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Volume 27 Number 2 Summer 2012 Living Through and Surviving Cancer Dental hygiene’s role in supporting patients with cancer Staying Healthy Fighting cancer with your fork Spotlight on Student Research The future of the profession The most advanced formulas in at-home whitening. It’s true. Other professional at-home whiteners might contain desensitizers or soothers but only Philips Zoom NiteWhite and DayWhite have both and ACP. Amorphous Calcium Phosphate (ACP), a patented technology developed by the ADA, leads to the rapid deposition of a new coating of hydroxyapatite over the original tooth surface. This science, combined with peroxide and potassium nitrate is why Philips Zoom NiteWhite and DayWhite do so much more than just whiten. Our unique formulas help reduce sensitivity, rebuild enamel, fill in surface defects and whiten, giving patients a more positive experience all around. Give your patients the most advanced formulas in at-home whitening with Philips Zoom NiteWhite and DayWhite. The science speaks for itself. Call today: (800) 278-8282 www.philipsoralhealthcare.com To be dispensed by or on the order of a dental professional only. ©2011 Discus Dental, LLC. All rights reserved. Philips is a registered trademark of Koninklijke Philips Electronics N.V. In this issue of the Summer 2012 3 From the Editor’s Desk Cancer in Our Lives 4 Remembering Liz Chaney 5 President’s Message Our Garden, Our Community 6 LifeLong Learning Cancer: An Epidemic of the 21st Century Practice Pointers – Caring for Patients with Cancer 15 FeatureFocus Tha Faces of Oral Cancer Living Through and Surviving Cancer 3 17StudentConnection Original Student Research Cora Ueland Scholarship Award Recipients 2012 Table Clinic Competition 23 CareerCorner Sharon Golightly, RDH, EdD 23 26StayingHealthy Fighting Cancer with Food and Activity 29 EducationExchange Mentoring Student Research The Role of the Dental Hygiene Educator 32NewsBytes What’s new around CDHA 29 Journal Sponsored by Philips Oral Healthcare This Journal is printed on 100% recycled paper 2011–2012 Executive Officers Contributions of scientific and original articles. The Journal of the California Dental Hygienists’ Association is formatted by and published under the supervision of the Editor. The opinions expressed or implied in this publication are strictly those of the authors and do not necessarily reflect the opinion, position or official policies of the CDHA nor are claims or statements by authors verified. The only permission granted for photocopying or storage of items is for personal use, or the use by libraries; all other uses require the written permission of the Editor or President. CDHA reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition they are contributed solely to the Journal. Contributors are notified within 90 days if a manuscript is accepted for publication. Correspondence should be addressed directly to the Editor: Cathy Draper, RDH, MS E-mail : [email protected] FAX: 408-252-4350 Mail: 1310 Regency Drive • San Jose, CA 95129 Display and classified advertising. The California Dental Hygienists’ Association does not assume liability for contents of advertisements. Inquiries regarding display advertising should be directed to: Shanda Wallace, RDH 611 Bristol Ave. • Stockton, CA 95204 [email protected] info available @ cdha.org Copyright ©2012 by the California Dental Hygienists’ Association. The Journal is published on a regular schedule by the California Dental Hygienists’ Association. Subscription rate is as follows: $15 for CDHA members $25 for non-CDHA members and ADHA members within U.S. $50 to ADHA members outside the U.S. and non-members within the U.S. All change of name or address should be sent to: California Dental Hygienists’ Association 130 North Brand Boulevard, Suite 301 Glendale, CA 91203 Phone: 818-500-8217 FAX: 818-247-2348 E-mail: [email protected] Internet: http://www.cdha.org President President Elect VP Membership & Professional Development VP Administration & Public Relations Lisa Okamoto, RDH, AS Susan Lopez, RDH, BS Terri Vosper, RDHAP, BA Karine Strickland, RDHAP, BS Secretary-Treasurer Lygia Jolley, RDH, BA Immediate Past President Ellen Standley, RDH, BS, MA Executive Administrator Rosie Tesselaar Component Trustees Central Coast Tracy Woods-Boyan, RDHAP East Bay Tresa Irby, RDH San FernandoValley Kirsten Thye, RDH San Francisco Michael Long, RDH Kern County Harriet A. Luzinas-Smith, RDH San Gabriel Valley Beverly Legg, RDH, MS Long Beach Beth Wilson, RDH San Joaquin Valley Fred Thomas, RDH Los Angeles Tricia Osuna, RDH, BS, FAADH Monterey Bay Mary Jo Cardinale, RDH, BS Mt. Diablo Frannie Driscoll, RDH, BS Napa-Solano Ivy Zellmer, RDH Santa Barbara Alexandra Major, RDH Santa Clara Valley Jocelyn Weinhagen, RDH, BA Kendra Edwards, RDH Shasta Six Rivers Eva Adams, RDH Orange County Rhonda McMorran, RDH South Bay Carole Broder, RDH, BS Peninsula Angela Punaro, RDH Tri County Darlene Cheek, RDH, BS, MPH Redwood Tamara Wells, RDH Valley Oaks Michelle Gray, RDH Sacramento Valley Carol Lee, RDH, BS Ventura County Erica Johnson, RDH San Diego County Jackie Buchanan, RDH Journal Staff Editor Cathy Draper, RDH, MS Advisory Board Toni S. Adams, RDH, MA Carol Lee, RDH, BS Elllen Standley, RDH, MA Donna Smith, RDH, MSEd Graphic Design Dorreen P. Davis Printer Moore Bergstrom Co. Calendar of Events August 11, 2012 Summer CE Extravaganza San Mateo, CA August 12, 2012 Summer BOT Meeting San Mateo, CA November 3, 2012 Fall BOT Meeting Burbank/Glendale, CA March 2-3, 2013 Student Regional Conferences About the Cover: Eva Grayzel in flight, photographed by her son, Jeremy Cohen. From the Editor’s Desk Cancer in Our Lives Cancer, a six letter word, has a profound effect on anyone who is touched by it. Ask anyone who has been diagnosed with any type of malignancy and they will tell you, that their lives are never quite the same. Add families, friends and colleagues and the impact of cancer grows exponentially. This year in the United States alone, approximately 1,638,910 individuals will be given a cancer diagnosis. This does not include most cases of carcinoma in situ (non-invasive cancer) or basal and squamous cell skin cancers. Approximately 77% of new cases will be in individuals 55 years of age and older.1 While the five year relative survival rate for all cancers continues to improve, from 49% in the mid 1970’s to 67% for cancers diagnosed in 2001-2007, over 1,500 people will die each day this year as a result of this complex group of diseases. Growing up in the 50’s and 60’s my memories of cancer were of whispered conversations amongst the adults in my family. The “Big C” had so many unknowns. Was it caused by a virus? Was it contagious? Society in general was not ready to discuss cancer openly. In the early 1950’s the New York Times informed a prospective support group organizer, Fanny Rosenow, that they were unable to print the words breast or cancer in their newspaper. It wasn’t until 1969 that the American Cancer Society challenged then President Nixon to direct his attention to wage the “war on cancer”.2 Unfortunately, a cancer victory would not be found in a universal cure or vaccine, the vision of the 1971 National Cancer Act. Scientists know today that cancer cells are genetic mutations of normal cells. Treating and curing cancer appears to lie in understanding the biology of the disease. Targeted therapies hold out great promise for the future. Prevention plays a vital role in this insidious disease. As healthcare providers, we are in an ideal position to educate and screen for early signs and symptoms of cancer, particularly in the area of the head and neck. As part of the healthcare team we also need to be prepared to support the estimated 12 Experiencing cancer is life-changing. million Americans who are living with and surviving cancer. Educate, screen and support your Understanding the various treatments and their potential side patients, families and friends. effects, particularly as related to oral health, is essential. Thirteen years ago, a young mother, Eva Grayzel, from Easton, Pennsylvania was diagnosed with stage IV squamous cell carcinoma of the tongue. She was given a 15% chance of survival. Today, she lectures around the world sharing her story, promoting oral cancer awareness, education and screening. Cancer has transformed her mission in life. In 1993, entrepreneur Brian Hill was diagnosed with late stage oral cancer. After his recovery from his therapy, he established the Oral Cancer Foundation, a national public service, non-profit entity designed to reduce suffering and save lives through prevention, education, research, advocacy, and patient support activities. In 1992, my sister was diagnosed with ovarian cancer. When she died two years later, I began to volunteer at the Stanford Hospital Health Library. I wanted to be able to support others as they made their way through the maze of medical choices within the hospital. Located in the Cancer Center, the Health Library provides scientifically-based, medical information to help people make informed decisions about their health and health care. September marks my 18th year as a library reference associate. 1. American Cancer Society. Cancer facts and figures 2012. Atlanta: American Cancer Society; 2012. 2. Mukherjee, S. The emperor of all maladies. A biography of cancer. New York: Scribner; 2010. 571p. CDHA Journal – Summer 2012 Cathy Draper, RDH, MS Editor 3 Tribute to Liz Chaney Remembering Liz Chaney Dental hygiene mourns the passing of Elizabeth “Liz” Chaney, advocate for the profession and friend to all, who died due to complications of pneumonia on April 5, 2012, at the age of 87. Dental Hygiene Career While Liz Chaney’s name is often synonymous with California and CDHA, she completed her dental hygiene education at the Ohio State University, graduating with a Bachelors degree in 1946. One of her first positions after graduation was working as an instructor at Ohio State, teaching gross anatomy to dental and medical students. Marriage brought her to sunny California. Following the premature death of her first husband, Liz re-married to a man in the military. Liz and her family travelled the world and she was able to work in a variety of places including Japan and Germany. Eventually Liz landed back in California at the March Air Force Base near Riverside and later at the Norton AFB in San Bernardino. Liz spent the majority of her career as a civil servant, working alongside military periodontists treating active duty - patients at Norton AFB. She was the first civil service dental hygienist at Norton and wasted no time in using her powers of persuasion to increase the professional pay scale for civil service dental hygienists. Through her persistence, the General Schedule pay scale system was raised two levels, thus increasing the compensation for all dental hygienists who would follow in the Air Force civil service. Reflecting back on this achievement, Liz Liz, Christine Charles, Katie Dawson said, “I just believed that if you Pfizer. ADHA Award 2006 went to school for more education that you should be paid accordingly.” Liz received many awards over her long career working with the military, most notable being the “Exceptional Civilian Service Decoration” presented personally by President Bill Clinton. Passion for Politics Liz first became interested in politics in the late 1960’s when Ronald Reagan was governor of California. She began by campaigning for SB 716, the first bill which would eventually lead to the establishment of the Committee on Dental Auxiliaries, the advisory body for dental hygiene and dental assisting to the Dental Board of California. She then enhanced her political savvy by canvassing the voters all over the Inland Empire for her son-in4 law, the former State Assemblyman Steve Clute. Liz said it was while campaigning for Steve that she got to know California’s legislators on a personal basis and realized education in all things related to dental hygiene would be key to moving our profession forward. She was instrumental in the formation of the California Dental Hygiene Political Action Committee, or CalHyPac, and served as its chair for 14 years. Created with the goal of educating and supporting legislators on the needs of the dental hygiene profession, CalHyPac continues to be a vital force in the political process for dental hygiene. Liz’s persuasive powers were put to good use working within the political process to improve oral health for all Californians; from the first COMDA bill to the funding of school oral hygiene and fluoride rinse programs, to the establishment of the Registered Dental Hygienist in Alternative Practice, Liz was always advocating for oral health. Fundraiser Extraordinaire Liz was also a dedicated advocate for dental hygiene education and research. She was instrumental in raising tens of thousands of dollars for the American Dental Hygienists’ Association Institute of Oral Health. If Liz asked you in her gently persuasive way to donate to the Institute, you would be hard pressed to say no. In 2001 she was the first recipient of the ADHA Institute of Oral Health Liaison of the Year Award, which has since been renamed the Liz Chaney Liaison of the Year Award. This award honors those who demonstrate exceptional service and accomplishment in the area of fundraising on behalf of the Institute. Achievements in “Retirement” After retiring from clinical practice, Liz continued to lecture to middle school children through the University of California Riverside’s “Healthy Body Healthy Mind” program, stressing the importance of oral health. Always active in CDHA, she attended almost every House of Delegates meeting and served as an ADHA delegate for many years. She was a member of the legislative action committees of the American Association of Retired People and the National Association for Active and Retired Federal Continued on Page 33 CDHA Journal Vol. 27 No. 2 Message from the 2011-2012 President Author(s) Our Garden, Our Community Dear Colleagues, Spring and summer are wondrous seasons. Life, hope, joy and renewal are evident all around us in a vibrant display of colorful blossoms. This is my favorite time of year at Filoli, a historical country estate just south of San Francisco built in 1915 with its 16 acres of beautiful gardens. You can roam among hundreds flowering plants and trees, with classic varietals interspersed with newer varieties. At Filoli, you witness life in collaborative harmony. A garden is a community of many elements, that have evolved to thrive in a symbiotic environment, encompassing everything around it -- insects, birds and other creatures all contributing to the success and health of the garden and each other. We are approaching the 100th anniversary of our profession. Over the past year I have been sharing the history, growth and evolution of our profession. It occurs to me that the name FILOLI could be applied to dental hygienists and our profession. It stands for FIght for a just cause, LOve your fellow man, LIve a good life. Our careers are defined by our passion for and pursuit of better health for our patients. Ours is a profession focused on living well. Given the opportunity, a wealth of possibilities exists for bettering the health of our patients and the public, especially if a collaborative approach is embraced. Many health care practitioners now accept the concept that a collaborative, patient centered, inter-professional approach is necessary to effectively meet today’s complex health care needs in our diverse and rapidly changing environment. Oral health is an integral part of overall health, and it only stands to reason that all facets of health care must be intertwined as well. Just as medicine now recognizes the impact of oral disease on systemic health, we must treat the whole patient not just disease in the oral cavity. Collaboration between dentistry and medicine is a necessity. However, of equal importance is the need for collaboration and respect for one another as members on the same team within the dental care delivery system. As we look to address the unmet health needs of the public, the isolated health care provider model is not a part of the solution, in medicine or dentistry. As already being practiced in medicine, overlapping scopes of practice in dentistry will need to enhance care for a greater portion of our population. The groundwork for widening the scope of practice is already being laid with expanded function assistants, advanced dental hygiene practitioners and CDHA Journal – Summer 2012 dental therapists. In January 2011 the UCSF Center for the Health Professions released its research report, “Collaborative Practice in American Dentistry: Practice and Potential”.1 The study evaluated the potential of collaborative practice models in oral health delivery systems. As California policymakers consider expanding or creating new oral health practice models, this report is an invaluable reference tool, providing definitions of collaborative practice arrangements and comparisons of five ideal collaborative practice structures. Key findings are discussed as they relate to the oral health care field. The report encourages comprehensive, inter-disciplinary health education programs as well as educating dentists and other health care providers together. Inter-professional education facilitates communication, improves understanding and fosters trust, all key elements necessary for effective and efficient collaborative practice. This is our garden, our community. We must all work together for it to grow and thrive. I would like to take this opportunity to thank you for allowing me to represent the profession as CDHA President this past year. It is with great pleasure and pride that I pass the gavel on to Susan Lopez, RDH, BS, to lead the association as you “step up and reach out” over the coming year. Adaptation and evolution promise bright advances for our profession. To paraphrase the late senator Ted Kennedy, “ For you and for me, for our profession and our Association – the work begins anew, hope rises again, and the dream lives on.” Smiles, Lisa 2011-2012 CDHA President 1. Dower, C, Lindler, V, Mertz, E. Collaborative practice in American dentistry: practice and potential. Center for the Health Professions at the University of California San Francisco. [Internet]. 2011 Jan 1[cited 2012 Jun 21]. Available from:www.futurehealth.ucsf.edu/Content/29/201101_Collaborative_Practice_ in_American_Dentistry_Practice_and_Potential.pdf 5 LifeLongLearning Debra Jo Johnson, RDH, Ph.D Cancer: An Epidemic of the 21st Century Introduction As recently as 2005, reports of a worldwide cancer epidemic have been appearing on professional editorial pages causing researchers considerable pause. Worldwide statistics demonstrate cancer incidence is elevated, and, not surprisingly, more evident in developing nations.4 In 2008, the International Agency for Research on Cancer (IARC) reported 12.7 million new cancer cases occurring worldwide, with 5.6 million cases arising in developed countries, compared to the 7.1 million found in the developing world.2 Mortality rates from cancer are estimated at approximately 21,000 per day.2 The global burden is anticipated to expand into 21.4 million new cancer cases and 13.2 million deaths by the year 2030 resulting from such factors as population growth, increasing longevity, reductions in infectious disease deaths, and declining childhood mortality rates.2 Shifting disease patterns worldwide also facilitate this epidemic global trend. However, national and world leaders are not yet directing sufficient resources and energies toward resolving the crisis. It is widely known that there are stark discrepancies in the economic resources of developing and developed nations. Economic conditions can either facilitate or impose blocks to education. Without adequate education, people tend to engage in more highrisk behaviors related to cancer acquisition. As developing nations evolve, they also transition to western lifestyles that include high risk behaviors such as tobacco use, poor nutrition and sedentary habits, as well as indiscriminant sexual practices.2, 3 Lung, breast, and colorectal cancers are associated with these lifestyle choices and are also the most common cancers found among developed countries worldwide.2 Meanwhile, the face of this epidemic is further complicated by other existing health system disparities. Healthcare systems worldwide are being challenged and the struggle to manage the burden of cancer as well as the efforts to effect global change is ongoing. Learning Objectives This continuing education article will examine the current status of cancer in the United States, discuss cancer risk factors and their implications, and consider guidelines for cancer screening during routine care. 6 Upon completion of this course, the dental hygiene professional should be able to: 1. Identify the influencing factors for the reclassification of cancer as a non-communicable disease. 2. List the cancer risk categories and specific risks, and identify which factors are modifiable. 3. Explain the challenges faced by cancer survivors for successful long-term prevention of recurrence. 4. Identify clinical objectives for incorporating a cancer screening into daily practice. The Cancer Epidemic in the United States In 2000, the U.S. Surgeon General attempted to direct healthcare change by identifying key healthcare issues.15, 19 Over time, these issues distilled into five objectives and include optimistic efforts to change perceptions, overcome barriers, enhance research and its application, strengthen infrastructure, and expand health promotion efforts.15 These objectives gave rise to “Healthy People 2000”, a focused initiative to change healthcare on a national scale.15 This first effort demonstrated some early success and promoted a resurgence of activity ten years later with “Healthy People 2010”, and currently “Healthy People 2020”. Despite this flurry of interest, support, and effort from national healthcare and political leaders, the surgeon general’s report has achieved only a modicum of change. Eliminating health disparities by the end of the decade, an identified goal from the first initiative, has not materialized.9, 15, 16 In fact, disparities in mortality and morbidity have risen rather than declined, and correlate to education gaps within the population. The gap between mortality and life expectancy across age, sex, disease type, and risk behaviors widens considerably in less educated populations.9 While many of the planned solutions for healthcare reform indirectly address patient awareness and health education for the masses, the specific level of education required for improving mortality rates is not known. One in four Americans will die from cancer related illnesses in 2012.6 Cancer is second only to cardiovascular disease as a leading cause of death in the United States and the mortality rate differential between the two has narrowed every year since the 1970’s.7, 16 During the first half of the twentieth century, infectious CDHA Journal Vol. 27 No. 2 LifeLongLearning diseases were primarily responsible for high mortality rates in the United States.3, 16 Today, deaths due to tuberculosis, influenza, and pneumonia have declined, creating a nearly inverse correlation between infectious disease mortality rates and cancer.3, 16 Population longevity has increased with the decline in deaths due to infectious diseases. The general cancer statistics as reported by the North American Association of Central Cancer Registries (NAACCR) are broken down by state with California reporting the highest number of cases followed by Florida, New York, Texas, and Pennsylvania.6 These figures are taken from age-standardized incidence rates for all combined cancers for 2002-2006, coupled with estimated new cases by state.6 Across the board, California exhibits the highest numbers of cases, spanning every type of cancer as well as leading the nation in numbers of annual cancer deaths.6 Although mortality trends command the larger preventive interest from the medical community, the number of new cases demand equivalent, if not greater, concern. Each reported case is an individual, a person, who lives not only with the physical and emotional consequences imposed by cancer therapy, but an individual who also bears the added specter of increased risk for recurrence. Recent U.S. statistics demonstrate a reduction in the numbers of new cancer cases and suggest, at least in this country, some degree of prevention efforts may be working to turn the tide.12 In a report from the National Cancer Institute, statistics indicate that mortality rates from all cancers across genders and age groups have been declining since the early 1990s.12 While survival rates from certain cancers are increasing, the report indicates the presence of cancer disparities across populations, a finding suggesting that survival rates are skewed favoring some demographic groups over others.4, 12 The increasing numbers of survivors also imposes added risks of cancer recurrence. The risk of recurrence, when paired with the numbers of new cases, supports a perspective that these changing disease patterns contribute to an ongoing national epidemic.4, 6 The increasing longevity of the population is another factor sustaining the cancer epidemic, with more cases being diagnosed because people are living longer. In the same sense that cancer is epidemic, it is also considered to be chronic, requiring long-term medical management and monitoring. An understanding of cancer and its risk factors is essential for all healthcare providers. Cancer and Risk Cancer, in its most basic terms, is a rapid proliferation of cell mutations growing in some area of the body. If the mutations remain unchecked, cancer cells will then travel to other parts of the body. Cancer statistics are frequently reported by body categories, related to how cancer assaults a wide range of bodily systems and organs. Broad cancer categories affecting both sexes include: the oral cavity and pharynx, the digestive, respiratory, genital, urinary, and endocrine systems, bones, joints, soft tissue, skin, breast, eye and orbit, lymphoma, myeloma, leukemia, brain and other nervous systems along with other and unspecified primary sites.6 Malignant cell growth, influenced by many factors, can either be rapid or slow. Cancer tumor staging relates to cancer cell type, tumor size, and growth rates at the initial diagnosis. Gender, age, and other risk factors broadly affect all cancers.1 A 2009 report from the American Cancer Society identifies two categories of risk: hereditary and environmental.1 In general, hereditary factors are Table 1: Cancer Risk Categories & Common Risk Factors Risk Category Behavioral Biologic Genetics Environment Risk Factor Modifiable Tobacco √ Alcohol √ Sun exposure √ Poor diet √ Sedentary lifestyle √ Not Modifiable Aging √ Obesity √ Some viruses & bacteria √ Certain hormones √ Family history √ Obesity √ Ionizing radiation √ Certain chemicals & other substances √ Certain hormones √ Ref. National Cancer Institute (NCI), Understanding the Puzzle. Accessed on 12/29/11, available from http://understandingrisk.cancer.gov/learn/whatareriskfactors.cfm. Continued on Page 8 CDHA Journal – Summer 2012 7 LifeLongLearning not modifiable since they stem from familial and genetic sources.1 Environmental or acquired factors are considered modifiable and include tobacco use, poor nutrition, sedentary lifestyles, obesity, some infectious agents and medical treatments, as well as exposure to excessive sun and other carcinogens existing in the air, food, water, and soil as pollutants.1 Modifiable risk factors, accounting for the greatest cancer burden, are generally manageable and preventable. Prevention and Screening of Non-communicable Diseases Non-communicable diseases, including cancer, are considered chronic diseases. Cancer prevention shares similar risk factors with non-communicable diseases.13 Non-communicable diseases led the 2003 global death toll of 56 million people.3 Of those deaths, 16 million were from cardiovascular disease, 7 million from cancer, 3-4 million from chronic respiratory disease, and 1 million from diabetes.3 National debate over cancer prevention grew out of the World Health Organization (WHO) discussion from the Framework Convention on Tobacco Control.13 The cancer prevention debate prompted the World Health Assembly (WHA) to urge the integration of oral disease prevention into national cancer-control programs, and then promote appropriate training across oral health professionals.13 Despite the WHA resolution, long-standing practices between dentistry and medicine continue to resist change.19 For the most part, dentistry and medicine continue to operate in the model of specialized and separate. Patients, including those with a cancer diagnosis, generally seek treatment and receive therapy from segregated health communities. Unfortunately, comprehensive patient therapy, regardless of the diagnosis, is still rare. The greatest cancer burden is due to deaths related to tobacco use at 30%, followed by a combination of risk factors related to nutrition, physical inactivity, and obesity at 35%.1, 2 Cancers caused by occupational and other environmental carcinogens produce a smaller risk, but still account for 6%, or approximately 33,700 of the annual cancer deaths 8 in the U.S.1 What is most remarkable about this data is, the majority of these risk factors stem from lifestyle choices which can be altered, by forming different habits. “Choice” suggests that many cancers may be preventable. Risk assessment coupled with focused patient-centered discussions for lifestyle change is a logical chairside approach for oral healthcare professionals not only for cancer prevention, but also for monitoring survivors. Modifying behavior requires action and long-standing, unhealthful behaviors are difficult to change. The challenge for oral health professionals is to engage the tough conversations necessary for effecting change and to establish the necessary interdisciplinary relationships with other health care providers. Permanent behavior change requires broad support. Screening for oral cancer is already embedded in dental and dental hygiene education. Expanding screening practices, including general cancer risk assessments coupled with patient-centered discussions for lifestyle change, has the potential to significantly diminish the national cancer burden. PATIENT SCREENING Patient Name: ________________________ Date: ___________ Patient Status Risk Factor General Cancer Signs & Symptoms Asymptomatic Modifiable Unexplained weight loss Symptomatic/undiagnosed Alcohol Fever Diagnosed Tobacco Fatigue Surgery Diet Pain Chemotherapy Sedentary Life Style Skin Changes: warts, moles, or any new skin change Radiation Sun Exposure GI: changes in bowel habits or bladder Cancer Survivor Not Modifiable Sores that do not heal Year 1 Age Oral: white patches in the mouth, white spots on the tongue Year 2 Family History Unusual bleeding or discharge Year 3 Viruses Breast: thickening lump in breast or other body parts Year 4 Bacteria Indigestion Year 5 Hormones Difficulty swallowing > 5years Chemicals Nagging cough or hoarseness Ref. National Cancer Institute (NCI), Cancer Care: Signs and Symptoms of Cancer. [Internet] Last revision: 2010 Jan. 6. Accessed on 5/19/12, available from http://www.cancer.org/Cancer/ CancerBasics/signs-and-symptoms-of-cancer This form is designed specifically for cancer screening purposes only and should not be used in lieu of a comprehensive medical examination. CDHA Journal Vol. 27 No. 2 LifeLongLearning Oral Cancer Risk Factors Oral cancers comprise a group of cancers that fall into a broader category known as head and neck cancers. Worldwide, head and neck cancers are the sixth most common cancer type with oral cancers comprising approximately 85% of all cancers within this category.8,14 Unfortunately, oral cancer mortality rates remain persistently high due to late stage diagnoses.14 Delayed diagnoses are often attributed to the issue that oral cancer symptoms often bear similarity to other oral problems and can be ignored or misdiagnosed in their early stages. This is particularly true when the individual does not present with the traditional risk factors. An oral cancer diagnosis often occurs after the primary lesion has metastasized to another location, usually the lymph nodes of the neck. Early detection of oral lesions permits isolation and localized treatment, whereas lymph node involvement promotes rapid spread within the total body system. The traditional oral cancer risk model identifies men of varying ethnicities, over the age of 40, coupled high risk behaviors of tobacco and alcohol abuse.14 Obesity, a significant risk factor for all cancers, is specifically linked to esophageal cancers.14 As alcohol and tobacco use have changed in the U.S., demographics for head and neck cancer have begun to shift into a younger population of male non-smokers between the ages of 40-50. The human papillomavirus (HPV), particularly HPV 16, has been implicated as the causative agent for this group.5,8,14 Although previously identified as a cause of anogenital cancers, the oral HPV 16 cancers now generate a new subset for squamous cell carcinomas of the head and neck creating a subtle shift in the demographics and causation for head and neck cancer in developed countries.5, 8, 14 Living Through and Surviving Cancer A cancer diagnosis commonly produces fear and anxiety in patients, their families and friends. While cancer can still be the ultimate cause of death, current therapies can prolong life, and in some cases, provide a cure. In general, cancer staging predicts disease progression, although staging is not an absolute predictor of survival. While individuals may receive the same cancer diagnosis, due to a wide array of variables, the outcomes may CDHA Journal – Summer 2012 differ. The presence or absence of a support group, for example, may influence the patient’s overall response and treatment outcome. Age, sex, spiritual practices, worldview, genetics, along with other factors may influence tolerance and response to cancer therapy. No matter what the individual circumstance, a cancer diagnosis and the corresponding treatment bring about permanent and lasting life changes in a myriad of ways. Breast Cancer Therapy Side Effects Prior to chemotherapy Chemotherapy day 10 2 months post radiation therapy In the face of surgical, chemical and/or radiation interventions, cancer patients require not only specific clinical care, but also, sensitivity to their condition, their disposition, the stage of their treatment, and their ongoing therapy. Physical, emotional, and mental challenges are common. Cancer patients may face multiple challenges and difficult realities throughout their treatment which can include multiple disfiguring surgical interventions, chemotherapy and radiation. Despite evolving technology and therapeutics, cancer treatment has, by no means, achieved its zenith. Chemotherapy and radiation targeted to cause cell death are not without serious, life altering side-effects and complications. Managing the consequences of cancer as a chronic disease is in its infancy. Cancer patients are ambulatory; they survive, and they walk among us. They enter our treatment rooms and require our care, discretion, and best efforts to maintain their health both during and following cancer therapy. Monitoring cancer survivors for disease recurrence is the responsibility of all healthcare providers. Conclusion Cancer is a global epidemic requiring greater intervention and dedication of healthcare resources. Ineffective health systems contribute to the cancer mortality and morbidity burden. The consideration of cancer as an epidemic has only recently come to light influenced by the declining incidence of infectious disease and increasing population longevity. These trends have promoted a shift in the perception and classification of cancer. Historically, cancer, like HIV, was viewed as a death sentence. Fortunately, this perspective is shifting. Cancer, reclassified as a non-communicable References on Page 10 9 LifeLongLearning disease, is like other non-communicable diseases, considered a chronic disease. Worldwide, cancer education is essential, not only for the population at large, but, also, for world leaders who are responsible for effecting change. In the U.S., while overall cancer mortality and morbidity rates are declining, the disease remains epidemic. As healthcare providers, dental hygienists play a key role in screening for the disease in addition to promoting cancer prevention strategies and supporting patients throughout cancer therapy. Cancer care and prevention is everyone’s responsibility. 7. Kochanek, K.D., Jiaquan, X., Murphy, S.L., Miniño, A.M., Kung, H-C. National Vital Statistics Reports, Vol. 59, No. 4, 2011 Mar. 16, p. 1-53, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System. About the Author: 10. National Cancer Institute (NCI), Cancer Care: Signs and Symptoms of Cancer. [Internet] Last revision: 2010 Jan. 6. Accessed on 5/19/12, available from http://www.cancer.org/Cancer/CancerBasics/signs-and-symptoms-of-cancer. Debra Jo Johnson, RDH, Ph.D. is an adjunct professor of dental hygiene at Southwestern College Dental Hygiene Program in National City, California. She also practices clinical dental hygiene in a periodontics and implantology specialty practice in La Jolla, California. For over thirty years, Dr. Johnson has facilitated the education of post-doctoral residents, and dental and dental hygiene students from Los Angeles to San Diego. Her research and writing interests, although varied, primarily involve curriculum and curriculum change. Her doctoral dissertation evaluated curriculum change in nursing. The lessons learned from her research as they apply to dental hygiene are planned for future publication. Dr Johnson is a breast cancer survivor. References 1. American Cancer Society. Cancer Facts & Figures 2009, Atlanta: American Cancer Society, 2009, 70 pages. Accessed on 5/11/12, available from http://www.cancer.org/Research/CancerFactsFigures/cancer-factsfigures-2009. 8. Marur, S., D’Sousa, G., Westra W.H., Forastiere, A.A. HPV-associated head and neck cancer: a virus-related cancer epidemic [Internet] www.thelancet.com/ oncology, 2010 Aug. Vol. 11: 781-789. 9. Meara, E.R., Richards, S., Cutler, D.M. The Gap Gets Bigger: Changes In Mortality And Life Expectancy, By Education, 1981-2000, Health Affairs, 2008 Mar., 27, No. 2, 350-360 Accessed on 2/17/2012, available from content.healthaffairs.org. 11. National Cancer Institute (NCI), Understanding the Puzzle. Accessed on 12/29/11, available from http://understandingrisk.cancer.gov/learn/ whatareriskfactors.cfm. 12. National Cancer Institute (NCI), Report to the nation finds continuing declines in cancer death rates since the early 1990s. [Internet] Accessed on 5/11/12, available from http://www.cancer.gov/newscenter/pressreleases/2012/ ReportNationRelease2012. 13. Petersen, P.E. Oral cancer prevention and control – The approach of the World Health Organization, Oral Oncology, 2008, Vol. 45, Issues 4-5, Pages 454460. 14. The Oral Cancer Foundation, Oral Cancer Facts [Internet]. Last update: 2012 Mar. 16, 2001-2011©. Accessed on 5/11/12, available from http://www. oralcancerfoundation.org/facts/index.htm. 15. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General [Internet] Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000, Sept. Accessed on 12/28/11, available from http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/sgr/ home.htm. 16. U.S. Department of Health and Human Services. (2000) Healthy People 2010 2nd Ed. [Internet] 2 vols. Washington, DC: U.S. Government Printing Office, 2000 Nov. Accessed on 12/28/11, available from http://www.healthypeople. gov/2010/redirect.aspx?url=/2010/. 2. American Cancer Society. Global Cancer Facts & Figures 2nd Edition, Atlanta: American Cancer Society, 2011, 59 pages. Accessed on 5/11/12, available from http://www.cancer.org/Research/CancerFactsFigures/ CancerFactsFigures/cancer-facts-figures-2011. 17. U.S. Public Health Service, Vital Statistics of the United States - 19001970, annual, Vol. I and Vol. II; 1971-2001, U.S. National Center for Health Statistics, Vital Statistics of the United States, annual; National Vital Statistics Report (NVSR) (formerly Monthly Vital Statistics Report); and unpublished data, 2005©. Accessed on 1/3/12, available from http://www.infoplease. com/ipa/A0922292.html. 3. Beaglehole, R., Yach, D. Globalisation and the prevention and control of noncommunicable disease: the neglected chronic diseases of adults, The Lancet, 2003 Sept. 13, Vol. 362: 903-908. 18. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd Edition, U.S. Department of Health and Human Resources, 1996, Williams and Wilkins, Baltimore, MD, p. 953. 4. Center for Disease Control (CDC), Rates for New Cancer Cases and Deaths based on Race/Ethnicity and Sex. Updated 2011 Aug. 11. Accessed on 12/30/11, available from http://www.cdc.gov/Features/dsCancerDisparities/. 19. World Health Organization. Strategies for oral disease prevention and health promotion, 2012, pp. 1-2, accessed on 12/29/11, from http://www.who.int/ oral_health/strategies/en/. 5. DeNoon, D.J. Virus Behind Oral Cancer Epidemic, 2010, LLC. Accessed on 11/19/11, available from WebMD News Archive at http://www.webmd.com/ cancer/news/20101013/virus-behind-oral-cancer-epidemic. 6. Jemal, A., Siegel, R., Xu, J, Ward, E. Cancer Statistics, CA Cancer J. Clin. 2010, 60: 277-300. 10 CDHA Journal Vol. 27 No. 2 LifeLongLearning Cathy Draper, RDH, MS Practice Pointers – Caring for Patients with Cancer Oral hygiene and oral care can often become a low priority for patients with a life threatening cancer diagnosis. Dealing with the physical and emotional impact of cancer, along with scheduling and keeping multiple appointments with a variety of medical specialists often leaves little room for the recommended pre-cancer treatment dental examination and dental hygiene care appointment. Yet, the oral manifestations resulting from chemotherapy and radiation can be the most debilitating and often dose limiting side effects of cancer treatment. Oral mucositis in its simplest terms is an inflammatory process affecting the mucous membranes of the oral cavity and the gastrointestinal tract. Varying degrees of mucositis can be seen in patients receiving cytotoxic therapy with the signs and symptoms ranging from mild sensory changes to multiple, confluent ulcerative lesions extending from the oral cavity through the gastrointestinal tract. Severe oral pain, bleeding and infection affect the patient’s ability to speak and eat and impact their overall quality of life. The oral pain of mucositis is often ranked by patients as the most significant complication of their cancer therapy.1 The incidence of oral mucositis varies depending on the specific type of cancer and the treatment modality used. It is estimated that anywhere from 30% to 75% of all patients undergoing chemotherapy and between 90% to 100% of all head and neck radiation therapy and stem cell transplant patients will experience oral mucositis.2 In the past, the majority of the research related to the prevention and treatment of oral mucositis was focused on adults receiving high dose chemotherapy and patients with head and neck cancers. However, more recent reviews of the literature, particularly from sources outside of the United States, show an increased focus on oral side effects in the pediatric population.3 There is a growing awareness in the medical community that oral care is an important aspect of cancer care from diagnosis, through treatment and the rest of the life span. Identifying and providing evidence based recommendations and interventions regarding changes in the oral cavity can expand the role of the dental hygienist as a provider of supportive care for patients throughout their cancer experience. Pre-treatment Oral Examination and Care A pre-treatment oral examination is recommended for all individuals ideally one month prior to beginning cancer therapy. This is particularly important for patients receiving radiation therapy to the head and neck region. Within the parameters of the pretreatment examination, the dental team can evaluate and treat any existing dental infections, fractured teeth and restorations and CDHA Journal – Summer 2012 periodontal disease. This examination also serves as a baseline for future comparisons of the patient’s oral health status. It is also beneficial to exchange information with the oncology team regarding the patient’s oral health status and proposed cancer treatment. The pre-treatment oral examination appointment is an ideal time to provide patient education regarding oral care during cancer treatment and the need for monitoring oral health during cancer therapy. Risks for oral complications such as mucositis should also be discussed at this time. New research indicates that good oral hygiene can reduce the incidence and severity of oral mucositis. Unfortunately, patients with cancer do not always receive oral care until complications develop.4,5 Oral Care During Cancer Therapy Vigilant monitoring of oral care and oral hygiene is essential to the prevention and treatment of oral complications during cancer therapy. The soft tissues should be examined regularly by the patient or caregiver in addition to members of the oncology team. There are a number of oral assessment guides and rating scales specifically designed for nursing interventions. The Oncology Nursing Society (ONS) has performed extensive reviews of the literature to create evidence based recommendations for oral care protocols during cancer therapy particularly in the area of managing oral mucositis. Recommendations from National Dental and Craniofacial Research and the ONS 2009 Putting Evidence into Practice Recommendations include the following:5,6 Brushing and Flossing • Use an extra soft toothbrush to brush all tooth surfaces at least twice a day for a minimum of 90 seconds • Soak the brush in warm water if needed for tender tissues • Allow the toothbrush to air dry before storing • Replace the toothbrush frequently and whenever the bristles are splayed or worn • Gently floss at least once a day or as advised • Waxed floss slides easily and is less likely to cause tissue trauma • Avoid flossing tender, bleeding areas Rinses, Toothpastes and Fluoride • Rinse the mouth four times a day with a bland rinse • Avoid mouth rinses that contain alcohol • Maintain adequate hydration Continued on Page 12 11 LifeLongLearning • Use a saline and sodium bicarbonate rinse to remove food debris and aid with oral hydration. Recommended proportions are ¼ teaspoon salt, ¼ teaspoon baking soda mixed in 1 quart warm water. Omit the salt if mucositis is present. • Use a mild flavored fluoride toothpaste • Mint or cinnamon flavoring may irritate the tissue • Use a prescription fluoride toothpaste for caries control • Use supplemental fluoride trays as prescribed Additional Recommendations • Avoid all tobacco products • Avoid acidic, hot, rough, or spicy foods • Avoid candy, gum and soda unless they are sugar free • Avoid acidic beverages Considerations for Patients Receiving Hematopoietic Stem Cell Transplants Patients undergoing stem cell transplantation for certain types of cancers are at extremely high risk of developing mucositis, ulceration and infection due to the immunosupressioncaused by the intensive conditioning regimens prior to transplantation. Stem cell transplant patients are under close supervision by the oncology team to manage their oral complications. While the complications begin to resolve once the hematologic status improves, immunosupression and the risk of infection may last for over a year following the transplant. These patients are also at risk of developing graft-versus-host disease manifested in mucosal inflammation, ulceration and xerostomia. Careful supervision of oral care during and following stem cell transplantation is critical for the patients’ general health.5 • Suck on ice chips • Use water based moisturizers to protect the lips • Petroleum based lip balms can potentially promote bacterial growth • Avoid the use of glycerin swabs and sponge tooth cleaners • Prevent jaw stiffness from head and neck radiation by opening and closing the mouth as far a s possible without causing pain. • Collaborate with a multidisciplinary team in all phases of treatment • Provide written instructions and education outlining the key points to patients and or their caregivers Patients experiencing oral mucositis may require a variety of treatments for pain and symptom control. Some of the targeted therapies include mixtures of lidocaine and diphenhydramine, keratinocyte growth factors, a bioadherant gel and low level laser therapy. Opiates may be necessary for pain relief in the more severe cases.7 Oral treatment including oral prophylaxis must be coordinated with the oncology team. Patients undergoing chemotherapy should have blood work performed 24 hours prior to dental treatment to determine whether the platelet and absolute neutrophil counts are sufficient to deliver dental care safely. Patients with central line catheters or implanted ports may require antibiotic prophylaxis prior to treatment.5 Again, collaboration with the oncology team is essential for coordinating patient care. Common Side Effects of Cancer Therapy5 AlopeciaAnemia Diarrhea/constipationDysgeusia FatigueInfection Memory issues Nausea/vomiting Oral mucositis/stomatitis Peripheral neuropathy Skin and nail changes Urinary tract changes Xerostomia Oral Manifestations Common to Chemotherapy and Radiation Abnormal dental development (children 9 and under) Anorexia Dysphagia Dysgeusia Oral Infections Oral Mucositis Malnutrition Xerostomia/Salivary Gland Dysfunction Additional Oral Complications due to Chemotherapy Dental Neurotoxicity Oral Bleeding Additional Oral Complications due to Radiation Therapy Lifelong risk of radiation caries Trismus or tissue fibrosis Osteonecrosis of the Jaw 12 CDHA Journal Vol. 27 No. 2 LifeLongLearning Oral Care for Life after Cancer About the Author Patients may resume their regular dental hygiene care schedule once all of the complications of chemotherapy have resolved. Individuals with ongoing immunosupression will need to have their hemotologic status confirmed prior to receiving care. Patients who have received intravenous bisphosphonate therapy for their cancer will be at increased risk of developing osteonecrosis of the jaw. Individuals who have undergone radiation therapy for head and neck cancer will need regular evaluations, every 4 to 8 weeks, for the first 6 months. Once the first 6 months have passed, a continuing care schedule can be made based on the individual needs of the patient. It is important to remember that oral complications such as radiation caries and osteonecrosis of the jaw can occur long after the treatment has ended. Meticulous oral hygiene, good nutrition and hydration coupled with lifelong fluoride applications are critical for patients with salivary gland dysfunction following head and neck radiation therapy.5 Cathy Draper, RDH, MS, graduated in 1975 from Foothill College and completed her MS in dental hygiene at the University of Michigan in 1978. She is an adjunct faculty member at Foothill College and works in private practice. Cathy has been a library reference associate at the Stanford Hospital Health Library for the past 18 years. She also lectures to patients and professionals groups on oral care during cancer therapy. Cathy is the editor of the Journal of the California Dental Hygienists’ Association. The ability to competently provide oral care throughout cancer treatment can prevent or reduce the severity of oral complications. Dental hygienists should be well prepared to provide supportive care to patients with all types of cancer and collaborate with healthcare providers as members of the comprehensive cancer care team. 2. Elting LS, et al. The burdens of cancer therapy. Clinical and economic outcomes of chemotherapy-induced mucositis. Cancer 2003; 98:1531-1539. Resources for Patients and Professionals The National Cancer Institute www.cancer.gov Comprehensive information and free education materials from the United States Government. References 1. Eilers J. Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncol Nurs Forum 2004;31(suppl):13-23. 3. Eilers J, Million R. Clinical update:prevention and management of oral mucositis in patients with cancer. Semin Oncol Nurs 2011; 4: e1-16. 4. Eilers J, Epstein JB. Assessment and measurement of oral mucositis. Semin Oncol Nurs 2004; 21:22-29. 5. US Department of Health and Human Services. Oral complications of cancer treatment: what the dental team can do. Bethesda, MD: National Institutes of Health: 2009. 6. Harris DJ, Eilers J, Harriman A, et al. Putting evidence into practice-improving oncology patient outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009: pp193-213. 7. Cawley MM, Benson LM. Current trends in managing oral mucositis. Clin J Oncol Nurs 2005; 5:584-592. The National Institute of Dental and Craniofacial Research www.nicdr.nih.gov/OralHealth/Topics/CancerTreatment/ Features oral health “Cancer Care and You” series of publications for patients and professionals Multinational Association of Supportive Care in Cancer www.MASCC.org An association dedicated to the prevention and management of the adverse effects of cancer and its treatment. Includes guideline on the management of treatment side effects. The Stanford Health Library http://healthlibrary.stanford.edu Features an online request form for customized research on medical or health related questions. CDHA Journal – Summer 2012 13 LifeLongLearning 2 CE Units (Category I) Home Study Correspondence Course “Cancer: An Epidemic of the 21srt Century and Caring for Patients with Cancer” 2 CE Units – Member $25, Potential member $35 Circle the correct answer for questions 1-10 1. Which of the following statements is true about cancer as a disease? a. cancer is infectious and communicable b. cancer is chronic and non-communicable c. cancer is chronic and infectious d. cancer is chronic and communicable 2. Factors contributing to the worldwide increase in cancer incidence and mortality include: a. population growth b. increased longevity c. reductions in infectious disease deaths d. reductions in childhood mortality rates e. all of the above 3. Without education and awareness people tend to engage in more high risk lifestyle behaviors. These correlate with increased cancer incidence. Among these high risk behaviors are: a. tobacco use b. poor nutrition c. sedentary lifestyle d. indiscriminant sexual practices e. all of the above 4. Cancer tumor staging helps predict disease progression. Factors contributing to cancer tumor staging are: a. cell type, tobacco and alcohol use b. age, weight and tobacco use c. cell type, tumor size and growth rate d. age, weight and sun exposure 5. Dental hygiene assessment and treatment plans should include screening, risk assessment and counseling for lifestyle choices: a. only for those patients who are perceived at risk b. only for those patients who have no history of cancer c. only for those patients over 40 d. for all patients 6. Dental examination and treatment are recommended prior to starting cancer therapy. The benefits for the patient include: a. treat existing restorative and periodontal needs to prevent unnecessary complications during and after cancer therapy b. establish a baseline for future comparisons c. provide education and support for cancer therapy and potential oral complications d. all of the above 7. Oral mucositis is a common and debilitating side affect of chemo and radiation therapy. The symptoms vary from mild to severe and include the following quality of life issues: a. pain and difficulty eating and speaking b. difficulty with cognitive processing and memory c. difficulty sleeping and breathing d. all of the above 8. Recommendations for oral care during cancer therapy include the following: a. use OTC and Rx fluoride products b. avoid use of ultrasonic brushes c. rinse frequently with bland alcohol-free rinses d. both a and c 9. Patients undergoing therapy for head and neck cancers should avoid the following: a. tobacco products and alcoholic beverages b. spicy, hot, rough, and acidic foods c. petroleum based lip balms d. all of the above 10. Maintaining hydration is important for oral cancer patients. Besides reminding patients to intake adequate fluids, advice can be given to: a. suck on ice chips b. avoid acidic beverages c. use super charged energy drinks d. both a and b The following information is needed to process your CE certificate. Please allow 4 - 6 weeks to receive your certificate. Please print clearly: ADHA Membership ID#: ________________________ Expiration:___________ ❑ I am not a member Name: _____________________________________________________ License #: ___________________ Mailing Address: __________________________________________________________________________ Phone: ______________________ Email: __________________________ Fax: ______________________ Signature: ______________________________________________________________________________ Please mail photocopy of completed Post-test and completed information with your check payable to CDHA: 130 N. Brand Blvd, Suite 301, Glendale, CA 91203 14 CDHA Journal Vol. 27 No. 2 FeatureFocus The Faces of Oral Cancer Eva Grayzel and Brian Hill were the featured speakers on June 1, 2012, at the California Dental Hygienists’ Association’s continuing education program prior to the opening session of the annual House of Delegates in Santa Clara. Both speakers, late stage oral cancer survivors, brought their personal experiences and perspectives to the disease as well as the ongoing need for oral cancer awareness and early detection and follow-up care. Of equal importance in the program was how both Eva and Brian have taken their own cancer experience and transformed it into an opportunity to change the outcome of the disease through education, advocacy and activism. Eva Grayzel Turning Adversity into Opportunity “I had the sore on my tongue for about a month but everything else in my life seemed more important as a wife and mother of two young children. Eventually I did see an oral surgeon who performed a biopsy without mentioning the possibility of oral cancer. The diagnosis was hyperkeratosis and I became asymptomatic for two years. When the lesion returned, I bounced back and forth between my dentist and oral surgeon for gels, rinses, occlusal adjustments and a nightguard. The day to day changes in the sore were subtle and I was continually being told to monitor it for changes and to come back if it didn’t improve. After eight months, I developed unbearable ear pain and was treated for water on my ear drum. Again, none of my doctors mentioned the possibility of oral cancer. Desperate for answers, a family friend suggested that I visit a medical center and see Dr. Mark Urken, chief of Head and Neck Surgery at Mt. Sinai Hospital in New York City. After examining the enlarged lymph nodes in my neck and the sore on the side of my tongue, Dr. Urken performed a biopsy and gave me the definitive diagnosis of stage IV squamous cell carcinoma of the tongue. As a professional storyteller and performance artist, this was a particularly devastating diagnosis. Plus, I ate well, exercised and did not use tobacco or abuse alcohol. Given a 15% chance of survival, in the spring of 1998, I had a radical neck dissection, partial glossectomy and tongue reconstruction surgery followed by a grueling course of radiation therapy. Fourteen years later, I have beaten the odds for survival and devote my energies to sharing my personal story in the hopes that it will inspire listeners to demand oral cancer screenings for themselves as well as for those they love. Together, we can save lives. It is more than my mission to educate. It’s my tribute to all those that came before me and my obligation to those who will follow.” As an author and motivational speaker, Eva Grayzel has developed a variety of educational materials and speaking programs for a wide range of audiences including healthcare professionals, cancer patients, survivors and the public. She received a honorary membership in the American Academy of Oral Medicine for her Six-step Screening, Best Practice in Oral Care postcard. Eva has recently published her second book in the Talk 4 Hope family book series, Mr. C Plays Hide & Seek, written to help children understand cancer. A full listing of Eva Grayzel’s programs and publications can be found at www.evagrayzel.com For more information on the Six-step Screening, best practice in oral care program visit www.sixstepscreening.org Brian Hill The Oral Cancer Foundation Executive Director and Founder Brian Hill can trace an interest in medicine back to his early experiences as a 19 year old medic serving in Vietnam with the First Medical Battalion. After returning from the war, Brian began working in sales for several big medical firms. Eventually he started his own company, Implant Support Systems Inc., designing, manufacturing and selling dental implants. In 1993, Implant Support Systems was sold to Lifecore Biomedical and Brian and his wife were able to enjoy life to the fullest. One day everything changed; an asymptomatic, painless lump appeared on the side of his neck, hidden under Continued on Page 16 CDHA Journal – Summer 2012 15 FeatureFocus his full beard. After visiting an ear, nose, and throat specialist the conclusion was that the lymph node was swollen due to a dental or unknown infection and he was prescribed a course of antibiotics. Having received dental care from two different dentists and regular continuing care from two different hygienists, Brian was certain that he did not have any dental issues causing this infection. He remembers, “My dentists were on top of my oral health and I took great care of my mouth. I didn’t smoke; I ate well and was physically active.” A second ENT was consulted after the antibiotics had no effect and this time a red patch on the pillar of the right tonsil was biopsied. The diagnosis came several days later, squamous cell carcinoma with bilateral metastases, a stage IV cancer that had gone unnoticed by a number of medical and dental professionals. Brian’s experiences as an oral cancer patient at MD Anderson Cancer Center in Houston and as a survivor, led him to look for ways to change the high morbidity and mortality rate of the disease, starting with a national effort in awareness and early discovery screening programs. He also saw the need to motivate professionals to provide more opportunistic oral cancer examinations. While medical science may one day cure oral cancers in the future, heightened awareness and early detection programs can provide tangible opportunities to reduce mortality rates today. Brian also found a critical need to support oral cancer patients and their families with access to evidence-based, scientific information to allow patients to make the best decisions possible in their cancer journey. The Oral Cancer Foundation (OCF) began as an idea in 1999 with Brian and his wife Ingrid serving as its original founders and financial supporters. Today, through the support of key oral cancer experts from all disciplines, professional medical and dental societies and thousands of donors and volunteers, the OCF has grown into a powerful national force for proactive change and improved quality of life. The OCF is Brian Hill’s passion; he is the face of the foundation, frequently lecturing on oral cancer, advocating for the disease and all those affected by it. Support the mission of the Oral Cancer Foundation by becoming a member or organizing an oral cancer awareness activity. Learn more about the Oral Cancer Foundation and its education, research, advocacy, and patient support programs at www.oralcancerfoundation.org 16 Oral Cancer Demographics 2012 The incidence of oral cancer is increasing in the United States with the emergence of the Human Papilloma Virus #16 bringing a new demographic of individuals to the disease. The human papilloma virus is one of the most common virus groups worldwide, affecting the skin and mucous membranes with over 120 identified variations. The majority of human papilloma viruses, transmitted by skin to skin contact, are non-cancerous and treatable. However, some forms of HPV are sexually transmitted and are associated with oncogenic potential in the genitalia and oral cavity. The virus, particularly HPV 16, has established a new pathway outside of the traditional high risk groups of individuals over the age of 50 with a history of heavy alcohol and tobacco use, into the population at large. This new demographic emphasizes the importance of vigilant oral cancer awareness and screening programs for all individuals. The sites of the presenting malignancies have also changed. HPV positive related cancers tend to appear more frequently in the tonsilar area, the base of the tongue and on the oropharynx with HPV negative malignancies appearing on the anterior tongue, floor of the mouth and buccal and alveolar mucosa. In all cases, a tissue biopsy and careful laboratory analysis is required for determining the pathology of the neoplasm. At this time, treatment modalities for HPV+ and HPV- tumors are the same although it is possible that future clinical trials may be conducted focusing on biologically targeted therapies for HPV+ cancers. Source: Oral Cancer Foundation www.oralcancerfoundation.org/hpv/index.htm CDHA Journal Vol. 27 No. 2 StudentConnection Original Student Research – The Effects of Proximity on Aerosol Distribution of Bacteria on Toothbrushes By Elly A. Montero, BSDH*, Isabelle B. Isom, BSDH*, Jeanne Fults, BSDH*, Samantha Cvijanovich, BSDH*, Aubree Chismark, RDH, MS and Benjamin B. Tran, MSc * The following research was conducted prior to completing the requirements for the BSDH degree. Interest in the microbial contamination of toothbrushes and the role that this contamination can play in oral infections has grown in recent years. Concerns on the transmissibility of disease via a contaminated toothbrush has become more than a theoretical discussion when considering the large number of individuals with compromised immune systems due to disease, organ transplantation or cancer therapy. Toothbrush storage guidelines along with methods of sanitization in the manufacturing process and during use require scientific evidence in order for clinicians to make recommendations for patients. In this original research study, students from West Coast University, along with their faculty advisors, studied the effects of the proximity of aerosols on toothbrush contamination, thus contributing to the body of knowledge in dental hygiene practice. This study supports the National Dental Hygiene Research Agenda (NDHRA) priority area, Health Promotion and Disease Prevention: Investigate the effectiveness of oral self-care behaviors that prevent or reduce oral diseases among all age, social and cultural groups. ABSTRACT Purpose: Bacteria found on toothbrushes may affect overall health. While it is common to find certain bacteria in one part of the body, they can be harmful if they inhabit elsewhere. Coliforms are indicator bacterium of the intestines, colon, and fecal matter. These particular bacteria can be found throughout the bathroom due to the aerosols created when a toilet is flushed. The aim of this study was to test toilet flushing aerosols and bacterial accumulation on a toothbrush by relating distance of the toothbrush from the toilet while flushing with the lid up. Methods: A control swabbing was performed on 32 sterile toothbrushes to test for coliforms. They were divided and placed into four typical residential restrooms at four determined locations. For 14 consecutive days, four investigators exposed each toothbrush to microflora and moisture. At the end of the experiment, each toothbrush was swabbed and tested for additional coliforms. CDHA Journal – Summer 2012 Results: There were significantly more coliforms on the toothbrushes stored in bathrooms when compared to those that were sterile. However, comparisons between the tested conditions did not reveal significant differences. Surprisingly, the covered condition showed as much bacteria accumulation as the exposed conditions. Conclusion: Our findings suggested there is a uniform distribution in aerosol bacteria from toilet flushing, which was indicated in additional coliform deposits on toothbrush bristles of those kept in the tested bathrooms. Moreover, our results suggested that storing of toothbrushes in drawers or cabinets does not diminish the levels of toilet aerosol exposures. One possible factor in this finding is the promotion of anaerobe growth in dark and possibly damp conditions indicative of drawers and cabinets. Keywords: Toilet aerosols, toothbrush bacteria, toothbrush storage, bacterial accumulation INTRODUCTION It has long been established that oral health is an integral component to overall patient health. Bacteria are found in different areas of the body including: saliva, oral mucosa, conjunctiva, lower gastrointestinal tract and superficial layers of the skin. Bacteria that are not harmful to the body are deemed microbiota and those that are harmful are deemed as pathogens.1 Bacteria in the Gastrointestinal Tract The gastrointestinal (GI) tract, also known as the alimentary canal, starts at the mouth and ends at the anus. Bacteria found in different areas of the GI tract can be classified as opportunistic pathogens capable of causing injury if there is an overabundant amount of certain bacteria.2 Thus, it is essential to have an understanding of the common bacteria found within the body. Although many bacteria are normally found within the body, when we are exposed to them from an outside source, the end result proves they are not always good bacteria. Continued on Page 18 17 StudentConnection Toilet Aerosols Flushing a toilet creates an aerosol, which contaminates most of the surfaces inside bathrooms. Although droplets are not visible, they can travel between 6 to 8 feet from the toilet leaving no surface safe from possible contamination.3 The aerosol is produced by force of the water dispensed along the walls of the toilet bowl along with the momentum used to flush waste.4 A single act of flushing a toilet disperses millions of bacteria into the air, which makes the bathroom a prime area for bacterial contamination and growth.5 The droplet formation of sewage from toilets has a high potential for disease spread because aerosols occur during each use of the toilet.6 It is also important to note, the aerosol produced creates an infection hazard and unfortunately, closing the toilet lid has little effect in the reduction of microorganisms released into the air.4 Bacteria on Toothbrushes After a toothbrush has been in use, one would expect to find bacteria on the bristles due to their contact with the microbiota found in the oral cavity. However, toothbrushes are manufactured free of microorganisms and therefore, will not harbor bacteria until first use.7 In addition to the oral microbes, other species can also be found on in-use toothbrushes. Sources of these contaminates include bacteria introduced by hands, aerosols from the toilet, and storage areas. The quantity and species of bacteria may differ, which is dependent on wet or dry storage conditions.8 Bacteria found on toothbrushes are predominantly Staphylococci. Other microorganisms were identified as Candida albicans, Cornybacteria, Pseudomonads, and coliforms. In addition to residing and multiplying on toothbrushes, these bacteria have the capability of transmitting and creating both local and systemic diseases and can create a source of infection in the immunocompromised. Oral manifestations that may arise include dental caries, sore throats, thrush, and Herpes Simplex.5 Other conditions that may result from these bacteria may include, but are not limited to, diarrhea, fever, hypertension, renal impairment, and cardiovascular disease.9 Bacteria Accumulation Previous studies have shown that regardless of the experimental design used to test toothbrushes, bacteria is always present with Streptococcus mutans being the most common bacteria tested. After a toothbrush is used for fifteen minutes, over ten million S. mutans are found to be present.5 An experiment of thirty toothbrushes demonstrated over 40% of at least 14 samples to be positive for anaerobes, aerobes, streptococci, and aerobic gram-negative bacteria. In detail, 83% of 25 samples tested positive for anaerobes, over 73% of 22 samples tested positive for aerobes, 80% of 24 samples tested positive for streptococci, and 18 over 46% of 14 samples contained aerobic gram-negative bacilli. Surprisingly, these data were collected from toothbrushes that had been disinfected.10 These findings indicated that numerous forms of microorganisms are found on toothbrushes regardless of the area they are stored or if they have been disinfected. In summary, bacteria found on toothbrushes may affect overall health. While it is common to find certain bacteria in one part of the body, they can be harmful if they inhabit elsewhere. Coliforms are indicator bacterium of the intestines, colon, and fecal matter.11 These particular bacteria can be found throughout the bathroom due to the aerosols created when a toilet is flushed. One question of interest is whether varying proximity to the toilet would affect collection of bacteria on toothbrushes kept in bathrooms. Another question of interest is whether an enclosed storage would affect microbial load found on toothbrushes. Our study aims to address these two questions. METHODS AND MATERIALS Four bathrooms were used in a 14 day study to collect bacterial samples on a total of 32 toothbrushes. Each bathroom was equipped with 8 toothbrushes in 4 different locations: 2 feet from the toilet bowl, 5 feet away from the toilet bowl, top of the toilet water tank and inside a cabinet or drawer. Prior to toothbrush placement, a control sampling was performed on the 32 toothbrushes by swabbing for coliforms. Control Study: All 32 toothbrushes used in this study were uniquely labeled and swabbed by submersion and agitation in 3 ml sterile distilled water in a sterile centrifugation tube. An additional 3 ml of nutrient broth was added to the sample for a total of 6 ml volume. The control sample mixtures were incubated for 24 hours at 37 ºC. Following incubation, the control samples were poured into sterile 100 mm x 10 mm Petri dishes with 10 ml of EMB molten media at 55 ºC by sterile serological pipette. These Petri dishes were incubated inverted for 48 hours and thereafter, manually counted for coliforms. Experimental Study: Following control swabbing, the same 32 toothbrushes were placed in four bathrooms, with eight toothbrushes in each bathroom. Within each bathroom, two toothbrushes were placed in each of the following locations: 2 feet away from toilet bowl, 5 feet away from toilet bowl, top of the water tank and inside a medicine cabinet or drawer. For each bathroom, each of the 8 toothbrushes were exposed to oral microbiota and moisture once a day. To ensure consistent and uniform exposure, each toothbrush was assigned to one quadrant of the oral cavity, with either AM brushing or PM brushing. The investigators kept a daily tally of toothbrush CDHA Journal Vol. 27 No. 2 StudentConnection exposure and bathroom usage. At the end of the experiment, the 32 toothbrushes were collected and re-swabbed for possible addition or growth of bacteria using the same methodology as the control study. Microbial Growth Quantification: Colony Forming Units (CFU) in the Petri dishes were manually tallied using a 6.5 mm square grid at 4x magnification. The resultant CFU counts were multiplied by 140 dilution factor for CFUs/ml. Control 61,800 137,000 59,000 42,000 SEM 8,860 39,100 6,400 10,000 Experimental 229,000 306,000 344,000 379,000 SEM 66,500 58,600 63,600 82,100 Table 2: Values of CFUs from Table 1 averaged per bathroom location. SEM calculations were with a sample size of 6 per location. Table 3: Aerosol Collection of Bacteria by Location One-way ANOVA of Experimental CFUs by Condition 2 feet 5 feet Tank Cabinet 560,000 276,000 428,000 490,000 156,000 560,000 246,000 220,000 150,000 284,000 480,000 634,000 190,000 360,000 536,000 548,000 174,000 150,000 184,000 192,000 144,000 206,000 190,000 189,000 6 6 6 6 229.000 306.000 344.000 378.833 163.035 143.633 155.779 201.125 X ave 314.458 source df SS MS F P-value treatments 3 74349.125 24783.042 0.8857 0.4654 error 20 559646.833 27982.342 total 23 633995.958 Table 3: Statistical comparisons between pre-study control and post study experimental CFUs by paired t-test. Inter-condition variance comparisons did not yield significant results. CDHA Journal – Summer 2012 Of the 32 toothbrushes in the study, CFU counts from 24 toothbrushes were used in the data analysis (Table 3). These 24 toothbrushes represented aerosol collection from 3 bathrooms. Eight toothbrushes, all from the same bathroom, were excluded from the analysis. CFU counts from these 8 brushes were statistical outliers when compared to counts from the remaining 24 toothbrushes. CFUs from the 24 toothbrushes were averaged per condition, resulting in 6 samples measured per condition. Standard Error Table 2: CFU Comparisons Two Tailed Paired t-Test Condition Control vs. Experimental 2 Feet 0.04 5 Feet 0.002 Tank 0.005 Cabinet 0.007 1 2 3 4 5 6 n X s CFU counts in the control and experimental samples were averaged and the standard error of the mean (SEM) were calculated (Table 1). Statistical comparison between the control average and the experimental average for each experimental condition was performed by paired t-tests. Inter-condition comparisons for control and experimental averages were performed using a one-way ANOVA (Table 2). RESULTS Table 1: Mean and Standard Error CFUs per Condition Condition 2 feet 5 feet Tank Cabinet Statistical Comparisons of CFU Counts: CFU/mL Control Experimental 86,000 560,000 63,000 156,000 50,000 150,000 86,000 190,000 56,000 174,000 30,000 144,000 Toothbrush ID 3 4 13 14 27 28 Condition 2 feet 2 feet 2 feet 2 feet 2 feet 2 feet 5 6 15 16 25 26 5 feet 5 feet 5 feet 5 feet 5 feet 5 feet 120,000 330,000 91,000 107,000 88,000 83,000 276,000 560,000 284,000 360,000 150,000 206,000 1 2 9 10 31 32 Tank Tank Tank Tank Tank Tank 84,000 48,000 66,000 47,000 43,000 66,000 428,000 246,000 480,000 536,000 184,000 190,000 7 8 11 12 29 30 Cabinet Cabinet Cabinet Cabinet Cabinet Cabinet 32,000 70,000 74,000 39,000 20,000 17,000 490,000 220,000 634,000 548,000 192,000 189,000 Table 1: Colony Forming Units (CFUs) of aerosol bacteria collected among four different bathroom locations on 24 toothbrushes within a 14 day study. Continued on Page 20 19 StudentConnection from the toilet does not have significant results on bacterial accumulation. Perhaps the dispersion of bacterial aerosols from the toilet bowl is fairly well distributed. More evidence is needed in demonstrating the amount of bacterial contamination on toothbrushes located at different distances from the toilet. Figure 1 Bacteria on Toothbrushes CFUs/ml 500,000 450,000 400,000 350,000 300,000 Control Experimental 250,000 200,000 150,000 100,000 50,000 0 2 feet 5 feet Tank Cabinet Figure 1: Comparison of values from Table 1. Mean and SEM CFUs by location. There are notable differences between pre-treatment controls and post treatment experimental samples. (SEM) values were also calculated for these conditions (Table 1). When comparing the CFUs between control and experimental samples, there were consistently and significantly more CFUs/ml in the experimental samples when matched with pre-treatment controls, as shown by paired t-test. The sample means and corresponding variance for the different bathroom locations were not statically different from one another, as shown by one-way ANOVA. This was true both for the control and experimental treatments (Figure 1). DISCUSSION The levels of bacteria found on toothbrushes before the study is in contrast to previous work demonstrating that toothbrushes are sterile when manufactured.7 Our study indicated that the control group, comprising of new and packaged toothbrushes, could be contaminated. One explanation of this result is the possible contamination of the control swabs. This contamination may have been caused by investigator error or incubation placement among other reasons. However, consistent with our understanding, bacteria were found to accumulate on the study toothbrushes once they were opened and used in the oral cavity.5 Bacterial accumulation on toothbrushes may be influenced by species antagonism on the bristles.12 Bacteria can come from contaminated hands, storage areas and toilet aerosols;8 although, the overwhelming source of exposure is the bacteria from the oral cavity. Additional factors affecting species diversity include frequency of exposure or use, toothbrush storage.8, 12 Previous studies showed that toilet aerosols can travel up to 6 to 8 feet.3 We expected to find differences in bacterial accumulation based on proximity to the toilet bowl; however, our study showed that distance 20 Toothbrushes located in cabinets, counter to our initial expectations, did not show a reduction in the amount of harbored bacteria. In support of our findings a previous study, reported in the Journal of Dental Hygiene, showed that covered toothbrushes had significantly higher amounts of bacteria in comparison to uncovered toothbrushes.13 Consequently, it is surmised that bacteria harbor better in areas with warmth and darkness, such as bathroom cabinets. To minimize the possibility of bacterial contamination on toothbrushes, either from manufacturing processes, aerosol accumulation, or bacterial growth during storage, many in the dental profession have advocated the use of UV light on toothbrushes.14 Further research is needed about UV sterilization products in reducing microbial accumulation on toothbrushes. CONCLUSION In conclusion, we recommend that either toothbrushes are kept outside of bathrooms, and thus they are out of aerosol range, or if they are kept within bathrooms, they are allowed to fully dry between use, as previous work has demonstrated that bacteria can harbor on moist toothbrushes.13 Practical application of this second recommendation would mean using two sets of toothbrushes, one for the morning and another for the evening, where each toothbrush is allowed time to fully dry in between daily use. In this instance, the brushes can remain in the bathroom uncovered. ACKNOWLEDGEMENTS The authors would like to thank West Coast University for contributing the materials needed for this study. About the Authors Elly A. Montero, BSDH, Isabelle B. Isom, BSDH, Jeanne Fults, BSDH, Samantha Cvijanovich, BSDH completed the requirements for a Bachelor of Science degree in Dental Hygiene from West Coast University in 2011. They conducted this original research as students in the dental hygiene program at WCU. Faculty Research Advisors: Aubree Chismark, RDH, MS, and Benjamin Tran, MS. From left to right: Elly A. Montero, BSDH, Isabelle B. Isom, BSDH, Jeanne Fults, BSDH, Samantha Cvijanovich, BSDH CDHA Journal Vol. 27 No. 2 StudentConnection References 1. Freeman J, Anderson D, Sexton D. Seasonal peaks in Escherichia coli infections: possible explanations and implications. European Society of Clinical Microbiology and Infectious Diseases. 2009;15:951-953. 2. Poxton R, Brown R, Sawyerr A, Ferguson A. Mucosa-associated bacterial flora of the human colon. Journal of Medical Microbiology. 1997;46:85–91. 3. Saini, R, Saini S. Microbial flora on toothbrush - at greater risk. Ann Nigerian Me. 2010;31-32. 4. Barker J, Jones M. The potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet. Journal of Applied Microbiology. 2005;9:339-347. 5. Ankola A, Hebbal M, Eshwar S. How clean is your toothbrush? International Journal of Dental Hygiene. 2009;7:237-240. 6. Morawska, L. Droplet fate in indoor environments or can we prevent the spread of infection? Inter J Indoor Env Health. 2006;16(5):335-347. 7. Nelson-Filho F, Bezerra da Silva R, Rossi M, Ito I. Evaluation of the contamination and disinfection methods of toothbrushes used by 24- to 48month old children. Journal of Dentistry for Children. 2006;3(3):152-158. 8. Taji S, Rogers A. The microbial contamination of toothbrushes: a pilot study. Australian Dental Journal. 1998;3(2):128-130. 9. Clark F, Sontrop M, Macnab J, Salvadori M, Moist L. Long term risk for hypertension, renal impairment, and cardiovascular disease after gastroenteritis from drinking water contaminated with Escherichia coli O157:H7: a prospective study. British Medical Journal. 2010;1-9. 10. Sato S, Ito I, Lara E, Panzeri H, Ferreira de Albuquerque R, Pedrazzi V. Bacterial survival rate on toothbrushes and their decontamination with antimicrobial solutions. Journal of Applied Oral Science. 2004;2(2):99-103. 11. Elliot E. Acute gastroenteritis in children. British Medical Journal. 2009; 334:35-40. 12. Kreth J, Zhang Y, Herzberg MC. Streptococcal antagonism in oral biofilms: streptococcus sanguinis and streptococcus gordonii interference with streptococcus mutans. Journal of Bacteriology. 2008;190(13): 4632-4640. 13. Borso H, Crump R, Schelling M. The effect of toothbrush covers on bacteria retention. The Journal of Dental Hygiene. 2004;78(4):19. 14. Berger JR, Drukartz MJ, Tenenbaum MD. The efficacy of two UV toothbrush sanitization devices. A pilot study. N Y State Dent J. 2008;74(1):50-52. 2012 Cora Ueland Scholarship Award Recipients Dental Hygiene Associates Incorporated (DHAI), the not-for -profit subsidiary organization of CDHA recently announced the 2012 recipients of the Cora Ueland Scholarship. First established as a loan fund in the 1950s in the memory of Cora Ueland, founder and director of the dental hygiene program at the University of Southern California, the fund has been a student scholarship since 1998. This year’s recipients continue to carry on Cora Ueland’s commitment to excellence in education and service to others. Morgan Kozek is a 2012 dental hygiene graduate from The Herman Ostrow School of Dentistry of the University of Southern California. President of the Student Chapter of the ADHA at USC, Morgan enjoys meeting new people in the dental hygiene profession. In 2011, Morgan participated in the ADHA table clinic research session, and continues to be interested in learning about new and innovative research in dental hygiene. Morgan is committed to providing services to those in need, both locally and internationally. She recently traveled to Cartagena, Colombia, where she provided dental hygiene care to both children and adults. Morgan is very CDHA Journal – Summer 2012 passionate about the dental hygiene profession and is excited to get involved in her local component and beyond. Lauren Umetani is a first-year dental hygiene student at Foothill College. She holds a B.A. degree in web design from Cogswell Polytechnical College in Sunnyvale, CA, graduating as class valedictorian in 2003. The following year, she graduated from the Baking and Pastry Arts Program of the California Culinary Academy in San Francisco and worked as a pastry chef and baker for six years. Ready for a career change, Lauren chose to follow in the footsteps of her mother Aileen, a 1968 graduate of Foothill College, and become a dental hygienist. Between studying and volunteering in the community, Lauren also played a key role in organizing the Foothill dental hygiene students’ inaugural Walk for Oral Cancer Awareness, raising over $5000 for the Oral Cancer Foundation. Lauren is honored to receive the Cora Ueland Scholarship and would like to thank her family and friends for all their love and support as she pursues her new profession. 21 StudentConnection California Students Share their Knowledge at the 2012 Table Clinic Competition Over two hundred dental hygiene students from dental hygiene programs throughout the state came together in Anaheim for the annual CDHA Table Clinic competition. This year’s program marked a new collaboration with the California Dental Association, the CDA Foundation and Calfiornia Dental Hygienist Assoiciation bringing additional judges and funding for the award winning clinics. CDHA and CDA member judges had a challenging time selecting the winning presentations in the table clinic and research categories. Informational Table Clinics By virtue of their hard work and valuable contributions to the exchange of information amongst fellow professionals, all of the student participants were truly “winners” in the competition. Abstracts of the top three research and informational table clinics are available online at www.cdha.org under student members. CDHA and CDA look forward to furthering our collaborative efforts, strengthening the relationship between our organizations and benefitting our profession and the public. 2nd Place – West Los Angeles City College Shine the Light on Bleaching 3rd Place – Cerritos Community College Enamel Facts on Celiacs Research Poster Presentations Sandy Levy and Sophia Perez Kaitlyn Tarbert & Amanda Roberts 1st Place – West Los Angeles City College Go Green Christopher Johnson, Jennifer Kuo, Samantha Nebel, Mizuho Sato Thank you to our team of judges from CDHA and CDA CDHA Judges 1st Place – Loma Linda University A Comparison of Three Surface Disinfectants Julianne Souza, Debra Gruzensky, Jeanne Gustafson 2nd Place – Loma Linda University The Effects of Magnolia Bark on Oral Microbial Growth 3rd Place – Fresno City College pH for the RDH Melissa Fife & Michelle Herrera CDHA and CDA leadership teams and CDA judges Special thanks to Crest Oral B and the CDA and CDA Foundation for sponsoring this year’s table clinic competition Michelle Kaiser, Lindsay Sharman, Amanda Armand 22 CDHA Journal Vol. 27 No. 2 CareerCorner Carol Lee, RDH, BS, FAADH Sharon Golightly, RDH, EdD Beginning with the End in Mind In the best-selling book, The 7 Habits of Highly Effective People, the late author and leadership consultant Steven Covey stated that the successful individual begins each task, project and day with a clear vision of the desired direction and then works to continue to make it happen. If you ask Sharon Golightly about this “habit” she would say, to make sure that the direction is proactive and the desire to reach it is undeterred, two qualities that describe her vision for her career and the profession. Sharon Golightly, RDH, EdD, has taken her career from California to South America, Maryland, Washington and back again to California. Sharon’s dental hygiene career began in 1964 when she received her Bachelor of Science in Dental Hygiene from Loma Linda University. After graduation, Sharon was inspired to give back to others by joining the Peace Corps. While serving in Brazil, Sharon had the opportunity to meet Robert Kennedy, whose words would continue to be a recurring theme, defining Sharon’s passion and vision for the profession. “Some see things the way they are and ask ‘why?’ I dream of things that never were, and ask, ‘why not?’” ~ Robert Kennedy After completing her tour in the Peace Corps, Sharon settled into private practice in northern California, followed by a move to Maryland, later returning to southern California to earn her credentials in Higher Education Instruction and Supervision from UCLA. Sharon then taught at Sacramento City College where she was offered the position of Interim Director of the dental hygiene program. However, school policy at the time required that only a dentist could serve as program director. Recognizing the limited leadership opportunities, in 1975 Sharon accepted a faculty position at Pierce College in Ft. Steilacoom, Washington. She would spend the next 32 years in Washington, expressing her vision for moving dental hygiene forward. Initially hired to teach didactic and clinical courses, Sharon soon became the program director, adeptly steering the program through a demanding accreditation process. While serving as director, she found many opportunities to address oral health disparities, access to care, and workforce issues. Sharon also found time to run for a seat in the Washington State Senate. Running as a Democrat in a Republican district, her bid fell short of a win, receiving 43% of the vote. However, her actions have continued to inspire other dental hygienists to run for public office. Always striving to advance her education, in 1998, Sharon received her Doctorate in Education Leadership from Seattle University. I recently caught up with Sharon at the ADHA Annual Session in Phoenix, Arizona and asked her a few questions about her career as a hygienist, educator, a mentor and most of all as a “change agent”. How has dental hygiene care changed since you were first licensed? Washington was the first state to allow dental hygienists to perform Expanded Functions back in 1971. Dental hygienists can be a force multiplier in a dental practice, freeing up the dentist to perform more complex procedures. Expanded functions have been a boon for the people of Washington and for the general dentists and specialists working with dental hygienists. Approximately one-third of practices employ hygienists in this fashion. Frequently, dentists employ dental hygienists specifically to administer local anesthesia in the office. Various studies have shown a 30-50% increase in productivity as one of the benefits of employing dental hygienists. What were some of your responsibilities as Director of the Pierce College Dental Hygiene Program? As director, I was responsible for the day to day operation of an educational program with a budget of over $650,000; supervised 14 employees; oversaw clinical operations and incorporation of technology for the program; taught didactic and clinical courses and successfully met accreditation standards for seven different American Dental Association Accreditation site visits. I was also active in the college governance and served as President of the Faculty Association. In 1997, Washington was the first state to bring the issue of dental hygiene independent practice, expanded scope of practice and self-regulation to the voters. Would you please provide some insight into the effort? After 18 years of failed attempts in the legislature, we decided to take the issue of independent practice to the people of Washington Continued on Page 24 CDHA Journal – Summer 2012 23 CareerCorner in the form of an initiative. I was on the steering committee and part of the campaign. We pounded the pavement and were able to collect an overwhelming number of signatures to get on the ballot. The landmark Initiative 678, also known as SHOUT (Support Hygienists and Oppose Unequal Treatment), received statewide endorsement from a wide range of stakeholders. Unfortunately, in the final weeks, voters were bombarded with negative TV and radio ads and mailers urging, “NO on I-678.” Additionally, there were several other initiatives on the ballot polarizing conservative voters. Unfortunately, I-678 was at the bottom of the ballot and we lost by 1% of the vote. Collaborative practice is often cited as a means to increase access to care and reduce health disparities. How does dental hygiene take a leadership role in promoting the collaborative practice model? Dental hygienists are in a unique position to spend more oneto-one time with a patient than other healthcare providers. The hygienist takes a comprehensive medical and dental history and performs full assessments, screening for disease both inside and outside of the oral cavity. I always convey our special responsibility to patients when I am working with my students. I encourage them to make referrals to other health care providers as necessary. I feel dental hygienists are under appreciated for what they contribute to a dental practice and health care. By working with other health professionals, we can reinforce the quality of our education and services. Value needs to be placed on the care we deliver to improve a patient’s oral and overall health. Third party payers need to assess their policies for preventive care. I feel we need to continue with our legislative goal nationally for professional autonomy; setting the educational standards and professional parameters for dental hygiene. Education is a key element for dental hygienists to lead the way for our profession. What is on your “Wish List” for California Dental Hygienists? • Attain self-actualization and become a true profession in every sense; complete “autonomy for dental hygienists.” • Establish a true pathway from entry level dental hygiene to the Dental Hygiene Practitioner level; using technology to bring educational opportunities to “place-bound” students. • The human and financial resources to move the dental hygiene profession forward. • Enlightened, forward thinking dental hygienists stepping forward to fill leadership positions within and outside of dental hygiene. 24 In 2007, Sharon retired from her position as Dental Hygiene Program Director at Pierce College. However, Sharon is not finished manifesting her vision for the profession. Since “retiring”, Sharon has contributed to the development of the curriculum for ADHA’s Advanced Dental Hygiene Practitioner. Back in California, Sharon is a member of the CDHA Government Relations Council and is an ADHA delegate. She urges every hygienist to be an active member as this is such a crucial time in California. She says, “We are at an intersection in our profession and we must to be poised to be in the best position to contribute and meet the needs of the public.” Recently, Sharon began what she refers to as her “encore career.” She has been named Director of the Dental Hygiene Program at Carrington College in Sacramento. “Best wishes to you, Sharon,” as you inspire and mentor a new generation of dental hygienists. “It is because of Sharon and the Expanded Functions Program she established that I am able to practice in the state of Washington. Her program was creative and organized, making, it easier to acquire the new skills I needed.” Susan Savage, RDH, BS ADHA President and Former Pacific NW Institute student “She taught me everything I know! She mentored me with patience and encouragement.” Lynn Steadman, RDH, MEd, MA Director of Columbia Basin College Dental Hygiene Program “She brought Washington State into the future, inspiring us to believe we could have it all, the whole enchilada. She was the major force in moving us forward.” Colleen Gaylord, RDH Chair of the WA State Government Relations Council “Having met Sharon during an accreditation site visit, I was inspired to pursue my doctorate.” Janet Woldt, RDH, PhD Associate Dean for Academic Assessment, A.T. Still University Arizona School of Dentistry & Oral Health “She is as passionate and enthusiastic today as she was when she moved to Washington. She definitely ‘takes the path less traveled.’ How fortunate for you that she is back in California.” Kathy Bassett, RDH, BSDH, MEd Professor of Dental Hygiene, Pierce College Author and Speaker CDHA Journal Vol. 27 No. 2 CareerCorner “Dental hygienists have advanced the practice of dentistry over the past 20 years. We have been the first to implement new technology, science and treatment into what is now considered mainstream dental care. After all, it was dental hygienists who embraced and incorporated comprehensive periodontal assessment, infection control, sealants, fluoride varnish, cancer screenings, loupes, salivary testing and even power toothbrushes into private practice. And by incorporating these important changes, dental hygienists have contributed to a higher overall standard of care.” Sharon Golightly, RDH, EdD Carol Lee, RDH, BS, FAADH has been practicing dental hygiene since 1977. A member of the adjunct faculty at Sacramento City College, Carol is also a frequently requested speaker for continuing education courses especially in the area of ergonomics and clinical practice. Passionate about community dental health, Carol has organized numerous outreach programs and activities particularly for seniors and the homebound. She is a past president of CDHA, a member of the Information Technologies Council, serves on the CDHA Journal Editorial Advisory Board, and is a Fellow in the American Academy of Dental Hygiene. The Time is Now! Earn Your BSDH Degree Online With over 50 years of dental hygiene experience, the Department of Dental Hygiene is dedicated to providing the highest quality education. Offering an environment for learning that emphasizes Christian values, intellectual development and community service, Loma Linda University encourages personal wholeness and professional growth. ◆ Online BSDH degree completion program ◆ Designed for licensed dental hygienists with a Certificate or Associate degree ◆ Two tracks available: Dental Hygiene Education Public/Community Oral Health Services ◆ Courses designed for the working professional ◆ Now accepting applications for March 2013 and September 2013 Contact us Today! [email protected] CDHA Journal – Summer 2012 25 StayingHealthy Vicky A Newman, MS, RD Fighting Cancer with Food and Activity Key to reducing cancer risk and progression are lifestyle choices we can control. These include the type and amount of food we eat, and the frequency and intensity of the physical activity we enjoy. Both diet and activity are lifestyle factors that affect the environment (or “terrain”) in which our cells reside. Actions we can take to encourage a “terrain” resistant to cancer growth include controlling weight, maintaining good circulation, eating plenty of plant foods (vegetables, fruits, whole grains, beans/legumes), and choosing healthy fats. Control Your Weight Being overweight or obese increases the risk of cancer. Common cancers associated with obesity include cancers of the gastrointestinal tract (esophagus, gallbladder, colon, rectum) and hormone-related cancers (breast, uterus). It’s not just the number of pounds on the scale that is a concern, but perhaps more importantly the amount of stored fat compared to lean body mass (muscle) that makes up those pounds. In addition to the amounts eaten, the type of foods and beverages we consume play a role in weight control. Diets plentiful in highly processed foods that are low in natural fiber and contain mainly refined carbohydrates (like white flour, sugar), as well as purified fats (like corn, cottonseed, safflower, soy oils) make it easy to consume excessive energy which favors fat storage. Excessive intake of simple sugars like fructose (as in high-fructose corn syrup) in the absence of fiber (as found in fruit) contribute to obesity by affecting the hormonal regulators of hunger and satiety. Physical activity increases metabolic rate, allowing us to consume more food and more disease-fighting nutrients without gaining weight. Inactivity contributes to loss of lean body mass and favors fat accumulation. Excess stored fat in turn leads to insulin resistance, which is associated with chronically higher levels of insulin and insulin-like growth factor, both associated with a “terrain” more conducive to cancer growth. The link between obesity, diabetes, and cancer is currently being studied. Most health authorities recommend that we maintain a healthy weight and avoid gaining weight during adulthood (preferably less than 11 pounds gained after the age of 18 years, assuming a healthy weight at 18). If weight loss is needed, it is best to avoid rapid weight loss of greater than 2 pounds/week. Extreme caloric restriction leading to rapid weight loss can deprive the body of key nutrients needed for optimal body functioning, as well as overwhelm the body’s detoxification systems by releasing too many potentially damaging environmental chemicals into the circulation for the body to neutralize and eliminate safely. 26 Maintain Good Circulation Good circulation is critical for good health. You might think of it like this: circulation = energy = life. Optimizing energy flow or Qi (pronounced “chi” or“chee”) is a fundamental premise of Chinese medicine. Taking a more Western view, we might focus on supporting a healthy flow through our cardiovascular and digestive systems. Our blood delivers oxygen and nutrients to our tissues, and the blood, bowels, kidney, liver, and lymphatic system remove the toxins. Regular physical activity supports good blood circulation and waste removal by stimulating the bowels and the lymph system. A diet rich in plant foods also helps to maintain a healthy circulatory system. Plant foods are generally lower in fat, especially saturated fats (hard at room temperature) that increase the tendency of the blood to thicken and clot. Plant foods are also rich in antioxidant and anti-inflammatory “protectors” that help to reduce cellular damage and inflammation that can lead to plaque buildup which ultimately affects blood flow. The fiber provided by plant foods supports regular waste removal via the bowels. In addition to its role in supporting weight control and circulation, regular moderate physical activity helps to reduce several key biological indicators of cancer risk, including sex hormone levels, insulin resistance, and inflammation. Physical activity can also help strengthen the immune system, which plays an important role in controlling the growth and spread of cancer cells. The current guidelines for moderate physical activity are 30-60 minutes at least 5 days/week. If walking is your activity of choice, aim for a minimum of 100 steps per minute (a 30-minute walk would be 3,000 steps or more). Or if you choose to walk on a treadmill, set the pace at 3-4 miles/hour (or a 15-20 minute mile). According to recent research, simply moving rather than being sedentary is critical to good health. Sedentary behavior (sitting for prolonged periods of time) has emerged as a distinct risk factor for cancer, as well as other chronic diseases. It’s helpful to wear a pedometer and set a goal of 10,000 steps/day. When you check your pedometer mid-morning and find you have only done 1,500 steps, it can be a powerful incentive to get up and move more through the rest of the day. Eat Plenty of Plant Foods A diet that helps fight cancer is one that includes plenty of plant foods (vegetables, fruits, whole grains, and beans/legumes), while limiting processed (refined) foods, and red meats. Plant foods provide fiber, along with protective nutrients and phytochemicals. CDHA Journal Vol. 27 No. 2 StayingHealthy Fiber-rich foods help us to feel full with fewer calories, which supports weight control. Fiber also lowers the glycemic load or elevation of blood sugar after a meal. Frequent ingestion of meals and snacks low in fiber contribute to chronically elevated blood sugar, which is in turn associated with higher levels of insulin and insulin-like growth factor, both of which are associated with increased cancer risk. Fiber also speeds transit through the gastrointestinal tract, reducing exposure of gut mucosa to cancercausing chemicals. Additionally, fiber enhances the excretion of carcinogens and helps normalize hormone levels, which in turn can reduce the risk of hormone-related cancers (like breast and uterine). Fiber also promotes the growth of “friendly bacteria” in the gastrointestinal tract. These “friendly bacteria” use fiber as a fuel source to produce some of the nutrients needed to keep the lining of the gut healthy, as well as some nutrients that are reabsorbed and used to keep our body systems working properly. Phytochemicals are what give plants their color, taste, and fragrance. Plant foods with BIG color and STRONG flavor not only please the senses, but also help to protect our health. Carotenoids, found in deep orange, red, and green plants, are powerful antioxidants that help to protect our DNA from damage that can lead to cancer. Carotenoids are also the raw material from which retinol or vitamin A is made. Vitamin A not only supports the health of epithelial cells (skin, GI tract, genitor-urinary tract), but is also critically important for the normal functioning of the immune system, which works to search out and destroy cancer cells. Flavonoids, supplied by plants, protect tissues from oxidative damage (acting as antioxidants) and also have anti-inflammatory properties. The sulfur compounds (indoles, isothiocyanates, allyl sulfur) found in cruciferous vegetables (like arugula, broccoli, cabbage, kale) and in onions and garlic, and the terpenoids found in herbs and spices increase the activity of detoxification enzymes in the body. It’s recommended that we consume about 25-35 grams of fiber each day. (Table 1) You can estimate your fiber intake by figuring that every serving of vegetable or fruit provides about 2 grams of fiber, each serving of whole grains provides about 3 grams of fiber, and each serving of beans/legumes provides about 6 grams of fiber. To determine if a grain product promoted as “whole grain” actually is whole grain, check to make sure the first ingredient is whole, sprouted or malted wheat or grain. Wheat flour is actually white flour so be sure and read the label. You can also check the label to confirm that a serving of the grain product actually provides at least 3 grams of fiber. To obtain a good supply of the plant protectors, it’s a good idea to eat at least 5 - 9 servings of vegetables and fruits every day. The range is based on body size and caloric intake. Smaller women need at least 5 servings every day, while larger people (most men) need at least 8 - 9 servings every day. A serving is a ½ cup cut-up vegetable or fruit, 1 cup raw leafy vegetable, or ¼ cup dried fruit. To insure adequate fiber and plant protector intake, it is best not to count iceberg lettuce, fruit juice, or white potatoes as you work toward your vegetable and fruit goal. Plant foods also provide a wide array of protective nutrients and phytochemicals that play important roles in maintaining health and preventing diseases like cancer. Phytochemicals are biologically active compounds produced by plants to protect them from damage from the environment. When we eat plants, these “plant protectors” in turn help to protect our body from damage that can lead to cancer and other chronic conditions. Table 1 – Getting Enough Fiber (25-35 g/day) Food Recommended Serving/day Fiber/Serving (g) Total Fiber (g) Vegetables 4 -5 2 8 -10 Fruit 2 -3 2 4- 6 Whole Grains 2- 3 3 6- 9 1/2 - 1 6 3- 6 Beans TOTAL 21-31 Serving = 1/2 cup cut-up fruit, vegetable; 1/2 cup cooked grains or beans; 1 slice bread CDHA Journal – Summer 2012 Choose Healthy Fats To reduce cancer risk, limited fatty food and choose healthy fat. Not only are fatty and fried foods energy-dense, making weight control more challenging, but fat can be a source of fat-soluble contaminants. The rancid fats found in aged meats, cheeses, and deli meats can contribute to oxidative damage of body tissues contributing to cancer risk. To reduce ingestion of fat-soluble contaminants, it is helpful to eat smaller sized animals (like chickens) and fish (like sardines) that are lower on the food chain. Continued on Page 28 27 StayingHealthy The larger, longer-lived animals (beef, lamb, pork) and fish store more contaminants in their fat. The EPA recommends that consumption of farmed salmon be limited to one serving (3 oz)/ month. It is also helpful to limit or avoid full-fat dairy products and red meats, as well as processed foods made with hydrogenated (trans) fats. Not only are these fats unhealthy for the cardiovascular (circulatory) system, but research continues to show an association between red and deli meats and cancer (both cancer risk and cancer mortality). The current guideline is to limit red meat (beef, lamb, pork) consumption to 18 ounces per month. Refined oils (corn, cottonseed, safflower, sunflower, soy) and processed and fried foods made with these oils are best minimized or avoided, because these oils tend to be pro-inflammatory. Chronic low-grade inflammation contributes to a “terrain” more permissive of cancer growth. The healthiest fats are those found in plant foods, like avocadoes, nuts, and seeds, because along with fat, these foods also provide nutrients and other plant protectors. Including some anti-inflammatory omega-3 fats in your diet several times each week is also helpful. While fish and seafood provide the most biologically active forms of omega-3 fatty acids (DHA and EPA), flaxseed, hemp, and chia seeds also provide these anti-inflammatory fats. Remember, you can use your fork to reduce cancer risk and progression by: • Avoiding excess weight gain • Eating plenty of vegetables, fruits, whole grains, beans • Reducing the consumption of fatty foods • Eating fish or seafood (not fried) 2-3 times each week • Avoiding sweetened beverages & food made with high-fructose corn syrup About the Author Vicky A. Newman, MS, RD, is Director of Nutrition Services for the Cancer Prevention & Control Program at the UCSD Moores Cancer Center, and an Associate Clinical Professor (Voluntary) in the Department of Family and Preventive Medicine, UCSD School of Medicine. Vicky has been involved in nutrition and behavior change research at UCSD for over 35 years. The second edition of her book “Food for Thought—Healing Foods to Savor” was published this spring. Read more about her work and the UCSD telephone nutrition coaching program at www.healthyeatingucsd.org References Reducing Cancer Risk and Progression • Maintain a healthy weight • Enjoy a physically active lifestyle: - 30-60 minutes/day moderate intensity activity - At least 10,000 steps/day • Eat plenty of plant foods: - Vegetables (4-5 servings/day) - Fruits (2-3 servings/day) - Whole grains (2-3 servings/day) - Beans/legumes (3-4 servings/week) • Limit fatty foods and choose healthy fats: - Minimize fried, savory snack foods, fast foods - Go easy on salad dressings, mayonnaise - Limit red meat (no more than 18 ounces/month) - Eat fish or seafood (not fried) 2-3 times each week (but farmed salmon no more than 1 serving/month) 1. Mayo Foundation for Medical Education and Health Research. Bone health: Tips to keep your bones healthy. [Internet] Rochester (MN); 2010 Dec 7. [cited 2012 Jan 3]. Available at: http://www.mayoclinic.com/health/bonehealth/MY01399. 2. World Health Organization. WHO scientific group on the assessment of osteoporosis. [Internet]Geneva(CH); 2004; WHO Press [cited 2012 Jan 3]. Available at: http://www.who.int/chp/topics/Osteoporosis.pdf 3. Institute of Medicine. Dietary Reference intakes for calcium and vitamin D. [Internet] Washington, DC; 2011. National Academy of Medicine [cited 2012 Jan 3]. Available at: http://www.iom.edu/Reports/2010/Dietary-ReferenceIntakes-for-Calcium-and-Vitamin-D.aspx 4. Office of Dietary Supplements. Dietary supplement fact sheet: Vitamin D [Internet] Bethesda(MD); 2011 June 24 National Institutes of Health [cited 2012 Jan 3]. Available from: http://ods.od.nih.gov/factsheets/vitamind 5. Office of Disease Prevention and Health Promotion. Dietary guidelines for Americans. [Internet] Washington, DC: US Government Printing Office; 2011 Jan 31 [cited 2012 Jan 3]. Available from: http://health.gov/ DietaryGuidelines/ • Avoid sweetened beverages and foods made with high-fructose corn syrup 28 CDHA Journal Vol. 27 No. 2 EducationExchange Aubreé Chismark, RDH, MS Benjamin B.Tran, MSc Promoting Student Research: The Role of the Dental Hygiene Educator Introduction The primary goal of dental hygiene programs is educating practitioners, with a large portion of the curriculum devoted to technical training. It is required that dental hygiene students evaluate the literature and make decisions based on evidence.1 The Commission on Dental Accreditation (CODA) requires that dental hygiene students utilize Evidence-Based Decision Making (EBDM) when treating patients.2 As faculty, incorporating critical thinking and EBDM into all coursework will teach students the necessary skills needed to incorporate these practices into the clinical setting.1 Having access to computers in the clinic allows greater access for students to incorporate EBDM into their daily practice.1 Providing the best care for patients requires the necessary skills of utilizing the Internet to search for reliable resources. Faculty should work closely with librarians on campus to ensure the school has access to a sufficient number of peer-reviewed journals to support the students in EBDM and research.1 EBDM in dental hygiene relies solely on research that has been conducted by dental professionals therefore, we have provided some guidelines to empower dental hygiene faculty when guiding students with their research assignments. existing skills.4 As dental hygiene faculty members, it is important to mentor our students when it comes to the scientific method. It is also important to have personal research experience and be able to collaborate with other departments when guiding students in their research efforts. Since dental hygiene research allows us to make decisions based on evidence, it is important to encourage students to pursue research topics they have a strong interest in. The use of the research agenda will facilitate the discovery of new knowledge in the field of dental hygiene.4 When students are brainstorming for a research topic, refer them to the NDHRA and be sure they identify the category and sub-category their research falls within. The content provided in the agenda reveals current health issues within the profession, and the decisions that clinicians must make in order to provide the best services for their patients based upon clinical experience and research.4 American Dental Hygienists’ Association National Dental Hygiene Research Agenda The American Dental Hygienists’ Association (ADHA) National Dental Hygiene Research Agenda (NDHRA) is a guide for dental hygiene researchers to identifying the research priorities within the profession. The NDHRA includes the following categories: Health Promotion/Disease Prevention; Health Services Research; Professional Education and Development; Clinical Dental Hygiene Care; Occupational Health and Safety.3 The importance of having a research agenda is to guide dental hygiene researchers to focus their topics on priorities where there is limited evidence. It also brings our profession to the same level as other health professional associations and allows us to share goals with a larger population.3 Facilitating Student Research Many schools require dental hygiene students to conduct original research, such as table clinic projects, or writing literature reviews on a specific topics. Undergraduate dental hygiene programs are responsible for teaching their students the basic skills required to conduct research, whereas graduate programs build upon their CDHA Journal – Summer 2012 Dental hygiene students conducting research projects at West Coast University in Anaheim, CA. Being a Suitable Mentor There has been much debate on the attributes or functions that constitute being a good mentor. Discussions on the role of the mentor date back over 2 millennia and the definition of a good mentor varies by industry, such as professional practice or education. Moreover, the definition of a good mentor can also vary within fields such as nursing, medicine, dentistry and academia.5,6 On the issue of research mentorship, there are certain criteria that are critical to the successful mentoring of student research. Qualifications of a Research Mentor The field of dental hygiene traditionally has focused on the education of clinicians both at the associate and baccalaureate levels. However, with the ever increasing scientific knowledge, dental Continued on Page 30 29 EducationExchange hygienists interested in mentoring student research must be skillful in a multitude of tasks typically taught at the graduate level. Such skills include: searching and evaluating the scientific literature to guide EBDM in clinical practice and teaching; being fluent in the scientific process; being competent and self-confident in one’s research technical skills, and having experience with scientific publishing.7 As such, the role of the research mentor typically requires at a minimum, a Master’s degree.1 Ideally, a student research mentor is one who has conducted research as part of their own clinical or academic profile, as opposed to either clinical practice or teaching. Successful research mentors should be able to teach students how to find information, organize the information, and share the information with life-long learners. Work experience alone is usually not enough to mentor student research projects, as this process requires skill sets not typically experienced in private practice or teaching.1 Attributes of a Research Mentor The role of the mentor is one of a teacher and role model. In these capacities the mentor also advises, counsels and coaches students in their research projects. The mentor utilizes their own research experience to guide the student projects through completion. In order to be successful, the student research mentor has to be approachable and interpersonal with the students and effectively demonstrate their research skill sets to form a personal and professional collegial relationship.7 The mentor and mentee relationship is one that should be based on shared interests, especially if that interest is within the expertise of the mentor. In such a case, that mentor is able to offer unique guidance on the student research project that other mentors, with differing expertise, may not. Therefore, the mentoring relationship should not be based on the convenience of available mentors.1 The mentoring role is often instigated by the mentee and as such, the mentee may find it suitable to have several mentors, rather than the single mentor, to fill the various support roles due to the functions that mentor serves for the mentee. The actual person acting as the mentor may not play as critical a role as in the case of career development within a department, where the specific mentor may have significant influence on one’s advancement.6 Mentoring roles that are biased, harassing or competing in interests or agendas should be avoided. Mentors should not impose their personal viewpoints or issues in the student project or workplace.8 Mentors within a student research project should have no tolerance for discrimination, preferential treatment, and have a clear understanding of 30 boundaries both personally and professionally. The mentoring role should be a no fault relationship without risk of harm to either the mentor or the mentee.6 Responsibilities of the Mentor The duties of a mentor vary by industry and field. Certainly there is a wide range of opinions in the literature even though there have been studies attempting quantification of the mentoring relationship.5,9 Common to many studies on the role of the mentor are these responsibilities: commitment to mentoring; provision of resources, expertise, or source materials; guidance and direction on research issues; encouragement of mentee ideas and work; constructive and actionable critiques for improving mentee work; and challenging the mentee to expand their abilities.5, 7, 9 The role of the mentor heavily emphasizes the experience, influence and achievement in the mentor’s field of expertise in order to leverage support for the student research project. In this regard, the mentoring relationship can be informal and short-term to formal and long-term. Thus, mentoring is a voluntary relationship instigated by the mentee to receive advice, information, guidance, support, and provide an opportunity for professional development.5 The efficacy of the mentor in fostering student research depends on how well the mentor understands their role in the relationship. Student learning is better supported when the mentor has a good understanding of their role in the relationship. Ultimately, the overarching goal of the mentor is to familiarize the mentee into their professional field.9 The Research Process and Publication Preparation Critical to the success of the student research project is formulating a testable hypothesis, wherein the research question can be easily defined, measured and evaluated. Students new to the scientific process will need considerable guidance in developing their research question, experimental design, data collection tools, and results analysis. The student research project may be unsuccessful due to any of these components. Moreover, even after project completion, peer rejection of the study during critical review may stem from poor implementation of any one these components. The research mentor responsible for offering the most guidance to the student project, should have expertise related to the critical project components in particular, the research laboratory techniques.1 Ideally, the mentor should be able to guide all aspects of the project, including data analysis. However, many clinicians may not have the expertise to apply statistical methods to their research CDHA Journal Vol. 27 No. 2 EducationExchange data. Consequently, many academic departments may have a dedicated statistician on staff. Student research work often requires restructuring and revision to improve the scientific argument and to conform to journal guidelines. Since the students are involved in other coursework, competing for their time during manuscript preparation can be challenging. Key to completing revisions, is the setting of timelines for each component of the project. Faculty mentor Aubreé Chismark (second from left) and dental hygiene student researchers at the CDA poster session. Benjamin Tran, MSc is an Assistant Professor in the Sciences Department at West Coast University in Anaheim, CA. His expertise in biomedical research includes published studies in neuroscience, molecular biology, and toxicology. Benjamin can be contacted at: [email protected] References 1. Spolarich AE, Gadbury-Amyot C, Forrest JL. Research issues related to education. J Dent Hyg.[Internet]. 2009 [cited 2011 Dec 3];83(2):79-83. Available from http://www.adha.org. Registration required for access. 2. Forrest JL, Miller SA, Overman PR, Newman MG. Introduction to evidencebased decision making. In: Evidence-based decision making. A translational guide for dental professionals. 1st ed. Philadelphia, PA. Lippincott Williams & Wilkins Publishing. 2009. p. 8. 3. Forrest JL. The American dental hygienists’ association national dental hygiene research agenda. J Dent Hyg. [Internet]. 2009 [cited 2011 Dec 3];83(4):159160. Available from http://www.adha.org. Registration required for access. Conclusion In order to expand the knowledge in areas where there is a lack of scientific evidence within the dental hygiene profession, it is important to use the NDHRA as a guide to facilitating research. Mentoring students in the research process takes time and commitment. Having the necessary skills and expertise to mentor and guide students is key to successfully completing a student research project. Our goal as dental hygiene educators is to share as much knowledge with our students as possible, as well as encourage students to look at other opportunities outside of clinical practice. The dental hygiene profession is in need of more researchers, and mentoring our students successfully through the scientific method will help to expand the body of knowledge within our profession. 4. Spolarich AE, Forrest JL. Utilization of the ADHA national dental hygiene research agenda. J Dent Hyg. [Internet]. 2009 [cited 2011 Dec 3];83(1):3335. Available from http://www.adha.org. Registration required for access. 5. Berk RA, Berg J, Mortimer R, Walton-Moss B, Yeo TP. Measuring the effectiveness of faculty mentoring relationships. Academic Medicine. 2005;80(1):66-71. 6. Jackson VA, Palepu A, Szalacha L, Caswell C, Carr PL, Inui T. Having the right chemistry: a quantitative study on mentoring in academic medicine. Academic Medicine. 2003;78(3):328-334. 7. Carr E, Ennis R, Baus L. The dental hygiene faculty shortage: causes, solutions and recruitment tactics. J Dent Hyg. [Internet]. 2010 [cited 2011 Dec 3];84(4):165-169. Available from http://www.adha.org. Registration required for access. 8. Warren O, Carnall R. Medical Leadership: Why it’s important, what is required, and how we dit. Postgrad Med J. 2011;87:27-32. 9. Stenfors-Hayes T, Hult H, Dahlgren LO. What does it mean to be a mentor in medical education? Medical Teacher. 2011;33:e423-e428. About the Authors Aubreé Chismark, RDH, MS, is an Assistant Professor in the Dental Hygiene Department at West Coast University Anaheim, CA. She recently contributed a research article to the Journal of Dental Hygiene entitled: Use of Complementary and Alternative Medicine for WorkRelated Pain Correlates With Career Satisfaction Among Dental Hygienists. Aubreé can be contacted at: [email protected] CDHA Journal – Summer 2012 31 NewsBytes May 18, 2012, marked the graduation of the first class of 12 students from the new Master of Science in Dental Hygiene degree program at the University of California, San Francisco, the only MS degree program in dental hygiene in California. The one-year program consists of three quarters of interdisciplinary dental hygiene science course work and one quarter of field work in preparation for graduates to assume roles as educators and research collaborators in academic, public health or oral healthcare-related industry settings. Graduates of the class of 2012 are already taking positions as educators, researchers, public health administrators and as entrepreneur developers of health applications. For more information about the UCSF program, go to http://dentistry.ucsf.edu. Susan Jordan Lopez, RDH, BS was installed as president of the CDHA on June 2, 2012 at the annual House of Delegates held at the Santa Clara Hyatt Regency Hotel. A 1972 graduate of UCSF, Susan has been a lifelong member of CDHA and the San Francisco Component. Her installation speech echoed her theme, “Step up, Reach out” encouraging hygienists to move outside of the walls of traditional private practice and embrace the new opportunities that are presenting themselves to oral healthcare providers. Joining Susan on the CDHA Executive Committee are President Elect Nadine Lavell, RDH MS, Secretary Treasurer Lygia Jolley, RDH BA, Vice President of Administration and Public Relations Karine Strickland, RDHAP, BS, Vice President of Membership and Professional Development Teri Vosper, RDHAP, BA and Immediate Past President Lisa Okamoto, RDH. 32 Katie Dawson, RDHAP, BS was honored at the 89th Annual Session of the ADHA as one of the recipients of the 2012 Johnson and Johnson/ ADHA Awards for Excellence in Dental Hygiene. Katie was recognized for her outstanding accomplishments spanning over 35 years in the profession. Starting out as Vice President of the Associated Dental Students of the University of California San Francisco in 1975 to her work as president of the ADHA in 2006, Katie’s leadership has been instrumental in advancing dental hygiene. Sharing in her special day were her granddaughters, Sierra and Amaya Dawson. East Bay Component member Cathy Critchfield was the happy winner of the 2011-2012 “It’s a Small World” drawing. As the grand prize winner, Cathy received a $2000 gift card to Costco.”You too, can a winner!” Support CDHA’s mission and programs by purchasing tickets for the 2013 CDHA “Step Up, Reach Out” drawing through your local component or at CDHA events. Each ticket is only $10 for the opportunity to win a $2000 gift card to a retailer of your choice! Stanford bioengineer Manu Prakash is leading a team of developers in testing a Smartphone oral cancer screening device, Oscan. Concerned by the high incidence of in his home country of India, along with the challenges of underserved rural populations, Prakash wanted to develop a device that could transmit the image of a suspicious lesion to a medical or dental provider for analysis. Oscan consists of an oral positioner, a circuit board and two rows of fluorescent-lightemitting diodes. It attaches to any smartphone’s built-in camera, and allows an operator to take a high-resolution, panoramic image of a person’s oral cavity. While only in its early stages of testing, the device shows promise as a future oral cancer screening device. For more information visit the Stanford School of Medicine web site http://med.stanford.edu/ism/2012/april. CDHA Journal Vol. 27 No. 2 NewsBytes Dental hygienists are needed for the upcoming CDA Cares oral health outreach event sponsored by the California Dental Association Foundation. The program will be providing oral health care services including oral prophyaxis, fillings, extractions, oral health education and assistance in finding a dentist for follow-up care at the Cal Expo in Sacramento on August 24 and 25, 2012. Healthcare volunteers, including dental hygienists, dentists, oral surgeons, assistants, lab technicians, nurses and pharmacists, are needed to make this event successful for the approximately 10 million Californians who do not have access to an oral healthcare provider. Registration information is available at www.cdafoundation.org/cdacares Angela Punaro, RDH and Michael Long RDH were among the northern California dental hygienists who came out to support the Remote Access Medical (RAM) dental clinics this past spring. RAM came to the Oakland Coliseum March 22-25 and went on to Sacramento March 30April 2. Over 6,114 patients, received care for a total cost of services provided estimated at 2.3 million dollars during the 6 days RAM was in California. Foothill College dental hygiene students sponsored Liz Chaney continued from Page 4 the first annual walk for oral cancer awareness on April 14, 2012 on the Foothill College Campus. The students solicited pledges from the community as well as family and friends. Walkers included, Foothill College President Judy Miner. The students were able to present a check for $5,300 to the Oral Cancer Foundation, director and founder, Brian Hill at the CDHA House of Delegates Continuing Education program in June. Plans are already underway to hold the next oral cancer awareness walk on April 13, 2013. Employees. Ever the advocate, Liz used her background as a dental hygienist to educate these organizations on oral health and the dental hygiene profession. Liz’s impact on the profession was recognized nationally at the American Dental Hygienists’ Association when she was the recipient of the Alfred C. Fones Award in 1996 and the 2007 Pfizer/ADHA Award for Excellence in Dental Hygiene. Both awards honor lifetime service and professional excellence. At the state level, in 2003, Liz was honored with life Liz surrounded by her Tri-County friends membership in CDHA. During a 2011 visit from members of the Tri-County Component, Liz reminisced about her dental hygiene career. “It’s been a long ride, but it’s been worth it! It’s been an exciting career. I never wanted to do anything else. I loved it from day one.” Liz, your lifetime dedication and passion for dental hygiene will never be forgotten. CDHA Journal – Summer 2012 33 Why I belong? Liz Marks, RDH CDHA member since 1994. I live in a small town in California. CDHA keeps me connected with legislative updates, continuing education, networking and much more. My membership really allows me to feel part of my profession. Living 35 minutes away from the major cities in my area and only working with one other hygienist in my practice, I am happy to be a part of an association that protects my profession. Having a local component nearby has helped me feel connected though outreach opportunities, social networking and professional guidance. I’m a proud member of the California Dental Hygienists’ Association and I thank all who continue to move our profession forward! Dental Hygiene Associates Inc. (DHAI) Established to support scholarships and research grants for CDHA members “I feel rewarded to be able to inspire my patients on a daily basis to appreciate not only periodontal treatment, but a new way of life, valuing their own oral health.” ~ Jessica Sanchez, RDH 2011 Scholarship Recipient “I am now applying for my Master’s degree in Gerontology with hopes of becoming a clinical professor in dental hygiene.” ~ Susan Hong, 2011 Scholarship Recipient Advance DHAI’s mission of improving oral health through education, research and community service by making a donation today! Make check payable to DHAI, and mail to: CDHA • 130 N. Brand Blvd., Suite 301 • Glendale, CA 91203 Donations are 100% tax deductible. DHAI is a 501 (c) (3) nonprofit organization. wTax ID # 95-3532416 Any questions, please call CDHA’s Central Office at 818-500-8217 34 CDHA Journal Vol. 27 No. 2 The Ultimate Sonicare Power Toothbrush New Philips Sonicare DiamondClean — the ultimate clean for ultimate results. Help your patients experience the difference of Sonicare technology. It will be love at first brush. • Removes up to four times more plaque than a manual toothbrush after four weeks of use 1 • Powerful yet gentle dynamic cleaning action helps improve gum health in just two weeks 1 • Clinically proven to whiten teeth in just one week 2 Experience Philips Sonicare for yourself — call 1-800-676-SONIC (7664) or go to sonicare.com/dp Be part of your community — join one of our Facebook groups just for dental professionals. www.sonicare.com/facebookDP 1. Milleman K, Milleman J, Putt M, et al. Comparison of gingivitis reduction and plaque removal by Sonicare DiamondClean and a manual toothbrush. Data on file, 2011. 2. Colgan P, DeLaurenti M, Johnson M, Jenkins W, Strate J. Evaluation of stain removal by Philips Sonicare DiamondClean power toothbrush and manual toothbrushes. Data on file, 2010. Rosie Tesselaar, Executive Administrator California Dental Hygienists’ Association 130 North Brand Boulevard, Suite 301 Glendale, CA 91203 Presorted STD U.S. Postage PAID Permit No. 104 San Dimas, CA CDHA2008 RETURN SERVICE REQUESTED CDHA Presents: A Sizzling Hot Summer CE Extravaganza! Saturday August 11, 2012 San Mateo Marriott 1770 South Amphlett Blvd. San Mateo, CA Education. . Exhibitors. . . Networking Earn up to 8 CEUS Morning Program 9:00AM – 12:00PM Betsy Reynolds, RDH, MS “Pathos of Pathology: Puzzles, Perplexities and Paradigms” Afternoon Program 1:30PM - 4:30PM Allen Budenz, MS, DDS, MBA “Numb, Numb-er, Numb-est: An Update on Anesthesia and Technology” RDHAP Session (open to all) 5:00PM – 7:00PM Spencer Schmerling, BS, CEO “Business Strategies and Marketing Medias: Start your Business” Register today at www.cdha.org or call 818-500-8217 for more information