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THE ESSENTIAL GUIDE TO INFECTION CONTROL GETTING STARTED AS AN INFECTION CONTROL COORDINATOR

Infection control is the cornerstone to any Where does this person start? How do they successful dental practice. While transmission ensure that evidence-based guidelines, regulations, of infectious agents and diseases in the dental standards, and best practices are being adhered 1-4 setting is rare, it does happen. Lapses in to? How do they create the protocols necessary infection control often involve simple and routine to be in compliance? What governing agencies infection prevention procedures such as treating do they need to be aware of? Part 1 of this guide dental unit waterlines is designed to lead or heat-sterilizing the infection control While transmission of handpieces.1-4 For this coordinator through reason, the Centers infectious agents and diseases the first crucial steps of for Disease Control setting up an infection in the dental setting is rare, and Prevention (CDC) control program. In encourages making Part 2, the guide will it does happen. Lapses in infection prevention a take a deep dive into priority and an integral infection control often involve the critical topic of part of creating a culture instrument reprocessing, simple and routine infection of safety.5 including best prevention procedures such as practices in instrument Both the CDC and Occupational Safety and treating dental unit waterlines transportation, Health Administration cleaning and care and or heat-sterilizing handpieces. sterilization. Together, (OSHA) state it is essential that at least this guide will provide one infection control you with a strong and prevention coordinator be assigned in all foundation and the confidence necessary to tackle dental practices. Whether it’s an individual position the important role of your practice’s infection or included as part of the job duties of a dental control champion. Let’s get started! assistant, an office manager or dental hygienist RESPONSIBILITIES OF THE depends on the size and demands of the dental INFECTION CONTROL COORDINATOR practice.5 In addition to the practice benefits, Create written infection prevention protocols there are many benefits to the individual that (policies and procedures) based on current accepts the role of infection control coordinator guidelines, regulations, and standards The role can provide an opportunity to gain valuable leadership and coaching experience, Keep the program consistent with current subject matter expertise and, by taking on regulations, requirements, policies, and additional responsibility, it can make the individual procedures a more valuable asset to the practice. Adhere to state and federal requirements The infection control coordinator must have and assess best practices training or be willing to be trained in infection Provide ongoing training as needed prevention. They must also stay on top of updates and conduct annual OSHA bloodborne in infection prevention protocols, manage the pathogen training inventory of personal protective equipment and reusable patient care items, train the staff, and Oversee infection control program and 6,7 monitor the program. act as a resource to the rest of the staff

• • • • •

HELPFUL TIP One simple way of assessing the needs of your dental practice is to review the 2003 CDC Guidelines for Infection Control in Dental Health Care Settings (https://www.cdc.gov/mmwr/PDF/ rr/rr5217.pdf) and utilize the CDC checklists included in the 2016 Summary of Infection Prevention Practices (https://www.cdc.gov/ oralhealth/infectioncontrol/pdf/safe-care.pdf) The checklists were developed to help ensure that offices have infection prevention practices in place to ensure a safe working environment. It also gives the infection control coordinator the tools to systematically assess staff compliance and provide feedback.

• Keep equipment in working order and ensure that staff is trained to use office equipment and that they follow instructions for use and adhere to the safety requirements

• See that necessary infection prevention

supplies are available, including personal protective equipment (PPE) for staff and patients

• Continually review policies and standard

operating procedures to identify gaps and outdated material

• Maintain related permits, licenses, copies of all manufacturer instructions for use (IFUs) and other documents

• Monitor compliance through checklists, interviews, and observations

GOVERNMENT AGENCIES THAT OVERSEE INFECTION CONTROL IN DENTISTRY Centers for Disease Control and Prevention (CDC) The mission of the CDC is “to protect America from health, safety, and security threats.” The recommendations and guidelines set forth by the CDC for infection prevention are generally adopted by state dental boards and legislatures as law. cdc.gov

Occupational Safety and Health Administration (OSHA) The mission of OSHA is “to assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance.” As part of the U.S. Department of Labor, their requirements are the law. osha.gov U.S. Food & Drug Administration (FDA) The FDA governs many things in dentistry, including drugs, medical devices, and electronic products that give off radiation. fda.gov U.S. Environmental Protection Agency (EPA) The EPA controls the disposal of toxins such as amalgams and hospital-grade disinfectants, which have to be approved before you can use them for cleaning and disinfecting clinical contact surfaces. epa.gov State Dental Boards Your state dental board develops and enforces the laws surrounding infection control. The laws that they put into place generally meet or exceed the guidelines and mandates from OSHA, the CDC, FDA, and EPA. Health Departments The local and state health department is also a resource and can help through crises and challenges. CULTURE OF SAFETY Applying a culture of infection control safety to the dental setting can bring the team together. Helping your team understand the process of implementation ultimately increases their level of compliance. Many areas within the dental practice need written protocols, training, education, and monitoring systems. As an infection control coordinator, it is your responsibility to create training modules and protocols for the team. It can be overwhelming, but a good first step is to review the chain of infection to help your team

understand the concepts of infection control and prevention. Then you can move on to prevention strategies and guidelines. CHAIN OF INFECTION

1 2

The presence of enough pathogens to cause disease

A susceptible host

A mode of transmission from the source to the host

A point through which the pathogen can enter the host

A source that allows the pathogen to survive and multiply (e.g. blood)

By reinforcing effective infection control strategies with your team, you can help prevent the spread of disease by interrupting one or more links in the chain of infection.

HAND HYGIENE Hand hygiene is the single most effective way to break the chain of infection and prevent the spread of bacteria in healthcare settings.5,8-9 Depending on the procedures to be performed and the state of the healthcare worker’s hands, proper hand hygiene practices should include the use of all of the following: plain or antimicrobial soap, alcohol-based hand sanitizers and skin moisturizers. For dental examinations and nonsurgical procedures, clinicians can use soap (plain or antimicrobial) and water or an alcohol-based hand antiseptic to clean or disinfect hands

prior to donning exam gloves and immediately following their removal. When hands are visibly soiled, they should always be washed with soap and water first. It is always good practice to ensure hands are completely dry before donning a new pair of gloves as wet hands can serve to attract pathogens. For surgical procedures, perform a surgical hand scrub before putting on sterile surgeons’ gloves. Repeated hand washing, antiseptic application and glove use can result in dry skin or other skin conditions such as dermatitis. Because of this, medical-grade, glove-compatible hand moisturizers should be used regularly to maintain healthy, unbroken skin-the body’s natural defense against infections. The use of a therapeutic cream can help restore the skin’s natural moisture barrier while delivering necessary nutrients to the skin. As an example, Hu-Friedy’s Skin Repair Cream contains Olivamine®, a patented blend of ingredients that delivers all of the essential nutrients necessary for optimal skin health including amino acids, vitamins, antioxidants, and methylsulfonlymethane (MSM). For all types of hand hygiene products, look for those specifically made to be used in healthcare settings and follow the product manufacturer’s label for instructions. In particular, take note of the recommended product application method and, in the case of antiseptics, the required amount of time that the product should remain wet on the skin. Antiseptics with a high alcohol content such as Hu-Friedy’s Sterillium® Comfort Gel™, which contains 85% alcohol, kills 99.99% pathogens within 15 seconds. Products with lower alcohol content will require a larger dosages and longer contact times. Finally, it is important to emphasize with your staff that gloves do not take the place of proper hand hygiene A great resource for hand hygiene is the 2002 CDC “Guideline for Hand Hygiene in Health-Care Settings,” which you can share with your team.10 After researching the guidelines from the CDC, your state dental practice act, and other

resources for hand hygiene, you can work with the staff to review best practices for the office’s specific settings. From there, you can move on to teach your staff about the other areas that have been identified as needing training. HAND HYGIENE TIPS

• Hand washing must be done if there is

the possibility that debris, blood, or body fluids such as saliva are present

• Alcohol-based hand sanitizers can be

used in the medical setting when hands are free of debris

• Hands must always be washed before

putting gloves on and after taking them off

• Make sure hand hygiene products are

medical-grade and will not degrade glove materials

• Read and follow the label directions,

paying special attention to recommended application and contact time

• Hand hygiene is always the last step

to the removal of personal protective equipment

HOW TO ENCOURAGE HAND WASHING Studies indicate the rate of compliance for proper hand hygiene in the healthcare field is about 40%.5,8-9 For that reason, visual cues have been shown to be a valuable tool in hand hygiene, decreasing the rate of infection.11 Simple things from posters to statements on compliance posted in the setting can help increase compliance throughout the day.12 The Hu-Friedy Hand Essentials Hand Care Guide13 is a great example of a tool that the whole dental team can use. Find it here: https://www.hu-friedy.com/ products/mastercontrol/index/file/id/79 PERSONAL PROTECTIVE EQUIPMENT Personal protective equipment (PPE) refers to wearable equipment that is specifically designed to protect the healthcare provider and patient from exposure to infectious agents. PPE effectively covers personal clothing and skin likely to be soiled with blood, saliva, or other potentially infectious materials. The PPE that should be made available include gloves, face masks, protective eyewear (for both the clinician and the patient), face shields, and protective clothing. Lack of or improper personal protective equipment can put both the clinician and the patient at risk. GLOVES Gloves must be worn when there is a potential for contact with blood, body fluids, mucous membranes, open wounds, or contaminated equipment.5, 18 Exam Gloves Single-use, disposable exam gloves are intended for examining patients and performing noninvasive procedures. They should always be changed between patients and when torn or punctured. Only medical-grade, powder-

Sterile Gloves Patient exam gloves are not intended for surgical procedures such as biopsies, periodontal surgery, apical surgery, implant surgery, and the surgical extraction of teeth. For surgical procedures, perform a surgical hand scrub before putting on sterile surgeons’ gloves. Sterile or surgical gloves are labeled as such and come sterile in individually packaged pairs, commonly with hand-specific designs for enhanced ergonomics. Utility Gloves Utility gloves are vital and yet underutilized. The CDC recommends the use of punctureand chemical-resistant utility gloves when cleaning instruments and performing housekeeping tasks involving contact with blood, other potentially infectious materials, or chemicals.14-17 Puncture-resistant utility gloves are designed to provide protection during operatory cleanup and reprocessing of instruments. It is important that each clinician have their own pair of well-fitting utility gloves.16 Unlike exam or surgical gloves that are for single use only, some utility gloves can be sterilized, washed, or disinfected for reuse.

For example, Hu-Friedy’s Lilac Utility Gloves can be autoclaved up to five times for ease of use and care. Prior to donning, utility gloves should be inspected for punctures, tears, cracks or other signs of deterioration and replaced when necessary.17-18 When utility gloves are worn during the cleaning step, gown or jacket sleeves should be tucked in and cuffs should be folded over to prevent liquids from accidentally contacting bare skin.

Change gloves between patients Do not wear the same pair for more than one patient PROPER GLOVE USE TIPS

free gloves approved by the Food and Drug Administration (FDA) can be used. Exam gloves are available in a variety of materials, including nitrile, latex, and vinyl and are generally made to be able to be worn on either hand. It is important to keep in mind that some individuals may be allergic to natural rubber latex. If your practice is using latex exam gloves primarily, it is prudent to have options available for use with a patient or by a clinician with latex allergies. Other considerations when choosing an exam glove for your team can include fit, comfort, tactile sensitivity, and durability.

Do not take gloves off and put them back on They are single-use and the material can be compromised by taking them off Do not wash for the purpose of reuse, even on a single patient Remove any glove that has been torn, cut, or punctured, then perform hand hygiene and put on new gloves Do not use wet utility gloves to package a clean and dry instrument or set-up Use a different pair of utility gloves during the packaging step

PROTECTIVE EYEWEAR Protective eyewear must be worn by both clinicians and patients during procedures that are likely to generate airborne debris, splashes or sprays of blood or other body fluids. It is especially important when highspeed handpieces are being used. The protective eyewear for a patient may also help with sensitivity to the overhead light.

stagnant water can enable biofilm formation,” writes the CDC. “Health care providers should promptly report suspected outbreaks of infectious diseases to public health authorities so that an investigation can be initiated and appropriate control measures implemented.” 18 It is important to utilize a complete dental unit waterline system that both cleans and maintains the water in order to remove the microbial contamination. Utilizing a proper maintenance product is also necessary to help prevent the waterborne organisms from attaching and forming in the tubing again between cleaning protocols.

to follow the manufacturer’s instructions for use for each product. With Hu-Friedy’s Team VistaTM Dental Unit Waterline Cleaner, cleaning and maintaining waterlines is a quick and easy process that includes shocking the waterlines monthly and adding daily irrigant drops to maintain the waterlines. Click here to view or print the Hu-Friedy Step by Step Instruction Guide (https://www.hu-friedy.com/products/ mastercontrol/index/file/id/69)

[TABLE FROM ARTICLE] Word doc had link to article but article was one page. I could not locate the Table 2 chart referenced.

Incorporating a dental unit waterline cleaning and maintenance protocol is simple. Various waterline treatment products are available to address microbial contamination and potential health risks. One of the more popular product types for both cleaning and maintaining waterlines uses chemical agents. Table xx lists the criteria that should be used when choosing a product for your office. Just remember

OSAP has a great resource for the infection prevention coordinator: the Waterline Tool Kit. This kit provides a comprehensive overview of the background and process necessary to keep the water line safe, incorporating CDC recommendations and resources. Find it at osap. org/?page=issues_DUWL. 24 PUTTING INTO PRACTICE WITH PROTOCOL DEVELOPMENT Protocol-based practices are systematically developed, taking into consideration the individual circumstances of delivery of care. 25 They are a benefit to medicine, increasing understanding of the steps involved to be in compliance and improving patient care.

Developing a protocol is an ongoing process that involves continual evaluation.

DENTAL PRACTICE PROTOCOLS AND POLICIES CHECKLIST

The first step in developing protocol is to assess the needs of your practice against the CDC Guidelines, state board laws and regulations, etc. Ask yourself what needs to be done, and then review once again the regulatory requirements and recommendations. At that point, you can also research best practices — that is, the steps followed to ensure the best results. Encourage staff input to make sure that you’re developing a protocol that works for your practice.

Following are some areas that may require written protocols or policies per CDC Guidelines and your local state dental board:

Once you’ve gathered the relevant information and input, you can begin to develop a written plan. Include a brief description of the problem or contributing factors, and make sure the information is based on scientific evidence. List the preventive measures and tasks that your staff should take, and include the details in question words such as who, what, when, where, why, and how. (There is an example of what a protocol should look like in the hand hygiene protocol below.) At that point, you can draft and edit the policies and procedures behind the protocol and obtain approval from your supervisory staff member. With the information in place, you can begin to educate the staff on the new protocol, communicating the need to adhere to it, as you will be monitoring and evaluating their use of the protocol. After evaluating the protocol in the practice, you can make any necessary revisions. Even if they are also available electronically, all of a practice’s protocols should be printed and stored together in one binder in the central sterilization area, easily and readily accessible by all staff members. All instructions for use for all infection prevention related equipment and products should be similarly organized and kept together with the practice protocols for easy reference.

p p p p p p p p

Exposure Control Plan

Cleaning, Maintenance and Monitoring of Dental Unit Waterlines

Sterilization and Disinfection of PatientCare Items and Devices

p p

Cleaning and Sterilization Monitoring

p p

Education and Training Plan

Immunization Policy Hand Hygiene Respiratory Hygiene/Cough Etiquette Sharps Safety Safe Injection Practices Personal Protective Equipment Environmental Infection Prevention and Control

Dental Setting Response in the Event of a Reprocessing Failure or Error

Routine Monitoring and Evaluation of the Infection Prevention and Control Program

THE BASIC STEPS OF WRITING A PROTOCOL Protocol-based practices are systematically developed, taking into consideration the individual circumstances of delivery of care.26 They are a benefit to medicine, increasing understanding of the steps involved to be in compliance and improving patient care. Developing a protocol is an ongoing process that involves continual evaluation.

• Review regulatory requirements and recommendations

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Cements SELF-ADHESIVE RESINS CAN ACCOMPLISH MANY JOBS Cements have long been an important component of dentistry, allowing practitioners to bond to tooth structures — and new advances promise even more. The new generation of self-adhesive resin cements — like BISCO’s TheraCem® — can be used to cement crowns (including metal, ceramic, porcelain and zirconia), bridges, implant-supported restorations, inlays and onlays, metal and nonmetal endodontic posts, and orthodontic bands and brackets.

S P O N S O R E D B Y:

The New Universal Composite:

One shade for every patient

BY TERRI LIVELY

The New Universal Composite:

One shade for every patient

omposites are a vital and useful tool in the dental practice. Not only do they facilitate excellent restorations, but they also look just like the natural tooth when the final restoration is complete. That is, composite restorations look natural after a concentrated effort to match the patient’s natural teeth to one of the shades in the guide, in the optimal environmental lighting and interior design. Plus, you must have the right shade of the proper category of the composite in inventory — that hasn’t expired. Or maybe the composite restoration looks natural because of your finesse, time and care with shade blending to get that unique hue your patient presents. In other words, composite restorations look fantastic, but shade matching is a time-consuming process. Or, rather, it was a time-consuming process. Tokuyama Dental’s OMNICHROMA can improve your practice efficiencies and clinical outcomes with new technology for shade matching. OMNICHROMA is a single-shade, structurally-colored universal composite designed to match every tooth shade with a single shade of composite. OMNICHROMA is the first and only to use one shade to match the entire VITA Classical Shade Guide, from A1 to D4. In this eBook, you’ll learn more about this revolutionary product. We’ll share how OMNICHROMA’s unique design and features allow it to match the 16 VITA classical shades with only one shade of composite. You’ll also learn how it eliminates the need for shade selecting. Furthermore, you’ll see how it reduces the composite inventory needed, so you have fewer wasted materials that expire before they can be used. Finally, we had 25 doctors rate OMNICHROMA’s performance on nearly 1,000 restorative cases and we’ll share what they had

S P O N S O R E D B Y:

to say about its performance. But first, let’s take a closer look at composites in general. A QUICK OVERVIEW OF COMPOSITES

Composite resins were designed for esthetics. Tooth-colored by design, they replace healthy tooth structure for restorations and serve all the same biological and functional jobs as a natural tooth would. Many times, after the composite resin restoration is complete, one can’t tell the tooth ever had a cavity — if it’s done well. But at the same time, it can be difficult and timeconsuming to attain a perfect esthetic match. Composites have been around since the 1960s. However, the first materials weren’t durable enough for the work surfaces of the back teeth. Today’s composites have addressed the strength and durability issues of the early materials. There are a few different types of composites, including: • Macrofills: Macrofills were the first composites. They had large particles, from 10-15 micrometers, and were strong but not esthetic.1 The large size of the fillers made them difficult to finish and polish. For all of these reasons, they’re no longer commonly used. • Microfills: Following the macrofills were the microfills. They had smaller particles, under 100nm.2 They looked better than macrofills, but they were weak and not suited to posterior restorations. Microfills are still in use for certain restorations today. • Hybrids: When you combine the strength of a macrofill with the esthetics of a microfill, you get the hybrid composites. The sizes of the particles are different as a result of the combination of macrofills and microfills. Many of the composites clinicians use today are in this category. • Nanocomposites: The latest composites are called nanocomposites. The particle size is

The New Universal Composite:

One shade for every patient as small as 20nm.3 However, the small particles form nanoclusters, which are groupings of smaller particles that function as a larger particle. The nanoclusters allow the nanocomposites to enjoy more strength and durability but still look great. There are also nanofilled resins and nanohybrids. There are a few of these products available today.

and create problems for the patient longterm? • Polishability: Will the restoration maintain its luster and have a life-like appearance? • Handling: Do you like how it feels to work with and can you produce the results you want with the material?

Composites aren’t perfect, however. Some composite types lack durability and have low flexural strength. Others have poor wear resistance. Some clinicians • Universals: As the name think composite materials implies, universal comsystems could be simpler posites are designed to Knowing your product, to use. Others feel like be used anywhere in the esthetics could still be the mouth and produce what its strengths and improved more, including long-lasting and naturallimitations are, and which the shades of composite looking dental restorations. type of cases you have the available. Materials are constantly • Flowables: Flowables improving. Furthermore, most success with that have more fluidity to not all composites are their composition and product is key to avoiding created equal — and we are mostly used for mean that in the literal smaller restorations and some of these challenges. sense. Knowing your prodas liners and bases. uct, what its strengths and • Bulk fills: Unlike the limitations are, and which other two product categories of composites, type of cases you have the most success with bulk fills can be layered thicker in preparathat product is key to avoiding some of these tions with less curing. Many times, bulk fills challenges. are used for posterior restorations, but the However, there’s an area of opportunity Most use of bulk fills is always evolving as materials composites have tried tackling or have tackled improve. this opportunity by having good shade matching abilities (i.e., chameleon effects, etc.), but Universals are the most versatile of the three none so far has perfected it to result in a oneproduct categories. When it comes to universal shade composite that works for every shade of composite performance, there are a few chartooth. Let’s take a closer look at shade matchacteristics clinicians should consider. ing in more detail. • Strength: How will it hold up when the patient THE CHALLENGES OF SHADE MATCHING is using compressive force? Many challenges exist with shade match• Esthetics: Will the composite match the paing teeth. Some difficulties arise based on the tient’s other teeth? operatory, while others happen as a result of the • Shrinkage: Will it shrink during polymerization materials. Still others stem from the processes Composites also have different product categories, which include:

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ocurreret no. Alia eius repudiandae id cum. Augue officiis voluptatibus has te, ea nonumy graeco torquatos vim, his ut solum persecuti eloquentiam. Quando contentiones has ne, at mazim laboramus eum, sanctus dolorum legendos an est. Cetero alterum expetenda mei at. Veritus evertitur voluptatibus vix ea, ius an melius nostrum lobortis. Ei qualisque erroribus vix. Id labitur accusam Ad aeque alterum sapientem usu, bonorum legimus in eum. Sit in ullum periculis, ut nec atqui numquam. Viris choro aliquid eum cu. Sed ex choro copiosae voluptaria.

Constituto intellegam theophrastus duo no. Pro nullam bonorum conclusionemque et. Mel ad graeco equidem oporteat. Vix tale movet torquatos in. Vel no eius oratio admodum, ei solum soleat nam, feugait vivendum adversarium vim et. Causae scripta fierent id nam. Vix eu error salutandi posidonium, qui ne nibh alienum accommodare, te mollis voluptua consulatu sed. Ad ius autem scribentur conclusionemque, usu an impedit partiendo honestatis. No aperiam gloriatur pro. Aeque nonumy nonumes vix in, et eam sonet graecis. Amet molestie pro te. Blandit erroribus vis te, legimus fastidii quo et. Vel et impetus accusam, sed an esse propriae, prima affert qui ut. Sit ut agam tation fastidii. Eos an senserit expetendis. Per veritus officiis perfecto ea. Habemus molestie id vim. Ex tempor quodsi nam, quot meliore repudiandae ne vel. Impedit suavitate persequeris cum ad. Per cu amet sapientem. At nec tantas quodsi, per ut tamquam civibus, ea eruditi percipit invenire nec. Lorem ipsum dolor sit amet, ea vel virtute laboramus intellegebat, pri labores delectus mediocrem ei. Vis dicta dissentias ad, qui dico regione ea, nec solet dignissim philosophia te. Omnium expetenda mei cu, no meis oratio nemore mei. Cu ius omnium

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LOREM IPSUM DOLOR SIT AMET, DOLORE INTELLEGAT EU QUI

admodum percipit, has an illum reprehendunt. Putant patrioque gloriatur ne est, ei cibo possit mentitum sea, eu vis reque pericula Ex mel fastidii disputationi definitionem, te quo qualisque splendide, novum docendi ei pro. Paulo tation ea vel. Harum mollis in mel, ut partem volutpat persequeris ius. Tation euismod et eam, ad duo eripuit imperdiet splendide. His aliquid mnesarchum mediocritatem ut, an qui veri everti animal. Constituto intellegam theophrastus duo no. Pro nullam bonorum conclusionemque et. Sint disputando cum id. Eu legimus perpetua cum, ne ius modo consetetur posidonium. Ad qui unum dicta, autem integre mea in, scripta fastidii sadipscing ea pro. Prima iudicabit omittantur no sea, quem minim mei ea. Latine corpora te sea, qui ex natum forensibus. Eam repudiare voluptatum ea, at cum detraxit dissentiunt, sed enim erant epicuri at. Dico posidonium in sea, mel stet iisque pertinacia an. Agam brute quodsi an cum, nibh meis cum et, quot unum perpetua eu pri. Ea vim mutat movet, ad vero essent per. Pri et invidunt efficiantur, ea oratio graeci commodo has, qui an eros debet. Vix at wisi blandit, ad pri utinam detracto. Ea cum omnes altera oportere, ne ferri vivendum nec, pri torquatos sententiae ad. Ius singulis accusamus vituperata te. Ius eu liber salutandi, sed ea equidem lobortis, ei vis velit iuvaret. Sea mutat petentium at. Usu eripuit legimus pericula an. Has rationibus definitiones ei, ei quis amet philosophia eam, te cum tantas option. In sed habeo debet gubergren. His ut alii conceptam eloquentiam, utamur reprimique ut mel. At nam populo nonumes fuisset. Duo vocibus posidonium ei, an sit amet vidit postea. Eam modo scriptorem cu, no mei petentium instructior. Cu alia nihil mnesarchum duo. Eu usu lucilius torquatos vulputate. Eam nisl doming prompta ex, qui autem persequeris suscipiantur ex. Nostrum molestie adipisci eu vis. Dico adipiscing

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sea an, id nonumy populo copiosae qui. Ex mea eripuit facilisis voluptatum, ne salutandi theophrastus duo. Usu ne nisl timeam, eu libris abhorreant ius. n vel antiopam rationibus ad, at per cibo volumus. Cu esse saperet epicuri pro, cu sed labores vulputate vituperatoribus. Ne ornatus periculis mei, eos et natum mundi aliquid, denique persequeris in quo. Et mei vocent iriure scripta. DR. JOUN FLUCKE,

FOR MORE INFORMATION Mea ullum invidunt explicari ea. Ornatus deleniti delicata cu pro, hinc vide no mea. Usu mollis timeam habemus ei, ex sea facilisis reprimique. Ea usu animal bonorum. Dicam altera ullamcorper ea quo, ea per elit vocent, ad odio saepe interesset eos. Eum amet errem at, his te ferri aliquando. Mea ullum invidunt explicari ea. Ornatus deleniti delicata cu pro, hinc vide no mea. Eu melius delenit sea. Pro ei epicurei singulis. Vim ipsum delectus in. Ei mel iriure aliquid aliquam, saperet partiendo qui ei. Melius definitiones et sea. Dolor sensibus comprehensam no mea, commodo reprimique ad usu. Ex probo ipsum moderatius eam. Qui cu iusto assentior. His illud vituperatoribus ut. No pri suscipit percipitur. Sea te sumo nemore appareat. Cum porro erant tritani cu. Ius an civibus accusata deseruisse. Cu pri debet intellegebat reprehendunt, an dictas inermis voluptua per. Ne ceteros recusabo sapientem usu, vide scripta mel ad, mel wisi ipsum reprehendunt in. Ei duo agam etiam mollis. Ludus sententiae eu vel, mea ubique vivendo no maiestatis quo ea, in eruditi constituam voluptatibus pro. Reque disputando quo id, te

possit democritum instructior usu. Diceret evertitur argumentum duo cu, mea omnium cotidieque reformidans et, duo eu legere saperet. Eum meliore maluisset assueverit et, ne modus nostrud volumus vim, te nam ponderum definitionem. Ne etiam solet iriure eam, vix t, duo eu legere saperet. Eum meliore maluisset assueverit et, ne modus nostrud volumus vim, te nam ponderum definitionem. Ne etiam solet iriure Eos wisi augue dicit ad, an debitis accusata pri. An eum mutat phaedrum concludaturque. At verear graecis sea. Ut pri admodum persequeris reformidans. Amet prima et has, sumo consetetur adversarium ad vel. Eos alia agam aeterno eu. Dolor sensibus comprehensam no mea, commodo reprimique ad usu. Ex probo ipsum moderatius eam. Qui cu iusto assentior. His illud vituperatoribus ut. No pri suscipit percipitur. His illud vituperatoribus ut. No pri suscipit percipitur. Sea te sumo nemore appareat. Cum porro erant tritani cu. Ius an civibus accusata deseruisse. Cu pri debet intellegebat reprehendunt, an dictas inermis voluptua per. Ne ceteros recusabo sapientem usu, vide scripta mel ad, mel wisi ipsum reprehendunt in.

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