Download CDHO Advisory Drug or Alcohol Dependency

CDHO Advisory | Drug or Alcohol Dependency
COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY
ADVISORY TITLE
Use of the dental hygiene interventions of scaling of teeth and root planing including
curetting surrounding tissue, orthodontic and restorative practices, and other invasive
interventions for persons 1 with drug or alcohol dependency.
ADVISORY STATUS
Cite as
College of Dental Hygienists of Ontario, CDHO Advisory Drug or Alcohol Dependency, 2010-07-15
INTERVENTIONS AND PRACTICES CONSIDERED
Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and
restorative practices, and other invasive interventions (“the Procedures”).
SCOPE
DISEASE/CONDITION(S)/PROCEDURE(S)
Drug or alcohol dependency
INTENDED USERS
Addiction specific counselors
Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies
ADVISORY OBJECTIVE(S)
To guide dental hygienists at the point of care relative to the use of the Procedures for
persons who have drug or alcohol dependency, chiefly as follows.
1.
2.
3.
4.
1
Understanding the medical condition.
Sourcing medications information.
Taking the medical and medications history.
Identifying and contacting the most appropriate healthcare provider(s) for medical
advice.
Persons includes young persons and children
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5. Understanding and taking appropriate precautions prior to and during the Procedures
proposed.
6. Deciding when and when not to proceed with the Procedures proposed.
7. Dealing with adverse events arising during the Procedures.
8. Record keeping.
9. Advising the patient/client.
TARGET POPULATION
Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged, 80 and over
Male
Female
Parents, guardians, and family caregivers of children, young persons and adults with drug or
alcohol dependency.
MAJOR OUTCOMES CONSIDERED
For persons who have drug or alcohol dependency: to maximize health benefits and
minimize adverse effects by promoting the performance of the Procedures at the right time
with the appropriate precautions, and by discouraging the performance of the Procedures
at the wrong time or in the absence of appropriate precautions.
RECOMMENDATIONS
UNDERSTANDING THE MEDICAL CONDITION
Terminology used in this Advisory and generally
Resources consulted
 Canadian Society of Addiction Medicine
 Centre for Addiction and Mental Health
 Dual Recovery Anonymous
 National Alliance on Mental Illness
 The Ohio State University Medical Center
A. Medical and scientific usages relating to drug and alcohol dependency
1. Addict, a person with the disease of addiction.
2. Addiction, a chronic disease characterized by
a. impaired control over one or both of
i. use of one or more psychoactive substances
ii. behaviours
b. manifestations variously in the realms of
i. biology
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3.
4.
5.
6.
7.
8.
9.
ii. psychology
iii. sociology
iv. spirituality
c. changes in mood
d. relief from negative emotions
e. provision of pleasure
f. preoccupation with one or both of
i. use of substance(s)
ii. ritualistic behaviour(s)
g. continued use of substance(s) despite adverse consequences
i. of a physical, psychological, or social nature
ii. arising from engagement in ritualistic or other behaviour(s)
h. a clinical course that may variously be
i. progressive
ii. relapsing
iii. fatal.
Agonist, a substance, such as methadone, that produces effects that are similar to but
less harmful than those of a psychoactive substance to which treatment is directed.
Alcohol problems, manifested by
a. empty bottles or cans in the garbage
b. irritability, depression or confusion
c. losing touch with friends or family
d. loss of co-ordination, falls
e. making excuses or making up stories to obscure the truth about drinking habits
f. memory lapses following drinking
g. neglect of personal care, including
i. not bathing
ii. not eating adequately or at all (CDHO Advisory)
iii. not taking care of health problems
h. sleeping problems
i. slurring of speech.
Antagonist, a substance that counteracts the effects of a psychoactive substance by
inhibiting or reversing its effects.
Concurrent disorder, similar in concept to comorbidity, a physical or psychiatric disorder
that
a. interacts with substance dependence
b. requires specific diagnosis and treatment to achieve stabilization and, where
possible, recovery.
Craving, a biological and psychological urge to return to addictive behaviour,
characterized variously by
a. strong desire
b. preoccupation
c. impulsivity.
Dependency, alternative term for substance-related disorder.
Dual diagnosis, concurrent or comorbid disorders, consisting of psychiatric illness and
substance abuse, and involving two distinct primary illnesses each of which requires
specific and concurrent treatment, for example
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a. the person begins use of mood-altering substances to cope with the psychiatric
illness; while the substances may have provided temporary relief they did not
address the psychiatric illness
b. the self-medication may lead to addiction, not likely to be cured by treating the
psychiatric illness; neither will treating the addiction cure the psychiatric illness.
10. Intoxication, a physiological condition that follows the administration of psychoactive
substances and results in disturbances in
a. perception
b. cognition
c. affect
d. level of consciousness
e. judgment
f. behaviour
g. other psychological and physiological functions and responses.
11. Maintenance therapy, treatment of substance dependence
a. with a prescription drug, such as
i. methadone for opioid dependence
ii. nicotine replacement therapy for tobacco
b. to prevent or minimize withdrawal effects
c. to reduce the harm associated with
i. a particular method of administration, such as sharing needles
ii. dangers to health
iii. social consequences.
12. Substance-related disorder, comprising
a. substance abuse, a pattern involving
i. abuse of illegal substances or the abusive use of legal substances such as
alcohol
ii. use that leads variously to significant problems or distress including
1. failure to attend work or school
2. substance use in dangerous situations like driving a car
3. substance-related legal problems
4. substance use that interferes with
a. friendships
b. family relationships
b. substance dependence, involving
i. continued use of drugs or alcohol, despite significant problems related to
their use
ii. signs such as
1. increased tolerance or need for increased amounts of substance to
attain the desired effect
2. withdrawal symptoms with decreased use
3. unsuccessful efforts to decrease use
4. increased time spent in activities to obtain substances
5. withdrawal from social and recreational activities
6. continued use of substance despite awareness of serious physical or
psychological problems.
c. chemical dependence, alternative term for the
i. compulsive use of drugs or alcohol
ii. inability to stop their use despite the serious problems.
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13. Tolerance, one of the following
a. need for substantially increased amounts of the substance to achieve
intoxication or the desired effect
b. substantially diminished effect with continued use of the same amount of the
substance.
B. Types of substances productive of dependency or addiction
1. Depressant, a psychoactive substance that suppresses, inhibits or decreases some
function of the central nervous system.
2. Hallucinogen, a psychoactive substance that
a. alters cognition, affect, and perception
b. may resemble psychoses (CDHO Advisory) in its actions
c. do not necessarily produce the gross impairment of memory and mental
orientation that is characteristic of the psychoses.
3. Inhalant, a volatile substance, such as a solvent, that vaporizes at ambient temperatures
and that is also a psychoactive substance.
4. Psychoactive substance, a substance that affects cognition, affect or perception,
involving
a. recurrent substance use in situations in which it is physically hazardous
b. recurrent substance use resulting in failure in fulfilling major role obligations at
work, school, or home
c. recurrent substance-related legal problems.
5. Sedative, reduces activity in certain parts of the brain and produces a calming effect.
6. Stimulant, a category of psychoactive substance that activates, enhances or increases
activity in the nervous system, and acts like adrenaline, one of the body’s natural
stimulants.
C. Imprecise and everyday usages of terminology
1. Alcohol, ethyl alcohol is a clear, colourless liquid; alcoholic beverages get their
distinctive colours from their other ingredients and from the processes of fermentation.
2. Alcoholic, an individual experiencing alcohol abuse or dependence.
3. Alcoholism, alcohol abuse or dependence.
4. Chemically dependent, substance-related disorder.
5. Drug addiction, substance-related disorder.
6. Drug habit, substance-related disorder.
7. Narcotic, opioid such as heroin, morphine and related drugs; the opposite of stimulant.
D. Drugs of dependency
1. Prescription medications available for lawful use in particular circumstances
a. prescribed
i. Amphetamines are stimulants; other or related stimulants include
1. caffeine
2. cocaine
3. ecstasy
4. ephedrine
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ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
xii.
xiii.
xiv.
xv.
5. methamphetamine
6. Ritalin®.
Anabolic steroids
1. are synthetic steroids with the same chemical structure as the
steroids found in testosterone, the male sex hormone
2. appeal to athletes and bodybuilders because of their anabolic
and androgenic effects.
Benzodiazepines, prescription sedatives used mainly to relieve anxiety
and to help with sleep.
Cannabis sativa, also known as the hemp plant, is the source of
marijuana, hashish and hashish oil, which are psychoactive substances.
Cocaine, a highly addictive stimulant that
1. produces “highs”
2. is called Crack in the form that can be smoked.
Codeine, an opioid, is used to
1. relieve mild-to-moderate pain
2. reduce coughing.
Crystal Meth, one of the street names used for methamphetamine.
Doda
1. is created by grinding dried poppy husks or poppy seeds
containing opiates into a fine powder
2. is usually ingested with hot water or tea, rather than injected
3. creates dependency
4. is used in some communities in Canada.
Ecstasy, has a chemical structure and effects similar to those of
amphetamine and to mescaline.
GHB, gamma-hydroxybutyrate, is
1. a depressant
2. produced naturally in the human body in very small amounts
3. potentially dangerous when taken as a recreational drug,
especially in combination with alcohol or other drugs.
Heroin is
1. an opioid
2. a dangerous and illegal drug with a high addictive potential
3. an effective analgesic.
Ketamine is
1. a hallucinogen
2. a fast-acting anesthetic and analgesic used primarily in
veterinary surgery
3. occasionally used in human medicine.
LSD, lysergic acid diethylamide, is a potent hallucinogen.
Mescaline is
1. a hallucinogen
2. found in
a. peyote cactus
b. designer drugs.
Methadone is
1. a synthetic opioid
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2. used to treat dependence on other opioids.
xvi. Methamphetamine
1. is a stimulant similar in structure to amphetamine
2. possesses a high potential for abuse
3. is limited in its medical uses for which the doses prescribed are
much lower than those typically abused.
xvii. Morphine, an opioid
1. relieves pain
2. relieves fear and anxiety
3. impairs mental and physical performance
4. produces euphoria
5. rapidly results in tolerance.
xviii. Opioids
1. are a family of drugs that have morphine-like effects, and
include
a. codeine
b. heroin
c. morphine
d. oxycodone
2. are used to
a. relieve pain
b. control coughs
c. control diarrhea
3. produce euphoria, making them prone to abuse.
xix. OxyContin®
1. is a time-released analgesic used for 24-hr pain relief
contains oxycodone
2. is an opioid also contained in
Endocet®
Oxycocet®
Percocet®.
xx. Rohypnol®, a sedative, is the brand name of flunitrazepam, a
benzodiazepine that, in Canada and the US, is illegal to possess, traffic,
import or produce.
xxi. Street methadone, methadone sold or given to someone for whom it was
not prescribed.
E. Used for non-medicinal purposes or illegally
Amphetamines
Anabolic steroids
Cannabis
Cocaine
Doda
Crack
Crystal Meth
Ecstasy
GHB
Hallucinogens
Inhalants
LSD
Marijuana
Methamphetamine
Rohypnol
Street Methadone
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F. Other substances
1. In food and drink or consumer products, such as
Alcohol
Alcohol, Medication and Older Adults
Caffeine
Tobacco
2. Manufactured, imported, grown and/or distributed illegally, or are unregulated, such as
Cannabis
Inhalants
Cocaine
LSD
Crack
Marijuana
Crystal Meth
Methamphetamine
Ecstasy
Rohypnol
GHB
Street Methadone
Hallucinogens
G. Other medical or scientific terminology
1.
2.
3.
4.
5.
6.
7.
8.
Affect, the experience of emotion and feeling.
Anabolic, muscle-building.
Androgenic, masculinizing.
Central nervous system, the part of the nervous system that comprises the brain and
the spinal cord.
Cognition, the process of thinking.
Palliative care, services of care for persons towards the end of life with terminal
illnesses such as cancer, when the focus of the care
a. is relieving symptoms
b. attending to physical and spiritual needs.
Perception, the process of gaining awareness or understanding of sensory information.
Supportive care, services of care to help persons meet the physical, emotional and
spiritual challenges arising from the condition or its treatment.
Overview of drug or alcohol dependency
Resources consulted
 Canadian Society of Addiction Medicine
 Centre for Addiction and Mental Health
 Dual Recovery Anonymous
 National Alliance on Mental Illness
 The Ohio State University Medical Center
1. Addiction
a. Is defined as a primary, chronic disease.
b. Is characterized by impaired control over the use of a psychoactive substance
and/or behaviour.
c. Exhibits biological, psychological, sociological and spiritual manifestations,
such as
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i.
ii.
iii.
iv.
v.
change in mood
relief from negative emotions
provision of pleasure
preoccupation with use of substance(s) or ritualistic behaviour(s)
continued use of the substance(s) and/or engagement in behaviour(s)
despite adverse physical, psychological and/or social consequences.
d. Is associated in pregnancy (CDHO Advisory) with adverse consequences for child
development such as fetal alcohol spectrum disorder (CDHO Advisory).
e. Creates risks for children.
f. Undermines mental health in children and youth.
g. Creates difficulties for families.
h. May be progressive, relapsing and fatal.
2. Psychoactive substances
a. variously affect cognitive, affective and perceptual processes of the brain and
include
i. depressants
ii. stimulants
iii. hallucinogens
iv. opioids
v. inhalants.
b. in recurrent use
i. generate physical danger in potentially hazardous situations such as
1. driving a car
2. operating a machine
ii. result in failure to fulfill major role obligations at work, school, or home,
such as
1. repeated absences or poor work performance
2. absences, suspensions, or expulsions from school
3. neglect of children or household
iii. lead to legal problems, such as arrests for substance-related disorderly
conduct.
Comorbidity, complications and associated conditions
Resources consulted
 Centre for Addiction and Mental Health: Alcohol Problems
 Centre for Addiction and Mental Health: Anxiety
 Centre for Addiction and Mental Health: Dementia
 Centre for Addiction and Mental Health: Depression
 Centre for Addiction and Mental Health: Gambling Problems
 Centre for Addiction and Mental Health: Medication Issues
 National Alliance on Mental Illness: Dual Diagnosis and Integrated Treatment of Mental
Illness and Substance Abuse Disorder
 National Institute on Drug Abuse Comorbidity: Addiction and Other Mental Illnesses
Comorbid conditions are those which co-exist with drug or alcohol dependency but which
are not believed to be caused by it. Complications and associated conditions are those that
may have some link with it. Distinguishing among comorbid conditions, complications and
associated conditions may be difficult in clinical practice.
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For drug or alcohol dependency, comorbid conditions, complications and associated
conditions include
1. Anxiety (CDHO Advisory)
2. Dementia (CDHO Advisory)
3. Depression (CDHO Advisory)
4. Liver disease (CDHO Advisory)
5. Hepatitis C (CDHO Advisory)
6. HIV/AIDS (CDHO Advisory)
Oral health considerations
Resources consulted
 CDHO Guideline for Best Practice in Initiating Dental Hygiene Care
Oral healthcare considerations include
1. Requirement for rescheduling of a patient/clients’ dental hygiene appointment if s/he
a. appears to be
i. impaired
ii. under the influence of a substance that could impair his or her judgment
b. states that he or she has ingested a significant amount of alcohol prior to the
appointment.
2. The undermining of oral health by
a. dry mouth and other adverse effects of
i. drugs or substances on which the person is dependent, such as
Crystal Meth
methamphetamine
ii. medications used to treat dependency, such as methadone
b. self-neglect that often accompanies dependency
c. cost of oral healthcare as a barrier to persons with dependency.
3. Adverse effects on the safety of dental hygiene services because drug and alcohol
dependency may
a. render the Procedures harmful
b. make informed consent difficult to obtain
c. put oral healthcare professionals at risk of
i. infection
ii. physical violence.
4. Benefits to the patient/client because oral healthcare for persons with drug and alcohol
dependency may
a. improve general health as well as oral health
b. enhance wellbeing, nutrition and social interactions.
MEDICATIONS SUMMARY
Sourcing medications information
1. Adverse effect database
 Health Canada’s Marketed Health Products Directorate
toll-free 1-866-234-2345
 Health Canada’s Drug Product Database
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2. Specialized organizations
 US National Library of Medicine and the National Institutes of Health Medline Plus
Drug Information
 WebMD
3. Medications considerations
a. All medications have potential side effects whether taken alone or in
combination with other prescription medications, or as over-the-counter (OTC)
or herbal medications.
Information on herbals and supplements
US National Library of Medicine and the National Institutes of Health Medline
Plus Drug Information All Herbs and Supplements
b. Psychoactive substances are used in maintenance therapy.
Types of medications
Warnings
Individual medications may be subject to important warnings, which
1. change from time to time
2. may affect the appropriateness, efficacy or safety of the Procedures
3. are accessible via the links to the particular medications listed below or through the
specialized organizations listed above
4. through the links, should be viewed by dental hygienists in the course of their
familiarizing themselves about a medication or combination of medications identified in
the patient/client’s medical and medications history.
Medications
1. For alcohol addiction, such as
acamprosate (Campral®)
disulfiram (Antabuse®)
naltrexone (ReVia®).
2. For opioid addiction, such as
methadone (Dolophine®, Methadose®)
buprenorphine (Suboxone®, Subutex)
naltrexone (ReVia®).
3. For mental health conditions associated with addiction, such as
alprazolam (Alprazolam Intensol®, Xanax®)
diazepam (Diazepam Intensol®, Valium®)
lorazepam (Ativan®, Lorazepam Intensol®)
triazolam (Halcion®).
Side effects of medications
See the links to the individual medications listed above.
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THE MEDICAL AND MEDICATIONS HISTORY
The medical and medications history-taking should
1. Focus on screening the patient/client prior to treatment decision relative to
a. key symptoms
b. medications considerations
c. contraindications
d. complications
e. comorbidities.
2. Explore the need for advice from the appropriate primary or specialized care
provider(s).
3. Inquire in a cautious yet unambiguous way about
a. symptoms indicative of impairment
b. the patient/client’s willingness to discuss his or her dependency relative to
i. its effects on his or her oral health and self-care
ii. any history of impaired control of behaviour while he or she received
1. any type of healthcare
2. dental/dental hygiene care
iii. problems with previous dental/dental hygiene care
c. problems with infections generally whether or not these are specifically
associated with dental/dental hygiene care
d. the patient/client’s understanding and acceptance of the need for oral
healthcare
e. medications considerations, including over-the-counter medications, herbals
and supplements
f. the patient/client’s current state of health
g. how the patient/client’s current symptoms relate to
i. oral health
ii. health generally
iii. recent changes in the patient/client’s condition.
IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE
Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain
medical or other advice pertinent to a particular patient/client
1. Record the name of the physician/primary care provider most closely associated with
the patient/client’s healthcare, and the telephone number.
2. Obtain from the patient/client or parent/guardian written, informed consent to contact
the identified physician/primary healthcare provider.
3. Use a consent/medical consultation form, and be prepared to fax the form to the
provider.
4. Include on the form a standardized statement of the Procedures proposed, with a
request for advice on proceeding or not at the particular time, and any precautions to
be observed.
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UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS
Infection control
Dental hygienists are required to keep their practices current with infection control policies
and procedures, especially in relation to
1. The Recommendations published by the Centers for Disease Control and Prevention
(a frequently updated resource).
2. Relevant occupational health and safety legislative requirements.
3. Relevant public health legislative requirements.
4. Best practices or other protocols specific to the medical condition of the patient/client.
DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED
1. With drug or alcohol dependency, the dental hygienist should consult with the primary
care physician to obtain advice before implementing the Procedures.
2. The dental hygienist may also postpone the Procedures pending medical advice, which
is likely to be required if the patient/client
a. has the appearance of or acknowledges being in an impaired state
b. is displaying symptoms or signs
i. of behavioural problems
ii. of serious infection
iii. attributable to comorbidity, complication or an associated condition of
drug or alcohol dependency
c. not recently or ever sought and received medical advice relative to oral
healthcare procedures
d. recently changed significant medications, under medical advice or otherwise
e. recently experienced changes in his or her medical condition such as medication
or other side effects of treatment
f. is deeply concerned about any aspect of his or her medical condition.
DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES
Dental hygienists are required to initiate emergency protocols as required by the College of
Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of
the patient/client.
First-aid provisions and responses as required for current certification in first aid.
RECORD KEEPING
Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2)
For a patient/client with a history of drug or alcohol dependency , the dental hygienist
should specifically record
1. A summary of the medical and medications history.
2. Any advice received from the physician/primary care provider relative to the
patient/client’s condition.
3. The decision made by the dental hygienist, with reasons.
4. Compliance with the precautions required.
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5. All Procedure(s) used.
6. Any advice given to the patient/client.
ADVISING THE PATIENT/CLIENT
The patient/client is urged to alert any healthcare professional who proposes any
intervention or test that he or she has a history of drug or alcohol dependency.
As appropriate, discuss
1. The importance of the patient/client’s
a. self-checking the mouth regularly for suspicious signs or symptoms
b. reporting to the appropriate healthcare provider any changes in the mouth
indicative of suspicious lesions.
2. The need for regular oral health examinations and preventive oral healthcare.
3. Oral self-care including information about
a. choice of toothpaste
b. tooth-brushing techniques and related devices
c. dental flossing
d. mouth rinses
e. management of a dry mouth.
4. The importance of an appropriate diet in the maintenance of oral health.
5. For persons at an advanced stage of a disease or debilitation
a. regimens for oral hygiene as a component of supportive care and palliative care
b. the role of the family caregiver, with emphasis on maintaining an infection-free
environment through hand-washing and, if appropriate, wearing gloves
c. scheduling and duration of appointments to minimize stress and fatigue
6. Comfort level while reclining, and stress and anxiety related to the Procedures.
7. Medication side effects such as dry mouth, and recommend treatment.
8. Mouth ulcers and other conditions of the mouth relating to drug or alcohol dependency,
comorbidities, complications or associated conditions, medications or diet.
9. Pain management, with reference to the addictive nature of various pain relief
medications.
BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS
POTENTIAL BENEFITS
1. Promotion of health through oral hygiene for persons who have drug or alcohol
dependency.
2. Reduction of the adverse effects of drug or alcohol dependency on oral health and selfimage by
a. encouraging the person to view oral healthcare as a positive influence on his or
her
i. life and job or other social prospects
ii. recovery
b. generally increasing the comfort level of the person in the course of the dental
hygiene interventions
c. using appropriate, non-judgmental techniques of communication
d. providing advice on scheduling and duration of appointments.
3. Reducing the risk that oral healthcare needs are unmet.
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POTENTIAL HARMS
1. Causing or failing to respond to appropriately to inappropriate, harmful or dangerous
behaviour on the part of the person.
2. Performing the Procedures at an inappropriate time, such as
a. when the person is in a disturbed mental state, is impaired or exhibits signs of
insufficient control over behaviour
b. when the person is suffering from a serious infection
c. in the presence of complications for which prior medical advice is required
d. in the presence of acute oral infection without prior medical advice.
3. Disturbing the normal dietary and medications routine of the person.
4. Inappropriate management of pain or medication in ways that encourage addiction or
undermine the person’s treatment program.
5. Unnecessarily causing or encouraging avoidance of the Procedures.
CONTRAINDICATIONS
CONTRAINDICATIONS IN THE REGULATIONS
Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III
ORIGINALLY DEVELOPED
2009-11-24
DATE OF LAST REVIEW
2010-07-15
ADVISORY DEVELOPER(S)
College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists
SOURCE(S) OF FUNDING
College of Dental Hygienists of Ontario
ADVISORY COMMITTEE
College of Dental Hygienists of Ontario, Practice Advisors
COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY
Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of
Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA
Lisa Taylor
RDH, BA, MEd
Elaine Powell
RDH
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ACKNOWLEDGEMENTS
The College of Dental Hygienists of Ontario gratefully acknowledges the Template of
Guideline Attributes, on which this advisory is modelled, of The National Guideline
Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality
(AHRQ), U.S. Department of Health and Human Services.
Denise Lalande
Final layout and proofreading
COPYRIGHT STATEMENT
© 2008, 2009, 2010 College of Dental Hygienists of Ontario
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