Journal of the American Dental Assistants Association July/August 2013The wide world ofdental assisting:Volunteering in Belize, usingenvironmentally responsiblepractices, more on the triple traytechnique, ADAA’s updatedCE course on nitrous oxide andoxygen sedation, and more.
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Cover image courtesy of iStockphoto.com The Journal of the American Dental Assistants Association 6 July/August 2013 FEATURES 6 Never Enough Hours in the Day by Cathy Warminsky–Blythe A dental assistant shares her experience volunteering with the Belize Mission Project. 12 Nitrous Oxide and Oxygen Sedation: An Update by Ann Brunick, RDH, MS, and Morris S. Clark, DDS, FACD ADAA’s updated CE course covering characteristics, indications and contraindications for N2O/O2 in a patient setting. 28 Responses to Infection Control Breaches for Dental Teams provided courtesy of Hu–Friedy Mfg. Co., LLC, Chicago, IL Strategies for how dental teams can talk about breaches in infection control practices with patients. 40 The Air Force Dental Service and the Environment by SSgt Dianet Santos How the U.S. Air Force practices dental care using environmentally–responsible practices and technology. 40 30 My Long and Winding Road by Kim M. McMahon, BS, CDA, RDA, COA, RDH 32 One dental assistant’s journey to the profession. 32 Triple Tray Crown and Bridge Procedures: A Guide to How Dental Assistants Can Assist the Dentist—Part 2 by John S. Mamoun, DMD, and Mariam Javaid, BDS The conclusion to an overview of the triple tray technique for producing accurate crowns and bridges for patients. DEPARTMENTS 23 Student News 26 Association Bulletin 2 Editor’s Desk 44 Health Beat 4 President’s Page 48 Advertiser Index 10 Annual Session Update 22 Legislative InfoNotes The Journal is printed using recycled materials and is a fully recyclable product.
Editor’s Desk Michi Trota t’s amazing that summer seems to have flown by so fast and fall is quickly approaching. This means that the ADAA Annual Session, October 31–November 2, is just around the corner. If you haven’t yet registered, you can still take advantage of early registration rates: $50 for dental assistants and FREE for dental assisting students. Participate in the future of your professional association through ADAA governance; attend special workshops and forums designed just for you, the dental assistant (for a complete list of workshops and forums, see pg. 10); network with your fellow professionals and socialize with old friends. But hurry—registration fees will soon increase: after September 20, 2013, 5pm CDT, registra- tion for dental assistants will double to $100 and dental assisting students will be charged $20. Go to ada.org/session to register so you don’t miss out on ADAA’s biggest annual event. The world of dental assisting is vast and diverse. Many elements come together in creating a healthy and vibrant profes- sion. In this issue, the U.S. Air Force talks about how environmental responsibility is important in providing quality dental care (pg. 40), while a dental assistant shares her experience as a volunteer on a dental mission to Belize (pg. 6) and another talks about her career path to dental assisting (pg. 30). This issue’s free ADAA CE course provides updated information about the uses, indications and contraindications of nitrous oxide and oxygen sedation (pg. 12), Hu–Friedy Mfg. Co., pro- vides scripts for addressing infection control breaches (pg. 28), and John Mamoun, DDS, and Mariam Javaid, BDS, con- clude their tutorial on the triple tray technique (pg. 32). Also, ADAA is proud to announce the winners of the ADAA student scholarships and awards for 2013 (pg. 23). Congratulations to these future members of the dental assisting world. The Journal wishes them all the best as they con- tinue building successful dental assisting careers. ❖ JOURNAL OF THE AMERICAN DENTAL ASSISTANTS ASSOCIATION The Dental Assistant (lSSN-1088-3886) is published bimonthly (every other month). Subscriptions for members are $10 as part of dues. July/August 2013 Volume 82, No. 4 Nonmember subscriptions: $30 in the U.S.; $40 in Canada/Mexico; $85 other foreign. Single copy price is $20. Allow 6-8 weeks for subscriptionADAA President Carolyn Breen, CDA, RDA, RDH, Ed.D entry and change of address. Publisher is the American Dental Assistants Association, 35 East Wacker Drive, Suite 1730, Chicago, IL 60601-2211.Executive Director Lawrence H. Sepin Periodicals postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Send address changes to The Dental Assistant, 35 EastEditorial Director Cynthia K. Bradley, CDA, CDPMA, Wacker Drive, Suite 1730, Chicago, IL 60601-2211. Copyright 2013 by the American Dental Assistants Association. Reproduction CPFDA, EFDA, MADAA, BA in whole or in part without permission is prohibited. DISCLAIMER: “Authors and advertisers are solely responsible for the accuracyEditor and of any and all material provided to The Dental Assistant. Authors and advertisers are also solely responsible for checking that any and all material relevant to dentalCommunications Director Douglas McDonough care in a clinical setting meets OSAP standards. The information and opinions expressed or implied in articles and advertisements that appear in The Dental 312-541-1550 x203 Assistant are strictly those of the authors and advertisers. They do not necessarily represent the opinion, position or official policies of the American DentalManaging Editor Michi Trota Assistants Association.” Note: The ADAA cannot honor claims for missed copies of The Dental Assistant 312-541-1550 x209 unless they are made within 90 days of the cover date. For example, requests for missed copies of the January/February issue must be made prior to May 31.Advertising Sales Manager Robert E. Palmer The Dental Assistant 815-777-1594 / 815-990-8069 35 East Wacker Drive, Suite 1730, Chicago, IL 60601-2211 *General inquiries 312-541-1550 x 200 fax 312-541-1496 • E-mailDirector of Education [email protected] www.dentalassistant.org& Professional Relations Jennifer K. Blake, CDA, EFDA, MADAA ADAA Mission StatementDirector of Information To advance the careers of dental assistants and to promote the dental assistingSystems & Meeting Planning Nancy Rodriguez profession in matters of education, legislation, credentialing and professionalEditorial Review Board Kathleen Brown, CDA, LDA, FADAA activities which enhance the delivery of quality dental health care to the public. Sharon K. Dickinson, CDA, CDPMA, RDA www.dentalassistant.org Mary Govoni, CDA, RDH David F. Halpern, DMD, FAGD Natalie Kaweckyj, CDA, CDPMA, COA, COMSA, CPFDA, LDARF, MADAA, BA Linda Kihs, CDA, EFDA, MADAA Linda L. Miles, CSP, CMC John Molinari, PhD Rhonda R. Savage, DDSTo obtain a copy of our Writer's Submission Guidelines or the Editorial Calendar,please go to the ADAA website, www.dentalassistant.org.2 The Dental Assistant July/August 2013
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President’s PageCarolyn Breen, CDA, RDA, RDH, Ed.DADAA President, 2012–2013 ADAA Working for You:Taking a Look Behind the ScenesWhat ADAA has done for dental assistants and the profession over the past years the completion of my term as ADAA President year, your staff and elected representatives have travelled nearswiftly approaches, it seems fitting to share a be- and far, whether in compromised health or leaving behindhind–the–scenes look at the Association with you, family on special occasions, to fulfill their commitment to rep-our highly valued members. In being a “newcomer” to your resent you and your needs as dental assistants.ADAA Board and “hitting the ground running,” I have con- Your Trustees and local members have also worked manysistently been amazed by the dedication and resourcefulness long hours setting up, staffing and breaking down ADAAof your Executive Committee, Trustees, Executive Director membership booths across the country. They volunteer theirand Staff in representing your interests. time to speak with dental assistants regarding the role of ourAs the national organization protecting the welfare of all Association, member benefits and what being a part of yourdental assistants from varying employment settings and po- professional organization means for you. Dental assistantssitions across the country, and making strides in elevating stop by the booth to obtain general information, provide feed-and promoting our profession, the daunting task of effective back for the enhancement of ADAA and to ask for guidancecommunication to facilitate the ongoing conduct of business relating to various issues of concern.has been far from easy. Your representatives have come from ADAA has been in the forefront in addressing and speakingall across the country during the past months and thanks to out regarding social issues pertaining to dental health care, asADAA Central Office staff, we have been able to utilize pre– well as the safety and protection of the public we serve. We havescheduled conference calls and access documents, materials helped provide testimony during multiple state board meetingsand needed information via a specific area of the ADAA web- and legislative hearings, with supporting letters and on–site ap-site to more easily complete many tasks on your behalf. pearances by ADAA members and officers. We have developedYour Executive Committee and Trustees, with uncondi- andcirculatedtheADAApositionstatementregardingtheneedtional support from—and participation by—ADAA staff, for education and credentialing of all dental assistants nation-have donated countless hours on weekends, holidays and late ally, as the time has come for preparation and qualification ofevenings during their regular work week to participate in mul- individuals to be commensurate with the significant functionstiple Council conference calls, facilitated by independent and performed and care provided by dental assistants.subcommittee work, in preparation for Council discussions. We have also made strides to collaborate with other pro-Each participant fulfills many tasks and each Council chair, fessions that support our initiatives and other professionalofficer, trustee and staff member is responsible for both pre- organizations and groups who share our concerns for qualityparing materials for discussion and submitting reports detail- care and assuring adequate preparation and credentialing ofing all Council and subcommittee activities for consideration individuals providing dental service to patients. By ensuringand action by the Board of Trustees. In order to participate inBoard meetings and other various activities during the past (Continued on page 47)4 The Dental Assistant July/August 2013 www.dentalassistant.org
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Dental BusinessCathy Warminsky–Blythe Never EnoughHours in the DayA dental assistant reflects on her experience volunteering with a dental mission in Belizeitting at the gate in the airport waiting to board my plane to able as possible. It is a great experience for those who have neverBelize, I looked around for other members of the “Belize been on a mission trip. Many also gravitate toward the Belize Mis-Mission Project” group. I noticed people wearing names sion Project because of the “not so rugged” environment and livingtags who were involved with the group had big smiles on their faces conditions during the trip.as they caught up with old friends and introduced themselves to the After landing in San Pedro, we were shuttled to our hotel, which“newbies.” My overall sense of the group was “these are good peo- would serve as our base camp for the entire trip. I was pleasantlyple,” and that we had a common interest to help others. So I stood surprised that the hotel lived up to its beautiful pictures on the web-up, put on my name tag, and walked over to introduce myself. Right site. After getting settled into the room and meeting my roommate,from the start, I felt like I belonged. I was warmly welcomed into the I headed down to the beach for the informational meeting and ourgroup as if I had been part of it from the beginning. welcome dinner. At this meeting, I received my work schedule forThe Belize Mission Project began in 1993. Dr. Frank Whipps, the week and met the dentist who I had been paired with. She wasa practicing orthodontist in Centralia, IL, was one of the individu- a returning pediatric dentist from Connecticut. We would be leav-als who helped start the mission. He began to feel an inner desire ing in a few days to work for three days at a preschool in the Bananato focus strictly on dental and medical mission work. This desire Bank area, along with another dentist, a dental assistant, a pediatricwas shared by many of the now–regular group of participants. The nurse practitioner and a pediatric nurse. Then we would return togroup, which travels to Belize for at least one week a year, typically San Pedro to work for two days at a dental clinic, called the Lion’sconsists of approximately 40 dentists, physicians, physician assis- Den, which was being set up in town.tants, nurse practitioners, dental hygienists and assistants, nurses, The day before we were to leave for our assignments, I spent thedental technicians, general helpers, and everyone in between. The afternoon with the dentist I would be working with and learnedproject participants are comprised of a diverse set of people, from how to assemble and operate our equipment. Some of the equip-all ages and backgrounds, with one similarity: a desire to volun- ment was powered by scuba tanks, while air compressors providedteer their time and talents to serve others less fortunate with den- the power to other units. We carefully inspected all of our equip-tal, medical and spiritual needs. ment because the salt air in Belize is very corrosive and these unitsThe project is organized in such a way as to minimize many con- had been in storage for almost a year before they were brought outcerns of first–time mission trip participants. It is the project’s goal to for us to use. Once we decided everything was in good working or-make the nature of the trip non–threatening, safe and as comfort- der and we had a better understanding of how to set up and break6 The Dental Assistant July/August 2013 www.dentalassistant.org
down the units, we signed out our equipment Belize Mission Project volunteers checking equipment before setting up a clinic.and packed it up for our trip. Preschool in Banana Bank. The next morning we departed for Ba-nana Bank. First, we took a fifteen–minute quickly disappeared. We saw many children them a fluoride treatment, and then tell themplane ride to Belize City. From there, we took with significant decay in their primary teeth. to come back the next day so we could worka two–hour van ride west towards the Gua- on the other side. We were at the school fortemala border to get to Banana Bank. As we For the teeth that were salvable, we three days and most of the patients cameapproached the preschool, the driver asked if placed an amalgam and used a rubber dam back for a second treatment.we wanted to drop off our luggage at the ho- to help isolate the teeth and to control thetel before going to the preschool. Everyone saliva flow. The teeth that were not salvable, The patients and the parents of the chil-in the van said, “No.” We were excited to start we simply extracted. The dentist and I would dren we saw were very thankful for the ser-our work. When we arrived at the preschool, work on one side of patients’ mouths, give vices we provided. Tears of thankfulness, ➤we noticed several nicely painted buildingsand a beautiful playground. The woman whoran the school came out to meet us and in-formed us that there were already patientswaiting to see us. The school had sent noticesto the nearby community that an Americandentist and doctors were going to be at theschool for three days to care for their medi-cal and dental needs. It took us about thirtyminutes to set up and to get organized. The quantity of supplies were not at ourfinger tips like they would be in a statesideoffice and the dentists only brought thebare necessities to get them through a pro-cedure. We used a lot of disposable items tohelp maintain the universal infection controlstandards and used cold sterilization for ourinstruments. After each procedure I had toscrub the debris from the instruments, rinsethem, place them into the cold sterilizationsolution for the appropriate time, and thenrinse them once again. Our first patient, a male who was ap-proximately 20 years old, was experiencingpain in the lower right side all the way in theback. We didn’t have an X–ray unit or theinstruments for an impacted third molarextraction. The dentist noticed a small cav-ity in the area, so we placed an amalgam fill-ing and gave him a fluoride treatment. Thatwas all we could do for him, which was verydisappointing to me. I had come here to helppeople, and as our first patient left I felt asthough I’d fallen short of my goal. But as themorning progressed and we saw more pa-tients, that feeling of falling short of my goal7www.dentalassistant.org 2013 July/August The Dental Assistant
hugs and big smiles were abundant and so Volunteers Needed!very heartwarming. Every day that we wereat the school, the parents supplied us with The Belize Mission Project announces two new trips to Belize in needlunch to show us how thankful they were of volunteers. The trips will take place from October 25 to Novem-for helping them and their children. I felt so ber 2, 2013, and November 2 to November 10, 2013.humbled, knowing that these people had so This mission will be both medical and dental. Anyone is welcome: den-little and lived in such poverty, yet were so tists, physicians, physician assistants, nurse practitioners, hygienists,happy and willing to share. dental assistants, non–medical help and everyone in between. If you would like more information concerning this experience or if you want I think the most challenging thing I expe- to sign up, contact:rienced was explaining to the parents of thechildren, and even the patients, themselves Dr. Frank Whippsthat just because they had a toothache, it 1020 Jonasdidn’t mean the tooth needed to be extract-ed. I found out by speaking to the patients Centralia, IL 62801that if there is not a dentist available in the 618–532–1821 (days) OR 618–233–5364 (nights)area, they have to go to the hospital where Unfortunately, the number of participants accepted is limited. Manythe standard protocol is to just extract the people enjoy taking part in the mission each year so don’t wait!tooth. Most of the patients we saw expectedto have their problem teeth taken out and For more information, please see their website at:they seemed very surprised that a simple fill- www.belizemissionproject.coming was all they needed. Dental equipment set up at the preschool. At the end of our third day in BananaBank, we started the journey back to basecamp in San Pedro. Once we got back to thehotel, a few of us decided to go into the resi-dential area of San Pedro and pass out fliersabout the free dental service we were provid-ing at the Lion’s Den for the next few days.The residents were eager to take our fliersand they questioned us about the servicesthat were being offered. Some even showedus past dental work. Many of them alreadyknew about the Belize Mission Project be-cause the group had been coming here yearafter year. I handed one man a flier and hejust gave me a great big smile and pointed tohis teeth. He told me he got his set of newteeth last year; he was so proud of them. For the next few days, we worked at theLion’s Dens, and we saw a lot of children withthe same dental needs as we’d seen at thepreschool. When we arrived every morning,the waiting room was always crowded withadults and children; by the end of the day, Iwould look over to see if the waiting roomhad cleared out, but there always seemed tobe more people in the chairs still waiting. Ifelt so guilty when the people in the waiting8 The Dental Assistant July/August 2013 www.dentalassistant.org
area were told they’d have to come back to- what you’d be doing from one patient to knowing that they have made someone’s lifemorrow. There never seemed to be enough the next, so you had to be flexible as to what just a little easier. The trip provides a chancehours in the day. At night before I fell asleep, instruments and material to use. We didn’t for someone to go out and do something forI would think about all the procedures we’d have the luxury of time; we couldn’t do a someone else out of pure love, knowing thatdone that day and the lives that we had pulpotomy with a stainless steel crown for they can’t repay you with money. It is heretouched, but more importantly how those these children as we would do in an office that most people grasp that a simple “Thankpatients had touched our lives. back in the States. You” and a big smile are worth more than all the money in the world. By doing this, it The core responsibilities of a dental as- The biggest life lesson I came away with helps put our own life into perspective.sistant on this mission trip were really no dif- from the Belize Mission Project was to ac-ferent than at an office. I was still responsible cept that I couldn’t do it all. I can only do as ❖for the delivery of quality oral health care. I much as time allows, and it’s all right to letassisted the dentist during the treatment pro- someone else pick up where I left off. That Cathy Warminsky–Blythe has been a den-cedures, I was responsible for developing in- is why I am sharing this story with you—so tal assistant for over 20 years. She recently re-fection control protocol , as well as preparing you can pick up where I left off. tired from assisting and volunteers her services toand sterilizing instruments. I helped the chil- such organizations as the Belize Mission Projectdren feel comfortable before, during and af- A common personal goal of many trip and Mission of Mercy. Ms. Warminsky–Blytheter their treatment, and both the dentist and participants is to professionally and spiritually enjoys gardening and spending time with herI taught our patients appropriate oral hygiene give to those less fortunate and those in need. husband and two children. She and her familystrategies to maintain good oral health. Although this goal is accomplished, what live in a suburb north of Chicago, IL. most discover is that they also receive much The noticeable difference was that the more than they had ever expected. Thesepace was quicker; you never knew exactly blessings are not of the material form, but of Your online dental industry job boardFind your next employee! • Post job openings, search resumes, or both. • Postings syndicated to Twitter, Facebook, Indeed.com, and more... • Dental professionals apply online or using our new Mobile App. • Resume database with pictures and personality test.Register your dental practice or yourself today - www.DentalPost.netQuestions? Email us at [email protected] Tonya Lanthier, RDH9www.dentalassistant.org 2013 July/August The Dental Assistant
Annual Session UpdateBrass band plays in front of St. Louis Cathedral. Photo by Jen Amato Bourbon Street nightlife. Photo by Richard NowitzWhether you’re interested in using social media, building Fellow/Master*membership in your local chapter or learning more about Friday, November 1, 1pm – 3pmlegislation and the profession, ADAA’s session of events Moderator: ADAA Vice President Bonnie Marshall, CDA, RDA,has something for everyone. Please note that all room lo- EFDA, EFODA, MADAAcations are currently to be determined and will be noted in For current Fellow/Master candidates and those interest-the ADAA Annual Session guide in the September/October ed, this program will include tips for filling out CE creditjournal issue. forms and identifying courses in non–traditional areas asDental Assistant Educator’s Forum: well as mentoring guidance.Effective Tools for the Dental Assisting Classroom LegislativeFriday, November 1, 9am – 12pmModerator: 1st District Trustee/Council on Friday, November 1, 1pm – 3pmEducation Chair, Claudia Gauthier, CDA, BS Moderator: ADAA Past President Natalie Kaweckyj, CDA, CDPMA, COA, COMSA, CPFDA, LDARF, MADAA, BAJoin educators from across the country for a variety of top- What is going on legislatively with regards to dental assis-ics including: Teaching Tips for Reaching Today’s Student; tants and dental assisting? This interactive workshop willBest Practices for Student Enrollment/Retention; The Ben- introduce you to suggestions and ideas on how to beginefit of a Formal Education to the Dental Assistant, Doctor the process in your area.and Patient; Minimum Education Standards for PerformingExpanded Functions; When and Why To Start a SADAA Chap- Membership*ter and How to Keep It Active; Service Learning Projects; Friday, November 1, 3pm – 5pmUse of Social Media; and Overcoming Generational Issues. Moderator: 12th District Trustee Jennifer Broyles, RDASocial Media* Join Jennifer for an interactive workshop to help states andFriday, November 1, 9am – 12pm locals build their membership. You will learn how to read,Moderator: PennWell Managing Editor, Kevin Henry understand and manipulate the membership lists.Social media is a rapidly growing market through which Business Assistantmany of your members and potential members receive in- Friday, November 1, 3pm – 5pmformation. Learn about Facebook, Twitter and LinkedIn and Moderator: Consultant, Debra Engelhardt–Nashgain useful tips on websites and the use of E–Newslettersand E–Blasts. What are the hot–button issues for business assistants today? Debra will share tips on maintaining proper dentalStudent Forum records, information on the HITECH Act and more.Friday, November 1, 9am – 11am *Participants encouraged to bring laptopsModerator: Student Trustee Katie Harstine, RDACome join dental assisting students from around the coun-try to discuss education, the profession and more.10 The Dental Assistant July/August 2013 www.dentalassistant.org
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Nitrous Oxideand Oxygen Sedation: An UpdateAnn Brunick, RDH, MS Morris S. Clark, DDS, FACDThis course will teach the desirable characteristics of nitrous oxide, indications and contraindications for N2O/O2 use,as well as facts and myths surrounding chronic exposure to nitrous oxide, the biologic effects associated with highlevels of the gas, and ways to assess and minimize trace gas contamination in an outpatient setting. itrous oxide and oxygen (N2O/O2) in combination agents. The properties of nitrous oxide allow it to provide pain have been used safely and successfully for over 160 relief while simultaneously reducing anxiety. This action happens years to assist in the management of pain and anxiety. within a short period of time. For example, bronchial asthma canDr. Horace Wells, a dentist in the early 1800s, dedicated his life to be triggered by various stimuli, including stress. By employing thepromoting its use for both dental and medical procedures. Be- N2O/O2 sedation technique, basic appointment stressors can because of his persistence in advocating the use of nitrous oxide as a minimized for a more comfortable experience.method of pain control, he was posthumously recognized as the“Discoverer of Anesthesia.” Since that time, N2O/O2 has been The drug can be titrated, which means the patient is given in-commonly used in many dental specialties. Other health disci- cremental amounts over time until the desired level of sedationplines have also benefited. is achieved. This allows for the greatest level of patient comfort In many instances, patients present to medical and dental of- and safety. Elimination of nitrous oxide from the body occursfices with both pain and anxiety. It is necessary to manage both, as rapidly as the induction. Patients are fully recovered follow-since they are interrelated. Nitrous oxide and oxygen sedation can ing N2O/O2 sedation because all but an insignificant amount ofassist patients with their pain and anxiety and can be employed drug is expelled from the lungs within minutes after the nitroussafely and effectively with minimal concerns. oxide is discontinued. These characteristics make it a desirable agent for practitioners.Advantages Nitrous oxide/oxygen (N2O/O2) sedation offers many In addition to these ideal characteristics, N2O/O2 sedation can be used on most patients with minimal side effects. Patients ofadvantages over other sedation methods or pharmacological any age can be given nitrous oxide and oxygen. In addition to re- lieving pain and anxiety, N2O/O2 sedation works very well at ➤COURSE OBJECTIVESUpon completion of this course, the dental professional should be able to:✓✓ Recognize characteristics of nitrous oxide that make it desirable to use for most patients.✓✓ Evaluate indications and contraindications for the use of N2O/O2 sedation.✓✓ Differentiate between the facts and myths surrounding chronic exposure to nitrous oxide.✓✓ Explain what the NIOSH and ACGIH recommended exposure limits signify.✓✓ Identify biologic effects associated with high levels and/or misuse of nitrous oxide.✓✓ Describe methods for detecting and assessing levels of trace gas in an outpatient setting.✓✓ List methods for minimizing trace levels of nitrous oxide in an outpatient setting.12 The Dental Assistant July/August 2013 www.dentalassistant.org
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calming a hypersensitive gag reflex that can occur in patients where a gas bub-prohibit taking intraoral radiographs. There ble was placed to assist healingare very few contraindications for its use in during a recent eye surgery. This is If a patient won’t sign a consent formthe dental office setting because it does not typically surgery involving retina for N2O/O2 sedation, or is unwillingnegatively impact the majority of the bodysystems to any significant extent. and macular hole repair.1 to receive it, you should not begin theContraindications Also, patients who have recent- procedure. You should also refrain There are some situations in which the use ly undergone ear surgery to repair/ replace the tympanic membrane from using N2O/O2 sedation withof N2O/O2 sedation should be postponed with a graft could have complica- persons who can’t communicate withor avoided. Whenever there is a questionabout whether N2O/O2 sedation should tions from the use of nitrous ox- you because of a language barrier orbe used, it is always recommended to consult ide.2 Patients may get precaution-a physician. The following are conditions in ary advice from their physicians those who have claustrophobic tenden-which medical consultation is advised prior about the use of nitrous oxide cies and are not able to wear the nasalto nitrous oxide administration and/or ni-trous oxide should be postponed until the following these types of surgeries. mask and scavenger system.condition is resolved, or not used at all. Otherpotentiallyproblematicsitu- The use of drugs during the first trimester ations related to gas expansion areof pregnancy is not recommended. Therefore, pneumothorax (hole in the lung)nitrous oxide during this period of organogen- and significant bowel impaction.esis should not be used. Dental treatment is However, it would be unlikely thatgenerally recommended to be completed dur- a patient would present to a dentaling the second trimester. N2O/O2 sedation office with these conditions.can be used during the second and third tri- Again, medical consultation ismesters, although medical consultation with always prudent in such situations.the patient’s physician is necessary. There is a potential to increase the incidence of pulmonary fibrosis Mask with scavenger system to redirect unused Upper respiratory tract infections (i.e. si- and other pulmonary diseases in nitrous oxide gas.nusitis) typically result in nasal obstructionin which the gases cannot enter the respira- patients who are currently receivingtory system. This is a situation where N2O/ bleomycin sulfate, which is a drugO2 sedation is appropriate when the condi- used to treat certain types of cancers.3 This be avoided. It is always best to obtain medi-tion is resolved. situation is not related to the use of nitrous ox- cal consultation whenever there is a question ide, but rather the use of oxygen (greater than about a specific situation. Remember, there There are certain chronic obstructive 30 percent) in combination with the nitrous are other modes of sedation that are availablepulmonary diseases (COPD) that pose oxide. This is an unlikely situation. for use in these instances.problems with N2O/O2 sedation. If a In addition, the literature cites notable in- If a patient won’t sign a consent form forpatient indicates health problems associ- tracranial pressure increases following recent N2O/O2 sedation, or is unwilling to receiveated with chronic bronchitis or emphysema, pneumoencephalography procedures. In it, you should not begin the procedure. YouN2O/O2 sedation is a contraindication due this case, nitrous oxide rapidly replaces the should also refrain from using N2O/O2 se-to narrowed or enlarged airways that prevent nitrogen resulting in an increase in pressure. dation with persons who can’t communicateproper inhalation or exhalation of the gases. N2O/O2 sedation should be postponed for with you because of a language barrier orDepending on the respiratory function of one week after this procedure.4 those who have claustrophobic tendenciesthe patient, some cases are not problematic; Situations involving patients with psy- and are not able to wear the nasal mask andtherefore, medical consultation is essential chological impairment, mental illnesses or al- scavenger system.for all patients with COPD. teredmentalstatesrequiresignificantcaution. There may in the future be other situations N2O/O2 sedation should not be used when in which N2O/O2 sedation will be deemed Because of the expansive nature of ni- a patient is intoxicated or “high” on drugs. In inappropriate. It is vital for all health care pro-trous oxide, there are several situations/con- addition, N2O/O2 sedation should not be viders to critically evaluate the latest research.ditions that warrant caution. The possibility used if a patient is unable to understand theexists in patients with active cystic fibrosis procedure because of a mind–altering condi- Evidence–based researchthat complications could arise if nitrous ox- tion(i.e.Alzheimer’sdisease).And,ifaperson Evidence–based evaluation of the scien-ide is used. Similarly, complications could has a condition in which psychotropic drugs tific literature is the necessary basis for sound are prescribed, N2O/O2 sedation should practice. One of the areas in which the litera-14 The Dental Assistant July/August 2013 www.dentalassistant.org
ture generally has not been scientifically vali- quality products and machines capable of experience numbness, tingling and possiblydated deals with nitrous oxide as an occupa- scavenging much of the trace gas. Also, it is parasthesia in their limbs. Impaired dex-tional hazard. Unfortunately, there have been important to note that these manufacturers terity, clumsiness, and slowed gait are alsomany references in scientific literature refer- are continually improving the capabilities of signs. Reflexes may be impaired; musclesring to nitrous oxide as a significant risk factor their equipment. Research is ongoing at each can weaken. The length of time and amountfor health care professionals exposed to the manufacturing site; new products and meth- of exposure can influence these signs andgas during patient treatment. Historically, the ods are constantly being evaluated. symptoms. The cases of overexposure statedliterature has made reference to nitrous ox- in the literature ranged from one to severalide as the causative agent for anything from There is one reputable study that has hours per day and up to several times perbirth defects to cancer. Validated research determined the level at which true biologic week. Some individuals report gradual im-suggests that low levels of trace nitrous oxide effect occurred on humans following nitrous provement of these symptoms upon termi-in the workplace are safe, and great strides oxide exposure. In 1985, Sweeney et al. used nation of the abuse activity while others notehave been made regarding the efficacy of the a sensitive measure, the deoxyuridine sup- permanent neural injury.13equipment used and the ability to scavenge pression test, to identify this critical level.trace gas from the dental office. It is now pos- His results showed the first signs of detect- Regulationsible to keep levels of trace gas to a minimum, able biologic effect were found at 1800 partsthus reducing occupational risk. per million (ppm).7 Noteworthy is the fact The National Institute for Occupational that, to date, no biologic effects have been Safety and Health (NIOSH) and the Ameri- Defining legitimate research often hinges evidenced when low levels of trace nitrous can Conference of Governmental Industrialon its design and methodology. From the oxide gas have been measured. Hygienists (ACGIH) were instrumental inmore than 800 articles that have been writ- establishing recommendations for thresholdten on the subject of nitrous oxide up to Biologic effects limitsduringadministrationandforaneight–1995, fewer than 25 were shown to merit re- The most significant biologic effect that hour time–weighted average. In 1977, theseliability and validity.5 There have been many organizations established threshold limitsinconsistencies and inaccuracies presented has been linked to nitrous oxide exposure is for health professionals. It was establishedin the literature regarding the harmful nature its ability to inactivate Vitamin B12. This inac- that a level of 25 ppm and 50 ppm must beof nitrous oxide to those professionals who tivation further affects an enzyme called me- achieved in operating rooms and dental of-use it for patient treatment. Many of these thionine synthetase. Methionine synthetase fices respectively. These levels were based onstudies were done using a retrospective sur- is essential for the production of DNA. Ab- unfounded research results later recanted byvey design. This type of research lends itself normalities in fetal development were seen in Bruce, Bach, and Arbit as well as the scav-to be unreliable because it is unable to con- animal fetuses that were exposed to 24 hours enging ability of the equipment at that time.trol for extraneous factors. of 60 percent nitrous oxide for 12 days.8 De- Health professionals are required to uphold spite flawed research, reproductive problems these arbitrary values even at the present The earliest study referring to nitrous ox- with humans have been reported in individu- time. The Occupational Health and Safetyide as a hazardous agent dates back to 1967. als chronically exposed to high levels of un- Administration (OSHA) is the organizationNitrous oxide was cited by a Russian anesthe- scavenged nitrous oxide.9 that has the authority to enforce these rec-siologist as the cause of both male and female ommended levels; however, because of thereproductive problems among anesthesiolo- The issue of DNA interruption is im- controversy regarding the appropriatenessgists.6 Since nitrous oxide was a common gas portant to those professionals early in preg- of the recommendations, OSHA recognizesused for operating procedures, it was singled nancy or trying to become pregnant. Know- that these limits must be validated.out as the etiologic factor. Articles of a simi- ing trace gas levels in the office would be In order to bring several issues up–to–lar nature surfaced in the United States in the beneficial in these cases. It is the individual’s date regarding nitrous oxide, a meeting was1970s and early 80s, each claiming similar decision whether to continue or postpone convened in October 1995 by the Americanresults. These studies quoted significant bio- employment during this time. The toxicity Dental Association Council on Scientificlogic effects when high levels of unscavenged, of nitrous oxide and its effects on the human Affairs. Several interested parties were rep-trace nitrous oxide were measured. body remains a topic of discussion in the resented including respected experts in the current literature.10–12 It is certainly recom- field, educators, manufacturers, and govern- Since those early studies, methods of de- mended to keep updated on this topic; how- ment officials. It was concluded that a truelivering and scavenging nitrous oxide have ever, it continues to seem that nitrous oxide recommended exposure limit to nitrous ox-improved tremendously. It is now consid- is safe when administered in low therapeutic ide has not been established.14 Sweeney andered the standard of care to use equipment doses for short periods of time. colleagues have proposed a level of 400 ppmwith scavenging capabilities. The equip- for regulatory consideration.ment manufacturing industry has been in- Neurologic signs and symptoms are ➤strumental in providing professionals with associated with nitrous oxide abuse. Indi- viduals professing misuse of nitrous oxide15www.dentalassistant.org 2013 July/August The Dental Assistant
RECOMMENDATIONS FOR CONTROLLING WASTE NITROUS OXIDEThe following is a list of recommendations and preventive measures to minimize trace gas contami-nation in your dental office.14✓✓ Establish baseline values of nitrous oxide concentra- are leaking, bubbles will form around the fittings. Wipe tions in the office. Evaluate the ambient air using an off the solution and tighten the lines. infrared spectrophotometer. ✓✓ Ensure the adequacy of the evacuation system in✓✓ If desired, use time–weighted dosimetry devices to place. monitor exposure of office personnel to nitrous oxide over a specified period of time. ✓✓ Assess room ventilation and air exchange in the office. It may be necessary to supplement local ventilation to✓✓ Every two years send the equipment to the manufac- assist the removal of waste nitrous oxide. Be wary of turer for routine maintenance and evaluation. air conditioners that may recirculate waste gas within the office rather than remove it. It is possible in the fu-✓✓ Visually inspect the conduction tubing and reservoir ture that fresh air exchanges will become mandatory bag for cracks and tears. in offices that use nitrous oxide/oxygen sedation.✓✓ Use the soap/water test on fittings and connections ✓✓ Make sure all office personnel are educated on the facts to assess for gas leaks. To do this, place a few drops regarding chronic exposure to nitrous oxide. Develop a of dishwashing detergent in a small amount of water. hazard control team to continually assess the effective- Wipe some of this solution around the fittings where ness of the office scavenging system. the gas lines attach to the flowmeter. If these areas They believe this level is attainable and It is also possible to determine the the system is portable or centrally installed. Cwell below the level (1800 ppm) at which amount of nitrous oxide exposure to an indi- The tanks themselves may leak at the valve Mthey first detected biologic effect. Other vidual over a specified period of time. A per- stems. Gas can leak through any portion of Ycountries have adopted exposure limits rang- sonal monitoring device is worn similar to a a central piping system or through connec- CMing from 25 ppm (France and Denmark) to radiation–dosimetry badge for the recom- tions near the flowmeter. MY100 ppm (Sweden and Germany). mended period. The time–weighted average CY (TWA) dosimetry device contains a mate- Manufacturers of nitrous oxide equip- CMYAssessing nitrous oxide levels rial that absorbs nitrous oxide. The badge or ment suggest periodic evaluation and rou- K In order to determine whether trace vial is returned to the supplier for analyzing. tine maintenance checks. Check with your manufacturer for the recommended timenitrous oxide levels are significant in your A written report is provided by the com- period; one company has suggested a maxi-facility, it is necessary to measure the levels pany indicating exposure levels for the speci- mum of two years. Conduction tubing andin parts per million. An instrument called an fied period of time. These devices are inex- reservoir bags provide a potential source ofinfrared spectrophotometer is designed to pensive, easy–to–use, and readily available trace gas. These items should be inspectedinstantaneously report nitrous oxide levels. through a number of reputable companies. frequently for cracks and tears. The soap/Many other gases can be measured with this The hand–held unit aforementioned also water test (instructions for this test are in theinstrument as well. This technology can de- has TWA measurement capabilities with next section) is appropriate for testing thesetect levels as low as parts per billion (ppb). immediate readout on the machine. items. The evacuation system used to pull trace gas from the mask into the suction must It is not necessary to purchase this piece Minimizing trace gas contamination be in good working order and have properlyof equipment since periodic evaluation is It is prudent to employ as many measures vented pumps. If equipment is used that isall that is needed. It may be rented directly not able to pull trace gas into the evacuationthrough a manufacturer or it is possible to to reduce the amount of trace gas contami- system from the nasal hood, the professionalconsult a biomedical engineering agency nation in the office as possible.14 Scaveng- is practicing below the standard of care setthrough a local hospital or surgical center for ing nitrous oxide can occur before, during, by the dental profession. This could lead toavailable services. Also available is a small, and after patient use. Nitrous oxide can leak serious legal repercussions.lightweight, hand–held device that gives from several sources. Certainly, the equip-a continuous measure of nitrous oxide in ment and its connections are a potential Another significant potential sourceroom air. This machine can also detect gas source of trace gas. Gas can leak at any place of trace gas is from the patient. One of theleaks around equipment. of connection on the equipment, whether most critical means for waste nitrous ox- ➤16 The Dental Assistant July/August 2013 www.dentalassistant.org
ide invading the operator’s breathing space ACRONYMS:is through patient talking. It is imperative to ACGIH – American Conference of Governmental Industrial Hygienistskeep patient talking to an absolute minimum NIOSH – National Institute of Safety and Healthduring administration. It is also possible for N2O/O2 – Nitrous oxide and oxygengas to escape into the room from the patient’s OSHA – Occupational Safety and Health Administrationmask. Considerable effort should be made ppm/ppb – parts per million/parts per billionto ensure a properly fitting mask. There are TWA – time weighted averagemany varieties of masks and a range of sizes. 2. Munson ES: “Complications of Nitrous Oxide Anes- University of Missouri–Kansas City, School of Appropriate flow will not force gas out the thesia for Ear Surgery,” Anesthesiology 11(3):559, 1993. Dentistry. She has served on numerous com-sides of the mask. Sometimes, all that is need- 3. Fleming P, Walker P: “Bleomycin Therapy: A Con- mittees at the local, regional and national levels,ed to create a snug fit around the patient’s nose traindication to the Use of Nitrous Oxide–Oxygen including the ADHA Institute for Oral Healthis a slight twist of the conduction tubing on the Psychosedation in the Dental Office,” Pediatric Den- Scholarship and Research Review Committees,mask. A physical property of nitrous oxide is tistry 10(4):345–6, 1988. the National Dental Hygiene Board Exami-that it is heavier than nitrogen (air). While it 4. Frost EA: Central Nervous System Effects of Nitrous nation Construction Committee, the Interna-may seem logical to think that because of this Oxide. In Eger EII, Editor: Nitrous Oxide N2O, New tional Federation of Dental Hygienists’ editorialproperty, the gas would immediately fall to York, 1985, Elsevier Science Publishing. board and the ADA Commission on Dentalthe floor and pose no risk to the operator(s), 5. Clark MS, Renehan BW, Jeffers BW: “Clinical Use Accreditation as a site visitor. Ms. Brunick hasone must not forget that the gas is extremely and Potential Biohazards of Nitrous Oxide/Oxygen,” published numerous articles and abstracts. Herexpansive in nature. The partial pressure of ni- Gen Dent 45:486–491, 1997. most recent work is the third edition of a text-trous oxide is 31 times greater than that of ni- 6. Vaisman A: “Working Conditions in Surgery and book entitled Handbook of Nitrous Oxidetrogen (air), so it will exit the patient’s mouth Their Effect on the Health of Anesthesiologists,” Eksp and Oxygen Sedation, which she co–authoredand enter the operators’ breathing space be- Khir Anesteziol 3:44–49, 1967. with Dr. Morris Clark.fore it falls to the floor. 7. Sweeney B et al: “Toxicity of Bone Marrow in Dentists Exposed to Nitrous Oxide,” Br Med J 291:567–569, 1985. Morris S. Clark, DDS, FACD, is a nation-Summary 8. Fujinagra M, Baden JM, Mazze RI: “Susceptible Peri- ally and internationally recognized expert on the od of Nitrous Oxide Teratogenicity in Sprague–Dawley subject of nitrous oxide/oxygen therapy. He is aNitrous oxide/oxygen sedation remains Rats,” Tetrology 40:439–333, 1989. graduate of the University of California Schoola viable option for managing a patient’s pain 9. Rowland AS et al.: “Reduced Fertility Among Women of Dentistry and completed his training in Oraland anxiety in the dental office. There are Employed as Dental Assistants Exposed to High Levels Maxillofacial Surgery at Columbia University.several advantages to its use and relatively few of Nitrous Oxide,” New Eng J Med 327:993–997, 1992. He is a Professor at the University of Coloradocontraindications. Knowing how to mini- 10. Weimann J: “Toxicity of Nitrous Oxide,” Best Pract School of Dental Medicine and on the facultymize the operator’s exposure to the gas is also Res Clin Anesthesiology 17(1):47, 2003. of the medical school there as well. He has beenan important consideration. N2O/O2 seda- 11. Myles PS et al: “A Review of the Risks and Ben- President of the American Society for the Ad-tion has a long–standing history of safety and efits of Nitrous Oxide in Current Anesthetic Practice,” vancement of Anesthesia in Dentistry and thesuccess and it is likely that this type of seda- Anesth Intensive Care 32:165, 2004. American Dental Society of Anesthesia for thetion will be used far into the future. 12. Weisner G et al: “High–Level, but Not Low–Level, states of Colorado, Arizona, Kansas, Utah,It is necessary to educate the entire office Occupational Exposure to Inhaled Anesthetics is As- Wyoming and New Mexico. Dr. Clark did theteam on the biohazard issues of nitrous oxide sociated with Genotoxicity in the Micronucleus Assay,” original clinical research on Versed (Midazo-safety in the dental office and keep abreast of Anesth Analg 93:118, 2001. lam) and Romazicon (Flumazenil), the ante-sound scientific literature in this area. Many 13. Layzer RB: “Myeloneuropathy after Prolonged Ex- cedent for all the benzodiazepine class of drugs.states are starting to include nitrous oxide posure to Nitrous Oxide,” Lancet 2:1227–1230, 1978. He is on the Board of Directors for the Americanadministration and monitoring in their state 14. “ADA Council on Scientific Affairs, ADA Council Dental Society of Anesthesia and a member ofpractice acts for dental assistants. Refer to on Dental Practice: Nitrous Oxide in the Dental Of- the American Dental Association Council onyour state practice act for current require- fice,” JADA 128:364, 1997. Scientific Affairs. He is co–author of the best–ments in your location. selling text Handbook of Nitrous Oxide and ❖ Ann Brunick, RDH, MS, is Chairperson Oxygen Sedation, published by Elsevier. and Professor of the Department of Dental Hy-Test begins pg. 20 giene at the University of South Dakota. SheTest answer sheet pg. 21 received an AA degree from the University of South Dakota, a BS degree from the UniversityReferences of Minnesota, and a master’s degree from the1. Hart RH, Vote BJ, McGeorge AJ, et al. “Loss of VisionCaused by Expansion of Intraocular Perfluoropropane(C3F8) Gas During Nitrous Oxide Anesthesia.” Ameri-can Journal of Ophthalmology 134(5):761–3, 2002.18 The Dental Assistant July/August 2013 www.dentalassistant.org
GLOSSARY anesthesiologist – a physician specializing in the administration of anesthetic anxiety – a condition of heightened, often disruptive tension accompanied by a feeling of impending harm or injury baseline values – a reference point used to indicate the initial condition against which future readings are compared bleomycin sulfate – an anti–neoplastic antibiotic consent form – willing permission in a written format; allowing treatment contraindication – a symptom that indicates against an otherwise normal form of treatment COPD – Chronic Obstructive Pulmonary Disease, such as emphysema and chronic bronchitis cystic fibrosis – an inherited disorder causing exocrine glands to produce abnormally thick secretions of saliva and an elevation of sweating evidence–based evaluation – a philosophy that relies on up–to–date, current research to evaluate the patient’s condition and course of treatment flowmeter – a physical device measuring the rate of flow of a gas graft – a slip or portion of tissue used for reimplantation hypersensitive – abnormally sensitive reaction when in contact with an allergen, bacteria or stimuli intracranial pressure – pressure occurring within the cranium due to head trauma, inflammation or infection macular hole repair – to repair the partial or full absence of the retina in the macular area of the eye methionine synthetase – one of the essential amino acids and essential for the production of DNA nitrous oxide – gas with a sweet odor and taste used with oxygen as an analgesic and sedative agent organogenesis – the formation of organs within an embryo, within the first trimester parasthesia – altered sensation where the sensory nerve in question has been afflicted by injury or disease pharmacological agents – drugs prescribed to treat patients pneumoencephalography – radiography of fluid–containing structures of the brain after cerebrospinal fluid is intermittently withdrawn by lumbar puncture and replaced by a gas pulmonary fibrosis – the formation or development of excess fibrous connective tissue (fibrosis) in the lungs, described as “scarring of the lung” psychological impairment – a mental state that disables a patient in some manner reservoir bag – a part of the NO2/O2 machinery, contains the excess gas scavenge – to collect and remove excess sedation – producing a sedative effect, the act or process of calming sinusitis – inflammation of the sinus spectrophotometer – an infrared instrument used to report nitrous oxide levels time–weight average device (TWA) – a dosimetry device containing a material that absorbs nitrous oxide, the badge or vial is returned for analysis titrated – incremental increase of a drug to a level that provides optimum result trace gas – any gas that represents an extremely small or insignificant portion of a mixture of gases trimester – one–third of a full pregnancy term tympanic membrane – a thin, semi–transparent membrane in the middle ear that transmits sound vibrations to the internal ear unscavenged trace – escaped, harmful gas left in the air for the dental team upper respiratory tract – the nose and throat and trachea, passages through which air enters and leaves the body19www.dentalassistant.org 2013 July/August The Dental Assistant
1111—Nitrous Oxide and Oxygen Sedation: FOR OFFICE USE ONLY An Update Date Received:___________________ Date Graded: ____________________Approved for TWO (2) continuing education credits.* Pass Fail: _______________________*Only current ADAA members are eligible to take this course as it appears in the Journal for continuing education credit.Tests submitted by nonmembers and E–Members will not be graded or returned.THERE IS NO GRADING FEE FOR THIS TEST ONLINE. Grading fee for processing paper tests is $10. Tests not accompa-nied by #10 self–addressed stamped envelope and correct fee WILL NOT BE GRADED OR RETURNED.DEADLINE for tests to be submitted to ADAA for grading is September 30, 2013.To access course and exam online and for immediate grading and certificate, go to www.adaa1.com, until September 30, 2013.All ADAA members have an account on the site, but if you don’t know your log–in info, contact Central Office at 877–874–3785 (toll–free).Post–Test: Choose the one best answer and fill in the circles on the answer sheet (opposite page)1. The dentist who has posthumously been recognized as the 6. Symptoms of N2O–induced neuropathy include all the“Discoverer of Anesthesia” due to his clinical use of nitrous following except:oxide is: A. unsteady gait, clumsiness B. tingling or paresthesia in extremitiesA. Humphrey Davy B. Joseph Priestly C. increased mental acuity, hyperactive sensesC. Gardner Quincy Colton D. Horace Wells D. impaired psychomotor function and dexterity2. All of the following are relative contraindications for 7. Chronic exposure to high levels of nitrous oxide can inhibitN2O/O2 sedation except: ___________ , a Vitamin B12–dependent enzyme.A. hypersensitive gag reflexB. severely claustrophobic patients A. methionine synthetase B. monoamine oxidaseC. current upper respiratory infection C. catechol–o–methyl transferase D. reverse transcriptaseD. first trimester of pregnancyE. alcohol intoxication or drug use 8. The level at which biologic effects of exposure to nitrous oxide were first evident according to sound research (by3. Nitrous oxide is primarily eliminated from the body via the: Sweeney) is:A. kidneys B. lungs C. skin A. 100 ppm B. 400 ppm C. 800 ppmD. urine E. liver D. 1200 ppm E. 1800 ppm4. The concept of titration is defined as: 9. The organization that enforces the exposure limits forA. large doses of a drug administered at one time nitrous oxide in a dental setting is the:B. incremental doses of a drug administered over time A. National Institute of Safety and Health B. Occupational Safety and Health Administration5. _____________ is/are advantages of using N2O/O2 C. International Federation of Industrial Hygienistssedation in a dental office setting. D. American Conference of Governmental Industrial HygienistsA. Rapid onset of actionB. Administered to patients of any age 10. Nitrous oxide has shown significant biologic effects on theC. No negative impact toward any of the body systems to any _______________ body system. significant extent A. respiratory B. circulatory C. hepaticD. Patients are fully recovered at the conclusion of the procedure D. cardiovascular E. none of the aboveE. All of the above20 The Dental Assistant July/August 2013 www.dentalassistant.org
11. In order to establish a baseline trace gas level in the office or 14. Administering nitrous oxide/oxygen sedation using equip-to periodically monitor the efficacy of the scavenging system in ment without the ability to pull trace gas into the evacuationplace, it is necessary to use a(n): system is considered an acceptable standard of care set forA. personal dosimetry badge B. infrared spectrophotometer health professionals. The partial pressure of nitrous oxide is 31C. passive diffusion monitor D. air–diffusion monitor X greater than that of air, so as it is exhaled from the patient’s mouth, it enters the operators’ breathing space before it falls to12. Flowmeters should be periodically sent to the manufac- the floor.turer for routine maintenance. A time guideline for this evalu- A. Both statements are true.ation has been suggested at: B. The first statement is true. The second statement is false.A. 6 months B. 1 year C. 2 years D. 5 years C. The first statement is false. The second statement is true. D. Both statements are false.13. A major source of trace nitrous oxide that contaminates 15. Scavenging devices recommended to minimize nitrousthe ambient air in a dental office is from: oxide concentrations in the dental operatory include all of theA. the patient talking following except:B. cracked reservoir bags A. adequate suction systems that vent outsideC. leaking valve stems on the cylinder B. use of scavenging mask/nasal hoodD. improperly soldered central piping C. regular inspection of equipment for leakage D. local recirculating exhaust ventilation system END TEST(Use pen or pencil to completely fill in the circle of your chosen answer.)1. A B C D E 6. A B C D E 11. A B C D E2. A B C D E 7. A B C D E 12. A B C D E3. A B C D E 8. A B C D E 13. A B C D E4. A B C D E 9. A B C D E 14. A B C D E5. A B C D E 10. A B C D E 15. A B C D EName:Address: City, State, Zip:Daytime Telephone Number: (_ __)_______________ *ADAA Membership Number:*DO NOT use CDA or RDA #. Membership # can be found above your name on the address line of the magazine cover.☐ Check or money order enclosed ☐ #10 SASE enclosedReturn to American Dental Assistants Association, Continuing Education Department 35 East Wacker Drive, Suite 1730, Chicago, Illinois 60601–221121www.dentalassistant.org 2013 July/August The Dental Assistant
Legislative InfoNotescompiled by Joanne Wineinger, RDA, Ninth District TrusteeBill requiring infection control education Also, Texas State Senate Bill 151 did not pass this year because of the inclusion of the requirement that all dentists must inform par-for dental assistants in Nevada killedNevada Bill AS324 raced along toward becoming reality ents/guardians of any patient under the age of 18 that they will bethrough the Assembly Committee and passed on the Assembly allowed in the treatment room. This provision was highly protestedfloor. It was sent to the Senate and passed out of Committee favor- by several professional dental organizations in the state.ably. It was on the Senate floor that the Nevada Dental Associa-tion succeeded in having it killed. Talking with the Bill Sponsor, Bill signed giving oversight of dental assistantsAssemblywoman, Maggie Carlton, she said “One of our greatest and oral maxillofacial surgery assistants toproblems was the lack of an organized Dental Assistant Associa- the Oklahoma State Board of Dentistrytion in our state.” It is her intention to introduce another Bill re- Oklahoma Senate Bill 684 was signed by the Governor onquiring infection control education for dental assistants because May, 31, 2013. This Bill gives oversight of and rule–making au-she is convinced that it is in the best interest of Nevada residents. thority for dental assistants and oral maxillofacial surgery assis-Assistance from ADAA was offered and she graciously and grate- tants (the first such designation by any state) to the Oklahomafully recorded information regarding access to that assistance. Board of Dentistry (OSBD). This authority includes approv- ing programs of study and testing in subjects the OSBD deems necessary and issuing permits for those who show proficiency inTexas unsuccessful in passing statute those programs. The OSBD has already expressed the desire for aadding a dental assistant to the course in infection control and the Oklahoma Dental AssociationState Board of Dental ExaminersTexas was unsuccessful in its efforts to have a statute passed Foundation is currently creating that course.adding a dental assistant to the State Board of Dental Examiners(SBDE). However, groundwork has been laid and work will con- Connecticut Senate Bill 993 remains unheardtinue for the next legislative session. The SBDE has 15 members, 10 Connecticut Senate Bill 993 did not come out of committeedentists, two hygienists and five members at large, all of whom “roll and was allowed to go unheard by Sine Die. This Bill seemed tooff” after staggered six year terms. The next public member to retire have had tremendous support from many directions but becamewill be in February 2015 before the next Texas Legislative session. muddied and weakened by the attempted addition of Mid–LevelAn encouraging comment came from a Texas Dental Association Provider provisions.staff member, “The statute does not preclude the Governor fromappointing a dental assistant as a public member at that time.” (Continued on page 47)Alabama creates Expanded Duty Assistant as a Licensed Certificate credential On May 16, 2013 Governor Bentley signed into law SB 203 which creates the Expanded Duty Assistant(EDA) as a Licensed Certificate credential. The Alabama Board of Dentistry (ABOD) became concerned aboutthe growing momentum of the Mid–Level Provider Model generated by the Provisions of the ObamaCare Act.For a viable answer to this provision, the ABOD contacted the Alabama Dental Association (ALDA) and theAlabama Academy of General Dentistry (AAGD) to obtain their support for the EDA. After surveying theirmembership which voted 2 to 1 in favor of the EDA, a Sponsoring Senator was contacted to submit a Bill. TheABOD now has the authority to write Rules determining which procedures the EDA will be allowed to perform.The ABOD has vowed to work with the ALDA, AAGD and the University of Alabama to create lists of proce-dures, objectives for courses and sponsors of the courses dental assistants will be required to attend. It appearsthat the state will have standardized testing for EDAs. To read more in the Dental Board of Examiners of Ala-bama’s newsletter, go to http://www.dentalboard.org to access the complete text of the June 2013 newsletter.22 The Dental Assistant July/August 2013 www.dentalassistant.org
Student News by Kathryn Harstine, RDA, ADAA Student Trustee 2013 ADAA STUDENT SCHOLARSHIP As you continue on with your education in the field of dental as- AND AWARD WINNERS sisting, you will learn about the management of hazardous materials and waste. You might wonder, “What does the term ‘hazardous ma-ADAA is proud to recognize the achievements of these stu- terial’ mean and what effect can it have?” Hazardous materials anddent members and congratulates them for their hard work. waste not only affect us as humans, they also have a huge effect on the environment as well. As future dental assistants, it is our respon-ADAA STUDENT ACHIEVEMENT AWARD RECIPIENT* sibility to do everything in our power to be advocates for the envi- ronment, especially when we handle such materials on a daily basis.*As in 2012, this award was given in memory of Regina V. Mihok, CDA Many chemicals and materials are used on a daily basis in aAllison Carpenter, Greenville Technical College, dental practice, most of which are used in the mouth and are evac- Greenville, SC uated through suction down water lines. This can be hazardous to the environment. Amalgam from silver fillings can cause damage.2013 ADAA/HU–FRIEDY MERIT SCHOLAR Even though amalgam is not used as often as it was a few yearsAWARD RECIPIENTS ago, it is still used in the dental field. Many people with amalgamJamie Bridges, Community College of Rhode Island, fillings today are also having them taken out and replaced with Lincoln, RI composite fillings to remove any mercury in the amalgam and for esthetic purposes.Erin Campi, U of M and D of New Jersey–School of Health Related Professions, Scotch Plains, NJ Removing the amalgam filling is a major way scrap amalgam can get into the water lines. When the dentist is removing the fill-Miranda Casey, Greenville Technical College, ing, the dental assistant uses the oral evacuating technique to re- Greenville, SC move the amalgam form the oral cavity. The amalgam is then suc- tioned into the water lines. There are traps in place in the dentalBianca Collins, Camden County College, Blackwood, NJ water line units, but they don’t stop all particles, and some traps that are not replaced regularly pose more of a threat.Heather Cope, Pasadena City College, Pasadena, CA Amalgam carries mercury within it which can harm the body andTaktom Rashid Farokhi, Houston Community College, the environment, mainly though our water systems. The mercury that Houston, TX gets into the water systems affects marine life that we consume, whichLisa Felton, A.I. Prince Technical High School, Hartford, CT (Continued on page 47)Alyssia Gustafson, Vatterott College, Omaha, NE ADAA JULIETTE A. SOUTHARD/ ORAL–B EDUCATION SCHOLARSHIP AWARD RECIPIENTSKatie Hollers, Wake Technical Community College, Veronica Arnest, College of San Mateo, San Mateo, CA Raleigh, NC Melissa Barnett, Lewis and Clark Community College, Godfrey, ILFelcia Hunsinger, Luzerne County Community College, Laura Dunn, Kaskaskia College, Centralia, IL Nanticoke, PA Melissa Hately, Kaskaskia College, Centralia, IL Heather Hayes, Del Mar College, Corpus Christi, TXFei Liu, Del Mar College, Corpus Christi, TX Jennifer Herrera, Del Mar College, Corpus Christi, TX Fei Liu, Del Mar College, Corpus Christi, TXEmery Mullen, Daytona State College, Daytona Beach, FL Amy McDonald, Kirkwood Community College, Cedar Rapids, IAMeghan Olson, Metropolitan Community College– Kim Owen, Camden County College, Camden, NJ Penn Valley, Kansas City, MO Cathy Perten, Stony Brook State University of NY, Stony Brook, NYAngelica Pettigrew, Mott Community College, Flint, MIGrace Ramirez, Citrus College, Glendora, CABrittani Smith, Kaplan University, Omaha, NEAutumn Stalf, Lewis and Clark Community College, Godfrey, ILNicole Tucker, Indiana University Northwest, Gary, INDeanna Twining, NHTI–Concords Community College, Concord, NHVenessa Williams, Orlando Tech, Orlando, FLVictoria Wood, Arkansas Northeastern College, Blytheville, AR23www.dentalassistant.org 2013 July/August The Dental Assistant
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Association BulletinDental association president–elects forADAA, ADA and AGD share a common history ADAA and DANB Jointly Launch ADAA President–Elect Lori Paschall, CDA, CPFDA, CRF- New Scholarship Program for Dental AssistantsDA, FADAA, recently visited with American Dental AssociationPresident–Elect, Dr. Charles Norman (from Greensboro, NC) and The American Dental Assistants AssociationAcademy of General Dentistry President–Elect, Dr. Carter Brown (ADAA) and the Dental Assisting National Board, Inc.(from Greenville, SC) during AGD’s Annual Session in Nashville, (DANB) have launched a new joint scholarship programTN. As all three hail from the Carolina states (Ms. Paschall is from to help dental assistants turn their professional develop-Irmo, SC, while Dr. Norman is from Greesnboro, NC, and Dr. ment plans into reality.Brown is from Greensville, SC), Ms. Paschall noted, “The Carolinasare standing tall in dentistry nationally!” The ADAA/DANB Scholarship will be awarded to dental assistants who demonstrate a strong commitment to career growth and lifelong learning. The winner(s) will be able to use the scholarship funds for professional activities such as continuing dental education, DANB exams or certification, some expenses associated with ADAA Fellowship or Mastership, registration for a den- tal conference, among other possible activities. To be considered for the scholarship, applicants should download and complete the application and sub- mit a letter of intent, along with any required documenta- tion. The scholarship is open to all ADAA members and student members in good standing. “As America’s largest membership organization for den- tal assistants, the ADAA is proud to partner with DANBPictured left to right: Dr. Norman, Ms. Paschall and Dr. Brown at the to create this new scholarship program to help dental assis-end of AGD’s 1st House at AGD’s Annual Session this past June. tants take their careers to the next level,” says ADAA Presi- Journal article from the U.S. Army DENCOM dent Carolyn Breen, CDA, RDA, RDH, Ed.D. on hiatus for this issue “DANB is a promoter of lifelong learning, and Due to unforeseen circumstances, this issue of the Jour- through the ADAA/DANB Scholarship, we hope to nal will not feature an article provided by the U.S. Army give dental assistants the additional funds necessary to Dental Command (DENCOM). The articles will resume help them achieve their continuing education and pro- in the fall, beginning with the September/October issue. fessional development goals,” says DANB Board Chair Frank Maggio, DDS.Registration fees for ADAA Annual Sessionincrease September 20, 2013 To learn more about the scholarship requirements and deadlines, download the application at either ADAA’s website, www.dentalassistant.org, or go to DANB’s website, www.danb.org.If you haven’t yet registered to attend the ADAA Annual Ses-sion in New Orleans, LA, October 31–November 3, 2013, hurryand take advantage of early registration rates! Registration fees will ADAA Student scholarship and award winners announcedincrease from $50 to $100 for dental assistants, and dental assist- A complete list of ADAA student recipients of the ADAA Ju-ing students’ currently free registration will increase to $20 after liette A. Southard/Oral–B Education Scholarship, ADAA StudentSeptember 20, 2013, 5pm CDT. Don’t miss out on participating Achievement Award and Hu–Friedy/ADAA Merit Scholar Awardin ADAA governance, special workshops and forums (pg. 10) and has been released (Student News, pg. 23). Congratulations to theevents. Register at ada.org/session to secure your attendance at winners on receiving these prestigious awards. May your futures inthe ADAA Annual session today! the dental assisting profession be bright! ❖26 The Dental Assistant July/August 2013 www.dentalassistant.org
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Clinicalprovided courtesy of Hu–Friedy Mfg. Co., LLC, Chicago, IL Responses to Infection Control Breaches for Dental TeamsSuggested scripts for dental teams to discuss concerns about infection control breachesEditor’s Note: The American Dental Assistants Association is delighted to present these suggested scripts for dentalteams addressing issues of infection control breaches in a variety of situations, developed by Hu–Friedy Mfg. Co.ADAA and the Journal thank Hu–Friedy for sharing this helpful information. To learn more about Hu–Friedy,please go to www.hu-friedy.com.Proactive ApproachThe patient has not asked questions, but team members bring up the subject of infection prevention and patient safety:“You may have heard some news recently about the lack of proper infection control procedures (issues) in dental offices in dif-ferent areas of the country. We want you to know that we are very concerned about your safety here at [NAME] Dental Practice.We want to assure you that we follow all of the infection control guidelines from the Centers for Disease Control and Prevention,as well as state and federal rules. Do you have any questions about this? Would you like to see the area where we sterilize ourinstruments? Please let us know if you ever have any questions or concerns about your safety here in our practice.”Reactive Approach (prior to appointment)The patient has questions/concerns that they have voiced on the phone prior to their appointment:“I understand your concern. There has been a great deal of publicity lately about a few dental practices whose sterilizationand infection control procedures did not meet the standards set by the Centers for Disease Control and Prevention. I canassure you that our doctor(s) and all of the employees do follow the standards set by the CDC, and we will be happy to showyou our instrument sterilization procedures when you come in for your appointment, as well as answer any additional ques-tions that you might have.”28 The Dental Assistant July/August 2013 www.dentalassistant.org
Reactive Approach (during appointment)The patient has questions/concerns that theyhave voiced at the time of their appointment:“I understand your concern. There has been a Photo provided courtesy of iStockphoto.com.great deal of publicity lately about a few dentalpractices where their sterilization and infectioncontrol procedures did not meet the standards setby the Centers for Disease Control and Preven-tion. I can assure you that our doctor(s) and allof the employees do follow the standards set bythe CDC. Would you like to see the area wherewe sterilize our instruments? Are there any otherconcerns that you have about your safety duringyour treatment?”Telecommunications ApproachesTelephone Message for Voice Mail or Message on Hold:“You may have heard the recent news about the lack of proper infection control steps (procedures) in dental practices. We wantto assure you that we follow all infection control guidelines from the Centers for Disease Control and Prevention. If you wish todiscuss any of our protocols with us, please let us know.”Message for Social Media:“The entire team at [NAME OF PRACTICE] wants to reassure all of our patients that your safety during dental treatment isour #1 concern. We follow all of the infection control guidelines from the Centers for Disease Control and Prevention, includ-ing weekly monitoring of our sterilizers.”Posting on Website:[Show photos of sterilization area, packaged instruments and sterilizer (but make sure the sterilization area is clean and uncluttered).]“At [NAME OF PRACTICE] your safety is our #1 concern. All of the instruments used during patient treatment are cleanedand sterilized, according to the guidelines from the Centers for Disease Control and Prevention (CDC). All of the instrumentsused for patient treatment are wrapped or packaged with internal monitors for each set of instruments, to indicate that eachset has been properly processed. The instruments are placed in sealed packages to protect the sterility of the instruments untilthey are opened at the time your treatment begins. Our sterilizer(s) are tested for effectiveness on a weekly basis, according toCDC guidelines.If you ever have any questions regarding the safety protocols we follow to protect you, please let us know. We are happy to discussthese issues with you and to show you how we sterilize our instruments.” ❖29www.dentalassistant.org 2013 July/August The Dental Assistant
Dental BusinessKim M. McMahon, BS, CDA, RDA, COA, RDHMy Long andWinding RoadPersonal reflections on finding the professional path to dental assistingknew what the answer would be, so when I needed to gan my journey to my degree, but could not imagine how Iwrite down what I wanted to be for my high school year- would ever possibly complete it. In addition, I became morebook, I wrote “to become a dental assistant.” After gradu- involved with my state dental assisting association. After aating high school, I completed an accredited program, passed short period of time, I was given an opportunity for a perma-my Certified Dental Assisting (CDA) and Radiology exams nent part time position teaching in the laboratory classes ofandbeganmycareerindentalassisting:Missionaccomplished. the program. I loved what I was doing and was very gratefulMy first job was in a general dentistry practice, followed by a to have the opportunity to utilize my many years of dental as-pediatric office during which I completed the requirements to sisting experience. After a few years of teaching and the cred-become a Registered Dental Assistant (RDA), which allowed its building towards my degree, I made a very unexpectedme to perform expanded functions. My longest job in private decision. While continuing to teach, I temporarily steppedpractice was in orthodontics and those 12 years were my favor- out of the bachelor’s program and entered a dental hygieneite. Orthodontics is still my preferred area of dentistry in part program. I felt that this was a good move because the depart-because this field really utilizes the skills of a RDA. When my ment I was in taught both dental assisting and dental hygienechildren were eight years old and five years old, my husband’s and my colleagues were all dual credentialed. I also felt thatwork schedule changed and they were eating dinner at my sis- my loyalty to dental assisting was going to be questioned.ter’shousethreenightsaweek.Iknewthingsneededtochange, After what seemed like eternity I completed the dentalsoaftermuchsoulsearchingIleftprivatepracticewith19years hygiene program, passed my boards and began to work as aof clinical experience but without a plan B. hygienist part time. I needed to do this so that I could obtainI decided to call the instructor from my dental assisting the necessary experience to also work as a dental hygiene in-program, who was now the Chair in an Allied Dental Edu- structor. Also at that time I became Vice President of my statecation Department. She suggested I send her my resumé, dental assisting association, and President the following year.especially since I had orthodontic experience that no one in After holding that position for two years, I took the office ofher department had. I was offered a position as an Adjunct Treasurer and Legislative Chair. I found that staying involvedLab Instructor, which required me to at least be working to- in my professional association afforded me the ability to sup-wards my baccalaureate degree. I took the position and be- port my profession as well as remain a role model to my stu-30 The Dental Assistant July/August 2013 www.dentalassistant.org
dents. I re–entered the bachelor’s program The need to trouble shoot is another re- It is my hope and dream to see man-and completed my degree. After I gradu- quirement that I find in dental assisting, datory education and credentialing andated with a BSHS, I became a full–time especially when there are two patients wish to be instrumental in that accom-faculty member and began to teach didac- being treated at the same time. Another plishment. This advanced movement fortically. In addition I was made the depart- critical role that a dental assistant plays dental assisting could benefit the profes-ment’s Dental Assisting Coordinator. is having a finger on the pulse regarding sion in so many ways. It is time that the infection control. Recent reports such as bar is raised and for dental assisting to be Throughout my dental assisting ca- the issue in Oklahoma where more than further acknowledged for the essentialreer, I have done several presentations, 50 people have tested positive for hepa- role it plays in the delivery of oral healthbeen invited to be on a national test titis or HIV due to major breaches in in- care. The reinforcement of respect andconstruction committee, was hired as a fection control in a dental office, clearly the increased capability of the professionsubject matter expert and reviewer for show just how life–threatening inappro- could be immeasurable with mandatorya major publisher, and have been a del- priate protocol can be. education and credentialing. This wouldegate to the American Dental Assisting be a tremendous achievement for a pro-Association’s Annual Session multiple A dental assistant’s ability to multi task fession that I have and will always love.times. I had no idea that I was not done is critical to the day flowing smoothly. Igrowing within the profession of dental enjoy that aspect of dentistry much more ❖assisting. When I first became involved than the routine of prophylaxis and homein my professional association, I used care as a hygienist. The diversity of being Kim McMahon, BS, RDA, CDA,to look at the officers in complete awe, involved in different procedures makes COA, RDH, is a faculty member in thewondering how they did it and how they for less monotony. Having an expanded Department of Allied Dental Educationknew so much. Little did I know that one functions credential also allows for more (ADE) at Rutgers, the State University, inday I would hold a leadership position. independence and utilization of a dental the School of Health Related ProfessionsThe camaraderie and unity that I felt assistant’s skill. Although, I am dual cre- (SHRP). She received a Certificate in Den-from within the association allowed me dentialed, my passion for dental assisting tal Assisting from Middlesex County Col-to overcome any fear I had. I was given has not wavered. In fact I feel that having lege in Edison, NJ, an Associate in Appliedguidance and support and I soon real- obtained my hygiene license has further Science (AAS) and Bachelors of Science inized that any hurdle I may face, I was not deepened my desire to help move the Health Science (BSHS) degree, from thefacing alone. My commitment to the ad- profession of dental assisting forward and University of Medicine and Dentistry ofvancement of dental assisting is continu- feel more determined to do so. New Jersey /SHRP.ally renewed for me, as well as the knowl-edge that it simply cannot be done alone. As Legislative Chair for my state as- Ms. McMahon has taught both dentalClearly there is strength in numbers. sociation, I attend the State Board of assisting and dental hygiene students since Dentistry meetings regularly. We cur- 1999. She is currently Treasurer and Legis- To me, dental assisting offers such rently do not have a dental assistant on lative Chair of the New Jersey Dental Assis-a range with regard to job description. this board even though they regulate tants Association (NJDAA). She is a mem-From assisting in four–handed dentistry our RDA credential. That is and has ber of the New Jersey Dental Associationfor restorative procedures to working been the focus of our state. Part of my Council on Annual Session as the NJDAAindependently while taking records for responsibility was to request support Liaison. In 2005, Ms. McMahon wasan orthodontic work up, the dental as- from the hygiene association, which we awarded the Kitty Hewitt Distinguishedsistant can be depended upon to be able received. This was appreciated but not a Service Award presented by the NJDAA.to switch gears many times throughout surprise as we have a great relationshipthe course of a day. While assisting chair with them. Although it can be frustrat-side, you need to be able to anticipate ing that legislative changes take so muchwhat the next step of the procedure is, time that is reality. My resolve will notyet while taking impressions or radio- be altered and I continue to actively sup-graphs you rely on your own knowledge. port the dental assisting profession.31www.dentalassistant.org 2013 July/August The Dental Assistant
ClinicalJohn S. Mamoun, DMD Mariam Javaid, BDSTriple Tray Crown and Bridge Procedures: A Guide to How Dental Assistants Can Assist the Dentist: Part 2This is the second part of a two–part article, and explains the techniques of making provisional restorations, suchas the shell technique, the bulk technique for making a temporary restoration from scratch, or the basic techniqueof using the mold of the unprepared abutment in the pre–operative impression, to form the temporary restoration.he manual dual–arch (or triple tray) technique is an effi- Unsupervised versus supervisedcient way of making a definitive impression and making setting of acrylic in the mouthtemporary provisional restorations for crown and bridge Someassistantsallowthe(initiallysoft)temporarymaterialcom-procedures. This article presents how a dental assistant can assist a pletely polymerize into a hard temporary crown inside the patient’sdentist during triple tray crown and bridge procedures. Other top- mouth while the patient is occluding into the triple tray. The authorsics include making the final impression, making a bite registration, do not recommend this approach. First, the dentist may have inad-filling out the laboratory slip and packaging the laboratory case, vertently prepared the abutment/s so that there are undercuts orcementing provisional restorations, and the special topic of mak- divots in the abutment/s (Fig. 1, pg 34). An undercut is basically aning impressions for round–house crown and bridge cases. axially directed indentation in the body of the abutment. It may be soIn the future, in–office CAD–CAM scanning and milling of smallas to be microscopic,butif ahard temporarymaterialinfiltratesrestorations, or digital scanning of tooth preparations, followed by into it, the temporary crown may lock into it. It may be impossible toE–mailingthescanstoadentallaboratory,mayreducethefrequen- remove the temporary without cutting it off and starting over. Also,cy of use of the manual triple tray impression technique. However, if the dentist is making bridge abutments, the bridge abutments mayits intrinsic efficiency may prevent it from becoming obsolete. not be fully aligned with one another, so that a hard plastic bridge made for the abutments may lock onto the abutments. Secondly, even if the abutment/s are free of undercuts, temporary material canPre–operative impression techniquefor making temporary restorations infiltrate into the inter–proximal areas between the abutment teethIn the triple tray technique, one way of making a temporary res- and the neighboring teeth (Fig. 2, pg 34). When the temporary ma-torationistofilltheimpressionoftheunpreparedtooth,inthepre– terial hardens, the crown may be locked into the neighboring teeth.operative triple tray impression, with a soft mixture of impression Thirdly, a temporary restoration that sets while inside the impressionmaterial. The pre–operative triple tray impression with the mate- may set too high in occlusion. Later, it can be time–consuming torial in it is then placed in the mouth, and the patient is instructed grind down the temporary tooth to adjust the occlusion.to bite down into it. The soft impression material is molded by the Instead, the authors recommend that the temporary is madepre–operative impression so as to be shaped into a tooth that has using a non–shrinking acrylic material that takes several minutesthe same shape as the original tooth of the pre–operative impres- to harden, and that the assistant actively adjusts the temporarysion. The soft material then self–polymerizes into a hard tempo- restoration while it is setting, while it has some flexibility and alsorary tooth after a few minutes. some tensile strength. Here, the assistant places the soft temporary material in the triple tray, seats the tray intra–orally, waits ap- ➤32 The Dental Assistant July/August 2013 www.dentalassistant.org
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proximately two to three minutes, and then neighboring tooth. The assistant also cuts occlusion is still there. The occlusion couldremoves the triple tray, while the temporary away excess amounts of temporary material distort due to the assistant flexing the softmaterial is still soft and rubbery. The tem- that has flowed past the margins of the tem- temporary while removing it and reseatingporary material will probably be in the tray porary crown, and excess that had flowed it, and also due to shrinkage of the tempo-when the tray is removed. The assistant waits over the neighboring teeth (Fig. 3, below). rary crown while it is polymerizing, so peri-until the temporary crown has polymerized odically re–confirming that the occlusion isenough to have enough tensile strength to The assistant then seats the (still soft) there helps to ensure that it is still there.be removed from the pre–operative impres- temporary crown and instructs the patientsion, using cotton pliers, without tearing to occlude into it. Occluding into the tem- By removing and re–seating the crownthe temporary crown. After removing the porary crown while it is still soft instantly repeatedly until the crown is set hard, thetemporary crown, the assistant uses fine sets the occlusion of the temporary crown. assistant can make the temporary crownscissors to trim away inter–proximal excess The assistant then removes the temporary rub against any undercuts that may be in thein the temporary crown, especially triangle– crown from the abutment, which should abutments. This shapes the inner surface ofshaped excess that is protruding from the be easy since the crown is still soft, and then the temporary crown so that it glides over“corners” of the temporary crown at the quickly re–seats the temporary crown. The the undercuts, instead of locking into the un-inter–proximal aspect of the temporary assistant then removes the temporary crown dercuts, which would happen if the tempo-crown at the CEJ level (Fig. 2, below). These again and reseats it. Also, while repeatedly rary crown was just left on the abutment tointer–proximal “corners” of acrylic often removing and re–seating the crown, the as- polymerize completely. Also, sometimes thecause the temporary tooth to lock into the sistant should have the patient occlude into acrylic shrinks slightly while polymerizing. the crown a few times to ensure that the Moving the temporary restoration on andFig. 1: This diagram shows a non–undercut abutment (left), and an abut- Fig. 2: An unrefined, still–setting provisional restoration in the mouthment (right) that was inadvertently prepared with a divot on its surface shows excess, obstructive inter–proximal “corners” of material at the line(green arrow) and also with an undercut axial slant of the abutment sur- angles of the restoration at the gingiva.face (red arrow). Temporary material can lock into these undercuts.Fig. 3: An initial, unrefined temporary bridge inside a pre–operative im- Fig. 4: A set of acrylic finishing and polishing burs that go on a straightpression just after removal of the pre–operative impression from the mouth. handpiece. Carbide burs on the left are for trimming, while colored polish-Material that has overflowed the abutment margin will be cut away with ing burs ranging from coarse to fine are for polishing. A rubber disk is usefulscissors while the temporary restoration is still soft. for inter–proximal shaping of the provisional restoration.34 The Dental Assistant July/August 2013 www.dentalassistant.org
off the abutment repeatedly will prevent this Then, the assistant instructs the patient material against the temporary tooth surface.acrylic shrinkage from causing the tempo- to occlude into the mass to set the occlusion. The assistant moves the temporary up andrary crown to harden into a temporary resto- After the patient opens again, the assistant down over the abutment to prevent the addedration that is too tight to fit the abutment. pinches the temporary mass lightly, and has material from locking into the abutment. the patient occlude into it again. The assis-The shell technique for tant then removes the forming temporary If an anterior tooth temporary or bridgemaking temporary restorations from the abutment while it is still soft, and features a rough anterior surface, the assistant uses scissors to cut away gross acrylic excess spatulates the entire face of each rough tooth Sometimes assistants use a shell tech- to the margin of the temporary (Fig. 3, oppo- with the temporary material, smooths thenique to make temporary restorations. Here, site pg.). The assistant then puts the still–soft material with a wet gloved finger, and thenthe assistant chooses a crown form that is ap- temporary mass on the abutment, and then uses the edge of the spatula to scrape tempo-proximately the right size for the abutment, repeatedly moves the temporary mass up rary material away from the embrasure andrelines the crown form with acrylic and plac- and down on the abutment, while at times inter–proximal spaces between the teeth. Ines the crown form on the abutment. One pinching the mass into the abutment lightly general, the most efficient way to contour thedisadvantage with this method is that the to maintain its shape while it is forming, and facial surface of the anterior tooth is to shapeplastic crown form may be too big, which having the patient occlude into the tooth to and smooth it as perfectly as possible whileprevents the patient from occluding into the ensure that the occlusion is still present, until the material is still soft, while preserving thecrown form to directly set the occlusion of the mass has hardened completely. boundaries between temporary teeth, tothe provisional restoration while the acrylic minimize the difficulty of refining the shapeis setting. Later, it can be time–consuming to After the temporary crown has hardened, after the temporary has hardened.adjust the occlusion of the shell–made pro- the assistant sets the unrefined and unpol-visional restoration. ished temporary crown aside, and asks the The assistant can use a hand–held straight dentist to come and take the final reline im- nose–cone hand piece and a set of polishingThe bulk technique for pression of the abutment. While the dentist burs to achieve coarse and fine polishing ofmaking temporary restorations is making the final impression, the assistant the provisional restoration (Fig. 4, opposite refines the temporary crown. pg.), or use a big bur on a lathe machine (Fig. Sometimes, an assistant may need to 5, pg. 36). The provisional restoration shouldmake a temporary without being able to use a Refining and polishing be smooth, and its margins should be flushpre–operative impression as a mold, if, for ex- the provisional restoration with the margins of the abutment, with noample, a patient presents with a crown prepa- margin overhangs. It should be in occlusion,ration where the original crown fell off and An initial temporary restoration, when it neither too high nor too low, and should havewas lost. Here, to make a temporary restora- first emerges from the mold, should be of a contact with the inter–proximal surfaces oftion, the assistant can place a bulk mix of tem- shape that requires only minor adjustments, the neighboring teeth. The temporary may beporary material on the abutment and make taking a few minutes before the refined tem- polished into a glossy finish, using a wet ragthe temporary restoration from scratch. porary is completed. If the initial temporary wheel with fine pumice on it, or using acrylic restoration is distorted from locking onto finishing and polishing burs, with different To bulk make a temporary, the assistant a tooth, or has large porosities or defects, it degrees of polish fineness from one bur tomixes the temporary material and then waits may be more efficient to start over than to another (Fig. 4, opposite page). High–magnifi-until it has polymerized into a soft, but slight- try to correct a grossly malformed tempo- cation (4–6x) loupes help in detecting roughly stiff dough texture. The assistant places this rary restoration. areas on the temporary restoration.on the abutment and then compresses thebulk temporary material into the tooth by Sometimes, the provisional restoration The dentist, or the assistant (depending“pinching” it using three fingers. The thumb has voids or marginal deficiencies that must on local regulations and degree of ability),and middle fingers pinch the temporary be filled with more temporary material. In adjusts the occlusion on the temporary bymass from the buccal and lingual aspects, general, to add temporary material to a provi- using articulating paper and a football dia-while the index finger simultaneously push- sional restoration, the assistant mixes tempo- mond to drill away excess occlusal material.es the mass apically into the abutment from rary material until the material is somewhat Drying the temporary tooth before placingthe occlusal aspect. The neighboring teeth thick but completely moist and smooth, the articulating paper helps ensure accuratehelp to box the material in on the mesial and with no powder in the mixture. The assistant marks. If the articulating paper is still inac-distal aspects of the abutment. The purpose then spatulates a small amount of the mate- curate, the assistant may attempt to directlyof this pinch is to make the temporary cover rial into the gap or void, and maybe adds a see where the high spot in the temporaryand encircle the entire abutment, so that the small excess, to be polished away later. is located. Using 4–6x magnification andintaglio surface of the mass is well–defined, head–mounted lighting aid in this direct vi-with a sharp circular margin, and looks like After the temporary material has set to the sual observation.the intaglio surface of a thimble. point where it is not liquid, the assistant uses a wet gloved finger to smooth the temporary ➤35www.dentalassistant.org 2013 July/August The Dental Assistant
Fig. 5: Using a triangle–shaped jumbo–sized bur on a lathe to trim and Fig. 6: A final triple tray reline impression showing detailed margins, andform temporary restorative material at the inter–proximal embrasure streak marks on the abutment surface made by the diamond bur used tospace between the temporary bridge teeth. shape the abutment.Making the final, reline to remove obstructions to closing. Also, prior streaks and scratches on the abutment surfacetriple tray impression to making the final impression, the dentist or made by the diamond bur that the dentist uses the assistant will have packed cord in the sul- to prepare the abutment (Fig. 6, above). To make a final, reline impression, the as- cus around the abutment, as needed, and re-sistant places low–viscosity VPS in the pre– moved the cord as needed to ensure adequate If the impression is inaccurate or defec-operative impression, such as to completely exposure of the abutment margin. tive, another reline impression may be re-cover the teeth on both sides of the impres- quired. Prior to the dentist making the sec-sion. The assistant then immediately hands Taking the reline impression ond reline, the assistant re–trims the triplethe triple tray to the dentist, who places the Before the dentist takes the final impres- tray impression as needed to ensure that thetray intra–orally over the previously dried patient can occlude fully into it.teeth. The patient then occludes into the tray sion, the assistant must remove any piecesuntil the material sets. of provisional acrylic material that may be Making the bite registration stuck on the abutment tooth or on the oc- After making the triple tray reline im- The authors advise against placing reline clusal surfaces of the teeth neighboring theimpression material only onto the abut- abutment tooth. pression, an assistant may also need toment teeth, but instead advise placing the make a bite registration. A bite registrationmaterial onto all of the teeth in both arches After the dentist places the triple tray with is a separate impression that uses just a biteof the tray. Placing the material only on the the reline material in the mouth, the patient registration material, and no tray, to captureabutment teeth may distort the occlusion on should occlude into the tray until the excess, an impression of how the patient’s jaws oc-the abutment teeth, making the abutments leftover impression material on the desktop clude (an inter–occlusal record).2 A separatetoo elevated on the model that will be made has set hard. The dentist then removes the im- bite registration is required if the occlusionfrom the impression. If all of the teeth in pression, and the assistant rinses the impres- between the two arches is not obvious whenboth arches are covered, any such elevation sion under tap water to remove blood and sali- observing how the unprepared teeth, thatwill elevate all of the teeth simultaneously. va, and dries the impression using an air–water are captured in the triple tray impression,The laboratory technician can usually hand– syringe. (Rinsing both sides of the impression occlude with one another. Many dentistsarticulate the models to obtain an accurate ensures that there are minimal amounts of po- prefer to use VPS, instead of less accuratebite, if the teeth are evenly elevated. tentiallyinfectious materialsin theimpression, wax, as a bite registration material for high– to help prevent infectious material from being precision crown and bridge procedures.Preparations to take prior blown around the operatory when the assis-to taking the reline impression tant air dries the impression). VPS bite registration material comes with a plastic cartridge that is locked into an impres- Prior to filling the initial triple tray impres- The dentist then observes the impression sion gun. The assistant attaches a spiral mixingsion to reline it, the assistant would have en- of the abutment teeth to ensure that the im- tip to the cartridge and dries the patient’s teeth.sured that the patient could close completely pression has captured all details, without air The assistant places VPS on the most posteriorinto the tray, when the assistant was trying in bubbles, gaps, de–lamination of the impres- mandibular tooth of one side of the arch, andthe tray when making the provisional restora- sion material, pulling of impression material, then, in a continuous movement, dispenses ation. The assistant would have trimmed the distortionsofthemargins,etc.1 Ideally,theim- continuous ribbon of VPS around the arch toimpression material within the tray as needed pression is accurate enough to capture tiny the most posterior tooth on the other side. ➤36 The Dental Assistant July/August 2013 www.dentalassistant.org
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The assistant then instructs the patient to cluding into the op-occlude into the VPS and keep occluding un- posing arch. Here,til the VPS sets. Bite registration VPS sets in the dentist mayeither two minutes or thirty seconds. The au- want to prepare allthors recommend the fastest set since this as- of the abutmentsures that the VPS will not be removed before teeth except for oneit has completely polymerized. However, the tooth that is in oc-assistant needs to work fast to dispense the clusion and makesmaterial to completely cover the teeth while the jaws stop at athe VPS is still soft enough for the patient to fixed and reproduc-be able to occlude completely into it. ible point in space. Then, the assis- Sometimes, there are no teeth on one tant takes a bite reg-side of the patient’s arch. Here, the assistant istration by placingbuilds up VPS between the opposing max- VPS on the abut-illary and mandibular edentulous areas, to ment teeth and the Fig. 7: A set of impressions that are useful for round–house crown andcapture the vertical relationship between the edentulous ridge bridge cases, showing (clockwise from bottom left) a pre–operative impres-ridges at various points along the arches. sion of the arch being treated, the final impression of that treated arch, segments between a counter–model impression, a pre–operative impression of the facial sur-Impressions for a full arch them and having faces of the anterior teeth, and a bite registration.round–house bridge the patient occlude using the one unprepared tooth. The assistant is instructed to occlude into the temporary If a dentist is making a round–house puts bite registration material between the pa- to ensure that the occlusion is still perfectbridge that bridges an entire arch of teeth, in tient’s gingiva and the teeth of the opposing with the cement in place.general separate arch impressions must be arch, and between the unprepared teeth and Carboxylate cement is stronger thanused. In addition, if most of the patient’s an- the teeth of the opposing arch, so that the bite eugenol–based cement and bonds weaklyterior teeth exist before the bridge teeth are registration material contacts and connects to the tooth itself. Unmixed Carboxylate ce-prepared, a separate pre–operative impres- the surfaces of the two arches. After this bite ment comes as a powder and liquid, that cansion of the unprepared teeth should be made registration has been obtained, the dentist be mixed on the plastic surface of a used auto-andsenttothelaboratory(Fig.7,above). The prepares the last remaining tooth. The labora- clavebag,usingthewoodenendofacottontiplaboratory will use this to make a model to torytechniciancanarticulatethecastsbyusing applicator. The mixed cement can be a thick,use as a reference for how the anterior teeth the bite registration that just goes on all of the opaqueliquid,orslightlytacky.3 Useofathick,of this bridge looked like prior to preparing abutmentsexcepttheonethatwasnotyetpre- tacky mix of a strong cement such as carboxy-the teeth, and what is the vertical dimension pared when the bite registration was made. late helps to fill in small voids under the inta-of the occlusion of the patient’s dentition. glio surface of the temporary restoration. Temporary restorations cemented with In addition, an impression of the facial Cementing thesurfaces of the unprepared anterior teeth canbe made to show how the anterior teeth look, provisional restoration carboxylate cement are less likely to fall outby having the patient occlude the teeth, andplacing fast–setting bite registration material Dentists often use a eugenol–based compared to those cemented with eugenol–on the facial surfaces of both the mandibular temporary cement to cement temporary based cement, even if there are small mar-and maxillary anterior teeth (Fig. 7, above). teeth, which allows relatively easy removal ginal voids in the temporary restoration.When the impression material has reached a of the temporary restoration at the try–in Carboxylate cement may require a cavitrontacky set, the assistant lightly uses fingers to visit to place the final crown. This cement to efficiently remove it from the abutmentpress the impression material into the teeth is dispensed with a 50–50 ratio of base and on the day of insertion. In addition, theto ensure the infiltration of the impression catalyst onto a mixing pad or onto the plastic provisional restoration cemented with car-material. This shows the relationship of the surface of a used autoclave bag. The cement boxylate cement often cannot be pulled offmaxillary midline to the mandibular midline, can be quickly mixed using the wooden end a tooth, but may need to be cut off.and how far the anterior teeth protrude. of the cotton tip applicator that was used to To remove excess cement, an assistant apply topical anesthetic to the patient. The uses a cotton roll to wipe away excess cement If a dentist is performing a round–house cement is placed into the temporary resto- whilethecementisstillliquid,andflossesthebridge on a patient, obtaining a bite registra- ration and swirled around until the intaglio temporary to remove inter–proximal excess.tion can be challenging because when all of surface is completely coated with cement. The assistant passes the tip of an explorer un-the teeth are prepared, there may be no natu- The abutment tooth is dried, the temporary der bridge pontics to remove excess cementral teeth occlusion but just abutments oc- is cemented onto the tooth, and the patient from underneath the pontics.38 The Dental Assistant July/August 2013 www.dentalassistant.org
After the cement has attained a some- The shade of the crown or bridge, and Conclusionwhat hard but brittle set, the assistant uses an the type of shade guide used to obtain the When assisted by a knowledgeableexplorer to chip away excess cement from the shade, should be indicated on the laborato-margins. The assistant removes inter–proxi- ry slip. The authors often use Vita porcelain dental assistant, a dentist performing triplemal cement by pushing an explorer tip into shade guide shade D–2 for posterior teeth, tray procedures may only need to anesthe-the interface between the cement and the because it tends to blend in the posterior. tize the patient and prepare the crown andtemporary restoration and moving the tip in The shade must be more precise for anterior bridge abutment/s. The assistant, depend-an apical and lateral movement to dislodge teeth, so an assistant should compare differ- ing on what tasks the assistant can legallythe cement. A cavitron may also be used to ent shades and consult with the dentist and and competently perform, can do most ofchip away at excess hardened cement. The the patient to agree on a shade. the remaining work while being supervisedassistant then instructs the patient not to eat by the dentist when the dentist’s expertise isfor two hours while the cement sets. If a dental laboratory technician person- needed. Although in the future, computer– ally picks up laboratory cases, the case may based crown and bridge procedures4–6 mayWriting the laboratory instructions be packaged into a small bag. A few crum- supplant various aspects of the manual tripleand packaging the case pled paper towels may be placed in the bag tray technique, the efficiency of the manual for cushioning and to absorb moisture, and technique may assure its continued usage. A laboratory slip contains written instruc- the impressions placed over this.tions that instruct a dental technician what to ❖make using the enclosed impression and other The dentist may also mail the case to amaterials. The laboratory slip should contain non–local laboratory. Here, the case is pack- Referencesthe office address and the name of the treating aged in a small box with foam cushioning,dentist, and the date when the treatment was so that the materials are not compressed but 1. Walker MP, Rondeau M, Petrie C, Tasca A, Williamsperformed. The assistant should always have also do not move inside the box. The assis- K.“Surfacequalityandlong–termdimensionalstabilitythe dentist review the instructions and tooth tant should never mix materials from differ- of current elastomeric impression materials after disin-numbers involved, and sign the laboratory slip. ent cases in the same package. fection,” J Prosthodont. 2007 Sep–Oct;16(5):343–51. (Continued on page 48) GuardinG aGainst infectionWhoever said all facemaskswere created equal definitelyhasn’t tried Tidishield™ VciobNlroeawrNstIntroducIng Procedure Facemask 9040DB Ocean Blue*See for yourself why many Dental Professionals are callingthe TIDIShield™ Facemask the lightest, most comfortablefacemask they’ve ever used.Breathe Easier - Superior breathability. TIDIShield™ facemasks are free of 9040DSA Pink Punch* 9040DY Lemon Dropnatural rubber latex, fiberglass-free, odorless and non-irritating. Coming Soon: 9040DL Lavender SwirlFluid Resistant - When facemasks become saturated from the inside or outside,transfer of substances and airborne pathogens through the mask are likely tooccur. TIDIShield™ SMS facemasks last for an entire procedure and are more fluidresistant than a facemask that contains tissue.Maximum Comfort - Longer, rounded earloop design will not pull or irritate ears.Soft, lightweight and non-irritating materials; perfect for longer wear.Unique Design - 3-ply download fold design provides an exact fit, betterprotection and eliminates pooling while meeting all ASTM F2100 safety standards.*TIDIShield™ Ocean Blue and Pink Punch facemasks meet higher Level 2 ASTM standardsand offer better protection than traditional dental procedure facemasks Call for a FREE SAMPLE 1.800.521.1314 or visit www.tidiproducts.com COPyrIghT © 2013 TIDI PrODuCTS, LLC. ALL rIghTS reServeD.39www.dentalassistant.org 2013 July/August The Dental Assistant
U.S. Air ForceSSgt Dianet SantosThe Air ForceDental Serviceand the EnvironmentHow the Air Force dental service provides environmentally–responsible dental careost people would not draw a correlation between den- remove amalgam particles from dental office waste water throughtistry and the environment. However, if we, as dental sedimentation, filtration, centrifugation and a chemical removalservice airmen, do not follow appropriate procedures, ionization process. Amalgam separators must meet the Interna-therewouldbeasignificantamountofhazardouswasteintroduced tional Organization for Standardization standard, which requiresinto our fragile ecosystem. The Air Force Dental Service (AFDS) that 95 percent of the amalgam discharge must be captured prioris not only a leader in dental innovation, our ability to render out- to entering into sewer systems. The AFPPP, as stated in Air Forcestanding patient care coupled with a clear focus on patient safety Pamphlet 36–2241, strengthens the Air Force’s mission capabili-and care for the environment is unparalleled as well. When was the ties by protecting human health and the environment. The AFPPPlast time you reflected on your responsibility to environmental focuses on the reduction or elimination of waste at the source byprotection as well as patient safety? The AFDS is fully compliant modifying production processes, promoting the use of non–toxicwith environmental policies and procedures and continually edu- or less–toxic substances, and implementing conservation tech-cates its airmen on proper disposal, reduction and prevention of niques through reusing materials rather than adding them to theenvironmental wastes. The Dental Service has championed the Air waste stream. Through diligence and compliance with appropriateForce’s Pollution Prevention Program (AFPPP) by reducing or amalgam disposal directives, we can ensure that our water supply iseliminating dependence on hazardous materials and implement- not unnecessarily contaminated with mercury.ing re–utilization on recoverable waste. Let’s look at two areas Every airman, whether part of the dental services or not, is awhere we play an integral role in pollution prevention: the disposal steward of the environment and should play an integral role in theof amalgam waste and digital radiography. AFPPP. When it comes to pollution prevention, innovative tech-Due to its stable properties, amalgam has been used in den- nology has enabled huge gains within the AFDS. Let’s take a look attistry since 1826. However, because of the significant mercury an area where innovation has had far reaching positive effects on ourcontent in amalgam, the AFDS has taken precautions. AFI 32– environment. With the development of digital radiography, hazard-7041 Water Quality Compliance Program provides implementa- ous waste produced by the antiquated dental radiography has beention guidelines which directs compliance with the Clean Water completely eliminated.Act and therefore requires attention to detail when disposing of In order to continue providing first class dental care to ouramalgam. The chairside traps and vacuum pump filters are a ba- customers, the AFDS is dedicated to using innovative and ad-sic filtration system which reduces the amount of mercury solids vanced technology. Since its inception, dental radiography has ex-passing into the sewer system and eventually contaminating valu- perienced an incredible evolution of technology. The importanceable water supplies. Amalgam separators are devices designed to and benefits of dental radiographs can never be understated. ➤40 The Dental Assistant July/August 2013 www.dentalassistant.org
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Radiographs can reveal abscesses, cysts, SSgt Dianet Santos (right) taking digital dental images of her patient, Ms. Petra Hense.bone loss, cancerous and non–canceroustumors, decay between the teeth, develop- SSgt Santos in the operatory.mental abnormalities, poor tooth and rootpositions, and problems inside of a tooth or ecuting our vital missions. Throughout the stein Air Base, Germany. She was born in thebelow the gum line. Air Force, accomplishing our mission safely Dominican Republic, grew up in the Bronx, and effectively is a top priority. Compliance New York City, NY, and joined the Air Force Through the advancement of digital ra- with Environmental Management System in 2003. SSgt Santos is currently enrolled at thediography, we have eliminated the necessity directives by every airman is key to making University of Maryland and pursuing a bach-for darkrooms, radiographic film, chemicals this priority a reality. elor’s degree in occupational therapy. She enjoysand generation of other associated hazard- volunteering with the wounded warrior pro-ous waste. Digital radiography is the latest ❖ gram and working with special needs children.technology used to take dental images, usingan electronic sensor rather than the radio- SSgt Dianet Santos is a dental assistantgraphic film with traditional radiography. assigned to the 86th Dental Squadron at Ram-Digital radiographs provide the best optionfor our patients, by quickly capturing imagesof teeth and gums and subsequently storingthem on a computer for ease of access andtransfer between health care providers. Without this technology, the AFDSwould be responsible for generating anenormous amount of hazardous wastethat would be devastating to our environ-ment. Therefore, I’d like to encourage youto be aware of the impact, both positive andnegative, that your daily activities have onour environment. You may be very astuteor quite the opposite when it comes to en-vironmental issues, but be assured the AirForce is not. In an attempt to reduce pollu-tion and improve our environment, the AirForce is championing the “Win the WarAgainst Waste” campaign. It encourages allairmen to do their best to recycle and divertwaste from landfills, which facilitates the AirForce’s sustainability and mission. During “For Earth Day 2013,” the AirForce is highlighting water resource man-agement programs, including conservation,water quality, pollution prevention, waste-water and storm water management, anduse of innovative water–saving technologiesin design, construction, landscaping andfacilities sustainment, restoration and mod-ernization. It is important to recognize thatfailure to properly protect and maintain theenvironment in which we operate may neg-atively impact mission effectiveness. There-fore, together we must commit to protectthe environment, the health of our airmenand surrounding communities while ex-42 The Dental Assistant July/August 2013 www.dentalassistant.org
ADessnistatal nts Affordable Dentures was founded in Kinston, North Carolina in 1975 and has grown into a network of nearly 200 affiliated practices operating in 39 states. Dental assistants play an important role in each Affordable Dentures practice. They provide skilled patient care and assist dentists with oral surgery, denture services and dental implants. If you are an experienced Dental Assistant and enjoy a high-volume, fast-paced environment and are willing to work to provide the best in patient care, consider a career with Affordable Dentures.Do Visit our web site at www.affordabledentures.com/careers to Well. learn about Dental Assistant positions currently available.Do Good. Competitive Benefits Package including: Medical, Dental, Vision Paid Life and AD&D Insurance Paid Vacation & Sick Days 401(k) Retirement Savings Plan Continuing Education www.affordabledentures.com/careers 1-800-313-3863Apply online or fax resume to (252) 208-7087 EOE
Health BeatBeyond the brush: Five ways to help • See the doctor. Regular check–ups by a physician can help with early diagnosis of several health issues, including peri-promote healthy teeth and gums odontal disease. A large body of research associates gumAccording to the American Academy of Periodontology disease with other chronic inflammatory diseases such as(AAP), pairing a few well–known healthy–lifestyle habits withyour daily oral health regimen may also help reduce your risk for diabetes, cardiovascular disease, and rheumatoid arthritis. Therefore, by screening for systemic disease early and re-periodontal disease. ceiving any needed treatment, you may also benefit yourPeriodontal disease is a chronic inflammatory disease that af-fects the gum tissue and other structures supporting the teeth. Ac- periodontal health.cording to Dr. Pamela McClain, President of the American Acade- “Taking good care of your periodontal health starts with dailymy of Periodontology and a practicing periodontist in Aurora, CO, tooth brushing and flossing. You should also expect to get a compre-“If left untreated, periodontal disease can lead to tooth loss andmay also interfere with other systems of the body. Several research hensive periodontal evaluation, or CPE, every year,” Dr. McClainstudies have indicated that one’s periodontal health may be related advises. A dental professional, such as a periodontist, a specialist into overall health. Therefore, it is crucial that you do everything you the diagnosis, treatment and prevention of gum disease, can con-can to establish good periodontal health.” duct a comprehensive exam to assess your periodontal health. According to the AAP, the following tips may help sustain both Treatment for gum disease can lower medicalhealthy teeth and gums and an overall healthy lifestyle: costs for people with diabetes • Eatanddrinkup.Itiswellknownthateatingabalanceddiet Medical costs are lower for people with diabetes who receive leads to proper nutrition and helps keep the body running effectively. Studies published in the Journal of Periodontol- treatment for gum disease, according to a study presented to the ogy (JOP) have also shown that certain foods can promote American Association for Dental Research by Dr. Marjorie Jeff- teeth and gum health. Foods containing omega–3, calcium, coat of the University of Pennsylvania. The study was done in col- vitamin D and even honey have all been shown to reduce laboration with United Concordia Dental and Highmark Inc. the incidence or severity of periodontal disease. “The study showed that periodontal treatment and ongoing maintenance is associated with a significant decrease in the cost of• Hit the gym. Frequent exercise is a recognized way to avoid medical care for people with diabetes—in the amount of $1,800being overweight, and it may ultimately reduce your risk of per year,” said James Bramson, DDS, chief dental officer for Unitedperiodontaldisease.InastudypublishedintheJOP,research- Concordia. “The findings also showed that hospitalizations de-ers found that subjects who maintained a healthy weight and creased by 33 percent and physician visits by 13 percent across thehad high levels of physical fitness had a lower incidence of entire study population of diabetics when gum disease is treatedsevere periodontitis than those that did not exercise. and managed afterward.” More than 25.8 million adults and children are living with dia-• Stress less. Stress can lead to a variety of health complica- betes in 2011—a number that has more than doubled since 1999, tions, including periodontal disease. Research published according to the Centers for Disease Control and Prevention. in the JOP showed a relationship between stress and peri- odontal disease. Increased levels of cortisol, which the body “These numbers clearly demonstrate the importance of the releases when experiencing stress, can intensify the destruc- study’s findings for people with diabetes, as well as the impact the tion of the gums and bone due to periodontal disease. In treatment of gum disease can have on the rising medical costs as- addition, another JOP study indicated that people experi- sociated with diabetes,” said. Dr. Bramson. encing stress are more likely to neglect their oral hygiene. “The study points to the ability to lower medical costs among• Kick the habit. Smoking is not only a leading cause of re- patients with diabetes through appropriate dental care,” said F.G.spiratory and cardiovascular disease in the United States, Merkel, United Concordia president and chief operating officer. “Weit is also a major risk factor for periodontal disease. Sev- believe that employers will realize reduced medical costs when theireral research studies have shown that smoking not only employees with diabetes receive appropriate periodontal care.”increases the chance of developing periodontal disease, itcan also affect the success of treatments for existing peri- “A considerable amount of literature exists pointing to an as-odontal disease. sociation between dental disease and certain medical conditions, including diabetes, heart disease, stroke, and premature or low birth weight infants,” said Dr. Jeffcoat. ➤44 The Dental Assistant July/August 2013 www.dentalassistant.org
2013The Largest Dental Meeting/Exhibition/Congress in the United StatesNo prE-rEGiSTrATioN FEE 89th MArK YoUr CALENDAr annual sessionMEETiNG DATES: ExhibiT DATES:Friday, November 29 - Sunday, December 1 -Wednesday, December 4 Wednesday, December 4 Attend At No Cost Never a pre-registration fee at the Greater New York Dental Meeting More Than 350 Scientific programs Seminars, hands-on Workshops, Essays & Scientific poster Sessions as well as Specialty and Auxiliary programs More than 600 Exhibitors Jacob K. Javits Convention Center 11th Avenue between 34-39th Streets New York City™ headquarters hotel New York Marriott Marquis hotelLatest Dental Technology & Scientific Advances Live Dentistry Arena - No TUiTioNEducational programs in various languages Social programs for the Entire FamilyEnjoy New York City at its best during the most festive time of the year!WWW.GNYDM.CoMNPGERLWNAEYSBDDESENMHNTOTSAWL For More information: Greater New York Dental Meeting 570 Seventh Avenue - Suite 800, New York, NY 10018 USA Tel: (212) 398-6922 / Fax: (212) 398-6934 E-mail: [email protected] / Website: www.gnydm.com Sponsored by: The New York County Dental Society and The Second District Dental Society
The information being released related Platelet–rich fibrin offers an alternative Additionally, the study reported no pain-to diabetes is the first in a series of findings biomaterial that is simple and inexpensive ful events, quick healing of soft tissue, andwhich will demonstrate that appropriate to prepare. Blood is collected in tubes with- complete wound closure within one weekdental treatment and maintenance can actu- out anticoagulant and centrifuged. It divides after oral surgery. Leukocyte– and platelet–ally help lower medical costs for individuals into three layers, creating a strong platelet– rich fibrin offers an excellent option for use inwith certain medical conditions. rich fibrin clot in the middle layer. Platelet– heart patients on an anticoagulant regimen. rich fibrin has proved useful in daily dental Full text of the article, “Prevention of The University of Pennsylvania study practice as filling material for regeneration in Hemorrhagic Complications After Dentalanalyzed data over a three–year period from order to place implants. Extractions Into Open Heart Surgery Pa-nearly 1.7 million individuals with United tients Under Anticoagulant Therapy: TheConcordia dental and Highmark medical In this study, 50 heart patients following Use of Leukocyte– and Platelet–Rich Fi-coverage. It focused on determining if dental an anticoagulant therapy were treated with brin,” Journal of Oral Implantology, Vol. 37,cleanings and/or treatment of gum disease leukocyte– and platelet–rich fibrin clots No. 6, 2011, is available for viewing onlinewould decrease the cost of medical care in placed into post-extraction sockets. Com- at http://www.joionline.org/. ❖patients who have diabetes. The study will plications of bleeding were reported in onlyalso analyze other chronic diseases and con- two of these patients, and 10 had mild bleed-ditions, such as heart disease, strokes and ing. All complications were resolved within apregnancy with pre–term birth. few hours after the oral surgery.Oral surgery protocol to control It’s hard to picture a member of thebleeding for heart patients XXXXXXXXAXDXAXAXXXXXXXXX without one.shows positive results Cardiac patients that take anticoagu- Personalize your newlant medications and need a tooth extrac- XXXXXXXXXAXDXAAXXXXXXXXXtion face an increased risk of bleeding that Visa® Platinum Rewards Card.must be addressed by the treating clinician.Therefore, a protocol for heart patients is • Points for purchases • Points for billed interestneeded that will avoid significant bleedingafter dental extractions without suspending • Bonus points at select merchants • Redeem for cash, travel, merchandise and moreanticoagulant therapy. • Points for balance transfers • Personalized custom cards A study reported in the current issue ofthe Journal of Oral Implantology evaluated ChohottspeC://hVwyowoiosswuaer.®cyaocoraufdfirrpdcoaifraftainclteiaXr(l.gcXAorDXomAuX/pApXroVXu/iasrXpalp®)X/atcXdoaaXdradaXtayoXtd.XayX. XXXthe use of leukocyte– and platelet–rich fi-brin biomaterial. This material is commonly The ADAA Visa card program is operated by UMB Bank, N.A. All applications for ADAA Visa credit card accounts will be subject to UMB Bank N.A.'s approval, atused in dentistry to improve healing and its absolute discretion. Please visit www.cardpartnerpro.com for further details of terms and conditions which apply to the ADAA Visa card program.tissue regeneration. It was tested as a safefilling and hemostatic material after dental Pro Powered by UMB CardPartner.com. The #1 provider of custom credit card programsextractions in 50 heart patients undergoing ©2011 UMB Financial Corporation. All rights reserved. UMB is a registered service mark of UMB Financial Corporationoral anticoagulant therapy. These heart patients had mechanicalvalve substitutions, and then were placed onanticoagulant oral therapy with warfarin. It isnot recommended that the anticoagulant besuspended and replaced with heparin before aminor surgery, although this substitution maycontrol the risk of postoperative bleeding. One method of controlling bleedingwithout suspending the anticoagulant is theuse of platelet–rich plasma gel placed in post-extraction tooth sockets. Although this pro-tocol has been successful, there are barriersto its daily use. The platelet concentrates areexpensive and take a long time to prepare.46 The Dental Assistant July/August 2013 www.dentalassistant.org
ADAA Working for You(continued from page 4)appropriate standards of preparation and practice, not only do ADAA means to bring you all of the latest and most helpfulwe elevate our profession, we also help to assure best practices, information to facilitate fulfillment of your daily responsibili-as well as the safety of those who come under our care. ties, whether you’re a front office manager, chairside assistant,Many new initiatives have also been developed to support laboratory assistant, business assistant or the all–encompass-ADAA members: E–membership criteria and parameters, new ing “jack of all trades” assistant.prescription and credit card plans, multiple scholarships and As we prepare for our upcoming Annual Session in New Or-awards, revised forms for reporting electronic submissions of leans, LA, this October, we hope that you will be able to join usMastership/Fellowship coursework, new and revised online to celebrate our accomplishments, welcome your new officerscontinuing education courses, and new course delivery systems and to plan for our continued success and our future. ADAAto facilitate enhanced professional and personal growth. welcomes your participation by way of attendance at profes-Increased cost–saving measures and enhanced transpar- sional meetings, involvement at the local, state and nationalency in reporting expenditures have been implemented by levels, and in encouraging other dental assistants to becomethe Board and Central Office to assure worthwhile and ap- members of our Association to help with assuring the protec-propriate use of all funds to support member initiatives. A new tion and promotion of dental assisting.marketing plan is being developed to heighten public and pro- The initiatives I’ve shared here are only a small snapshot offessional awareness of the valuable role that dental assistants all the behind–the–scenes work that has been accomplished forplay as significant members of the dental health care team. A you over the past several months. Yes, ADAA is working hardvariety of new authors have also been identified who contrib- on your behalf in promoting dental assisting and in protectingute relevant high–level articles to The Dental Assistant Journal the patients we serve. ADAA is your voice, the voice of dentaland other online communications to keep you well informed. assistants to the public and to all other professionals. ❖Legislative InfoNotes Student News(continued from page 22) (continued from page 23)Bill adding CDA as a voting member of the Board of Den- in turn can harm us. It is our job as dental assistants to make sure thattistry passed out of Committee in Rhode Island all water lines are functioning properly each day and that traps are changed regularly and are functioning properly. Rhode Island SB 539 passed favorably out of Committee on Scrap amalgam can also be stored in an airtight properly labeledMay 22, 2013 and was referred to the House Health, Education scrap amalgam container, which is then recycled by an amalgamand Welfare (HEW) Committee. If passed, this Bill will add a Cer- recycler. Never throw amalgam in the trash, rinse down the sinktified Dental Assistant as a voting member of the Board of Den- or place in a biohazard bag. It should only be placed in the propertistry. At the time of this writing, the Bill has not been heard in the container and disposed of by the proper recycling company.House or in Committee. Other chemicals that are hazardous to our environment are X– ray fixer solution with silver and developer solutions. These materi-Bill providing for post graduate education for als should never be mixed together and disposed down a drain. Ifhygienists tabled in Maine House of Representatives they are mixed, they should only be disposed through a hazardous waste company. Other chemicals, such as disinfectants and clean- A Maine LD 1230 Bill would provide for post graduate educa- ers, should always be disposed properly—read labels completely totion for hygienists to become Midlevel Providers (MLP). The RDH make sure that the rules of handling these products are followed. Of-MLP would work under direct supervision of a dentist and may fice waste such as paper should always be gone through to make sureeven have private practice with a contractual relationship of direct that proper recycling is taking place. It is up to us to help protect thesupervision of a dentist who would see the patient within a reason- environment. Many of us may not realize it but as dental care profes-able period of time. The MLP would be allowed to do fillings and sionals we have a job and a role to play to make sure that our workextractions in addition to other listed procedures beyond the tradi- doesn’t affect the environment in a negative way.tional hygienist. On June 19, the Bill was indefinitely tabled in the ❖Maine Senate. On June 20, the Bill was tabled in the House. ❖www.dentalassistant.org 47July/August 2013 The Dental Assistant
Triple Tray Crown List of Advertisers(continued from page 39) ADAA Credit Card Program 462. Boksman L. “Optimizing occlusal results for crown and bridge prostheses,” Affordable Dentures 43Dent Today. 2011 Jan;30(1):154, 156–7.3. Behr M, Rosentritt M, Loher H, Kolbeck C, Trempler C, Stemplinger B, Ko- Colgate 11pzon V, Handel G. “Changes of cement properties caused by mixing errors: thetherapeutic range of different cement types,” Dent Mater. 2008 Sep;24(9):1187– Cetylite 3793. Epub 2008 Mar 26.4. van der Meer WJ, Andriessen FS, Wismeijer D, Ren Y. “Application of in- Crosstex C3tra–oral dental scanners in the digital workflow of implantology,” PLoS One.2012;7(8):e43312. Epub 2012 Aug 22. DentalPost 95. Kachalia PR, Geissberger MJ. “Dentistry a la carte: in–office CAD/CAM tech-nology,” J Calif Dent Assoc. 2010 May;38(5):323–30. Greater New York Dental 456. Kassem AS, Atta O, El–Mowafy O. “Fatigue resistance and microleakage of CAD/CAMceramic and composite molar crowns,” J Prosthodont. 2012 Jan;21(1):28–32. Henry Schein Dental 5 John S. Mamoun, DMD, is a 2003 graduate of the University Hu–Friedy C4of Medicine and Dentistry of New Jersey. He completed a one–yearAdvanced Education in General Dentistry residency at the Eastman Kerr TotalCare 13Dental Center in Rochester, NY, and later earned his Fellowship awardfrom the Academy of General Dentistry. He is currently in private prac- Patterson Advantage 33tice in Manalapan, NJ. Patterson Dental 24–25 Mariam Javaid, BDS, graduated from the Altamash Institute ofDental Medicine (AIDM) in 2009, in Pakistan. She completed a resi- Septodont C2dency at the AIDM in 2010, and an externship at the Karolinska Insti-tute in Stockholm, Sweden, then came to the United States, where she is Solutions Reach/Smile Reminder 17a dental assistant in Philadelphia, PA. Sultan 3 Classifieds Sultan 27 Classified ad rates: $20 minimum for 30 words or less, 25 cents for each addi- tional word. Blind box number: $3 additional. Display classified ad rates: $100 TIDI Products 39 per column inch. Maximum depth accepted: 4 inches. Line art must be supplied as high–res (minimum 300 dpi) .jpeg or .tif file. To place a classified or classified dis- Tokuyama 41 play ad, contact The Dental Assistant — Classifieds, (312) 541–1550 x209 or [email protected]. Ads must be paid in advance. ADAA neither investigates DISCLAIMER: “Authors and advertisers are solely responsible for nor assumes responsibility for ads published in this space. the accuracy of any and all material provided to The Dental Assistant. Authors and advertisers are also solely responsible for checking thatASSISTANT PROFESSOR & any and all material relevant to dental care in a clinical setting meetsDENTAL ASSISTING PROGRAM COORDINATOR OSAP standards. The information and opinions expressed or impliedThe University of Maine at Augusta–Bangor campus’s Dental Health in articles and advertisements that appear in The Dental Assistant arePrograms invites applications for a full–time, tenure–track, Assistant strictly those of the authors and advertisers. They do not necessarilyProfessor & Dental Assisting Coordinator. Responsibilities include: represent the opinion, position or official policies of the Americancoordinating the Dental Assisting Program; didactic, clinical and labo- Dental Assistants Association.”ratory teaching in the Dental Assisting program; academic advising,scholarly activity, professional and institutional service. This is a nine– Next Issue: The 2013 Guide to the ADAAmonth faculty position (September 1 through May 31) with one ad- Annual Session in New Orleans, LA. Also, anditional month worked during June, July and August. The start date overview of social media for dental assistants byfor this position is January, 2014. Interested candidates should visit the PennWell Managing Editor, Kevin Henry, andUniversity’s website at http://www.uma.edu/employment.html the final Product Report of the year.for additional information about the position and the applicationprocess. EEO/AA www.dentalassistant.org48 The Dental Assistant July/August 2013
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