Patient Management

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

1. expressing needs

2. stimulating motivation

3. recognizing needs

4. evaluating results

5. reinforcing learning

6. setting goals

7. acting to achieve goals

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PATIENT MANAGEMENT

BS Identify each of the following statements that are true concerning needs and learning.

needs are driving forces that prompt a person to act

• the process of learning is continuous

• learning occurs as a person attempts to satisfy needs A

• expressing needs helps to pinpoint them for the patient and dentist w *

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

• all of the above statements are true

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PATIENT MANAGEMENT

• 3 , 1 , 2 , 6 , 7 , 5 , 4 Although each learning situation will not fol-low these steps in exact sequence, most situa-tions will include all of these seven steps in some form:

• recognizing needs • expressing needs • stimulating motivation • setting goals • acting to achieve goals • reinforcing learning • evaluating results

Stepl • recognizing needs • dentist recognizes educational needs as treat-ment needs are determined • dentist helps patient recognize needs Step 2 • expressing needs • dentist records educational needs • dentist helps patient state needs Step 3 • stimulating motivation • motivation arouses & maintains interest • dentist may appeal to inner needs or use arti-ficial stimuli

Step 4 • setting goals • short-range or long-range guides to ac-tivity • must be meaningful, attractive & at-tainable Step 5 • acting to achieve goals • activity is needed for learning • must be directed at specific goals Step 6 • reinforcing learning • review & repetition aid in learning re-tention

Step 7 • evaluating results • aid in judging what patient has learned • aid in determining how effective dentist's teaching has been

• can help clarify or redefine goals

Needs & Learning • needs & goals may provide motiva-tion • motivation arouses & maintains in-terest • motivation may be artificial or built-in • patients rarely learn without motiva-tion • learning is continuous and occurs when a person attempts to satisfy needs • motivation stimulates a person to act on needs • motivation is a fundamental part of every learning situation •^tofciaaeS-gQalg;_are less remote &

^moraeasily attained • goals should be attractive & attain-able in order to be meaningful • goal-directed activity is necessary for learning

' all of the above statements are true

Assessment of behavior • in order to change behavior, assess-ment of the behavior is needed • how to assess behavior

- identify problem - consider motivation - consider readiness - consider willingness to change - consider ability to change - collect baseline data - reassess behavior after imple-

memtation

Anu Singh

BS Most researchers believe that changes in behavior are a prerequisite to changes in attitude.

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

• both statements are true

• both statements are false

• the first statement is true, the second is false

• the first statement is false, the second is true

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PATIENT MANAGEMENT

BS The principal nonverbal cue that two or more persons can use to regulate ver-bal communication is:

• posture

• facial expression

• eye contact

• gestures

• proximity

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Behavior • changes in behavior are a prerequisite to changes in attitude • behavior is defined as a determined, purposeful unit of activity

- determined the assumption that the behavior is lawful & has determinants

- purposeful the assumption that the behavior is goal-oriented, that it seeks to achieve positive and re-duce negative need or motivated states

- unit of activity what a person does that can be re-ported or described as discrete elements

Behavior examples

• a common behavior for a dentist is to observe that a problem exists (e.g., tooth decay) • a common behavior for a patient is to avoid the dentist even though a need exists & treatment is required

both of the above examples meet the criteria of being "determined, pur-poseful units of human activity "

Behavior management

• as described by the ADA, tech-niques or therapies used to alter or control the actions of a patient who is receiving dental treatment; exam-ples include.gducation or anxiety relief techniques • the means by which the dental health team effectively and effici-ently performs treatment for the patient, and, at the same time, instills a rjositive attitude

Communication • the process by which information is exchanged between 2 or more persons • communication is essential in the dentist-patient relationship • acceptable verbal & non-verbal communication varies with fhfiage, sex, ethnicity and culture of the patient • communication is both verbal & non-verbal; also includes listening

Verbal communication • involves use of language • choice of words is important • delivery of speech is important (fast vs. slow, loud vs. soft)

Non-verbal communication • involves use of body language • conveyed by eye contact, posture, body movement, hand gestures & expressions

Empathy & Rapport • empathy (is the ability to experience the feelings of another person jj^yjportfis a mutual sense of trust and openness between individuals

• eye contact

Listening • receiving & understanding messages • a good listener shows attention & interest • listening techniques include

• paraphrasing (repeating in own words)'"

• intCTjrjretation (identifying the underlying reason)

• preparation (allowing time for dis-cussion & eliminating distractions)

Eye contact • is the principle non-verbal cue used to regulate verbal communication • when listening to a patient, a dentist should maintain eye contact • a dentist should engage the patient's eyes as often as is comfortable for both parties

Facilitative skills • facilitative skills make communication easier and help to develop trust • include encouraging patient questions, answering questions, respondz'rcp; to re-quests & communicating with warmth

BS Which term describes a behavioral response that operates by the simple process of association of one stimulus with another?

• operant conditioning

• classical conditioning

• observational learning


PATIENT MANAGEMENT

BS Which type of aggression is an act of hostility unnecessary for self-protection or preservation that is directed toward an external object or person?

• destructive aggression

• inward aggression

• constructive aggression

PATIENT MANAGEMENT 6

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Classical conditioning • a stimulus leads to a response • a.k.a. pavlovian or respondent condi-tioning

• a process of behavior modification by which a subject comes to respond in a desired manner to a previously neutral stimulus that has been repeatedly pre-sented along with an unconditioned stimulus that elicits the desired response

Operant conditioning • process of behavior modification in which the likelihood of a specific be-havior is increased or decreased through positive or negative reinforcement each time the behavior is exhibited, so that the subject comes to associate the pleas-ure or displeasure of the reinforcement with the behavior

• four types: positive reinforcement, negative reinforcement, punishment & extinction

• classical conditioning Observational learning

• or modeling, is a type of learning that occurs as a function of observing, re-taining and replicating behavior exe-cuted by others in a social context

• two phases: acquisition of the behavior & performance of the behavior

Example Classical conditioning

• before conditioning, a painful injection (unconditioned stimulus) would elicit a fear reaction (unconditioned response)

• during conditioning, the dentist with syringe (neutral stimulus) is linked with the painful injection and elicits a fear reaction

• after conditioning, the dentist with a syringe (conditioned stimulus) will en-courage a fear reaction (conditioned response)

Destructive aggression • act of hostility • unnecessary for self-protection or

preservation • directed toward external object or

person

• destructive aggression

Aggressive personality • personality with behavior patterns

characterized by irritability, tantrums, destructiveness or vio-lence in response to frustration

• aggressive personalities are individ-

Constructive aggression • act of self-assertiveness • in response to a threatening action • for purpose of self-protection and

preservation

Inward aggression • destructive behavior directed

against oneself

uals whose overall "style" of inter-acting involves considerable, per-sistent, maladaptive aggression expressed in a variety of ways and in a wide range of circumstances characteristics include the following: - seek a superior position in any relationship or encounter

- abhor submission - self-advancing at expense of

others - have disdain for truth - lack internal "brakes"

Match the type of question

direct probing laundry list open-ended leading facilitating

i. 2. 3. 4. 5. 6.

on the left to the correct example on the r

You're not afraid of needles, are you? How are you doing with brushing & flossing! How are you? Is it easier to hold the brush this way? What else did you notice about your gums? Is the pain sharp, dull, or throbbing?

BS ight.

>

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PATIENT MANAGEMENT

BS

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

• the "know-it-all" patient

• the anxious patient

• the shy patient

• the talkative patient

• the stubborn patient


PATIENT MANAGEMENT

• 4 , 5 , 6 , 2 , 1 , 3

X

# 4

5

6

2

1

3

Type

direct question

probing question

laundry list question

open-ended question

leading question

facilitating question

Example

Is it easier to hold the brush this way? direct questions asked for a specific bit of information

What else did you notice about your gums? probing questions ask for more specific information that the Patient offers spontaneously

Is the pain sharp, dull, or throbbing? laundry list questions give the patient a list of choices

How are you doing with brushing & flossing? open-ended questions request information in the patient's own words and specify a content area

You're not afraid of needles, are you? leading questions entice a patient to answer in a specific way; leading questions should not be used with patients

How are you? facilitating questions encourage the patient to say more without specifying an area or topic

Communica t ion hints • ask questions/never presume • carefully inquire/never interrogate • be specific/avoid being vague or abstract • provide information & educate/instead of giving advice • provide accurate information/fully discuss concerns & offer support • exhibit professionalism/it is an essential component of dentist-patient relationships • exhibit confidence, care & warmth

Anxious patient • is the most difficult patient to manage

in dentistry • anxiety is defined as unpleasant nega-

tive emotional state without identifi-able cause

• anxiety is the feeling of apprehension, uneasiness, agitation or uncertainty re-sulting from the anticipation of a threat of danger whose source is unknown

• most anxious patients have had a trau-matic experience in a healthcare setting

• anxiety causes patients to avoid dental treatment & interferes with treatment

• anxiety may cause problems with pain

Indicators of anxiety vâffective - patient is emotional, talks a

lot, talks fast ^/cognitive - patient is not listening &

does not follow instructions n^/^motor - increase in body movement

& muscle tension **« psychological - increase in heart rate,

respiration, sweating & dry mouth

• the anxious patient Management of the anxious patient

• be friendly • be calm & patient • build trust; use empathy & respect • create a relaxing environment • make the patient feel welcome • convey a sincere concern for patient's

well-being • explain procedures before doing them • encourage the patient to ask questions • use understandable words • pay attention to what the patient is

saying and how it is said • forewarn patient about possible pain • watch a patient's eyes & eyebrows to

see if the patient is feeling pain • give patient control by giving option

to "raise your hand if you feel any-thing"

• provide moral support during proce-dure

• use headphones or TV as a distraction • use SUDS (the subjective unit of dis-

tress scale) to assess the level of pat-ient anxiety throughout treatment; ask the patient to rate their level of anxiety from 0 (none) to 10 (highest level)

BS Which type of parent has an excessively demanding attitude?

• neglectful parent

• overprotective parent

• manipulative parent

• hostile parent


PATIENT MANAGEMENT

=SSSSS2X=SSSSS2~ pain) occurs.

.both statements are true

.both statements are false

. t h e first statement is true, the second is false

.the first statement is false, the second is true

pÊNTMANAGEMENf

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Manipulat ive pa ren t • is demanding • demands usually start with appoint-

ment times • may try to provide diagnosis and di-

rect the course of treatment

Overprotective pa ren t • insists on remaining with child in

operatory regardless of situation or age of child

• usually has a child who is shy, docile and manageable

• by pointing out the lack of appre-hension of the child and the impor-tance of establishing a one-on-one relationship between the dentist and child, this will usually satisfy most overprotective parents

• manipulative parent

Hostile pa ren t • questions the necessity of treatment • questions stem from distrust and not

curiosity

Neglectful paren t • fails to keep appointments • misses recall visits • does not oversee oral hygiene of

child

the uncooperative child • may be described as stubborn or

spoiled & is usually a child with defiant behavior

• may be hostile or angry; with this child, the dentist must try to iden-tify the underlying source of these emotions

Dental fear • refers to the fear of dentistry and receiving dental care

• is defined as an unpleasant mental, emotional or physiologic sensation derived from a specific dental-re-lated stimulus

• elements common to all fears - fear of unknown - fear of pain/bodily injury - fear of loss of control - fear of helplessness & dependency

• understanding the above elements of fear allows for effective planning for the treatment of fearful & anxious patients

• when evaluating a patient's dental fear, take note of what the patient says and how the patient behaves & appears while in the dental office

Dental anxiety • is defined as a non-specific uneasiness,

apprehension or negative thoughts about what may happen during a dental appointment

• patients who are fearful or anxious avoid dental appointments

• both s tatements are true

Stress • is defined as the body's reaction to a

change that requires a physical, men-tal or emotional adjustment or response

• stress can be caused by physical, emo-tional or psychological influences

Stress, anxiety, & fear • of stress, fear & anxiety — stress is

associated with a response "^-stress is the body's response to danger »v»» "fear is a feeling of uneasiness in

response to imminent danger **V**anxiety is a feeling of uneasiness when

no danger is present • the interaction of the intensity of an

emotional response with threat appraisal determines the behavior that will follow — whether to show up to a dental appointment, submit to an injection, accept the need for extraction etc.

Anu Singh

Anu Singh

Anu Singh

Anu Singh

BS A 32-year-old woman visits the dental office for a routine dental cleaning. The dental hygienist discovers that the patient has not been following the home care program that was recommended six months ago. The hygienist believes that the problem is not a skills deficiency but a management deficiency in-stead. What is the best course of action for the hygienist?

• accept that the patient might never change her habits

• provide the patient with a pamphlet on periodontal disease

• collaborate with the dentist to determine the course of action

• go over brushing & flossing techniques

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PATIENT MANAGEMENT

BS

Behavior shaping is also called:

• aversive conditioning

• successive approximation

• restraining

• hypnodontics


• collaborate with the dentist to determine course of action

Motivating the patient • reviewing home care instructions will

not solve the problem, since this is not a skills deficiency; a plan must be determined to motivate this patient

• if the patient knows what to do, and how to do it, members of the dental team must collaborate and find a way to motivate the patient to embrace the recommended home care regimen

Stages of change model (SCM) 1 - pre-contemplation (no admission of

problem ) 2 - contemplation (consideringproblem

& change) 3 - preparation (getting ready to change) 4 - action / willpower (changing

behavior) 5 - maintenance (maintain behavior

change) 6 - relapse (abandon change)

Motivating patients • use good communication techniques • express empathy and engage the patient

• identify the patient's current oral hygiene status and the agree on achievable goals for improvement

• avoid arguing; gently challenge the thought that underlies the behavior

• support self-efficacy; encourage the patient to believe that they can change the behavior and they will achieve their desired goals

• develop a partnership with the patient • consult your patient & elicit their

views , the patient will feel that their voice is heard & their needs are considered

• ultimately, the patient must believe that the decision to follow a partic-ular course of action is theirs

Behavior shaping • a.k.a. successive approximation • shaping is used when an existing

behavior needs to be changed into a more appropriate or new behavior

• the strategy involves use of reinforce-ment of successive approximations of a desired behavior

• immediate positive reinforcement includes verbal praise and nonverbal indications of approval

• each approximate desired behavior that is demonstrated is reinforced, while behaviors that are not approximations of the desired behavior are not reinforced

• examples of behavior shaping methods include tell-show-do and modeling

• successive approximation

Aversive conditioning • using a punishment or something u pleasant to stop an unwanted behavior

• like all forms of punishment, it may work but is less effective than reinforc-ement

• an example is the HOME technique (Hand-Over-Mouth)

Hypnodontics • the application of hypnosis and

controlled suggestion in dentistry

Restraining • a dental restraint is defined as any

form of restriction of movement by a patient in the dental environment

• a dental restraint includes the following characteristics : - short duration - limits movement of head & body - prevents injury to the patient and/or

dental staff during the procedure - provides physical control to allow

dental staff to complete treatment - is usually well tolerated by patient

• an example is papoose boardj

BS Which one of the following is a conceptual framework that describes a per-son's health behavior as an expression of his or her health beliefs?

• health maintenance model

• health role model

• health belief model

• leading circle model


PATIENT MANAGEMENT

BS Behavior modification is also known as:

• behavior evaluation

• behavior therapy

• behavior shaping

• behavior training


health belief model Health belief model (HBM)

• is a psychological model that a attempts to explain and predict health behaviors by focusing on the attitudes& beliefs of indivi-duals

• developed in the 1950s by social psychologists working in the U.S. Public Health Services

• developed in response to the failure of a free tuberculosis (TB) health screening program

• has been adapted to explore a variety of long- and short-term health behaviors, including sexual risk behaviors and the transmission of HIV/AIDS

INDIVIDUAL PERCEPTIONS

©•(•suggests that individuals act to prevent disease only when they are

. susceptible to it MODIFYING FACTORS LIKELIHOOD OF ACTION

Pereeiired susceptibility' sericiusness ofdiseas*

Age, sex, ethnicity Personality So do-economics Knowledge

Perceived threat of disease

Cues to action • education • symptoms • media information

Perceived bene Its versus

barriers to behavioural change

Likelihood of behavioural change

Behavior modification • a.k.a. behavior therapy • type of psychotherapy that attempts to modify observable, maladjusted patterns of behavior by the substitution of a new response to a given stimulus

• mostly used in pediatric dentistry

Techniques for modifying behavior

/• classical conditioning Q operant conditioning

-3 aversive conditioning <•$• modeling ,3 • systemic desensitization

classical conditioning • a.k.a. pavlovian or respondent condition-SS.

• a naturally occurring stimulus is paired with a response - next, a previously neutral stimulus is

paired with the naturally occurring stimulus

- eventually, the previously neutral stim-ulus comes to evoke the response with out the presence of the naturally occur-ring stimulus

• the two elements are known as condi-tioned stimulus & conditioned response

• behavior therapy operant conditioning

• a.k.a. instrumental conditioning • a method of learning that occurs through rewards & punishments for behavior

• positive & negative reinforcement strengthen behavior

• punishment & extinction weaken behavior

aversive conditioning • using a punishment or something unpleasant to stop unwanted behavior

• is less effective than reinforcement • an example is the HOME technique

(Hand-Over-Mouth)

modeling • form of learning where individuals

ascertain how to act by observing another individual

systemic desensitization • therapy for phobias, fears & aversions • premise is to reduce a person's anxiety responses through counter conditioning

• teaches a person to replace the feelings of anxiety with feelings of relaxation when the object or behavior is present

BS Five techniques are used to facilitate patient dialogue: empathy, respect, re-flection, interpretation and silence.

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






PATIENT MANAGEMENT

Each of the following are ways to communicate EXCEPT one. Which one is the EXCEPTION?

• describe

• evaluate

• be specific

• be responsive

• pay attention

effectivel

copyright £

BS y with patients

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PATIENT MANAGEMENT

r

• ~>.:\.>>

Facilitation j Five techniques are used to facilitate patient dialogue: empathy, respect, reflection, in-terpretation and silence.

empathy •Tsltne ability to accurately understand

the patient's feelings • empathy also involves being able to

communicate this understanding • when properly done, empathy increases

rapport, encourages expression and promotes trust

• the dentist must actively listen and con-centrate on what the patient is trying to say both verbally and nonverbally

• when communicating empathically, it is helpful to respond with the same feeling as the patient's statement

' the first statement is true, the second is false

reflection • is~a response that restates or

repeats a segment of the patient's statement

• reflection encourages the patient to continue communicating

• reflection is a subtle way of asking a question and is less intimidating than asking a direct question

interpretation • is the dentist's explanation and

understanding of the patient's comments

• an interpretation may stimulate dialogue by requiring the patient to agree or to disagree with the statement

• an interpretation does not need to be correct in order to stimulate dialogue

respect • respect promotes rapport, open

expression & trust • respect is communicated via the way

the dentist works with the patient • communicate respect by regarding each

patient as an individual

silence • is iised to facilitate dialogue by stimulating the patient to comment and therefore break the silence

• when using silence, it is very important to communicate interest by nodding the head "yes", leaning toward the patient, and/or maintaining eye contact

Communications Effectively with Patients

• evaluate

Do Describe

Be specific

Be responsive

Pat attention

Listen carefully

Make eye contact

Use lay terms

Lean forward

Use gestures

Use expression

Ask questions

Don't Evaluate

Be general

Be evasive

Be distracted

Interrupt

Let eyes wander

Use jargon

Lean back

Fold arms

Show disinterest :

Presume

Suggestions from Patients

How to Reduce Anxiety Prevent pain

5e reassuring

Have a calm demeanor

Provide moral support

Work efficiently

Be friendly

BS Each of the following are considered to be aversive conditions of interaction between the dentist and patient EXCEPT one. Which one is the EXCEPTION?

> psychophysiological reactions

•stress, anxiety & fear

< preventive oral health behavior

pain

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PATIENT MANAGEMENT

BS

Which of the following suggests that change does not happen in one step and people tend to progress through different stages on their way to successful change.

• ABC model (behavior theory model)

• stages of change model (SCM)

• social cognitive theory

• contemporary public health model


PATIENT MANAGEMENT

r

Aversive conditions • any negative condition to which a per-

son will learn to make a response to avoid it

• the dentist-patient interaction seeks to minimize conditions that are perceived as aversive

• aversive conditions - psychophysiological reactions - stress, anxiety & fear -pain

Non-aversive conditions • non-aversive conditions

- preventive oral health behavior - communication - gathering information - identifying problems - giving information

• the dentist-patient interaction seeks to maximize the conditions that are perceived as non-aversive

• preventive oral health behavior Dental fear, anxiety & pain

• dental fear is an unpleasant emotional or physiologic sensation derived from a specific dental-related stimulus

• dental anxiety is a non-specific uneasi-ness, apprehension or negative thoughts about what may happen during dental treatment

• dental phobia is when dental treatment is^WiHeToFehdured with intense

• dental fear & anxiety can come from different sources

• dental fear & anxiety are often from a previous bad experience, or, from hearing of a bad experience , or a gen-eral fear of needles

• dental fear happens during childhood or adolescence in approximately 50-85% of cases

• dental fear, anxiety & pain are all interrelated

• fear may cause a person to endure pain and not seek treatment

• pain & anxiety - as pain increases, anxiety increases - as anxiety increases, pain is enhanced & is less tolerable

Stages of change model (SCM) • behavior change does not happen in

one step • a person will progress through dif-

ferent stages on the way to successful change

• each person will progress at their own rate

Stages of change 1 - pre-contemplation

not acknowledging there is a prob-lem that needs to be changed

2 - contemplation acknowledging problem but not

ready or sure of wanting to make a change

3 - preparation getting ready to change

4 - action/willpower changing behavior

5 - maintenance maintaining behavior change

6 - relapse abandoning change, returning to old behavior

• stages of change model (SCM) Social cognitive theory

• behaviors are learned through obser-vation, modeling & motivation such as positive reinforcement

• learning is strengthened if the observer identifies with their "model

• learning is strengthened if someone models a behavior he or she has seen rewarded; this motivates the person to model the behavior to get a reward

ABC model (behavior theory) • behavior has 3 components :

A = antecedents (trigger) B = behaviors C = consequences

• "B" comes between "A" and "C" • rather than occurring in isolation,

behavior is preceded by an antecedent that sets off the behavior and is followed by a consequence

Contemporary community (public) health model

• a prevention model that considers so-cial, cultural, economical & enviro-nmental factors as having significant influence on a person's health behaviors

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

• veracity

• documentation

• autonomy

• negligence


PATIENT MANAGEMENT

ic Identify which one of the following is a false statement concerning personal protective equipment (PPE):

1 . protective clothing must be worn by dental professionals when contact with blood or other bodily fluids is anticipated

2. gloves must be worn to prevent contact with blood, saliva or mucous membranes

3. wearing gloves replaces the need for handwashing

4. protective clothing must be removed before leaving the dental office

5. masks must be changed between patients


PATIENT MANAGEMENT

Risk management • refers to the policies and procedures the dentist should follow in order to reduce the chance that a patient will file legal action against him or her

• includes issues of legal competence, informed consent, liability, confiden-tiality and documentation

Informed consent • informed consent (written or oral) must be obtained by the dentist from adult patients prior to treatment

• informed consent components - WHO will render treatment - WHAT are the treatment options - WHAT treatment will be done - WHEN will the treatment occur - WHERE (if referring the patient) - WHY purpose of the procedure and risks versus benefits

- QUESTIONS the opportunity for the patient to ask questions & obtain info

Patient record • the patient record is the property of the dentist and must be retained by the dentist

• documentation Documentation

• is essential to risk management • dental records must be thorough, con-sistent & complete

• must include actual visits, missed visits & evidence of noncompliance

Documentation tips • inform the insurance carrier if an incident with a patient occurs

• remember that everything written in the record can be used in court

• always document informed consent • never change any written entry - add an addendum / separate entry instead

• if a mistake is made - draw a single line through the error, mark it "error" and initial & date it

• be specific - write facts only, not opinions • be objective - avoid personal charac-terizations, state behaviors

• be complete • be timely • write legibly • maintain integrity of the patient record • never sign a patient record entry for

someone else, or vice versa • countersign carefully - you are as

responsible as original person who signed

> wearing gloves replaces the need for hand washing

Protective clothing • protective clothing includes gowns,

lab coats & jackets • may be disposable • is worn over existing clothing (street

clothes or scrubs) • is used to prevent skin & mucous

membrane exposure when contact with blood or other body fluids is anticipated

• must be changed daily or more often if visibly soiled

• protective clothing must be removed before leaving the dental office

Masks & protective eyewear • if spatter & aerosolized sprays are

likely, surgical masks & protective eyewear, or chin-length plastic face shields must be used

• a mask must be changed between patients or more often if it becomes wet or moist

• face shields & protective eyewear must be washed/disinfected with appropriate cleaning agents

Gloves • wearing gloves does not replace the

need for handwashing • dental professionals must wear gloves

to prevent skin contact with blood, saliva or mucous membranes

• new gloves must be worn for each patient

• gloves must be worn when touching contaminated items or surfaces

• non-sterile gloves are recommended for examinations & nonsurgical procedures

• sterile gloves are recommended for all surgical procedures

• utility gloves are recommended for cleaning and instrument processing

• gloves must be changed whenever they are torn, cut or punctured during treatment

• gloves should never be washed before use, or, disinfected for reuse

IC Identify each of the following that is a true statement regarding the launder-ing of contaminated laundry in the dental setting:

1. contaminated laundry must be handled as little as possible

2. the dentist may choose to use an outside laundry service

3. the dentist or assigned office personnel may launder the clothes on-site

4. contaminated laundry should be bagged at the location of use

5. contaminated laundry should be handled with appropriate PPE

6. if contaminated laundry is transported to a laundromat, the employee must be trained in the handling of contaminated laundry

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PATIENT MANAGEMENT

Match each term with the correct definition:

IC

clinical contact surface

disinfectant

disinfection

hospital disinfectant

intermediate level disinfectant

low level disinfectant

tuberculocidal

1. a disinfectant that makes the label claim 'tuberculocidal'

2. a germicide effective against HIV and HBV

3. an agent capable of inactivating Mycobac-terium tuberculosis

4. any surface directly contaminated from patient materials, gloved hands, blood, or OPIM

5. a process which destroys a majority of, but not all, microorganisms

6. a chemical agent used to destroy recognized pathogens; kills some but not all microorgan-isms

7. a germicide effective against Salmonella choleraesuis, Staphylococcal aureus and Pseudomonas aeruginosa , ,„ ,

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PATIENT MANAGEMENT

• all statements are true Protective clothing

• for optimal protection — gowns, jackets or coats are required to be long sleeved and high necked

• such clothing minimizes the potential for exposed skin to contact blood, saliva or other potentially infectious material

Disposable gowns • if used, eliminates the need to launder

contaminated protective clothing

Contaminated laundry • defined as laundry that has been

soiled with blood or OPIM (other potentially infectious material)

• handling of contaminated laundry includes the following: - handle as little as possible - handle with appropriate PPE - bag at location of use - do not sort or rinse at location of use " Jf lbdJB^grtbggLgJft a biohazard

Laundry choices • in the dental office — contaminated

laundry includes protective clothing that is used to cover street clothes or scrubs

• the dentist may choose to use an out-side laundry service

• the dentist or assigned office personnel may launder the clothes in a washer and dryer on-site

• if contaminated laundry is trans-ported to a laundromat — the employee or dentist must use PPE, be trained in handling of contaminated laundry and transport the laundry in a red/orange bag that is labelled with a biohazard symbol

• a dentist who is unincorporated and is the owner may take laundry home; if the owner is unincorporated, the owner is not subject to OSHA regulations

Clinical contact surface • any surface directly contaminated from

patient materials, gloved hands, blood or OPIM (otherpotentially infectious material)

• these surfaces can then cross contam-inate other instruments, devices, hands, gloves & other items

Disinfectant • chemical agent used to destroy recog-

• 4 , 6, 5, 7, 1, 2, 3

Intermediate level disinfectant • disinfectant that makes the label claim

'tuberculocidal'

Low level disinfectant • germicide effective against HIV &

HBV

Tuberculocidal • agent capable of inactivating Mycobac-

terium tuberculosis nized pathogens; kills some but not all microorganisms

Disinfection • a process which destroys a majority of,

but notall, microorganisms • while disinfection is lethal to some

organisms, only sterilization kills all organisms

Hospital disinfectant • germicide effective against Salmonella

choleraesuis, Staphylococcal aureus and Pseudomonas aeruginosa on non-living objects

Disinfectant selection factors to consider

• ability to inactivate TB, HIV and Hepa-titis B

• suitability for use as a cleaner and disin-fectant

• health hazards and precautions • contact time requirements • compatibility with equipment, devices

and materials • shelf life and storage • sensitivity to temperature

Basic terminology an understanding of the terminology related to infection control is important for the den-tal professional

• antisegtic "Vi^ a substance that inhibits the growth of

bacteria • asepsis

the absence of pathogens, or disease-causing microorganisms

• bloodborne pathogens pathogens present in blood that cause disease in humans

• disinfect the use of a chemical or physical proce-dure to inhibit or destroy pathogens; highly resistant bacterial and mycotic spores are not killed during disinfection

• disinfection the act of disinfecting

• exposure incident &^ a specific incident that involves contact with blood or other potentially infec-tious materials that results from proce-dures performed by the dental profes-sional

•6,4,1,3,7,2,5 • infectious waste waste that consists ofolood, blood products„contaminated sharps, or other ^nierobiologic products

• occupational exposure contact with blood or other infectious materials that involves the skin, eye, or mucous membranes and that results"" from procedures performed by the den-tal professional

• parenteral exposure exposure to blood or other infectious materials that results from piercing or puncturing the skin barrier

• personal protective equipment (PPE) protective attire, gloves, mask and eye wear

1 sharp any object that can penetrate skin, in-cluding, but not limited to, needles and scalpels

1 standard precautions measures designed to protect health care

CDC recommended infection control practices in dental health care set-tings

• primary purpose of infection control procedures is to prevent the trans-mission of infectious diseases

• infectious diseases may be trans-mitted - from patient to dental professional - from dental professional to patient - from one patient to another patient

• use of recommended infection con-trol guidelines greatly reduces the transmission of infectious diseases

• recommended infection control practices are applicable to all set-tings in which dental treatment is provided and must be observed in conjunction with required OSHA (Occupational Safety and Health Administration) practices and procedures for worker protec-tion


Recommendations • vaccination of dental professionals • use of protective attire and barrier

techniques • hand washing and care of hands • proper use and care of sharps

(instruments and needles) • sterilization of instruments • cleaning & disinfection of the

dental unit and environmental surfaces

• disinfection of the dental laboratory • use and care of hand pieces, anti-

retraction valves, and other devices attached to air & water lines of dental units

• single use of disposable instruments • proper handling of biopsy specimens • proper use of extracted teeth in

dental educational settings • proper disposal of waste materials • implementation of recommendations

Basic terminology an understanding of the terminology related to infection control is important for the den-tal professional

• antiseptic •\»5^*a*"substance that inhibits the growth of

bacteria • asepsis

the absence of pathogens, or disease-causing microorganisms

• bloodborne pathogens pathogens present in blood that cause disease in humans

• disinfect the use of a chemical or physical proce-dure to inhibit or destroy pathogens; highly resistant bacterial and mycotic spores are not killed during disinfection

• disinfection the act of disinfecting

• exposure incident <S^ a specific incident that involves contact with blood or other potentially infec-tious materials that results from proce-dures performed by the dental profes-sional

• 6 , 4 , 1 , 3 , 7 , 2 , 5

• infectious waste waste that consists oFblood, blood products„contaminated sharps, or other microbiologic products

• occupational exposure contact with blood or other infectious materials that involves the skin, eye, or mucous membranes and that results from procedures performed by the den-tal professional

• parenteral exposure exposure to blood or other infectious materials that results from piercing or puncturing the skin barrier

• personal protective equipment (PPE) protective attire, gloves, mask and eye wear

• sharp any object that can penetrate skin, in-cluding, but not limited to, needles and scalpels

• standard precautions measures designed to protect health care

CDC recommended infection control practices in dental health care set-tings

• primary purpose of infection control procedures is to prevent the trans-mission of infectious diseases

• infectious diseases may be trans-mitted - from patient to dental professional - from dental professional to patient - from one patient to another patient

• use of recommended infection con-trol guidelines greatlv reduces the transmission of infectious diseases

• recommended infection control practices are applicable to all set-tings in which dental treatment is provided and must be observed in conjunction with required OSHA (Occupational Safety and Health Administration) practices and procedures for worker protec-tion

• both statements are false Recommendations

• vaccination of dental professionals • use of protective attire and barrier

techniques • hand washing and care of hands • proper use and care of sharps

(instruments and needles) • sterilization of instruments • cleaning & disinfection of the

dental unit and environmental surfaces

• disinfection of the dental laboratory • use and care of hand pieces, anti-

retraction valves, and other devices attached to air & water lines of dental units

• single use of disposable instruments • proper handling of biopsy specimens • proper use of extracted teeth in

dental educational settings • proper disposal of waste materials • implementation of recommendations

IC Instruments in the dental practice can all be classified as either critical or non-critical.

For infection to occur, these three conditions must be present: a susceptible host, a pathogen with sufficient infectivity and numbers to cause infection, and, a portal of entry through which the pathogen may enter the host.







IC Match each term with the

pasteurization

sanitization

antiseptic

disinfectant

bacteriostatic

bactericidal

correct definition:

1 . pathogens present in blood that cause disease in humans

2. an agent that prevents further growth of bac-teria

3. an agent capable of killing bacteria

4. to expose food to an elevated temperature for a period of time sufficient to destroy certain dis-ease-causing microorganisms

5. a chemical agent used on inanimate objects to destroy or inhibit the growth of harmful organ-isms 6. treatment of water to reduce microbial counts to safe levels

7. an antimicrobial agent that can be safely applied to living tissues


PATIENT MANAGEMENT


Disease transmission • for an infection to occur by one of these routes of transmission, the fol-lowing three conditions must be present: - a susceptible host - a pathogen with sufficient infecti-

vity and numbers to cause infection - a portal of entry through which the

pathogen may enter the host • effective infection control practices

are intended to alter one of these three conditions and prevent disease transmission

Classification • all instruments in the dental practice

can be classified as crjjtical^jenu-critical or noncritical

• instruments are classified depend-ing on the risk of transmitting infec-tion & the need to sterilize between uses

critical instruments • penetrate soft tissue or bone • must be sterilized after each use • examples include forceps, scalpels,

bone chisels, scalers and surgical burs

semicritical instruments • contact but do not penetrate soft

tissue or bone • must be sterilized after each use • if the instrument can be damaged by

heat and sterilization is not feasible, a disposable one-use item is required

• examples include x-ray beam align-ment devices, mirrors, amalgam condensers and burs

noncritical instruments ""« do riot come in contact with mu-

cous membranes • because there is little risk of trans-

mitting infection, an intermediate level or low-level disinfectant is required between uses in different patients

Definitions • antiseptic

an antimicrobial agent that can be safely applied to living tissues (e.g., alcohol); inhibits but does not necessarily destroy microorganisms

• bactericidal an agent that is capable of killing bacteria; bactericidal agents are preferable over those which are bacteriostatic

• bacteriostatic an agent that prevents the further growth of bacteria

• 4 , 6 , 7 , 5 , 2 , 3

disinfectant a chemical agent used on inanimate objects to destroy or inhibit the growth of harmful organisms; not considered safe for use on human tissues (e.g., bleach); a disinfec-

tant kills some, but not all microor-ganisms

pasteurization to expose food to an elevated tem-perature for a period of time suffi-cient to destroy certain disease-causing microorganisms; the target of pasteurization is the destruction of Mycobacterium tuberculosis

sanitization treatment of water supplies to reduce microbial counts to safe public health levels

IC Match each term with the correct definition:

1 . pathogens present in blood that cause disease antiseptic . . M in humans

asepsis 2. includes protective attire, gloves, mask and eyewear

_ bloodborne pathogens 3> | n v o | v e s C Q n t a c t w j t h b | o o d o r Q t h e r p o t e n _

tially infectious materials and that results from exposure incident d e n t a , p r o c edures

infectious waste 4 - t n e absence of disease-causing microorgan-isms

personal protective equipment 5 . measures designed to protect operators & pa-tients from pathogens spread by blood or any

standard precautions other body fluid, excretion, or secretion

6. a substance that inhibits the growth of bacte-ria

7. waste that consists of blood, blood products, contaminated sharps or other microbiologic 23 prodUCtS copyright C 2013-2014- Dental Decks

PATIENT MANAGEMENT

ic The interpretation of the Centers for Disease Control & Prevention (CDC) rec-ommended infection control practices in dental healthcare settings varies from state to state; not all guidelines apply in all states.

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






PATIENT MANAGEMENT

IC Identify each of the following that is a true statement regarding the pur-pose of cleaning prior to disinfection:

1. cleaning destroys all pathogens

2. cleaning reduces the concentration of pathogens

3. cleaning removes blood and debris which can interfere with disinfection

4. cleaning is optional prior to disinfection


PATIENT MANAGEMENT

ic Identify the term that BEST describes the complete destruction of all forms of microbial life, including heat-resistant bacterial spores:

• pasteurization

• sanitization

• sterilization

• disinfection


PATIENT MANAGEMENT

2,3

Cleaning • is defined as the physical removal

of debris • with aseptic technique, you must

clean before you disinfect • the cleaning step is not optional, it

is required • all disinfectant products include

specific instructions for cleaning prior to disinfection

Cleaning Results in

• a reduction in the number of microorganisms present

• the removal of blood, tissue biobur-den and other debris that can interfere with disinfection

Sterilization • defined as the destruction of all forms

of microbial life • limiting requirement is the inactiva-

tion of bacterial spores • proof of such destruction is the ultimate

criteria for sterilization because spores are the most heat-resistant microbial forms

• per the Centers for Disease Control and Prevention (CDC), sterilization is required for all instruments and items that are placed in the patient's mouth

• if an item cannot withstand heat sterili-zation, a disposable (one-time use) item should be used instead

• heat is the most efficient and depend able physical mode of achieving sterilization of dental instruments; the heat may be moist or dry

• three equipment options for heat sterilization include the autoclave, the chemical vapor sterilizer and the dry heat oven

• sterilization Biological monitoring

• sterilizers must be monitored for proper functioning. — this is done via the use of biological indicators (BI) or spore tests

• both the CDC and ADA recommend weekly spore testing of all sterilizers

Other definitions • disinfection

the inhibition or killing of pathogens; spores are not killed during disinfection

• pasteurization to expose food to an elevated tempera-ture for a period of time sufficient to destroy certain disease-causing microorganisms; the target of pasteur-ization is the destruction of Mycobacterium tuberculosis

• sanitization treatment of water supplies to reduce rHicrobial counts to safe public health

^--'levels

X

IC Identify the type of pathogen that provides the ultimate test for efficacy of sterilization:

• fungal organisms

•HIV

hepatitis B virus

bacterial spores


PATIENT MANAGEMENT

ic For a steam autoclave, identify each of the following that lists the correct tem-perature, pressure and time that must be used for sterilization.

>250°F, 15 psi, 20 minutes

'270°F, 30 psi, 08 minutes




PATIENT MANAGEMENT

• bacterial spores Biological monitoring

• involves the processing of highly resistant bacterial spores to determine if they have been killed

• a biological indicator (BI) or spore strip contains the spores used in biological monitoring

• a spore strip is a small piece of paper that contains one or more types of spores - Bacillus atrophaes spores are used for testing dry heat oven units and Geobacillus stearothermophilus spores are used for testing steam and chemical vapor units

• the spore strip is enclosed in a protective glassine envelope

Spore testing • after a spore strip is processed in a

sterilizer, it is mailed to a monitoring service

• in a laboratory setting, the spore strip is aseptically placed in a test tube of culture media for 7 days

• for each of the 7 days, the tube of culture media is inspected for cloudi-ness

• if spores are viable & have not been killed, the culture media appears cloudy

• if no cloudiness is noted in the culture media, then sterilization is confirmed

• cloudiness in the culture media indi-cates a failed test (spores were not killed), also known as a positive biolog-.«---• 7 r • .-..S ical spore test

•ToTule~out contamination during testing, a Gram stain is prepared to identify the bacteria in the failed test

• when the gram-positive Bacillus organism is observed on the test slide, sterilization failure is confirmed

• 250° F, 15 psi, 20 minutes — or — 270° F, 30 psi, 8 minutes Autoclave

• the use of steam heat under pre sure remains the oldest, most com-mon and most acceptable method for instrument sterilization

• the typical autoclave uses - a temperature of 121 °C (250 °F) - a pressure of 15 psi - cycle time of 20 minutes or - a temperature o f l32^C (270 °F) - a pressure of 30 psi - cycle time of 8 minutes

Advantages & Disadvantages • advantages

- a short efficient cycle time - good penetration - a wide range of materials can be

processed without destruction • disadvantages

- corrosion of unprotected carbon steel instruments

- dulling of unprotected cutting edges - packages may remain wet at the

end of a cycle - use of hard water may leave

deposits - possible destruction of heat-

sensitive materials

Autoclave problems that may result in a failed spore test

• faulty temperature gauge • faulty pressure gauge • faulty timer • faulty or dirty gasket / seal • faulty heating coil, exhaust line • faulty or clogged bleeder valve • mineral deposit build-up

IC For a dry heat oven, identify the correct temperature and time that must be used for sterilization.

•375°F, 60 minutes





PATIENT MANAGEMENT

ic For a chemical vapor sterilizer, identify the correct temperature, pressure and time that must be used for sterilization.

• 250°F, 20 psi, 20-40 minutes

• 250°F, 30 psi, 40-60 minutes

• 270°F, 15 psi, 40-60 minutes

• 270°F, 20 psi, 20-40 minutes


PATIENT MANAGEMENT

Dry heat oven • in the absence of moisture, destruction

of all forms of microbial life requires conditions very different from the auto-clave

• dry heat sterilizes much less efficiently than moist heat

• a HIGHER TEMPERATURE & LONGER CYCLE TIME is required for sterilization to occur

• the typical dry heat oven uses - a temperature of 160 °C (320 °F) - cycle time of 120 minutes or - a temperature of 170 °C (340 °F) - cycle time of 60 minutes

• the use of a commercial cooking oven is not a substitute for an FDA-app-p roved sterilizer

1

• 320°F, 120 minutes


- no dulling of cutting edges - no corrosion of metal instruments

• disadvantages - the long cycle time - poor penetration - may discolor or char items - destroys heat-labile items - cannot sterilize liquids - not suitable for hand pieces

lmztmmm®m.j!mm

Forced air convection ovens • a.k.a. rapid heat transfer ovens • another option for dry heat sterilization • use a HIGHER TEMPERATURE \

and a CONTROLLED INTERNAL AIRFLOW

• uses a temperature of 190 °C (375°F) and a cycle time of 12 minutes for wrapped items and 6 minutes for unwrapped items

Dry heat oven problems that may result in a failed spore test

• faulty temperature gauge • faulty timer

Chemical vapor sterilizer • requires the use of organic solvents

(chemicals) instead of water to produce the sterilizing vapor

• the typical chemical vapor sterilizer uses - a temperature of 132 °C (270 °F) - a pressure of 20 psi - cycle time of 20-40 minutes

• instead of distilled water (used in steam autoclaves), a solution of >tTKohol,,formaldehyde,'tolcetone,

\aeetone and Water is used to produce the sterilizing vapor

• 270° F, 20 psi, 20-40 minutes Advantages & Disadvantages

• advantages - no corrosion of metal instruments

including carbon steel - no dulling of cutting edges - suitable for orthodontic stainless

wires • disadvantages

- instruments must be completely dried before processing

- special chemical solutions must be used

- destroys heat sensitive plastics - produces a strong chemical odor in

poorly ventilated areas - cannot sterilize liquids

Chemical vapor sterilizer problems that may result in a failed spore test

• faulty temperature gauge • faulty timer • faulty or dirty gasket/seal • faulty or clogged metering valve

IC How many hours are required to kill bacterial spores when a dental instru-ment is placed in a 2% solution of glutaraldehyde?

•8 hours

• 10 hours

• 12 hours

• 24 hours


IC Identify which one of the following is the most efficient way to kill microbes:

• cold sterilization

• heat sterilization

• glutaraldehyde

• all of the above


PATIENT MANAGEMENT

Glutaraldehyde 2% • is a liquid chemical sterilant • capable of killing spores if

sufficient contact time is provided and there is absence of extraneous organic material required contact time is 10 hours

• a.k.a. "cold sterilization" • if this method is used to sterilized

an instrument, after 10 hours, it must be rinsed with sterile water, dried and placed in a sterile container (if not used immediately)

Important note • use of a chemical sterilant in

dentistry is no longer considered appropriate for sterilizing heat-stable instruments

L

• 10 hours


- most potent category of chemical germicide

- EPA registered as chemical sterilant

• disadvantages - long time period required for

sterilization - allergenic - WgWjaaxkJtoJ^gues - no way to monitor efficacy

Reminders • CDC refers to heat sterilization as

the method of choice when sterilizing instruments and devices

• dental instruments must be appropriately cleaned, packaged & sterilized between uses with a heat-based, biologically monitored process

• if heat sensitive, a heat-stable alternative or disposable item must be used

Heat sterilization • use of heat has long been recog-

nized as the most efficient and reliable method of sterilization

« using a steam autoclave, chemical vapor sterilizer or dry heat oven — cell death is accomplished via heat inactivation of critical enzymes and other proteins within cells

• moist heat destroys bacteria by denaturation; the denaturation process is quickened by the use of pressure

•_dryheat destroys microorganisms by causing coagulation of proteins

\ \ ^

• heat sterilization

• heat sterilization as the method of choice when sterilizing instruments and devices

• dental instruments must be appro-priately cleaned, packaged & steril-ized between uses with a heat-based, biologically monitored process

• if heat sensitive, it is preferable to use a heat-stable alternative or disposable item

IC Identify which one of the following is a false statement concerning infection control in the dental setting:

• exposure is not synonymous with infection

« do not disinfect what you can sterilize

• environmental surfaces must be sterilized between patients

• all dental patients can be treated using standard bloodborne precautions


PATIENT MANAGEMENT

IC Identify which one of the following is a false statement regarding potential operator errors that may cause the failure of a spore test:

• the sterilizer was overloaded

• the sterilizer cycle was interrupted

> improper packaging was used

> inadequate time, temperature and/or pressure was used

• inadequate warm up time was completed

• mineral deposit build up


• environmental surfaces must be sterilized

• it is not possible to sterilize the environmental surfaces that become contaminated during patient care

' thorough cleaning ofthe surfaces is sufficient to break the cycles of cross-contamination and cross-infection

' chemical disinfectants used on sur-faces should: - kill as many microbes as possible

in the shortest time possible - not damage the surface being

decontaminated - not be harmful to humans or

animals - not be affected by presence of

organic material - be compatible with soap,

detergents and other chemicals - be inexpensive - be stable during storage

Operator errors • overloading • interrupting sterilization cycle • using inadequate time • using inadequate warm up time • using inadequate temperature • using inadequate pressure • using improper packaging • using expired chemical solution

• mineral deposit build up

Errors & Problems A number of conditions may cause a spore test to fail - overloading the steril-izer, inadequate temperature and/or pres-sure, inadequate time, or improper packaging of instruments.

In the majority of cases, OPERATOR ERROR is responsible for the failure.

Equipment problems • faulty temperature gauge • faulty pressure gauge • faulty timer • faulty or dirty gasket/seal • faulty heating coil, exhaust line • faulty or clogged bleeder valve • mineral deposit build-up • faulty or clogged metering valve

Of all the errors listed in the question, only one is not an operator error — it is an EQUIPMENT PROBLEM — "mineral deposit build up".

IC Identify which one of the following is a true statement concerning chemical monitoring:

• chemical monitoring is a definitive means of determining sterilization

• chemical monitoring determines if critical pressure has been reached

• chemical monitoring uses heat sensitive chemicals

• when a chemical indicator changes color, sterilization is complete

• a chemical indicator is part of the spore strip glassine envelope


PATIENT MANAGEMENT

ic Identify which one of the following is a false statement concerning the use of alcohol hand gels in the dental setting:

• the convenience of alcohol hand gel use helps to increase compliance with hand washing guidelines

• hand washing with an alcohol product takes less time than using soap & water

• alcohol hand gels can save busy practitioners valuable time between patients

• studies have shown that alcohol hand gels reduce microorganisms significantly better than soap & water

• alcohol hand gels cause more dryness than soap & water hand washing


• chemical monitoring uses heat sensitive chemicals

Chemical monitoring • uses heat sensitive chemicals (not spores) to assess the physical condi-tions during the sterilization process

• involves the use of indicators that change color when exposed to certain temperatures

• examples includeia'utoclave tape, special markings on bags and

pouches^jehemical indicator strips,jtabs or packets

• a color change only indicates that the sterilizer reached the proper temperature but does not indicate

/ how long the temperature was maintained or what pressure was reached and maintained

• confusion often exists between biological monitoring (spore test-ing) & chemical monitoring

• weekly testing of the sterilizer via biological indicators is the ONLY definitive way to verify steriliza-tion success

• a chemical indicator can serve as a routine check for all item proce-ssed in the sterilizer

• provides immediate feedback concerning the critical steriliza-tion temperature; identifies if the sterilizer does not reach critical temperature

• chemical indicators should be placed inside each sterilizer pouch or wrapped cassette to verify the sterilizing parameter for that indica-tor has been satisfied internally

• these indicators should also be placed on the outside of the package

hand gels cause more dryness than soap & water washing

Hand gels • the convenience of alcohol hand gel use helps to increase compliance with hand washing guidelines

• increasing popularity of hand gels is due to flexibility & convenience

• hand washing with an alcohol product takes less time than water washing and does not require a sink, water or paper towels for drying

• for the busy practitioner who has to clean their hands often, the quickness of hand sanitizers can save valuable time between patients

• studies have also confirmed that alco-hol hand gels kill more germs; hand gels with 60% - 70% alcohol reduce microorganisms including bacteria, fungi and viruses significantly better than soap and water

• there is a misguided belief that alcohol-based hand gels will dry out the skin, particularly with frequent use

• alcohol hand gels on the market today contain moisturizers specifi-cally to prevent such dryness

• studies have shown that this new generation of gels cause less dryness and irritation than the traditional soap and water method of hand washing

IC Identify which one of the following is a false statement concerning when to use hand hygiene techniques in the dental setting:

' before touching a patient

• before aseptic procedures

• after donning gloves

• after touching a patient

after touching patient surroundings


PATIENT MANAGEMENT

ic Identify which one of the following is a false statement concerning the use of disinfectants in the dental setting:

• the disinfectant used must be registered by the EPA

• each practice must maintain a written schedule for surface disinfection

• PPE must be used when using disinfectants

• when using a disinfectant, the use of vinyl exam gloves is recommended


PATIENT MANAGEMENT

> after donning gloves

Hand hygiene recommendations • soap & water hand washing

should be used when hands are dirty or visibly soiled with blood or other bodily fluids, before eating, after using a restroom, and, if hands come in contact with spores

• in all other cases, alcohol based hand gel can be used for routine decontamination of hands

• once gloves are placed on the hands, hand gel or soap & water should not be used on the gloves

When to clean hands... • before touching a patient • before aseptic procedures • after body fluid exposure or risk • after touching a patient • after touching patient surroundings

Techniques • soap & water hand washing - wet hands - apply amount of soap recom-

mended by the manufacturer - rub hands together for at least 15

seconds MiuiMuu nammmaKw.

• rmse with water and dry thoro-ughly with a disposable towel

- use towel to turn off faucet - avoid use of HOT water

• alcohol based hand gel - apply the amount of gel recom-

mended by the manufacturer to one palm

- rub hands together, covering all surfaces

- continue rubbing hands together until all surfaces are dry

- if hands feel dry after 10 seconds or less of rubbing, too little prod-uct has been used

. when using a disinfectant, the use of vinyl exam gloves is recommended

Surface disinfection • surfaces without barriers must be cleaned and disinfected with an intermediate-level disinfectant

Manufacturer instructions • disinfecting solutions must be prepared following manufacturer guidelines

• disinfecting solutions must beJJPA^ registered

• manufacturer instructions for pre-cleaning surfaces must be followed before disinfection

• the disinfectant must be applied to the surface for the contact time designated on the product label

Personal protection equipment • puncture and chemical resistant utility gloves must be used when cleaning and disinfecting surfaces

• in addition to gloves, protective clothing, eye protection & mask must be worn when cleaning and disinfecting surfaces

Housekeeping surface • reusable pails, bins and containers must be regularly inspected, cleaned and disinfected

• housekeeping surfaces contaminated with body fluids must be cleaned and disinfected with an EPA-registered intermediate level disinfectant

Cleaning schedule • the office must have a cleaning schedule based on the type and degree of contamination and location

Surface disinfection & OSHA •,the office must have a written

* schedule for disinfection of surfaces as required by OSHA

9

IC Between patients, all surfaces without protective coverings must be cleaned and disinfected with an intermediate-level disinfectant.

Between patients, all protective coverings used in place of surface disinfec-tion must be changed/replaced.






PATIENT MANAGEMENT

ic The Occupational Safety and Health Administration's (OSHA) Bloodborne

Pathogens Standard mandates that all dental healthcare professionals re-

ceive, at a minimum, the Hepatitis B vaccination series.

The Centers for Disease Control and Prevention (CDC) mandates all other vac-

cinations.





42 copyright ©201 3-2014-Dental Decks

• both statements are true Protective coverings

• the use of protective covers on disinfected surfaces and non-critical equipment is acceptable

• covers (barriers) must be resistant to fluids and puncture in order to protect surfaces from contamination

• these coverings may be used instead of surface disinfection between patients

• coverings must be replaced/ changed between patients

• protective covers eliminate the need to disinfect the covered areas between patients

• areas covered with barriers during the treatment day should be disinfected at the end of the day


Immunizations • the Occupational Safety and Health Administra-tion's (OSHA) Bloodborne Pathogens Standard mandates that all dental healthcare profess-ionals receive, at a minimum, the Hepatitis B vaccination series

• OSHA defers to the Centers for Disease Control and Prevention (CDC) for all other required vaccinations and screenings

• the CDC recommends the following vaccinations for dental healthcare professionals:

j - influenza <£- mmr ~ - varicella 4 - tdap ts - hepatitis b

IC All employees with potential exposure to bloodborne pathogens are required to have the Hepatitis B vaccination.

The vaccination record of each employee must be kept for 30 years beyond the employee's last day of employment in the practice.






PATIENT MANAGEMENT

ic A booster dose of the Hepatitis B vaccine is required.

The Hepatitis B vaccine series requires that at least 16 weeks elapse between dose 1 and dose 3.






PATIENT MANAGEMENT

• both statements are true In the dental setting, who needs the Hepatitis B vaccination?

• all employees with potential exposure to bloodborne pathogens

• front office and housekeeping staff should be assessed as to their exposure level; if the answer to the following questions is "yes", the vaccination is needed - do they handle contaminated laundry? - do they enter patient treatment areas

where there is potential for exposure? - are they designated to perform first

aid or CPR?

When should the dentist employer offer Hepatitis B vaccinations to employees?

• employers are required to provide Hep B vaccinations to all new employees free of charge after train-

. ing.and within 10 days of working in a position where there is potential exposure to bloodborne pathogens

• the only exception is if the employee has previously received the vaccine series, and, antibody testing has revealed the worker is immune

What Hepatitis B vaccination documenta-tion is required?

• according to OSHA, a vaccination record is part of the employee's medical record, and is required to be kept for 30 years beyond the employ-ees last date of employment

• all part-time and temporary employ-ees are required to provide documenta-tion of Hep B vaccination which must be kept for the same amount of time, 30 years

• according to the CDC and OSHA 29 CFR 1910.1030 (h) (1) (ii) (B), employ-ers are required to keep accurate copies of each employees Hep B vaccination status, including the date of each dose

Is a post vaccination titer required? • post vaccination titer testing must be

done 1 - 2 months after the original vaccine series is completed

• documentation is treated like an employee medical record and kept for 30 years from last date of employment

• the first statement is false, the second is true What if a new employee has been previously vaccinated but has no documentation?

• check with employee's previous employers — per OSHA requirements, a copy of the vaccination records should be part of the medical record and retained

• if all attempts are unsuccessful, OSHA requires documentation verifying the employers attempt to obtain the record and should include a written statement from the employee about vaccination status and approximate dates of the vaccinations

• if original documents cannot be obtained then the Hep B vaccination must be made available unless the employee has titer documentation

What if an employee started, but did not complete the three doses of the vaccine?

• if the vaccine series was interrupted after dose 1, the Hep B vaccine series should be continued where it left off

• at least 16 weeks must elapse between doses 1 & 3

• at least 8 weeks must elapse between doses 2 & 3

• if only dose 3 is delayed, it should be administered as soon as possible

What if a titer, administered within the proper amount of time, showed the employee status to be negative?

• repeat the three dose series and test for anti-HBs one to two months after dose 3

• if the employee is still negative after a second vaccine series, the employee is considered a npn-responder and should be tested for chronic HBV infection

• if results are positive for infection, the person should receive appropriate counseling and medical management

• if the person is not infected, they should be counseled on how to protect themselves from infection and the need to obtain Hep B immune globulin prophylaxis for any known or likely exposure to a Hep B positive individual

Is a booster for Hep B vaccine required? • no • there are currently no guidelines requiring a booster

4M,

':;' N3

\

IC Identify which one of the following is the most common form of a glove-as-sociated reaction seen on the hands of health care professionals:

• irritant contact dermatitis

• latex allergy /type I immediate hypersensitivity

• allergic contact dermatitis/type IV delayed hypersensitivity

• fungal infection of the cuticles


PATIENT MANAGEMENT

IC Identify each of following that is a true statement concerning providing safe treatment for patients with possible or documented latex allergy:

1 . be aware of common predisposing conditions (e.g., allergies to avocados, kiwis, nuts, or bananas)

2. be familiar with the different types of hypersensitivity — immediate and delayed

3. frequently clean all working areas contaminated with latex powder/dust

4. frequently change ventilation filters and vacuum bags used in latex-contaminated areas

5. have latex-free kits (e.g., dental treatment and emergency kits) available at all times

6. be aware that allergic reactions can be provoked from indirect contact as well as direct contact


PATIENT MANAGEMENT

irritant contact dermatitis Contact dermatitis

• contact dermatitis can develop from frequent and repeated use of hand hygiene products, exposure to chemicals and glove use

• contact dermatitis is classified as either irritant or allergic

Irritant contact dermatitis • is common & nonallergic • develops as dry, itchy, irritated areas

on the skin around the area of contact

Allergic,contact dermatitis • type IV hypersensitivity • can result from exposure to accelera-

tors and other chemicals used in the manufacture of rubber gloves

• can result from exposure to other chemicals found in the dental practice setting

• often manifests as a rash beginning hours after contact

• like irritant dermatitis, is usually confined to the areas of contact

Latex allergy • type I hypersensitivity to latex

proteins • a more serious systemic allergic

reaction • begins within minutes of exposure

but can sometimes occur hours later

• produces varied symptoms, which include runny nose, sneezing, itchy eyes, scratchy throat, hives & itchy burning sensations

• may involve more severe symptoms including difficult breathing, cough-ing spells, and wheezing; cardiovas-cular and gastrointestinal ailments

• in rare cases, anaphylaxis & death may occur

Considerations for patients with latex allergy

• screen all patients for latex allergy • be aware of common predisposing

conditions (e.g., allergies to avocados, kiwis, nuts or bananas)

• be familiar with the different types of hypersensitivity

• consider sources of latex other than gloves; prophy cups, rubber dams and ortho elastics

• provide an alternative treatment area free of latex in which no patient contact occurs with any latex devices, materials and products

• remove all latex-containing products from the patient's vicinity and adequately cover/isolate any latex-containing devices that cannot be removed from the treatment environment

• be aware that allergens in the ambient air can cause respiratory and or anaphy-lactic symptoms in people with latex allergies

• all of the statements are true

• to minimize exposure to airborne latex particles, schedule patient as the first appointment of the day

• frequently clean all working areas contaminated with latex powder

• frequently change filters and vacuum bags used in latex-contaminated areas

• have latex-free kits (e.g., dental treat-ment and emergency kits) available at all times

• be aware that allergic reactions can be provoked from indirect contact as well as direct contact (e.g., being touched by someone who has worn latex gloves)

• communicate latex allergy procedures (e.g., verbal instructions, written protocols, posted signs) to other personnel

• if latex-related complications occur, manage the reaction and seek emergency assistance as indicated

• follow medical emergency response recommendations for anaphylaxis

IC Identify each of following that is a true statement concerning hepatitis C virus (HCV) infection:

1 . injection drug users are at risk for HCV infection

2. HCV infection is the leading indication for liver transplants in the United States

3. HCV infection signs and symptoms may include fever, fatigue, dark urine, loss of appetite, nausea, vomiting and jaundice

4. 70-80% of persons with HCV infection are asymptomatic

5. there is no cure for HCV infection


PATIENT MANAGEMENT

ic Identify which one of the following is an option for treating a patient with a confirmed latex allergy:

• wear vinyl or nitrile gloves

• wear hypoallergenic latex gloves

• do not wear any gloves

• refuse to treat the patient


PAHENT MANAGEMENT

Hepatitis C Virus (HCV) Infection • is a contagious disease that ranges

in severity from a mild illness last-ing a few weeks to a serious, life-long illness that attacks the liver

• results from infection with the Hep-atitis C virus which is spread through contact with the blood of an infected person

• may be "acute" or "chronic"

• acute HCV infection - is a short-term illness - occurs within the first 6 months

after someone is exposed to HCV - often leads to chronic infection

• chronic HCV infection - is a long-term illness - occurs when the HCV remains in a

person's body - can last a lifetime and lead to

serious liver problems, including cirrhosis or liver cancer

• all of the statements are true At Risk for HCV Infection

• current injection drug users • past injection drug users • blood, blood products & organ

recipients • hemodialysis patients • persons who received body

piercing or tattoos done with non-sterile instruments

• persons with known exposures to the HCV - health care workers injured by

needle sticks - recipients of blood or organs from

a donor who tested positive for HCV

• HIV-infected persons • children born to mothers with HCV

Common glove materials • natural rubber latex (NRL) • nitrile • polyvinyl chloride (vinyl) & other

synthetics • polyethylene (plastic) • combinations of latex and/or

synthetics

Non-latex glove options • a wide variety of non-latex items

are available for use in the dental practice

• vinyl or nitrile gloves can be used to treat patients with latex allergies; these gloves do no cross-react with latex allergens

• hypoallergenic gloves are no longer labeled as latex alternatives as they contain latex with a chemical coating over the latex

• wear vinyl or nitrile gloves

Glove types • the type of glove used should be

based upon the type of procedure to be performed (non-sterile vs. sterile vs. utility)

• both non-sterile examination gloves and sterile surgical gloves are medical devices regulated by FDA

• sterile surgical gloves are used for all surgical procedures & must meet

FDA standards for sterility assurance

• utility gloves are used for house keeping procedures (cleaning & disinfecting) and are not FDA regulated because they are not promoted for medical use

IC An infection caused by normally non-pathogenic microorganisms in a host whose resistance has been decreased or compromised is known as:

• a nosocomial infection

• a secondary infection

• an opportunistic infection

• a recurrent infection


PATIENT MANAGEMENT

ic Identify which one of the following that is not a vaccine preventable disease:

• hepatitis A infection

• hepatitis B infection

• hepatitis C infection

• VZV (varicella zoster virus) infection


PATIENT MANAGEMENT

Infection • invasion by and multiplication of

pathogenic microorganisms in a bodily part or tissue, which may produce subsequent tissue injury and progress to overt disease through a variety of cellular or toxic mechanisms

• instance of being infected • an agent or a contaminated

substance responsible for one's becoming infected

• the pathological state resulting from having been infected

Opportunistic • an infection by a microorganism

that normally does not cause disease but becomes pathogenic when the body's immune system is impaired and unable to fight off infection

• an opportunistic infection

Nosocomial infection • a hospital acquired infection • nosocomial means originating or

taking place in a hospital, especially in reference to an infection

• the term "nosocomial" comes from two Greek words "nosus" meaning "disease" + "komeion" meaning "to take care of;" "nosocomial" refers to any disease contracted by a patient while under medical care

List of Vaccine preventable diseases

• Anthrax • Cervical Cancer • Diphtheria* • Hepatitis A • Hepatitis B* • Haemophilus influenzae type b (Hib) • Human Papillomavirus (HPV) • H1N1 Flu (Swine Flu) • Influenza (Seasonal Flu)* • Japanese Encephalitis (JE) Lyme Disease • Measles* • Meningococcal • Monkeypox

• hepatitis C infection

* recommended vaccines for all health care professionals

• Mumps* • Pertussis (Whooping Cough)* • Pneumococcal • Poliomyelitis (Polio) • Rabies Rotavirus • Rubella (German Measles)* • Shingles (Herpes Zoster) • Smallpox • Tetanus* • Tuberculosis • Typhoid Fever • Varicella (Chickenpox)* • Yellow Fever

What does OSHA stand for?

• Occupational Safety & Health Administration

• Occupational Safety & Hazard Administration

• Occupational Standards & Health Administration

• Occupational Standards & Hazard Administration

PATIENT MANAGEMENT

OSHA

51 copyr ight©2013-20!4-Dental Decks

OSHA The Occupational Safety & Health Administration (OSHA) is a federal agency that develops and enforces regulations designed to protect the:

patient

• employer

• employee



PATIENT MANAGEMENT

r • Occupational Safety & Health Administration (OSHA)

Occupational Safety & Health Administration

• OSHA is a federal agency • created in 1970

workplace • under the Occupational Safety & Health Act of 1970 (OSH Act), employers are responsible for providing a safe and healthful work place for their workers

OSHA and its state partners have dramatically improved workplace safety, reducing work-related deaths and injuries by more than 65 percent since 1970

Employer responsibilities under OSHA law

• employers have the responsibility to pro-vide a safe workplace • employers must provide their work-ers with a workplace that does not have serious hazards and must follow all OSHA safety and health standards • employers must find and correct safety and health problems • employers must first try to eliminate or reduce hazards by making feasible changes in working conditions rather than relying on personal protective equipment • visit wwjojsha^gov for more informat-ion

employee

Occupational Safety & Health Administration

• is a federal agency • a division of the U.S. Department of Labor • protects employees from hazards in the work place through standards or regulations • employers must provide their workers with a workplace that does not have serious hazards and must follow all OSHA safety and health standards

Occupational rules & regulations • OSHA standards are rules that de-scribe the methods that employers must use to protect their employees from hazards • there are OSHA standards for const-ruction work, agriculture, maritime operations, and general industry • standards limit the amount of hazar-dous chemicals workers can be exposed to, require the use of certain safe pract-ices and equipment, and require employ-ers to monitor hazards and keep records of workplace injuries and illnesses • examples of OSHA standards include

vjGeneral Safetyj^Hazard Communica-tion & Bloodborne Pathogens

OSHA Identify which one of the following is considered to be "infectious" and "reg-ulated" medical waste:

• gowns

• plastic barriers

• extracted teeth

• cotton rolls


PATIENT MANAGEMENT

OSHA Each one of the following is considered regulated waste EXCEPT one. Which oneistheEXCEP770/V?

• blood soaked gauze

• contaminated needles

• surgically removed tissue

• gloves


PATIENT MANAGEMENT

• extracted teeth

Regulated medical waste • comprises l%-2% of waste in dental set-ting • requires special handling, storage & dis-posal • in the dental setting, defined as

- liquid or semi-liquid blood or OPIM - contaminated items that would release

blood or OPIM in a liquid or semi-liq-uid state if compressed

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

- contaminated sharps

Types of regulated medical waste • bulk (in liquid or semi-liquid form) blood or OPIM, including saliva • items that would release blood or OPIM in a liquid or semi-liquid state if compressed • items that are caked with dried blood or OPIM and are capable of releasing these ma-terials during handling • contaminated sharps • pathological including extracted teeth

Regulated medical waste containers • regulated medical waste must be placed in a biohazard container that is closable • constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping • puncture resistant if discarding contaminated sharps • marked with fluorescent orange or orange-red labels with lettering and symbols in a contrasting color • closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport or shipping

Non-regulated medical waste • examples include used gloves, masks, gowns, lightly soiled gauze or cotton rolls, disposable plastic barriers • can be disposed of in regular trash

^r BIOHAZARD

• gloves

Non-regulated vs. Regulated medical waste

• studies have compared microorganisms in residential waste with waste from multiple health-care settings — general waste from hospitals or dental prac-tices is no more infective than residen-tial waste • the majority of soiled items in dental offices are general medical waste and thus can be disposed of with ordinary waste • although any item that has had contact with blood, exudates, or secretions might be infective, treating all as infective is neither necessary nor practical • waste that carries a substantial risk of causing infection during handling and disposal is regulated medical waste

Regulated medical waste • bulk (in liquid or semi-liquid form) blood or OPIM, including saliva • items that would release blood or OPIM in a liquid or semi-liquid state if compressed • items that are caked with dried blood or OPIM and are capable of releasing these materials during handling • contaminated sharps • pathological including extracted teeth

Non-Regulated medical waste • examples include used gloves, masks, gowns, lightly soiled gauze or cotton rolls, disposable plastic barriers • can be disposed of in regular trash

OSHA Identify which one of the following is a true^statement from the American Dental Association's Best Management Practices for Amalgam Waste?

• use bleach to flush waste water lines in order to minimize the dissolution of amalgam

• dispose of teeth with amalgam restorations ih biohazard or sharps containers

• salvage amalgam pieces from restoration removal and recycle with amalgam waste

• stock bulk elemental mercury in addition to precapsulated alloys

55 copyright e 2013-2014 - Dental Decks

OSHA Identify each one of the following that is a true statement regarding what must be included in the training of employees as detailed by the OSHA Blood-borne Pathogens Standard:

Qpxm -• information on the hepatitis B vaccine OtfrvW'i pOfcM^CHJW-M

• explanation of biohazard labels used in the office %

• a copy of the standard and explanation of its contents • opportunity for interactive guestions & answers with the person conducting the training session

• explanation of the basis for selection of PPE

• general explanation of the epidemiology & symptoms of bloodborne diseases

• explanation of the modes of transmission of bloodborne pathogens

• instructions on disposal of amalgam waste copyright©2013-2014-Dental Decks

PATIENT MANAGEMENT

Do

• salvage amalgam pieces from restoration removal and recycle with amalgam

American Dental Association Best Management Practices for Amalgam Waste

Do not • use precapsulated alloys & stock var-ious sizes • recycle used disposable amalgam capsules • salvage, store & recycle scrap amal-gam • salvage, store & recycle amalgam pieces from restorations after removal & recycle the amalgam waste • use chair-side traps, vacuum pump filters and amalgam separators to retain amalgam & recycle contents • do recycle teeth that contain amalgam restorations • manage amalgam waste through as much recycling as possible • use line cleaners that minimize disso-lution of amalgam

• use bulk mercury • put used disposable amalgam cap-sules in biohazard containers, infec-tious waste containers or regular garbage • put scrap amalgam in biohazard con-tainers, infectious waste containers or regular garbage • put removed amalgam pieces from restorations in biohazard containers, in-fectious waste containers or regular garbage • rinse devices containing amalgam over drains or sinks • dispose of teeth with amalgam restorations in biohazard containers, in-fectious waste containers or regular garbage • flush amalgam waste down the drain or toilet • use bleach or chlorine-containing cleaners to flush wastewater lines

• information on the hepatitis B vaccine • explanation of biohazard labels used in the office • a copy of the standard and explanation of its contents • opportunity for interactive questions & answers with the person

conducting the training session • explanation of the basis for selection of PPE • general explanation of the epidemiology & symptoms of

bloodborne diseases • explanation of the modes of transmission of bloodborne pathogens

OSHA Bloodborne Pathogens Standard • requires that all employees with occupational exposure receive training at the time of initial assignment & at least annually thereafter • employees mustTrecerve additional training when changes or procedures affect the em-ployee's exposure

Employee training must include: • copy of the current standard & explanation of contents • general explanation of the epidemiology & symptoms of bloodborne diseases • explanation of the modes of transmission of bloodborne pathogens • explanation of the employer's exposure control plan & how the employee can obtain a copy of the written plan • explanation of how to recognize tasks that may involve exposure to blood & OPIM • explanation of how to prevent or reduce expo-sure including engineering controls, work prac-tices & PPE

• explanation of basis for selection of PPE • info on types, proper use, location, removal, handling, decontamination & disposal of PPE • info on hepatitis B vaccine, including efficacy, safety, method of administration, benefits & that it will be offered at no cost • info on actions to take & who to contact in an emergency involving blood or OPIM • explanation of the procedure to follow if an ex-posure incident occurs, including the method of reporting & what medical follow-up will be made available • info on post-exposure evaluation & follow-up that will be provided following an exposure inci-dent • explanation of the biohazard signs & labels and/or color coding required

Trainer must: • provide an opportunity for interactive ques-tions & answers • be knowledgeable in the subject matter & how the info relates to that workplace

OSHA Identify which one of the following is a false statement regarding the OSHA Bloodborne Pathogens Standard training of employees:

• training must be provided at no cost to the employee

• training must be conducted during normal working hours

• training must be reviewed twice per year

• training must take place as soon as the employee is hired


PATIENT MANAGEMENT

OSHA

The OSHA Bloodborne Pathogens Standard requires that a written exposure control plan (ECP) be reviewed:

biannually

. annually

. quarterly

• none of the above

58 copyright €> 2013-2014-Dental Decks

PATIENT MANAGEMENT

• training must be reviewed twice per year

OSHA Bloodborne Pathogens Standard

Employee Training • requires that all employees with occupational exposure receive training at the time of initial assignment

• training should take place as soon as possible for all new hires

• training must be reviewed and take place annually thereafter

• employer must provide the training at no cost to the employee

• employer must provide the training during normal working hours

• employer must document attendance of the employee and maintain attendance records for a minimum of 3 years

annually

Exposure Control Plan (ECP) • the employer shall ensure that a written copy of the ECP is accessible to all employees • the ECP shall be reviewed & updated at least annually and whenever nec-essary to reflect new or modified tasks and procedures which affect oc-cupational exposure, and, to reflect new or revised employee positions with occupational exposure • the ECP shall reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens

ECP Elements • exposure determinations • schedule & method of implementa-tion which includes:

- methods of compliance - hepatitis b vaccination - post exposure evaluation/follow up - communication of hazards - recordkeeping

• provisions for the initial reporting of exposure incidents • hepatitis B vaccination series for un-vaccinated employees • effective procedures for

- evaluating the circumstances surr-ounding exposure incidents

- work practice controls - gathering sharps injury log info - making periodic determinations of

the frequency of use & types/brands of sharps involved in exposure inci-dents

- identifying & selecting currently available engineering control devices

- actively involving employees in the review & update of the ECP for the procedures they perform

OSHA Which of the following diseases prompted OSHA to adopt the Bloodborne Pathogens Standard for dentistry:

• tuberculosis

• HIV disease

• HBV/hepatitis B

• HCV/hepatitis C



PATIENT MANAGEMENT

OSHA The OSHA Bloodborne Pathogens Standard is a comprehensive set of rules and regulations that have been created to prevent the transmission of blood-borne diseases:

• to patients

• to employers

• to employees

• to all of the above


PATIENT MANAGEMENT

• HIV disease

OSHA Bloodborne Pathogens Standard • HIV disease prompted the OSHA reg-ulatory action

- in 1986, unions representing health care workers (HCW) petitioned OSHA for an emergency rule to pro-tect workers from work place expos-ure to HIV and HBV

- the petition was denied but OSHA created a permanent rule on exposure to bloodborne pathogens; it took 5 years to develop this rule

• bloodborne pathogens are infectious microorganisms present in blood that can cause disease in humans • pathogens include, but are not limited to, HBV, HCV and HIV • workers exposed to bloodborne pathogens are at risk for serious or life-threatening illnesses

• all of the requirements of the OSHA Bloodborne Pathogens Standard can be found in Title 29 of the Code of Fed-eral Regulations at 29 CFR 1910.1030 • the standard's requirements state what employers must do to protect workers who are occupationally exposed to blood or OPIM (other potentially in-fectious materials) • the standard protects workers who can reasonably be anticipated to come into contact with blood or OPIM as a re-sult of doing their job duties

> to employees

Bloodborne Pathogens Standard Overview

• bloodborne pathogens are infectious microorganisms present in blood that can cause disease in humans • workers exposed to bloodborne pathogens are at risk for serious or life-threatening illnesses • the standard's requirements state what employers must do to PROTECT EMPLOYEES who are occupation-ally exposed to blood or OPIM (other potentially infectious materials) • all of the requirements of OSHA's Bloodborne Pathogens Standard can be found in Title 29 of the Code of Fed-_ eral Regulations a(2^FR19Tfj!l030

Bloodborne Pathogens Standard Requirements for Employers

• establish an exposure control plan • update the plan annually • implement standard precautions • identify & use engineering controls • identify & ensure use of work practice controls • provide PPE • make hepatitis B vaccinations avail-able to all employees with occupational exposure • make post-exposure evaluation avail-able to any employee who experiences an exposure incident • use labels & signs to communicate hazards • provide information & training to em-ployees • maintain employee medical & training records


Exposure incident Is a specific eye, mouth, other mucous membrane, non-intact skin or parenteral contact with blood or OPIM that results from the performance of an employee's duties

• an example of an exposure incident is a needle stick • the employee must report the expos-ure incident to the designated person in the practice as soon as possible • when an exposure incident occurs, the steps to follow include: - immediately report exposure - administer basic first aid - ensure the device involved is not

reused on the patient - refer to an appropriate HCP as

soon as possible for evaluation & fol-low-up

- create exposure incident report

Exposure incident report Each of the following must be included in the exposure incident report, the exposed person's confidential medical record & pro-vide to the qualified HCP:

• date & time of exposure • details of the procedure being performed, including where & how exposure occurred • if involving a sharp device, the type of device & how/when during its handling the exposure occurred • details of the exposure, including the type and amount of fluid or material and the severity of the exposure • for percutaneous injury — depth of the wound, gauge of the needle & whether fluid was injected • for a skin or mucous membrane expos-ure - estimated volume of material, contact duration & skin condition • details about the exposure source — whether the source material contained HBV, HCV or HIV • if the source patient has HIV, the stage of disease, history of therapy & viral load • vaccination info of exposed person • details about counseling, postexposure management & follow-up

both statements are true

Source testing • follow-up includes identifying the source individual, unless the employer can establish that identification is infeasi-ble or prohibited by stat or local law, and, determining the source's HBV & HIV status • if the status of the source individual is not already known, the employer is re-quired to test the source's blood as soon as feasible, provided the source individ-ual consents • if the source individual does not con-sent, the employer must establish that legally required consent cannot be ob-tained • if state or local law allows testing with-out the source individual's consent, the employer must test the individual's blood, if it is available • the results of these tests must be made available to the exposed employee & the employee must be informed of the laws & regulations about disclosing the source's identity and infectious status

Evaluation & Follow-up • the employer must make immediate confi-dential medical evaluation & follow-up available to the employee • must be at no cost to the employee and at a reasonable time & place • performed by a licensed physician or other licensed HCP • provided according to recommendations of the U.S. Public Health Service • tests must be conducted by an accredited laboratory at no cost to the employee • the employee may consent to have blood drawn for infection status, but may withhold consent for HIV testing at that time; in such cases, the employer must ensure that the blood sample is preserved for at least 90 days in case the employee changes decision • post-exposure prophylaxis for HIV, HBV & HCV, when medically indicated, must be offered to the employee • must include counseling about the possible implications of the exposure & infection sta-tus, including the results, interpretation of all tests & how to protect personal contacts • must include evaluation of reported ill-nesses that may be related to the exposure

OSHA As denned by OSHA, an exposure incident is a specific eye, mouth, other mu-cous membrane, non-intact skin or parenteral contact with blood or other po-tentially infectious materials (OPIM) which results from the performance of a worker's duties.

An example of an exposure incident is a needle stick.






PATIENT MANAGEMENT

OSHA Unless the employer can establish that identification of the source individual is infeasible or prohibited by state or local law, following an exposure inci-dent — the source individual must be identified and the HBV and HIV status must be determined.

If the source individual does not consent, the employer must establish that legally required consent cannot be obtained.






PATIENT MANAGEMENT

In 1996, Universal Precautions were revised and r<

• mandatory precautions

• hazard precautions

• standard precautions

• OSHA precautions

snamed:

copyrightO2013-2014

OSHA

63 - Dental Decks

PATIENT MANAGEMENT

OSHA According to the CDC, which of the following are common infection control violations observed in the dental office:

improper disposal of biohazardous waste

• improper biological monitoring of sterilizer

• improper disposal of sharps

• improper hand hygiene

• improper storage of dental instruments

• improper flushing of dental water lines

• improper disinfection of environmental surfaces

«improper instrument debridement copyright © 2013-2014 - Dental Decks

PATIENT MANAGEMENT

• standard precautions

Standard Precautions • the practice of considering that all blood & body fluids might be con-taminated with blood and should be treated as infectious • all patients must be treated with the same infection control procedures because patients with bloodborne in-fections can be asymptomatic or un-aware they are infected • standard precautions must be used for all patient encounters • standard precautions apply to con-tact with 1) blood; 2) all body fluids, secretions, and excretions (except sweat), regardless of whether they con-tain blood; 3) non-intact skin; and 4) mucous membranes

• although the OSHA Bloodborne Pathogens Standard still uses the term universal precautions — in 1996 the CDC expanded the concept of universal precautions and changed the term to standard precautions • elements of standard precautions

- hand washing - using PPE - proper handling of contaminated items

- cleaning & disinfecting of surfaces - using engineering & work practice

controls - using appropriate respiratory hyg-

iene/cough etiquette - using safe injection practices

• although standard precautions apply to all patient encounters, the application of standard precautions during pa-tient care is determined by the task being performed & the anticipated exposure to pathogens

• improper disposal of biohazardous waste • improper biological monitoring of sterilizer • improper disposal of sharps • improper hand hygiene • improper storage of dental instruments • improper flushing of dental water lines • improper disinfection of environmental surfaces • improper instrument debridement

Common Violations Observed in Dental Offices

• improper disposal of biohazardous waste • improper biological monitoring of sterilizer • improper disposal of sharps • improper hand hygiene • improper storage of dental instru-ments • improper flushing of dental water lines • improper disinfection of surfaces • improper instrument debridement •lack of PPE • lack of written exposure control plan • failure to sterilize handpieces

• lack of written protocol for instrument processing & sterilization • lack of verification of employee hepa-titis B vaccination • inability to verify instrument steriliza-tion • repeated use of single use disposables • cross contamination of surfaces • failure to use surgical gloves when providing surgical services • failure to use utility gloves when han-dling contaminated items in sterilization area • failure to separate contaminated areas from non-contaminated areas in the sterilization area

OSHA Identify each one of the following that is a true statement concerning the use of a face mask in the dental setting:

• a new mask should be used for each patient

• a mask should have a 95% filter efficiency for small particle aerosols

• a mask is required when spatter of blood or body fluids is likely

• a mask is used to protect nose & mouth from spatter

• a mask that is damp is still effective as a barrier


PATIENT MANAGEMENT

OPIM stands for.

OSHA

- other possibly irritating materials

• only potential infectious matter

• only potently infectious matter

• other potentially infectious materials


• a new mask should be used for each patient • a mask should have a 95% filter efficiency for small particle aerosols • a mask is required when spatter of blood or body fluids is likely • a mask is used to protect nose & mouth from spatter

Surgical mask • the function is to protect the wearer from large droplets or spatter that may contact mu-cous membranes of nose, lip & mouth • face masks also protect the patient from health-care worker oral or nasal respiratory secretions • masks should fit the face well, creating a light seal over the nose and mouth • because they only cover the nose and mouth, face masks should always be worn with pro-tective eyewear • change the face mask between patients, and sooner if it becomes moist

Wet masks • condensation from the wearer's breath adds moisture to the mask material • when wet, resistance to the airflow through the mask increases which causes more air to pass through & around the edges of the mask, weakening the seal between mask & face • wet masks also may collapse against the skin; direct contamination quickly results, making the mask an ineffective protective bar-

Tips on Choosing a Mask • filtration - must meet the requirements for bacterial filtration efficiencyfXFi?,)

-look for 95% BFE • comfort & fit - coverage of both nose & chin - comfortable nosepiece that easily conforms

& stays in place - snug fit over nose helps eliminate fogging of protective eyewear

- earloop bands, ties, or elastic backs that provide a close fit yet do not pull or apply pressure

- comfort & fit with protective eyewear in place

- mask design & quality of construction • breathability

- good airflow reduces moisture build-up within the mask

• cost-effectiveness - consider overall value in terms of comfort,

fit, quality, and protection

• other potentially infectious materials

Other Potentially Infectious Materials (OPIM)

• is a term used by OSHA • includes human body fluids - semen, vaginal secretions, cerebro-

spinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid

- saliva in dental procedures - any body fluid that is visibly cont-

aminated with blood - all body fluids in situations where it

is difficult or impossible to differ-entiate between body fluids

• includes any unfixed tissue or organ (other than intact skin) from a human (living or dead)

• includes HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions • includes blood, organs, or other tis-sues from experimental animals in-fected with HIV or HBV • includes blood and tissues of experi-mental animals infected with blood-borne pathogens • includes any pathogenic microorgan-ism • includes human cell lines

OSHA Documents that contain information concerning hazardous chemicals are called

•MDDS

•MSSD

'MSDS

'MDSD


OSHA Material Safety Data Sheets (MSDS) must be readily available to employees for all potentially hazardous chemicals used in the dental practice.

Identify each one of the following that is found on the MSDS:

• fire & explosion data

• hazardous ingredients

• dental office contact information

• chemical & common names

• protection information

• reactivity data


PATIENT MANAGEMENT

Material Safety Data Sheets-^** • are an important component of prod-uct & workplace safety • intended to provide employees & emergency personnel with procedures for handling a substance in a safe manner • includes information such as jShysical data (melting-point, boiling point, flash pointyetc.), toxicity,Walth effects, Yfrst aid, reactivitystorage, disposal, prot-ective equipment &„spill-handling procedures • MSDS formats can vary from source to source within a country depending on national requirements • OSHA requires that MSDS be read-ily available to employees for all pot-entially harmful substances handled in the workplace under the Hazard Communication Standard

•MSDS

• MSDS should be obtained directly from the manufacturer or product distributor; to obtain the MSDS you may contact the manufacturer or dist-ributor directly or online • OSHA does not require that MSDS be provided to purchasers of household con-sumer products when the products are used in the workplace in the same manner that a consumer would use them (for example — Windex or White Out); this exemption in OSHA's regula-tion is based, however, not upon the chemical manufacturer's intended use of his product, but upon how it actually is used in the workplace • employees who are required to work with hazardous chemicals in a manner that results in a duration and frequency of exposure greater than what a normal consumer would experience have a right to know about the properties of those hazardous chemicals • the American Dental Association of-fers MSDS information, resources, and materials including manuals

Material Safety Data Sheets include the following information:

• product identification - product name

commercial or marketing name - synonym

approved chemical name or synonym

- chemical family group of chemicals with related physical and chemical properties formula chemical formula, if applicable

• hazardous ingredients • physical data - boiling point, vapor pressure, etc.

• fire and explosion hazard data

• fire & explosion data • hazardous ingredients • chemical & common names • protection information • reactivity data

• health hazard data • reactivity data • spill, leak & disposal procedures • protection info • handling & storage precautions • emergency & first aid procedures • date of MSDS preparation • name & address of manufacturer

OSHA Which one of the following is regulated by OSHA?

•all sharps

•contaminated sharps

• non-contaminated sharps

none of the above


OSHA Identify each one of the following that is a true statement concerning sharps containers.

• must be puncture-resistant

• must have sides & bottom that are leak proof

• must be labeled or color-coded as hazardous

• must be a reusable containers

• must beclosable

• must be kept upright

• must be replaced routinely and not be overfilled


PATIENT MANAGEMENT

contaminated sharps

Sharps • objects that can penetrate a worker's skin • includes, but not limited to — needles, scalpels, broken glass, capillary tubes & the exposed ends of dental wires • if blood or OPIM are present or may be present on the sharp, it is a contamin-ated sharp & PPE must be worn • a contaminated sharp can result in an employee being infected with HIV, HBV, HCV or other bloodborne pathogens • careful handling of contaminated sharps can prevent injury & reduce risk of inf-ection • employers must ensure that contami-nated sharps are disposed of in sharps disposal containers immediately or as soon as feasible after use • sharps disposal containers must be readily accessible & located as close as feasible to the area where sharps are used • contaminated sharps must never be sheared or broken

• recapping, bending, or removing needles is permissible only if there is no feasible al-ternative or if such actions are required for a specific medical or dental procedure • if recapping, bending, or removal is necessary, employers must ensure that workers use either a mechanical device or a one-handed technique; the cap must not be held in one hand while guiding the sharp into it or placing it over the sharp • «»fiwAaaiteLII^ uses the needle itself to pick up the cap, and then the cap is pushed against a hard surface to en-sure a tight fit onto the device; the cap may be held with tongs or forceps and placed over the needle • contaminated broken glass must not be picked up by hand, but must be cleaned up using mechanical means, such as a brush and dust pan, tongs or forceps

• must be puncture-resistant • must have sides & bottom that are leak proof • must be labeled or color-coded as hazardous • must be closable • must be kept upright • must be replaced routinely and not be overfilled

Sharps containers • must be puncture-resistant • sides and the bottom must be leakproof • must be labeled or color-coded red to warn that the contents are hazardous • must be closable • must be kept upright to keep the sharps & any liquids from spilling out • must be replaced routinely & not overfilled • disposal containers that are reusable must not be opened, emptied, or cleaned manually or in any other man-ner that would expose workers to the risk of injury

Handling containers • employers must ensure that reusable sharps that are contaminated are not stored in a manner that requires workers to reach by hand into the containers where these sharps have been placed • before sharps disposal containers are re-moved or replaced, they must be closed to prevent spilling the contents • if there is a chance of leakage from the disposal container, the employer must en-sure that it is placed in a secondary con-tainer that is closable, appropriately labeled or color-coded red, and con-structed to contain all contents and pre-vent leakage during handling, storage, transport or shipping

OSHA Engineering controls are controls that are intended to isolate or remove haz-ards in the workplace.

Work place controls are controls that are intended to reduce the likelihood of exposure by altering the manner in which a task is performed.






PATIENT MANAGEMENT

OSHA For each employee whose job involves occupational exposure to blood and OPIM, what must be maintained in the employee medical record by the den-tist employer?

• occupational exposure/incident records

• test results pertaining to exposure incident

• hepatitis B vaccine record


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Percutaneous Injuries (Pis) • Pis pose the single greatest risk of transmission of a bloodborne infection to a dental healthcare worker • result from injuries by contaminated needles, burs, scalpels, broken glass, ex-posed ends of dental wires or other sharps that penetrate or break skin • prevention of Pis is influenced by equipment design and technology as well as worker knowledge, training & skill • action strategies to prevent Pis in-clude the use of appropriataladministra-tive controls,\ehgineering controls and

^jyork practice controls

lAdmJni j tojdYfi jCo^^^^ • safety rules implemented by the em-ployer to help assure a safe work envi-ronment • examples include written programs, exposure control plan, education and training, as well as task-specific Stan-dard Operating Procedures designed to minimize exposure

ngineering Controlsf/jC • technology-based ^ • used to remove or isolate hazards in the workplace • examples include rubber dams (mini-mize exposure to oral fluids by creating a dry field), needle recappers (place con-taminated ends of the needles away from DHCW hands) and sharps containers (isolate & contain contaminated sharps in a puncture-resistant receptacle)

\ Work Practice Controls"! • behavior-based • subject to human error & non-compli-ance • used to change or alter a task or pro-cedure in order to reduce the likeli-hood of an exposure • greatly influences the success of other control measures • example is using the one-handed scoop technique to recap dental needles & prohibiting the recapping of needles by a two-handed technique


Employee Medical Records • the employer must maintain a med-ical record for each employee whose iob involves occupational exposure to blood or OPIM • the employee medical record must include:

- hepatitis B vaccine documentation - details concerning exposure incid-

ents - medical evaluations & opinions (re-

garding exposure incidents) - test results (regarding exposure in-

cidents) • each employee is entitled to review his or her own medical record

Maintaining Employee Medical Records • medical records must be maintained for the duration of the employment plus 30 years • the record must be kept confidential

Transferring Employee Medical Records

• when selling a dental practice, the em-ployee medical records must be trans-ferred to the new owner • in cases where there is no new owner of the dental practice, you must notify the director of NIOSH (National Insti-tute for Occupational Safety & Health) at least 3 months prior to closing the dental practice and offer to transmit/transfer the employee records to NIOSH

OSHA Per the current CDC guidelines, dental unit water lines should be flushed at the beginning of the day for how long?

• 30 seconds

• 45 seconds

• 60 seconds




OSHA Per OSHA guidelines, what is the minimum amount of time required for em-ployers to keep employee training records?

• 2 years

• 3 years

• 5 years

• 7 years


PATIENT MANAGEMENT

• 30 seconds

Flushing of Dental Unit Water Lines • flush water lines at the beginning of the day for 30 seconds (may tem-porarily reduce the level of microbes in the water) • flush air/water through handpieces for 20-30 seconds after each patient (helps reduce any patient-borne mi-crobes that may have entered the handpiece and were "sucked back" down the dental unit line)

Dental Unit Water Lines • obtain & follow the dental unit manu-facturer's recommendations for treating dental unit waterlines • if recommended by manufacturer, in-stall & maintain antiretraction valves to prevent oral fluids from being drawn into dental waterlines • avoid heating dental unit water; warming the water may amplify biofilm formation • consider using a separate water reser-voir system to eliminate the inflow of municipal water into the dental unit • use sterile solutions for surgical irri-gations • educate & train oral healthcare work-ers on effective treatment measures • monitor scientific & technological de-velopments to identify improved ap-proaches as they become available • ensure that any sterile water system or device marketed to improve dental water quality has FDA approval

• 3 years

Employee Training Records • training records are completed for each employee upon completion of training • documents must be kept for at least three years • training records include:

- the dates of the training sessions - the contents or a summary of the training sessions - the names and qualifications of persons conducting the training - the names and job titles of all persons attending the training sessions

• employee training records are provided upon request to the employee or the em-ployee's authorized representative

OSHA Per OSHA guidelines, what is the minimum amount of time required for em-ployers to keep a sharps injury log?

• 2 years

• 3 years

• 5 years

• 7 years

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PATIENT MANAGEMENT copyright © 2013-2014 - Dental Decks

OSHA Per OSHA guidelines, no employee in the dental practice may decline the hep-atitis B vaccination.

The hepatitis B vaccination is non-infectious and there is no risk of develop-ing HBV from the vaccine.






PATIENT MANAGEMENT

• 5 years

Sharps Injury Log • all percutaneous injuries resulting from contaminated sharps must be recorded in a Sharps Injury Log • all incidences must include at least:

- date of the injury - type and brand of the device involved (syringe, suture needle) - department or work area where the incident occurred - explanation of how the incident occurred

• this log must be reviewed as part of the annual program evaluation • must be maintained for at least five years following the end of the calendar year covered • if a copy is requested by anyone, any personal identifiers must be removed from the report


Declining the Hepatitis B Vaccine • any employee may decline the hep-atitis B vaccine • employers must ensure that workers who decline the vaccination sign a dec-lination form • the purpose of the form is to encour-age greater participation in the vac-cination program by stating that a worker declining the vaccination re-mains at risk of acquiring hepatitis B infection • the form also states that if a worker initially declines to receive the vaccine, but at a later date decides to accept it, the employer is required to make it available, at no cost, provided the worker is still occupationally ex-posed

Statement for Declination Form / understand that due to my occupa-tional exposure to blood or other po-tentially infectious materials that I may be at risk of acquiring hepatitis B virus (HBV) infection.

I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time.

I understand that by declining this vac-cine, I continue to be at risk of acquir-ing hepatitis B, a serious disease. If in the future I continue to have occupa-tional exposure to blood or other po-tentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

employee signature date

PH Identify which one of the following is the organization that maintains records on all diseases that occur in the United States.

• CDC (Centers for Disease Control & Prevention)

• OSHA (Occupational Safety & Health Administration)

> FDA (Food & Drug Administration)

• EPA (Environmental Protection Agency)

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PATIENT MANAGEMENT

PH

Identify which one of the following is the test result that erroneously assigns ndividual to a specific diagnostic or reference group, due to insufficient

an exact methods of testing

• a false negative test

• a true negative test

• a false positive test

• a true positive test

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• CDC (Centers for Disease Control & Prevention)

1DHHS| "Department of Health & Human Services • principal agency of U.S. government for pro-tecting the health of Americans • provides essential human services • involved with the delivery, funding and re-search aspects of oral health

-enters for Disease Control & Prevention • 1 of 13 major components of the DHHS • monitors & maintains records of all diseases found in U.S. & develops recommendations to protect the health of the population • formulates health care worker guidelines & recommendations for prevention of infectious diseases

F D A ^ 1 promotes & protects public health by helping safe & effective products reach the market in a timely way • monitors products for continued safety after in use • provides public with accurate, science-based info needed to improve health

EcFl Administration for Children & Families • responsible for federal programs that promote the economic & social well-being of families, children, individuals & communities • responsible for the Head Start program

CMS, -enters for Medicare & Medicaid Services

• administers Medicare & Medicaid programs that provide health services to roughly 25% of Americans

, HRSA i ""Health Resources & Services Administration

• provides access to essential health care serv-ices for people who are low-income, uninsured or who live in rural or urban areas where health care is limited

IHS Thdian Health Service

• focuses on raising the health status of Native Americans & Native Alaskans

ml National Institutes of Health • premier medical r^sjjarch organization • NIDCR (National Institute of Dental & Craniofacial Research) is part of NIH

^ M M M M I ...

IAHRQ AHRQJ Agency for Healthcare Research & Quality • supports research on health care systems, health care quality and cost issues • supports research on access to health care, & effectiveness of medical treatments

a false positive test

Types of errors • a false positive result means that the test indicates presence of the disease when it is absenT"*

Categories of tested individuals • true positives those who test positive for a condition and are positive (have the condition)

• false negative result means that the test indicates absence of the disease when it is present

• false positives those who test positive for a condition but are negative (do not have condi-tion)

• true negatives those who test negative and are nega-tive

• false negatives those who test negative but are positive

PH Identify which one of the following is defined as the percent of persons with-out the disease who are correctly classified as not having the disease:

• specificity

• sensitivity

• reliability

•validity

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PATIENT MANAGEMENT

PH

Identify which one of the following is defined as the measure of quality of care provided in a particular setting:

• quality assurance

• quality control

• quality assessment

• quality inspection

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' specificity

Definitions Validity

• refers to whether questions asked by the study are answered by the method • a valid test is sensitive, specific & unbiased

Reliability • is the repeatability & reproducibility of test • produces very similar results when used to measure a variable at different times

Sensitivity • percent of persons with the disease who are correctly classified asliaving the disease

- true positive (IP) those who have the dis-ease - false negative (FN) those who incorrectly are classified as not having the disease

Specificity • percent of persons without the disease who are correctly classified as not having disease

- true negative (TN) those who do not have the disease - false positive (FP) those who have the dis-ease but not identified by the test

Inferential statistics • used to make claims about the populations that give rise to the data collected • allow generalizations to be made from sample data to a larger group

p value • is a probability • answer calculated by a statistical test of a hy-pothesis (HQ or null hypothesis) • its magnitude informs the researcher as to the validity of the hypothesis

< .05 (5%), reject the H0 results are statistically significant > .05 (5%), accept the HQ results are not statistically significant

Correlation/correlation coefficient (r) • quantifies relationship between variables (x andy)

Multiple regression ""•"provides a mathematical model of linear re-

lationship between a dependent & two or more independent or predictor variables

Chi-square • a test commonly used to compare observed data with data we would expect to obtain ac-cording to a specific hypothesis

T-test "^"used to analyze the statistical difference be-

tween two means

• quality assessment

Quality assessment • is limited to the appraisal of whether or not standards of quality have been met

Quality assurance • includes the action to take the necessary corrective steps to improve the situation in the future • is the measurement of the quality of care PLUS the implementation of any neces-sary changes to either maintain or improve the quality of care rendered

Quality assurance concepts • structure refers to the layout and equipment of a facility • process involves the actual services that the dentist and assistant perform for the patients & how well they perform • outcome is the change in health status that occurs as a result of the care delivered

Informed consent • in the informed consent process for den-tal treatment, legally there are three com-ponents that must be addressed: %^-explanation of a procedure

so that a competent adult understands êxplanation & assessment

of risks & benefits of the procedure, or the consequences if no procedure is per-formed

Vc discussion of alternative choices • the interaction between dentist and pa-tient is the foundation of informed consent, not the written word • obtaining informed consent should be viewed as good dental practice • there is a moral duty not to act against a patient's will; a patient should not be co-erced into, unduly influenced to, receive in-ducements to or be intimidated into having a procedure

PH Identify which TWO of the following indices were developed in an attempt to provide a standardized method of measuring periodontal disease, and, are criticized because they combine gingivitis and periodontitis measures into a common score?

• PDi (periodontal disease index)

• OHI-S (simplified oral hygiene index)

• PI (periodontal index)

< Gl (gingival index)


PATIENT MANAGEMENT

PH If the major purpose of an epidemiologist's study is to determine caries sus-ceptibility instead of immediate treatment needs, the best caries index to use is:

• TSIF

• PSR

. DMFT

. CPITN

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PATIENT MANAGEMENT

r

• PDI (periodontal disease index) • PI (periodontal index)

s=&iH-:,fo;SBi.^&e,-'.,-jH;0L^,

PI & PDI • neither is considered the best method to measure periodontal disease • both developed in an attempt to provide a standardized method of measuring periodon-tal disease among groups of people in epi-demiologic studies • both combine gingivitis & periodontitis into a single tooth score or average score for the individual or group

El • identifies two levels of gingivitis based on extent and two levels of periodontitis based on severity of destruction • total score is achieved by averaging the in-dividual tooth scores

fPDlf • a modification of PI • distinguishes three levels of gingivitis based on the extent of the inflammation & sever-ity of the inflammation • quantitatively measures periodontitis by loss of attachment with a periodontal probe & defines degrees of periodontitis severity based on the amount of attachment lost • total score is achieved by averaging the in-dividual tooth scores

j Gingival index (GIj • introduced in 1960's by Loe & Sillness • only measures gingival inflammation • widely accepted index for gingivitis • allows for clear distinction between thejoca-tion/quantity of gingivitis & the severity/ quality of gingivitis • applies a four-category qualitative assess-ment (normal, mild, moderate or severe in-flammation) to four sites (mesial, distal, buccal and lingual surfaces) on each examined tooth • each area is scored on a 0 to 3 ordinal scale; values can then be averaged to yield a score for an individual

Other Indices • P-M-A(Papillary-Marginal-Attached) meas-urements confined to within gingiva • Plaque Index (PI) to determine plaque accumulation • Sulcus Bleeding Index (SBI) to determine bleeding & gingival health • OHI & OHI-S are debris indices • DMFS & DMFT are caries indices

DMFT

DMFT • way to define dental caries in a population • measures either the number of teeth (DMFT) or the number of tooth surfaces (DMFS) that are decayed, missing or filled due to caries • with the permanent dentition, acronyms DMFT and DMFS are used • with the primary dentition, acronyms deft and defs are used, with e referring to a tooth that is indicated for extraction • is an irreversible index • results of this index indicate a group's caries susceptibility • widely accepted & best known dental index

DMFT Limitations • values are not related to the number of teeth at risk • index can be invalid in older adults be-cause teeth can become lost for reasons other than caries • index can be misleading in children whose teeth have been extracted for orthodontic rea-sons • cannot be used for root caries • cannot account for sealed teeth

Dental Caries • caries prevalence in U.S. declined substan-tially in the 1970s & 1980s due to fluorida-tion, the use of fluorides and other preventive measures • in the 1970's, the mean DMFS for U.S. chil-dren ages 5 to 17 was 7.1; in the latel980's the value dropped to 2.5 (a 65% reduction) • the proportion of DMFS that is either un-treated caries or missing surfaces also dra-matically decreased during this period • baby bottle tooth decay affects approxi-mately 5% of U.S. infants; ethnic minority & low socioeconomic children are at the great-est risk • coronal caries prevalence has declined among U.S. adults under age 45 • nearly all dentate U.S. adults have at least one decayed or filled tooth

PH According to the plaque index (PI) of Sillness & Loe, tooth #14 would have what PI score?

•1.0

•1.5

•2.0

2.5

Tooth #14

surface

buccal

lingual

mesial

distal

scores

2 1

2

3

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PATIENT MANAGEMENT

PH Identify which one of the following describes the gingival index (Gl):

reversible index

irreversible index


PATIENT MANAGEMENT

2.0

Plaque Index for tooth #14: • 2 + 1 + 2 + 3 / 4 = 2.

Plaque Index (PI) • developed by Sillness & Loe to be used with the Gingival Index (GI) • same surfaces of same teeth are scored as in the GI and a 0 to 3 scale is used • used extensively;not universally ac-cepted • PI scores the plaque present according to thickness at the gingival margin rather than its coronal extent as seen with the OHI-S

Scores

0

1

2

3

Criteria for Plaque Index

no plaque

film of plaque adhering to free gingival margin & adjacent area of tooth; plaque may be seen only after application of disclosing solution or by running a probe across tooth surface.

moderate accumulation of soft deposits within the gingival pocket and/or on the tooth & gingival margin which can be seen with the naked eye.

abundance of soft matter within the gingival pocket and/or on the tooth & gingival margin.

Periodontal Disease • some studies suggest 80-90% of chil-dren have inflammatory periodontal disease (gingivitis or periodontitis) by age of 15 • localized acute gingivitis is the most common form • studies show the strongest relation-ship between prevalence & severity of periodontal disease is with oral hy-siene & age

.. , . . . -a . ,V ' ^ ' - i ' " ; ^ ' : " ; ' •

reversible index

Dental Index • a data collection instrument • numerically expresses the oral health status of a population • may be reversible or irreversible

- irreversible index measures conditions that cannot be reversed; example is dental caries - reversible index measures conditions that can be changed; examples are plaque & bleed-ing

Common Indices •DMFT

- decayed-missing-filled teeth index - irreversible index - determines total dental caries experience, past

and present - only used on permanent teeth - almost universally accepted - best known of all dental indices

•GI - gingival index - reversible index - measures inflammation of the gingiva - distinguishes between location/quantity of

gingivitis and the seventy/quality of the gin-givitis

• P-M-A - papillary-marginal-attached - oldest reversible index - precursor to the GI

Common Indices (continued) •PI

- periodontal index - reversible index - combines gingivitis & periodontitis into a

single tooth score or average score for the individual or group

•PDI - periodontal disease index - reversible index - combines gingivitis & perodontitis into a

single tooth score or average score for the individual or group

O J ' C P I T N v - community periodontal index of treatment

% d s ' ' - — - reversible index - provides conclusions about the incidence of

periodontitis in a population, as well as treatment needs

• OHI-S - simplified oral hygiene index - reversible index - used to measure OH status by using a debris

index & calculus index; both are combined for a single score

• Pi/plaque index - reversible index - used to assess thickness of plaque at the

gingival margin

PH Identify which one of the following is a system where a provider of coverage contracts to pay for some of the patient's dental treatment:

• first-party dentistry

• second-party dentistry

• third-party dentistry

• fourth-party dentistry

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PATIENT MANAGEMENT

PH The major objective of public health programs is:

• prevention

• cost efficiency

• teamwork


86 copyright £> 2013-2014 - Dental Decks

' third-party dentistry

Third-Party Reimbursement • usual, customary & reasonable (UCR) fee

- reimbursement based on the dentist's usual charge, unless the charge exceeds certain pa-rameters - in order to determine UCR fees, a dentist must become a participating provider with a plan & agree to file fees periodically

• Table of allowances - a third-party payer determines what fees it will pay for each procedure - a participating dentist agrees to charge plan members these pre-negotiated fees as pay-ment in full

• Fee schedules - a list of fees established by a dentist for de-livery of specific dental services - fee schedule usually presents payment in full, whereas table of allowances may not - example is Medicaid • Reduced fee for service - commonly associated with Preferred Provider Organization (PPO) plans - participating dentist agrees to provide care for fees usually lower than other dentists in a particular geographic area

• Capitation - dentist is paid a fixed amount, usually on a monthly basis, directly by the capitation plan - for this fixed payment, the dentist agrees to provide specified dental services for patients who present and who are assigned to the practice by the capitation plan

Panel of providers • closed panel - dental services provided by salaried dentists at specified locations only • open panel - dental services provided by any dentist willing to accept third party pay-ment

Fee-for-service • dentistry is financed mainly through fee-for-service self-pay • 56% of all dental expenses are paid out-of- pocket by the patient • third-party payers represented by private insurance pay approximately 33% of total dental expenses, followed by government-financed or public programs (Medicaid, Veterans Affairs)

prevention

Prevention •is major objective of PH programs • more ethical to prevent disease than cure it • teamwork is necessary to handle large groups efficiently • cost efficiency plays a major role because prevention is cheaper than a cure • may be primary, secondary or tertiary

- primary prevention is preventing disease before it occurs; is the most effective way to improve health & control costs; examples include water fluoridation & sealants - secondary prevention is controlling the disease after it occurs; example is placing an amalgam restoration - tertiary prevention is limiting a disability from disease, or rehabilitating an individual with disability; example is providing den-tures

Education • plays an important role in public health • it decreases need for government interven-tion; when people learn why regulations are of value they comply

Fluoridation of community water • single most effective & efficient way to pre-vent dental caries regardless of age, race or in-come • defined as adjusting fluoride concentration in community water for optimal oral health • recommended level ranges from 0.7 to 1.2 ppm of fluoride depending on the mean max-imum daily air temperature over a 5-year pe-riod • most communities are fluoridated at 1 ppm = 1.0 mg fluoride / liter of water • at this level fluoridated water is odorless, col-orless and tasteless

CJ>effectiveness of community water fluorida-"Vtion is 20% to 40%

Fluoridation of school water • developed & tested in 1960 's for use in rural schools with an independent water supply • recommended concentration for school water fluoridation is 4.5 times the fluoride concen-tration for community water • higher concentrations needed to compensate for part-time exposure because children spend limited time at school • caries is reduced 20% to 30% when children consume fluoridated water at school tor 12 years

PH Fluoride supplements are available by prescription only.

Fluoride mouth rinses are the most popular school-based fluoride regimen in the United States.





PATIENT MANAGEMENT

In regards to reporting child abuse, a dentist is:

• morally obligated to report suspected cases

• ethically obligated to report suspected cases

• legally obligated to report suspected cases


87 copyright e 2013-2014 - Dental Decks

PH

PATIENT MANAGEMENT


r

Topical Fluoride • the application of topical fluoride to teeth in-creases tooth resistance to caries • fluoride can be delivered either brushed on as a varnish or in a tray as a gel • fluoride varnish

- a vehicle for holding fluoride in close contact with tooth for a period of time - way to use high fluoride concentrations in small amounts of material - useful to prevent root surface caries in older adults with gingival recession - useful in patients with disabilities

Fluoride Supplements • available by prescription only • intended for use by children living in non-flu-oridated areas; daily supplements should be used from 6 months to 16 years • tablets

- chew for 30 seconds, swish for 30 seconds, then swallow - provides systemic & topical benefits - studies show a 30% reduction in caries with daily use of fluoride tablets on school days

• mouth rinse - most popular school-based regimen - studies show 25%-28% reduction in caries by rinsing daily or weekly in school with dilute so-lutions of fluoride

, -rinsing weekly with 0.2% neutral sodium flu-^-y/oride-fjVaF) is more" common than using a

0.05% NaF solution

• both statements are true Office-Based Methods

• sealants - most decay in children occurs on the chewing surfaces - use of fluorides & pit and fissure sealants is needed to prevent caries - effectiveness of dental sealants has been re-ported as 51% to 67%

• fluoride gels - most common fluoride used is acidulated phosphate fluoride (APF) -APF has apH of about 3.0 - most common concentration is 1.23%, usually as,Msl£ in orthophosphoric acid

Home-Based Methods • brushing

- use a fluoride toothpaste - use a pea-sized amount of toothpaste - brush 2 times per day

• fluoride gels - contain stannous fluoride (0.4%) or sodium fluoride (1.0%) - formulated in a nonaqueous gel base without abrasives - gel should remain in the mouth for 4 minutes and then spit out

Repor t ing Child Abuse • a dentist is morally, ethically and legally ob-l igated to report a suspected case of child abuse • from ADA Principles of Ethics and Code of Profess ional C o n d u c t "dentists shall be obliged to become familiar with the signs of abuse and neglect and to report suspected cases to the proper authorities, consistent with state laws" (Section i.e. Abuse and Neglect) • once an injury of a suspicious nature is ob-served, the dentist 's f irst and immediate re-sponsibility is the protection of the child • child abuse most commonly involves new-boms and children up to age three • physical indicators

- fractured teeth - oral lacerations - fractures of the jaw - braising of the face

• behaviora l indicators - watchfulness and tearfulness - sullen and withdrawn demeanor - cowering at adult displeasure - extreme anxiousness or nervousness - excessive need to please - aggressive or out of control behavior

• all of the above M a n d a t o r y Repor t ing

• dentists are obligated to be well versed in the mandatory reporting procedures in the state in which they practice • each state has its own guidelines that must be followed when reporting cases of suspected abuse • in all states, however, it is standard that once abuse is suspected against a child, elderly or disabled patient, it mus t be re-ported to the appropriate agency • dentists must identify the appropriate agencies within their state in which they practice and ensure that this information is readily available should the need arise

a dentist is ethically obligated to iden-tify and refer cases of domestic violence • a dentist must be familiar with the phys-ical signs of domestic violence • domestic violence injuries

- 6 8 % involve the face - 4 5 % involve the eyes - 12% involve the neck

r PH

Identify which one of the following describes the proportion of existing cases of disease in a population at one point in time, or, during a specified time:

• incidence

• prevalence

•epidemiology

•frequency


Random assignment and blinding are methods hance study validity and

• increase bias

• decrease bias

• have no change on bias


used

PH in clinical trials to en-


PATIENT MANAGEMENT

Prevalence V ^ • is the proportion of a population with a problem at a desigriafed'time *'** • it depends on both the incidence and the duration of the problem • prevalence is more relevant than incidence when assessing the impact of a problem within a community & to assess the needs • expressed as percentage of the population

Incidence ""•^ferCumulative incidence

• is the number of new cases of a disease that occurs in a population at risk of the disease during a specific time period • expressed as a rate

Frequency • is a count

Epidemiology • study of the distribution & cause of disease • groups are studied to answer questions about etiology of diseases, prevention, disease pat-terns & allocation of resources • communicable disease is one that is trans-mitted from one to another • non-communicable disease is one that is not transmitted from one to another; usually caused by one's own normal flora or an envi-ronmental reservoir

• prevalence

Oral Cancer • most oral & pharyngeal cancers are squa-mous cell carcinoma (SCC) • SCC is twice as common in males as in fe-males ^ / f r • SCC causes nearly twice as many deaths in males as in females • SCC is closely related to advancecrage, alco-hol consumption and'smoking • SCC of the lip and oral cavity account for 2/3 of all new oral & pharyngeal cancers • the tongue is the most common site of can-cers of the oral cavity • survival rates vary depending on the cancer site, gender and race

. (l>*-year survival rate for oral & pharyngeal cancers is about 50% • 5-year survival rates for cancer of the lip are about 90%; of the tongue it is about half that • erythroplakia, rather than leukoplakia, may be the first sign of cancerous change in a le-sion

• decrease bias

Definitions

Randomized study • all subjects have an equal chance of being assigned to either study or con-trol group • researchers prefer the random as-signment method for placing subjects into either the study or control group because, any uncontrolled variables in-fluencing the outcome are likely to af-fect subjects in both groups equally

:• . • '.••» Blind study

• subjects are unaware of whether they are in a test or control group; one way to achieve a blinded study is with the use of placebos

•^0i^m^&tis^^^î^^< Double blind study

• neither participants nor examiners know the group allocations (test or control groups)

Randomized & blinded study • when a study is both randomized & blinded, subjects have no say in their choice of experimental treatment nor do they have information about what experimental treatment they are receiv-ing

O^randomized & blinded studies require '^justification

Dependent variable • a variable whose value depends on those of others • in the formula x = 3y + z x is the dependent variable

Independent variable • variable whose value determines that of others • in the formula x = 3y + z y & z are the independent variables

PH The most important concept of public health as defined by C.E.A. Winslow is:

• to encourage mental and physical efficiency

• promotion of health through organized community effort

• individuals acting alone can solve any problem

• the science and art of preventing disease


PATIENT MANAGEMENT

As used in epidemiology, the term MORTALITY refers to:

• disease

• lifespan

• death

• birth

PH


PATIENT MANAGEMENT

• promotion of health through organized community effort

• definition - as defined by C.E.A. Winslow - the science & art of preventing dis-ease, prolonging life and promoting physical health and efficiency through organized community efforts

• principles of public health - a problem exists - solutions to the problem exist - the solutions to the problem are applied

• a public health problem must meet the following criteria:

- a condition or situation that is wide-spread and has an actual or potential cause of morbidity or mortality - there is a perception on the part of the public, government, or public health au-thorities that the condition is a public health problem

Dental Public Health

• definition - as defined by the American Board of Dental Public Health - the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts

• form of dental practice which serves the community as a patient rather than the individual

• is concerned with the dental health education of the public, with applied dental research, with administra-tion of group dental care programs as well as the prevention and control of dental disease on a community basis

Definitions • mortality (death rate) reflects the number of deaths caused by a specific disease; it is the ratio of the number of deaths caused by the disease to the total number of cases of the disease at a spe-cific time • morbidity (illness) is the incidence of a specific disease within a given population • natality is the birth rate; ratio of births to the general population • birth-death ratio (vital index) is the number of births in a given year di-vided by the number of deaths in a given year. It is an indication of the population growth, stability or reduc-tion • crude death rate is the ratio of the number of deaths occurring within a given time period and population to the total population during that time

• death

• attack rate is the proportional number of cases developing in the population that was exposed to the infectious agent • endemic is a disease or other occur-rence that is constantly present in a pop-ulation • epidemic is a disease or other occur-rence whose incidence is higher than ex-pected • index case is the first identified case of a disease in an outbreak or epidemic • outbreak is a cluster of cases occur-ring during a brief time interval and af-fecting a specific population; an out-may be the onset of an epidemic • pandemic is a worldwide epidemic • portal of entry is a surface or orifice through which a disease-causing agent enters the body • portal of exit is a surface or orifice from which a disease-causing agent exits and disseminates • reservoir is the natural habitat of a disease-causing organism

PH A method of payment for dental services in which the provider is paid a fixed amount without regard to the actual number or nature of services provided to each patient is called a:

• capitation fee

• fixed fee

• contractual fee

• managed fee


PATIENT MANAGEMENT

PH Identify which one of the following is NOT a fundamental principle defined in the American Dental Association Code of Professional Conduct:

• justice

• autonomy

• beneficence

• maleficence

• veracity


PATIENT MANAGEMENT

• capitation fee Dental Managed Care

• an arrangement whereby a third-party payer (insurance company, federal government or cor-poration) mediates between doctors & pa-tients, negotiating fees for services & oversees the types of treatment given • examples include D-HMO, D-PPO & D-IPA

D-HMO • Dental Health Maintenance Organization • plan most commonly associated with dental managed care • usually a self-contained staff model practice where no distinction is made between providers of insurance and providers of care • also called a capitation dental plan • participants are limited in dentist selection -%-'"!.e-.,.,-,'?„. •„•,!*.•,•• •.•••••• D-PPO & D-IPA

• Dental Preferred Provider Organization Dental Individual Practice Association • represent groups of doctors who practice in the community and are distinct from the insurance provider • an insurance agency contracts with the provid-ers for discounted rates and may refer patients to these providers exclusively • typically involve contracts between insurers and a number of dentists; patients can choose from list of dentists

Capitation Fee • payment to the dentist for these managed-care programs (D-HMO, D-PPO, D-IPA) is usually made on a capitation basis • capitation fee is usually a fixed monthly payment paid by a carrier to a dentist based on the number of patients assigned to the dentist for treatment • fee is the same regardless of how much or how little care is delivered

Delivery Model • staff model usually has one or more den-tal offices that use salaried staff dentists • network model uses multiple dental of-fices in various locations and is the most common method of delivering dental bene-fits in managed dental care • closed model (a.k.a. Exclusive Provider Organization) is where the patients have a limited choice of offices where they can go to obtain dental care

maleficence

ADA Code includes three main components

• The Principles of Ethics • The Code of Professional Conduct • The Advisory Opinions

ADA Code includes five fundamental principles

1. justice or "fairness" - the dentist has a duty to treat people fairly 2. autonomy or "self-governance" - the dentist has a duty to respect a patient's rights to self-determination and confi-dentiality 3. beneficeucj|,or^'do good" - the den-tist has the duty to be kind and to give the highest quality of care that one is capab-le of 4. nonmaleficence or "do no harm" -the dentist has a duty to refrain from harming the patient 5. veracity or "truthfulness" - the den-tisTlaTa'auô'communicate truthfully

The dental profession holds a special position of TRUST within society.

As a consequence, society affords the profession certain privileges, in return, the profession makes a commitment to society that its members will adhere to high ethical standards of conduct.

These standards are embodied in the ADA Principles of Ethics and Code of Professional Conduct.

The ADA CODE is a written expres-sion of the obligations arising from the implied contract between the dental profession and society.

Members of the ADA voluntarily agree to abide by the code as a condition of membership. They recognize that con-tinued public trust in the dental pro-fession is based on the commitment of individual dentists to high ethical stan-dards of conduct.

PH All of the following are true concerning the ADA (Americans with Disabilities Act) EXCEPT one. Which one is the EXCEPTION?

• a dentist cannot deny anyone care due to a disability

• dental offices must structurally allow access for the disabled

• a dentist cannot dismiss an employee due to a disability

• a person with HIV is not protected by the ADA


PATIENT MANAGEMENT

PH A descriptive epidemiological study helps to define the of disease in a population.

• cause

• cure

• extent

• mortality


PATIENT MANAGEMENT

• a person with HIV is not protected by the ADA

Americans with Disabilities Act (ADA) • signed into law in 1990 • applies to all private and state-run busi-nesses, employment agencies and unions with more than fifteen employees • gives federal civil rights protections to individuals with disabilities similar to those provided on the basis of race, color, sex, national origin, age and relig-ion • guarantees equal opportunity for indi-viduals with disabilities in public accom-modations, employment, transportation, state and local government services and telecommunications • public accommodations such as a doc-tor's office may not discriminate on the basis of disability • reasonable changes in policies, pract-ices, and procedures must be made to avoid discrimination

ADA Goal • to make sure that no qualified person with any kind of disability is turned down for a job or promotion, or re-fused entry to a public access area

Definition a person with a disability is legally defin-ed as anyone who:

• has a physical or mental impairment that substantially limits one or more major life activities • has a record of such an impairment is regarded as having such an impairment

ADA and HIV • persons with HIV disease, both symp-tomatic & asymptomatic, have physical impairments that substantially limit one or more major life activities and are pro-tected by the ADA • persons who are discriminated against because they are regarded as having HIV disease are also protected by the ADA • persons who are discriminated against because they have a known association or relationship with an individual who has HIV are also protected by the ADA

• extent

Epidemiological Studies can be organized into three categories

• descriptive epidemiology - used to quantify disease status in the community; major param-eters of interest are prevalence and incidence

- prevalence is the proportion of existing cases of a disease in a population at one point in time or during a specified period of time; expressed as percentage from 0 % -100%

Prevalence = # of people with disease total # of people at risk

- incidence is the number of new cases of a dis-ease that occur in a population at risk of the disease during a specified time period

Incidence = # of new cases of disease total # of people at risk

• analytical epidemiology - also called "obser-vational epidemiology", is used to assess the re-lationship between exposures and disease by observing exposure-disease associations as they naturally occur in the population under study; the three main types are as follows: cross-sec-tional study, case-control study and cohort study

- cross-sectional study - looks at both the ex-posure of interest & disease outcome at the same point in time - case-control study - identifies subjects on the basis of whether disease of interest is pres-ent and then, by a history, looks for association between the disease and one or more past ex-posures - cohort study - identifies subjects according to if they have a particular exposure of interest & then follows them over time to see if an as-sociation exists between exposure & develop-ment of disease

• experimental epidemiology - used in inter-vention studies'; once etiology is established, re-searchers determine effectiveness of a program of prevention; may be clinical or community tri-als

- clinical trials - conducted to test new pre-ventive or therapeutic agents, with subjects as-signed by the investigator to different treatment groups, usually by random assignment; well-designed clinical trials use a double-blind de-sign - community trials - in situations in which an intervention can be practically evaluated only at the community level, a community trial can be conducted; group as a whole is studied rather than the individuals in it

PH Identify which one of the following is the part of a published research study that includes the statement of intent, theory and hypothesis:

• abstract

• introduction & literature review

• methods

• results

• discussion

• summary & conclusion


PATIENT MANAGEMENT

PH Identify which one of the following is described as the presentation, organi-zation and summarization of data:

• inferential statistics

• descriptive statistics

• informative statistics

• reliability statistics


PATIENT MANAGEMENT

introduction & literature review

Format of a Research Study 1. Title

- topic and focus of study

2. Abstract - research focus - method - summary of results - concluding statement - key words

. Introduction & Literature review - importance - literature review - statement of intent, theory and hypothesis

4. Methods - sampling strategy - measurement strategies & instruments - experimental design - statistical analytical procedures

5. Results 6. Discussion

- review and summary of results - discussion of results - comparison to theoretic presentation or hypotheses

7. Summary & Conclusion 1. Bibliography & References

> descriptive statistics

Definitions • Jjiostatistics is the mathematics of collec-tion, organization, and interpretation of nu-meric data having to do with living organisms • statistics is the practice, study, or result of the application of mathematical functions to collections of data in order to summa-rize or extrapolate the data • statistics can be used to describe data and to make inferences from them • descriptive statistics is a way of summa-rizing data or letting" one number stand for a group of numbers; three ways we can sum-marize data:

- tabular representation of data - graphical representation of data - numerical representation of data

• inferential statistics allow someone to gen-eralize from the sample of data to a larger group of subjects • frequency distributions is a tabulation of values that one or more variables take m a sample • normal distribution is a random variation that conforms to a particular probability dis-tribution; is the most commonly observed probability distribution; the shape resembles a bell and is referred to as a "bell curve"

• skewed distribution is symmetrical with dispersion skewed to the left or right of the median; dispersion skewed to the right is said to be positive with the mean being greater than the mode and median • mean or average is the value obtained by adding all the measurements and dividing by the number of measurements • median is the middle measurement in a set of data where half the data is above and half the data is below the number • mode is the most frequent measurement in a set of data • range is the difference between the highest and lowest value in the distribution • variance & standard deviation measure variability within a distribution • standard deviation is a number that indi-cates how much on average each value in the distribution deviates from the mean of the dis-tribution • variance measures the same thing as stan-dard deviation (dispersion of scores in a dis-tribution); variance is the square of the standard deviation

The portion of covered dental care costs for which the covered financial responsibility, usually a fixed percentage

• copayment

• coinsurance

• deductible

• balance billing

is called:

PH person has a


PATIENT MANAGEMENT

• coinsurance Definitions

• deductible is the amount of eligible expenses a covered person or family must pay each year from his/her own pocket before the plan will make pay-ment for eligible expenses; on family policies, de-ductibles are typically per person and usually have a maximum of 2 or 3 family members that will need to meet the deductible • copayment is a cost-sharing arrangement in which an insured pays a specified charge for a spec-ified service, such as $25 for an office visit; the in-sured is usually responsible for payment at the time the service is rendered; if a plan has copayments on dental office visits, this charge typically does not count toward coinsurance and deductible payments because the service is covered before the deductible and coinsurance • coordination of benefits (COB) is a provision in ffie contract that applies when a person is covered under more than one dental plan; it requires that payment of benefits be coordinated by all plans to eliminate over-insurance or duplication of benefits • coinsurance is the portion of covered dental care costs for which the covered person has a financial responsibility, usually a fixed percentage; coinsur-ance usually applies after the insured meets his/her deductible • balance billing is the (usually) illegal practice of dental offices and other medical facilities billing pa-tients for the balance between what they want to charge their patients for services and what the in-surance company has already reimbursed them

• reasonable & customary (R & C) is a term used to refer to the commonly charged fees for dental services within a geographic area; a fee is generally considered to be reasonable if it falls within the pa-rameters of the commonly charged fee for the par-ticular service within that specific community • preferred provider organization (PPO) is a den-tal care delivery arrangement which offers access to participating providers at reduced costs; PPOs provide insured incentives, such as lower de-ductibles and copayments, to use providers in the network; network providers agree to negotiated fees in exchange for their preferred provider status • point-of-service plan (POS) is a dental insurance plan that offers members options for different de-livery systems such as DMO &, PPO • participating provider is a provider who has been contracted to render dental services to the in-sured at a pre-negotiated fee • out-of-network provider is a dental care provider with whom a managed care organization does not have a contract to provide dental care services; be-cause the beneficiary must pay either all of the costs of care from an out-of-network provider or their cost-sharing requirements are greatly increased • network is a list of dentists who provide dental care services to the beneficiaries of a specific man-aged care organization

Patient Management

Documents

needs motivation

learning needs goals

expressing needs

recognizing needs

inner needs

true concerning needs

patient state needs

treatment needs