Oral Hygiene November 2018 by Annex Business Media

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THE EVOLUTION OF OF

DENTAL HYGIENE INSTRUMENTS

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NOVEMBER 2018

Inside this issue ORAL HYGIENE

Creating a Unique Tray Set-up, and the Evolution of Dental Hygiene Instruments Kathleen Bokrossy, RDH

Saliva – More Important Than You Think Dorothy Garlough, RDH, MPA

Backflow Matters – Think Disposable Sheri B. Doniger, DDS

Gloves Spread Disease and have created an Infection Control Dilemma John Hardie, BDS, MSc, PhD, FRCDC

Lisa Philp Chief Visionary Officer - TGNA Transitions Group North America

DEPARTMENTS 5

Managing Your Hygiene Schedule

EDITORIAL Take Your Time

NEWS Children with Severe Dental Decay ‘Should be Referred to Safeguarding Teams’ Poor Oral Health Linked to Higher Blood Pressure, Worse Blood Pressure Control Oral Health Concerns with Marijuana Use

43 DENTAL MARKETPLACE

NOVEMBER 2018

28 www.oralhealthgroup.com

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EDITORIAL

Take Your Time

Jillian Cecchini Managing Editor

NOVEMBER 2018

It’s that time of year. The alarm goes off and you get out of bed to start the day. You peek outside the window and surprise – it’s still dark. Your motivation to get the day started is lagging. You pull yourself together and head to work. You manage to have a successful and productive day. When it’s time to leave, surprise – it’s dark again. Your energy levels are back down. The feeling you had first thing in the morning is slowly making a comeback. These days are back upon us. The days of missing the warmth and sunshine. The days of cancelling evening plans to get home to the couch. The days of feeling unmotivated. Though these days can have a negative connotation, I’ve personally come to embrace them. These are the days I now take advantage of when my body tells me to. In today’s society, it’s a constant feeling of go, go, go. With hectic lifestyles of non-stop demands and schedules, we must remember how important it is to take the time to rest and recharge. And maybe these darker evenings are just the solution we’ve all been looking for. Dealing with stress is inevitable yet we all tend to accept stress as it is. We stay stressed thinking it’s our fate. Trying to find constant motivation when managing a busy lifestyle can be an everyday struggle but the solution is simple. We all seem to forget that rest is one sure way to ease stress and it requires no skill at all. It’s easy for all of us to let rest become a foreign concept. It's often considered an indulgence and most people feel guilty for taking time to simply do nothing. I’m not suggesting that we write-off all responsi-

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bilities when the workday ends. We can't simply just put our feet up and expect others to take on the work for us. Of course, we have commitments and families and schedules. But what I am suggesting is that we be more mindful of our down time and understand that taking the time to recuperate can do wonders for the body and mind. It is essential to keep in mind that leading a life with minimal to no rest is mentally and physically exhausting. We are not designed to push our bodies to the limit. A well-rested mind will make every aspect of our lives more productive. Down time is one of the most essential ingredients for continued workplace success. Rest allows us to recharge our abilities to deal not only with our careers but our busy schedules, relationships, and not to mention our overall health and well-being. We all lead different lifestyles but here are two key changes that I've implemented in my life to keep a (somewhat) healthy lifestyle despite a busy schedule. First and foremost, I’ve made sleep nonnegotiable. Sleep is essential. Enough said. Secondly, I’ve allowed myself to not feel guilty for doing nothing at all, even if it’s just for a short period of time. My suggestion for you: take a few moments to yourself. Read a book, exercise, have a bath, or simply just pause, breathe and reflect. Trust me, it works. I’ll leave you with this – your body and mind know best. Listen to them. It’s okay to temporarily leave behind the stresses of life and put yourself first. You are the greatest project you will ever get to work on. Take your time.

May 2017

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NEWS

Canada’s Dental Hygienists Elect New President A NEWCOM Media Inc. Publication

Managing Editor: Jillian Cecchini 416-510-5125 jillian@newcom.ca

Director, Business Development: Tony Burgaretta 416-510-6852 tonyb@newcom.ca

Assistant Editor: Krysten McCumber (416) 510-6777 krysten@newcom.ca

The Canadian Dental Hygienists Association (CDHA) is pleased to announce the installation of its new president, Tracy Bowser, at its recent Leadership Summit held in Charlottetown, PEI. Tracy is from Prince Edward Island and joins president-elect Leanne Huvenaars (Saskatchewan), past president Sophia Baltzis (Quebec), and directors Mandy Hayre (British Columbia), newly elected Alexandra Sheppard (Alberta), Deanna Mackay (Manitoba), Beth Ryerse (Ontario), Francine Trudeau (Quebec), Wendy Stewart (Nova Scotia), Anne Marie Caissie (New Brunswick), Tiffany Ludwicki (Newfoundland & Labrador), and Natasha Burian (North) on CDHA’s board of directors for 2018-2019.

Poor Oral Health Linked to Higher Blood Pressure, Worse Blood Pressure Control People with high blood pressure takheir condition ing medication for their nefit from m tthe he he are more likely to benefit ood oral a health, al therapy if they have good according to new research searcch in the American Heart Association’s ociatio on’s journal Hypertension. Findings of the analysis, ysis, based b se ba sed d on a a exam exam re re-review of medical and dental cords of more than 3,600 people 00 peo e pl eo p e with wiitth h high blood pressure, reveal veal that att those tho hose with healthier gums have ve lower blood ded better to pressure and responded blood pressure-lowering ng medications, uals who have compared with individuals gum disease, a condition known as

periodontitis. Specifically, people with periodontal dise disease were 20 percent le ess ss llikely ikely to reach ik rea healthy blood presless sure ran nge g s, com ranges, compared with patients in good orall health health. Consid dering the findings, the reConsidering searche ers say er s y patients with perisa searchers odon ntal disease diseease may warrant closer odontal bloo o d pr oo pres res esssure monitoring, while blood pressure thos th ose se diagnosed diagnose with hypertension, those or persistently elevated blood pressure, might ben benefit from a referral to a dentist. Find the full story: https://www.eurekalert org/pu rekalert.org/pub_releases/2018-10/ aha-poh101718.php

Oral Health Concerns with Marijuana Use Among the reaction to the legalization of pot on October 17th, there have been some concerns from the dental industry. The Ontario Dental Association is reminding people of one of the downsides of marijuana use, and the potential impact on people’s oral health. Dr. Deborah Saunders is the director of the medical oncology program at the Northeast Cancer Centre and is a member of the Ontario Dental Association. She wants people to be aware of

oralhygiene

the side effects of any kind of marijuana use. “Smoking marijuana has the same health consequences as smoking tobacco, smoking tea leaves. Anything combustible puts patients at higher risks for certain types of cancer, one of those being oral cancer, secondarily throat cancers and lung cancer.” said Dr. Saunders. Find the full story: https://northernontario.ctvnews.ca/oral-health-concerns-with-marijuana-use-1.4139889

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OFFICE: Located at 5353 Dundas Street West, Suite 400 Toronto ON M9B 6H8 Telephone 416-442-5600, Fax 416-510-5140. Oral Hygiene serves dental hygienists across Canada. The editorial environment speaks to hygienists as professionals, helping them build and develop clinical skills, master new products and technologies and increase their productivity and effectiveness as key members of the dental team. Articles focus on topics of interest to the hygienist, including education, communication, prevention and treatment modalities. Please address all submissions to: The Editor, Oral Hygiene, 5353 Dundas Street West, Suite 400 Toronto ON M9B 6H8

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ORAL HYGIENE

CREATING A UNIQUE TRAY SET-UP, AND THE EVOLUTION OF DENTAL HYGIENE INSTRUMENTS

Kathleen Bokrossy RDH is the president of ‘rdhu’, a professional development company, which provides team events, hands-on programs and online learning (Dental Hygiene Quarterly). Her vision is to help ‘Transform the Dental Hygiene Experience’ for dental hygienists, practices and clients.

oralhygiene

o you find that each of your instrumentation kits typically contain the same instruments? Are most of your instruments similar to what you were taught in school? I usually start my instrumentation presentations by asking the audience these two questions. More times than not, the majority of the room agrees that their kits are the same for each client with perhaps just one ‘new’ style of instrument. In dental hygiene school, we were taught to use instruments that are ‘safe’ for beginners and were introduced to the most common styles. Is it safe to have a student use a perio file or a hoe? Definitely not. But as we improve and master our skills, we need to explore new options that will help improve client care and will also help us ergonomically. As we become more proficient and confident in exploring the dentition and develope our understanding of tooth morphology with all its concavities, projections and furcations, we can expand our instrument armamentarium. We should choose instruments that have been created for advanced instrumentation. After working clinically in a variety of offices across the country, and struggling with the instruments that the offices provided, I decided to start my own dental instrument company back in 1998. It started off

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as a sharpening and re-tipping company, as I had mastered the skill of sharpening and re-tipping was a new concept at the time. We grew to an international company with our own line of instruments, education and maintenance programs. I have since sold this company but still feel very passionate about dental instruments, as I truly believe that a dental hygienist can only be as good as the instruments in his/her hands! We cannot provide effective, efficient or safe care for our clients when we are using worn-out, misshaped instruments. The designs available, the type of material, the choice of handle, and metals have greatly evolved since I started practicing back in the late 80’s. When I first starting practicing, instruments needed to be sharpened after every sterilization cycle because the process dulled the instruments. Now we have instruments that do not require sharpening as often and instruments that require no sharpening at all! Major instrument companies will use superior steel that offers greater longevity and retains its sharpness longer. One specific company, LM Dental, from Finland, has a special proprietary micro-coating over their already high-end carbide enhanced alloy, which leaves a very smooth finish that is super sharp, and maintains an edge that never requires sharpening. NOVEMBER 2018

Over the years, I still hear the same most common challenges and pains that many dental hygienists face. I would like to address them and offer some suggestions.

CHALLENGE: Many dental hygienists are using instruments far beyond the time to replace them without realizing it. This results in poor care, an uncomfortable appointment for both you and your client, decreased tactile sensitivity, increased fatigue and risk of Repetitive Strain Injuries (RSI).

SOLUTION: Keep a master set in your practice to use while sharpening, as a guide, so that you can maintain the original design as much as possible. This is also a great way to compare what you are currently using to what you should be using, if you need to demonstrate to your DDS or Office Manager that it is time for new instruments!

CHALLENGE: The office will not buy instruments for the dental hygienists when they need to, so they are using the old instruments beyond their safe use.

SOLUTION: Schedule a meeting with your DDS or Office Manager. Put a plan in place and set it up like a ‘Case Presentation’. NOVEMBER 2018

Show the practice’s current instrumentation situation: • cost/yearly budget (or lack thereof at times) • how many kits, instruments available • acknowledge that we can no longer sharpen chairside (due to IPAC concerns), and show how this will affect the practice • client response (to treatment) and complaints (do they complain to the receptionist that they no longer want to see ‘that’ heavy-handed dental hygienist and request a new one for next time – or worse…they do not want to create a scene and just find a new practice!) • RDH’s pain - fatigue/Repetitive Strain Injury/unnecessary pinch force and lateral pressure, etc. Show your future plan: • cost, potential budget • number of kits required and type of instruments in each kit • who will take care of the ordering process • how the plan can be sustained • systemize your instrument program by frequently assessing instruments in the DH Department together, compare to Master Set, determine frequency of replacement • share all the benefits the practice will experience by supplying your team with sharp well-main-

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tained instruments. i.e. efficient and effective care, increase referral, retention (happy clients and RDH’s) to name a few If these arguments fall on deaf ears and they still will not purchase instruments for you, I highly recommend to invest in yourself and purchase your own. Keep them in your own cassettes and make sure no one else uses them. Between using ultrasonic scalers and having instruments that only you take care of, your instruments will last much longer. We spend approximately a third of our life working. If you wish to extend the longevity of your clinical career, invest in yourself. Your clients, and your body, will thank you. Price is always a factor, and I have a solution for you below in the “Typical Day’ section.

CHALLENGE: Heavy stainless instruments are being used in every kit, and pain and fatigue are starting to set in. It is especially noted during the last few appointments each day. “There may be a greater risk of developing upper extremity disorders among dental hygienists than among dentists due to the long hours of dental scaling and root planing.” (1)

SOLUTION: Studies have shown that lighter, larger silicone handles will help

May 2017

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Instrument set-ups containing several styles of handles give the clinician the opportunity to rest different muscle groups while completing care, which decreases the occurrence of RSI.

prolong your career by preventing repetitive strain injuries (RSI). The function of the larger-diameter handles is to open the grasp just enough to dissipate the mechanical forces over a larger area of muscles. Instrument set-ups containing several styles of handles give the clinician the opportunity to rest different muscle groups while completing care, which decreases the occurrence of RSI.

achieve, or maintain, a sharp cutting edge.

CHALLENGE:

With so many new instrument styles and designs being introduced, how can you try an instrument on a tight budget?

Many dental hygienists go through different stages in their career where they feel bored, get tired of the routine and feel that they are doing the same thing day after day, client after client.

SOLUTION: There are many ways to try out an instrument without having to make a significant investment. Attend a handson course. Instrumentation courses are offered at dental hygiene conferences, or at RDHU (or RDHU on-the-road events). Attend a conference/exhibit floor and ask to try one on a typodont. Speak to your rep or look for specials where you can get one for free with an order, trade-in, etc.

CHALLENGE: Many dental hygienists struggle with sharpening and cannot

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SOLUTION: Participate in a hands-on sharpening course. If you struggle with this skill and are worried that you alter instruments from their original angle and design (which can cause harm), consider purchasing some sharpen-free instruments and eliminate that worry.

SOLUTION: See the uniqueness in every client and create Unique Tray Set-ups! Reviewing your charts the night before, or the morning of, to see who is coming in and what instruments you will need can really help you get re-engaged in your practice. You will enjoy planning out your treatment kits for each client based on their specific needs. So, let’s take a look at what a ‘Typical Day’ could look like and

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how you could create Unique Tray Set-ups: 1. 5 Re-care Kits: Each kit would include a Mirror, Explorer and a Probe. You could then add two instruments that could complete the entire dentition for a re-care appointment. The LM Syntette and a Universal Sickle (SharpJack). For those of you who would like Sharpen-Free. The ‘Sharp-Jack’ is an option for a universal sickle along with the Syntette. The Syntette is a Dual-Gracey meaning it is a Hybrid Instrument. It has the characteristics of a Gracey with its complex shank and it has twocutting edges, like the Universal Curette. The instrument acts as a Gracey 11/12 and a Gracey 13/14. The nice thing about this instrument is not only do you not have to switch instruments (for mesial and distal) but also, you do not need to switch ends while working on the same surface. 2. 1 Furcation Kit: This kit could contain a Nabors Probe, two Furcation Files and a Furcator. The Furcator has a small excavator as its working end and is NOVEMBER 2018

SHE KNOWS THAT STRAWBERRIES HAVE A HIGH ANTIOXIDANT CAPACITY. WHAT ELSE WOULD SHE WANT TO KNOW? Young people today are staying informed to stay healthy.1 But do they know that healthy foods including fruit, juices and sports drinks are highly acidic and can put their enamel at risk?2-5 Exercise your inﬂuence as their trusted dental professional. Help educate every young patient about the effects of acid erosion. Because the investment in their enamel should start today.

For your acid erosion candidate. 1. GSK data on ﬁle, 2013. 2. Lussi A. Erosive tooth wear – a multifactorial condition. In: Lussi A, editor. Dental Erosion – from Diagnosis to Therapy. Karger, Basel, 2006. 3. Lussi A. Eur J Oral Sci. 1996;104:191–198. 4. Hara AT, et al. Caries Research. 2009;43:57–63. 5. Lussi A, et al. Caries Research. 2004;38(suppl 1):34–44.

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By switching up your instruments and creating Unique Tray Set-ups, you will find that your Typical Day won’t be so ‘typical’ and you will be re-engaged and confident with the treatment you provide. great to use on Furcations I and II; while the furcation files have a rough diamond coating on them for a more advanced furcation involvement. 3. 2 Gracey Kits: These two kits would contain your favourite Graceys and perhaps you add Graceys 15/16 and 17/18 for those difficult to reach molars. 4. 1 Perio Kit: With the Gracey extended shank and mini blades to access deeper tighter pockets and the PDT Queen of Hearts. The Queen of Hearts is a unique design as it has a cutting edge of 6 mm. Reducing the number of instruments in your everyday tray, you will save money. Having specialty kits used and sterilized only when needed is much more economical as these instruments will last you longer.

Regardless of what brand you prefer, I would recommend using Sharpen-Free instruments where you can. Also, master your sharpening technique for your regular instruments to ensure that you are always using optimally sharp instruments. Your clients will thank you and your body will thank you! By switching up your instruments and creating Unique Tray Set-ups, you will find that your Typical Day won’t be so ‘typical’ and you will be re-engaged and confident with the treatment you provide. To a master, nothing is ‘typical’. If you cannot attend a hands-on sharpening course, and because I feel so passionate about this topic, I am gifting you a free sharpening and instrument selection online course. Visit www.rdhu.ca/ instrumentcourse to receive this online course (1-hour CE) along with other resources that will help you.

REFERENCES 1. Evaluation of Ergonomics and Efficacy of Instruments in Dentistry; Nina Nevala, Erja Sormunen, Jouko Remes and Kimmo Suomalainen; The Ergonomics Open Journal, Volume 6, 2013 2. rdhu YouTube Channel 3. LM-Dental.com NOVEMBER 2018

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May 2017

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ORAL HYGIENE

SALIVA – MORE IMPORTANT THAN YOU THINK

Dorothy Garlough RDH, MPA Dorothy is an entrepreneur, writer, speaker and thought leader. Having contributed over 70 articles to dental magazines internationally, her message is one of continuous improvement, both in the delivery of science and team cohesion. Her programs have been described as being “edutainment”, as they are both educational and entertaining, and her business, Innovation Advancement, www. innovationadvancement.ca is the medium where she delivers her message of Creating Tomorrow Today. Dorothy can be reached at dgarlough@ innovationadvancement.ca.

oralhygiene

he public’s perception of saliva is low indeed. The act of spitting on someone is considered a vile act, one of disrespect, and even hate. Yet, in some cases, spitting can be done in a joking manner, as in a Canadian produced comedic program where residents of one town, upon hearing the name of their rival town, spit humorously in unison. In actuality our lowly saliva serves us royally. Saliva is packed with proteins that carry masses of microbes that are beneficial to people by helping guard against pathogenic microorganisms.1 At least one protein in saliva (SLPI) has anti-inflammatory, anti-viral, anti-fungal and antibacterial properties. 2 This alkaline ropey fluid has multifaceted functions and as it lubricates the oral mucosa, it limits oral bacterial growth and can even help to remineralize teeth. Saliva plays an important role in digestion. Spittle begins the digestion process with the salivary enzyme, amylase, breaking down some starches (dextrin and maltose).3 Saliva also helps heal wounds, aids in balancing hormones and protects our teeth. from dissolving. Interestingly, it also tells stories. Saliva can reveal if people smoke,4 have consumed alcohol, used drugs, and can even have some diseases.5 Malmö University's Fac-

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ulty of Odontology in Sweden has recently discovered that illnesses such as cancer leave traces of their presence in patients’ saliva. Easy and safe to obtain, saliva is also used for genetic research and clinical diagnostic application. DNA, which holds a wide spectrum of genetic data, is easily obtained with a buccal epithelial cell swabbing.6 The lowly saliva is seemingly a magical potion. Yet another notable function of this excretion is the regulation of the flow of water in and out of the cells. Magnesium, potassium, calcium and regular table salt dissolve into positive and negative charges adjusting the balance of water at the cellular level within our bodies.7 Healthy adults extract about 1 to 1.5 liters a day from three major pairs of salivary glands.4 Without the stringy substance of saliva, mouths feel like a desert, parched and dry and it can feel as if epithelial tissue will peel off the hard palate as patients try to remove their pasted tongues. Without succulent saliva, tongues become like craters, fissured and cracked and an ideal breeding ground for bacteria and yeast. 8 With the rich vascular supply of nerves to the tongue, it can become sore and a constant irritant. Cavities bloom in a spit-depleted world and even speaking or swallowing become challenging. NOVEMBER 2018

Gums or pastilles

Rinses

X-Pur (Oral coat) Xyliments (Oral Coat)

Hydris Dry Mouth (Colgate)

3M ESPE TheraMints (3M Oral Care) XyliMelts (Oral Coat) Salese (Nuvora) Epic gum (Epic Dental) Spar X candies (Xlear) Salese (Nuvora)

Biotene Dry Mouth

PreviDent 5000 Dry Mouth (Colgate) Oral Balance (Biotene)

Plaque HD Extreme Dry Mouth Rinse (TJA Health)

Clinpro Tooth Crème (3M Oral Care)

Sprays

Mouth Kote Allday Dry Mouth Spray (Elevate Oral Care)

Rx rinses

SalivaMax (Forward Science) NeutraSal (OraPharma)

CTx2 Spray (CariFree) Spry Moisturizing Mouth Spray (Xlear)

XylGel (OraCoat)

Act Dry Mouth (Chattem) CTx3 rinse (Cari Free)

Spry Moisturizing Mouth Gel (Xlear)

TheraBreath Dry Mouth Oral Rinse (ThereBreath)

Orajel Dry Mouth Moisturizing Gel (Church & Dwight)

The numbers of people suffering from xerostomia (dry mouth) are growing as the population ages. Saliva reduces naturally with age and there is a higher incidence of disease as well. Many diseases, such as Diabetes, Alzheimer’s, Lupus, HIV/ Aids, and Parkinson’s contribute to dry mouth. 3 Additionally, over 400 medications affect salivary production Anti-inflammatory, antihistamines, antidepressenats and antihypertensive medications dry up the oral cavity, leading to a multitude of problems ranging from discomfort to rampant caries. Chemotherapy and radiation are two common medical therapies that damage or destroy salivary glandular tissue. Salivary glands do not regenerate after radiation therapy and liquid production diminishes permanently. There are a multitude of other conditions that can contribute to xerostomia as well; Bone marrow transplants; Trauma or disease to the head, neck or mouth; Stress: Mouth Breathing; Nerve damage from wounds or surgery; and Infections prior to or following surgery.8 NOVEMBER 2018

Pastes & gels

Plaque HD Pocket Moisturizing Spray (TJA Health) Biotene Moisturing Spray

Dental professionals work in prevention and therapy. Educating patients on some of the contributing factors of dry mouth (smoking, alcohol, spicy foods, etc.)ii will help with prevention and aggravation. Clinicians can also encourage drinking water often and much, sucking on sugar free lozenges, sleeping with a humidifier in bedrooms and they can offer hydrating mouth rises. Hydrating rinses are a means of keeping patients comfortable. As the demographics of the population changes, dental clinicians will need to be armed with products that help with the discomfort of xerostomia. Affected by medical therapies, medications and simply the passage of time, primary care providers will be a resource of knowledge for patients suffering with xerostomia. Some products that have been shown to provide comfort to patients suffering with xerostomia are in the chart above.. Research is ongoing in the science of saliva. The potential links to the micro biome of saliva and its

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Saliva is packed with proteins that carry masses of microbes that are beneficial to people by helping guard against pathogenic microorganisms.

May 2017

oralhygiene

Stem cell research and gene therapy is being studied to aid in the repair of salivary glands and medications are being developed to help salivary flow.

relation to health and disease is an emerging field. Techniques and medications are being researched to protect glands when medical intervention is required. Stem cell research and gene therapy is being studied to aid in the repair of salivary glands and medications are being developed to help salivary flow. Saliva screenings are being developed to distinguish between bacterial and viral infections and the ability to detect serious illness is the early stages are being ex-

plored. Saliva gland implants are innovations that may be on the horizon with the possibility of coaxing these small glands to produce the hormones needed for healing.8 Science is improving and with new studies and research, lowly saliva is being elevated. However, it will take time to develop innovations and methodologies around this member of the royal court of body fluids. In the mean time, your patients will welcome hydrating rinses.

REFERENCES 1. Lavoie, H. M. (1998, Mar). Oral Microbial Ecology and the Role of Salivary Immunoglobulin . US National Library of Medicine National Institutes of Health, 71-109 2. Alty, C. T. (2003, 06 01). The Wonders of Spit. Retrieved 04 03, 2018, from RDH Magazine: http://www.rdhmag.com/articles/print/volume-23/issue-6/feature/ the-wonders-of-spit.html

oralhygiene

Wikipedia. (n.d.). Saliva. Retrieved 04 04, 2018, from Science Daily: https:// www.sciencedaily.com/terms/saliva.htm

Chi, K. R. (2015, 07 01). Tools for Drool. Retrieved 04 03, 2018, from The Scientist - Exploring Life, Inspiring Innovation: https://www.the-scientist. com/?articles.view/articleNo/43347/title/Tools-for-Drools/

H., L. (2017, 03 09). How Long can Alcohol be Detected in a Mouth Swab Test? Retrieved 04 07, 2018, from Drug Test in Bulk: https://drugtestsinbulk.com/ blog/how-long-can-alcohol-be-detected-in-a-mouth-swab-test/

Smith, B. (2010, 03 31). DNA Genotek's Sample Collection Blog. Retrieved 04 06, 2018, from The Genetic Link: log.dnagenotek.com/blogdnagenotekcom/ bid/35944/Rinse-Swab-or-Spit-What-s-the-Real-Source-of-DNA-in-Saliva

LEVI, A. (2017, 04 27). What Are Electrolytes and Why Do We Need Them. Retrieved 04 07, 2018, from Health: http://www.health.com/fitness/what-areelectrolytes

Mestel, R. The Wonders of Saliva. Retrieved 04 3, 2018, from The Oral Cancer Foundation: https://oralcancerfoundation.org/dental/wonders-saliva-rosiemestel/

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Sheri B. Doniger DDS Sheri practices clinical dentistry in Lincolnwood, IL. Her book, “Practical Practice Solutions in Dentistry” focuses on building practice success. She has served as an educator in several dental and dental hygiene programs, has been a consultant for a major dental benefits company, speaks internationally on a myriad of topics, and writes for several dental publications. She is a member of the American Dental Association, Illinois State Dental Association, Chicago Dental Society, a Fellow in the American College of Dentists, a Fellow in the International College of Dentists and a past president of the American Association of Women Dentists. You can reach her at donigerdental@aol.com.

oralhygiene

o you ever request your patients to close on the saliva ejector to evacuate fluids from their mouths? If so, when was the last time you effectively cleaned out the valve? When a patient closes on the saliva ejector or the tip becomes occluded, backflow may occur due to a temporary drop in vacuum pressure. Saliva ejector backflow has been proven to potentially occur in an estimated 2125%, as studied by the University of Montreal in 1998.1 These studies indicated water contamination containing bacterial levels ranging from 1 CFU to 300 CFU* per occurrence. [*CFU (cfu or cFu) is defined as colony forming units in microbiology used to estimate the number of viable bacteria or fungal cells in a sample.] More plainly stated, one in five patients may receive the backwash in their mouths from the last patient. Think of how many times you ask your patient to “close”? That is a lot of bacteria! This backflow problem is not new. University of Alberta had published articles in 1993, documenting the backflow issue and the potential pathogens present in the water from the saliva ejector backflow.2,3 Bacteria isolated from these samples include staphylococci, micrococci, Pseudomonas aeruginosa, Staphylococcus aureus, Legionella pneumophila and nonfermentive Gramnegative rods.4,5,6 These bacteria are consistent with the bacteria found in dental unit waterline biofilm.7,8

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Biofilm in our waterlines has taken a front row seat in infection control. The concern is the biofilm growing in our water lines. The CDC has defined biofilm as: Biofilm is a thin, slimy film of bacteria that sticks to moist surfaces, such as those inside dental unit waterlines. Biofilm occurs in dental unit waterlines because of the long, small-diameter tubing and low flow rates used in dentistry, the frequent periods of stagnation, and the potential for retraction of oral fluids. As a result, high numbers of common water bacteria can be found in untreated dental unit water systems. Regular disinfection of waterlines should be a component of infection control protocols for the office. Risk of infection, especially in immunocompromised patients, is a possibility. An 83-year-old woman in Italy died from the Legionnaires disease after being treated at a dental office. In February 2011, the woman was admitted to the hospital with a fever and respiratory distress, which quickly denigrated to septic shock and she passed away within two days. The Legionella strain found in the dental water lines matched what was found in the patient.10,11 The possibility of cross contamination due to this backflow is a constant potential risk. The U.S. Centers for Disease Control and Prevention advises that dental patients not be instructed to close their lips around the SE tip when it NOVEMBER 2018

is in use.12 As with the dental waterlines, saliva ejector and HVE13 tubing contain bacterial biofilms that may create an infection. Although these studies did not provide direct proof of cross-contamination, they suggested an infectious risk since a reservoir of pathogens may be given off from tubing biofilms. The method to prevent this backwash of fluids from occurring is to have a backflow prevention valve in place. Manufacturers have anti-retraction devices placed on handpieces, so residual bacteria are prevented from going back down into the handpiece after each use. They also have specifications for cleaning and maintaining their evacuation equipment. What do offices do to disinfect their evacuation devices? Some offices cover their HVE and saliva ejector with a plastic sheath (Figs. 1 & 2) Most wipe the used saliva ejector and HVE with a disinfectant after each patient encounter. Some use evacuation enzymatic cleaners to flush the lines14 (Table 1). Instructions for use are included with each manufacturer’s product. Protocols are slightly different for each, but they should be followed to achieve optimal efficiency and outcomes. All standard HVE and Saliva Ejector Valves contain up to three O-rings (Fig. 3). When the Orings are not lubricated, changed, and inspected, they result in leaking and or dripping (Fig. 4). LeakNOVEMBER 2018

age frequently occurs when the parts stick and are not free moving due to all of the debris that is not routinely cleaned. All recommend daily flushing of the suction lines. These protocols assist in the freeflowing capabilities of the tubing, but do little to truly remove the biofilm risk and cross contamination. Though manufacturers’ recommendations should be followed, protocols vary on each office: some flush after each patient, at the end of the day or at the end of the week. As we receive instructions for use (IFU) for any dental material or other product in our offices, these integral components of our operatory also have instructions for maintenance. Each suction and HVE component comes with an instruction sheet, detailing the precise method for disassembling the piece and cleaning it. O-rings need to be maintained, cleaned and lubricated for proper seal. Some of the valve bodies are autoclavable. Recommendations are offered for daily and weekly maintenance, including changing the screen inside the saliva ejector as well as the HVE. Please see a sample below of HVE maintenance, which is the ADec recommendation, provided with all new equipment (Fig. 4). These are critical procedures, not only to improve the flow and operability of the saliva ejectors and HVE, but to decrease the potential of cross contamination from backflow and valve leakage. They are

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also time consuming. Another, simpler method of prevention is to use disposable products. As we have many single use products in our practices, these disposable valves and attachments would be an additional safeguard to break the link of potential cross contamination occurrences. Currently, two companies manufacture disposables on the market that prevent backflow. One is a complete valve replacement system and one is a modification of existing saliva ejectors and HVE attachments. Dove® is a single use product, available for both saliva ejectors and HVE, replacing the current metal valve on the tubing. The Dove® saliva ejector and HVE valves only allow for one-way flow or suction, and an internal flap prevents any opportunity for backflow of oral fluids. Dove® valves offer a complete valve replacement. The Dove® valves contain an on/off lever, which allows for the replacement of the current metal valves. Since no O-rings are used, there is no concern about leakage from the metal valves in the form of a bubble or leaky drip that often occurs when the valves have not been properly maintained. Each valve alleviates the multiple steps required to clean metal HVE and saliva ejector valves. Any saliva ejector, HVE or aspirator tip on the market can be inserted in the Dove® valve. Dove® valves ad-

May 2017

oralhygiene

Figure 1 Saliva ejector covered with plastic sheath.

Figure 2 Example of Air/Water Syringe Cover.

Biofilm occurs in dental unit waterlines because of the long, small-diameter tubing and low flow rates used in dentistry, the frequent periods of stagnation, and the potential for retraction of oral fluids.

oralhygiene

Figure 4 Unassembled HVE from Yaeger Dental demonstrating four O-rings.

Figure 3 Unassembled HVE from Yaeger Dental demonstrating four O-rings.

dress backflow and guarantee every valve is clean, safe and works perfectly for each patient. Once the procedure is complete, the entire unit, disposable saliva ejector or HVE valve, are disposed in the appropriate methods. These valves are time saving, as no maintenance is required for O-rings. Dove® makes their valves to fit almost 99% of all dental unit tubing. Crosstex SAFE-FLO® Saliva Ejector products all contain unique one-way internal backflow prevention providing a barrier that prevents the fluids from the tubing to enter back into the patient’s mouths. The SAFE-FLO® HV internal valve closes when the suction is stopped or restricted and prevents backflow. The SafeFlo® saliva ejector and HVE functions as a single use saliva ejector or HVE and are inserted into current metal

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valves in your system. Both HVE and saliva ejector metal valves still require the multiple steps to clean. Only disassembling and reprocessing will guarantee the metal valve to be for every patient as per the instructions for use. The SafeFlo® products do not address leakage that often occurs between connections, as they are inserted into the metal valve. Crosstex SafeFlo® products include saliva ejectors that may be used with your existing metal valves, or a protection adapter device that connects into your existing metal saliva ejector or HVE valve. Crosstex SafeFlo® does not have an on/off switch, therefore the metal valves must be maintained, as per manufacturer recommendations. With both systems, it is still important to follow manufacturers’ recommendation for flushing and NOVEMBER 2018

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Gorur A, Lyle DM, Schaudinn C, Costerton JW. Compend Contin Ed Dent 2009; 30 (Suppl 1):1 - 6. Rosema NAM et al. J Int Acad Periodontol 2011; 13(1):2-10. Goyal CR, Lyle DM, Qaqish JG, Schuller R. J Clin Dent 2016; 27: 61-65.

WATER FLOSSER

BEFORE

AFTER

Figure 5 A-Dec HVE/Saliva Ejector Valve Disinfection Instruction and Maintenance. Figure 6 Unclean vs. clean suction trap (From Bryce Hough How to maintain a clean, healthy evacuation system, DPR, June 27,2013.)

maintaining the suction lines. Suction lines should be cleaned every day to remove bio burden. Just as with your waterlines, a shock treatment should be done periodically, along with the daily maintenance. Disposable saliva ejector screens should be changed weekly, or sooner if clogged with large chunks of calculus or restorative debris from a single patient (Fig. 6). Tubing should be replaced periodically. Examine tubing for breaks or tears. Unaesthetic, dirty or discolored tubing affects the clean visuals in your office. Our offices are so aware of the infection control standards, including disinfecting countertops, sterilizing instruments and discarding disposable items from our procedures, such as saliva ejectors and HVE, though we may have missed one area where cross contamination may occur. We believe every patient should be provided a clean safe valve. To do this, offices should either follow the instructions for use or consider disposables as they are the emerging trend to alleviate cross contamination risk, alleviate backflow, alleviate leakage and guarantee every patient has a safe clean valve while saving valuable time. By this method, we close off the potential backflow and cross contaminaNOVEMBER 2018

Table 1 Sample of Enzymatic Cleaners for suction lines

PRODUCT

MANUFACTURER

BioPureÂŽ

BioPure Products

Monarch CleanStream

AirTechniques

Pro E-VacTM

Certol

PurevacÂŽ

Sultan Healthcare

Sani-Treat and Sani-Green

Enzyme Industries

SlugBusterTM

DentalEz

Vac AttackTM

Premier

VacuKleen E2

Heraeus Kulzer

Vacusol Ultra

Biotrol

www.oralhealthgroup.com

May 2017

oralhygiene

tion from bacteria and virus’ that build up in the valves and tubing. With these disposable valves, we eliminate the risk of backflow and ensure each patient received the cleanest possible dental visit. Disclaimer: The author has received material support from Dove Dental Products.

REFERENCES References 1. Mann GL, Campbell TL, Crawford JJ. Backflow in low-volume suction lines: the impact of pressure changes. J Am Dent Assoc. 1996;127:611-615. 2. Watson CM, Whitehouse RL. Possibility of cross-contamination between dental patients by means of the saliva ejector. J Am Dent Assoc. 1993;124:77-80. 3. Whitehouse RL. Danger of inter-patient cross-contamination from saliva ejector suck back. J Can Dent Assoc. 1996;62:499-500. 4. Barbeau J, ten Bokum L, Gauthier C, Prévost AP. Cross-contamination potential of saliva ejectors used in dentistry. J Hosp Infect. 1998;40:303-311. 5. Barbeau J, Gauthier C, Payment P. Biofilms, infectious agents, and dental unit waterlines: a review. Can J Microbiol. 1998;44:1019-1028. 6. Meiller TF, Depaola LG, Kelley JI, Baqui AA, Turng BF, Falkler WA. Dental unit waterlines: biofilms, disin fection and recurrence. J Am Dent Assoc. 1999; 130:65-72. 7. Costa, D., Mercier, A., Gravouil, K., Lesobre, J., Delafont, V., Bosseau, A., Verdon, J., Imbert, C. Pyrosequencing analysis of bacterial diversity in dental unit waterlines Water Research V81, September 2015, pp 223-231 https://doi.org/10.1016/j.watres.2015.05.065 8. Singh, R. et al Microbial Diversity of Biofilms in Dental Unit Water Systems Appl Environ Microbiol. 2003 Jun; 69(6): 3412–3420 9. Barbeau J, ten Bokum L, Gauthier C, Prévost AP. Ibid 10. Ricci, ML. et al. Pneumonia associated with a dental unit waterline. Lancet. 2012 Feb 18 11. Atlas R, Williams J, Huntington M. 1995. Legionella Contamination of Dental Unit Waters. Applied and Environmental Microbiology 61; 1208-1213. 14. Guidelines for infection control in dental health-care settings, 2003. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5217a1.htm. MMWR 2003;52(RR-17):1-61. Published December 19, 2003. 13. Miller, Chris. Back flow in low-volume suction lines may lead to potential crosscontamination RDH January 1996 14. Givoni, Mary Cleaning or disinfection: What's right for the suction lines? Dental Economics March 2013 https://www.dentaleconomics.com/articles/print/ volume-103/issue-3/practice/cleaning-or-disinfection-whats-right-for-thesuction-lines.html

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INFECTION CONTROL

GLOVES SPREAD DISEASE AND HAVE CREATED AN INFECTION CONTROL DILEMMA INTRODUCTION

John Hardie, BDS, MSc, PhD, FRCDC Although retired from practice Dr. Hardie maintains a thirty plus years interest in the discipline of infection control as it relates to dentistry. He has published extensively on the subject and has lectured on it and related subjects throughout North America and in the UK, Europe, the Middle and Far East.

oralhygiene

Non-sterile clinical gloves are a key component of Standard Precautions. It was envisaged that their use, when there was a risk of direct contact with blood, body fluids, non-intact skin or mucous membranes, would prevent potential pathogens in those locations from being transmitted to other patients and, therefore, assist in reducing healthcare associated infections. As is often the case with seemingly logical actions, the wearing of gloves has had unintended consequences as illustrated by the following titles of recent articles in professional and lay publications. “Contaminated Gloves Increase Risks of Cross-Transmission of Pathogens.” American Society of Microbiology, June, 2016 “ Hygienic? No, Your Doctor’s Rubber Gloves Could Infect You With a Superbug.” Mail Online, August, 2012. “Wearing Gloves: The Worst Enemy of Hand Hygiene?” Future Microbiology, June, 2011. “Gloves Are No Guarantee Your Doctor’s Hands Are Clean.” The New York Times, November, 2011 “The Misuse and Overuse of Non-Sterile Gloves: Application of an Audit Tool to Define the Problem.” Journal of Infection Prevention, February, 2015.

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Rather than prevent infections, it appears that glove wearing has a real potential for spreading disease. This article will attempt to describe why this has occurred and how it might be corrected. It will begin with discussing the role that hands play in the spread of disease.

HANDS AND DISEASE TRANSMISSION Microbiology It is now appreciated that the hands of health care workers (HCWs) are frequently colonized by transient micro-organisms such as; methicillin resistant S. aureus, vancomycin resistant Enterococcus, Candida species, and Clostridium difficle. 1Approximately 30,000 to 40,000 skin epithelial cells containing viable pathogens are shed per hour from normal skin. Dirty hands and these shed cells have the potential to contaminate exposed skin, uniforms, chairside furniture, bibs, equipment and instruments in the patient’s immediate environment. When clean hands touch those objects they- in turn- are colonized by the pathogens creating a potential for cross-contamination.1 This explains why contaminated hands and shed cells from the hands of HCWs act as efficient means of spreading pathogens across working and non-working surfaces, be-

NOVEMBER 2018

MOMENT

WHY

EXAMPLE

One: Clean Hands before touching patient

Protect patient from pathogens on DCWs hands

Before shaking hands with patient, before sitting patient in chair

Two: Clean hands before performing clean/aseptic procedure

Prevent pathogens invading patient from the patient, DCW or operatory surfaces and devices

Before performing intra-oral procedures including injections, impressions, restorations, imaging and surgery

Three: Clean hands immediately after body fluid exposure

Protect DCW and operatory surfaces and devices from patient’s pathogens

After contact with blood, oral mucosa, after removing gauzes, dentures, rubber dam, imaging devices

Four: Clean hands after touching patient

Protect DCW and operatory environment from patient’s pathogens

After shaking hands with patient, after sitting patient in chair after any non-invasive treatment or procedure

Five: Clean hands after cleaning up operatory following treatment

Protect the DCW, staff and other patients from treated patient’s pathogens

After contact with instruments, countertops, trays and chairs

experienced by HCWs when hand hygiene is needed to effectively reduce the potential for microbial transmissions during the administration of treatment. The five moments are described in Table 1. To provide a dental perspective, the Table is a modification of the Five Moments for Hand Hygiene (5MHH) published by the World Health Association.4 The examples offered are for illustrative purposes and are not the only situations where the five moments should be enacted. The five moments are standardized logical actions which can be applied to a wide range of health care activities. They are simple to teach, practice and monitor. They avoid the introduction of individual variations on when hands should be cleaned. 3 They have been endorsed by the World Health Organization (WHO) as their strict adherence in both developed and developing countries does result in significant

decreases in HCAIs.1 In fact, according to the WHO, the simple five moments for hand hygiene properly practiced are one of the most important and effective methods of infection control. 5 Therefore, it follows that failure to perform any of the five moments will result in contaminated hands which have the potential to spread disease.

Table 1: Five Moments for Hand Hygiene. (DCW Dental Care Worker)

tween patients, and between clean areas and contaminated locations on the same patient, and are a significant cause of health care associated infections (HCAIs).2 Although these transient micro-organisms are readily removed from the skin surface by water and soap or are destroyed by alcohol hand rubs, the HIV/AIDS scare of the mid-1980s promoted the wearing of gloves by HCWs as an extra precaution against the spread of HCAIs. To understand why glove use is now associated with disease transmission, it is necessary to discuss failures in the five moments for hand hygiene, cross contamination, and the misuse of non-sterile clinical gloves.

Five Moments for Hand Hygiene In 2007 Sax and colleagues developed the concept of “My Five Moments for Hand Hygiene. 3 It describes work situations commonly

NOVEMBER 2018

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Hands and Cross Contamination Sax and colleagues reported a compliance rate for hand hygiene at less than 50% among hospital staff. 3 Dr. Jennie Wilson, a prominent UK infection control researcher, found that the adherence to proper hand hygiene among HCWs was around 40%.6 A 1999 study of Canadian Dentists demonstrated that the percentage of dentists who did not wash their hands before patient contacts ranged from 13-60%.7 More recently 19% of USA dentists admitted to

May 2017

oralhygiene

never washing or disinfecting their hands between patients.8 These findings support the conclusion by Larsen that the adherence by HCWs to proper hand hygiene is abysmal.9 The potential for dirty hands to spread disease is real and has not be reduced by the equally abysmal failure of most hand hygiene compliance programs.10 Unfortunately, glove wearing by HCWs has not compensated for the inadequacies in hand hygiene. To understand why, it is necessary to discuss the use and misuse of non-sterile clinical gloves. In the following text NSCGs and gloves will be used interchangeably to refer to non- sterile clinical gloves. Sterile gloves used in the operating room are not the subject of this article.

Moore et al in 2013 reaffirmed that during their use gloves do become contaminated with micro-organisms which, in turn, are transferred to other surfaces touched by the gloves and, when removed, to the wearer through the phenomenon of “back spray”.

oralhygiene

NON- STERILE GLOVES AND DISEASE TRANSMISSION Non-sterile Clinical Gloves –Their Use In 1996 as part of Standard Precautions, non-sterile clinical gloves (NSCGs) were to be worn by HCWs when exposure to blood, body fluids, mucous membranes and non-intact skin was anticipated.11,12 This is a highly specific purpose. These exposures create “portals of entry” and make vulnerable patients prone to crosscontamination from micro-organisms present on the hands of HCWs who might have previously treated a patient with an undiagnosed bloodborne infection.13 The primary purpose for wearing NSCGs was and remains the protection of the patient.13 The fact that gloves might also protect the HCW is a secondary consequence.13 Equally important is the removal of the gloves immediately after the contact which justified their use.13 This ensures that potential bloodborne infections from the treated patient are not transferred to other patients, equipment, or surfaces.13 Thus, when used properly, NSCGs

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should assist in reducing the likelihood of cross-contamination and hence the number of HCAIs.11,12 To-day, the specific purpose for wearing NSCGs appears to have been lost as their use has become routine throughout all aspects of healthcare delivery.14 This common but inappropriate behaviour poses a real risk for cross-contamination.15

Non-sterile Clinical GlovesTheir Misuse Throughout the last twenty five years numerous clinical investigations have been undertaken on the glove wearing habits of HCWs. For example, in 1997 Thompson et al found that the rate for not changing gloves at the appropriate time was as high as 84%.16 Girou in 2004 was able to recover pathogens from 86% of the NSCGs used by HCWs.12 A controlled trial by Bearman and colleagues in 2007 demonstrated a definite increase in the number of HCAIs when NSCGs were used for all patient contacts compared to the number of such infections when the gloves were used solely for their intended purpose.17 The investigation by Fuller in 2011 confirmed that gloves were not being changed between patient contacts and that compliance with routine hand hygiene was significantly reduced when NSCGs were used.18 Moore et al in 2013 reaffirmed that during their use gloves do become contaminated with micro-organisms which, in turn, are transferred to other surfaces touched by the gloves and, when removed, to the wearer through the phenomenon of “back spray”.19 In 2013 Wilson recorded a 33% failure rate to wash hands after gloves were removed, and that in 5% of cases a gloved hand touched 5 objects before performing the procedure justifying the glove usage. 20 Loveday in 2014 and Wilson in 2017 observed that among all HCWs up to 58% of glove wearing episodes were unnecessary and unjustified. 21,2 An interesting finding by Hughes in NOVEMBER 2018

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CORRECT MOMENT

VIOLATION OF MOMENT

One: Clean Hands before touching patient

Wearing or removing gloves immediately before direct contact with patient

Two: Clean hands before performing clean/aseptic procedure

Wearing gloves which have touched non-sterile objects including patient’s skin before performing an intra-oral procedure

Three: Clean hands immediately after body fluid exposure

Wearing gloves during an intra-oral procedure which subsequently touch the patient, DCW or an operatory surface

Four: Clean hands after touching patient

Not removing gloves before leaving operatory for whatever reason or duration

Five: Clean hands after cleaning up operatory following treatment

Wearing gloves outside an operatory that were used in any aspect of patient care

Table 2: Five Moments for Hand Hygiene related to Misuses in Glove Wearing

2013 was that during the retrieval of NSCGs in an orthopedic ward, the dispensers containing them were contaminated by the skin commensals and pathogens on the hands of HCWs. 22 In turn, this creates the very real potential of fresh gloves being contaminated before they are used, and the realization that boxes of NSCGs are a source of spreading pathogens throughout the entire clinical environment. Such a situation has been identified in the dental office. 23 The significant findings from these and similar studies are: • if gloves are not removed after contact with potentially infectious sources they assume the qualities of a contaminated “second skin” and that these dirty gloves are capable of causing cross-contamination in a similar manner as dirty hands; 24,25,26 • in many instances gloves are not changed at the appropriate time;16 • the habitual use of gloves over a wide range of health care activities means that in many instances their use is inappropriate.15 From this Wilson and others have agreed that NSCGs are being misused because they are: NOVEMBER 2018

• • • •

put on when not required; put on too early; removed too late; not changed at critical points in patient care. 2,15,18

Wilson and others have proposed that the overuse and misuse of gloves has desensitised HCWs to the triggers that would normally initiate hand hygiene as dictated by the five moments.14,15,18,21 In her recent paper, Wilson lists the failures to recognize these triggers and by relating them to the 5MHH illustrates why the misuse of gloves creates a potential for HCAIs. 2 Table 2 describes this situation from a dental perspective. Not donning fresh NSCGs immediately before exposure to a patient’s body fluids, mucous membranes or non-intact skin but continuing to wear ones which have been used for prior procedures is a failure to acknowledge the significance of Moment 2. In dentistry, an example of this would be wearing the same pair of gloves to handle non-sterile items prior to an intraoral procedure as are worn while performing the procedure. Situations where this might occur are

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the wearing of NSCGs while placing bibs or protective glasses on patients, entering drawers, touching countertops, giving mouthwashes or medications and recording histories. Similarly, failure to remove gloves immediately after an exposure prone procedure is a violation of Moment 3. In dentistry, this would be the equivalent of the gloves that were worn for an intraoral procedure being used to clean up after the procedure. HCWs who ignore the occasions when gloves should be removed, hand hygiene performed and, if necessary, fresh gloves worn, are creating lapses in infection control which in 50% of such instances produce a potential for cross-contamination and an increase in HCAIs. 2 The majority of investigations on NSCGs have involved medical and/ or nursing personnel. However, it would be naïve to assume that dental staff are not similarly abusing gloves. Wearing the same pair of gloves while roaming from one operatory to another, not changing gloves between patients, wearing the same pair of gloves while performing separate intra-oral procedures on the same patient, remov-

May 2017

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ing gloves and donning fresh ones without hand hygiene, wearing gloves while greeting and seating patients and recording their histories, wearing gloves while in non-clinical environments, wearing gloves while performing an external TMJ examination or lymph node assessment, and somehow believing that wearing gloves justified less rigorous hand hygiene practices, are all examples of the misinformed and unjustified use of gloves. If gloves are being used inappropriately, it is reasonable to ask, â&#x20AC;&#x153;Why wear them?â&#x20AC;? To understand why this almost universal pervasive misuse of gloves has occurred, it is necessary to explore the drivers for glove wearing by HCWs.

THE DRIVERS OF GLOVE USE As part of Universal Precautions gloves were to be worn when contacting blood and other body fluids known to be infected with HIV, HBV and other blood borne pathogens. 27 Thus, before gloves were required to be worn the patientâ&#x20AC;&#x2122;s infectious status had to be determined. This all changed with Standard Precautions. They required that gloves were to be worn when performing exposure prone procedures such as contacting blood, body fluids, mucous membranes or non-intact skin regardless of the patientâ&#x20AC;&#x2122;s infectious status. 27 Standard Precautions negated the need to perform a risk assessment prior to such procedures. The unintended result of Standard Precautions was that HCWs treated all procedures as risky and so began wearing NSCGs for all patient contacts. Why such behaviour should occur was the catalyst for series of interviews with HCWs conducted by Loveday in 2014 and Wilson in 2017. 2,21 They found that the two principal reasons why HCWs wore gloves were based on emotion and socialization.

Emotion as a Driver Common emotions justifying glove use were: selfprotection against unspecified pathogens; prolonged use to ensure self-protection; easing mental stress from fears of contamination; disgust at touching patients, surfaces and items perceived as being unclean; saving time and reducing the need for hand hygiene; and by depersonalizing care there was the avoidance of demonstrating disgust at performing unpleasant tasks. 2, 6, 13, 28 Surprisingly, HCWs either were not concerned with or unaware of the fact that gloves are not sterile coverings for hands but become contaminated and pass on infections in a manner similar to dirty hands.6 Common attiNOVEMBER 2018

tudes and beliefs regarding the wearing of NSCGs are identified in this response received by Wilson. “Obviously, the idea is to protect yourself and the patient from infection so I suppose you could say that you should wear them all the time, which all of us do to be honest, you don’t know what patients have infections you don’t know that if you haven’t got information then you treat everybody the same so you’re protecting yourself and you’re protecting the public.” 2 Based on her interviews with HCWs, Wilson has concluded that, “The decision to wear NSCGs was strongly influenced by an emotional need for protection of self, driven by fear and disgust.” 2

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Socialization as a Driver The ready availability of NSCGs appears to give HCWs permission to routinely wear them without assessing – as mandated by infection control recommendations – if the risks associated with a specific procedure justify their use. 2 Many HCWs admitted to “automatically” wearing gloves despite their training and infection control policies recommending otherwise. 2 Peer behaviour did influence glove use but not without reservations. The following is an example of a HCW’s approach to NSCGs. “I would use personal experience and knowledge. I wouldn’t be influenced by somebody saying you don’t need to wear gloves if I feel I need to wear gloves I would wear them.” 2 Not surprisingly, Wilson found that the most common influence on nurses’ decisions to wear gloves was their own judgement. This was so strongly held that, as demonstrated in the above quotation, it was not open to being challenged. 2 Other influences in descending order were infection control policies, the advice from lecturers/trainers and directions received from senior staff. 2 There is minimal information on to what degree the public`s perception of glove wearing influences the decisions of HCWs. The idea that glove wearing might give patients the impression that they are dirty or contagious does not appear to be an influencing factor. 2 However, patients do have their opinions on the use of NSCGs. A recent study found that 63% of patients had a negative opinion on glove use including observations that they were overused, not changed between patient tasks or patients, worn to avoid hand hygiene and used primarily for the benefit of the treating personnel who disliked being questioned on their use.15 In NOVEMBER 2018

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addition, those patients were never asked if they had an allergy to the gloves’ ingredients.15 Only 24% of patients had a positive approach to NSCGs which included the idea that HCWs knew when to wear them to avoid infections, and that hands were protected by them.15 The same group of patients believed that the routine wearing of gloves was unifying as it prevented the identification of infected patients.15 Patients are excused for having this idea, but HCWs ought to know that such an outcome was not the purpose of Universal or Standard Precautions.

Influences on Dental Staff Many dental procedures are intraoral and exposure prone, which according to Standard Precautions justifies glove wearing. However, it is reasonable to assume that like other HCWs, the primary reason for dental staff using NSCGs is selfprotection. With this as the primary and seemingly dominating nonquestionable influence, it is highly NOVEMBER 2018

likely that gloves are routinely used by dental staff for procedures for which there is no justification apart from one of selfprotection. If the answer to “Why Wear Them” is “To Protect Myself”, dental staff might wish to consider that practicing proper handwashing is the most effective method of protecting themselves and their patients.

DISCUSSION The references cited throughout this article represent a small sample of the numerous studies on the side effects of wearing NSCGs. The conclusion to be drawn from these investigations is that by their inappropriate use of gloves and less reliance on hand hygiene, HCWs are promoting health care associated infections and compromising the goals of Standard Precautions. Unfortunately, there is no reason to assume that the dental environment is immune to this infection control dilemma. It is suspected that the majority of dental staff misuse gloves and in doing so, no

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If the answer to Why Wear Them” is “To Protect Myself”, dental staff might wish to consider that practicing proper handwashing is the most effective method of protecting themselves and their patients.

May 2017

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doubt unintentionally, violate the principles governing Standard Precautions. The correction of this situation will require that dental staff are emphatically informed that glove use is not a substitute for enacting the five moments for hand hygiene. They must appreciate that proper infection control necessitates assessing the risk of infection-principally to the patient-before donning gloves. This means that infection control recommendations must indicate clearly not only when and how gloves should be used but when and why they should not be used. Such actions should reduce selfprotection and personal judgements as the principal drivers of glove use and permit glove use to be questioned by peers

It is suspected that the majority of dental staff misuse gloves and in doing so, no doubt unintentionally, violate the principles governing Standard Precautions.

and patients. If this causes the habitual and inappropriate use of NSCGs to be broken and replaced by rational behaviour, it is possible that the intended purpose of Standard Precautions will be accomplished and that dental offices will not be the source of spreading health care associated infections. However, a simpler solution is at hand. The current misuse of gloves by dental staff has the potential to cause disease transmission. To avoid such an unintended consequence the profession should forget gloves and revert back to the simple, cheap, effective and environmentally friendly practice of hand washing albeit modernized to reflect the Five Moments for Hand Hygiene.

References 1. P. Mathur, Hand hygiene: Back to the basics of infection control. Indian J Med Res 2011; 134(5): 611-620. 2. J. Wilson et al, Applying human factors and ergonomics to the misuse of nonsterile clinical gloves in acute care. Am J Infect Control 2017; 45(7): 779-786. 3. H. Sax et al, “My five moments for hand hygiene”: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hospital Infection 2007; 67: 9-21. 4. World Health Association, Hand Hygiene: Why, How & When? 2009 5. Guide to implementation of the WHO multimodal hand hygiene improvement strategy. Available at: http://www.who.int/patientsafety/en/ 6. J. Wilson, Hand hygiene: to glove or not to glove. Nursing Review 2015; 15 (5):1-10. 7. G. M. McCarthy et al, Infection Control Practices Across Canada: Do Dentists Follow the Recommendations? J Can Dent Association 1999; 65: 506-511. 8

R. Myers et al, Hand Hygiene Among General Practice Dentists: A Survey of Knowledge, Attitudes and Practices. JADA 2008; 139(7): 948-957.

9. E. Larson et al, Compliance with handwashing and barrier precautions. J Hospital Infection 1995; 30: 88-106. 10. M. Whitby et al, Why Healthcare Workers Don’t Wash Their Hands: A Behavioral Explanation. Infection Control Hospital Epidemiology 2006; 27(5): 484-492. 11. M. Eveillard, Wearing gloves: the worst enemy of hand hygiene. Future Microbiology 2011; 6(8):835-837 12. E. Girou et al, Misuse of gloves: the foundation for poor compliance with hand hygiene and potential for microbial transmission? J Hospital Infection 2004; 57: 162-169. 13. J. Wilson et al, Does glove use increase the risk of infection? Nursing Times; 2014; 110 (39): 12-15.

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NOVEMBER 2018

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References (continued) 14. J. Wilson et al, The misuse and overuse of non-sterile gloves: application of an audit tool to define the problem. J Infect Prevention 2015; 16(1): 24-31. 15. J. Wilson et al, Public perceptions of the use of gloves by healthcare workers and comparison with perceptions of student nurses. J Infect Prevention 2017; 18(3): 123-132. 16. B. L. Thompson et al, Handwashing and glove use in a long- term care facility. Infect Control Hospital Epidemiology 1997; 18: 97-103. 17. G. M.L. Bearman et al, A controlled trial of universal gloving versus contact precautions for preventing the transmission of multi-drug resistant organisms. Am J Infection Control 2007; 35(10): 650-655. 18. C. Fuller et al, â&#x20AC;&#x153;The Dirty Hand in the Latex Gloveâ&#x20AC;?: A Study of Hand Hygiene Compliance When Gloves Are Worn. Infect Control Hospital Epidemiology 2011; 32(12): 1194-1199. 19. G. Moore et al, The effect of glove material upon the transfer of methicillinresistant Staphylococcus aureus to and from a gloved hand. Am J Infect Control 2013; 41: 19-23. 20. J. Wilson et al, The misuse of clinical gloves: risk of cross-infection and factors influencing the decision of healthcare workers to wear gloves. Antimicrobial Resistance and Infection Control 2013; 2 (Suppl 1): 03. 21. H. P. Loveday et al, Clinical glove use: healthcare workers actions and perceptions. J Hospital Infect 2014; 86:110-116. 22. K. A. Hughes et al, Bacterial contamination of unused, disposable non-sterile gloves on a hospital orthopaedic ward. Australian Medical J 2013; 6(6): 331-338. 23. J. B. Luckey et al, Bacterial count comparisons on examination gloves from freshly opened boxes and from examination gloves before treatment versus after dental dam isolation. J Endodontics 2006; 32: 646-648. 24. A. Tenorio et al, Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant Enterococcus species by healthcare workers after patient care. Clinical Infect Diseases 2001; 32: 826-829. 25. J. E. Patterson et al, Association of contaminated gloves with transmission of Acinetobacter calcoaceticus var. anitratus in an intensive care unit. Am J Med 1991; 91: 479-483. 26. S. Lund et al, Reality of glove use and handwashing in a community hospital. Am J Infection Control 1994; 22: 352-357. 27. Occupational Safety and Health Administration, Health Care Wide Hazards. Available at: https://www.osha.gov/SLTC/etools/hospital/hazards/univprec/univ. html 28. T-H. Jang et al, Focus Group Study of Hand Hygiene Practice among Healthcare Workers in a Teaching Hospital in Toronto, Canada. Infection Control Hospital Epidemiology 2010; 31(2): 144-150.

Acknowledgement The author wishes to acknowledge Dr. Jennie Wilson who kindly provided access to a number of the articles referenced in this paper.

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NOVEMBER 2018

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ORAL HYGIENE

MANAGING YOUR HYGIENE SCHEDULE

Lisa Philp Chief Visionary Officer TGNA – Transitions Group North America Lisa is committed to being an eternal student in the areas of personal growth, leadership, change management, human capital development, adult learning, advanced training techniques and communication skills. She may be contacted at www.tgnapracticemanagement or info@tgnadental.com

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here are many systems that can be implemented in a dental practice to enhance time management between dentists and hygienists. Although these solutions are relatively simple and easy to implement, they require the cooperation of all members of the administrative team. Let’s look at managing hygiene exams and assessments. The first question to ask is, “Do we have a hygiene coordinator?” This role delegates one person to manage the entire hygiene schedule. This person would take all incoming hygiene appointment calls, confirm all hygiene appointments and manage all aspects of the hygiene schedule. In other words, they would have their “finger on the button” for all things hygiene. Rather than having “too many hands in the pot” (or in this case, the hygiene schedule), the hygiene coordinator would effectively manage and engineer the hygiene schedule. For a dental practice to be running at peak efficiency and profitability, the days of filling voids must become a thing of the past. An efficient hygiene schedule should have varied appointments throughout the day that will enable overall production goals to be achieved. The hygiene coordinator should prepare the hygiene schedule with appropriate blocked time throughout the day for specific appointments, just as the dentist’s schedule is prepared in the same manner. In turn, this would support team members by aligning appointments

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throughout the day that do not conflict with the varied procedures happening at the practice. The entire team needs to train themselves to look at an appointment schedule across the board horizontally, not just vertically at their own day. As we are aware, the ripple effect that can occur in a dental practice because of scheduling issues can be devastating on days and weeks. One way to avoid scheduling headaches is to provide all team members with a copy of the entire office’s schedule, not just their own for that particular day. Another easy solution to introduce at your practice is the morning meeting or ‘huddle.’ When handled correctly, this can be the most beneficial fifteen minutes at your dental practice. In general, the dental industry expects its staff to come to work completely unaware of what they are doing that day. Instead, they are asked to “go to it” and we wonder why chaos ensues and stress levels rise. Take fifteen minutes prior to each day to focus the group around what is going to happen during the workday. During the morning meeting, have each team member come prepared with their chart audits complete and have each hygienist identify which clients will require an assessment or an exam. This allows everyone to determine the time required for hygiene that day. The dental practice environment is unpredictable enough, so it helps to prepare the team as much as possible. NOVEMBER 2018

To advertise contact: Karen Shaw • tel: 416-510-6770 • cell: 437-991-7187 • e-mail: karen@newcom.ca Toll Free CDA & USA: 1-888-639-2669

CAREERS

VANCOUVER, BC

MORDEN, MB

REVELSTOKE, BC

DENTAL PRACTICE MANAGER

FULL TIME CDA REQUIRED.

HYGIENISTS AND CDA’S REQUIRED.

E-mail: smile.dentalcareers@gmail.com

HYGIENISTS YUKON, BRITISH COLUMBIA, ALBERTA Dental Hygienist. Multiple opportunities, Full-time and Part-time. Email: smile.dentalcareers@gmail.com

AURORA AND NEWMARKET, ON Experienced hygienist available for temping services in Aurora and Newmarket. 10+ years experience. Will bring own dental hygiene kits and handpieces to your office. Please contact: chomper80@hotmail.com for resume.

ASSOCIATESHIPS

OTTAWA, ON An associate is required for a full-time permanent position in a busy, modern state-of-the-art Ottawa practice. We are committed to providing the highest standard of care using cutting edge technology. The ideal candidate is enthusiastic and caring with good communication skills and would enjoy working in a team setting. Continuing education allowance and future buy in opportunity maybe available for the right candidate. Please email resume: maisiouti@gmail.com

SCARBOROUGH AND STOUFFVILLE, ON LOCATIONS Modern established dental practices looking for highly motivated Associate to join our team. Candidate must be friendly, compassionate and maintain the highest quality standard of care for all our patients. Tuesday’s, Thursday’s, alternate Friday’s and 1 Wednesday a month. Please email resume to arlinda@tddental.ca

TORONTO, ON ORTHODONTIST Email: smile.dentalcareers@gmail.com NOVEMBER 2018

ASSOCIATESHIPS

THOMPSON, MB

TRENTON-BELLEVILLE, ON

ASSOCIATE – NEEDED IMMEDIATELY!!

Well established patient base, supported by a talented team of professionals is seeking a passionate full time associate/partner to join our team, that thrives on patient experience & excellence, with potential partnership. This ideal candidate must be enthusiastic, dynamic, conscientious, work well in a team environment and has 2+ years experience. Please forward resume to dentistsopportunity@gmail.com

Full-time, energetic, detail oriented associate needed immediately for established, busy family practice with high income potential per month. Enjoy a fully booked schedule and ability to reach your goals as a dental professional. Experience preferred. Excellent opportunity. New grads welcome. Living accommodations provided. E-mail cv: thompsondent@gmail.com P: 204-939-0083.

GTA

LLOYDMINSTER, AB

Various clinics within the dentalcorp network Opportunity: Periodontist Flexible days per month E-mail: careers@dentalcorp.ca

Modern and nicely equipped clinic with a well established and growing patient base seeking a full-time, long-term, experienced Associate. Paid on PRODUCTION! Contact: admin@oriondentalgroup.ca

WINNIPEG, MB

Large, modern dental practice in the heart of Bloor West Village is looking for a DENTAL ASSOCIATE. Applicants should have some Canadian experience. Prefer Russian/Ukrainian language. E-mail: wzigan@gmail.com

Full-time Associate smile.dentalcareers@gmail.com

TORONTO WEST, ON

LABRADOR CITY, NL

REGINA, SK

Enthusiastic dentist required for a family dental practice, in Labrador City, Newfoundland,friendly staff to assist you. For further information, please contact Rehan at 709 944 4294 or e-mail rmalik@crrstv.net

Seeking motivated and dynamic Associate for long-term, full-time position in a growing, modern and well-appointed clinic. Paid on PRODUCTION! New grads welcome, mentoring available. Contact: admin@courtsidedental.ca

EDMONTON, AB General practice in northeast Edmonton seeking a full time Associate to begin in January. Current associate is leaving Alberta. We are seeking a positive individual dedicated to practising excellence with compassion and honesty. Ours is a bright and welcoming office with an opportunity to use most all of your clinical skills. If you are interested in seeking a position in a progressive practice please call. We can be reached at gzenith@interbaun.com or call Marilyn during regular office hours at 780-478-2797 for further details.

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ASSOCIATESHIPS

COURTICE, ON

PICKERING, ON

BRANDON, MB

Very busy office just outside of the GTA in a city called Courtice, Ontario. We are in need of an associate for Mondays (11-7), Tues (11-7), Wed (11-7) and Saturdays (9-3). If you are energetic and friendly, we would love to hear from you. Please email to courticedental@gmail.com with a copy of your resume.

PART-TIME ASSOCIATE NEEDED Large group practice with great NP flow is seeking an experienced dentist with additional skills in Surgery and Endodontics. Some evenings and Saturdays required.

We look forward to hearing from you.

Calgary location is seeking part timefull time associate dentist. Busy practice with long term patient retention and excellent new patient flow. Offer a digital setting with new technology, as well as supportive team and busy schedule.

We are currently seeking a full-time Associate Dentist for an established, busy family practice with high income potential in Brandon, MB. The Associate will take over an existing patient load and will be busy from day one. This is an excellent opportunity to grow your skills quickly and learn from experienced dentists. Compassion, strong ethical conviction and positive attitude will ensure a good fit with our vision. Working hours: Monday to Friday 8:30am to 5:00pm. No Evenings, No Weekends. Offer 4 weeks vacation a year. Brandon offers a low-stress lifestyle and a quality of life that you will not find anywhere else. Send CV and Resume to manitoba.dental.hiring@gmail.com

CASTOR, AB (1/2 HR EAST OF STETTLER)

Castor Dental Center, located half an hour east of Stettler, Central Alberta is looking for a full time associate to join our growing team. Please email your resume to: smiles1@gmx.com

Respond in confidence to apply@sheridandentalcentre.com

CALGARY, AB

Please email CV’s in strict confidence to: dentistcalgary@yahoo.com

OAKVILLE, ON

YELLOWKNIFE, NT

Looking for part time dentist for busy dental office in Oakville. Must be available to work alternate Saturdays and 2 evenings. At least one year of dental experience required. Excellent people and communication skills an asset. Proficiency in endo and crown an asset. Please forward your resume to oakdent6@gmail.com

An exciting opportunity for an associate position in the North’s most vibrant city. The office has all of the most advanced technology, 3D imaging, ITERO, fully computerized with a visiting orthodontist and its own dental laboratory. Reply to HKOBAISY@HOTMAIL.COM or Fax: 867-873-4410.

DOWNTOWN OTTAWA, ON

GTA AND SURROUNDING AREAS PT leading to FT Pediatric dentist required.

Looking for a periodontist in downtown Ottawa. One day per week. E-mail: norma@xyzdimension.com

LEDUC, AB

OTTAWA VALLEY, ON

PT ORTHODONTIST ASSOCIATE

ASSOCIATE REQUIRED IN THE BEAUTIFUL OTTAWA VALLEY Busy and well established practices in Deep River and Pembroke currently looking for a full time associate. Great long term opportunity to work alongside our amazing long term teams. 50% associate fee. Please apply with resume and cover letter to amyfudge16@gmail.com

Currently seeking a part time, licensed Orthodontist for our new state of the art Clinic. The office encourages meaningful, relationshipbased care for the patients. Potential for partnership. Please forward your resume to manager@leducdentists.ca

OTTAWA, ON Full time dentist required asap for well established downtown clinic to take over a full patient load. Excellent team and great potential. Please apply with resume and cover letter to: ottawaddssearch@gmail.com

WINNIPEG, MB Opportunity for Oral Maxillofacial Surgeon for busy, full scope practice in Winnipeg with emphasis on Dental Implants and Reconstruction. smile.dentalcareers@gmail.com

E-mail: careers6@dentalcorp.ca

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CHILLIWACK, BC SYDNEY, NS, LETHBRIDGE, AB, REGINA, SK, MISSISSAUGA, CAMBRIDGE AND TORONTO ON

Periodontist Multiple opportunities, Full-time and Part-time Email: smile.dentalcareers@gmail.com

OTTAWA, ON FULL TIME ASSOCIATE WANTED General dentistry office seeking a driven, personable individual, with a minimum three years’ experience. Must have good communication and clinical skills. No evenings or weekends. E-mail: dentist.cdc@gmail.com

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TORONTO, ON Yonge Finch Subway Practice needs highly competent dentist who uses nitrous and can outline treatment plan and perform a variety of treatment options. Permanent Mondays, Tuesdays, Thursdays. 8am to 6pm - also available x 2 Saturdays and every Wednesday 427 Finch. 5 years experience and 2 year commitment required. 911@willowdaledentalgroup.com

ST. JOHN’S, NFLD Associate 1 full time opportunity Email: smile.dentalcareers@gmail.com

WEST END TORONTO AND MILTON, ON Associates with own patients or specialists needed to share our dental facilities in West End Toronto and Milton. Modern, digital offices, close to major transportation routes. Contact Lidia at oksania@bellnet.ca

RED DEER, AB Full time associate invited to join a big dental family. Red Deer is centrally located between Edmonton and Calgary. Excellent opportunity, existing patient base, strong new patient flow, modern office & wonderful staff. All applications strictly confidential. Please email CV to reddeerdentist@gmail.com

NOVEMBER 2018

ASSOCIATESHIPS

WHITECOURT, AB FULL TIME ASSOCIATE

TORONTO, ON

PART TIME ASSOCIATE AND DENTAL HYGIENIST NEEDED

We are looking for an experienced full-time associate to join our team of general dentists and specialists in our busy and well established Toronto practice. Minimum 5 years general dentistry experience Excellent communication skills. Experience restoring dental implants. CEREC training and experience preferred. Paediatric dentistry experience an asset. IV parenteral conscious sedation certification (or higher) an asset.

Family Dental Health in Whitecourt requires a Full-Time Associate for a well established, modern dental practice. We are located just 1.5 hours north west of Edmonton and only a 2 hour drive to the Rocky Mountains. Accommodations available. Join our friendly and dedicated team today. New graduates are welcomed. Email resumes to fdh2006@hotmail.ca or Fax 780-778-2609.

Part time associate and part time dental hygienist are needed for our busy, full service, family dental practice in downtown Toronto. Candidate must be friendly and self motivated as well as be available to work evenings and Saturdays. Please send resumes to bcddental@gmail.com Attn: Tanya

OTTAWA, ON

BOLTON, ON

WINDSOR, ON

Periodontist Part-Time

PT oral surgeon required.

Ortho associate needed.

E-mail: careers4@dentalcorp.ca

E-mail: careers6@dentalcorp.ca

E-mail: smile.dentalcareers@gmail.com

COBOURG, ON

SASKATCHEWAN

VANCOUVER, BC

Multiple Associates

Associate Dentist 1 opportunity

smile.dentalcareers@gmail.com

Email: smile.dentalcareers@gmail.com

Associate 1 part time opportunity Email: careers6@dentalcorp.ca

Please email resumes to dental9180@gmail.com

VICTORIA, BC Part-time(Monday/Tuesday) associate wanted in the Westshore of Victoria, B.C. Our office offers Cerec, Invisilign, Implants, Surgery and orthodontics. We also have a periodontist on staff, as well as 9 hygienists. We are located in one of the fastest growing communities on the island. Experience, skill, and a pleasant personality an asset. This position will lead to a full-time position early in 2019. Please contact (250) 474-5308 or email resume to dawn@westshoredental.com

WHITEHORSE, YT FULL TIME DENTIST Very Busy practice located in beautiful city of Whitehorse Yukon. Perio, Crown and Bridge, Implants, Orthodontics and all aspects of General Dentistry. Office is modern and up to date. FULL TIME DENTAL HYGIENIST Busy 8 Op practice requires full time Hygienist. Located in beautiful city of Whitehorse, Yukon. Population of 30 000 and growing. Great outdoor adventures waiting at your door. Kayaking, fishing, hiking, skiing. All waiting for you to experience. The office is a general practice that includes implants, endo, perio, ortho and oral surgery. Please send resume to pinedental@northwestel.net

OTTAWA AREA Sandhu Dental Group is looking for full time Associate in one of 13 locations in Eastern Ontario

Apply if you are enthusiastic, hard working, flexible and willing to learn. Implant Mentorship will be provided by Dr. Raja Jang Sandhu

Please check our website

www.sandhudental.ca We are elite dental group with opportunity and growth for Dentist

If interested please email you resume to Dr Raja Jang Sandhu: jangsandhu88@gmail.com

Experience preferred. NOVEMBER 2018

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ASSOCIATESHIPS

AD INDEX

TORONTO, ON

OWEN SOUND, ON

Buying a dental office is a very difficult step in a dentist’s life. If you work as an associate in the office you will know exactly what is going on there. In our dental office I am looking for a part time associate who especially works on Saturday and who is interested in purchasing a dental office. Please send your resume to mansoursadaf@gmail.com

Seeking a part time Associate to join well established, very busy dental clinic (4 Dentists) in Owen Sound, On. This is an excellent opportunity for a dentist looking to work 3 days weekly, Tuesday to Thursday with a possibility of a fourth day down the road and enjoy a wonderful lifestyle in the Georgian area whilst practicing dentistry at it’s best. Please e mail your resume to guychouinard@hotmail.com or contact us at 519-376-4244.

OTTAWA, ON Endodontist Part-Time

AMD Medicom . . . . . . . . . . . . . . . . . . . IBC Crest Oral-B, P&G . . . . . IFC, 8-9, 19, 27, 32 dentalCorp . . . . . . . . . . . . . . . . . . . . . 7, 36 GSK – GlaxoSmithKline . . . . . . . . . . . . . . 13 McCaughey Consumer Products . . . . . . . 35 ODA – Ontario Dental Association . . . . . . 39 ORALdent Pharma . . . . . . . . . . . . . . . . . 24 Premier Dental Products . . . . . . . . . . . . . 14

E-mail: careers4@dentalcorp.ca

MIDLAND, ON

Sable Industries Inc . . . . . . . . . . . . . . . . 34

We are currently looking for an associate dentist to join our dynamic and friendly team for 3-5 days. We are a busy clinic with current dentists booking well in advance over a month. Please send CV to nathanchodds@gmail.com

BOLTON, ON Associate wanted for busy dental practice for 3-4 days per week. Potential for purchase in future. Candidates must be team and patient oriented. Please email resume to boltondental@outlook.com

SciCan . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 VOCO Canada . . . . . . . . . . . . . . . . . . . OBC Waterpik . . . . . . . . . . . . . . . . . . . . . . . . . 23

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