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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 P a g e |1 CDHO Advisory | Drug or Alcohol Dependency 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 P a g e |2 CDHO Advisory | Drug or Alcohol Dependency 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 P a g e |3 CDHO Advisory | Drug or Alcohol Dependency 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. P a g e |4 CDHO Advisory | Drug or Alcohol Dependency 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 P a g e |5 CDHO Advisory | Drug or Alcohol Dependency 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 P a g e |6 CDHO Advisory | Drug or Alcohol Dependency 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 P a g e |7 CDHO Advisory | Drug or Alcohol Dependency 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 P a g e |8 CDHO Advisory | Drug or Alcohol Dependency 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. P a g e |9 CDHO Advisory | Drug or Alcohol Dependency 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 P a g e | 10 CDHO Advisory | Drug or Alcohol Dependency 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. P a g e | 11 CDHO Advisory | Drug or Alcohol Dependency 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. P a g e | 12 CDHO Advisory | Drug or Alcohol Dependency 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. P a g e | 13 CDHO Advisory | Drug or Alcohol Dependency 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. P a g e | 14 CDHO Advisory | Drug or Alcohol Dependency 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 P a g e | 15 CDHO Advisory | Drug or Alcohol Dependency 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 P a g e | 16