle and dispose of regu-lated medical waste are trained in appropriate han-dling and disposal methods and are informed of the possible health and safety hazards (IC).132. Management of regulated medical waste in dental health care facilitiesa. Use a color-coded or labeled container that pre-vents leakage (e.g., biohazard bag) to contain non-sharp regulated medical waste (IC).13b. Place sharp items (e.g., needles, scalpel blades, orth-odontic bands, broken metal instruments, and burs) in an appropriate sharps container (e.g., puncture re-sistant, color-coded, and leakproof ). Close container Wilkins9781451193114-appx5.indd 1200 07/10/15 10:51 AM APPENDIX V | Guidelines for Infection Control in Dental Health Care Settings 12012. Use single-dose vials for parenteral medications when possible (II).376,3773. Do not combine the leftover contents of single use vials for later use (IA).376,3774. The following apply if multidose vials are used:a. Cleanse the access diaphragm with 70% alcohol before inserting a device into the vial (IA).380,381b. Use a sterile device to access a multiple-dose vial and avoid touching the access diaphragm. Both the needle and syringe used to access the multidose vial should be sterile. Do not reuse a syringe even if the needle is changed (IA).380,381c. Keep multidose vials away from the immediate pa-tient treatment area to prevent inadvertent con-tamination by spray or spatter (II).d. Discard the multidose vial if sterility is compro-mised (IA).380,3815. Use fluid infusion and administration sets (i.e., IV bags, tubings, and connections) for one patient only and dis-pose of appropriately (IB).378D. Single-Use (Disposable) Devices1. Use single-use devices for one patient only and dispose of them appropriately (IC).383E. Preprocedural Mouthrinses1. No recommendation is offered regarding use of prepro-cedural antimicrobial mouthrinses to prevent clinical infections among DHCP or patients. Although studies have demonstrated that a preprocedural antimicrobial rinse (e.g., chlorhexidine gluconate, essential oils, or povidoneiodine) can reduce the level of oral microor-ganisms in aerosols and spatter generated during routine dental procedures and can decrease the number of mi-croorganisms introduced in the patient’s bloodstream during invasive dental procedures,391–399 the scientific evidence is inconclusive that using these rinses prevents clinical infections among DHCP or patients (see discus-sion, Preprocedural Mouthrinses) (Unresolved issue).F. Oral Surgical Procedures1. The following apply when performing oral surgical procedures:a. Perform surgical hand antisepsis by using an antimi-crobial product (e.g., antimicrobial soap and water, or soap and water followed by alcohol-based hand scrub with persistent activity) before donning ster-ile surgeon’s gloves (IB).127–132,137b. Use sterile surgeon’s gloves (IB).2,7,121,123,137c. Use sterile saline or sterile water as a coolant/ irrigatant when performing oral surgical procedures.d. Use devices specifically designed for delivering ster-ile irrigating fluids (e.g., bulb syringe, single-use dis-posable products, and sterilizable tubing) (IB).2,121b. Disinfect dental waterlines as recommended by the dental unit manufacturer (II).IX. Special ConsiderationsA. Dental Handpieces and Other Devices Attached to Air and Waterlines1. Clean and heat-sterilize handpieces and other intra-oral instruments that can be removed from the air and waterlines of dental units between patients (IB, IC).2,246,275,356,357,360,4072. Follow the manufacturer’s instructions for cleaning, lubrication, and sterilization of handpieces and other intraoral instruments that can be removed from the air and waterlines of dental units (IB).361–3633. Do not surface-disinfect, use liquid chemical sterilants, or ethylene oxide on handpieces and other intraoral instruments that can be removed from the air and wa-terlines of dental units (IC).2,246,250,2754. Do not advise patients to close their lips tightly around the tip of the saliva ejector to evacuate oral fluids (II).364–366B. Dental Radiology1. Wear gloves when exposing radiographs and handling contaminated film packets. Use other PPE (e.g., protec-tive eyewear, mask, and gown) as appropriate if spatter-ing of blood or other body fluids is likely (IA, IC).11,132. Use heat-tolerant or disposable intraoral devices when-ever possible (e.g., film-holding and positioning de-vices). Clean and heat-sterilize heat-tolerant devices between patients. At a minimum, high-level disinfect semicritical heat-sensitive devices, according to manu-facturer’s instructions (IB).2433. Transport and handle exposed radiographs in an aseptic manner to prevent contamination of developing equip-ment (II).4. The following apply for digital radiography sensors:a. Use FDA-cleared barriers (IB).243b. Clean and heat-sterilize, or high-level disinfect, be-tween patients, barrier-protected semicritical items. If the item cannot tolerate these procedures, then, at a minimum, protect with an FDA-cleared barrier and clean and disinfect with an EPA-registered hospital disinfectant with intermediate-level (i.e., tuberculo-cidal claim) activity, between patients. Consult with the manufacturer for methods of disinfection and sterilization of digital radiology sensors and for pro-tection of associated computer hardware (IB).243C. Aseptic Technique for Parenteral Medications1. Do not administer medication from a syringe to mul-tiple patients, even if the needle on the syringe is changed (IA).378Wilkins9781451193114-appx5.indd 1201 07/10/15 10:51 AM 1202 APPENDIX V | Guidelines for Infection Control in Dental Health Care Settingswhen using lasers in dental practice. Practices to reduce HCP exposure to laser plumes/surgical smoke have been suggested, including use of (a) standard precau-tions (e.g., high-filtration surgical masks and possibly full face shields)437; (b) central room suction units with in-line filters to collect particulate matter from mini-mal plumes; and (c) dedicated mechanical smoke ex-haust systems with a high-efficiency filter to remove substantial amounts of laser-plume particles. The effect of the exposure (e.g., disease transmission or adverse respiratory effects) on DHCP from dental applications of lasers has not been adequately evaluated (see previ-ous discussion, Laser/Electrosurgery Plumes or Surgical Smoke) (Unresolved issue).K. Mycobacterium Tuberculosis1. General recommendationsa. Educate all DHCP regarding the recognition of signs, symptoms, and transmission of tuberculosis (TB) (IB).20,21b. Conduct a baseline TST, preferably by using a two-step test, for all DHCP who might have contact with persons with suspected or confirmed active TB, re-gardless of the risk classification of the setting (IB).20c. Assess each patient for a history of TB as well as symptoms indicative of TB and document on the medical history form (IB).20,21d. Follow CDC recommendations for (1) develop-ing, maintaining, and implementing a written TB infection-control plan; (2) managing a patient with suspected or active TB; (3) completing a community risk-assessment to guide employee TSTs and follow-up; and (4) managing DHCP with TB disease (IB).2,212. The following apply for patients known or suspected to have active TB:a. Evaluate the patient away from other patients and DHCP. When not being evaluated, the patient should wear a surgical mask or be instructed to cover mouth and nose when coughing or sneezing (IB).20,21b. Defer elective dental treatment until the patient is noninfectious (IB).20,21c. Refer patients requiring urgent dental treatment to a previously identified facility with TB engineering con-trols and a respiratory protection program (IB).20,21L. Creutzfeldt-Jakob Disease (CJD) and Other Prion Diseases1. No recommendation is offered regarding use of special precautions in addition to standard precautions when treating known CJD or vCJD patients. Potential in-fectivity of oral tissues in CJD or vCJD patients is an unresolved issue. Scientific data indicate the risk, if any, of sporadic CJD transmission during dental and oral surgical procedures is low to nil. Until additional information exists regarding the transmissibility of CJD or vCJD during dental procedures, special precautions G. Handling of Biopsy Specimens1. During transport, place biopsy specimens in a sturdy, leakproof container labeled with the biohazard symbol (IC).2,13,142. If a biopsy specimen container is visibly contaminated, clean and disinfect the outside of a container or place it in an impervious bag labeled with the biohazard sym-bol, (IC).2,13H. Handling of Extracted Teeth1. Dispose of extracted teeth as regulated medical waste unless returned to the patient (IC).13,142. Do not dispose of extracted teeth containing amalgam in regulated medical waste intended for incineration (II).3. Clean and place extracted teeth in a leakproof con-tainer, labeled with a biohazard symbol, and maintain hydration for transport to educational institutions or a dental laboratory (IC).13,144. Heat-sterilize teeth that do not contain amalgam before they are used for educational purposes (IB).403,405,406I. Dental Laboratory1. Use PPE when handling items received in the labo-ratory until they have been decontaminated (IA, IC).2,7,11,13,1132. Before they are handled in the laboratory, clean, disin-fect, and rinse all dental prostheses and prosthodontic materials (e.g., impressions, bite registrations, occlusal rims, and extracted teeth) by using an EPA-registered hospital disinfectant having at least an intermediate-level (i.e., tuberculocidal claim) activity (IB).2,249,252,4073. Consult with manufacturers regarding the stability of specific materials (e.g., impression materials) relative to disinfection procedures (II).4. Include specific information regarding disinfection tech-niques used (e.g., solution used and duration), when labo-ratory cases are sent off-site and on their return (II).2,407,4095. Clean and heat-sterilize heat-tolerant items used in the mouth (e.g., metal impression trays and face-bow forks) (IB).2,4076. Follow manufacturers’ instructions for cleaning and sterilizing or disinfecting items that become contami-nated but do not normally contact the patient (e.g., burs, polishing points, rag wheels, articulators, case pans, and lathes). If manufacturer instructions are un-available, clean and heat-sterilize heat-tolerant items or clean and disinfect with an EPA-registered hospital disinfectant with low-level (HIV, HBV effectiveness claim) to intermediate-level (tuberculocidal claim) ac-tivity, depending on the degree of contamination (II).J. Laser/Electrosurgery Plumes/Surgical Smoke1. No recommendation is offered regarding practices to reduce DHCP exposure to laser plumes/surgical smoke Wilkins9781451193114-appx5.indd 1202 07/10/15 10:51 AM APPENDIX V | Guidelines for Infection Control in Dental Health Care Settings 1203ACKNOWLEDGMENTThe Division of Oral Health thanks the working group as well as CDC and other federal and external reviewers for their efforts in developing and reviewing drafts of this re-port and acknowledges that all opinions of the reviewers might not be reflected in all of the recommendations.ReferenceA comprehensive list of references can be found in the original article: Centers for Disease Control and Prevention. Guide-lines for Infection Control in Dental Health Care Settings, 2003. MMWR. 2003;52 (RR-17):1–61. http://www.cdc.gov/ oralhealth/infectioncontrol/guidelines. Accessed October 2011.in addition to standard precautions might be indicated when treating known CJD or vCJD patients; a list of such precautions is provided for consideration without recommendation (see Creutzfeldt Jakob Disease and Other Prion Diseases) (Unresolved issue).M. Program Evaluation1. Establish routine evaluation of the infection-control program, including evaluation of performance indica-tors, at an established frequency (II).470,471Wilkins9781451193114-appx5.indd 1203 07/10/15 10:51 AM Wilkins9781451193114-appx5.indd 1204 07/10/15 10:51 AM 1205Appendix VIAverage Measurements of Human TeethTABLE A-1 Average Measurements of the Primary Teeth (In Millimeters) OVERALL LENGTH LENGTH OF CROWN LENGTH OF ROOTWIDTH OF CROWN (MESIALDISTAL AT WIDEST POINT)Maxillary Central incisorLateral incisorCanineFirst molarSecond molar16.015.819.015.217.56.05.66.55.15.710.011.413.510.011.76.55.17.07.38.2Mandibular Central incisorLateral incisorCanineFirst molarSecond molar14.015.017.515.818.85.05.26.06.05.5 9.010.011.5 9.811.34.24.15.07.79.9(Reprinted with permission from Black GV. Descriptive Anatomy of the Human Teeth. 4th ed. Philadelphia, PA: The S.S. White Dental Manufacturing Company; 1897, according to Ash MM. Wheeler’s Dental Anatomy, Physiology, and Occlusion. 7th ed. Philadelphia, PA:W.B. Saunders, Co; 1993:58.)Wilkins9781451193114-appx6.indd 1205 07/10/15 10:52 AM 1206 APPENDIX VI | Average Measurements of Human TeethTABLE A-2 Average Measurements of the Permanent Teeth (In Millimeters)OVERALL LENGTHLENGTH OF CROWNLENGTH OF ROOTWIDTH OF CROWN (MESIALDISTAL AT WIDEST POINT)Maxillary Central incisorLateral incisorCanineFirst premolarSecond premolarFirst molarSecond molarThird molar23.522.027.022.522.5B L 19.5 20.5B L 17.0 19.017.5 10.5 9.9 10.0 8.5 8.5 7.5 7.0 6.513.013.017.014.014.0B L 12 13B L 11 1211.0 8.5 6.5 7.5 7.0 7.0 10.0 9.0 8.5Mandibular Central incisorLateral incisorCanineFirst premolarSecond premolarFirst molarSecond molarThird molar21.523.527.022.522.521.520.018.0 9.0 9.5 11.0 8.5 8.0 7.5 7.0 7.012.514.016.014.014.514.013.011.0 5.0 5.5 7.0 7.0 7.0 11.0 10.5 10.0B, buccal measurement; L, lingual measurement.(Reprinted with permission from Ash MM. Wheeler’s Dental Anatomy, Physiology, and Occulsion. 7th ed. Philadelphia, PA: W.B. Saunders, Co; 1993:15.)Wilkins9781451193114-appx6.indd 1206 07/10/15 10:52 AM 1207Appendix VIIPrefixes, Suffixes, and Combining FormsAa-, an- absence, lack, without, e.g., amorphousab- from, away, e.g., abnormalad- (change d to c, f, g, p, s, or t before words beginning with those consonants) to, toward, e.g., adhesion, accretionadeno- gland, e.g., adenobroma-algia pain, e.g., neuralgiaambi- all (both) sides, round, e.g., ambidexterityamelo- enamel, e.g., amelogenesisamphi-, ampho- on both sides, double, e.g., amphodiplopiaana- up, excessive, again, e.g., anabolismandro- masculine, male, e.g., androgenangio- vessel, e.g., angiomaante- before, e.g., antefebrileanti- against, e.g., antidoteaqu-, aqua- water, e.g., aqueousarthro-, arth- joints, e.g., arthritis-ase denotes an enzyme, e.g., dextrinase-asthenia weakness, e.g., myasthenia gravisauto-, aut- self, e.g., autotransplantBbi- two, twice, double, e.g., bifurcationbio-, bi- life, living, e.g., biopsy-blast formative cell, e.g., osteoblast-brachy- short, e.g., brachydactylicbrady- slow, e.g., bradycardiabucc- cheek, e.g., buccinatorCcalc- stone, calcium, lime, e.g., calcicationcardio-, cardi- heart, e.g., cardiovascularcata- down, against, e.g., catabolism-cele swelling, protrusion, hernia, e.g., meningocelecephalo-, cephal- head, e.g., cephalometrycerebro-, cerebr- brain, e.g., cerebral palsycheilo-, cheil- lip, e.g., cheilitischloro-, chlor- pale green, e.g., chlorophyllchromo-, chromat- color, pigmentation, e.g., chromogenic-cidal killing, e.g., bactericidal-clast break up, divide into parts, e.g., osteoclast-clus- shut, e.g., occlusionco-, com-, con-, cor- with, together, e.g., congenitalcoll- glue, e.g., colloidcontra- opposite, e.g., contralateralcryo, cry- cold, freezing, e.g., cryotherapycuti- skin, e.g., cuticlecyan- blue, e.g., cyanotic-cyto-, -cyt- cell, e.g., leukocyteD-dactyl, dactylo- ngers, e.g., dactyledemade- down, away from, separation, e.g., decalcicationdenti-, dent- tooth, e.g., dentition-derm-, derma- skin, e.g., hypodermicdextr-, dextro- right, toward right, e.g., dextrocardiadi- twice, two, e.g., diplopiadis- separation, opposite, taking apart, e.g., disinfectdisto-, dist- posterior, distant from center, e.g., distobuccal-drome course, e.g., syndromedur- hard, e.g., indurationdys- bad, ill, difcult, e.g., dystrophyEecto-, ect- without, outer side, e.g., ectoderm-ectomy surgical removal, e.g., gingivectomy-emia (-aemia) blood condition, e.g., bacteremiaen- in, on, into, e.g., endemicencephal-, encephalo- brain, e.g., encephalomeningitisendo- inside, e.g., endodonticsentero-, enter- intestine, e.g., enterotoxinepi- upon, after, in addition, e.g., epidermiserythro-, eryth- red, e.g., erythemaesthesio-, esthesia (-aesthesia) sensation, perception, e.g., anesthesiaex- beyond, from, out of, e.g., exudateextra- outside of, beyond the scope of, e.g., extracellularFfaci- face, e.g., facial-facient causes or brings about, e.g., rubefacient-ferent carry, bear, e.g., afferentWilkins9781451193114-appx7.indd 1207 07/10/15 10:53 AM 1208 APPENDIX VII | Prefixes, Suffixes, and Combining FormsLlabio- lip, e.g., labioversionlacto-, lact- milk, e.g., lactationlaryngo-, laryn- larynx, e.g., laryngitislater- side, e.g., lateroversionleuko-, leuk- white, e.g., leukoplakialinguo, lingu- tongue, e.g., linguallipo-, lip- fat, fatty, e.g., lipoma-logy doctrine, science, e.g., periodontologylympho-, lymph- lymph, e.g., lymphangioma-lysin, -lysis, -lytic dissolving, destructive, e.g., hemolysisMmacro-, macr- enlargement, elongated part, e.g., macrodontiamal- bad, ill, e.g., malnutritionmast-, mastro- breast, e.g., mastectomy-megalo-, -megal- large, great, e.g., megaloblastmelano- dark-colored, relating to melanin, e.g., melanogenesismeningo-, mening- meninges, e.g., meningitismeno- month, e.g., menopausemes-, medi, mesio- middle, intermediate, e.g., mesodermmeta-, met- over, beyond, transformation, e.g., metabolismmetro-, metra- uterus, e.g., metrobroma-metry measure, e.g., cephalometrymicro-, micr- small, e.g., microorganismmono- one, single, e.g., monosaccharidemorpho-, morph- form, shape, e.g., morphologymuco-, muc- relating to mucous membrane, e.g., mucogingivalmyel-, myelo- bone marrow, spinal cord, e.g., myeloblastmylo- molar teeth or posterior portion of mandible, e.g., mylohyoidmyo-, my- muscle, e.g., myocardiumNnaso- nose, e.g., nasopalatinenecr- death, e.g., necroticneo-, ne- new, recent, e.g., neoplasmnephro-, nephr- kidneys, e.g., nephritisneuro-, neuri-, neur- pertaining to nerves, e.g., neurasthenianucleo-, nucle- pertaining to nucleus, e.g., nucleoproteinOob- (change b to c before words beginning with c) against, toward, e.g., occlusionodonto-, odont- tooth, e.g., odontalgia-oid like, resembling, e.g., ameboid-olig-, oligo- a few, a little, e.g., oligodontia-oma swelling, tumor, e.g., lipoma-opia, -opy sight, eye defect, e.g., myopiaoro- mouth, oral, e.g., oronasalbro-, br- bers, brous tissue, e.g., broblastfract- break, e.g., fractionalGgalacto-, galact- milk, e.g., galactosegastro-, gastr- stomach, e.g., gastritis-gen- produced, e.g., glycogengenio- chin, lower jaw, e.g., genioplastygerm- bud, early growth, e.g., germinalgero- old age, e.g., gerodonticsglosso-, gloss- tongue, e.g., glossitisgluco-, glue- glucose, e.g., gluconeogenesisglyco-, glyc- sweet, e.g., glyceringnatho-, gnath- jaw, e.g., gnathodynamometer-gnosis knowledge, e.g., prognosis-gram, -graph write, draw, e.g., radiographicgran- grain, particle, e.g., granulomagyn-, gyne-, gynec- woman, e.g., gynecologyHhemi- half, e.g., hemisectionhemo- (haemo-) blood, e.g., hemorrhagehepato-, hepat- liver, e.g., hepatitishetero-, heter- other, different, e.g., heterogeneoushisto-, hist- tissue, e.g., histologyhomo-, homeo- like, similar, e.g., homeostasishydro-, hydr- water, e.g., hydrocephalichygro-, hygr- moisture, e.g., hygrophobiahyper- abnormal, excessive, e.g., hypertrophyhypno-, hypn- sleep, e.g., hypnotichypo-, hyp- deciency, lack, below, e.g., hypotonichystero-, hyster- uterus or hysteria, e.g., hysterectomyI-ia state or condition, e.g., glycosuriaiatro- relation to medicine, a physician, dentist, or other health professional, e.g., iatrogenic-ic of, pertaining to, e.g., gastricidio- one’s own, separate, distinct, e.g., idiopathicin- not, without, e.g., inactivateinfra- beneath, below, e.g., infraorbitalinter- between, among, e.g., intercellularintra- within, into, e.g., intraoralischo-, isch- suppression, stoppage, e.g., ischemiaiso- equality, similarity, e.g., isotonic-ist one who practices, holds certain principles, e.g., hygienist-itis inammation, e.g., dermatitisJ-ject- throw, e.g., injectionjuxta- next to, near, e.g., juxtapositionKkaryo-, kary- nucleus of a cell, e.g., karyolysiskerato-, kerat- horny, keratinized tissue, e.g., keratinizationkin- move, e.g., kineticWilkins9781451193114-appx7.indd 1208 07/10/15 10:53 AM APPENDIX VII | Prefixes, Suffixes, and Combining Forms 1209retro- back, backward, behind, e.g., retromolar-rhage breaking, bursting forth, profuse ow, e.g., hemorrhage-rhea (-rhoea) ow, discharge, e.g., pyorrhearhino-, rhin- nose, e.g., rhinitisrube- red, e.g., rubefacientSsarco- esh, muscle, e.g., sarcomasclero- hard, e.g., scleroderma-scopy examination, inspection, e.g., microscopysemi- half, partly, e.g., semipermeablesero- serum, serous, e.g., seropurulentsial-, sialo- saliva, e.g., sialographysomat-, somato-, -some body, e.g., chromosome-squam- scale, e.g., desquamativestomat- mouth, e.g., stomatitissub- beneath, under, decient, e.g., subacutesuper- above, upon, excessive, e.g., supernumerary toothsupra- above, e.g., supragingival calculussyn- with, together, e.g., syndromeTtachy- swift, e.g., tachycardiatact- touch, e.g., tactiletera-, terato- monster, malformed fetus, e.g., teratogenicthermo- heat, e.g., thermophilethrombo-, thromb- clot, coagulation, e.g., thrombin-thym-, thymo- mind, soul, emotions, e.g., dysthymiatrans- beyond, through, across, e.g., transplantationtropho-, trophic nutrition, nourishment, e.g., hypertrophic-tropic turning toward, changing, e.g., hydrotropicU-ule diminutive, small, e.g., tubule-uria urine, e.g., glucosuriaVvaso- blood vessels, e.g., vasodilationvita- life, e.g., vitaminXxero- dry, e.g., xerostomiaortho-, orth- straight, normal, e.g., orthodontics-osis condition, state, e.g., cyanosisosteo-, oste- bone, e.g., osteoporosisoto-, ot- ear, e.g., otoplasty-ous full of, having, e.g., aqueousovi-, ovo-, ovu- egg, e.g., ovulationPpan- all, every, general, e.g., panaceapara- beyond, beside, near, e.g., parasitepatho-, path- disease, e.g., pathognomonicpedia-, pedo- (paedo-) child, e.g., pedodontics-penia deciency, e.g., leukopeniaper- throughout, completely, e.g., percussionperi- around, near, e.g., periapicalphago- to eat, e.g., phagocytic-phile, -phil- loving, e.g., hemophiliaphlebo-, phleb- vein, e.g., phlebitis-phobe, -phobia fear, dread, e.g., photophobiapilo- hair, e.g., piloerection-plas- mold, shape, e.g., gingivoplastyplasmo-, plasm form, e.g., cytoplasm-plegia, -plexy paralysis, stroke, e.g., hemiplegiapleo- more, e.g., pleomorphism-pnea (-pnoea) breathing, e.g., dyspneapneumo- air, lung, e.g., pneumothorax-poiesis, -poietic production, e.g., erythropoieticpoly- many, much, e.g., polysaccharidepont- bridge, e.g., ponticporo-, -por- opening, pore, duct, e.g., porouspost- behind, after, e.g., postnatalpre- before, in front of, e.g., premaxillapro- before, in front of, e.g., prognathicproprio- one’s own, e.g., proprioceptiveproto- rst, e.g., protoplasmpseudo- false, deceptive, e.g., pseudomembranepsycho-, psych- mind, mental processes, e.g., psychosomaticpulmo- lung, e.g., pulmonarypur- pus, e.g., purulentpyo- pus, e.g., pyorrheapyro- fever, heat, e.g., pyrogenicRre- back, again, e.g., regurgitate-renal kidney, e.g., adrenalWilkins9781451193114-appx7.indd 1209 07/10/15 10:53 AM Wilkins9781451193114-appx7.indd 1210 07/10/15 10:53 AM 1211Appendix VIIICharting Symbols and Standardized Abbreviations Useful for Documenting Dental Hygiene Care*SELECTED SYMBOLS COMMONLY USED IN DENTAL CHARTINGSYMBOL MEANING“X” or “ = ” Missing tooth or ponticñFractureOpen contact➜Increase➜Decrease➜ midline ➜Drifted mesially➜ midline ➜ Drifted distallyRotated clockwiseRotated counterclockwiseC/ Complete upper denture/C Complete lower dentureSTANDARDIZED ABBREVIATIONSABBREVIATION TERMabn abnormalBOP bleeding on probingbp blood pressurebrux bruxism or bruxerbw, bwx, or bwxr;pa or pax;pan or panobite wing radiograph; periapical radiograph; panoramic radiographCAL clinical attachment levelCalc calculusCC chief complaintCEJ cementoenamel junctionchk check, observecm centimetercons consultationdebrd debridementdecid deciduous, primarydemo demonstratedent hx dental historydup duplicatedx diagnosisemerg emergencyesp especiallyeval evaluate, evaluationEx, exam examinationexf exfoliateext extractionf/u follow-upF, fl, Ftx APF NaFSnF fluoride, fluoride treatment; acidu-lated phosphate fluoride; sodium fluoride, stannous fluoride*Selected from the complete list available in: American Dental Association. Dental Abbreviations, Symbols, and Acronyms. 2nd ed. Chicago, IL; American Dental Association; 2008:5–20. Used with permission.Wilkins9781451193114-appx8.indd 1211 07/10/15 10:55 AM 1212 APPENDIX VIII | Charting Symbols and Standardized Abbreviations Useful for Documenting Dental Hygiene CareABBREVIATION TERMpre op; post op preoperative, postoperativeprev prevention, preventiveprog, Px prognosispt patientq4h every 4 hours q6h every 6 hoursq1d every dayqid every dayqod every other dayquad; LRQ; URQ quadrant; lower right quadrant; upper right quadrantreapp, reappt reappoint(ment)re-eval re-evaluationRMH reviewed medical historyrp/sc, RPS, S&RP, SRP scaling and root planing Rx prescriptionS&Sx, S/S signs and symptomsS/D BP systolic/diastolic blood pressureSPT supportive periodontal treatmentstat immediatelysut suturesub, subggv, subgin subgingivalsupp supperatioSupra ggv supragingivaltb toothbrushTID three times per day TMD temporomandibular joint disordertmj temporomandibular jointTx treatmentunk unknownvar varnishwnl within normal limitsABBREVIATION TERMfgm, GM free gingival margin, gingival marginfood imp food impactionfur, furc furcationging gingival, gingivalH, hx, hist, h/o history, history ofHH, med hx health history, medical historyhtn, hbp hypertension, high blood pressurehyg dental hygieneIC informed consentINS insuranceLA; lido xylo; vasolocal anesthesia, Lidocaine; Xylocaine; vasoconstrictormand; max mandibular; maxillarymdl midlinemeds medicationsMGJ mucogingival junctionn/a; n/c; n/d not applicable; no change; not determinedN2O nitrous oxideNKA; NKDA no known allergies; no known drug allergiesNSPT non surgical periodontal therapynv next visitocc, occl occlusal or occlusionOHI oral hygiene instructionsOTC over the counterpk, pkt pocketPLD partial lower denturePOI post operative instructionsPFG porcelain fused to goldPFM porcelain fused to metalpol polishPPE personal protective equipmentWilkins9781451193114-appx8.indd 1212 07/10/15 10:55 AM 1213AAbfraction, 764b, 767f, 800bAbilify, 1074, 1079Abrasions, 57, 273, 781bgingiva, 449btooth, 449b, 909–910, 910fAbrasive, denition, 595b, 781bAbrasive particlescharacteristics of, 785–786Mohs hardness value of, 785tprinciples for application of, 786Abscess, 740bAbsence seizure, denition, 1059, 1059bAbsolute contraindication, 635bAbstinence, 1087bAbuse, 1049, 1087bAbutment, 515b, 534bAcademy of Periodontology, 780Acamprosate, 1093Acanthosis negricans, 1179fAcceptance, motivational interviewing and, 423Accessory root canal, 270bAccommodative speech, 36Accuracy, denition, 136tAcellular, 256bAcetaminophen, 636, 838t, 1120Acid etchant, 620b, 621Acid production, 437Acidogenic bacteria, 436, 436bAcidogenic, denition, 488b, 595bAcidulated phosphate uoride (APF), 595bAcne rosacea, 1087bAcne vulgaris, 888bAcoustic turbulence, 715bAcquired hemolytic disorders, 1152Acquired immunodeciency syndrome (AIDS), 60, 61b. See also HIV/AIDS infectionAcquired lymphocytopenia, 1156Acquired pellicle, 256–258formation, 256–257removal, 258signicance, 258types, 257–258Acquired platelet dysfunction, 1157Actinomyces, 50Active immunity, 47bActive listening, 420bActivities of daily living (ADL), 396b, 982bAcute bronchitis, 1113comparison of viral and bacterial, 1114tAcute, denition, 740b, 1109bAcute Graft-Versus-Host Disease (GVHD), 949Acute necrotizing ulcerative gingivitis (ANUG), 740Acute periodontal conditions, key words, 740bAcute primary herpetic gingivostomatitis, 1048bAcute pulmonary edema, 1140Acute seroconversion syndrome, 62Adaptation, denition, 664bAdaptive behavior, 1036b, 1037Addiction, 1087bAddis, William, 449Adequate intakes (Als), 573, 573bAdjunctive therapyantibiotics for, 730–731antimicrobials for, 730, 730tdocumentation, 735, 736bAdministrator/manager, 8tAdolescence and puberty. See also Adolescentscommunication skills, 34–35uoride therapy, 897hormonal contraceptives, 895menopause, 895–896menstruation, 894pubertal changes, 893–894stages of, 893Adolescents. See also Adolescence and pubertybleaching of tooth, 803health, 840oral health care, 854, 854b, 858accident and injury prevention, 872dietary and feeding pattern recommendations, 870eating disorders, 870iron-deciency anemia, 870oral health considerations for, 872–873psychosocial development of, 859tAdrenal crisis, symptoms of, 893bAdrenal glands, 892–893hyperadrenalism/Cushing’s syndrome, 892–893hypoadrenalism/Addison’s disease/adrenal insufciency, 893Adrenalin, 643, 645Adsorption, 256bAdult-onset diabetes. See Type 2 diabetes mellitusAdult speech aid prosthesis, 878bAdultsblood pressure classications, 182tbody temperature of, 174brush and head design of power toothbrushes, 461health history form, 155fpulse, 176respiratory rate, 177–178selection of uoride dentifrice, 611Advanced cardiac life support (ACLS), 115bAdvanced dental hygiene practitioner (ADHP), 4b, 10, 982bAdvanced dental therapist, 982bAdvanced life support (ALS), 115bAdvanced practice dental hygiene, 10–11Adverse pregnancy outcomes, 397Advisory Committee on Immunization Practices (ACIP), 68Aerobe, 256bAerosols, 47b, 49, 70microorganisms in, 49production, 49Affect, 30b, 1070bAfrmation, 420b, 423, 427Ageism, 901bAgenda setting, for motivational interviewing, 425–426Aging, 901bbiological and chronological, 900caries prevention, 911classication by function, 900immunologic functioning of, 903optimal, 900oral ndings inabrasion, 909–910, 910fangular cheilitis, 907attrition, 909lips, 907–908oral candidiasis, 908oral mucosa, 908periodontium, 911pulpal changes, 909, 909froot caries, 910–911, 910fteeth, 908–909tongue, 908xerostomia, 908IndexNote: Page numbers followed by “f”, “t” and “b” refer to gures, tables and boxes, respectively.Wilkins9781451193114-index.indd 1213 08/10/15 9:40 AM Aging (continued)physiologic, 900–901primary, 900secondary, 900Agitation, 1070bAgranulocytes, 1150AIDS–dementia complex, 62Air-powder polishing system, 781b, 793–796, 794fcontraindicated risk patients, 795–796principles of application, 793recommendations and precautions, 795recommendations for use of airpolishing on restorative materials, 796tspecially formulated powders for use in, 793–794techniques, 794–795uses and advantages of, 794Airborne infection, 48–50control of, 50isolation measures, 53precautions, 46Akinesia, 997bAlbuterol (Ventolin, Levabuterol, Pirbuterol), 1120tAlcohol-based hand rub, 74Alcohol intoxication, 1087b, 1086. See also Alcohol useAlcohol-related disorder, 1086–1093alcohol abuse in seniors, 906Alcohol-related neurodevelopment disorder (ARND), 1091bAlcohol-sensitizing agents, for alcoholism, 1092Alcohol use, 1086–1088, 1173alcohol withdrawal syndrome, 1091–1092cardiovascular diseases, 1090clinical pattern of, 1086digestive system, 1090etiology, 1088fetal alcohol spectrum disorders, 1090–1091health hazards of, 1089–1090immunity and infection, 1090liver disease, 1089–1090metabolism of, 1088–1089blood alcohol concentration, 1089diffusion, 1089ingestion and absorption, 1088liver metabolism, 1089neoplasms, 1090nervous system, 1090nutritional deciencies, 1090reproductive system, 1090spectrum of, 1088fAlcohol withdrawal syndrome, 1091–1092complications, 1092predisposing factors, 1092rehabilitation, 1093signs and symptoms, 1092Alcoholism, 1087b, 1093. See also Alcohol usein older adults, 905signs of, 1086, 1088treatment for, 1092Alexidine, 363Alginate, 240bAligner system, 502bAllergens. See AntigenAllergic rhinitis, 1112tAllergy, 152blocal anesthesia and, 647–648Allograft, 535Alloplast, 535denition, 534bAlopecia, 945b, 947, 1048bAltered taste sensations, 580tAlternative settings, dental hygiene care in. See Dental hygiene care, in alternative settingsAlumina, 786Aluminum lters, 168Aluminum trihydroxide, 793Alveolar bone, 303biomechanical force, 535classication of, 535evidence of adequate depth of, 538grafting and regeneration, 535Alveolar crest ber, 303Alveolar mucosa, 302, 319Alveolar process fractures, 937–938Alveolectomy, 752bAlveologingival bers, 302Alzheimer’s disease, 901b, 904–905bdental hygiene care, 903–904, 905bearly onset, 903guidelines for caregivers, 905blate onset, 903stages of, 904bsymptoms, 903–904treatment, 904Ambient air, 635bAmbivalence, 420bAmbulate, 982bAmelogenesis, 270bAmelogenesis imperfecta, 360b, 364Amenorrhea, 888bAmerican Academy of Orthopedic Surgeons (AAOS), 168American Academy of Pediatric Dentistry (AAPD), 595b, 601, 854American Academy of Periodontology (AAP), 313b, 449, 854American Dental Association (ADA), 83b, 595b, 601, 764b, 854evidence-based dentistry website, 23brecord forms, 153Seal of Acceptance Programbackground, 496–498product submission and acceptance process, 497, 498fpurposes, 497American Dental Association Council on Scientic Affairs (ADACSA), 595b, 602American Dental Hygienists’ Association (ADHA), 4b, 14, 780Code of Ethics for dental hygienists, 1183–1186roles of dental hygiene, 8tStandards for Clinical Dental Hygiene Practice, 2American Heart Association (AHA), 115bantibiotic prophylaxis, 168American manual alphabet, 1028fAmerican sign language (ASL), 1027American Society of Anesthesiologists (ASA), 396bphysical status classication system, 169–170, 397, 398tAmerican Water Works Association (AWWA), 595b, 599Americans with Disabilities Act (ADA), 956, 956b, 1022Amethystic agent, for alcoholism, 1087b, 1092Amide anesthetic drugs, 642–643Amitriptyline, 1073Ammeter, 205bAmnesia, 1087bAmorphous calcium phosphate (ACP), 773for extrinsic stain removal, 787Amorphous, denition of, 350bAmoxicillin, 731, 838tAmpere, 206Amphetamines, 1096tAmyotrophic lateral sclerosis (ALS), 1004–1005dental hygiene care, 1004–1005diagnosis, 1004etiology and pathogenesis, 1004occurrence, 1004symptoms, 1004treatment, 1004two forms of, 1004Anabolic steroids, 1096tAnaerobe, 256bAnalgesia, 635b, 1087bAnalgesic, denition, 1109bAnalog, 209bAnaphylaxis, 1109bAnaplasia, 945bAnatomic tooth drawings, 143f, 145Anemia, 1151–1152bone marrow failure, 1152clinical characteristics of, 1152folate-deciency, 1153–1154iron deciency, 1152–1153megaloblastic, 1153–1154nutritional deciency, 1152pernicious, 1153Anergy, 47bAneroid sphygmomanometer, 178Anesthesia, 635bAnestheticsbuffered local, 661with epinephrine, 838t, 842intranasal dental, 661reversal agent, 660–661Aneurysm, 1130bAngel dust, 1096Angina, 1130blocal anesthesia and, 648Angina pectoris, 1130b, 1138Angioneurotic edema, 114bAngled, denition, 449b1214 INDEXWilkins9781451193114-index.indd 1214 08/10/15 9:40 AM INDEX 1215Angular cheilitis, 923Angular cheilosis, 580tAngulationbitewing surveys, 228denition, 664bdigital radiography, 224occlusal surveys, 229Animal studies, 26Ankylosis, 286b, 997bAnodontia, 918bAnorexia nervosa, 1075, 1076fcharacteristics of, 1076bAnoxia, 175b, 1130bAntabuse, 1087b, 1092–1093Anterograde amnesia, 1087bAnti-HBe-positive, 56Anti-HBsAg, 56Anti-HSV, 57Antianxiety agent, 1070bAntibacterial agents, 862Antibiotic prophylaxisfor cardiac conditions for, 168bfor dental and dental hygiene procedures, 168–169, 168–169bdental, oral, respiratory tract, or esophageal procedures, 169tguidelinesAmerican Academy of Orthopedic Surgeons (AAOS), 168American Heart Association (AHA), 168recommendations, 169Antibiotic(s)denition, 701bpremedication, 152bfor adjunctive therapy, 730–731Anticariogenic food, 572bAnticholinesterase, for myasthenia gravis, 1006Anticipatory guidance, 396b, 836b, 845t, 854b, 868–873accident and injury prevention, 871dietary and feeding pattern, 868–870digit habits, 871oral health considerations for toddlers/preschoolers, 870–871speech and language development, 871Anticoagulant, 1130bfor cardiovascular disease, 1142–1143Anticonvulsant, 1059bfor Alzheimer’s disease, 904Anticraving agents, for alcoholism, 1092Antidepressants, for Alzheimer’s disease, 904Antiepileptic/antiseizure, 1059bAntigen, 1109bAntigingivitis dentifrice, 489Antimicrobial agent, 83b, 488bAntimicrobial soap, 69b, 74Antimicrobial therapy, 701bAntimicrobials, 838tfor adjunctive therapy, 730local delivery of, 730t, 731–732Antioxidants, 572bAntipsychotics, for Alzheimer’s disease, 904Antipyretic, 1109bAntiretroviral therapy (ART), 60Antiseptic, 83bAntiseptic mouthrinse, 50Anxiety control, 403Anxiety disorders, 13b, 635b, 1071–1072dental hygiene care, 1072treatment of, 1072types and symptoms of, 1071–1072Anxiolytic medication, 1070bApatite, 350b, 595bAphasia, 30b, 997bAphtha, 186bApical ber, 303Apnea, 175b, 1130bApoptosis, 997bAppearance, as form of communication, 31Appliance, 502bAppointment plan, for multiple visits, 413Arch wire, 502b, 503Area-specic curet, 664bapplication, 669description, 668design, 669purposes and uses, 668–669Ariboavinosis, 572bAripiprazole (Abilify), 1074, 1079Arkansas stone, 686b, 687, 687fArrested caries, 270b, 436bArrhythmia, 114b, 1130bArterial blood, 1130bArteriosclerosis, 1130bArthralgia, 1130bArthritis, 904–905, 1012–1013, 1013fArticaine HCL, 644Articulating paper, 620b“5 A’s,” for tobacco cessation methods, 562–565, 563fAs Low as reasonably achievable (ALARA), 205bASA classication, 635bAscorbic acid, 579tAsepsis, 83b, 752bAseptic technique, 83b“Ask, Validate, Document, Refer (AVDR) Tutorial for Dentists,” 1053Asperger disorder, 1042bAsphyxia, 1130bAspiration, 635bAspirin, 838t, 1118, 1120, 1155, 1157, 1159Assessment, 396bAssociation of State and Territorial Dental Directors’ (ASTDD) Basic Screening Survey, 371, 389, 390t, 391tAsthma, 1118–1121atopic, 1119attack, 1119dental hygiene care, 1121, 1121tetiology, 1118, 1118foral manifestations, 1121treatment, 1119–1121types, categories, and examples of medications, 1120tAstigmatism, 1023bAstringent, 488bAsymptomatic carrier, 47bAt-home bleaching, 807Ataxia, 997b, 1059bAtaxic palsy, 1007–1008Atheroma, 1130bAtherosclerosis, 1130b, 1137, 1137fAtonic, 1059bAtrophy, 997bAttached gingiva, 301–302examination ofconsistency, 307size, 302surface texture, 307Attachment, 701bapparatus, 298bAttenuation, 205bAttitudinal barrier, to communication, 32tAttrition, 272–273Audiogram, 1023bAudiologist, 1023bAudiometer, 1023bAudiotactile, 1023bAugment, denition, 534bAugmentation, 534bAura, 1059b, 1060Aural, 1023bAuscultation, 175bAuthenticity, denition, 136tAutism spectrum disorder (ASD), 1041–1043, 1042bcharacteristics, 1041–1042dental hygiene care, 1043etiology, 1042levels of severity, 1042bprevalence, 1042treatment, 1042–1043Autistic disorder, 1042bAutograft, 535, 878bAutoinjector, 114bAutomated external debrillator (AED), 115bAutomatism, 1059bAutonomic dysreexia, 998–999Autonomic neuropathy, 1175Autonomic symptoms, 1059bAutonomy, 420b, 423Autopolymerization, 620b, 621Avulsion, 270bAzithromycin, 731AZT (ZDV), 61bBB-cell lymphoma of brain, 62B complex, 580Backscatter, 208bBacteremia, 152b, 466, 701bBacteria-laden aerosols, 50Bacterial infections, associated with HIV infection, 63Bacterial toxin, 313bBacteroides melaninogenius, 839Balanced instrument, 667, 667fBand, 502bBarbiturates, 1095tBarrier-free environment, 956b, 960–961Wilkins9781451193114-index.indd 1215 08/10/15 9:40 AM Barriersfor HCP, 69bfor patient, 69bprotection, 69bBasic cardiac life support (BCLS), 115bBasic life support (BLS), 114b, 115bcertication, 122–123Basophils, 1150Bass method (sulcular brushing)of anterior surfaces, 455limitations, 455position of brush, 454procedure, 454–455, 454fpurposes and indications, 454repositioning of brush, 455strokes, 454Becker muscular dystrophy, 1010Beclomethasone dipropionate (Vanceril), 1120tBedaquiline fumarate, 1117tBehaviorchange, 420bdenition, 420bmodication, 956btherapy, 956bBell’s palsy, 1002Benign, 945bBenzocaine (ester), 658, 659, 659tBenzodiazepines, 1095tBest practice, 20bBeta cells, 1164bBetel leaf chewing, 363Bibulous, denition, 620bBidigital palpation, 187, 187fBidis, 550bBid uvula, 878bBilateral palpation, 187, 188fBimanual palpation, 187, 188fBinder, 781bBinge-eating disorder, 1075Bioabsorbable, denition, 701bBioaccumulated stress, 100bBioburden, 83bBiocompatibility, 534b, 620bBiodegradable, denition, 701bBiolm, 83b, 256bbacterial multiplication and colonization, 259calcium and phosphorus in, 263carbohydrates in, 263carious lesions and, 266changes in microorganisms, 259–261, 260fcharacteristics of supragingival and subgingival, 261–262tcomposition, 263–264denition, 258detection of, 264–265distribution of, 264documentation, 267, 267beffect of diet on, 266effect of food debris, 267uoride in, 293formation, 489, 912–913, 93. See also Dental biolm control programgingivitis effect on, 261growth and maturation, 259index, 976materia alba, 266–267matrix formation, 259maturation, 353microorganisms in, 265pellicle formation, 258and periodontal infectious diseases, 265pH of, 265–266proteins in, 264signicance of, 265stages in formation of, 258–259supragingival and subgingivalmicroorganisms, 261, 263forganization of, 262source, 261Biolm control record, 373fprocedure, 373purpose, 372scoring, 373calculation, example, 375interpretation, 375selection of teeth and surfaces, 372Biolm-free score, 370, 374fpapillary bleeding on probing, 375procedure, 374purpose, 373scoring, 374–375calculation, 375interpretation, 375selection of teeth and surfaces, 374Biolm-induced gingivitis, 863Biohazard, 83bBiologic age, 901bBiologic effects, of radiation, 215bBiologic indicator, 83bBiologic or permucosal seal, 534bBiologic vector, 48bBiomedical databases, 20b, 23, 23bBiopsy, 198–199Biotherapy, 945bBipolar disorder, 1074–1075dental hygiene care, 1075signs and symptoms, 1074treatment of, 1074–1075Bisphenol A-glycidyl methylacrylate, 620bBisphosphonates, 906Bitewing surveys, in radiation, 223lm/sensor placement, 227–228, 228flm/sensor position, 228horizontal angulation, 228preparation, 227Black, G. V., 275Black-line stain, 362Blackout, 1087bBlade, 664banatomy, 667Blade form dental implant, 534bBleaching of tooth, 800bdental hygiene of care, 810–811documentation, 811–812, 812bhistory, 800–801indications and methods of treatment, 805tissues associated with light-activated, 803bnonvital, 800–801, 809–810procedure for, 810bvital, 801vital vs nonvital, 800benets of, 806color change with, 801comparisons of modes of, 808tcontraindications, 803decision making for, 804tdesensitization procedures, 806tefcacy, 803, 805against uorosis, 805indications, 805tinteractions with bleaching agents, 802irreversible tooth damage, 806–807longevity of results, 805–806materials used for, 801–802mechanism of, 801modes, 807, 809against nicotine, 805over-the-counter bleaching preparations, 810bsafety, 802–803side effects, 806against tetracycline and minocycline staining, 805, 805fvs whitening, 800Bleeding on probing, 13bBlind spot, 1023bBlindness, 1023bBlisterform lesions, 194Block anesthesia, 635bBlock-out resins, 800bBlood alcohol concentration (BAC), 1089effects of, 1089tBlood cellsred. See Red blood cellsreference values, 1151twhite. See White blood cellsBlood disordersanemia, 1151–1152bone marrow failure, 1152clinical characteristics of, 1152nutritional deciency, 1152bleeding disorders, 1157–1158, 1158bcoagulation disorders, 1157–1158dental hygiene care plan, 1158–1160documentation, 1160, 1160biron deciency anemia, 1152–1153megaloblastic anemia, 1153–1154normal blood, 1148patient teaching, 1161platelet disorders, 1156–1157polycythemias, 1155–1156sickle cell disease, 1152, 1154–1155, 1154fwhite blood cells, 1156Blood pressure, 178–182classication of, 1136tcomponents of, 178diastolic pressure, 178pulse pressure, 178systolic pressure, 178equipment for determining, 178–179factors inuencing, 178follow-up criteria, 181–1821216 INDEXWilkins9781451193114-index.indd 1216 08/10/15 9:40 AM INDEX 1217levels, 1135–1136maintenance of, 178procedure for determining, 179–181recordings, 180selection of cuff and position, 178–179, 179f, 180fBody language, 100bBody mechanics, 100bBody position, as form of communication, 31Body temperatureof adults, 174care of patient with temperature elevation, 176of children, 174–175factors that alter, 175fever, 175hyperthermia, 175hypothermia, 175indications for taking, 174locations of measurement, 175maintenance of, 174–175measuring using thermometer, 175–176method of determining, 175–176normal, 174–175of older adults, 174variations, 175Bond strength, 620bBonded bracketsadvantages, 502–503arch wire, 503base, 503characteristics of bonding and rebonding, 504clinical procedures for bonding, 504disadvantages, 503effect of ller particles, 504elastomer, 503xed appliance system, 502–503f, 503and uoride-releasing bonding systems, 504forms, 503, 503fmaterials, 503removable aligner system, 503–504Bonding (mechanical), 502b, 620bBony ankylosis, 997bBooster dose, 69bBorder mold, 752bBordetella pertussis, 52tBoxing technique, 248Brachycephalic, denition, 1036bBracket, 502bBradycardia, 175b, 1130bBradykinesia, 997b, 1070bBraille, 31, 1023bBrainstorming, motivational interviewing and, 431Bremsstrahlung radiation (white radiation), 208bBrief motivational interviewing (BMI), 423Bristle, 449bBrittle diabetes, 1164bBroad spectrum, 83bBronchitis, due to tobacco use, 552Bronchodilator, 1109bBrown pellicle, 363Brown stain, 363, 363fBrush-on gel with uoridepreparation, 610procedure, 611Bruxism, 270b, 292, 1078parafunctional, 286bBuccal frena, 302Buccoversion of teeth, 289Buffer, 436bBulimia nervosa, 1075, 1077fcharacteristics of, 1077bBulla, 194Bupivacaine HCL, 644–645Bupriopion (Wellbutrin), 1073, 1075Bupropion SR, 558t, 559Burning mouth syndrome, 896Burnishing, 686b, 764b, 772, 772fButamben, 659CCachexia, 1048bCalcitonin, 906Calcium carbonate (whiting, calcite, chalk), 786, 793Calcium, for extrinsic stain removal, 787Calcium phosphate, 802Calcium sodium phosphosilicate (Novamin), 773–774, 794Calculogenic, 256bCalculus, 346, 350f, 542–543, 706. See also Subgingival calculusattachment of, 354by direct contact, 354by means of an acquired pellicle, 354by mechanical locking, 354biolm maturation, 353classication and distribution of, 350–352subgingival, 351–352, 351t, 352fsupragingival, 350–352, 351t, 352fclinical characteristics, 351t, 355composition, 352–353inorganic content, 352–353organic content, 353dental endoscopy, 355documentation, 356–357, 357bformation, 353–354complete denture, 522prevention using dentifrice, 489gingival tissue color change, 355keywords, 350bmineralization, 353morphology of, 708pellicle formation, 353prevention of, 355personal dental biolm control, 356professional removal, 356using anticalculus dentifrice and mouthrinse, 356radiographic examination, 355signicance of, 354–355relation to attachment loss and pocket formation, 355relation to dental biolm, 355structure, 353–534subgingival examination, 355, 356fsupragingival examination, 355tactile examination, 355time of formation, 354Calculus removal, 703using manual instruments, 709Calibration, 328b, 370bCAMBRA (Caries Assessment and Management by Risk Assessment), 399, 412, 436b, 854b, 863Canadian Dental Hygienists’ Association (CDHA), 4b, 14Code of Ethics, 1189–1191CancerAcute Graft-Versus-Host Disease, 949chemotherapy, 946–947Chronic-Graft-Versus-Host Disease, 949common signs and symptoms of, 946bdental hygiene care, 950–952, 951bdescription, 944documentation, 953, 953bhematopoietic cell transplantation, 948–949incidence and survival, 944keywords, 945bmucositis management, 949–950prevention/oral health maintenance, 949treatment, 949–950multidisciplinary team for care, 946bradiation therapy, 947–948risk factors, 944surgery for, 944, 946and tobacco use, 552treatment, 944types of, 944Candida albicans, 53t, 63t, 527, 922Candidiasis, 63, 580tCannabinoids (Marijuana), 1094, 1096Cannula, 114b, 701bCarbamazepine, 1061t, 1072Carbamide peroxide, 775, 801f, 802, 802fCarbatrol, 1061tCarbocaine, 644Carbopol, 802Carcinogen, 549b, 945bCarcinoma, 945bCardiac arrest, 114bCardiac pacemakers, 1141–1142, 1142fCardiac surgery, for cardiovascular disease, 1143–1144Cardiopulmonary resuscitation (CPR), 115bCardiovascular disease (CVD), 397, 829, 907angina pectoris, 1138classication, 1131congenital heart diseases, 1132–1134congestive heart failure, 1139–1140documentation, 1144, 1144bdue to tobacco use, 552, 553hypertension, 1135–1136hypertensive heart disease, 1136infective endocarditis, 1131–1132ischemic heart disease, 1137mitral valve prolapse, 1134–1135Wilkins9781451193114-index.indd 1217 08/10/15 9:40 AM Cardiovascular disease (CVD) (continued)myocardial infarction, 1138–1139rheumatic heart disease, 1134treatment, 1140–1144Caries management based on risk assessment (CAMBRA) protocol, 399, 412, 436b, 854b, 863Caries risk assessment, 436bCariogenic challenge, 595bCariogenic, denition, 256b, 270bCariogenic exposure, 572band biolm pH, 588fCariogenic food, 572bCariology, 436bCariostatic, denition, 595bCarious, denition, 270bCarrier, 47bCase reports, 26Case–control series (retrospective), 25Casein phosphopeptide–amorphous calcium phosphate (CPP-ACP), 773Cassette, 205bCast (model), 240bCasual plasma glucose, 1164bCataract, 1023bCatatonia, 1070bCause-and-effect relationships, 25Cavitated carious lesion, 436bCavitation, 436b, 715bCavity, 436bCD4 + T lymphocytes, 61bCementicle, denition, 270bCementoenamel junction, 339Cementum, 303, 703Centers for Disease Control and Prevention (CDCP), 47b, 69b, 549b, 595bprevention recommendations tuberculosis (TB), 54Central hearing loss, 1026Centric occlusion, 240b, 286bCentric relation, 286bCephalometer, 286bCephalometric analysis, 286bCephalosporins, 838tCephalostat, 286bCeramic aluminum oxide, 687, 687fCeramic, denition of, 502bCerebral palsyaccompanying conditions, 1008classications, 1007description, 1007medical treatment, 1008oral characteristics, 1008–1009Cerebrovascular accident (CVA), 997bCervical carcinoma, 62Cetylpyridinium chloride mouth rinse, 838tChain of asepsis, 83bChange talk, 420beliciting and recognizing, 429–430mobilizing, 429b, 430preparatory, 429–430, 429bsustain talk versus, 427–428Characteristic radiation, 208bCharcot’s joints, 1164bCharge-coupled device (CCD), 209bCharters method of toothbrushing, 457–458of anterior lingual and palatal surfaces, 458limitations, 458position of brush, 457strokes, 458Charting, 138bdental, 145forms used for, 142items to be charted, 145for patient chair time, 142periodontal and dental, 141–142, 143fpurpose, 142radiographic, 143sequence for, 142–143systematic procedure, 142–143Chaw, 550bCheiloplasty, 878bCheilorhinoplasty, 878bChelation therapy, 1148bChemical cure, 752bChemical-cured dressings, 758Chemical dependence, 549b, 1087bChemical disinfectantscategories, 91criteria for selection of chemical agent, 91–92principles of action, 91properties of ideal, 91buses, 91Chemical indicator, 83bChemical vapor sterilizer, 90Chemiclave sterilizer, 90Chemotherapeutic agent, 488, 488bcharacteristics of, 495bChemotherapy, 488b, 701b, 945bcomplications, 947dental hygiene plan of care, 951–952indications, 947objectives, 947systemic side effects, 947types, 947, 947bChest radiography (imaging), for respiratory disease, 1108, 1110Chewing tobacco, 550bChewstick, 448Chickenpox (varicella), 46, 59Chief complaint, 396, 396bChild maltreatment, 1048–1052denitions, 1049extraoral wounds and signs of trauma, 1049general signs of abuse and neglect, 1049intraoral signs of abuse, 1049, 1051intraoral signs of neglect, 1049major types of, 1048tparental attitude, 1051–1052physical and behavioral indicators, 1050tsigns of oral neglect, 1051signs of sexual abuse, 1049Childhood disintegrative disorder, 1042bChildrenbleaching of tooth, 803body temperature, 174–175brush and head design of power toothbrushes, 461environmental tobacco smoke (ETS), impact in, 554–555gingivachanges in disease, 308–309mixed dentition, 308mucogingival problems, 309periodontitis, 308primary dentition, 308signs of health, 308–309health history form, 156fhealth promotion and disease prevention plan, 431, 432bmaltreatment. See Child maltreatmentand periodontal infection, 504pulse, 176oral health care. See Children, oral health carerespiratory rate, 178selection of uoride dentifrice, 611and use of dentifrice, 491Children, oral health careadolescents, 854anticipatory guidance, 868–873caries-risk assessment, 864tclassication of, 863principles, 863purpose, 863steps, 863child-friendly terms, 855tdocumentation, 873, 873bearly childhood caries (ECC), 865–868rst dental hygiene visit, 854–855infants, 854key words, 854bmilestones in child development, 857toral malodor, 871oral soft and hard tissue conditions/pathology, 856tas patient, 854periodontal risk assessment, 862–863gingival and periodontal evaluation, 862–863periodontal infections, 863preschoolers, 854referral, 872–873school-aged children, 854tobacco/piercings/substance abuse, 872toddlers, 854, 855–856treatment planning and consent, 873Chisel scaler, 672, 672fChlorhexidine (CHX), 363, 443, 488b, 540, 838t, 1064availability and use, 492–493, 492fconsiderations for use, 493, 493fefcacy, 493mechanism of action, 492Chlorophyll, 360bChlorpromazine (Thorazine), 1079Cholinergic crisis, 1006–1007Chromogenic pigment, 360bChronic bronchitis, 1121–1122Chronic, denition, 740b, 1109b1218 INDEXWilkins9781451193114-index.indd 1218 08/10/15 9:40 AM INDEX 1219Chronic-Graft-Versus-Host Disease, 949Chronic lymphocytic leukemia, 1156Chronic obstructive pulmonary disease (COPD), 549b, 639, 1121–1123chronic bronchitis, 1121–1122classication, 1122dental hygiene care, 1123due to tobacco use, 552emphysema, 1122oral manifestations, 1123stable, 1122–1123, 1122ftreatment of, 1122Chronologic age, 901bChronologic, denition, 360bChurchill, H.V., 598Cicatrix, 313bCigar, 550bCigarette, 550bCipro and minocycline, 365Ciprooxacin, 731Ciproozacin, 838tCircuit voltmeter, 206Circumferential bers (circular), 302Circumferential molar bands, 502Circumpubertal, 888bCitanest, 644Clarithromycin, 838tCleaning agents, 785Cleaning procedures, for infection controlcare of brushes, 86manual cleaning, 86methods for precleaning instruments, 85, 85fprocedure for manual scrubbing, 86ultrasonic processing, 86, 86fusing washer/thermal disinfector, 85, 85fClearance time, 572bCleft lip and/or palate, 878b, 880fclassication, 879dental caries, 881–882dental hygiene care, 883–884documentation, 884, 885betiology, 879general physical characteristics, 879keywords, 878bmalocclusion, 880muscle coordination, 881open palate, 880–881oral characteristics, 879–881orthodontics, 882periodontal tissues, 881prosthodontics, 882restorative dentistry, 883speech therapy, 882tooth development, 879–880treatment, 881–883, 882bClefts, 307Clenching, 292Clindamycin, 731, 838tClinical attachment level (CAL), 298b, 328bClinical attirehair and head covering, 69–70protective clothing, 69Clinical Practice of The Dental Hygienist, 6b, 12Clinical signicance, 20bClinical trialpurpose, 371uses, 371Clinical/patient circumstances, 21Clinician, 8tchair, 82experience and judgment, 21Clonazepam, 1061tClonic, 1059bClopidogrel, 1159Clorazepate, 1061tClosed neural tube defect, 1010Clostridium tetani (tetanus bacillus), 48Clozapine (Clozaril), 1079Coagulation disorders, 1157–1158types of, 1157–1158Coagulation factor, 1148bCoapt, 752bCobalamin, 578tCocaethylene, 1098Cocaine, 1095t, 1096t, 1097, 1101bCocaine hydrochloride powder, 1097Cochrane Collaboration database, 24Cochrane Library, 23bCode of ethics, 14, 27Codeine, 838tCoe-Pak, 758Cognitive behavioral therapy (CBT), for anxiety disorders, 1072Cognitive disorder, 1070bCognitive skills, for health learning, 33tCoherent scattering, 208bCohort studies (follow-up or prospective), 25Col, 301, 301f, 472bCollaborative practice, 982bof dental hygiene, 4bCollagen, 313bdressings, 758Collagenase, 313bCollimation, 212, 218Collimator, 212Colony-forming unit (CFU), 47bColor blindness, 1023bColor, denition, 800bComa, 982bComatose, 982bCombined cognitive/psychosocial skills, for health learning, 33tCommercial-based journals/magazines, 24Comminution, 930bCommission on Dental Accreditation, 11Communicable disease, 1109bCommunicable period of disease, 47bCommunication, 30b, 420bacross lifespanadolescents, 34–35infants, 34older adults, 35–36school-age children, 34tips, 35btoddlers and preschoolers, 34–35modes of, 1026–1027predicament, of older adults, 36style, 420bCommunity-acquired pneumonia, 1114Community oral health assessment, 370bCommunity periodontal index (CPI), 379f, 380adolescents, 380for adults, 380for children, 380LOA codes, 380, 381fprocedure, 380purpose, 380selection of teeth, 380Community surveillance of oral health, 371Comorbid, 1036b, 1109bCompassion, motivational interviewing and, 423–424Compensatory behavior, 1070bCompetency, 4bComplementary-metal-oxide semiconductor (CMOS), 209bComplete denture prostheses, 515b, 521f, 918bcare of, 522components of, 521–522denture adhesives for, 526denture base, 521and denture deposits, 522denture teeth, 522occlusal surface, 522polished surface, 522deposits on, 522impression surface, 522mandibular, 523bmaxillary, 523bremoval, 522, 523bself-cleaning, 523–526by brushing, 524–525, 525fcare of plastic resin, 526description, 523by immersion, 524, 524bpreparation for, 524procedure for, 524purpose, 523when to, 523using abrasive cleansers, 526using alkaline detergent, 525using denture cleansers, 525–526using disinfectant, 526using enzyme agents, 526using paste cleansers, 526using soft conditioning lining material, 526types, 521Complete denture prosthodontics, 918bComplete patient history, 153Complex cavity, 275Compliance, 420b, 826bCompound cavity, 275Compromised therapy, 396bCompton scatter radiation, 208bComputer screen reader, 1023bConditioner, 620bConductive hearing loss, 1026Condyloma acuminatum, 1048bCone-cut technique, 212Condence, 100Condentialitydenition, 136tlaws, 35Wilkins9781451193114-index.indd 1219 08/10/15 9:40 AM Congenital, denition, 878bCongenital heart diseases, 1132–1134dental hygiene concerns, 1134signs and symptoms of, 1134Congestive heart failure (CHF), 1139–1140clinical manifestations, 1139–1140emergency care for, 1140etiology, 1139treatment during chronic stages, 1140Conscious sedation, 635bConscious state, 635bConsciousness, 1059bConstitutional disease, 62Consultation, 826bContact precautions, 46Contaminated waste, 83bContamination, 83bContinuing care, 826bContinuing care programappointment procedures, 827–828appointment intervals (frequency), 828–829care plan, 827criteria for referral to periodontist, 828dental caries control, 827oral cleanliness and self-care measures, 827oral hygiene instruction/motivation, 827periodontal scaling and debridement, 827preparation of assessment, 827supplemental care procedures, 827documentation, 830, 830bgoals of, 826key words, 826bmethods for, 829–830Continuing education unit (CEU), 4bContinuous positive airway pressure (CPAP), 1124, 1126fControlled release, 701bConventional denture, 521Convulsion, 1059bCoping, 515bCopper, 579tCo-polymer, 488bCoprolalia, 1036bCore skills, for motivational interviewing, 426–427, 426bCore temperature, 175bCore values in dental hygiene, 14b, 15lifelong learning, 15patient rst thoughts, 15personal values, 15in professional practice, 15, 15bCorium, 186bCoronal polishing, 781bCoronary artery bypass grafting (CABG), 1141, 1141fCoronary artery disease (CAD), 115bCoronary dilation, 1141Coronary heart disease, 1130blocal anesthesia and, 648Corporate, 8tCorrelational relationship, 25Corticosteroidsfor Bell’s palsy, 1002for multiple sclerosis, 1004bfor muscular dystrophies, 1010Corynebacterium diphtheriae, 52tCoryza, 1109bCosmetic effects, of dentifrice, 489Cotherapist, 4bCotinine, 549bCotton pliers, 681–682Cotton-roll isolation, 629Coumadin (warfarin), 1159Coumarin, 1142Crack, 1097Crack cocaine, 1097Craniofacial, 878bCrepitation, 114bCricothyrotomy, 114bCritical pH, 270bCromolyn sodium (Intal), 1120tCross-cultural communicationfamily decision making, 37language prociency, 37nonverbal communication, 37, 38tusing an interpreter, 37Crust, 186b, 195Cryptogenic, denition, 1059bCultural barrier, to communication, 32tCultural competence, 30b, 37–39and dental hygiene process of careassessment, 38diagnosis, 38evaluation, 39feedback, 39implementation, 39language appropriate instructions for, 39planning, 39self-evaluation, 39using “plain language” oral health materials, 39Cultural sensitivity, 30bCulturally effective oral healthcare, 30b, 37Culturally sensitive delivery, of dental hygiene serviceschecklist to enhance cultural awareness, 36bculturally effective oral care, 37effect of culture on health status, 37Culture, 30bCumulative Index to Nursing and Allied Health Literature (CINAHL), 23bCumulative index, types of, 371Cumulative trauma disorder, 100bCuret, 664b, 690, 709, 710fangulation, 677–678, 678fmaintenance of, 735parts of, 665fCurettage, 664bCuring, 620bCutting edge, 686, 686b, 687fangulation to be restored, 690examining, 690selection of, 690Cyanosis, 1130bCyclosporine, 306-induced gingival enlargement, 314Cymbalta, 1073Cyst, 186bCystic brosis (CF), 1123–1124characteristics, 1123–1124clinical signs and symptoms of, 1123tdental hygiene care, 1124treatment, 1124Cytological smear technique, 198Cytomegalovirus (CMV), 52tinfections, 60ulcers, 63DDalfampridine, for multiple sclerosis, 1004bData, 370bcollection, 370bdenition, 818bDEA drug schedules, 1087bDEA registration number, 1087bDean, H. Trendley, 598Dean’s uorosis index, 387–388procedure, 387purpose, 387scoring, 388, 388tselection of teeth, 387Debonding, 502bDebridement, 701bDecayed, indicated for extraction, and lled (df and def), 385–386calculation and interpretation, 385–386difference between deft/defs and dft/dfs, 385procedure, 385purpose, 385scoring, 385–386selection of teeth or surfaces, 385Decayed, missing, and lled (dmft and dmfs), 386calculation, 386procedure, 386purpose, 386scoring, 386selection of teeth and surfaces, 386Decayed, missing, and lled teeth (DMFT)/surfaces (DMFS), 384–385calculation and interpretation, 385procedures, 384purpose, 384scoring, 384–385selection of teeth and surfaces, 384Decibel, 1023bDecision-making processclinical/patient circumstances, 21clinician’s experience and judgment, 21model, 21fpatient preferences or values, 21scientic evidence, 21Decisional balance, 428Decoding, 30bDecompensate, 1070bDecontamination, 83bDecubitus ulcer, 997bDefective tooth development, 364–365Debrillation, 114bDebrillator, 114bDenitive care, 396b1220 INDEXWilkins9781451193114-index.indd 1220 08/10/15 9:40 AM INDEX 1221Denitive nonsurgical periodontal therapy, 705Deuoridation, 595b, 600Degenerative joint disease (osteoarthritis), 1012–1013Deinstitutionalization, 956bDelirium, 1087bDelirium tremens, 1087bDelta agent, 51t, 56Delta hepatitis virus (HDV), 51tDelta infection, 56Delusion, 1070bDementia, 901b, 1070b, 1087bDemineralization, 436b, 437, 595b, 782, 938Demyelinate, 997bDental abrasionand toothbrushing, 466contributing factors, 466corrective measures, 466denition, 466location, 466Dental ankylosis, 286bDental biolm accumulation, 13bDental biolm control program, 421from abutment teeth, 516–517diabetes mellitus, 1179effect of tobacco, 554method, 561implant systems, 540, 542prevention using dentifrice, 489toothbrushingamount of, 453–454bass method, 454Dental biolm removal, nonsurgical periodontal therapy and, 702Dental bridges, 515Dental calculus, 350b. See also CalculusDental caries, 13b, 265–266, 265f, 270b, 436bcare planningrecommendations for risk levels, 442characteristics of patients at risk for, 784chlorhexidine rinsing, 443classication, 275, 275fand consistency of food, 581counseling for, 581dental hygiene care plan for, 399development, 274diagnosis and detectionprerequisites, 437–438stages of caries, 438, 438f, 439fdietary assessment and counselling for, 581dietary modications, 443documentation, 443–444, 444bfeeding and eating disorders and, 1078uoride dentifrice for preventing, 611uoride mouthrinse, 443indices for measuring experiencedecayed, indicated for extraction, and lled (df and def), 385–386decayed, missing, and lled (dmft and dmfs), 386decayed, missing, and lled teeth (DMFT)/ surfaces (DMFS), 384–385early childhood caries (ECC and S-ECC), 386, 387troot caries index (RCI), 386–387maintenance, 443meal pattern and, 588prevention management, 439, 581prevention using dentifrice, 488–489review of initiation of, 588risk assessment, 864t, 865bapplication, 441classication of, 863current principles of management, 439identify and evaluation, 441oral health check sheet, 441bprinciples, 863purpose, 863purposes and uses of patient, 439–441risk factors, 439, 440tsteps, 863systemic disease factors, 442risk factor for, 397role of cariogenic foods, 581, 588Dental carious lesions, 443Dental chair, 82body positions for delivery of care in, 102use of, 102Dental chart, 142Dental endoscopic system, 723fDental facilities and precautionary measures for preventing diseaseinfections, 48–50process of, 48–50microorganisms of oral cavity, 46standard precautions, 46Dental ossing, for peri-implant hygiene, 540Dental uorosis, 364–365, 596indices for measuringDean’s uorosis index, 387–388tooth surface index of uorosis (TSIF), 388, 388tDental healthcare personnel (DHCP), 47b, 59, 68Dental home, 836b, 854–855, 854bDental hygiene care, 4, 4b, 5acute phase, 743–744in alternative settingsapproach to patient, 985–986assessment and care planning, 988barriers to access, 983candidiasis infection, 991common oral problems, 984community-based settings for, 984critically ill or unconscious patient, 988, 990denture problems, 991documentation, 991, 992beliminating barriers, 983instruments and equipment to provide, 986bkeywords, 982bobjectives of care, 984oral mucosa, changes in, 991portable delivery of care, 983preparation for home visit, 984–985, 985bprotocols for prevention, 988, 989tsignicance of oral health to overall health, 984terminally ill patient, 990–991treatment location, 986–987, 987fxerostomia, 991assessment and preparation for, 742–743brush selection, 505brushing procedure, 505considerations for, 1014–1016dental caries and periodontal disease control, 505–506development of profession of, 5–6bgeneral instructions, 505maintenance, 744for neurodevelopmental disorder, 1043–1045re-evaluation, 744risk factorsage groups, 504–505gingivitis, 505position of teeth, 505problems with appliances, 505self-care, 505use of hygiene instrumentation, 506Dental hygiene care centers, preparation for, 44Dental hygiene care plan, 4, 4b, 5, 13assessment ndingspatient’s statement, 396risk factors, 396–397for biolm control measures, 413considerations for providingfour-handed dental hygiene, 403pain and anxiety control, 403preprocedural antimicrobial rinsing, 403role of patient, 402tissue-conditioning program, 402–403cultural considerations, 416for dental caries, 399documentation of assessment data, 404, 404b, 416, 416bfor gingival infections, 413hygiene diagnosisbasis, 399diagnostic models, 401, 402tdiagnostic statements, 401and hygiene prognosis, 401–402, 402binformed consent, 414–416, 415bkey words, 396bmaintenance during dental therapy, 403nonsurgical periodontal therapy, 720objectives, 408parameters of care, 399, 400–401tparts ofdental caries control, 408periodontal/gingival health, 408patient-specic, 410–411fWilkins9781451193114-index.indd 1221 08/10/15 9:40 AM Dental hygiene care plan (continued)patient’s health statusActivities of Daily Living (ADL) classication, 398tphysical, 397use of tobacco, 397patient’s healthcare knowledge, 397patient’s self-care ability, 397periodontal diagnosisadvanced periodontitis, 399classication of disease, 399description of past and current periodontal conditions, 397early periodontitis, 399gingival disease, 399moderate periodontitis, 399for periodontal infections, 413presentation of plan to dentist and patient, 414and refusal of care, 416sequencing and prioritizing carefactors affecting, 413–414objectives, 413written care plan, 408components, 409–413, 409trationale for, 408Dental hygiene core values, 44tDental hygiene diagnosis, 4b, 13, 396bmodels, 401, 402tDental hygiene diagnostic statements, 412, 412tDental hygiene interventionsexpected outcomes following, 819bDental hygiene management, in HIV infection, 63–64Dental hygiene of care, 810–811care plan, 811diagnosis, 811evaluation, planning for maintenance, 811implementation, 811patient assessment, 810–811, 811fDental hygiene periodontal maintenance, 826bDental hygiene plan of carecancer patients, 950–952, 951bDental hygiene practiceassessment in, 150dental hygiene specialties, 9objectives for, 350supervision and scope of, 7types of supervision in, 9bDental Hygiene Practice Act, 7Dental Hygiene Process: Diagnosis and Care Planning, 6bDental Hygiene Process Model, 402tDental hygiene process of care, 1f, 2, 4b, 12–14, 13f, 43f, 44, 135f, 136, 149f, 150, 393f, 417f, 418, 631f, 632, 815f, 816, 833f, 834, 1099assessment, 13, 1099–1101, 1101bobjective data, 13dental biolm control, 1104dental hygiene care plan, 13dental hygiene diagnosis, 13, 13b, 1103of diabetes patients, 1176–1179diagnosis segment, 394diet and nutrition, 1104diet planning, 938–939, 939fdocumentation of care, 14evaluation, 14, 1104evaluation, 14before general surgery, 940implementation, 13–14, 1103–1104instrumentation, 938intraoral examination, 1102–1103older adults, 911–915oral and maxillofacial surgery, 931–933, 938–940personal oral care procedures, 939–940planning, 1103purposes of, 13Dental hygiene prognosis, 396b, 401–402, 402bcriteria for various prognoses, 402bexpected outcome, 401factors determining, 401Dental hygiene visitcomponents of, 858–862dental care, 855developing dentition, occlusion, and TMJ, 858–859dietary assessment, 861family conguration, 858initial interview, 858intra- and extra-oral examination, 858medical history of child, 858oral prophylaxis, 861preparation of child for, 857prevention, 861–862radiographic assessment, 860Dental hygienist, 2, 4b, 448American Dental Hygienists’ Association Code of Ethics for, 1183–1186Canadian Dental Hygienists’ Association Code of Ethics for, 1189–1191legal factors in practice, 16personal factors in practice, 16–17role in patient care, 7, 418Dental implants, need for, 534Dental index, 370bDental lesionsabrasion, 273attrition, 272–273enamel hypoplasia, 271–272erosion, 273tooth fractures, 273–274Dental local anesthetic drugs, 642Dental neglect, denition of, 1049Dental phobia, 13bDental plaster, 240bDental prosthesis, 918bDental radiographic imagingabbreviations used in, 205bgeneral radiography terms, 205bDental records, 145Dental sealants, 862Dental stains and discolorationclassication, 360with copper amalgam, 365dentures, 522differential diagnosis, 360documentation, 366, 366bfrom endodontic therapy, 365endogenous intrinsicblood-borne pigments, 365cipro and minocycline, 365defective tooth development, 364–365pulpless teeth discolor, 364tetracyclines, 365exogenous intrinsic, 365–366, 365fin dentin, 366extrinsicblack-line, 362brown, 363, 363fgreen, 361–362metallic, 364orange or red, 363–364tobacco, 362–363, 362fyellow, 361, 361fimperfect tooth development, 364–365incorporated within tooth deposits, 361keywords, 360boccurring directly on tooth surface, 360–361procedures for removal, 360–361recognition and identication, 360removal using dentifrice, 489with restorative materials, 365signicance, 360–361with silver amalgam, 365Dental stone, 240bDental therapist, 4bclinical role of, 11impact of, 11Dentally dysfunctional, 878bDentifriceactive components, 491benets of, 488cosmetic effects, 489denition, 488documentation, 498, 498buoridebenets, 611–612development, 611guidelines, 611indications, 611instructions for use, 611preparations, 611against halitosis, 489inactive components, 489–491binders (thickeners), 490cleaning and polishing agents (abrasives), 490detergents (foaming agents or surfactants), 490avoring agents (sweeteners), 491humectants (moisture stabilizers), 490preservatives, 490–491ingredients and function of, 490tkeywords, 488band pediatric patients, 491in preventing biolm formation, 489in preventing remineralization, 4891222 INDEXWilkins9781451193114-index.indd 1222 08/10/15 9:40 AM INDEX 1223in preventing supragingival calculus, 489recommendations for use, 491selection of, 491in stain removal, 489Dentin, dental stains and discoloration in, 366Dentin hypersensitivity, 764babfraction, 766adding smear layer, 767–768arginine and calcium carbonate, 773attrition, abrasion, and erosion, 766behavioral changes for, 771–772calcium phosphate, 773characteristics of pain from, 765dened, 764–765dental biolm control, 772dentifrices for, 773–774dentin-bonding agents, 774desensitization therapy, 767–768, 771, 772–773diagnostic techniques and tests, 770dietary modications, 771–772differential diagnosis, 768–770, 769tdocumentation, 775, 776benamel and cementum loss, 766etiology, 765–766evaluation of treatment interventions, 771–775for extrinsic stain removal, 787uoride gels, 773, 774uoride varnish, 774gluteraldehyde, 773, 774key words, 764blaser therapy, 774management, 770–771mouthrinses, 774occurrence of gingival recession, 765f, 766oxalate preparations, 774oxalate salts, 773pain from biting pressure, 770potassium salts, 772–773prevalence, 768prevention using dentifrice, 489and removal of calculus deposits, 768and secondary dentin, 767soft tissue grafts, 774stimuli for pain, 764–765toothbrush type and technique, 772treatment hierarchy, 771unlled or partially lled resins, 774Dentinogenesis imperfecta, 360b, 364Dentistry, 4bDentition, 270b, 858–859mixed, 270–271, 271fpermanent, 271primary, 270Dentoalveolar ber groups, 303Dentogingival bers, 302Dentoperiosteal bers, 302Denture, 515b, 918badhesive, 515b, 918bcleansers, 525–526foundation area, 918birritation hyperplasia, 923placement, 918bfor primary teeth, 919stomatitis, 515b, 527Denture-related oral changes, 922–923bone changes, 920effects of xerostomia, 920, 922oral mucosa changes, 920, 923sensory changes, 922Deontology, 150tDeoxyribonucleic acid (DNA), 61bDepakote, 1061t, 1074Dependence, 1087bDependent (outcome) variable, 20bDepolarization mechanism, 764bDepressants, 1096Depressed lesions, 194–195Depressive disorders, 1072–1074dental hygiene care, 1073–1074during pregnancy, 844signs and symptoms, 1073treatment, 1073types of, 1073Descriptive research, 25Descriptive statistics, 20bDesensitization, 956bmechanisms of, 771Desensitizers, 802Desmosome, 298bDesquamation, 313bDeterminant, 370bDetoxication, 1087bDevelopment hyperactivity (hyperkinesis), 1036bDevelopmental disability, 956b, 1036bDexterity development, 680–682, 681fmouth mirror, cotton pliers, and explorer, 681squeezing therapy putty or soft ball, 680, 681fstretching, 680–681writing, 681Diabetes mellitus, 397, 829, 903classication, 1168–1170complications, 1175–1176cardiovascular disease, 1176infection, 1175neuropathy, 1174–1175retinopathy, 1175denition, 1165dental caries, 1166dental hygiene care plan, 1176–1179dental implants, 1166diagnosis, 1170–1171documentation, 1179–1180, 1180bendodontic infections, 1166extraoral/intraoral ndings associated with, 1166timpact, 1165insulin, role of, 1166–1168insulin therapy, 1173–1174keywords, 1164b, 1165blocal anesthesia and, 649medical nutrition therapy, 1173medications, 1179oral, 1174, 1175toral health implications of, 1165–1166periodontal disease and, 314, 1165–1166periodontal treatment on, 1165–1166pharmacological therapy, 1173–1174risk factors, 1171standards of medical care for, 1171, 1173Diabetic coma. See HyperglycemiaDiagnose, denition, 396bDiagnosis, denition, 396bDiagnostic and Statistical Manual of Mental Disorders (DSM-5), 1070Diagnostic or study cast, 240bDiamond-coated le scaler, 671, 671fDiamond-coated stainless steel, 687, 687fDiamond polishing paste, 786Diaphoresis, 1130bDiastema, 286b, 298b, 313bDiastole, 175bDiastolic blood pressure, 1135Diastolic pressure, 178Diazepam, 1099Diet and dietary analysisadolescence, 897ChooseMyPlate guidelines, 573, 574fcleft lip and/or palate, 883counseling for, 587–589evaluation of progress, 589–590frequency and time of exposure, 588retention, 588–589dietary assessmentforms used, 582, 583t, 585tpreliminary preparation, 582purpose, 581–582using food diary, 582–587, 583–584t, 585bdietary standards, 573dietary supplements with uoride, 601–603, 602tdocumentation, 590, 590bfood intake pattern recommendations, 574“Food Pyramid” by the United States Department of Agriculture (USDA), 576–577tgovernment standards, 572guidelines for Americans, 573, 574bkeywords, 572bnutrient standards for diet adequacy in, 571–591older adults, 914–915and oral health relationships, 574, 580–581dental caries, 581dietary assessment for periodontal conditions, 581–587nutrients and tissue repairing, 580periodontal tissues, 574, 580skin and mucous membrane, 574tooth structure and integrity, 581during pregnancy, 843recommendations, 589Dietary assessment, 572bDietary calcium, 579t, 580Dietary reference intakes (DRIs), 573, 573bDietary standards, 573Differential cell count, 1148bDifferential diagnosis, 396b, 1048bWilkins9781451193114-index.indd 1223 08/10/15 9:40 AM Diffuse reectance spectroscopy, 198Diffusion effect, 595b, 601Diffusion hypoxia, 635b, 640Digital radiography, 209b. See also Radiationadvantages, 210anatomic landmark, 233–234angulation, 224bitewing surveys, 223characteristics of radiographic image, 210–211, 211tradiopacity and radiolucency, 211clinical applications, 217–222clinical situations, 221tprocedures for periapical, bitewing, and occlusal radiographs, 222diagnostic interpretation of completed radiographs, 233, 235–236direct imaging, 208, 208fdisadvantages, 210documentation, 36b, 236essentials of darkroom, 232factors inuencing nished radiograph, 211–214, 211–212blm processinganalysis of completed radiographs, 233–236, 234–235tautomatic, 232, 233fcollimation, 212developer and xer ingredients, 232tdistances and impact, 213–214ltration, 212–213image production, 231–232kilovoltage, 213manual, 232–234milliamperage, 213standard procedures, 231type of lms, 214lm selecting for intraoral surveys, 222–223identication of errors in radiographs, 234imaging principles, 208indirect imaging, 209, 209fkey words, 209blighting, 232darkroom, 232safelighting test, 232long axis of tooth, 224occlusal plane, 224occlusal surveys, 223periapical survey inarea covered, 222lm sizes, 222sensor sizes, 223procedures for lm placement and angulation of ray, 222recommendations for prescribing dental radiographs, 220–221tsteps in production, 209–210Digital sensors, 205bDigital subtraction, 164bDigitize, 209bDilantin, 1061tDilution, 595b3,4 Dimethoxymethamphetamine (MDMA), 106Diphtheroids, 50Diplegia, 997bDiplopia, 997b, 1023b, 1059bDirect access, 4b, 982bsupervision, 9bDirect Access for Dental Hygienists, 9Direct digital imaging, 209b, 210fDisabilities, 956b, 982bbarriers to dental care, 959tcommunity-based services for, 959–960denition and classication, 956, 957–958tdental and dental hygiene careappointment scheduling, 967–968, 967b, 967–969assistance for ambulatory patient, 969dental hygiene assistant, 970–971disease prevention and control, 962–966four-handed dental hygiene, 970–971in-service programs, 974–977instruction for caregiver, 974instrumentation, 971pain and anxiety control, 971patient positioning and stabilization during treatment, 969–970wheelchair accessibility, 960fwheelchair transfers, 971–973, 972f, 973fdental hygienist with, 977documentation, 977, 977boccurrence, 959oral disease prevention and controlbiolm control, 963diet plan, 966uoride program, 965–966objectives, 962pit and ssure sealants, 966preventive care, 962–963self-care aids, 963toothbrushing, 963–964, 964f, 965frisk assessmentfunctional ability, 961–962medical status, 962oral manifestations, 961types, 958–959Disease activity, 826bDisease transmissionhorizontal, 48bvertical, 48bDisinfectant, 83bDislocated mandible, treatment for, 132fDisposable paper thermometer, 175, 176fDissociative anesthetics, 1096Disulram (Antabuse), 1092–1093Diurnal, 175bDMFT (decayed, missing, and lled teeth) Index, 371, 595bDocumentation, 484b, 485, 761, 761bbleaching of tooth, 811–812, 812bblood disorders, 1160, 1160bcalculus, 356–357, 357bcancer, 953, 953bcardiovascular disease, 1144, 1144bcare plan records, 145charting, 142–143cleft lip and/or palate, 884, 885bcontinuing care program, 830, 830bdental biolm, 267, 267bdental caries, 443–444, 444bdental hygiene care plan, 404, 404b, 416, 416bdental records, 145dental stains and discoloration, 366, 366bdentifrice and mouthrinse, 498, 498bdentin hypersensitivity, 775, 776bdiabetes mellitus, 1179–1180, 1180bdiet and dietary analysis, 590, 590bdigital radiography, 236, 236bemergency care, 124, 132–133, 132bevaluation of treatment, 822, 824bevidence-based dental hygiene practice, 27–28, 28bextra-and intraoral examination, 140, 199, 199bextrinsic stain removal, 796b, 797uoride, 615, 615bgingival or periodontal condition, 309, 309bhealth communication, 39–40, 40bHealth Information Portability and Accountability Act of 1996 (HIPAA), 139–140health promotion and disease prevention, 432, 432bimplant systems, 545, 545bindices, 389, 391binfection control procedures, 96, 96binformation related to personal protection, 79, 79binformed consent, 145instrumentation, 683–684, 683bkey terms related to patient records and charting, 138bmaxillofacial patients needs, 940–941, 941bmental health disorder, 1082, 1082bnecrotizing ulcerative gingivitis (NUG), 749, 749bneurodevelopmental disorder, 1045, 1045bnonsurgical periodontal therapy and adjunctive therapy, 735, 736boabused patient, 1054, 1055boanesthesia, 661occlusion, 294, 294bofcare provided for patient with disability, 977, 977bolder adult, 915, 915boral health care of children, 873, 873borthodontics, 511, 511bpatient health history, 170patient recordcomponents of, 138–139electronic, 139handwritten, 139purposes and characteristics, 1381224 INDEXWilkins9781451193114-index.indd 1224 08/10/15 9:40 AM INDEX 1225patient visits, 145–147dental hygiene progress notes, 145–146, 146bpurpose, 145risk reduction and legal considerations, 147SOAP, 146–147, 146t, 147bpatient wearing denture, 926–927, 926bpatient with an infectious disease, 65, 65bpatient with oral manifestations related to hormonal uctuations, 897, 897bpatient with seizures, 1066b, 1067patients with sensory disabilities, 1032, 1032bperiodontal disease development, 324b, 325periodontal examination, 347, 347bperiodontal records, 143–145personalized dental chair positioning, 109, 109bphysically impaired patient, 1016b, 1017pregnancy and infant, 848–849, 849bprostheses, 529, 530brespiratory disease, 1124, 1127bsealants, 629, 629bstudy models, 252, 252bsutures and dressings, 761, 761bteeth, 283, 283btobacco use, 566–567, 566btooth-numbering systems, 140–141toothbrushing and tongue cleaning, 467, 467bvital signs, 183, 183bDominant hand, 664b, 673Dopamine norepinephrine reuptake inhibitor, 1073Dorsal, 186bDown Syndrome, 1039–1041, 1041fcomorbidity and health considerations, 1040eye characteristics, 1040fhand, 1040foral ndings, 1041personal characteristics, 1040physical characteristics, 1040Doxycycline hyclate, 730t, 731, 732, 733–734, 734fDressing, periodontal, 759facceptable dressing material, 757characteristics of well-placed dressing, 758–759collagen dressings, 758dressing placement, 758patient dismissal and instructions, 759posttreatment care, 760tpurposes and uses, 756–757removal and replacement, 759, 761biolm control follow-up, 761follow-up, 761patient examination, 761procedural suggestions for dressing replacement, 761procedure for, 761typeschemical-cured dressings, 758zinc oxide with eugenol dressing, 757–758visible light–cured (VIC) dressing (Barricaid™), 758Drifting, 292Droplet, 47bnuclei, 54fprecautions, 46Drug, 1087babuse. See Drug abuseaddiction, 549binteraction, 152btolerance, 1087bDrug abuse, 549b, 1094–1097, 1100bcardiovascular effects, 1097gastrointestinal effects, 1097infections, 1098kidney damage, 1097liver damage, 1098medical effects of, 1097–1098musculoskeletal effects, 1098neurological effects, 1097prenatal effects, 1098prescription. See Prescription drug abuserespiratory effects, 1098treatment methods for, 1098–1099, 1099bDrug-resistant TB, 53Dry heat, 89–90Dry stone, 687–688D-termined program, for ASD, 1043Duchenne muscular dystrophy (DMD), 1009Duloxetine (Cymbalta), 1073Dust-borne organisms, 48–49Dyadic, 30bDyclonine hydrochloride, 659, 659tDysarthria, 30b, 997b, 1070bDysgenesis, 1036bDysgeusia, 945bDyskinetic or athetoid palsy, 1007Dysmenorrhea, 888bDysmorphism, 1036bDyspepsia, 1059bDysphagia, 901b, 997b, 1109bDysphoria, 549b, 888bDysplasia, 945bDyspnea, 114b, 1109b, 1130bEEarly childhood caries (ECC), 386, 387t, 836b, 865–868demineralization or white-spot lesions, 868, 868feffects, 276, 866, 868etiology, 276microbiology, 865predisposing factors, 866prevalence, 865progression of, 868frecognition, 277risk factors, 865–866, 866t, 867tEastman interdental bleeding index (EIBI), 382–383, 382fareas examined, 382calculation, 383number of bleeding sites, 382–383percentage scores, 383procedure, 382purpose, 382scoring, 382–383Ebers Papyrus, 448Ecchymosis, 930b, 1048bEchinacea, 838Echocardiography, 1130bEcholalia, 1036bEcstasy, 1096, 1101bEctopic, denition of, 350bEctopic oral calcication, 350bEdema, 313b, 1048b, 1109b, 1130bEdentulous mouth, 919bone, 919mucous membrane, 919Edentulous patient, 270bcontinuing care, 924–925, 924tdenture hygiene, 923denture-induced oral lesions, 922–923denture marking, 925–926criteria for, 925inclusion methods, 925–926, 925finformation to include on marker, 926, 926fsurface markers, 926denture-related oral changes, 920, 922diet and nutrition, 924documentation, 926–927, 926bkeywords, 918bpatient instruction for complete dentures, 921tpatient with new dentures, 919–920patient counseling, 919–920postinsertion care, 920preparation for denture insertion, 919–920purposes for wearing dentures, 918relief from xerostomia, 924Editorials, 26Educational services, of dental hygiene, 8Educator, 8tEfcacy, 488b, 595bEIA, 47bElastomer, 502b, 503Elder maltreatment, 1052–1053denitions, 1052extraoral/intraoral signs of, 1052–1053general considerations, 1052general signs of abuse and neglect, 1052physical signs of abuse and neglect, 1052, 1052freporting, 1053–1054Electrical pulp tester, 281–282Electrocardiogram (ECG), 115b, 1130bElectroconvulsive therapy (ECT), 1070bfor depressive disorders, 1073Electroencephalography, 1059bElectrolyte, 270bElectromagnetic radiation, 208bElectronic record, 138b, 139Electronic sphygmomanometer, 178Wilkins9781451193114-index.indd 1225 08/10/15 9:40 AM Electronic thermometer, 175, 179fElectronic timer, 207Elevated lesions, 194Elicit, 420bElicit-provide-elicit (EPE), 425ELISA (enzyme-linked immunosorbent assay), 47b, 61Embolism, 1130bEmbrasure, 472bEmergency cardiac care (ECC), 115bEmergency care, 121fbasic life support certication, 122–123care of drugs, 117, 119division of duties for three-person emergency team, 122fdocumentation, 124, 132–133, 132bemergency reference chart, 125–131tequipment for use in, 117, 118tfactors contributing to, 115keywords, 114bmaterials and preparation, 117–122medical emergency report form, 119, 120foxygen administration, 123–124patient assessment, 115–116extraoral and intraoral examinations, 116medical history, 115–116for routine treatment, 115vital signs, 116preparedness, 114prevention of, 114–115, 115battention to, 114–115seizure, 1065–1067stress minimization, 116–117telephone numbers for medical aid, 117Emergency medical dispatcher (EMD), 115bEmergency medical service (EMS), 115bEmergency medical technician (EMT), 115bEmergency medical technician paramedic (EMT-P), 115bEmery (corundum), 786Emery–Dreifuss muscular dystrophy, 1010Empathy, 423Emphysema, 901b, 1122due to tobacco use, 552Enamel cariespit or ssure irregularity, 276in smooth surfaces, 276steps in formation of, 276Enamel hypocalcication, 595bEnamel hypomineralization, 364Enamel hypoplasia, 270b, 271–272, 364Encode, 30bEncryption, 138bEnd points, 826bEnd-rounded bristle, 449bEndemic agent, 47bEndocrine system, 888bglands, 888, 889fand hormones, 890thormones, 888–889Endodontic therapy, 528Endogenous infection, 701bEndogenous stains, 360, 360bEndometriosis, 888bEndometrium, 888bEndoscope-assisted periodontal debridement, 713–715advantages, 714–715description, 714, 714fdisadvantages, 715indications for use, 714objectives, 714Endoscopy, 701bEndosseous or root form dental implant, 534bbone physiology, 534–535denition, 537, 537fdescription, 537parts of, 537fprosthodontic steps, 537surgical preparation for placement, 537Endotoxin, 701b, 702, 729Entrepreneur, 8tEnvironmental Protection Agency (EPA), 83bEnvironmental tobacco smoke (ETS), 548, 549bcardiovascular effects, 552, 553impact in children, 554–555infants and, 553lung and respiratory effects, 553toxicity, 553in utero, 553Enzyme, 313bEnzyme-linked immunosorbent assay (ELISA), 47b, 61Eosinophils, 1150EPA-registered hospital disinfectant, 91Epicanthus, 1036bEpidemic agent, 47bEpidemiologic surveyspurpose, 371use, 37Epidemiology, 370bEpidermis, 186bEpilepsy, 1059bEpinephrine (Adrenalin), 643, 645Epinephrine, 635b, 644, 888b, 1119, 1120Epistaxis, 1130bEpithelium, 298bEpstein–Barr virus (EBV), 52t, 59Epulis ssuratum, 923Ergonomic dental hygiene, 106, 106bErgonomic risk factors, 106, 108tErgonomics, 100bErosion, 186b, 195, 273Erythema, 186b, 195Erythroblastosis fetalis, 365, 1152Erythrocytes. See Red blood cellsErythrocytosis, 1156Erythromycin, 1121Erythroplakia, 197Erythropoiesis, 1148bEster anesthetic drugs, 642–643Esthetic, denition, 800bEstimated average requirements (EARs), 573, 573bET-NANB, 51tEthambutol, 1117tEthical applications, to dental hygiene practice, 136, 136t, 150, 150tEthical decision concept, 418, 418tEthical dilemma, 14b, 15, 418steps in resolving, 15Ethical standards, to dental hygiene practice, 2, 44, 44t, 394, 394t, 418, 632, 632t, 816, 834, 834tapplicationsethical dilemma, 15ethical issue, 15everyday ethics, 16nal decision, 15steps in resolving issue or dilemma, 15, 16bcode ofdental hygiene, 14purposes, 14Ethics, 14b, 15in research, 26–27informed consent, 27Institutional Review Board, 27involving human subjects, 27standards, 27steps in resolving, 15Ethosuximide, 1061tEtiology, 270bEtrafon, 1079Eugenol, 752bEuphoria, 1070b, 1087bEvaluation, denition, 420bEvaluation of treatmentbased on goals and outcomes, 819of clinical outcomes, 819comparison of assessment ndings, 820design, 818–819, 818bdocumentation, 822, 824bof health behavior outcomes, 820methods, 818bprocess, 819purpose, 818self-assessment and reective practice, 822, 823tstandard of care, 820–821, 821tEvidence, 20bEvidence-based care, 396bEvidence-based decision-making process, 21Evidence-based dental hygiene (EBDH) practice, 2, 20bdecision-making processclinical/patient circumstances, 21clinician’s experience and judgment, 21model, 21fpatient preferences or values, 21scientic evidence, 21denition, 20documentation, 27–28, 28bfundamental principles, 20need for, 20–21changing educational requirements, 21differences in practice procedures, 211226 INDEXWilkins9781451193114-index.indd 1226 08/10/15 9:40 AM INDEX 1227gap between current research knowledge and application, 21information explosion management, 21protocols, 404purpose, 20skills needed, 21–22systematic approachdetermining clinical issue, 22developing researchable question, 22–23evidence analysis, 24evidence application, 24result evaluation, 24steps for, 22fEvocation, motivational interviewing and, 424Exacerbation, 1109bExfoliation, 270bExfoliative cytology, 198Exocrine, 1164bExodontics, 930bExogenous infection, 701bExogenous insulin, 1164bExogenous stains, 360, 360bExophytic, denition, 186b, 195Exostosis, 186b, 918b, 919, 930bExperimental group, 25Expert witness, 818bExpiration. See InspirationExplore, 420bExplorers, 328b, 681–682basic procedures for use of, 332–333description, 330–331, 330f, 331fgeneral purposes and uses, 330preparation, 331specic, and their uses, 331–332subgingival exploration for defects, 333–334supragingival exploration for defects, 333Exposure controlkey words, 69band latex hypersensitivity, 77–78personal protection for dental team, 68–70clinical attire, 68–70gloves and gloving, 76–77, 77fhand care, 72–76immunizations, 68maintain records, 68protective eyewear, 71–72, 72fuse of face mask, 70, 70b, 71fExposure incident, 69bExtension cone paralleling (XCP), 205bExtensively drug-resistant TB (XDR-TB), 53External bleaching, 807Extracellular polymeric substance (EPS), 256bExtraoral/intraoral examination, 192–193tassessment of lymph nodes, 194fassessment of temporomandibular joint, 188fchild maltreatment, 1049documentation, 191, 193, 199, 199bhistory, 191location and extent, 191physical characteristics, 193record form, 195felder maltreatment, 1052–1053emergency care, 116key words, 186bmethodsauscultation, 187–188electrical test, 187examination instruments, 187palpation, 187percussion, 187visual, 187morphologic categoriesdepressed lesions, 194–195elevated lesions, 194at lesions, 195objectives, 145oral cancer, 195–198preparation for, 188–189rationale for, 186sequence, 189–193signs and symptoms, 188tobacco use, 560of tongue, 195ftypescomplete, 187follow-up, 187limited, 187screening, 187Extrinsic, denition, 800bExtrinsic stain removalabrasives, 786air-powder polishing system, 793–796cleaning agents, 785ingredients, 786–787clinical application, 783–784documentation, 796b, 797effects of cleaning and polishing, 781–783environmental preparation, 788factors affecting abrasive action with polishing agents, 785–786indications for, 783polishing agents, 785porte polisher, 788, 788fpower-driven instruments, 789–790procedure, 788prophylaxis anglesattachments, 789–790, 790fprocedure, 791–792with rubber cup, brush, or rubber point, 791types of, 789t, 790, 790fuses of, 791–792from proximal surfaces, 792–793purposes, 780Extrinsic stains, 360, 360bEye movements, as form of communication, 31FFace mask protection, 70, 70b, 71faerosols, 70Facet, 270b, 286bFacial expression, as form of communication, 31Facies, 1059bFacioscapulohumeral muscular dystrophy, 1009–1010Facultative, 256bFasting plasma glucose (FPG), 1171Fédération Dentaire Internationale (FDI) system, 141, 141fFeedback, 30b, 818bFeeding and eating disordersdental hygiene care, 1077–1079medical complications of, 1076treatment for, 1077types and symptoms of, 1075Felbamate, 1061tFelbatol, 1061tFentanyl, 1095tFermentable carbohydrates, 436–437Ferromagnetic, 715bFestoon (“McCall’s festoon”), 306Fetal alcohol spectrum disorders (FASD), 1090–1091, 1091bcharacteristics of individual with, 1091, 1091bcriteria for, 1091Fetal alcohol syndrome (FAS), 1091b, 1091fFetal development, 836–838Fetor oris, 740bFetus, 836beffect of depression on, 844Fever, 175Fibrillation, 114bFibroblast, 298bFibrosis, 298bFibrous encapsulation, 534bFilament, 449bFile scaler, 671, 671fFilled sealant, 620bFilms, used in radiography, 214Filtration, 212–213, 218Financial abuse, denition of, 1052Finger rest, 664b, 672–673and balance, 676digits used for, 675effects of excess pressure, 676intraoral nger rest, 675location of, 675objectives, 675touch or pressure applied to, 676Fingerspelling, 1027Fissure, 186bFissure biolm, 264Fistula, 740bFixed appliance, 502bFixed partial denture, 515bapplication of brush for, 458area requiring daily attention, 517care procedures, 517–518characteristics, 515–516criteria, 516debris removal, 516dental biolm control, 516–517dental ossing of, 517, 517fdescription, 515–516interdental brushes for, 516–517toothbrushing for cleaning, 516, 517types, 516, 516fFlat lesions, 195Floor covering, 84Wilkins9781451193114-index.indd 1227 08/10/15 9:40 AM Flora, 256bFloss cleft, 307, 472bFloss cut, 242bFlossing, 448Flunitrazepam, 1095tFluorapatite, 595bFluorhydroxyapatite, 595bFluoridationbackground, 598control cities, 598–599, 599bdeuoridation, 600discontinued, 601effects and benetson adults, 600dental caries, 599, 600on periodontal health, 600root caries, 600teeth, 599tooth loss, 600mottled enamel and dental caries, 598school, 600of water supply, 599chemicals used, 599Fluoride-releasing bonding systems, 504Fluorides, 443, 579t, 595b, 861–862absorptionblood stream, 594gastrointestinal tract, 594availability and use, 492in bottled water, 601brush-on gel withpreparation, 610procedure, 611calculation of amount ingested, 615in cementum, 597combined program, 612considerations for use, 492dentifricesbenets, 611–612development, 611guidelines, 611indications, 611instructions for use, 611preparations, 611in dentin, 597deposition, 595dietary supplements with, 601–603benets, 602–603dose schedule, 602tforms, 602limitations, 602–603prescription guidelines, 602distribution and retention, 594documentation, 615, 615bin early dental caries, 597effect of excess, 596efcacy, 492in enamel, 597, 598fexcretion of, 594for extrinsic stain removal, 787in foods, 601halo or diffusion effect of, 601for implant systems, 540in infant formula, 601intake, 594key words, 595blethal and safe doses of, 613bmanagement, 612mechanism of action, 437, 492mouthrinsing withbenets, 610for dental caries, 443indications, 609limitations, 609preparations, 609–610, 609tprophylaxis pastes, for extrinsic stain removal, 787and remineralization, 489safety, 612–615in saliva and biolm, 597in salt, 601self-applied, 607–608indications, 607methods, 608systemic, 596ftherapy post-debonding, 511and tooth development, 594–596, 596ftopical applicationappointment sequence, 604–605compounds, 603–604, 604tfor dental caries, 604historical perspective, 603indications, 603, 603bpatient counseling, 605–606post application care, 607preparation of teeth, 604–605for remineralization of demineralized areas, 604tray technique (home application), 605t, 606, 607f, 608, 609bvarnish technique, 606–607, 606ttoxicity, 612–613chronic, 613–614emergency treatment for, 613signs and symptoms of acute toxic dose, 613in water lters, 601Fluoroquinolone, 1116Fluorosis, 595b, 613–614Fluoxetine (Prozac), 1072, 1073, 1075, 1077Focal seizures, 1059Folate, 579t-deciency anemia, 1153–1154Fold (or wrinkle) test, 342, 342fFomes, 47bFomite, 47bFones, Alfred C., 5, 7Fones method, 459t, 460fFood and Drug Administration (FDA), 83b, 595b, 764bbrief history of, 496documentation process, 496tpurpose, 496regulation of dental products, 496Food diaryanalysis of diet consistency, 585, 587benets of, 587instructions, 585bnutritional analysis, 585Food impaction, 256b, 313bForensic, 138b, 152b, 186b, 1048bForensic dentistry, 138b, 152b, 1054Formative evaluation, 818, 818bFormoterol, 1120tFour-handed dental hygiene, 403Fracture toughness, 502bFractured jaw, 933–935causes, 933clinical signs, 933–934emergency care, 933history, 933treatment, 934–935types, 934, 934f, 935fFrail elderly, 982bFree gingiva, examination of, surface texture, 307Fremitus, 328b, 343–344, 344fFrenum, 302Fulcrum, 675–676alternative, 676denition, 675extraoral, 675–676elements of, 675location of, 676intraoral, 675objectives, 675Full-mouth disinfection, 705Functional age, 901bFunctional contacts, 292Functional dependence, 982bFunctional movement exercises, 107–109, 110fFunctional occlusion, 292Fungal infections, associated with HIV infection, 63Furcation, 701banatomic features, 344examination methods, 344–345invasion, 701bGGabapentin (Neurotin), 1061t, 1072, 1074Gabitril, 1061tGamma-knife radiosurgery, for seizure disorder, 1062Gamma radiation, 208bGastroesophageal reux, 1109bGastrointestinal mucositis, 947Gastroparesis, 1164bGel, 595bGeneral anesthesia, 635bGeneral physical health, 16General supervision, 9bGeneralized anxiety disorder, 1071Genital herpes, 59Geometric charting, 142Geriatric dentistry, 901bGeriatrics, 901bGermfree, 350bGerontology, 901bGestation, 836bGestational diabetes mellitus (GDM), 836b, 840, 1164b, 1170Gingiva, 706actual position of, 307alveolar mucosa, 302apparent position of, 307attached, 301–302crevice, 3031228 INDEXWilkins9781451193114-index.indd 1228 08/10/15 9:40 AM INDEX 1229effect of polishing, 783gingival sulcus uid (sulcular uid, crevicular uid), 300gingival tissues, 300finterdental gingiva, 301junctional epithelium, 300–301keywords, 298bmarginal, 299–300mucogingival junction, 302after periodontal surgery, 309and record ndings, 144and tooth eruption, 301fof young childrenchanges in disease, 308–309mixed dentition, 308mucogingival problems, 309periodontitis, 308primary dentition, 308signs of health, 308–309Gingival abscesses, 748Gingival and periodontal health, indices forcommunity periodontal index (CPI), 380Eastman interdental bleeding index (EIBI), 382–383gingival bleeding index (GBI), 382periodontal screening and recording (PSR), 378–380sulcus bleeding index (SBI), 380–382Gingival and periodontal infections and toothbrushing, 455Gingival biolm, 264Gingival bleeding index (GBI), 382areas examined, 382criteria, 382instruments, 382procedure, 382purpose, 382scoring, 382steps, 382Gingival crevicular uid (GCF), 298b, 300Gingival, denition, 740bGingival enlargement, 307Gingival examinationbleeding, 308of clinical markers, 304–305tcolor, 306consistency, 307exudate, 308position, 307–308shape, 306–307, 306fsize, 306surface texture, 307Gingival ber groups, 303fGingival grafting surgery, 309Gingival hyperplasia, 314fGingival index (GI), 372, 383–384, 383f, 976for area, 383calculation and interpretation, 383–384for group, 384for individual, 383procedure, 383purpose, 383scoring, 383–384selection of teeth and gingival areas, 383for tooth, 383Gingival infections, 413Gingival overgrowth/gingival hyperplasia, 1062–1064dental biolm, 1063effects, 1063mechanism, 1062occurrence, 1062–1063phenytoin-induced gingival enlargement, 1063ftissue characteristics, 1063treatment, 1064Gingival recession, 277, 308factual, 307denition, 307localized, 307–308measurement, 308visible, 307Gingivitis, 261, 505, 554, 839biolm-induced, 863development of, 938inammation, prevention using dentifrice, 489nonsurgical periodontal therapy, 702Gingivitis, 313bGland, 888bGlass ionomer, 774Glatiramer acetate, for multiple sclerosis, 1004bGlaucoma, 1023blocal anesthesia and, 649Glossitis, 580t, 1148bGlossodynia, 580t, 1148bGloves and gloving, 76–77ergonomic choice factors, 76factors affecting glove integrityagents used, 76complexity of procedure, 76hazards from hands, 76length of time worn, 76packaging of gloves, 76pressure of time, 76size of gloves, 76storage of gloves, 76procedures for use ofin case of torn or cut gloves, 76glove placement, 76mask and eyewear placement, 76pregloving hand hygiene, 76preventing contamination, 76removal of gloves, 76, 77fsafety factors, 76typesmaterial, 76for patient care, 76utility, 76Gluconeogenesis, 1164bGlucose meter, 1171Glycated hemoglobin assay (HbA1c or A1c), 1170–1171Glycated or glycosylated hemoglobin (HbA1c), 1164bGlycemia, 1164bGlycerin, 781b, 802Glycine, 793Glycolysis, 595bGoblet cell, 1109bGoiter, 888bGonad, 888bGoogle, 23Gracey curets, 668–669, 669f, 709Graft, 878bGrand mal, 1059bGranulocytes, 1150–1151Grasp dynamics, 673Gray (Gy), 205bGrazing, 854bGreen stain, 361–362Grit, 781bGroup A streptococci (beta-hemolytic), 53tGuided tissue regeneration, 534bGum boil, 740bGynecologist, 888bHHaberman feeder, 878bHabilitation, 878bHabitual occlusion, 240bHaldol, 1079Half value layer (HVL), 205bHalitosis (bad breath)and dentifrice, 489due to tobacco use, 560Hallucination, 1070b, 1087bauditory and visual, 1092Hallucinogens, 1096Halo, 595b, 601Haloperidol (Haldol), 1079Hand caringarticial nails, 73ngernails, 73gloves, 73hand-hygiene principlesantiseptic hand rubs, 74, 75bantiseptic handwash, 74, 75bfacilities, 73–74, 74findications, 74methods, 74–76, 75bpreliminary steps, 75purposes, 73rationale, 73routine handwashes, 74, 75buse of second sterile brush for second hand, 76using surgical liquid antimicrobial soap, 74, 75bwristwatch and jewelry, 73Hand hygiene, 69bHandicap, 956bHandle of instrument, 665, 666–667, 666fHandpiece, 789with straight mandrel, 790Haptics, 30bHarvey sterilizer, 90Hawley retainer, 502b, 510fHazardous material, universal label for, 95fHazardous waste, 83bHBsAg carriers, 56HBsAg-positive persons, 56Healing process, 728Health behavior changemodel, 422, 422tmotivation for, 422–423Wilkins9781451193114-index.indd 1229 08/10/15 9:40 AM Health communication. See also Motivational interviewingattribution of effective health information, 31–32barriers to effective, 31–32, 32twith caregivers, 39documentation, 39–40, 40bfactors inuencing, 32–33health literacy and, 33–34interprofessional communication, 39across lifespanadolescents, 34–35infants, 34older adults, 35–36school-age children, 35tips, 35btoddlers and preschoolers, 34–35objectives of, 31skills and attributes of, 31social and economic aspects of health, 36types of, 30–31media communication, 31nonverbal, 31verbal, 31web-based health messages, 32Health, dened, 4bHealth Information Portability and Accountability Act of 1996 (HIPAA)privacy rule, 139–140security rule, 140Health Insurance Probability and Accountability Act, 976Health-learning capacity, 33, 33tHealth on the Net Foundation, 26Health promotion, 4bnutrient standards for diet adequacy in, 571–591Health promotion and disease preventionassessment of patient needs, 420clinical, 421documentation, 432, 432bevaluation of progressive changes, 421implementation, 421for intervention, 420–421key words, 420bmotivation, 422–423motivational interviewingelements of “MI spirit,” 423–424, 423texploring ambivalence, 427–429guiding principles, 424implementation, 424–427processes of, 424, 425f, 425bpatient counseling, 421–422prevention care plan, 418of short and long-term maintenance, 421steps, 420–421Healthcare-associated infection, 47b, 83bHealthcare personnel (HCP), 47bHealthy People 2020, 371Healthy spine, 108Hearing, 1023bHearing aids, 1026Hearing impairment, 902, 1023b, 1025–1027, 1032causes of, 1026characteristics suggesting, 1026cochlear implants, 1026hearing aids, 1026modes of communication, 1026–1027types of, 1026Heartanomalies, 1132etiology, 1132–1133failure, local anesthesia and, 648normal, 1132, 1132fpatent ductus arteriosus, 1133fprevention, 1133–1134types of defects, 1133valve, defective, 48ventricular septal defect, 1133fHemarthrosis, 1148bHematocrit, 1148bHematogenous, denition, 152bHematologic prole, 945bHematopoiesis, 945b, 1148bHematopoietic cell transplantation, 948–949complications, 949dental hygiene plan of care, 952stages in, 948–949types, 948Hemidesmosome, 298bHemiparesis, 997bHemiplegia, 997bHemoglobin, 1148b, 1150Hemolysis, 1148b, 1152Hemolytic, 1148bHemolytic anemia, 1152Hemolytic disorders, 1152Hemophilia, 1158local anesthesia and, 648Hemoptysis, 1109bHemostasis, 752b, 901bHeparin, 1130b, 1142, 1157, 1159Hepatitis A virus (HAV), 55tHepatitis B virus (HBV), 51t, 54–56, 55tcarrier state, 56maternal transmission, 55prevention of, 56active immunization, 56blood bank control measures, 56immunization of infants and children, 56prenatal testing, 56use of disposable syringes and needles, 56vaccines, 56protective immunity, 56transmission, 54–56Hepatitis C virus (HCV), 51t, 55tprevention, 56serologic test, 56transmission, 56through blood, 56from environmental contamination, 56in sexual partners, 56Hepatitis D virus (HDV), 51t, 55tprevention, 56immunization, 56transmission, 56in intravenous drug users, 56Hepatitis E virus (HEV), 51tHerbal dietary supplements, during pregnancy, 837Hereditary hemolytic disorders, 1152Hereditary lymphocytopenia, 1156Hereditary platelet dysfunction, 1157Heredity, 878bHeroin, 1097Herpes barbae, 47bHerpes gladiatorum, 47bHerpes labialis, 58–59Herpes lymphotrophic virus (HLV), 60Herpes simplex 1 skin related viruses, 47bHerpes simplex virus, 51t, 62Herpes viruses diseases, 58tclinical management of, 57–60general characteristics, 57genital herpes, 59HHV-1 herpes simplex virus type 1 (HSV-1), 57–59HHV-2 herpes simplex virus type 2 (HSV-2), 59HHV-4 Epstein–Barr virus (EBV), 59HHV-5 cytomegalovirus infections, 60HHV-6 herpes lymphotrophic virus (HLV), 60HHV-7 human herpes virus (HHV), 60human herpesvirus-8 (HHV-8), 60Kaposi’s sarcoma (KS), 60neonatal herpes, 59relation to periodontal infections, 57shingles (herpes zoster), 59varicella-zoster virus (VZV), 59Herpes zoster, 59Herpesvirus-positive periodontitis, 57Herpetic gingivostomatitis, 58–59, 740b, 744–746, 745fclinical recognition, 745comparison with NPD, 744tetiology, 744management and treatment considerations, 745oral lesions, 745oral presentation, 745palliative treatment, 745–746pathogenesis, 745resolution, 746signs and symptoms, 745Herpetic whitlow, 59Heterotrophic, denition, 256bHeterotrphic material, 47bHHV-1 herpes simplex virus type 1 (HSV-1), 51t, 57–59in children, 57genital and oral–facial infections, 58herpetic gingivostomatitis, 58–59latent Infection of, 57flesions, 58oral vesicular lesions, 58primary infection with, 57recurrent HSV symptomatic lesions, 58–591230 INDEXWilkins9781451193114-index.indd 1230 08/10/15 9:40 AM INDEX 1231HHV-2 herpes simplex virus type 2 (HSV-2), 51t, 59High blood pressure (HBP). See HypertensionHigh pain threshold, 635bHighly active antiretroviral therapy (HAART), 61b, 62Hippocrates, 448Hirsutism, 1059bHits, 23HIV antibody (anti-HIV), 61bHIV infection, 51t, 61–64and chickenpox, 59dental hygiene management in, 63–64early symptomatic disease, 62extraoral assessment of, 62HIV-1, 61AIDS indicating conditions, 62clinical course of, 62incubation period, 62HIV-2, 61intraoral assessment of, 63bacterial infections, 63fungal infections, 63periodontal infections, 63viral infections, 63late-stage disease, 62oral manifestations of, 62–64, 63tprevention ofgoals, 64ongoing programs, 64secondary, 64serological tests, 61–62and skin lesions, 62modes, 61transmission, 62HIV wasting syndrome, 62Hoe scaler, 671–672Home tray bleaching treatment, 807, 809fHomeostasis, 888bHone, 686bHoning, 686bHookah pipe, 550bHorizontal ber, 303Horizontal transmission, of disease, 48bHormone, 888bregulation of, 889Hormone replacement therapy, 888bHospice, 982bHuman herpesvirus-8 (HHV-8), 60Human immunodeciency virus (HIV). See HIV/AIDS infectionThe Human Needs Model, 402tHuman papilloma virus (HPV), 51t, 60–61, 63Humectant, 488bHydrocodone, 838t, 1095t, 1097Hydrodynamic theory, 764b, 766Hydrogen peroxide, 801–802, 802fHydrokinetic activity, 488bHydrolysis, 752bHydromorphone, 1095tHydrotherapy, 242bHydroxyapatite, 595bHygiene, dened, 4bHyperactivity, 1036bHyperadrenalism/Cushing’s syndrome, 892–893Hyperbaric oxygen, 945bHypercholesterolemia, 997bHyperglycemia, 1164b, 1165b, 1168, 1168tHyperkalemia, 888bHyperkeratosis, 298b, 307Hypernatremia, 888bHyperopia, 1023bHyperparathyroidism, 892Hyperplasia, 298bHyperpnea, 1164bHypersensitive teeth, feeding and eating disorders and, 1078Hypertension, 175b, 181, 907, 1135–1136blood pressure levels, 1135–1136in children, 1136clinical symptoms of, 1136etiology, 1135lifestyle modications for, 182t, 1136blocal anesthesia and, 648treatment, 1136Hyperthermia, 175, 175b, 1087bHyperthyroidism, 891–892local anesthesia and, 648Hypertrichosis, 1059bHypertriglyceridema, 997bHypertrophy, 298bHyperventilation, 1109bHypoadrenalism/Addison’s disease/adrenal insufciency, 893Hypoallergenic, denition, 69bHypocalcication, 595bHypodermic needles, 94Hypogeusia, 1164bHypoglycemia, 1164b, 1165b, 1167–1168, 1168tmanaging, 1177fHypokalemia, 888bHypoparathyroidism, 892Hypoplasia, 270b, 360b, 364Hypotension, 175bHypothermia, 175, 175bHypothyroidism, 891Hypoxemia, 114bHypoxia, 114b, 635b, 1109b, 1130b, 1148bIIADLs (Instrumental Activities of Daily Living), 396bIatrogenic, denition, 800bIatrogenic, denition of, 313bIatrogenic dentistry, 256bIatrosedation, 635bIbuprofen, 838tIctal, 1059bIdiopathic, denition, 186b, 270bIdiopathic thrombocytopenia purpura, 1048bIF (intrinsic factor), 1148bIllicit, 1087bIllusion, 1070bImage receptors, 205bImaging, 945bImmediate denture, 515b, 521, 918–919, 918bImmediate evaluation, 818Immobile patient transfer, 972Immune globulins, 55tImmunity, 47bImmunization, 69bImmunocompromised, denition, 152bImmunoglobulin E, 1119Immunosuppression, 947Immunosuppressive therapy, for cardiovascular disease, 1144Impaired liver or kidney function, local anesthesia and, 648Impairment, 956bImpersonal/objective, denition, 136tImplant denture, 918Implant prosthesis, 918bImplant-retained overdenture, 528Implant surgery, 309Implant systemsappointments following placement, 541–542complicationsailing implant, 544failed implant, 543failing implant, 545maintenance phase of treatment, 543pre-implant problems, 543restorative phase of treatment, 543restorative/prosthetic hazards, 543–544surgical phase of treatment, 543systemic factors, 543documentation, 545, 545beffect of tobacco, 555implant-supported prostheses, 540interfacesimplant/bone, 535implant/soft tissue, 535–536, 536flong-term success of an implant, 541patient selectionoral examination, 538systemic health, 538tobacco use, 538peri-implant hygiene, 539–540biolm microorganisms around, 540care of natural teeth, 539–540rinsing and irrigation, 540toothbrushes, 540using uoride preparations, 540postrestorative evaluation, 539preparation and placementcollaborative treatment planning, 539dental implant team responsibilities, 538information for patient, 539limiting factors during, 539professional maintenance and monitoring, 541–542continuing care appointment, 542–543, 542fWilkins9781451193114-index.indd 1231 08/10/15 9:40 AM Implant systems (continued)frequency of appointments, 541–542probing of dental implants, 541typesendosseous (endosteal), 537, 537fsubperiosteal, 536, 536ftransosseous (transosteal), 536, 537fImplant thread, 534bImplantable cardioverter debrillators (ICD), 1142Implantitis, 555Implementation phase of care, 13Implied consent, 415Impression of an oral structure, 240bImpulse, 205bIn-service program, 974–977continuing education, 977follow-up, 977preparation for, 975–976program content, 976–977records, 977In utero oral cavity, 46In vitro research, 26, 620bInanimate objects, 92tIncidence, 370bIncipient, 270bIncipient caries, 620bIncubation period, 47bIndependent (intervention) variable, 20bIndependent practice, 9bIndex, 370bIndia stones, 687, 687fIndicator tape, 87Indicators, 370b, 818bIndicesfor community-based oral health surveillanceAssociation of State and Territorial Dental Directors Basic Screening Survey, 389, 390t, 391tWorld Health Organization Basic Screening Survey, 389cumulative, 371DMFT (decayed, missing, and lled teeth) Index, 371documentation, 389, 391bgeneral categories, 371for gingival and periodontal healthcommunity periodontal index (CPI), 380Eastman interdental bleeding index (EIBI), 382–383gingival bleeding index (GBI), 382gingival index (GI), 383–384gingival index, 372periodontal screening and recording (PSR), 378–380sulcus bleeding index (SBI), 380–382gingival and periodontal indices, 378–384irreversible, 371for measuring dental caries experiencedecayed, indicated for extraction, and lled (df and def), 385–386decayed, missing, and lled (dmft and dmfs), 386decayed, missing, and lled teeth (DMFT)/ surfaces (DMFS), 384–385early childhood caries (ECC and S-ECC), 386, 387troot caries index (RCI), 386–387for measuring dental uorosisDean’s uorosis index, 387–388tooth surface index of uorosis (TSIF), 388, 388tmeasuring oral hygiene, 372–377biolm control record, 372–373biolm-free score, 373–375patient hygiene performance (PHP), 375–376plaque index, 372Simplied Oral Hygiene Index (OHI-S), 375–377presence of dental biolm, 372reliability of, 370breversible, 371selection of, 371simple, 371validity of, 370bIndirect digital imaging, 209bIndirect uorescent antibody (IFA) test, 61Indirect vision, 664bIndividual assessment scorepurpose, 370uses, 370Individual screening, 370bInduration, denition, 186b, 195Infantscommunication skill of, 34components of rst dental visit, 847–848, 847f, 848fand cytomegalovirus infections, 60and environmental tobacco smoke (ETS), 553and genital herpes, 59and oral cavity microorganisms, 46oral health care, 854, 854banticipatory guidance, 845–846daily oral hygiene care, 846feeding patterns, 846nonnutritive sucking, 847, 847foral soft and hard tissue conditions/pathology in, 848tInfarct, 1130bInfection controlclinical procedures forantiseptic application, 94basic factors for conduct of safe practice, 82basic procedures, 94cleaning of face, 95cleaning procedures, 85–86clinic preparation, 94dental team, 94instrument processing center, 85objectives, 82occupational postexposure management, 94–95ofce policy manual, 96optimal treatment room features, 84foral hygiene measures, 93–94packaging step, 86–87patient factors, 94posttreatment factors, 94reception area, 96smoking and eating, 96steps for recirculation of instruments, 85–86fsterilization, 88–89, 96supplemental recommendations, 95–96treatment factors, 94treatment rooms, 82, 84, 84fwaste disposal, 95in dental health care settings, 1195–1203key words and abbreviations, 83bduring radiographybasic procedures, 231daylight loader method, 231bno-touch method, 231practice policy, 230standard precautions, 68Infections, 47b, 256b, 701bperiodontal, 863Infectious agent, 47bInfectious mononucleosis (IM), 59Infectious rhinitis, 1112tInfectious waste, 83bInfective endocarditis (IE), 397, 1131–1132description, 1131disease process, 1131etiology, 1131prevention, 1132, 1132bInferential statistics, 20bInltration, 313b, 945bInltration anesthesia, 635bInammatory mediator, 488bInuenza, 46, 1112tInuenza viruses (A, B, C), 52tInformation exchange, for motivational interviewing, 424–425, 426bInformation overload, as barrier to communication, 32tInformed consent, 13, 152b, 414–416, 415bInfraversion of teeth, 289Inhalants, 1097Injection-drug user (IDU), 61bInoculation, 69bINR (international normalized ratio), 1148bInsomnia, 1070bInspiration, 1109bInstitutional review board (IRB), 27Instrument care and sharpeningangulation, 688basic principles, 687–690instrument handling, 687preparation of stone for, 687–6881232 INDEXWilkins9781451193114-index.indd 1232 08/10/15 9:40 AM INDEX 1233sterilization of sharpening stone, 687care of sharpening stone, 688curets and scalersselection of cutting edges, 690technique objectives, 690dynamics of, 686–687evaluation of technique, 689keywords, 686bmaintain control, 688moving at stone, stationary instrument, 692–693objectives, 688tests for, 688–689when to sharpen, 688types of devices, 687, 687fwire edge, removal of, 689, 689fInstrument grasp, 672–673Instrument wear, 689–690Instrumental activities of daily living (IADL), 982bInstrumentationand adaptation, 676–677cervical area, 677convex and rounded surfaces, 677line angles, 677, 677fproblem areas, 677relation to tooth surface, 676root surfaces, 677soft tissue, 676working end of instrument, 676and angulationof explorer, 677of probe, 677of scalers and curets, 677–678, 678farea-specic curetapplication, 669description, 668–669design, 669purposes and uses, 669balanced instrument, 667, 667fcare plan for, 704denitive debridement of furcations, 713description of instrument, 665dexterity development, 680–682documentation, 683–684, 683beffect on pocket microora, 703tendoscope-assisted periodontal debridement, 713–715handle of instrument, 665, 666–669, 666fidentication of instruments, 665instrument grasp, 672–673and lateral pressureof detection instruments, 678impact of errors, 678of treatment instruments, 678location of, 707, 707fneutral positions for wrist, forearm, elbow, and shoulder, 674–675parts and balance, 665–667, 665fpreparation for, 705–706prevention of cumulative trauma, 682–683principles of, 664b, 672–673recognition of instruments, 665scalerangulation of shank, 670application, 670–671chisel, 672, 672fcontraindications for, 670le, 671, 671fhoe, 671–672internal angles of, 670f“Jacquette,” 669–671, 670fpurposes and uses of, 670“sickle,” 669–671shank of instrument, 665–666specialized debridement instruments, 713and strokebalance of pressure, 679–680characteristics, 678–679factors inuencing, 679nature, 679ultrasonic. See Ultrasonic instrumentationuniversal curetblade, 667–668description, 667–668, 668fpurposes and uses, 668shank, 668visibility and accessibility, 680working end of instrument, 665zone, 664bInstrumentation zone, 701bInsulin, 1164bcomplications, 1167–1168denition, 1166description, 1166for diabetes mellitus, 1173–1174effects of absolute insulin deciency (type 1 diabetes), 1166–1167effects of impaired secretion or action of (type 2 diabetes), 1167functions, 1166, 1167bpancreas and action of, 1167fshock. See Hypoglycemiatypes and action of, 1174tInsulin-dependent diabetes mellitus (IDDM). See Type 1 diabetes mellitusIntal, 1120tIntellectual capability, 1037Intellectual disorder, 1036–1039classication of, 1037–1038denition, 1036–1037dental hygiene care, 1039dimensions of, 1037etiology, 1038examples of risk factors for, 1039tgeneral characteristics, 1038–1039key words, 1036bsupportive interventions, 1037Intellectual functioning, 1036bIntelligence quotient (IQ), 1036b, 1037–1038Intensifying screen, 205bInterceptive/preventive orthodontics, 502bInterdental areaanatomy of, 472–473planning interdental care, 473–474proximal tooth surfaces, 473Interdental brush, 462, 462fInterdental care. See also Dental ossingdocumentation, 484b, 485keywords, 472bInterdental gingiva, examination of, 308Interferon beta, for multiple sclerosis, 1004bInterim denture prosthesis, 918Interim prosthesis, 515b, 521Interim therapeutic restoration (ITR), 854bIntermaxillary xation (IMF), 930b, 933, 935–936, 936fInternational Federation of Dental Hygienists (IFDH), 4b, 14International Federation of Dental Hygienists Code of Ethics, 1193–1194International system. See Fédération Dentaire Internationale (FDI) systemInterocclusal record, 240bInterpersonal barrier, to communication, 32tInterprofessional collaborative practice (ICP), 4b, 11, 11b, 982bInterproximal space, 242bInterradicular ber, 303Interstitial, 945bIntertubular dentin, 764bIntervention, dened, 4bInterview technique, 154–158advantages, 158disadvantages, 158form, 158participants, 154pointers, 158setting for conducting, 154Intimate partner violence, 1053Intimate relationship, 1048bIntrathecal, 945bIntratubular or peritubular dentin, 764bIntrinsic, denition, 800bIntrinsic stains, 360, 360bInvasive procedure, 83bIonizing radiation, 214–215Iron, 579tIron deciency anemia, 1152–1153Irradiation, 205bIrreversible coma, 982bIrrigant, 242bIrrigation, 242bIschemia, 997b, 1130bIsogenic, denition, 945bIsolated systolic hypertension, 901bIsoniazid, 1116, 1117tJJaundice, 47bJournal of the ADHA, 5bJunctional epithelium, 300–301, 309Juvenile diabetes. See Type 1 diabetes mellitusJuvenile-onset diabetes. See Type 1 diabetes mellitusJuvenile rheumatoid arthritis, 1012KKaposi’s sarcoma (KS), 61b, 62Kennedy classication of edentulous areas, 515bWilkins9781451193114-index.indd 1233 08/10/15 9:40 AM Keppra, 1061tKeratinization, 298bKeratinized epithelium, 242bKetamine, 1095tKetoacidosis, 1164b. See also HyperglycemiaKetogenic diet, 1062Ketone bodies, 1164bKetonuria, 1164bKilohertz (kHz), 715bKilovoltage, 213Kinesics, 30bKlonopin, 1061tKnots (surgical)characteristics, 754management, 754Knowledge barrier, to communication, 32tKnutson, Dr. John W., 603Korotkoff sounds, 175b, 1090Kreteks, 550bKussmaul breathing, 114bKVp (selector), 206, 502badvantages of high, 213disadvantages of high, 213impact on radiographic image, 213Kyphosis, 100b, 997bLLabioversion of teeth, 289Lack of interest and barrier to communication, 32tLactation, local anesthesia and, 648–649Lactobacilli, 50Lamallae, 350bLamotrigine (Lamictal), 1061t, 1074Lanugo, 1070bLaser bleaching, 800bLaser-induced autouorescence spectroscopy, 198Laser therapy, 724–726Latent image, 205bLatent infection, 47bLatent tuberculosis infection (LTBI), 1116Lateral abscesses, 746Lateral, denition, 740bLateral pressure, 664bof detection instruments, 678impact of errors, 678of treatment instruments, 678Latex allergy, 69bLatex hypersensitivityclinical manifestations, 78equipments that contain latex, 77bindividuals at risk of, 78management, 78reason for, 77Lavage Magnetic eld, 715bLe Chirurgien Dentiste, 448Leakage radiation, 208bLearning, 420bLegal blindness, 1023bLegal factors, in dental hygiene practice, 16Legionella pneumophila, 46Leonard method, 459tLesions, 313bblisterform, 194dentalabrasion, 273attrition, 272–273enamel hypoplasia, 271–272erosion, 273tooth fractures, 273–274denture-induced oral changes, 922–923depressed, 194–195chart, 196felevated, 194chart, 196fexophytic, denition, 186bat, 195chart, 197fgingival and periodontal infectionsadvanced, 317–318clinical appearance, 319early, 317established, 317progressive destruction of connective tissue, 317herpetic gingivostomatitis, 745idiopathic, denition, 186bindurated, denition, 186bnonblisterform, 194attachment of, 197fprocedure for follow-up forbiopsy, 198–199cytological smear technique, 198exfoliative cytology, 198laboratory report, 199oral cytology technique, 155fspectroscopy, 198purulent, 186brubefacient, 186bsessile, 186bLeukemia, 945bLeukocytes. See White blood cellsLeukocytosis, 1148b, 1156Leukopenia, 1148bLeukoplakia, 197Levabuterol, 1120tLevels of evidence, 20b, 25fLevetiracetam, 1061tLevo-alpha-acetyl-methadol (LAAM), 1099Levooxacin, 838tLevonordefrin (Neo-Cobefrin), 644, 646Libido, 888bLicense by credential, 4bLichenication, 1048bLidocaine, 643, 658–659, 659tLife expectancy, 901bLifestyle, 901bLigation, 752bLigature, 502bLimb-girdle muscular dystrophy, 1010Linear gingival erythema (LGE), 63, 740bLingual frenum, 302Linguistic competence, 30bLinguoversion of teeth, 289Lining mucosa, 189, 919Lip/cheek biting, 292Lipopolysaccharides (LPSs), 702Listening, 420b, 424Lithium, for bipolar disorder, 1074Liver disease, 1089–1090Local anesthesia, 635b, 651badvantages, 657adverse reactions, 655–656armamentarium foradditional, 650–651anterior middle superior alveolar (AMSA) injections, 651cartridge/carpule, 650computer-controlled delivery system, 651needle, 649–650, 650fpalatal anterior superior alveolar (P-ASA) injections, 651periodontal ligament (PDL) injections, 649sequence of syringe assembly, 651, 651fsyringe, 649clinical procedures for administering, 653baspiration, 653–654injection selection, 651needle disposal, 655fneedle recapping, 654, 654f, 655, 655fneedle removal, 655prevention of percutaneous injury, 650fsharps injury protection, 654–655color code for, 650bcriteria for drug selection, 646and dental hygiene procedures, 646for dental hygiene procedures, 652tdisadvantages, 657local complications, 656–657patient assessment for administering, 647–649allergy, 647–648angina, 648atypical plasma cholinesterase, 648coronary heart disease, 648diabetes, 648general medical considerations, 647glaucoma, 648heart condition, 648heart failure, 648hemophilia, 648hypertension, 648hyperthyroidism, 648impaired liver or kidney function, 648information for complete preanesthetic assessment, 647malignant hyperthermia, 648methemoglobinemia, 648potential drug interactions, 649pregnancy and lactation, 643b, 648–649specic medical considerations, 647–649treatment options, 647and patient factors, 647pharmacology1234 INDEXWilkins9781451193114-index.indd 1234 08/10/15 9:40 AM INDEX 1235contents of local anesthetic cartridge, 642ester and amide anesthetic drugs, 642–643vasoconstrictors, 645–646, 645tpsychogenic reactions, 656Local delivery system, 731Local hypoplasia, 364Lorazepam, 1072Lordosis, 100bLow pain threshold, 635bLower or terminal shank, 664bLubricated stone, 688Lumen, 1130bLuminal, 1061tLung cancer and tobacco use, 553Lymphadenectomy, 945bLymphadenopathy, 60, 62, 186bLymphadenopathy-associated virus (LAV), 61bLymphocytes, 1150Lymphocytopenia, 1156Lysergic acid diethylamide (LSD), 1096MMacrocephaly, 888bMacroglossia, 1036bMacrognatia, 888bMacronutrients, 572bMagnesium, 579tMagnetostrictive, denition, 715bMagnetostrictive ultrasonic scalers, 716–717Main caregiver, 854bMainstream smoke, 549b, 550fMainstreaming, 956bMaintenance appointmentsblood pressure, 178of body temperature, 174–175dental caries, 444during dental therapy, 403of normal pulse, 176–177professional, for implant systems, 541–542continuing care appointment, 542–543, 542ffrequency of appointments, 541–542probing of dental implants, 541respiration, 177–178sealantsreplacement, 628retention, 628short and long-term plan, 421Major depressive disorder, 1073Malaise, 740b, 1109bMalignant, denition, 945bMalignant hyperthermia (MH), local anesthesia and, 648Malnutrition, 572beffect on immune system, 580Malpractice, 138bMalrelations of groups of teethcrossbites, 287, 287–288fedge-to-edge bite, 287, 288fend-to-end bite, 287, 288fopen bite, 287, 288foverbite, 288–289, 288–289foverjet, 287, 288funderjet, 287, 288fMandibular distraction, 878bMandibular fractures, 935–937Manual instrumentsdull, consequences of, 686sharp, benets from use of, 686Marcaine, 644Marginal irrigation, 242bMarijuana, 1094, 1096Marker, 298bMass communication, 30bMass media, 30bMasses, 197–198Mast cell, 1109bMastalgia, 888bMaster model, 240bMastication, 298bMasticatory mucosa, 189, 299, 919Materia alba, 256bclinical appearance and content, 266–267effects, 267prevention, 267Matrix, 350bMaturation, 256b, 595bMaturity, 888bMaxillary and mandibular anterior frena, 302Maxillary obturator prosthesis with denture, 882fMaxillofacial, denition, 930bMaxillofacial prosthetics, 930bMaximum permissible dose (MPD), 205bMcKay, Dr. Frederick S., 364, 598Meal plan, 572bMeasles virus (Morbillivirus), 52tMechanical biolm control, 449bMedia communication, 31Mediator, 1109bMedical emergency report form, 119, 120fMedical subject headings (MeSH), 20bMEDLINE, 23bMedline database, 23, 23bMegaloblastic anemia, 1153–1154Menarche, 888bMeningocele, 1010Menopause, 888bMenses, 888bMenstrual cycle, 894–895, 894fMental disordersdocumentation, 1082, 1082bkey words, 1070boverview of, 1070–1071prevalence of, 1070–1071Mental health, 17Meperidine, 838t, 1095tMepivacaine HCL, 644Mercury sphygmomanometer, 178Mercury thermometer, 176, 176fMesognathic appearance, 287, 287fMeta-analysis, 25Metabolic syndrome, 397Metallic stains, 364Metastasis, 945bMetered spray, 635bMeth mouth, 1101bMethadone, 1099Methamphetamine, 1096t, 1097Methemoglobinemia, local anesthesia and, 648Methicillin-resistant Staphylococcus aureus, 46, 64–65Methylmethacrylate polymer, 774Methylphenidate, 1042, 1096tMetronidazole, 730, 838tMI spirit, 420bMicro mini-blade, 669Microabrasion, 800bMicrobial aerosol, 47bMicrobiota, 47b, 256bMicrocephalus, 1036bMicrocephaly, 997bMicrognathia, 1087bMicronutrients, 572bMicroorganism, 256bMicropores, 620bMilliammeter, 206Milliamperage, 213Milliampere (mA), 205bMilliampere impulse (mAi), 205bMilliampere second (mAs), 205bMilligray (mGy), 205bMillisievert (mSv), 205bMineralization, 350b, 353Miniblade, 669Miniplate osteosynthesis, 930bMinocycline hydrochloride (HCL), 730t, 731, 732–733, 733fMitoxantrone, for multiple sclerosis, 1004bMitral valve prolapse, 1134–1135Mixed dentition, 270bMixed hearing loss, 1026Mobilizing change talk, 429b, 430Mode of entry, 48Mode of transmission, 48Modiable risk factor, 396bModied pen grasp, 673–674, 673fModied Stillman method of toothbrushing, 456–457position of brush, 456procedure, 456–457purposes and indications, 456strokes, 457Monoamine oxidase inhibitors, 1073Monocytes, 1150Montelukast (Singulair) (Zarlukast), 1120tMonthly reminder method, 830Moral, 14bMorbidity, 1109bMorbidity and Mortality Weekly Report (MMWR), 61bMorphine, 838t, 1095tMorphology, 186bMortality, 1109bMotivation, 420b, 422–423Motivational interviewing, 30b, 31, 420belements of “MI spirit,” 423–424, 423tacceptance, 423compassion, 423–424evocation, 424partnership, 423Wilkins9781451193114-index.indd 1235 08/10/15 9:40 AM Motivational interviewing (continued)exploring ambivalence, 427–429decisional balance, 428pro/con matrix, 428, 428f, 428breadiness ruler, 428–429, 429f, 429bsustain talk versus change talk, 427–428guiding principles, 424implementation, 424–427agenda setting, 425–426core skills, 426–427, 426binformation exchange, 424–425, 426bwith pediatric patients and caregivers, 431, 432bprocesses of, 424, 425f, 425bstrengthening commitment, 430–431, 430t, 431ttraining and coaching, 432Mouth mirror, 328–329, 681–682attachments, 328care of, 329diameter of, 328disposable, 328handles, 328parts, 328procedure for use, 329purpose and uses, 329types of surfaces, 328Mouthrinses, 494tchemotherapeutic rinses, 491commercialactive ingredients, 494–495inactive ingredients, 495contraindications, 495documentation, 498, 498bwith uoridebenets, 610indications, 609limitations, 609preparations, 609–610, 609tformulation, 494tgeneral functions, 492bkeywords, 488bas part of personal oral self-care, 492patient-specic recommendations, 495preventive and therapeutic agents ofchlorhexidine (CHX), 492–493uoride, 492oxidizing agents, 494oxygenating agents, 494phenolic-related essential oils, 493–494quaternary ammonium compounds, 494triclosan, 493before professional treatment, 492purposes and uses, 492steps to rinsing, 495, 495bMovement of body parts, as form of communication, 31Moxioxacin, 838tMucogingival defect, 321fMucogingival junction (MGJ), 298b, 302, 319fold (or wrinkle) test, 342, 342fmeasurement of attached gingiva, 342, 343fprobing, 342tension test, 342tissue examination, 343Mucosal lesions, feeding and eating disorders and, 1078Mucositis management, 949–950prevention/oral health maintenance, 949treatment, 949–950Mucositis/stomatitis, 580Mucus, 1109bMultidrug-resistant TB (MDR-TB), 53Multifactorial, 878bMultiple sclerosis, 1002–1003medications used to, 1004bMumps virus (paramyxovirus), 52tMurmur, 1130bMuscular dystrophies, 1009–1010Musculoskeletal disorders, affecting dental hygienists, 107tMutans streptococci, 436Mutism, 1036bMy Plate Food Guide, 861Myalgia, 1109bMyasthenia gravis, 1005–1007Myasthenic crisis, 1006Mycobacterium tuberculosis, 46, 52t, 1115Mycoplasma, 256b, 1109bMyelomeningocele, 1010–1012description, 1010medical treatment, 1011–1012, 1011fphysical characteristics, 1011types of deformities, 1010–1011Myelosuppression, 947Myocardial infarction, 1138–1139Myocardium, 1130bMyoclonus, 1059bMyopathy, 997bMyopia, 1023bMyotonic dystrophies, 1010Myotonic muscular distrophy (Steinert’s disease), 1010Mysoline, 1061tMyxedema coma, 888bNNadir, 945bNail biting, 292Naltrexone (Revia), 1093Naproxen, 838tNasal cannula, 114bNasoalveolar molding technique (NAM), 878bNasopalatal defect, 1102fNatalizumab, for multiple sclerosis, 1004bNational Asthma Education and Prevention Program, 1119National Dental Hygienist Association Code of Ethics, 1187National Institute for Occupational Safety and Health (NIOSH), 70, 641National Institute of Dental and Craniofacial Research website, 33National Institutes of Health, 23bNational Standards for Diabetes Education and Support guidelines, 1171Natural tooth-retained overdenture, 528Necrosis, 740bNecrotizing gingivitis (NG), 740Necrotizing periodontal diseases (NPD), 740, 740bNecrotizing ulcerative gingivitis (NUG), 63, 413, 740, 741fbasic characteristics, 742care for acute stage, 743clinical ndings, 742dental hygiene care, 742–744disease-resistance factors, 741documentation, 749, 749bin HIV-positive patient, 740initial signs and symptoms, 742interdental necrosis, 742local factors, 741microbiology, 741pseudomembrane, 742scaling and root debridement, 743stress factors, 741toothbrushing, 743Necrotizing ulcerative periodontitis (NUP), 63, 740, 741fbasic characteristics, 742care for acute stage, 743clinical ndings, 742–743dental hygiene care, 742–744disease-resistance factors, 741general debridement, 743in HIV-positive patient, 740initial signs and symptoms, 742interdental necrosis, 742local factors, 741microbiology, 741pseudomembrane, 742scaling and root debridement, 743stress factors, 741subgingival instrumentation, 743toothbrushing, 743Needles, 753f, 754fattachment, 754body, 753characteristics, 754components, 753, 753fcutting edge, 754material, 754point of, 754requirements, 754swaged, 753–754Neglect, denition of, 1049Neisseria gonorrhoeae, 52tNeo-Cobefrin, 644, 646Neonatal herpes, 59Neoplasms, 62, 945b, 1090Nephropathy, 1175Neural depolarization mechanism, 764bNeurodevelopmental disorderautism spectrum disorder, 1041–1043intellectual disorder, 1036–1039overview of, 1037bdown syndrome, 1039–1041Neurolinguistics, 30bNeurologic disorders, 996Neurontin, 1061t1236 INDEXWilkins9781451193114-index.indd 1236 08/10/15 9:40 AM INDEX 1237Neurosis, 1070bNeurotin, 1074Neutral working position, 100bclinician/patient positioning, 103–104, 103–104fdescription of neutral seated position, 103effects of, 103objectives, 102–103Neutropenia, 1148b, 1156Neutrophils, 1150New attachment, 701bNewman, Irene, 5Niacin, 578tNicotine, 549babsorptiondistribution, 549intestinal, 551in lungs, 549, 550foral cavity, 551addiction, 555–556combination medications therapy, 560dependency, 555, 555belectronic delivery devices of, 551–552free therapy, 559–560gum, 549b, 558t, 559inhaler, 549b, 558t, 559levels of various tobacco products, 551tlozenge, 549b, 558t, 559metabolism, 548–552nasal spray, 549b, 558t, 559patch, 549b, 558t, 559peak blood plasma concentrations for, 549, 551fpharmacotherapies used for addiction, 557–559second-line medications, 560withdrawal symptoms, 556, 556–557tNicotine replacement therapies (NRTs), 549, 559Nidus, 350bNifedipine, 306Nifedipine-induced gingival enlargement, 314Night guard vital bleaching (NGVB), 800b, 801, 807, 809fNitroglycerin, 119Nitrosamines, 549bNitrous oxide, 838tanesthetic, analgesic and anxiolytic properties, 636–637blood solubility, 637chemical and physical properties, 637pharmacology of, 637Nitrous oxide-oxygen conscious sedation, 636–638, 641badvantages, 642contraindications, 639correlation of signs and symptoms to levels of, 640tdisadvantages, 642dismissal following recovery, 641equipment for, 637–638equipment forequipment maintenance, 638gas delivery system, 637gases, 637nasal hood, nose piece, mask, 637reservoir bag, 637safety features, 638scavenger system, 638sources of leak, 638findications, 638–639methods for minimizing exposure, 641occupational exposure, 641and ophthalmic surgery, 639patient selection, 638–639potential hazards to exposure, 641and pregnancy, 639and pulmonary disease, 639recommended exposure levels, 641record keeping, 641recovery, 641and respiratory tract obstruction or infection, 639signs and symptoms of, 640tsteps for administration, 639bcompletion of sedation, 640–641equipment preparation, 639–640patient preparation, 639technique for gas delivery, 640Non-Hodgkin’s lymphoma, 62Nonambulatory, 982bNonblisterform lesions, 194attachment of, 197fNoncariogenic food, 572bNoncompliance, 420b, 1070bNondominant hand, 673Noninjectable anesthesiaarmamentarium and pharmacology, 657–658characteristics, 659tcontraindications, 658technique, 658Noninjectable local anesthesia, 635bNoninsulin-dependent diabetes mellitus (NIDDM). See Type 2 diabetes mellitusNonkeratinized mucosa, 298bNonnutritive sucking, 847, 847fNonopioid analgesics, 636Nonsteroidal anti-inammatory drugs (NSAIDs), 1119, 1120, 1157Nonsurgical periodontal therapy, 313b, 323, 350, 701badvanced instrumentation, 713–715appointment systems, 704–705calculus removal, 707–708location of instrumentation, 707, 707fscaling process, 707–708subgingival anatomy, 708subgingival calculus, 708care plan for instrumentation, 704clinical preparation for, 720–722, 721fcompletion of, 727–728components of, 702–703denitive, 705dental biolm removal, 702–703documentation, 735, 736beffects of, 728–729healing and resolution of inammation, 703initial preparation for surgical periodontal therapy, 703interrupt or stop progress of disease, 703–704key words, 701blaser therapy, 724–726manual subgingival scaling steps, 708–713, 711f, 712f, 713foverhanging restorations, 726–727power-driven scalers, 716f, 717–718premedication requirements for high risk patient, 706preparation for instrumentation, 705–706preparation of clinician, 702preventive services, 702quadrant scaling, 704quality and quantity of subgingival bacterial ora, 703re-evaluation, 729restorative biolm-retentive factors, 703sonic scaling devices, 717subgingival examination, 706supragingival examination, 706tissue conditioning, 704treatment, 702advanced periodontal conditions, or poor response to routine therapy, 702early-to-moderate periodontitis, 702surgical or advanced periodontal therapy, 702uncomplicated gingivitis, 702ultrasonic and sonic tip design, 718–720, 719fultrasonic instrumentation, 722–724ultrasonic scaling devices, 716–717Nonverbal communication, 30b, 31and cross-cultural communication, 37, 38tNonvocal communication, 31Norepinephrine, 888bNormalization, 956bNormotensive, denition, 175bNosocomial, 1109bNosocomial pneumonia, 1109bNovamin, 793–794Novocain, 642Nurse practitioner (NP), 982bNursing home, 982bNutrient density, 572bNutrients, 572brelevant to oral health, 578–579tNutrition, 572bNutritional deciencies, 572band oral manifestations, 580tperiodontal infections, 580–581Nyctalopia, 1023bNylon, 449Nystagmus, 1087bOObjectives, 818bObligate, 256bOblique ber, 303Wilkins9781451193114-index.indd 1237 08/10/15 9:40 AM Obsessive-compulsive disorder (OCD), 1071Obturators, 515b, 521f, 878bcare of, 522description, 520purposes and uses, 520Occlusal guard, 286bOcclusal overload, 534bOcclusal pits and ssures, 13bOcclusal plane, 224, 240bOcclusal prematurity, 286bOcclusal surveys, in radiation, 223, 229Occlusal vertical dimension, 515bOcclusion, 858–859, 1130bdocumentation, 294, 294bfunctional, 292key words, 286bmalocclusion, 287determination of, 289–291, 290fof primary teeth, 291, 291fnormal (ideal), 286–287of primary teeth, 291recommendations for patient with orthodontic needs, 293–294and sealants, 628static, 286–289trauma from, 292–293effects of, 292–293methods of application of excess pressure, 293signs of, 293Occulesics, 30bOccupational exposure, 69b, 635b, 641Occupational Safety and Health Administration (OSHA), 4b, 83bOcular, denition, 1023bOcular herpetic infection, 59Oculopharyngeal muscular dystrophy, 1010Offset blade, 664bOlanzapine (Zyprexa), 1074, 1079Older adultsaging, 900and alcoholism, 905Alzheimer’s disease, 903–904assessment, 912barriers to care, 911–912biolm control, 912–913body temperature, 174cardiovascular system, 901–902central nervous system, 902communication skillsaccommodative speech, 36“baby talk” or “elderspeak” approach, 36cognitive and physical difculties, impact of, 36communication predicament, 36and dysarthria and aphasia, 36and sensory loss, 36“sing song” cadence, 36strategies for effective communication with, 36buse of plural pronouns, 36use of terms of endearment, 36voice tremor, pitch, loudness, and speaking rate, impact of, 36dental biolm control in, 912–913dental caries control, 914dental hygiene care, 911–915diet and nutrition, 914–915documentation, 915, 915bendocrine system, 902factors inuencing health status, 902–903gastrointestinal system, 902immune system, 902musculoskeletal system, 901oral health in, 907–911osteoarthritis, 904–905osteoporosis, 905–906, 906fpathology and disease, 902–903periodontal care, 914peripheral nervous system, 902physiological aging, 900–901preventive care plan, 912respiratory system, 902, 907response to disease, 903sensory abilitieshearing, 902vision, 902sensory systems, 902sexually transmitted diseases, 907skin, 900strategies for enhancing communication with, 913tstrategies for oral health instruction for, 913tsupportive interventions to aid, 903ttemperature response, 903bOligomenorrhea, 888bOmalizumab, 1120tOncology, 945bOngoing evaluation, 818Opalescent dentin, 364Ophthalmologist, 1023bOphthalmology, 1023bOpiate antagonist, 1087bOpinions, 26Opioids, 1087b, 1096Opium, 1095tOpportunistic infections (OI), 62, 701bOpportunistic pathogen, 47bOptician, 1023bOptimum physical health, 16Optometrist, 1023bOral and maxillofacial surgeryalveolar process fractures, 937–938dental hygiene care, 931–933diet selection, 932postsurgical instructions, 932–933presurgery treatment planning, 931–932presurgical instructions, 932documentation, 940–941, 941bexternal skeletal xation (external pin xation), 936–937, 936f, 937fkeywords, 930bmandibular fractures, 935–937midfacial fractures, 937patient preparation, 931patient with fractured jaw, 933–935patient with intermaxillary xation, 933Oral cancer, 195–198, 549bOral candidiasis, 63Oral cavity, anatomical landmarks of, 189, 190f, 191f, 199bOral cavity, transmission of microorganisms in, 46airborne infections, 50cross-contamination, 46in infants, 46oral ora, 46pathogens transmissible by oral cavity, 50potentials for infection, 46prevention, 50biolm removal, 50cleaning with water, 50preprocedural oral hygiene measures, 50use of an antiseptic mouthrinse, 50salivary bacteria, 46Oral communication, 1027Oral epithelium, 298bOral ndings, during seizure, 1062–1064Oral ora, 256bOral glucose tolerance test, 1164bOral hairy leukoplakia (OHL), 59, 61bOral healthadvocacy for, 11–13check sheet, 441bdisparities, 30bOral Health in America, 371The Oral Health-Related Quality of Life (OHRQL) Model, 402tOral healthcare practice, objectives, 46Oral hygiene, 4bOral hypoglycemic agent, 1164bOral implications, for feeding and eating disorders, 1077–1078, 1078fOral inammation, impact, 488Oral irrigation, 506for peri-implant hygiene, 540Oral malodour, 872Oral manifestations of HIV infection, 62–64, 63tOral mucosa, 189, 189fcleaning, 527impact of daily removal of prostheses, 527massage, 527rinsing, 527tissue changes in patients with prostheses, 527tissue examination and oral cancer screening, 527Oral mucositis/stomatitis, 945bOral prophylaxis, 847, 861Oral prostheses, 94Oral self-care, level of function and implications for, 962bOrange or red stains, 363–364Organization for Safety and Asepsis Procedures Research Foundation (OSAP), 83bOrthodontic and dentofacial orthopedics, 286bOrthodontic appliance, 502bOrthodontic therapy, 50Orthodontics1238 INDEXWilkins9781451193114-index.indd 1238 08/10/15 9:40 AM INDEX 1239application of aluminum oxide, 508, 508fapplication of rubber cap, 508–509, 509fbonded bracketsadvantages, 502–503arch wire, 503base, 503characteristics of bonding and rebonding, 504clinical procedures for bonding, 504disadvantages, 503effect of ller particles, 504elastomer, 503xed appliance system, 502–503f, 503and uoride-releasing bonding systems, 504forms, 503, 503fmaterials, 503removable aligner system, 503–504cement removal, 507cemented bands, 502–504clinical procedure for debonding, 507–509completion of therapy, 506–507demineralization, 509dental hygiene caredental caries and periodontal disease control, 505–506oral irrigation, 506risk factors, 504–505and dentofacial orthopedics, 9documentation, 511, 511benamel loss, 509post-debonding evaluation, 509post-debonding preventive caredental caries, 510uoride treatments, 511periodontal evaluation, 510removal of orthodontic adhesive resin, 507–509, 507b, 507–508fand retention of dental biolm, 510Orthognathic surgery, 878b, 930bOrthognathics, 930bOrthopedic appliance, 502bOrthopedics, 286b, 878bOrthopnea, 1109bOrthosis, 997bOrthostatic hypotension, 114bOSCAR (Oral, Systemic, Capability, Autonomy, and Reality), 396bplanning guide, 398tOSHA (Occupational Safety and Health Administration), 4b, 83bOsmosis, 764bOsseointegration, 534b, 535Osteoarthritis, 904–905, 1012–1013symptoms, 905treatment, 905Osteoid, 901bOsteonecrosis of jaw (ONJ), 945bOsteopenia, 901bOsteoporosis, 397, 901b, 905–906, 906factivity and exercise, 906causes, 905dental hygiene management considerations, 906medications for, 906and periodontal disease, 906and periodontal disease development, 314prevention, 905, 906risk factors, 906symptoms, 906Osteoradionecrosis, 945bOsteosynthesis, 930bOtalgia, 1109bOtitis media, 1023bOtologist, 1023bOutcome, 20bassessment, 818bOver-the-counter (OTC), 152b, 595b, 764banalgesics, 636Overdenture, 528f, 918, 918bdental hygiene care foruoride application plan, 528–529maintenance appointments, 529using sealants, 529description, 527and endodontic therapy, 528implant-retained, 528natural tooth–retained, 528and periodontium, 528purposes, 527–528Oxcarbazepine, 1061tOxidizing agentsavailability and use, 494considerations for use, 494efcacy, 494mechanism of action, 494Oxycodone, 838t, 1095t, 1097Oxygen delivery systems, 123–124, 123t, 124f, 124bOxygenating agentsavailability and use, 494considerations for use, 494efcacy, 494mechanism of action, 494Oxyhemoglobin, 1148bOxymetazoline, 661PPaciers, criteria for selecting, 847fPackaging, to prevent contaminationinstrument arrangement, 86–87, 87fpreparationindicator tape, 87using seals, 87, 87fwrapping, 87purpose, 86Pain, 403, 635bcontrol mechanisms. See also Local anesthesia; Nitrous oxide-oxygen conscious sedation; Noninjectable anesthesianew developments in, 660–661removal of stimulus, 636use of analgesics, 636use of general anesthesia, 636use of iatrosedation, 636use of local anesthetic, topical anesthetic, 636use of nitrous oxide–oxygen conscious sedation, 636–638use of NSAIDs, 636perception, 634reaction, 634threshold, 634, 635bPain, of dentin hypersensitivitydifferential diagnosis of, 769tdifferentiation of, 768–769experience, 768impact of, 768subjective pain assessment form, 770bteeth affected, 768Palatoplasty, 878bPalifermin, 949Palliation, 945bPalliative, denition, 945b, 982bPallidotomy, 997bPalm grasp, 674, 674fPalmer system, 141, 142fPalpation, 186bexamination, 187Palsy, 997bPancreas, 893Pancytopenia, 945bPandemic disease, 47b, 61Panic disorder, 1071, 1071bPanoramic radiography, 229–230limitations, 230procedures, 230uses, 230, 230bPapillae, 186b, 306Papillary hyperplasia, 923, 923fPapillary lesion, 195Papillary masses, 197–198Paraclinical procedures, 205bParafunctional contacts, 292Parafunctional, denition, 286bParalysis, 997bParanoia, 1070bParaplegia, 997bParasite, 256bParathyroid glands, 892Parathyroid hormone (PTH), 906Parenteral, denition, 114bParenteral injection, 47bParesis, 997bParesthesia, 997b, 1059bParietal, denition, 740bParkinsonism, 997bParkinson’s disease, 1005Parotid gland, 1078Parotitis, 47bParoxetine (Paxil), 1072, 1073, 1075Paroxysm, 1059bPARQ (procedures, alternatives, risks/benets, and questions), 701bPartial fetal alcohol syndrome (PFAS), 1091bPartnership, motivational interviewing and, 423Parts per million (ppm), 595bPassive immunity, 47bPassive listening, 420bPassive smoke, 549bPatch, 186bPatent, 764bPathogen, 47b, 256bWilkins9781451193114-index.indd 1239 08/10/15 9:40 AM Pathognomonic, denition, 1036bPathologic migration, 286b, 292Pathophysiology, 1109bPatient education and counseling, 418Patient education brochures, 31Patient education strategies, 2Patient health historyAmerican Society of Anesthesiologists (ASA) physical status classication system, 169–170dental history, 158–159, 160–161tdocumentation, 170health history form, 155–157fimmediate application ofmedical consultation, 167prophylactic premedication, 167radiation therapy, 167for referral, 167telephone or personal contact, 167use of antibiotic premedication, 167bwritten request, 167interview method for collecting, 154–158introduction to patient, 153items included in, 158–167, 159–165tkeywords, 152blimitations, 153–154medical history, 159–167, 162–166tpersonal history, 158, 158tpreparationcomplete history, 153preappointment information, 153self-history, 153pretreatment antibiotic prophylaxis, 167–169purposes, 152questionnaire, 154record formsadequate basic history form, 153basic history forms, 153supplementary forms, 153review and update of, 170, 170bsignicance of taking complete and accurate, 152Patient hygiene performance (PHP), 371of mandibular molars, 375of maxillary molars, 375procedure, 375purpose, 375scoring, 375–376calculation and interpretation, 376debris score for individual tooth, 375PHP for group, 375PHP for individual, 375selection of teeth and surfaces, 375Patient preferences or values, 21Patient reception and ergonomicsbody positions for delivery of careadjustment steps, 102contraindications for supine position, 102in dental chair, 102prepositioning for patient reception, 102semi-upright, 101, 101fsupine, 101–102f, 102trendelenburg, 101f, 102upright, 101, 101fconclusion of appointment, 102ergonomic risk factors, 106, 108tescorting patient to dental chair, 101key words, 100bneutral working position, 102–104preparation of patient, 100–101related occupational problem, 106scope of ergonomic dental hygiene, 106self-care for dental hygienist, 106–109daily functional movement exercises, 107–109treatment area centersclinician’s chair, 104cords, 105–106handpieces, 105lighting, 104–105, 105fmagnication of light, 105working position of clinician, 103–104, 103–104fPatient records, 138bcomponents of, 138–139electronic, 139handwritten, 139key terms related to, 138bpurposes and characteristics, 138Patient teachingabused patient, 1055anesthesia, 661bleaching of tooth, 812calculus and good oral hygiene, 357cancer, 953cardiovascular disease, 1144care provided for patient with disability, 978cleft lip and/or palate, 885continuing care program, 830dental biolm, 268dental caries, 444dental hygiene care, in alternative settings, 992dental hygiene care plan, 405, 416dental hygiene practice, 97dental stains and discoloration, 367of dentifrice and mouthrinse, 498dentin hypersensitivity, 776diabetes mellitus, 1180diet and dietary analysis, 591documentation, 147emergency care, 133ergonomic practice, 111evaluation of treatment, 824evidence-based dental hygiene practice, 28extrinsic stain removal, 797uoride, 615gingival or periodontal condition, 310health communication, 40health promotion and disease prevention, 433implant systems, 545indices, 391instrumentation, 684interdental care, 485maxillofacial patients needs, 941mental health disorder, 1082necrotizing ulcerative gingivitis (NUG), 749neurodevelopmental disorder, 1046nonsurgical periodontal therapy and adjunctive therapy, 736occlusion, 295older adult, 916oral health care of children, 873orthodontics, 511patient wearing denture, 927patient with endocrine disorder or hormonal change, 897patients with sensory disabilities, 1032periodontal disease, 325periodontal examination, 348personal, medical, and dental history, 171personal protection, 79physically impaired patient, 1017pregnancy and infant, 849prostheses, 530radiation, 237respiratory disease, 1127role of dental hygienist, 17sealants, 630seizure disorder, 1067study model, 253sutures and dressings, 762teeth, 284tobacco use, 567toothbrushing, 468about vital signs, 174vital signs, 183Paxil, 1072, 1073, 1075Pediatric dentistry, 9American Academy of, 854specialty of, 854Pediatric speech aid prosthesis, 878bPedunculated, denition, 186bPeer review, 20bPeer-reviewed (refereed) publications, 24–25Pellicle formation, of calculus, 353Penicillin, 838tPenumbra, 205bPercutaneous infection, 47bPeri-implant hygiene, 539–540Peri-implant mucositis, 543Peri-implantitis, 534b, 543Periapical, denition, 740bPeriapical survey, in radiationarea covered, 222bisecting-angle technique, 228–229lm holders, 229lm sizes, 222paralleling technique, 224–227, 225–226fsensor sizes, 223Pericoronal abcess, 52–749Pericoronitis, 740b, 748–749Perimylolysis, 1070b, 1077–10781240 INDEXWilkins9781451193114-index.indd 1240 08/10/15 9:40 AM INDEX 1241Perinatal transmission of HBV, 55–56PerioCare, 758Periodontal abscesses, 746–748biolm and calculus, 747care plan, 747–748chronic state, 746clinical signs and symptoms, 746comparison with periapical abscess, 747denitive therapy, 748development, 746effects of instrumentation, 746–747etiologic factors, 746–747physical condition, 746pockets of chronic inammatory periodontal infection, 746tooth condition, 746trauma, 747Periodontal chart, 142Periodontal debridement, 700endoscope-assisted. See Endoscope-assisted periodontal debridementPeriodontal, denition, 740bPeriodontal disease developmentacute inammatory response, 317associated with HIV infection, 63complications of pocket formation, 318contributing factorscontributing, 312dental, 315diet and eating habits, 316etiologic, 312gingiva, 316local, 312personal oral care, 316predisposing, 312risk, 312systemic, 312furcation involvement, 319classication, 320fgingival and periodontal infectionsadvanced lesion, 317–318causes of tissue changes, 321classication, 320classication, 322–323t, 323, 325clinical examination, 321description terminology, 321–323early lesion, 317early recognition of tissue changes, 323established lesion, 317initial lesion, 317signs and symptoms, 321gingival pocket, 318mucogingival involvement, 319–320, 320fperiodontal pocket, 318, 319fpseudopocket, 318recurrence of, 828risk factors, 313–316, 397diabetes, 314drug related, 314osteoporosis, 314psychosocial, 314tobacco smoking, 313–314, 313fself-cleansing mechanism and, 316tooth structure involved, 318–319Periodontal examinationapplication of air, purposes and use, 329–330basic setup, 328clinical attachment levelprocedure, 341, 342frationale, 341, 342fdocumentation, 347, 347bexplorersbasic procedures for use of, 332–333description, 330–331, 330f, 331fgeneral purposes and uses, 330preparation, 331specic, and their uses, 331–332subgingival exploration for defects, 333–334supragingival exploration for defects, 333extraoral/intraoral examination, 338of fremitus, 343–344, 344ffurcationanatomic features, 344methods, 344–345guide to probing, 337–338evaluation of tooth surface, 337factors affecting probe determination, 337–338pocket characteristics, 337, 337fkey words, 328bof mobility, 343mouth mirror, 328–329mucogingival junctionfold (or wrinkle) test, 342, 342fmeasurement of attached gingiva, 342, 343fprobing, 342tension test, 342tissue examination, 343parameters of care for, 339–345precautions, 330preliminary assessment prior to, 338–339probescharacteristics, 336manual, 336–337materials, 336purpose and use, 334–336, 335fselection, 336–337types of, 334, 336tprobing procedureadaptation of probe for individual teeth, 340–341advance probe to base of pocket, 339–340anterior teeth, 341circumferential, 340, 340fmolars and premolars, 340–341periodontal pocket, 339position possible for reading, 340probe along tooth surface, 340–341probe insertion, 339, 339fproximal surfaces, 341reading probe, 340recording of measurements, 341, 341fradiographic examination, 338–339overhanging restorations, 346relationship to pockets, 346risk assessment, 338Periodontal health, 538Periodontal infections, 413and dental biolm, 265and diet, 574, 580and uoridation, 600nutritional deciencies and, 574, 580, 580tobesity and, 580radiographic changes in, 345–346bone level, 344f, 345crestal lamina dura, 346furcation involvement, 346periodontal ligament space, 346, 346fshape of remaining bone, 245f, 345radiographic examinationcalculus, 346treatment, 8Periodontal maintenance (PM), 826, 826bcriteria for referral during, 828Periodontal manifestations, feeding and eating disorders and, 1078Periodontal probe, 187Periodontal records, 143–145deposits, 144fremitus determination, 144gingiva and its record ndings, 144items to be included, 144mobility of teeth, 144occlusion-related habits, 144possible food impaction areas, 144radiographic ndings, 144severity of periodontal disease, 144soft deposits, 144stains, 144supragingival and subgingival calculus, 144Periodontal risk calculator, 313bPeriodontal screening and recording (PSR), 378–380, 379fcalculation and interpretation, 379–380procedurecriteria, 378probe application, 378recording, 378–379WHO Periodontal Probe, 378, 378fpurpose, 378scoring, 379–380selection of teeth, 378Periodontal subgingival explorer, 723Periodontal surgery, 930Periodontal therapy, nonsurgical. See Nonsurgical periodontal therapyPeriodontic clinics, 9Periodontics, 9Periodontitis, 313b, 863in children, 308diabetes as risk factor for, 1165on glycemic control, 1165nonsurgical periodontal therapy, 702in tobacco users, 554Wilkins9781451193114-index.indd 1241 08/10/15 9:40 AM Periodontium, 298b, 528alveolar bone, 303cementum, 303documentation, 309, 309bgingival ber groups, 303fkeywords, 298bperiodontal ligament, 299, 302–303principal ber groups, 303fPeriodontometer, 328bPeripheral neuropathy, 1175Permanent dentition, 270bPermeable, 313bPermucosal infection, 47bPernicious anemia, 1153Perphenazine (Etrafon, Trilafon), 1079Persistent generalized lymphadenopathy (PGL), 61b, 62Personal factors, in dental hygiene practice, 16–17Personal protective equipment (PPE), 83bPersonalized patient counseling, 421–422Pervasive, 1036bPervasive developmental disorder, not otherwise specied (PDD-NOS), 1042bPetechia, 152, 186b, 195, 1148bPetit mal, 1059bPEW Report, 10, 2009PH, 270bPhagocytosis, 1148bPharyngitis/tonsillitis, 1112tPhenelzine, 1073Phenobarbital, 1061t, 1099Phenolic-related essential oilsavailability and use, 493considerations for use, 493–494efcacy, 493mechanism of action, 493Phentolamine mesylate, 660, 661Phenytoin, 306, 1061tPhenytoin-induced gingival enlargement, 314Phobia, 1070bPhosphate, for extrinsic stain removal, 787Phosphoric acid, 627Phosphorus, 579tPhotoelectric effect, 205bPhoton, 205bPhotopolymerization, 620b, 621Photostimuable phosphor plate (PSP), 205b, 209bPhysical abuse, denition of, 1052Physical barrier, to communication, 32tPhysical dependence, 1087bPhysical impaired patientamyotrophic lateral sclerosis, 1004–1005arthritis, 1012–1013autonomic dysreexia, 998–999Bell’s palsy, 1002body temperature, 998cardiovascular instability, 998cerebral palsy, 1007–1009dental hygiene care, 1000, 1014–1016documentation, 1016b, 1017impaired respiratory function, 998mouth-held implements, 999–1000multiple sclerosis, 1002–1003muscular dystrophies, 1009–1010myasthenia gravis, 1005–1007myelomeningocele, 1010–1012neurogenic bladder and bowel, 998neurologic disorders, 996Parkinson’s disease, 1005postpolio syndrome, 1007pressure sore (decubitus ulcer), 998scleroderma, 1013–1014spasticity, 998spinal cord injury, 996–1000stroke, 1000–1002vulnerability to infection, 998Physical neglect, denition of, 1052Physicians’ Desk Reference (PDR), 152bPhysiological aging, 900–901Physiological barrier, to communication, 32tPica, 1036b, 1075PICO questions, 22, 22t, 27Piezoelectric, denition, 715bPiezoelectric ultrasonic scalers, 717Pigmentation, 198Pilot study, 370bPipe tobacco, 550bPirbuterol, 1120tPituitary gland, 889–890oral health risk assessment, 890symptoms of, 890tumors, 890Pixel, 209bPlacebo, 370bPlacenta abruptio, 549bPlacenta previa, 549bPlain language, 33publication, 30bPlanktonics, denition, 47b, 256bPlaque control record. See Biolm control recordPlaque-free score. See Biolm-free scorePlaque index (PL I), 372Plasma, 1148, 1150Plasma cholinesterase, atypical, 649Plastic testing stick, 688–689, 688fconrming sharpness using, 689Platelets, 1151disorders, 1156–1157dysfunction, 1157Pleomorphism, 256b, 945bPleura, 1109bPleurisy, 1109bPneumococci, 50Pneumocystis pneumonia (PCP), 61b, 62Pneumonia, 1113–1115categories and role of oral bacteria, 1114–1115community-acquired pneumonia, 1114comparison of viral and bacterial, 1114tdental hygiene care, 1115etiology, 1113healthcare-associated (nosocomial), 1115hospital-acquired, 1115nonventilator-associated, 1115nursing home–acquired, 1115symptoms, 1114treatment of, 1115ventilator-associated, 1115Pneumothorax, 1109bPocket ora, effects of nonsurgical periodontal therapy on, 728–729Pocket microora, effect of instrumentation on, 703tPocket reduction surgery, 309, 309fPoliovirus types 1, 2, 3, 52tPolishing, 240b, 781bagents, 785effect on gingiva, 783effect on teeth, 782science of, 781Polycythemia vera (primary polycythemia), 1155–1156Polycythemias, 1155–1156Polydipsia, 1164bPolymer, 620bPolymeric, denition, 256bPolymerization, 620b, 621Polymorphonuclear leukocytes (PMNs). See NeutrophilsPolyp, 186b, 195Polyphagia, 1164bPolypharmacy, 901b, 982bPolysubstance dependence, 1087bPolyuria, 1164bPontic, denition, 515bPoor communication skills, as barrier to communication, 32tPort of entry, 48Port of exit, 48Porte polisher, 788, 788fPosition-indicating device (PID), 205bPostexposure prophylaxis (PEP), 83bPostictal, denition, 1059bPostpartum depression, 1073Postpolio syndrome, 1007Postprandial, denition, 1164bPosttraumatic stress disorder (PTSD), 1071Postural hypotension, 100b, 175bPotassium uoride, 773Potassium nitrate, 773, 800b, 802Potency, 635bPounds per square inch, 781bPower-driven scalers, 716f, 717–718Power toothbrush, 449bPragmatics, 30bPrebook or preschedule method, 829–830Precision attachment, 515bPrediabetes, 1164b, 1171management of, 1171Pregnancyalcohol use during, 1090–1091aspects of patient care, 840–842dental caries control, 843–844dental hygiene caredental biolm control, 843–844patient instruction, 843–8441242 INDEXWilkins9781451193114-index.indd 1242 08/10/15 9:40 AM INDEX 1243smoking effect, 837diabetes mellitus in, 1176domestic violence, 844fetal developmentfactors that can harm fetus, 837, 838trst trimester, 836–837second and third trimesters, 837and infantdental hygiene care, 842documentation, 848–849, 849bfetal development, 836–838key words, 836blocal anesthesia and, 648–649oral ndingsenamel erosion, 840gingival enlargement, 839–840gingival inammatory changes, 839gingivitis, 839periodontal infections, 840positions during, 842fand prenatal uoride intake, 844referrals, 844transitioning to infancy, 844Premaxilla, 878bPremedication, 152bPremenstrual syndrome (PMS), 894Premenstrual syndrome, 888bPrenatal care, 836Preparatory change talk, 429–430, 429bPreprocedural antimicrobial rinsing, 403Presbycusis, 901bPresbyopia, 901bPreschoolersoral health careparental involvement, 857positioning, 857preparation of child for dental visit, 857Prescription drug abuse, 1093commonly abused, 1095–1096tdental team responsibilities, 1094prevention of, 1094risk management for legal, 1093–1094strategies to prevent, 1094Prevalence, 370bPrevent Abuse and Neglect through Dental Awareness (PANDA) program, 1053Prevented fraction, 595bPreventive counseling, 420bPreventive services, 8categories of, 9bPrevotella intermedia, 839Prilocaine, 644, 658, 659, 659tPrimary (deciduous) dentition, 270bPrimary aging, 900Primary caries, 270bPrimary healthcare, 5bPrimary herpetic gingivostomatitis, 740bPrimary infection, 47bPrimary polycythemia, 1155–1156Primary prevention, 9bPrimary radiation, 163bPrimary teethdental caries, 860fdevelopmental disturbance of, 860fpremature loss of, 861ftooth development and eruption, 860tPrimate space, 286bPrimidone, 1061tPrincipal ber groups, 303fPrion, 47bPrivacy, denition, 136tPrivate practice dental care settings, 2Private practice orthodontics, 9Probe, 328bProbing depth, 298b, 328bProcaine (Novocain), 642Pro/con matrix, 428, 428f, 428bProdrome, 47b, 1059b, 1070bProfession, 5bProfessional dental hygiene practice, 2clinical practice goals, 12overall goals, 12personal goals, 12Professional interpreter, 39Professional journals, 24Professional periodontal therapy, in HIV infection, 62Prognathic appearance, 287, 287fPrognosis, 5b, 396bProlapse, 1130bProphylaxis anglesattachments, 790, 790fprocedure, 791–792with rubber cup, brush, or rubber point, 791types of, 789t, 790, 790fuses of, 791–792Propoxyphene, 1095tProstheses, 240b, 514, 515b, 878b, 918b. See also Oral mucosacomplete denturecare of, 522components of, 521–522denture base, 521and denture deposits, 522denture teeth, 522deposits on, 522impression surface, 522mandibular, 523bmaxillary, 523bocclusal surface, 522polished surface, 522removal, 522, 523bself-cleaning, 523–526types, 521documentation, 529, 530bxed partial denturesarea requiring daily attention, 517care procedures, 517–518characteristics, 515–516criteria, 516debris removal, 516dental biolm control, 516–517dental ossing of, 517, 517fdescription, 515–516interdental brushes for, 516–517toothbrushing for cleaning, 516, 517types, 516, 516fimplant-supported, 540obturatorscare of, 522description, 520purposes and uses, 520, 521foverdenturedental hygiene care for, 528–529description, 527and endodontic therapy, 528implant-retained, 528maintenance appointments, 529natural tooth–retained, 528purposes, 527–528removable partial denturedescription, 518immersion cleaning, 520objectives for patient, 519receiving removable prosthesis, 518removal of, 518rinsing for cleaning, 519self-care procedures for, 518toothbrushing and interdental cleaning methods, 519–520, 520ftypes, 518, 518fremovable wearer, 528types of oral prostheses and appliances, 515bProtective eyewear, 71–72, 72fcare of, 72contact lenses, 72for dental team members, 71eye wash station equipment, 72face shield, 71general features of acceptable eyewear, 71for patients, 71–72types, 71child-sized sunglasses, 71with curved frames, 71dental loupes, 71disposable glasses, 71goggles, 71with side shields, 71use of, 71–72Provisional prosthesis, 534bProxemics, 30bProximal contacts, 292Prozac, 1072, 1073, 1075, 1077Pruritis, 114b, 1164bPseudomembrane, 186b, 195, 740bPsoralen, 800bPSP plates, 205bPSR (periodontal screening and recording), 854bPsychiatric emergency, 1081Psychic, denition, 1059bPsychoactive drug, 549bPsychologic age, 901bPsychologic dependence, 1087bPsychological abuse, denition, 1052Psychological neglect, denition, 1052Psychosis, 1070bPsychosocial skills, for health learning, 33tPsychosomatic method, 635bPsychotherapy, 1070bPsychotropic drug, 1087bWilkins9781451193114-index.indd 1243 08/10/15 9:40 AM Psychotropic medication, 1070bPuberty, 888bPubescence, 888bPublic health, 8tPubMed, 23, 23bPulmonary diseases, due to tobacco use, 552Pulmonary hypertension, 1109bPulp testing, 280–281, 282fPulse, 176–177of adults, 176brachial, 177carotid, 177of children, 176count and record, 177decreased, 177emergency situations, 177factors inuencing, 176–177increased, 177location of measurement, 177maintenance of normal, 176–177normal, 176patient preparation for reading, 177procedure to determine, 177, 177fpressure, 175b, 178radial, 177, 177flocate, 179Pulse oximetry, for respiratory disease, 1108, 1111fPumice, 786Punctate, 186b, 195Pupils, examination of, 1102fPuried protein derivative (PPD), 69bPurpura, 1148bPurulent, 186b, 740bPus, 298bPustule, 194Pyogenic granuloma, 839, 839fPyrazinamide, 1117tPyrexia, 175, 175bPyridoxine, 578tPyrolysis, 549bPyrophosphate, 350bPyrophosphate salts, 489QQuadriplegia, 997bQuantity of radiation, 213Quasi-experimental group, 25Quaternary ammonium compoundsavailability and use, 494considerations for use, 494efcacy, 494mechanism of action, 494Questionnaireadvantages, 154culture oriented, 154disadvantages, 154disease oriented, 154symptom oriented, 154system oriented, 154Quetiapine (Seroquel), 1074, 1079Quid, 550bRRaccoon sign, 1048bRadiation, 205bbiologic effects, 215band cell sensitivity, 216exposure impacts, 215–216entrance, 215erythema, 215skin, 215surface, 215threshold, 215permissible dose, 215protection and measurementsof clinician, 217dental, 217from leakage radiation, 217monitoring, 217of patient, 218from primary radiation, 217rules, 217from secondary radiation, 217risk of injury from, 217–222sensitivity of tissues and organs, 217btissue reaction to, 216–217unit of measurement of exposure, 215, 215tRadiation absorbed dose (Rad), 205bRadiation doseabsorbed dose, 216bcumulative dose, 216berythema dose, 216bexit dose, 216bLD 50-30, 216blethal dose, 216bmaximum permissible dose, 216b, 216tskin dose, 216bthreshold dose, 216bRadiation therapy, 945b, 947–948complications, 948, 948fdental hygiene plan of care, 950–951indications, 947systemic effects, 948types, 947–948Radiography, 205bRadiologic health, 205bRadiology, 205bRadiolucency, 205bRadiopacity, 205bRadium, 945bRamfjord Index Teeth, 370bRampant caries, 270b, 436bRampant dental caries, 829Randomized clinical trials (RCT), 25, 764bRare earth, 205bRe-evaluation appointment, 413Readiness ruler, 428–429, 429f, 429bReattachment, 701bReciprocity, 4bRecommended dietary allowances (RDAs), 573, 573bRecovering alcoholic, 1087bRecovery position, 114bRectal carcinoma, 62Rectication, 205bRectier, 205bRecurrent caries, 270bRecurrent infection, 47bRed areas of cancer, 197Red blood cells, 1149f, 1150Reference citation, 20bReective listening, 427, 427bRefractory, 701b, 826bdenition, 313bRefractory epilepsy, 1059bRegistered dietitian, 572bRegulated waste, 83bRehabilitation, 878bRelapse, 945bRelative contraindication, 635bReliability, 20b, 370bRemineralization, 436b, 437, 595b, 782prevention using dentifrice, 489protocol, 442–443initiate daily preventive measures, 443professional and prescribed applications, 444removal of nidus of infection, 442–443Remission, 945bRemote supervision, 9bRemovable aligner system, 503–504Removable partial denture, 515bdescription, 518immersion cleaning, 520objectives for patient, 519receiving removable prosthesis, 518removal of, 518rinsing for cleaning, 519self-care procedures for, 518toothbrushing and interdental cleaning methods, 519–520, 520ftypes, 518, 518fRepetitive strain injury, 100bReplication, 47bRepolarization mechanism, 764bRescue breathing, 114bResearcher, 8tResection, 918bResidence-bound (homebound) patients, 982b, 983–984Residual ridges, 515bResin-bonded brackets, 502Resorption, 270bRespirationcount of, 178decreased, 178emergency situations, 178factors inuencing, 178factors to observe, 178increased, 178maintenance, 177–178normal rate, 177–178procedures for observing, 178recording of, 178respiratory rateof adults, 177of children, 178Respiratory disease, 397acute bronchitis, 1113anatomy, 1108, 1110fassessment, 1108, 1110asthma, 1118–1121blood gas analysis, 1110chest radiography (imaging), 1108, 1110classication, 1111, 1111t1244 INDEXWilkins9781451193114-index.indd 1244 08/10/15 9:40 AM INDEX 1245COPD, 1121–1123cystic brosis, 1123–1124cytology and hematology evaluation, 1110–1111documentation, 1124lower, 1113physiology, 1108pneumonia, 1113–1115pulse oximetry, 1108, 1111fsleep apnea syndrome, 1124spirometry, 1108, 1111ftuberculosis, 1115–1118upper, 1111–1113, 1112tvital signs, 1108Respiratory mucosa, function of, 1108, 1110fRespiratory system, 1108, 1110–1111Rest, 515bRestenosis, 1130bRestorative dental services, 11Retainer, 502bRetinitis, 1023bRetinopathy, 1164b, 1175of prematurity, 1023bRetrognathic appearance, 287, 287fRetrograde amnesia, 1087bRetrovirus, 47bRett disorder, 1042bRevia, 1093Revolutions per minute, 781bRheumatic fever, 1134Rheumatic heart disease, 1134Rheumatoid arthritis, 1012Rhinitis, 69bRhinoplasty, 878bRiboavin, 578tRibonucleic acid (RNA), 61bRifampin, 1116, 1117tRights, 14bRights theory, 150tRilusole, 1004Risk factors, 100b, 396b, 826bcancer, 944for dental caries, 397dental hygiene careage groups, 504–505gingivitis, 505position of teeth, 505problems with appliances, 505self-care, 505included in written care plan, 412for oral cancer, 397for periodontal infections, 396–397poor response to periodontal therapy, 396–397for systemic conditions, 397Risk population, 47bRisperdal, 1042, 1072, 1074, 1079Risperidone (Risperdal), 1042, 1072, 1074, 1079Ritalin, 1042Roentgen (R), 205bRoentgen equivalent man (Rem), 205bRolling stroke method, of toothbrushing, 455–456for anterior lingual or palatal surfaces, 457limitations, 456, 457position of brush, 456procedure, 456purposes and indications, 455–456strokes, 456Root caries, 277fclinical recognition, 277effects, 277gingival recession, 277involvement of enamel, 277pH for, 277primary organisms associated, 277risk factors, 277, 278bsteps in formation of, 277Root caries index (RCI), 386–387calculation and interpretation, 387procedure, 386–387purpose, 386scoring, 387selection of teeth, 386Root form dental implant, 534bRoot planning, 701bRoot preparation, 701bRouge (jeweler’s rouge), 786Rubber dam application, 629Rubefacient, 186bRubella virus (togavirus), 53tRumination, 1036bRx, 595bSSachets, 550bSaddlenose deformity, 1087bSafe work practice, 100bSaliva, functions of, 437Salivary gland dysfunction, 945bSalmeterol, 1120tSample, 370bSanitation, 83bSarcoma, 945bSaturated, denition, 350bScale photography, 1048bScalers, 664b, 667, 667f, 690. See also specic scalersangulation, 670, 677–678, 678fapplication, 671chisel, 672, 672fcontraindications for, 670le, 671, 671fhoe, 671–672internal angles of, 670f“Jacquette,” 669–671, 670fmaintenance of, 735purposes and uses of, 670“sickle,” 669–671Scaling, 664b, 701bdenition of, 707Scar, 186bScatter radiation, 208bScavenging device, 635bSchizophrenia, 1079–1081dental hygiene care, 1080–1081effects of antipsychotic medication, 1080tsigns and symptoms, 1079treatment, 1079School-age childrencommunication skill of, 35oral health care, 854, 854b, 858accident and injury prevention, 872dietary and feeding pattern recommendations, 870School-based dental sealant programs, 628, 629fScience-based information, 23–24ethics in research, 26–27internet-based health informationaccuracy of site, 26computer/internet literacy, 26content analysis, 26databases for biomedical information, 23bobjectivity of site, 26quality control of site, 26sites for educational and governmental information, 26reading and understanding researchlevels of evidence, 25–26publication types, 24–25, 24bresearch approaches, 25research types, 25Scientic articles, 23Scientic evidence, 20b, 21Scleroderma, 1013–1014Sclerosis, 186b, 997b, 1130b. See also Amyotrophic lateral sclerosis (ALS)of dentin, 767Scoring methods, types, 370–371Screening, 370bSealants, 620b, 829classication, 621clinical proceduresacid etching, 627cotton-roll isolation, 629evaluate for complete etching, 627for occlusion, 628patient preparation, 624placement of, 627–628, 628tpreparation of tooth, 626rinse and air dry tooth, 627rubber dam application, 626steps for placement of dental sealant, 624–626ttooth isolation, 626, 627fcured, 628development, 620documentation, 629, 629bindication for placement, 621–622contraindications for, 622patients with risk for dental caries, 621tooth selection, 621, 622fmaintenance appointmentreplacement, 628retention, 628materials, 621overdenture and, 529penetration ofamount, 623contents of pit or ssure, 623effect of cleaning, 623pit and ssure anatomy, 622, 623fpurposes, 620Seals, 87, 87fSearch engine, 20bSecond-hand smoke, 553Wilkins9781451193114-index.indd 1245 08/10/15 9:40 AM Secondary aging, 900Secondary caries, 436bSecondary dentin, 764bSecondary polycythemia, 1156Secondary prevention, 9bSecondary radiation, 208bSecurity, denition, 136tSedation, 635bSeizure disorder, 1059bantiepileptic/antiseizure medications, 1061tclassication, 1058, 1060bclinical manifestations, 1060–1061denition, 1058dental hygiene care plan, 1064–1065differential diagnosis of, 1066documentation, 1066b, 1067effects of accidents during, 1062emergency care, 1065–1067etiology, 1059–1060gingival overgrowth/gingival hyperplasia, 1062–1064implications, 1060oral ndings, 1062–1064prevention, 1061prognosis, 1060treatment, 1061–1062types, 1058–1059Selective estrogen receptor modulators (SERMs), 906Selective mutism, 1036bSelective serotonin re-uptake inhibitors, 1073Self-care for dental hygienist, 106–109Self-cleansing mechanism, of oral cavity, 316Self-directed learning, 22Self-injury, 1036bSelf-neglect, denition of, 1052Semantics, 30bSenescence, 901bSenility, 901bSensor, 164f, 209bSensorineural hearing loss, 1026Sensory impairmentsdocuments, 1032, 1032bhearing impairment, 1025–1027, 1032keywords, 1022visual impairment, 1022–1025Septic, denition, 752bSequestra, 740bSeroconversion, 48bSerologic diagnosis, 48bSeroquel, 1074, 1079Serotonin and noradrenergic reuptake inhibitors, 1073Sertraline (Zoloft), 1072, 1073, 1075Serum marker, 48bSessile, 186bSet-square, 141Severe early childhood caries (S-ECC), 836bSexual abuse, denition of, 1052Sexually transmitted diseases (STDs), 48bchlamydia, 907genital herpes, 907gonorrhea, 907HIV/AIDS, 907human papilloma virus (HPV), 907incidence in seniors, 907syphilis, 907Shank, 664bof instrument, 665–666Sharpening. See Instrument care and sharpeningSharpening stone, 687preparation of, 687–688sterilization of, 687Sharpey’s bers, 298b, 317Sharpness, 686bSharps precautions, 46Shedding (viral), 48bShelf life, 83b, 91–92Shingles (herpes zoster), 59Shunt, 997b, 1130bSialorrhea, 997b“Sick Day Rules,” 1173Sickle cell disease (SCD), 1152, 1154–1155, 1154fappointment management, 1155clinical course, 1154diagnosis, 1154oral implications, 1155treatment and management, 1154–1155Sidestream smoke, 549bSievert (Sv), 205bSign, 138bSign language, 31, 1027, 1029–1031fSignals, 31Silex (silicon dioxide), 786Simple cavity, 275Simple index, types of, 371Simplied calculus index (CI-S), 376Simplied debris index (DI-S), 376Simplied oral hygiene index (OHI-S), 375, 375f, 376fcalculation and interpretation, 377calculus score, 377components, 376debris score, 376location and tooth surface areas scored, 377procedure, 376purpose, 376–377scoringgroup, 377individual, 377selection of teeth and surfaces, 376Singulair, 1120tSink, 84Sinus augmentation (sinus lift), 534bSinus tract, 740bSinusitis, 1112tSippy cup, 854bSjögren’s syndrome, 901bSkin, bacteriology of, 73Skin lesions, in HIV, 62Sleep apnea syndrome, 1124Sliding board transfer, 972–973Slurry, 781bSmear layer, 764bSmoke, denition, 549bSmokeless tobacco, 549–551, 550bSmoking cessation, cleft lip and/or palate and, 884. See also Tobacco useSmoking tobacco, 550b. See also Tobacco useSnuff, 550bSnus, 550bSOAP, patient care documentation using, 146–147, 146t, 147bSocial determinants of health, 30b, 36Sodium bicarbonate, 661, 793Sodium bisulte, 645Sodium uoride, 603, 610, 610t, 774, 802Sodium hexametaphosphate, 489Sodium hydroxide, 802Sodium metabisulte, 647Soft deposits, acquired pellicle, 256–258Soma, 205bSomatic, 205bSonic, denition, 449bSonic scaler, 715bSonic scaling devices, 717Sonic tip, 718–720, 719fSordes, 982bSore or burning tongue, 580tSpace maintainer, 502bSpace regainer, 502bSpasm, 1059bSpastic palsy, 1007Spatter, 49–50Special-interest groups, 26Specialized mucosa, 919Speech aid prosthesis, 878bSpeechreading, 1023b, 1027Spermatogenesis, 888bSphygmomanometer, 178–179Spina bida occulta, 1011Spinal cord injury (SCI), 996–1000levels of, 999fSpinal shock, 997bSpirometer, 1109bSpirometry, for respiratory disease, 1108, 1111fSpore testing, 89tSporicide, 83bSPT (supportive periodontal therapy), 826bSputum, 1109bSquamous epithelium, 298bStack, 715bStaging, 945bStandard of care, 818bStandard precautions, 46, 48bStandards for clinical dental hygiene practice, 12, 821Stannous uoride, 595b, 610, 610t, 774for brown stains, 363Staphylococcus albus, 50Staphylococcus aureus, 46, 50, 53tStaphylococcus epidermidis, 53tStaphylococcus pyogenes, 50Statistical signicance, 20bStatus, denition, 370bStatus epilepticus, 1059b, 1067Steam under pressure sterilization procedure, 89Steel alloys, 687Stenosis, 1130b1246 INDEXWilkins9781451193114-index.indd 1246 08/10/15 9:40 AM INDEX 1247Stereotype, 30bStereotypic movement disorder, 1036bSterilization, 83b, 88–89approved methods, 88dry heat, 89–90steam under pressure, 89using chemical vapor sterilizer, 90care of sterile instruments, 90–91methods for, 88tselection of methods, 88tests for, 88–89of treatment room, 92–93using chemical disinfectants, 91–92Steroids, 1097, 1098Stethoscope, 175b, 179, 180, 181fStiffness, 449bStillman method of toothbrushing, 456Stillman’s cleft, 307Stimulants, 1097Stippling, 298bStomatoxic, 945bStones, 687. See also specic stonesStorage phosphor imaging, 209bStray radiation, 208bStreet drugs, abuse of, 1093Streptococcus pneumoniae, 53tStreptococcus pyogenes, 53tStreptococcus viridans, 50Stress, 100bminimization in emergency care, 116–117reduction of, 117Stretching exercises, 681f, 682Stroke (cerebrovascular accident), 664b, 1001fbalance of pressure, 679–680characteristics, 678–679dental hygiene care, 1001–1002directions of instrument, 670fetiologic factors, 1000factors inuencing, 679medical treatment, 1001, 1002bnature, 679signs and symptoms, 1000–1001Study modelsclinical preparationassemble materials and equipment, 241beading, 243–244, 243f, 244fclinician preparation, 241of impression materials, 244–245of impression trays, 242–244of mandibular tray try-in, 243of maxillary tray try-in, 241preparing patient, 241documentation, 252, 252bnished, 248f, 249, 249f, 250fnishing and polishing, 251and impressiondisinfection of impressions, 246madibular, 245maxillary, 242, 242f, 245–246paraclinical procedures, 246–247steps for tray insertion, 245tray selection, 243finterocclusal recordprocedure, 242purposes, 242key words, 240bmixing stone, 247paraclinical procedures, 246–247equipments and materials, 246–247preparation of impressions, 247responsibility of dental laboratory technician, 246–247pouring castanatomic portion, 247methods for forming base, 247–248separation of impression from cast, 248–249purposes and uses of, 240records and storage of, 251–252steps in preparation, 240–241trimming castsanterior, 250, 252fof bases, 249–252, 250fmandibular, 250maxillary, 250of posterior borders, 249–250, 251fof sides and heels, 250, 251fsteps, 249use of model trimmer, 249Subacute bacterial endocarditis (SBE), 152bSubgingival biolm, 264Subgingival calculus, 339, 351–352, 352f, 363, 377, 399, 811. See also Calculusclinical characteristics of, 351tSubgingival exploration for defects, 333–334Subgingival irrigation, 242bSubgingival pellicle, 258Subgingival scaling, 668, 708–713, 712f, 713fand root planning, 711fSubperiosteal frame dental implant, 534bSubstance abuse, 1087bSubstance-related disorderalcohol use, 1086–1088Substantivity, 488bSubsurface lesion, 595bSuccedaneous dentition, 270bSudden infant death syndrome (SIDS), 549b, 847Sulcular brushing, 449b, 505Sulcular epithelium, 57, 300Sulcular uid, 300Sulcus bleeding index (SBI), 380–382for area, 382areas examined, 381for individual, 382procedure, 381purpose, 380scoring, 382–383for tooth, 382Summative evaluation, 818, 818bSupersaturated, denition of, 350bSupervisiondened, 5btypes in dental hygiene practice, 9bSupine, 100bSuppuration, 298b, 534bSupragingival biolm, 264Supragingival calculus, 339, 350–352, 352f, 668clinical characteristics of, 351tSupragingival exploration for defects, 333Supragingival irrigation, 242bSupragingival pellicle, 257–258Supraversion of teeth, 289Surveillance (of disease), 48b, 370bSusceptible host, 48, 48bSustain talk, 420bversus change talk, 427–428Sustained-release theophylline (Theolair, Theo24), 1120tSutures, 752babsorption properties of materials, 752apposition, 752bblanket (continuous lock), 754characteristics of materials, 752circumferential, 755classication of materials, 752–753continuous uninterrupted, 755denition, 752documentation, 761, 761bfunctions of, 752interdental, 755interrupted, 754key words, 752bprocedures, 754–755removal procedure of, 757fpatient preparation, 756review previous documentation, 755safety measures, 756steps, 756sterile clinic tray setup, 755supplies, 761selection of materials, 753, 753tsling or suspension, 755Swage, 752bSwimmer’s stain, 363Symptom, 138bSyncope, 114bSyndrome, 878bSynergism, 83b, 488b, 800bSynergistic effect, 488bSynthesis, 572bSystematic approach, to evidence-based dental hygiene practice, 22fdetermining clinical issue, 22developing researchable question, 22–23evidence analysis, 24evidence application, 24result evaluation, 24steps for, 22fSystematic reviews, 25Systemic disease factors, 442Systole, 175bSystolic blood pressure, 1135Systolic pressure, 178TT-helper cells (CD4 + ), 62Tachycardia, 175b, 176, 1109b, 1130bTachypnea, 1109bWilkins9781451193114-index.indd 1247 08/10/15 9:40 AM Tactile, 328b, 1023bTactile discrimination, 328bTactile sensitivity, 682explorer, 681–682probe, 682Tapping, 292Tardive dyskinesia, 1070bTartar control using dentifrice, 489Tartrazine, 1119Taste bud, 298b“Teach-back” method, of asking patients, 34Teethanatomic crown, 298anatomic root, 298average measurements of, 1205–1206tclinical crown, 298clinical root, 298dentinal tubules, 765, 765f, 767fdocumentation, 283, 283bexamination of, 277–280, 278–279tcavitated and noncavitated lesions, 277factors to observe, 277radiographic, 280testing for pulpal vitality, 280–282keywords, 270bmissing, 515dental hygienist’s role, 514migration of adjacent teeth, 514migration of opposing teeth, 515replacement options for, 515nerve ber endings, 765, 765fpermanent, development and eruption, 271tpulp, 765self-cleansing mechanisms, 282–283structure, 765Tegretol, 1061tTeledentistry, 982bTeleology, 150tTemporal artery thermometer, 175–176, 176fTemporomandibular disorder (TMD), 186bTemporomandibular joint (TMJ), 858–859disorders, 515Tensile, denition, 502bTensile strength, 502b, 752bTension test, 328b, 342Teratogenesis, 1059bTerminally ill patient, 982bTertiary prevention, 9bTertiary/reparative dentin, 764bTesting stick, 686bTetracaine, 658, 659, 659t, 661Tetracycline antibiotics, 365, 731, 837, 838tTetralogy, 1130bTetralogy of Fallot, 1130bText telephone device (TTY), 1023bTextbooks, 24Thalassemia, 1152Theo24, 1120tTheolair, 1120tTherapeutic rinse, 488bTherapeutic services, 8Thermometers, types of, 175–176, 176fThiamine, 578t, 1092Third-hand smoke, 549b, 553Thixotropic, denition, 595bThree-body abrasion, 781bThrombocytes. See PlateletsThrombocytopenia, 1156–1157Thrombus, 1130bThyroid cancer, 173Thyroid gland, 891–892characteristics of disorders, 891thyperthyroidism, 891–892hypothyroidism, 891myxedema coma and, 891bThyroiditis, 888bThyrotoxic crisis (thyroid storm), 888bTiagabine, 1061tTic, 1036bTime-delay switch, 206Tin oxide (putty powder, stannic oxide), 786Tinnitus, 901b, 1023bTissue-conditioning programanticipated outcomes, 403and bacterial accumulation, 403conditioning of tissue for scaling, 403and gingival healing, 403procedure, 403purpose, 403Tissue-supported complete denture, 918Titanium, 534bTitanium alloy, 534bTitration, 635bTobacco cessation methods, 563f. See also Tobacco use“5 A’s,” 563–565assisted strategies, 556–557community oral health program, 566diabetes mellitus, 1179motivational interviewing, 562and periodontal disease development, 313–314, 313fpharmacotherapies, 558–559tprogram for, 562public health policy, 566reasons for quitting, 556self-help interventions, 556sources for educational materials, 565tteam approach, 566Tobacco-free environment, 565Tobacco pipe, 550bTobacco-specic nitrosamines, 549–550, 549bTobacco stain, 362–363, 362fTobacco useamong children and adolescents, 562–563components of tobacco product, 548consultation, 561dental clinical treatmentbiolm control, 562diet and nutrition planning, 562–563nonsurgical periodontal therapy, 562dental hygiene care for, 560disease consequences of, 552tdocumentation, 566–567, 566band halitosis, 560health hazards, 548life expectancy, 548women, 548implant system and, 538key words, 549bnicotine metabolism, 548–552oral effects of, 553, 554tpatient assessmentextraoral examination, 562form, 560, 561fintraoral examination, 560–561pregnancy and, 837as risk factor for periodontal diseases, 554–555systemic effects of, 552–553use of alcohol with, 553and use of other drugs, 553Tobacco user tracking system, 565Toddlers and pre-schoolerscommunication skills of, 34–38oral health care, 854accident and injury prevention, 872dietary and feeding pattern recommendations, 868–870oral examination, 856oral health considerations for, 870–871patient management considerations, 855–856toothbrushing, 870toothpaste, 870Toirimate, 1093Tolerance, 555, 1087bToluene, 1097Tongue cleaners, 464–465Tongue, cleaning of, 463–465Tongue thrust, 286bTonic, denition, 1059bTonic–clonic seizures, 1058–1059, 1059bTooth crown, 534bTooth deposits, 257tTooth designation systems, Universal or ADA system, 140Tooth fractures, 273–274classication, 274line of fracture, 274radiographic signs of recent trauma, 274Tooth-numbering systemscontinuous numberspermanent teeth, 140f, 141primary or deciduous teeth, 141Fédération Dentaire Internationale (FDI) two digit, 141fpermanent teeth, 141primary or deciduous teeth, 141quadrant numberspermanent teeth, 141primary or deciduous teeth, 141Tooth sensitivity, 784Tooth surface index of uorosis (TSIF), 365, 388, 388tTooth whiteningfor extrinsic stain removal, 787–induced sensitivity, 7751248 INDEXWilkins9781451193114-index.indd 1248 08/10/15 9:40 AM INDEX 1249Toothbrush head, 449bToothbrushescare of, 466–467cleaning of, 467for cleaning removable partial denture, 519–520, 520fcomparison of natural with synthetic bristles, 451tdevelopment of, 448–449documentation, 467, 467bearly, 448hog’s bristles, 448for implant systems, 540manual, 450–452, 505brush head, 451characteristics of, 450dimensions, 450end-rounded laments, 451–452, 452fhandle, 450–451parts, 450, 450fstiffness of laments, 451trim proles, 450fnylon, 449power, 505brush and head design, 461description, 460–462effectiveness, 459–460laments, 462instruction for use, 462interdental brush, 462, 462fmotion of, 460tprocedure, 462purposes and indications, 460source, 462speed of, 461replacement of, 466–467selection ofand gingiva, 452inuencing factors, 452position of teeth, 452size and shape, 450–451, 452soft nylon brush, 452storage of, 467supply of, 466Toothbrushing, 505–506, 506famount of, 453–454Charters method, 457–458of complete denture prostheses, 524–525, 525f, 525bcritically ill or unconscious patient, 988, 990disabilities and, 963–964, 964f, 965fdental and dental hygiene care, 960–961documentation, 467, 467bearly methods, 449effects ofbacteremia, 466dental abrasion, 466on gingiva, 465–466with uoridated toothpaste, benets, 611Fones method, 459t, 460ffrequency of, 454grasping and manipulation of brush, 453historical perspective on proper, 449bLeonard method, 459tmanualguidelines for, 452–454methods for, 454–458methods considered detrimental, 458modied Stillman method of, 455f, 456–457necrotizing ulcerative gingivitis (NUG), 743necrotizing ulcerative periodontitis (NUP), 743procedure for use of suction, 990brolling stroke method, 455–456scrub-brush procedure, 458sequencing, 453Smith’s method, 459tfor special conditionsacute oral inammatory or traumatic lesions, 465acute stage of necrotizing ulcerative gingivitis, 465following dental extraction, 465following dental restorations, 465following periodontal surgery, 465Stillman method of, 456sulcular, 454–455supplementalocclusal areas, 463, 464fproblem areas, 462–463, 463fTopamax, 1061tTopical anesthesia, 635baction, 658aerosol spray, 660agents used, 658–659, 659tapplication technique, 660characteristics, 659tcompletion of, 660controlled-dose spray method of application, 660indications for use, 658patient preparation, 659surface application, 660Topiramate, 1061tTorsiversion of teeth, 289Torus, 186b, 195Torus mandibularis, 919Torus palatinus, 919Toxic waste, 83bToxin, 313bToxoid, 69bTracheostomy, 878b, 1109bTranquilizers, 1092Transdermal drug, 549bTransducer, 715bTransient ischemic attack (TIA), 997b, 1001Transillumination, 329Translucency, 800bTransmission-based precautions, 46Transmucosal drug, 549bTransseptal bers, 302Transtheorectical model, 422, 422tTranxene, 1061tTranylcypromine, 1073Trauma, 1078from occlusion, 286bTraumatic alopecia, 1048bTray technique, 605t, 606, 607fhome application, 608, 609bTreatment instrumentscategories, 667scalers, 667, 667fTreatment rooms, for infection control, 82, 84, 84fpreparation ofclean and disinfect environmental surfaces, 93objectives, 92preliminary planning, 92–93unit water lines, 93Trench mouth, 740Trendelenburg’s position, 100b, 114bTreponema pallidum, 52tTriage, 138b, 982bTribiology, 781, 781bTricalcium phosphate (TCP), 773Triclosan, 489availability and use, 493considerations for use, 493efcacy, 493mechanism of action, 493Tricyclic and heterocyclic antidepressants, 1073Trilafon, 1079Trileptal, 1061tTriplegia, 997bTrismus, 186b, 930b, 945bTuberculin test (Mantoux), 69bTuberculosis (TB), 62, 70, 1115–1118areas of infection, 54clinical procedures to prevent, 54dental hygiene care, 1117–1118diagnosis, 1116disease development, 1116drug-resistant TB, 53etiology, 1115extensively drug-resistant TB (XDR-TB), 53history of, 1118multidrug-resistant TB (MDR-TB), 53Mycobacterium tuberculosis, 53oral manifestations, 1116, 1118fpreventionCenters of Disease Control and Prevention (CDC) recommendations, 54factors affecting, 53–54inhalation, 53standard precautions, 53using ultrasonic and other handpieces, 53transmission, 1115–1116treatment, 1116Tuft, 449b, 451Tuning fork, 1023bTutorial, 20bTwo-body abrasion, 781bTwo-step or double-pour method, 248Tympanic membrane, 1023bTympanic thermometer, 175, 179fType 1 diabetes mellitus, 1166–1167, 1169–1170, 1169tType 2 diabetes mellitus, 1167, 1169t, 1170, 1172fWilkins9781451193114-index.indd 1249 08/10/15 9:40 AM UUlcer, 152, 197Ulcerated lesions, 923Ulceration, 740bUlceromembranous gingivitis, 740Ultrasonic cleaner, 515bUltrasonic denture cleaner, 519fUltrasonic instrumentationevaluation, 723manual scaling, 723principles for technique, 722, 722ftroubleshooting, 723–724ultrasonic scaling, 722–723water control, 723Ultrasonic scaler, 715bUltrasonic scaling, 50scaling devices, 716–717Ultrasonic scaling devices, 716–717Ultrasonic tipdesign, 718–720, 719fmaintenance of, 736Ultrasonography, 1036bUltraviolet light system, 800bUnique identier, 138bUnited States Department of Agriculture (USDA), 573bUnited States Department of Health and Human Services (USDHHS), 573b, 595b, 599United States Public Health Services (USPHS), 595bUniversal curet, 664b, 709blade, 667–668description, 667–668, 668fpurposes and uses, 668shank, 668Upper intake levels (ULs), 573, 573bURAC Health Website Accreditation Program, 26Urticaria, 114bU.S. Department of Health and Human Services, 33Use, denition, 549bUser, denition, 549bUtilitarianism, 150tVVaccination, 69bVaccines, 69bValerian, 838–839Validity, 20b, 370bValium, 1072Valproic acid (Depakote), 1061t, 1074Vanceril, 1120tVancomycin-resistant enterococci, 46Varenicline tartrate, 558t, 560Variable, 20bVaricella-zoster virus (VZV), 51t, 59Varnish technique, 606–607, 606tVaso-occlusion, 1148bVasoconstrictors, 635b, 645–646, 645tdrugs, 645potential risks with use of, 645preservatives, 645reasons for use, 645Vector, 48bVegan diet, 572bVehicle, 48bVelopharyngeal insufciency, 878bVelum, 878bVelum palatinum, 878bVenlafaxine (Efexor), 1073Venous blood, 1130bVentolin, 1120tVentral, denition, 186bVentricular brillation, 114bVentriculoatrial shunt, 997bVentriculoperitoneal shunt, 997bVerbal communication, 30b, 31Verruca, 186bVertical transmission, of disease, 48bVertigo, 1023b, 1148bVesicle, 194Vesiculation, 740bVincent’s disease, 740Vincent’s infection, 740Viral hepatitis, abbreviations and their signicance, 55tViral infections, associated with HIV infection, 63Virion, 48bVirtue, 14bethics, 150tVirulence, 48bVirus, 48bVisceral, 997bViscosity, 620bVisibility and accessibility, 680Visible light–cure, 752bdressing (Barricaid™), 758Visual impairment, 902, 1022–1025, 1023bVisual or glare test, 688Vital signsadult, 174tblood pressure, 178–182body temperature, 174–176dental hygiene care planning, 174documentation of, 183, 183bkey words, 175bpatient preparation and instruction, 174pulse, 176–177respiration, 177–178Vitamin A, 578tVitamin C, 580Vitamin D, 578tVitamin E, 578tVitamin K, 578t, 1157Vocal characterizers, 31Vocal communication, 31Vocal qualiers, 31Vocalics, 30bVolatile sulfur compounds (VSCs), 489WWalking bleach, 801, 809Washer/thermal disinfector, 85, 85fWaste disposal, 84guidelines, 95regulations, 95Water on stone, 688Waterlines, 50Wean, 854bWeb-based health messages, 32Web-based information, 23Wellbutrin, 1073, 1075Wernicke–Korsakoff’s syndrome, 1090Wernicke’s encephalopathy, 1090Western blot (WB), 47b, 61Wheelchair transfers, for patient with disabilities, 971–973, 972f, 973fWheeze, 1109bWhite areas of cancer, 197White blood cells, 1149fagranulocytes, 1150disorders of, 1156functions, 1150granulocytes, 1150–1151types of, 1150White-coat hypertension, 175b, 181“White spot,” 595bWhite spot lesion, 436bWhitening, 800bWikipedia, 23Window period, 48bWire edge, removal of, 689, 689fWithdrawal syndrome, 1087bWork-related musculosketal disorder, 100bWork simplication, 100bWorking end of instrument, 665World Health Organization Basic Screening Survey, 389Wound healing, 580tWriting, 1027Written care plan, 31caries risk assessment, 412components, 409tappointment plan, 413assessment ndings and risk factors, 409, 412clinical examination details, 412demographic data, 409dental hygiene diagnostic statements, 412, 412tevaluation methods, 412–413expected outcomes, 412medical history, 409planned interventions, 412re-evaluation appointment, 413risk factors, 412social and dental history, 412description, 408objectives, 408periodontal diagnosis and status, 412rationale for, 408XX-ray timer, 207X-ray tube, 204faluminium disks, 206anode, 206aperture, 206cathode, 206circuits, 206dental machine, 207flead diaphragm, 206machine control devices, 206–2071250 INDEXWilkins9781451193114-index.indd 1250 08/10/15 9:40 AM INDEX 1251milliamperage, 206time, 207position-indicating device (PID), 206, 212fproperties of, 206bsteps in production of, 207–208transformers, 206Xerostomia, 313b, 495, 621, 888b, 914, 945b, 988, 1072, 1079disorders, 889Xylitol, 836b, 838tuse in caries prevention, 862, 862bXylocaine, 643YYellow stain, 361, 361fZZarlukast, 1120tZarontin, 1061tZenograft, 535Zidovudine (ZVD/AZT), 64Zinc, 579tZinc oxide with eugenol dressing, 757–758Zinc salts, 489Zoloft, 1072, 1073, 1075Zonegran, 1061tZonisamide, 1061tZostavax, 59Zyprexa, 1074, 1079Wilkins9781451193114-index.indd 1251 08/10/15 9:40 AM Wilkins9781451193114-index.indd 1252 08/10/15 9:40 AM Wilkins9781451193114-index.indd 1253 08/10/15 9:40 AM Wilkins9781451193114-index.indd 1254 08/10/15 9:40 AM

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