Policy Manual Final_2016

a high content of tubercular bacilli. Patients with such ulcerations should not receive
elective dental treatment until their T.B. infection is resolved.

Hepatitis
 Be alert for signs of jaundice. Follow the protocol for liver dysfunction.

HIV
 Be alert for oral manifestations of immunosuppression such as oral yeast infections, viral
infections and periodontal problems. Follow the protocol for immunosuppression.
 Be alert for poor healing response and bone sequestration following extractions.

Herpes/Flu
 With herpes, avoid traumatizing tissue as it may trigger a herpes attack.
 If patient knows that herpes attack is precipitated by trauma, consider prophylactic
antiviral medication.

Preventative/Precautions
Tuberculosis

 Faithful taking of medication.
 Good personal hygiene, hand washing, and not coughing on anybody.
 Good nutrition and rest.

Hepatitis
 See liver dysfunction protocol.

HIV
 See immunosuppression protocol.

Herpes/Flu
 For herpes, keep lesion lubricated.
 Consider antiviral therapy.
 Remind patient that herpetic lesion is contagious, especially when blister present and up to
two days after it bursts. Encourage observation of appropriate personal hygiene and
avoidance of mucous membrane contact with other people when active lesion present.
 For flu, wash hands frequently.
 Avoid coughing on people or possible contact with nasal secretions.

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Kidney Problems
Questions to Ask/Necessary Information

 What kind of kidney problem do you have?
 Does it interfere with your everyday living?
 Does it alter the way you eliminate medication?

Diagnostic Tests

 BUN (blood, urea, nitrogen).
 Creatine clearance rate.

Management during Dental Treatment

 Do not use drugs toxic to the kidney, i.e., acetaminophen
 Use caution and alter dosage when using drugs eliminated by the kidney, i.e., penicillin

(often reduced to 500 mg two times per day versus four times per day).
 If patient on renal dialysis, dental treatment should be done on the day following dialysis.
 If patient has kidney transplant, see considerations under immunosuppression protocol.

Be Alert For

 Drug toxicity because of accumulation.
 Poor healing and oral ulcerations.

Preventative/Precautions

 No special dental precautions needed.
 Patient should be counseled as to potential toxicity problems from certain prescriptions and

over-the-counter drugs, plus alcohol.

Liver Problems
Questions to Ask/Necessary Information

 How long have you had a liver problem?
 What type of liver problem is it and how was it caused?
 Do you feel unwell relative to the liver problem?
 Have you noticed any problems such as bleeding, difficulty in metabolizing/digesting food,

or increased or decreased sensitivity to medication, from the liver problem?
 Do you ever get jaundice (do the whites of your eyes or your skin turn or look yellow)?
 Have you ever needed to be hospitalized because of your liver problem?

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Diagnostic Tests

 SMA20 (specifically SGOT, AST, ALT).
 PT & PTT.
 INR.

Management during Dental Treatment

 If bleeding problems, follow bleeding problem protocol.
 If unable to metabolize drugs, avoid using drugs metabolized in the liver such as

erythromycin and ketoconazole. Minimize local anesthetics.
 If patient having problem with drug interactions, avoid drugs with high potential for drug

interaction used in dentistry, i.e., erythromycin and ketoconazole.
 Avoid drugs with potential for liver toxicity, i.e., acetaminophen, Tylenol and any other

over-the-counter/non-prescription drug.

Be Alert For

 Easy bleeding
 Yellow tint to skin, oral mucosa, and the whites of the eye.
 Poor healing.
 Oral ulcers.

Preventative/Precautions:

 Good oral hygiene to minimize oral hygiene problems.
 Avoidance of drugs which are toxic to the liver, i.e., acetaminophen, alcohol.

Pregnancy

Oral health is undoubtedly an integral portion of a healthy pregnancy, both for the mother and
unborn child. Over half of women do not visit a dentist while pregnant. Recent research and the
Michigan Department of Health and Human Services “Guide to Michigan Perinatal Oral Health states
that “pregnancy is NOT a valid reason to delay routine dental care or treatment of oral health
conditions. It is also NOT necessary to have approval from the prenatal care provider for
routine dental care of the healthy patient.”

Questions to Ask/Necessary Information

 What month of pregnancy are you in, and when is your due date?
 Since becoming pregnant have you been vomiting? If so, how often?
 Are you receiving prenatal care?
 Have you had complications with prior pregnancies?

Diagnostic Tests
 None. Patient will make the diagnosis.

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Management during Dental Treatment
 Manage seating position to a comfortable semi-reclined position. A small pillow placed
under the hip may help prevent Postural Hypotensive Syndrome.
 AVOID prescribing:
o Ciprofloxacin
o Clarithromycin
o Levofloxacin.
o Moxifloxacin
o Tetracycline

Be Alert For
 Pregnancy gingivitis and the increased risk of periodontitis. Besides the patient’s own risk
of bone loss, severe periodontal disease has been associated with low-birth-weight, pre-
term babies. Good periodontal health is paramount to minimizing this risk.
 Pyogenic granulomas (pregnancy gingivitis).
 Increased risk of caries, tooth mobility, and tooth erosion.

Preventative/Precautions
 Good home care.
 Emphasize good nutrition. Adequate protein, folic acid supplements, and eliminate alcohol,
tobacco, and other drug use.

Prosthetic Joints

In 2014, the ADA Council on Scientific Affairs assembled an expert panel to update and clarify the
clinical recommendations found in the 2012 evidence-based guideline, Prevention of Orthopaedic
Implant Infection in Patients Undergoing Dental Procedures.

As was found in 2012, the 2014 updated systematic review found no association between dental
procedures and prosthetic joint infections. Based on this review, the 2014 Panel concluded that
prophylactic antibiotics given prior to dental procedures are not recommended for patients with
prosthetic joint implants.

You are encouraged to review the full 2014 guideline and take this recommendation into account,
consult with the patient's orthopedic surgeon as needed, and consider the patient's specific needs
and preferences when planning treatment.

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HIV Compromised

Medical assessment of HIV-infected patients, relative to their safe dental treatment, is primarily
based upon current laboratory test values. “Significant Laboratory Tests” are listed below, along
with their relevance to the patient’s health. “Critical Laboratory Test Values,” the values at which a
change in dental management is appropriate, are listed in the next section. “Frequency of
Laboratory Tests” is also outlined and is primarily dependent on the patient’s CD4 T-helper cell
count.

If you feel the patient needs a more through medical evaluation, refer to his/her physician. Such an
evaluation/physician consult is seldom necessary relative to dental treatment planning.
Appropriate and timely laboratory tests, along with a current health history, are almost always
adequate to identify any problems and safely manage the patient.

Diagnostic Tests

The laboratory tests listed below provide important information relative to the HIV-infected
patient’s overall health. All, except CD4 and viral load, can be gotten by ordering a “Complete Blood
Count (CBC) with a differential.” The next section “Critical Laboratory Test Values,” outlines their
impact on dental management.

 CD4, T-Helper Cell Count - Measures the number of T-helper cells. These cells stimulate the
immune system to fight infections. As their numbers go down, the risk of infection goes up.
Less than 50 (normal values 590-1120 cells/mm): Evaluate patient for severe opportunistic
disease. Usually there is no problem with routine dental care. If white count is expected to
increase, then you may consider delaying elective dental procedures until white count
improves. Emphasize good oral care and have patient contact you immediately if oral
problems start.

 CDR-CD8 Ratios - CD4 cells, as mentioned above, are T-helper cells. CD8 cells are T-
suppressor cells. As this ratio goes down, essentially by a decrease in the number of CD4
cells, the risk of infection goes up.

 Viral Load/Plasma HIV-1RNA - This measurement reveals the number of copies of the virus
per milliliter of blood. Ideally, there would be zero detectable copies (virus). As the viral
load goes up, indicating the virus is replicating at an increasing rate, the incidence of
secondary problems increases. However, even the highest number of copies has no impact
on the provision of dental care. As noted, viral load does not have an impact on dental
treatment planning. The number of viral copies is indicative of disease, but any
modification of dental treatment would be based on the other (above) laboratory test
results and not on viral load.

 CBC with Differential Platelets - Platelets are necessary, along with other factors, for blood
to clot. An important concern in HIV-infected patients is low platelets (thrombocytopenia)
(see critical laboratory test values). If this occurs, the risk of bleeding may be so severe as
to delay any elective and, at times, even emergency therapy, until the platelets can be

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replaced. Less than 60,000 (Thrombocytopenia) (normal values: 150,000-450,000 cells/
mm3): Consult with physician and recommend intervention to boost platelets prior to
invasive procedures. Physician may elect to give platelet infusion or administer prednisone
to increase platelet count. The dentist must receive laboratory confirmation of platelet
count immediately (1-2 days) before invasive procedure. Delay elective dental procedures
until platelet count improves. Platelet count should be above 60-80,000, depending on
invasiveness (risk of bleeding) and extent of planned procedure.
 White Count - The white cells in the body are designed to do a variety of things, including
fight infections. As the white count decreases (leukopenia), the risk of infection increases.
Less than 2,000 (Granulocytopenia) (normal values: 4,000-10,000 cells/mm3): Low counts
are a cause for concern because the body becomes more susceptible to infection. Consider a
therapeutic regimen of antibiotics concurrently with invasive procedures or delay elective
dental procedures until white count improves.
 Absolute Neutrophils - The neutrophils are a special class of white cells which are also
important in fighting infection. If their numbers decrease, the risk of infection increases.
Less than 1,000 (Neutropenia): Consider regimen of antibiotics concurrently with invasive
procedures. Delay elective dental procedures until white count improves.
 Hematocrit - The hematocrit is the percentage of whole blood that is red cells. In most cases
of anemia the hematocrit will decrease. Less than 10%: Consult with physician (normal
values: female 37-47%, male 42-52%). Consider red cell transfusion, at the
recommendation of the physician, for invasive procedures. Low values are an indicator of
anemia.
 Hemoglobin - Hemoglobin is the oxygen-carrying component of the red blood cells. In
certain types of anemia it is possible to have an adequate number of red blood cells, but
inadequate amount of hemoglobin and, therefore, a decreased capacity for the blood to
carry oxygen. Less than 10 (normal values: female 12-16q/dL, male 14-18q/dL): Consider
red cell transfusion, at the recommendation of the physician, for invasive procedures.
 Red Blood Cell Count - Red blood cell count measures the number of red blood cells per
cubic mm of blood. A decrease in number means an inadequate number of red blood cells
(anemia). This leads to an inadequate ability to carry oxygen. The patient becomes easily
fatigued and is a poor healer. A low red blood cell count is usually reflected in a low
hematocrit. Less than 1.0 million/mm3 (normal values: female 4-5 million/mm3, male 4-6
million/mm3): Consult with the patient’s physician and consider red cell transfusion for
invasive procedures. Low values are an indicator of anemia.

Suggested Frequency of Obtaining Lab Reports

Laboratory tests are important to monitor the patient’s health. The suggested frequency of tests is
listed below and is based on the patient’s prior CD4 test results. Current laboratory test results are
very important for some dental procedures. For example, those associated with significant
bleeding or dental infection. At the same time, clinical judgment is appropriate; most dental
procedures should not be delayed just because the laboratory results are older than ideal.

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Use of Good Clinical Judgment

Evaluate each patient on a case-by-case basis. Use the above recommendations as general
guidelines. Proper and timely patient care, especially urgent care, may require flexibility with
critical values. Keep current on your patient’s medical care and antiretroviral therapy. Your
knowledge of his/her medical status, just like your knowledge of all of your patients’ medical
statuses, will insure the safest and most efficient dental care.

Treatment and Management of Common Oral Diseases

Fungal Infections including Oral Candidiasis
A. Treatment - Intraoral
Mycelex® (clotrimazole) troches 10 mg
Dis: 70 troches
Sig: Dissolve 1 troche slowly in mouth 5 times a day, for 2 weeks

Mycostatin® (nystatin) pastilles 200,000 IU
Dis: 70 pastilles
Sig: Dissolve 1 pastille in mouth 5 times a day for 2 weeks

Nystatin oral powder - 150,000,000 IU USP

Dis: 15 grams

Sig: Apply powder to inside of denture after each cleaning. Continue
treating for 2 weeks

Note: Make sure oral powder is prescribed; topical nystatin contains talc,
which should not be used intraorally

Note: Chlorhexidine Gluconate (Peridex®/Perioguard® Oral Rinse) may
also be used adjunctively for treating intraoral candida infections

B. Treatment - Angular Cheilitis
Nizoral® (ketoconazole) 2% cream
Dis: 15-gram tube

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Sig: Apply to corners of mouth 5 times a day for 2 weeks

Nystatin ointment
Dis: 15-gram tube
Sig: Apply to corners of mouth 5 times a day for 2 weeks
Lotrisone® (10mg clotrimazole-0.64mg betamethasone dipropionate) 1%
cream
Dis: 15-gram tube
Sig: Apply to corners of mouth 3-4 times a day for 2 weeks

Vytone® (10mg hydrocortisone-10mg iodoquinol) 1% cream
Dis: 15-gram tube
Sig: Apply to corners of mouth 3-4 times a day for 2 weeks

C. Treatment - Oral infections requiring systemic therapy

Diflucan® (fluconazole) 100 mg tablets

Dis: 15 tablets

Sig: 2 tablets for initial dose, then 1 tablet per day thereafter till gone

Note: Clotrimazole and nystatin contain sugar; prolonged use of these
medications can lead to increased caries formation. May need a
prescription strength fluoridated dentifrice (e.g., Prevident® 5000
Plus)

Viral Infections and Herpetic Infections
It is of note that intraoral herpes are usually found on keratinized tissues (e.g. hard palate, gingiva).
Therapy should be initiated at the earliest symptom of a cold sore (e.g. tingling, itching, or burning).

A. Treatment - Intraoral Herpes Simplex Virus (HHV-1, HHV-2) - Oral infections requiring
systemic therapy.

Zovirax® (acyclovir) 200 mg capsules
Dis: 35 capsules
Sig: Take 1 capsule 5 times daily for 7 days

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Famvir® (famciclovir) 250mg tablets
Dis: 14 tablets
Sig: Take 1 tablet bid for 7 days

Valtrex® (valacyclovir) 1000mg (1 gram) caplets

Dis: 4 caplets

Sig: Take 2 caplets (2 grams) twice daily for 1 day, taken 12 hours apart.
Limit usage to 1 day

Note: Valtrex® may be contraindicated for immunocompromised patients.
Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome
(TTP/HUS) has been reported in patients with advanced HIV
disease, bone marrow transplant, and renal transplant recipients
with high dosages (8 gm/day) of Valtrex®. This has not been
observed in immunocompetent patients.

B. Treatment - Herpes Labialis (HHV-1, HHV-2) - Extra oral infections requiring topical
therapy.

Zovirax® (acyclovir) 5% ointment

Dis: 15-gram tube

Sig: Apply to lip lesion 6 times a day for 7 days

Denavir® (penciclovir) 1% ointment
Dis: 2-gram tube
Sig: Apply to lip lesion 6 times a day for 7 days
Note: Corticosteroids are contraindicated for viral conditions

C. Treatment - Varicella Zoster Virus (HHV-3), Shingles - May need systemic treatment and
topical ointment to cutaneous lesions in severe cases.

Zovirax® (acyclovir) 800 mg capsules
Dis: 35 capsules
Sig: Take 1 capsule (800 mg) 5 times daily for 7 days

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Famvir® (famciclovir) 500mg tablets
Dis: 21 tablets
Sig: Take 1 tablet (500 mg) tid for 7 days

Valtrex® (valacyclovir) 1000 mg (1gram) caplets
Dis: 21 caplets
Sig: Take 1 caplet (1 gram) orally tid for 7 days
Note: Need to increase dosages and extend treatment for HHV-3 (zoster)
infections. May need referral to physician for management of systemic
condition.

Recurrent Aphthous Ulcers (RAU)
Usually only found on non-keratinized tissues (e.g., buccal mucosa, posterior oropharynx, labial
mucosa)

A. Treatment - Solitary ulcerations
Lidex® (fluocinonide) 0.05% gel (high potency)
Dis: 15-gram tube
Sig: Apply thin film 4-6 times daily to affected area

Diprolene® (betamethasone dipropionate) 0.05% gel (very high potency, limit
treatment to 2 weeks)

Dis: 15-gram tube
Sig: Apply thin film 4-6 times daily by gently applying compound on affected
area

Temovate® (clobetasol propionate) 0.05% gel (very high potency, limit treatment to
2 weeks usage)

Dis: 15-gram tube
Sig: Apply thin film 4-6 times daily by gently applying compound on affected
area
Note: May initiate therapy with fluocinonide; however with more severe
lesions, betamethasone or clobetasol would be a better choice

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B. Treatment - Multiple ulcerations
Decadron® (0.5mg/5ml dexamethasone) elixir (elixirs contain 5% alcohol)
Dis: 100 ml
Sig: Rinse with 1 teaspoon (5ml) for 2 minutes, then spit - qid

Celestone® (3mg/ml betamethasone) syrup
Dis: 5ml multiple dose vial
Sig: Rinse with 1 teaspoon (5ml) in mouth for 2 minutes, then spit - qid

Oral Mucosal Disease - Erosive Lichen Planus (same treatment as for aphthous ulcers)
A. Treatment – Solitary ulcerations
Lidex® (fluocinonide) 0.05% gel (high potency)
Dis: 15-gram tube
Sig: Apply thin film 4-6 times daily by gently applying compound on affected
area
Diprolene® (betamethasone dipropionate) 0.05% gel (very high potency, limit
treatment to 2 weeks)
Dis: 15-gram tube
Sig: Apply thin film 4-6 times daily by gently applying compound on affected
area
Temovate® (clobetasol propionate) 0.05% gel (limit treatment to 2 weeks usage)
Dis: 15-gram tube
Sig: Apply thin film 4-6 times daily by gently applying compound on affected
area
B. Treatment - Multiple ulcerations
Decadron® (0.5mg/5ml dexamethasone) elixir (elixirs contain 5% alcohol)
Dis: 100 ml
Sig: Rinse with 1 teaspoon (5ml) in mouth for 2 minutes, then spit - qid

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Celestone® (3mg/ml betamethasone) syrup
Dis: 5ml multiple dose vial
Sig: Rinse with 1 teaspoon (5ml) in mouth for 2 minutes, then spit - qid

Xerostomia
A. Treatment - Artificial Saliva Substitutes (OTC)
Biotene® Oral Balance® moisturizing gel (Laclede)
Dis: 42-gram (1.5 oz.) tube
Sig: Apply to oral cavity prn

Biotene® Salivart® Oral Moisturizer aerosol spray
Dis: 75-gram can
Sig: Spray in oral cavity prn

Biotene® MouthKote® (Yerba Santa extract)
Dis: 2 to 8 oz. bottle
Sig: Spray in oral cavity prn

Xerolube® or Optimoist® solution (Colgate)
Dis: 6-ounce spray bottle
Sig: Spray in oral cavity prn

B. Treatment - Salivary Stimulants (sugarless gum/candy to stimulate salivary production)
Xylitol - non-cariogenic and the most cariostatic of all sugar alcohol sweeteners
Sig: prn

Sorbitol - non-cariogenic sugar alcohol, chronic use may increase S. mutans

Salix® SST (salivary substitute tablets), buffered citric acid tablets

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Dis: 30-count trial size, 120-count box for longer term usage
Sig: Use 4 or 5 times daily

C. Treatment - Salivary Stimulants (cholinergic agonists) - Prescription needed
Evoxac® (cevimeline) capsules 30 mg
Dis: 100 capsules
Sig: Take 1 capsule tid

Salagen® (pilocarpine) tablets 5 mg
Dis: 100 tablets
Sig: Take 1 tablet qid

Pilocarpine 4% ophthalmic solution (generic)
Dis: 15 ml bottle
Sig: Place 2 drops in 1-2 tablespoons of water, swish and swallow - qid

D. Adjunctive Treatment

Prevident® 5000 Plus

Dis: 56-gram tube

Sig: Brush for 2 full minutes bid, a.m. and hs. Do not rinse or eat for 30
minutes

Bacterial Infections - Necrotizing Ulcerative Gingivitis (NUG)
A. Treatment
1. Betadine® (10% povidone-iodine) solution debridement
2. Thorough scaling, dental prophylaxis
3. Oral hygiene instruction - meticulous home care emphasized
4. Use of Peridex®/Perioguard® Oral Rinse (0.12% clorhexidine gluconate)

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Dis: 1 pint bottle
Sig: Rinse with 15ml for 1 full minute, then spit out. Repeat twice daily for
7-10 days
5. Antibiotic therapy (if indicated)

Flagyl® (metronidazole) 250 mg (first drug of choice for gram negative
anaerobic organisms)

Dis: 28 tablets
Sig: Take 1 tablet qid until all are taken
Note: Avoid alcohol intake with metronidazole due to Antabuse®

like effect

Penicillin VK 500 mg
Dis: 28 tablets
Sig: Take 1 tablet qid until all are taken

Augmentin® 500mg
Dis: 28 tablets
Sig: Take 1 tablet qid until all are taken

6. Analgesic coverage:
Avoid aspirin compounds that may tend to increase bleeding time

Acetaminophen with hydrocodone (Vicodin®, Loracet®)

Schedule II drugs may be necessary if pain is severe (Tylox®, Percocet®)

Palliative Treatment for Oral Lesions
Rx Xylocaine 2% viscous
Dis: 45 ml
Sig: Rinse with 2 teaspoons as needed for pain

Rx Baking soda and hydrogen peroxide
1 teaspoon baking soda in cup of solution that is ½ water: ½ 3% hydrogen peroxide
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Management of the Patient with a Medical Emergency

Basic Considerations

Significant untoward events can generally be prevented by careful preoperative assessment.
However, emergencies may develop in any setting where medical-dental services are provided.
Therefore, a dental office must have a detailed set of emergency protocols. Dental staff must be
prepared to manage untoward events should they arise.

The first priority in a medical emergency is always to ensure airway patency. Once patency is
established, breathing or ventilation should be continually assured.

1. If the patient is conscious, ask him to take a slow deep breath.

2. If the patient is unconscious, look, listen, and feel for breathing.

3. Carotid pulse can be palpated.

4. If the patient is breathing and has pulse, blood pressure should be recorded.

5. Initiate CPR and emergency protocol. CALL 911.

For further medical benefit it may be appropriate to create an enriched oxygen concentration that
can be given for patients who are spontaneously breathing. This can be achieved by using a nasal
hood which should be set to deliver at least 6 L/min O2. This is an ideal concentration for patient
suffering any form of chronic obstructive pulmonary disease (COPD).

If an emergency arises, the involved staff will call, “HELP, CALL 911.” Administrative assistant will
inform the patient’s family or guardian of the emergency. Always stay with patient until help
arrives. It is important to document the time and description of the emergency, staff actions taken,
vital signs, condition, and mode of discharge. Staff must be made available to execute medical
emergency procedures according to their level of training, skill, and proficiency. All dental facilities
should have trained first responders on staff. Important aspects of consideration in an emergency
include:

 Dentist - refers all emergencies to paramedics for hospital transportation, after appropriate
assessment and management.

 Remaining staff - defers all activities to dentist and refers to the paramedics as soon as
possible. Executes emergency first aid according to training and competence. Patients with
a medical emergency should never, ever be left alone.

 If emergency drug kits are available, staff should be adequately trained prior to an
emergency’s arising. No medications should be administered without full knowledge and
competence as to the drug being administered.
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 Likewise for clinics fortunate to have an AED, training should be a part of normal operations
prior to an actual emergency.



MANAGEMENT OF THE EMERGENCY IN THE DENTAL OFFICE

Primary Responder 1st Assistant 2nd Assistant
(R.N./RDH/DA) (DA/Clerk/Other Staff)
(Dentist/R.N./Nurse
Practitioner)

1) Patient seated or supine 1) Loosen clothing. 1) Arrange transport to
position. closest Emergency
2) Check blood pressure, Room by family or
2) Evaluate for signs and pulse, and respiratory other responsible
symptoms listed. rate. individual, or call 911
for ambulance
3) O2 at 6 L/minute by nasal 3) Repeat vital signs every 5 transport to
cannulas or mask as minutes. Emergency Room.
needed.
4) Give vital signs, treatment 2) Record all necessary
administered, and other information in the
information to the 2nd patient chart.
assistant to record.

CPR Certification
It is recommended that all clinical staff be trained to provide CPR. Most licensed professionals in
the health care setting are required to maintain this certification through the various state dental
boards. This includes recognition and treatment of respiratory and cardiac emergencies,
management of foreign body obstruction of the airway, and cardiopulmonary resuscitation. All
clinical staff are encouraged to maintain current American Red Cross or American Heart
Association Certification in CPR.

Emergency Equipment
Blood pressure monitor, emergency medical kit, first aid kit, oxygen tank, and AED (if equipped)
should all be located within the dental facility.

Management of Adverse Reactions to Anesthetic or Any Dental Material

Anaphylaxis

Anaphylaxis is a rare event which does happen in the dental office. There are two common patterns
with anaphylaxis. One is respiratory distress from laryngeal edema and/or severe bronchospasm.
A second would be shock resulting from profound hypoxia. Signs and symptoms of anaphylaxis
include:

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 Wheezing and labored breathing
 Cyanosis
 Swelling of the tongue, face, or lips
 Hoarseness, choking, or coughing
 Hives (urticaria) and itching
 Hypotension
 Tachycardia
 Cool, clammy, pale skin
 Apprehension
 Loss of consciousness
Management of anaphylaxis would include the following: never administer any drugs without full
training and understanding of the drug being administered.

Delayed Allergic Reaction
A delayed reaction-type allergic response may occur 5-30 minutes after administration of a medication or

102

immunization. These reactions do not involve life-threatening anaphylaxis. Symptoms may involve
moderate to severe laryngeal edema. These reactions, while not immediately life-threatening, require
transport to a physician’s office or emergency room for further observation and treatment. Signs and
symptoms of delayed allergic reaction include:

 Hives (urticaria)
 Itching
 Flushing
 Nausea
 Sweaty palms
 Apprehension
 Tachycardia
 Wheezing and labored breathing
 Normal blood pressure
Management may include recommendations for Benadryl and referral to the patient’s physician.

Syncope (fainting)
This is an unusual psychogenic or autonomic nervous system reaction to the administration of a local
anesthetic injection or other event. Recovery is usually within several minutes. Failure to recover rapidly
and completely could indicate another medical condition. The signs and symptoms of syncope include:

 Pallor
 Weakness
 Cold Sweat
 Lightheadedness
 Nausea
 Transient hypotension
 Weak, rapid pulse
Management of syncope would include aspects included in the following diagram:

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First Responder MANAGEMENT OF SYNCOPE
(Dentist/RDH/Other Staff)
Assistant
(RDH/Other Staff)

1) If patient is seated, assist to supine and 1) Monitor pulse and respiration as
elevate feet. needed.

2) If a patient is standing, assist to supine and 2) Monitor for signs of shock or other
elevate feet. condition.

3) If patient loses consciousness, carefully 3) Administer smelling salts as needed.
assist to the floor and elevate legs.
4) Check a sitting and standing blood
4) Summon an assistant. pressure to rule out continued
orthostatic hypotension.
5) O² at 6 L/minute by nasal cannula or mask.
5) Be sure the patient fully recovers and
6) Smelling salts administration. is released to a responsible person.
Arrange for physician evaluation as
needed.

Cardiopulmonary Arrest

If a person loses consciousness in the clinic, clinical staff should make an immediate assessment of
airway, breathing, and circulation. In the event of cardiac or pulmonary arrest, clinical staff will
begin cardiopulmonary resuscitation (CPR). The most current American Red Cross protocols or
AHA should be followed.

CPR will be continued until the person is successfully revived or emergency medical responders
take over medical care. Clinical staff performing CPR should complete a standard incident report
and assist emergency medical responders with assessing the patient’s history and known medical
conditions relevant to the incident.

Shock

Clinical manifestations may include a pulse which is present but weak and fast, cool and clammy
skin, blood pressure less than 80 systolic and pallor around mouth or cyanosis.

Management of shock would include:
 Call paramedics (911).

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 Raise feet above heart level. If victim is on exam table, rest legs on pillows or stack of drape
sheets. If victim is on floor, elevate legs on edge of chair.

 Cover victim with light blanket to conserve body warmth without overheating.
 Maintain an open airway and administer oxygen via nasal accentual at no more than 6

liter/min.
 Be prepared to begin CPR if cardiac arrest occurs.

Hypotension
In hypotension the patient’s blood pressure has a sudden and severe drop. The patient should be semi-
reclined. An evaluation of tissue perfusion will be done and is accomplished by applying finger
pressure to nail beds or oral mucosa. Hypotensive patients should activate the clinic emergency
policies and 911 should be called.

Hypertension
Hypertensive crisis is a sudden elevation in diastolic pressure above 120mmHG.

The episode is considered urgent if the patient remains asymptomatic. It is considered an
emergency if symptoms present themselves such as chest pain, tightness, headache, or visual
disturbances. In an emergency situation, immediately call 911 and administer to the patient as
necessary.

Angina and Myocardial Infarction
Ischemic heart disease is a condition whereby coronary perfusion is inadequate for myocardial
oxygen requirements and is often accompanied by angina chest pain. When a patient experiences
chest pain, initiate a typical syncope protocol and direct attention to reducing myocardial oxygen
demand. Administer patient’s own sublingual nitroglycerin if available. Blood pressure and pulse
should be assessed before administering each dose of nitroglycerin. If chest pain persists, prompt
medical attention is necessary. Call 911.

Seizures
Drug toxicity, injuries, or diseases may cause convulsive seizures. If they have a chronic pattern of
recurrence they are called epileptic. Manifestations include: being unconscious; often incontinent
of urine and/or feces; jerking movements of body, limbs, jaw or eyeballs; pulse generally above 60.
Seizure-like activity may accompany cardiopulmonary arrest, shock or vasovagal reaction. Check
for those conditions.

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When faced with a patient undergoing a seizure, manage with these appropriate actions:
 Do not restrain patient but protect him/her from obvious injury.
 Do not place any object into mouth while convulsing.
 Seizures generally run their own course. Wait it out. If the seizure does not subside within
five minutes, call the paramedics/ambulance.
 Oxygen may be administered via nasal cannula at no more than 6 L/min.
 Following the seizure, the victim may remain unconscious, be confused, or appear partially
paralyzed. Allow resting after seizure.
 Discontinue treatment for the day.
 Instruct victim to see his/her physician for evaluation.

Hypoglycemia
Hypoglycemia is the most common acute event in diabetic patients, and can be attributed to
excessive medication and/or inadequate carbohydrate intake.

In a hypoglycemic reaction the patient must receive a concentrated glucose.
Actions
1. Give to the patient a glass of soda (not sugar free), cake icing, or Tang.
2. If patient does not recover call EMS.

Restoring the Dentition in the Public Health Setting

Cavity Preparation in the At-Risk Population
Before fluoridated water supplies, availability of fluoride toothpaste, and dental insurance to
encourage preventive dental visits, the general population of the U.S. suffered from a high incidence
of dental disease. Especially prevalent were dental caries. The entire dental patient population was
highly “at-risk” for dental caries.

Today, that same situation exists predominately in the dentally underserved patient population
that routinely presents to public health dental clinics. This population may not have access to
fluoridated water, has little to no dental insurance, has poor nutritional habits, and maintains
inadequate oral hygiene. Given the situation and conditions in this patient population, the
philosophy historically utilized was “extension for prevention.” This meant to extend the cavity

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preparation on a carious surface of a tooth to include all pits and fissures that could become carious
in the future. It also included the extension of the preparation into the inter-proximal carious
surfaces to self-cleansing areas buccally and lingually.

In patient populations that routinely access preventive services, the need to extend cavity
preparations has diminished, and the philosophy is to “conserve tooth structure.” This method of
tooth preparation is acceptable only if future disease can and will be controlled via proper oral
hygiene and diet. As a result, dental educators now teach small conservative cavity preparations
and small bonded restorations, which are appropriate for those patients whose potential for future
disease is minimal. This is generally not the population that seeks care in the dental public health
setting.

To treat patients to their individual needs it is appropriate to perform a caries risk assessment on
every patient. This would include noting their oral hygiene, diet, age, dental history, education and
family support, and then treat the patient accordingly. Those at high risk for dental disease should
be counseled as to oral hygiene and diet, including parents of children. In the population with a
high caries risk, any needed treatment should be more aggressive, and utilize the “extension for
prevention” philosophy of cavity preparation.

Unfortunately, far too many of the patients seen in public health dental clinics fall into the high-risk
category; this is a result of ignorance, not finances, so the solution is as much a function of dental
health education as it is dental treatment.

Restorative Materials for Posterior Teeth

Choosing restorative materials can be a difficult part of patient care. With so many manufacturers,
claims of success and reported ease of use, deciding what materials to use for a given situation can
be a daunting task. One of the questions posed is often what material to use. In general, using
composite restorative materials on posterior teeth in the public health patient population presents
a number of challenges.

It is the role of dental public health to provide patients who have limited access to care with the
best possible care and the best long-term prognosis. As such, an amalgam remains the material of
choice not only in children, but adults. In a study conducted by MCDC it was found that for every
posterior amalgam failure, there were three posterior composite failures noted. There are
additional challenges with children and their restorations. In this regard it is important to
remember that primary teeth are not just little permanent teeth. They carry with them a different
enamel matrix structure and a much different anatomy. The enamel crystals are not well-aligned
on the floor of the box to bond with composite restorative materials. Primary teeth also have less
enamel volume, and the enamel is not as well-mineralized as it is in permanent teeth. This creates a

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situation where enamel bonding is difficult to achieve, predisposing the restorations to micro
leakage.

Another issue to consider when choosing a restorative material for patients is whether or not the
tooth can be properly isolated. Rubber dams should be utilized in placing all posterior restorations.
This will vastly improve quality and efficiency as the provider becomes comfortable with its use. In
children, their small mouths, often less-than-ideal cooperation, and their desire to feel what you’re
doing with their tongues, it is almost impossible to adequately isolate teeth for restorations without
a rubber dam. The odds of success will improve dramatically with proper isolation. It will also
make interaction with patient and parent a more positive one while creating an easier environment
for the dental team to work within. The benefit of the dam is of such high value, that as a best
practice, it should be used whenever possible. If it cannot be used, the practitioner should question
whether the teeth are even amenable to restoration.

The Indirect Pulp Cap

The indirect pulp cap (IPC) is a very useful procedure for primary and permanent teeth that helps
maintain the vitality of the pulp and preserve vital tooth structure. It is used extensively in the
young permanent dentition to avoid pulp exposures in teeth that do not have fully formed apices.
By maintaining vitality longer, we can assure full root formation and a better outcome for any
endodontic procedure in the future, should one be necessary.

Teeth with deep caries are the primary indication for the IPC procedure. It is, however, important
to recognize that only asymptomatic teeth should be considered as good candidates. Any tooth that
is causing sensitivity or pain has inflammation of the coronal pulp extensive enough that it requires
more invasive treatment (pulpotomy, RCT, etc.). The clinical procedure involves the removal of
gross caries, and the establishment of a clean dentin-enamel junction all the way around the
preparation leaving clean axial walls. Clinical studies suggest that minimal caries can be left behind
to avoid pulp exposure, but it is important that it be covered with a biocompatible and radiopaque
material. When used in the appropriate manner the dentin will re-calcify, and as long as the
restoration has been adequately sealed, any remaining microbes will provide minimal to no future
problems. This procedure is appropriate for both primary and permanent teeth with a similar
clinical success rate.

The Stainless Steel Crown

The stainless steel crown (SSC) is an exceptional, valuable and an often under-utilized restoration
in the public health dental setting. The SSC can be used for either primary or young permanent
teeth and the indications include:

 Extensive carious destruction

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 Hypo-plastic primary or permanent tooth cannot be adequately restored with amalgam
or composite.

 Restoration of teeth with hereditary anomalies (dentinogenesis imperfecta, etc.)
 Restoring teeth that have undergone pulpal therapy procedures (either IPC, pulpotomy,

RCT) that have either extensive carious destruction or are difficult to restore a marginal
seal.
 Attachments for habit-breaking or space maintenance appliances

The most common indication for the placement of an SSC is the restoration of primary molars with
extensive carious lesions. The literature has consistently demonstrated that SSCs are the single
best restoration for sealing the tooth. They are easy to place, reliable, and very appropriate in our
high-caries risk population. Common indications for them in the public health setting include the
following;

 Patients who require MOD restorations on primary molars are under 5-6 years of age.
 Patients who require proximal restorations in primary teeth and also have visible

decalcification tracing the free gingival margin buccally and lingually.
 Patients whose primary molars have caries that cause the cavity preparation to extend

beyond the line angles of the proximal contact area.
 High-risk patients who require the replacement of prior restorations as a result of

recurrent decay.
 Molars with extensive carious destruction that have had indirect pulp cap procedures.

Successful pulp therapy is predicated on having a good marginal seal. Most primary molars, which
have extensive caries that also require use of either a pulpotomy or an IPC, would benefit from the
use of a SSC. The marginal seal that can be obtained with a SSC often provides the best chance of
longevity of any pediatric restoration.

Requirement for Rubber Dam Use

While the use of the dental rubber dam can, at times, be cumbersome and awkward, nonetheless it
remains the standard of care for the completion of routine restorations and endodontic procedures.
The proper application of the rubber dam provides for:

 A working field minimizing saliva contamination
 Safety in regards to swallowing or aspirating dental materials and tools
 Can provide for faster operative time
 Increases safety by minimizing damage which could otherwise occur to oral mucosa,

the lips, and tongue
 Increases the effectiveness and longevity of dental restorations being completed in

the isolated environment

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As a matter of policy all employees should be required to complete all endodontic procedures with
proper and adequate rubber dam isolation in place. Teeth which can’t be isolated have a poor
prognosis, and that is not adequate justification for dismissing the use of the rubber dam. The
rubber dam also provides a method of increasing patient safety when properly utilized. A tooth
which cannot be isolated by a practitioner with a rubber dam should either be referred or given
consideration for an alternative treatment.
As a guideline, the use of a rubber dam is highly encouraged on all other restorative procedures as
mentioned previously in this text.

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Section 6

Office Appearance and Maintenance

Taking Pride in our Office

Maintenance of the office and equipment not only reduces costs and
helps maintain sustainability of an operation; it is also a direct
reflection of the quality rendered within that facility. Several
published studies have found this to be true. These studies suggest
that while it is often difficult to define quality, one often knows quality
and a quality operation when they see it. In this regard, every effort
should be made to keep the office environment reflective of the clean
and clutter-free medical environment that it is. Operatories must be
viewed as mini-surgical suites, and the only thing that should be out in
this room is that which absolutely needs to be out. Personal
belongings, pictures, forms, magazines, and other such clutter are
strongly discouraged from being stored in this environment.

Far too often, those who may work in the office environment become
desensitized to what our office may come to look like over time. A
brand new, uncluttered office, without continual maintenance to keep
it that way drifts to clutter and disorganization. This follows the law of
entropy that some of us may have been exposed to in a high school or
college level physics class. Entropy states that without continual input
of energy to maintain a system it will decline and degrade. What
happens in an office is a slow decline and disorganization without
proper maintenance. It happens so slowly we don’t even really notice
what is happening around us. This would be akin to placing a frog in a
pot and turning up the heat slowly—he never realizes he is being
cooked! BUT our patients will take note of a degraded and
disorganized office, and it will not be a positive reflection.

Patients want to have confidence and trust in their healthcare
providers. An environment needs to be established that cultivates it.
Their first visual impression of us begins at our front door. What do
our patients see as they enter our office? Does it reflect positively and
appropriately upon the care we render within the walls? Is the
landscaping tidy, the yard mowed, trim painted, and trash removed?
Once inside, we may find value in taking an opportunity to sit back in
an operatory chair and recline it and turn the operatory light on. Look

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up and around what do you see? Do you see a sparkling operatory
light free of stains and smudges, operatory lighting that is fully lit and
clean, and a clean ceiling? Or do you see operatory light handles
spackled with some staining of unknown origin, a light shield of filth
and smudges, operatory overhead lights with burnt-out bulbs and
covers littered with long dead insects, or cobwebs in the corners with
stained ceiling tiles? What would you see if you were to look up?
When is the last time you looked up? Recalibrate your eyes and revisit
your office each and every day with the eyes of a patient new to your
office.

Finally, part of our appearance package is ourselves and our staff. One
thing little known among the dental profession is the profound impact
our dress and personal appearance has upon the trust our patients
impart upon us. Published studies indicate that time and again,
patients want to see their doctors in business attire and white jackets.
Scrubs, while common and comfortable, do not instill confidence in
our patients.

Preventative Maintenance Program for Equipment

Little is more frustrating in the dental office than to have to
discontinue operations and turn patients away when equipment fails.
While even the best maintained equipment can fail, very often failure
is the result of improper maintenance. It is imperative that routine
maintenance is performed, at the required schedule, to keep a facility
functioning.

All equipment, small and large, has its own maintenance schedule to
be adhered to. Each facility should compile a maintenance log for the
equipment specific to it. Of equal importance is assigning one staff
member responsibility for maintaining the log and insuring that the
proper maintenance has been conducted. Below are checklists of
items which will require maintenance and servicing at the indicated
time intervals.

Daily Maintenance Schedule

 X-ray processor - Units should be kept clean and fluid levels of
fixer and developer should be adequate. Digital equipment
should be surface cleaned per manufacturer directions.

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 Air compressor - At the beginning of the day visually check for
any abnormalities (leaks, drainage on or around the unit) with
the unit. Check oil level (if oil type) and moisture indicators.
The unit should be powered on while listening for any
abnormal noises in its operation.

 Vacuum pump - At the beginning of each work day a check
should be conducted to visually look for any abnormalities on
unit. Check the trap and replace if necessary. Listen for
normal equipment sounds when the unit is powered on. If
your vacuum system is of the “dry vacuum” type, know that
some manufacturers require that the drain tank be purged
daily.

 Ultrasonic unit - Each day should start by replacing the
ultrasonic with fresh ultrasonic solution. When the solution
appears even slightly cloudy the solution should be changed
for optimum effectiveness. If cloudy, the enzymes in the
cleaning solution have deteriorated beyond their ability to be
effective. At the end of the work day the unit should be
emptied, rinsed and wiped thoroughly. A visual check of the
drain trap and drain screen for debridement should be
conducted. Clean out as necessary.

 Operatory delivery systems - Before turning on the units for
the day, visually check the system for any irregularities. Check
all traps of the unit and ensure they are clean and free of
debris. Replace as necessary. Turn on the units, look for leaks
and listen for abnormal sounds. Check all the instrumentation
for proper readouts. Throughout the day, run evacuation
cleaner through the unit. On heavy operator days, cleaner
should be run through the evacuation systems in each
operatory. At the completion of the work day, evacuation
cleaner should be run through the delivery units. A check
should be completed of the traps and the entire unit should be
cleaned and prepped for the next day.

 Hand pieces - Clean and lube according to manufacturer’s
instructions. Run all hand pieces during maintenance
procedure for at least 60 seconds. Run all hand pieces prior to
seating each patient to insure operation. At the end of each
day detach all hand piece motors (this includes all hand pieces
high speed & low speed motors) from delivery system tubing.

 X-ray units - Clean the surface of the entire unit daily and in
between patients. Adjustment of the arms may be required if
they are found to be drifting after being positioned. To

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accomplish this often requires only a tweak of the set screw
with a proper Allen wrench. Caution: never over-tighten any
adjustments as this results in premature wear of the friction
bearing.

 Curing lights - Clean the curing tip at the beginning of each day
and between uses. An effective method of keeping it clean is to
wipe it with a 2x2 sponge wet with alcohol. Visually inspect to
ensure that there are no chips on the tip. For curing units with
UV filters, turn on the light and trigger the unit to cure. Then
hold the tip on the back of your hand and, if after 20 seconds
you feel extreme heat, your filter is bad and should be replaced
ASAP. Failure to do so may result in pulpal damage to the
tooth. If a composite build up is found on the tip, a more
thorough cleaning and polishing of the tip of the probe will be
required.

 Lab equipment - Above all, keep equipment clean, and this
should be accomplished on a daily basis. Ensure proper
infection and disinfection protocols with rag wheels and other
lathe instrumentation.

 Autoclave - At the beginning of each day the sterilizer should
be powered on to obtain the required operating temperature
before operations begin. At this time, check to make sure the
reservoir is full of distilled water, check the gaskets thoroughly
and wipe off any debris with a clean cloth using warm water
and Ivory/Dawn soap, then wipe clean (the Ivory/Dawn soap
has glycerin in it that actually lubricates the rubber of the
gaskets). With the first sterilization cycle of the day, run a
daily spore test strip to assure proper sterilization.

Weekly Maintenance Schedule

 X-ray processor (where still used) - Fluid levels should be
checked for replacement at the end of each work week.
Visually inspect rollers at this same time.

 Sterilizer - The distilled water should be completely drained
from the reservoir tank. The trays and all internal metal
surfaces inside of chamber should be cleaned with high quality
sterilized cleaner and distilled water. Clean and inspect the
door gasket for damage that could prevent proper sealing. The
reservoir should be refilled with clean distilled water.

 Air compressor - Turn the unit on and listen to it for any
abnormal noises. Also check the oil level as well as the drying

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system. If equipped, the condensate drain canister should be
emptied.
 Vacuum pump - Check visually for any abnormalities on the
unit. At this time the line trap should be cleaned or replaced.
 Ultrasonic unit - Empty the unit and thoroughly cleanse the
basin. Refill the basin with fresh solution. Check the drain
trap and drain screen for debridement. Clean out as necessary.
 Operatory delivery systems - Visually check the system for any
irregularities. Check the traps insuring they are clean and
replace as necessary. Turn on the units, look for any leaks and
listen for abnormal sounds. Check all the instrumentation on
the units to assure everything is functioning properly. Take
note of any sticking buttons or switches. Clean and prep the
units for next work day.
 Hand pieces - Clean and lube according to manufacturer’s
instructions. Run all hand pieces during maintenance
procedure for at least 60 seconds. Run all hand pieces before
seating each patient to eliminate any surprises when the
doctor begins his operative procedures.
 X-ray units - Keep clean and follow daily maintenance.
 Curing lights - Follow daily maintenance.
 Lab equipment - Keep clean and follow daily maintenance and
appropriate infection control and disinfection procedures.

Following equipment maintenance schedules will increase your
success in preventing down periods related to equipment failure. This
does not mean that equipment will not break down, but it does mean it
will likely result in less down time and fewer service calls to the office.
Equipment will be more likely to last longer prior to needing
replacement.

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Infection Control

Infection control has become a major focus in today’s dental health care
environment. The threat of infectious disease through occupational
exposure remains a primary concern. Infection control strategies break
the chain of infection. Universal precautions, careful patient
assessment, vaccinations, hand hygiene along with the use of adequate
personal protective equipment, sterilization of instruments,
environmental surface and equipment disinfection, and aseptic
technique is conscientiously utilized to prevent or minimize the
occupational exposure of employees to blood and other potentially
infectious materials.

Occupational Exposure in Dentistry

Occupational exposure means contact with blood or other potentially
infectious materials. The CDC has categorized individuals based on the
following criteria.

Category A: Employees who perform occupation-related tasks that
involve exposure or reasonably anticipated exposure to blood or saliva
and while performing dental care services.

 Dentists

 Dental Hygienists

 Dental Assistants

Category B: Employees who perform occupation-related tasks that do
not involve exposure or reasonably anticipated exposure to blood or
saliva and which do not perform or assist in dental care services.

 Office Administrator/Regional Office Administrator

 Front Desk Staff

Recommended Quality & Patient Safety Protocols

Providing a safe work environment for the entire staff is essential to
providing high-value care. Continuous education and training of all
employees is paramount in patient safety compliance. Employees will
receive initial role-specific training on or before their first day at work

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and annually. Additional training will be provided when there are
changes in procedures or tasks that will affect occupational exposure.

Recommended protocols:
 Blood-Borne Infectious Diseases Exposure Control Plan
 Medical Waste Management and Amalgam Recycling Protocol
 Sterilization & Disinfection Protocol
 Hazard Communication Protocol
 Fire Safety & Evacuation Protocol
(Please see ‘Forms’ section for detailed documents)

Educating patients about the infection control initiatives and exhibiting
obvious patient safety control measures can serve to alleviate patient
anxieties or concerns. For example, washing/sanitizing hands in front
of the patient, using surface barriers, and use of disposable supplies
(when possible) clearly demonstrate safety measures to the patient.

Below are examples of packaging disposable materials, which serve to
prevent cross-contamination. Utilizing a procedure tub system will
also allow for improved patient safety and reduce the risk of
contamination. Materials used during a procedure are stored in the
tubs, until setting up the procedure (once the patient is seated). All
tubs have a secure lock cover that secures items during transportation
and keeps items clean during storage.

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Disinfection & Sterilization Protocols
Overview: Dental instruments become contaminated with patient blood and
oral fluids during treatment. Instrument processing is required to assure that
contaminated patient care items are rendered safe for reuse. Along with
sterilization of instruments and materials, sterilizer monitoring is an essential
part of the clinic infection control program.

Purpose: To provide staff with specific procedure steps necessary to properly
process reusable patient care items. An instrument processing center has
been set up so that as you walk patient care items through receiving, holding,
cleaning, preparing, packaging, sterilization and storage, you move from the
dirty to the clean side. Maintaining this work flow area not only contains
contamination, but also helps make the process more efficient.

Materials/Equipment:
 Ultrasonic/Hydrim
 Autoclave
 Packaging sleeves
 Chemical indicator tape
 Personal Protective Equipment

Laboratory: Central instrument processing area divided into distinct “dirty”
and “clean” areas.

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Cleaning Process of the Operatory

1.1 To prepare the operatory for the next patient, contaminated materials
must be safely removed and discarded or transferred to the processing area.
Cleaning is the most important step in instrument processing. All remaining
blood, body fluids, and other visible debris must be cleared away. It is
imperative that personal protective equipment be utilized at all times.

1.2 Discard all contaminated single use disposable items in the operatory.

1.3 Transport all reusable patient care items in a leak-proof, puncture-
resistant tray to the designated processing area. Cover the tray to prevent
accidental exposures.

1.4 Don puncture-resistant utility gloves, eye protection, and protective
apparel to carefully transfer dirty instruments into the ultrasonic with an
enzymatic cleaning solution for a minimum of 10 minutes. ( If applicable)

1.5 Don puncture-resistant utility gloves, eye protection, and protective
apparel to carefully transfer dirty instruments and cassettes into the Hydrim.
After cycle is completed, allow contents to cool down before removing for
packaging.

1.6 Please note that small items such as bib clamps, rubber dam clamps,
SSC, or acrylic adjusting burs are to be placed into the basket provided within
the Hydrim.

1.7 Trays need to be sprayed and wiped down with a disinfectant spray
for future use.

Packaging Process

1.8 After cleaning, with personal protective equipment in place, inspect
instruments and other dental supplies to make sure they are free of debris.

1.9 Separate instruments and assemble items into instrument cassettes
and wrap securely with sterilization wrap and secure with indicator tape. For
individual instruments or dental supplies, place in packaging sleeves and seal
in preparation for sterilization in autoclave.

1.10 Label each instrument pack with the date of sterilization. If your clinic
has multiple sterilizers, also note the sterilizer being used (i.e. #1 or #2). Do
not use water-soluble ink.

1.11 Reminder: All packaging occurs in the “dirty” area.

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Sterilization Process

1.12 Follow the autoclave manufacturer’s instruction for warming up and
operating the autoclave.

1.13 Load the instrument packs or wrapped cassettes into the autoclave
chamber. Leave room between the packs to allow for proper sterilization. Do
NOT overload the chamber.

1.14 Never interrupt a sterilization cycle by opening up the chamber door.
If you must retrieve an item, start the cycle over from the beginning. Verify
that door is properly closed and no error indicators are flashing or beeping.

1.15 Flash sterilization is NOT intended for routine instrument processing.
It should be used when an urgent need arises for an instrument that will be
used immediately after the cycle.

1.16 To keep from contaminating freshly sterilized items, allow instrument
packs to dry inside the chamber before moving and handling them. Please
wash hands before handling.

1.17 Check external chemical indicators on tape or sleeve for appropriate
color changes. Failure of an indicator to change color indicates that it was not
exposed to the proper sterilization environment (i.e., proper temperature). In
this case, the instrument load should be re-sterilized.

Distribution of Sterilized Instruments

1.18 Store sterile instrument packs away from contaminants, preferably in
a closed or covered cabinet or drawer chair side or in a clean utility.

1.19 Leave packaging intact until instruments are ready to be used in
patient care.

1.20 Prior to use in patient treatment, inspect all packages containing
sterile supplies to verify that the packaging material has not become torn,
punctured, or wet. Damp packages are not considered sterile.

1.21 If a sterile package has been compromised, do not use the instruments
inside for patient care. Instead, clean and repackage the instruments and
subject the package to another sterilization cycle in the autoclave.

Sterilization Monitoring

1.22 Chemical indicators cannot replace biological indicators, as only a
biological indicator consisting of bacterial endospores can measure the
microbial killing power of the sterilization process. The CDC recommends at
least weekly biological indicators be used.

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1.23 Once per week, place a biological indicator (spore test strip) inside
each autoclave to run in the first wrapped cycle of the day.

1.24 Label test strip with date, staff initials, and number of autoclave.

1.25 Control strip should be stored in clean utility away from autoclave.

1.26 Perform biological spore tests for all autoclaves on the same day,
consistently each week.

1.27 Each sterilizer requires its own spore test kit.

Biological Test Reporting & Follow Up for Failed Sterilization

1.28 Safety coordinator responsible for maintaining spore test log and
sending with monthly OSHA documentation.

1.29 A positive spore test result or failed chemical indicator indicates that
sterilization has failed.

1.29.1 Take the sterilizer out of service immediately.

1.29.2 Review the sterilization process being followed in the clinic to rule out
operator error as the cause of failure.

1.29.3 Correct any identified procedural problems, and retest the sterilizer
using biological, mechanical, and chemical indicators.

1.29.4 If the repeat biological indicator is negative and the other test results
fall within normal limits, the sterilizer can be returned to service.

1.29.5 If no procedural errors are identified or failures persist after
procedural errors are corrected, the sterilizer should not be used until the
reason for failure has been identified or corrected.

1.30 Before the sterilizer can be returned to service, negative results should
be returned for biological indicator tests conducted during three consecutive
empty-chamber sterilization cycles to ensure that the problem has been
corrected.

1.30.1 To the extent possible, reprocess all instruments that were sterilized
since the last negative spore test.

1.31 Record the positive test results and all actions taken to ensure proper
functioning of the sterilizer in the spore test monitor log.

Dental Instrument Classification

1.32 Critical: Penetrates soft tissue or bone, enters into the bloodstream,
or other normally sterile tissue.

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1.32.1 Example: surgical instruments, scalers, scalpel blades, surgical dental
burs.
1.33 Semi-Critical: Contact with mucous membranes, but will not penetrate
soft tissue, bone, or enter into the bloodstream or other normally sterile
tissue.
1.33.1 Example: Dental mouth mirrors, amalgam condenser, reusable dental
impression trays, or dental hand pieces.
1.34 Non-Critical: Contact with intact skin.
1.34.1 Example: Blood pressure cuff, stethoscope, bib clip.
References
1.35 Centers for Disease Control and Prevention. Guidelines for infection
control in dental health-care settings 2003. MMWR 2003; 52 (No. RR-17):
43. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm
1.36 American Dental Association. Biological indicators for verifying
sterilization. J Am Dent Assoc.1988; 117:653-654.

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Inventory Control System

Inventory control is included in the communication section of this text, as
communication is key to maintaining an adequate inventory to maintain
an ability to operate and provide services, but also limit inventory to
control overhead. It is commonplace to have one bulk of items which
seems to sit on shelves for months, if not years, and then another group
which we seem to consistently be unable to keep an adequate stock on the
shelves. Lean practices from the manufacturing sector can be used in the
dental office. As a cost savings matter, the goal should be just-in-time
ordering tempered with the reality of our ability to order on some
frequent basis. It is suggested that weekly ordering of supplies and
sundries is an acceptable practice incorporating lean concepts.

A proper inventory control system is really a mini-logistics operation for
each facility and for the organization as a whole. In an effort to control
inventory and its associated overhead, an organization or office may
benefit from establishing a clinical formulary. Such a formulary will
standardize a process and system for inventory control and those items
ordered. This is another form of standardization mentioned earlier.
Standardization is a key component to quality improvement and cost
reduction. A formulary offers the additional benefit of reduced ordering
time and increased value in purchases. The person responsible for
inventory control often would be a dental assistant.

Other advantages of an inventory control system are to increase time
management efficiency in the area of reordering, inventory, and cost
control of clinical supplies. When a formulary is in place, to the extent
practical, supplies should be ordered off a formulary. It is expected that
offices should be able to purchase 95% of needed supplies and sundries
off a properly designed formulary. To reiterate, the standard practice of
the office should be to practice “just-in-time” ordering.

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A properly designed
system will provide
information about the
name of the product,
size/quantity per package,
date last ordered, and
quantity ordered,
company ordered from,
how many items are
needed on hand to last
through the next ordering
period, and the price of the
item. Items should be
purchased via Internet
where possible, as it is not
generally possible for a
team member to give a
verbal order to a visiting
sales rep due to time
constraints.

With increasing
technology, it is expected
that ordering will
ultimately be a process
fully integrated into an electronic system. It is the intention of the office to
continue to train toward a logistics system which minimizes staff time,
reduces costs, and maximizes office efficiency.

The graph indicated above is an example of one methodology relative to
creating a decision tree for standardization of an ordering process. This
example can be used as a starting point for discussion as you develop your
own system.

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Fire Safety & Evacuation Protocol

Overview: In the event of a fire, emergency preparedness and timing are
essential to the safety of patients and staff. This protocol has been developed
to provide guidelines and direction for staff in the event of a fire. This
protocol is reviewed and updated annually.

Purpose: To familiarize staff with Fire Emergency procedures.

Emergency Preparedness

 Fire extinguishers are inspected monthly by safety coordinator and
inspected annually by professionals to ensure proper function.

 Smoke detectors and battery charge are inspected monthly by safety
coordinator, with batteries being replaced annually and detectors
every ten years.

 Automatic sprinkler systems and alarm systems are inspected
annually by professionals to validate they are working properly.

 An annual review of fire safety protocol, along with a fire drill, is
facilitated by the Office Administrator of each clinic with
documentation of staff participation.

 Location of proper emergency exits
 Location of fire extinguishers
 Staff roles reviewed along with key duties
 Notification of 911
 Patient evacuation procedure
 Shutdown procedure

Smoke or Fire Confirmed by Alarm, Sight, or Smell
R: Remove anyone from immediate danger.
A: Activate the building fire alarm system and/or call 911.
C: Confine the fire by closing all windows and doors.
E: Evacuate immediately, leave the building.
Do not try to remove any supplies or personal belongings.
If you encounter smoke, drop down to the floor and crawl towards exit.
Feel doors before opening-opening slowly a few inches at a time. If heat and
smoke are present quickly shut the door.
Go to nearest exit – DO NOT use Elevators

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Meet at a designated assembly area, which should be at least 50 feet from the
building.
No one is permitted to return to the building under any circumstances.

Staff Roles & Responsibilities in the Event of a Fire/Evacuation
Office Administrator/Manager
Notify 911 – Providing facility name, address and location of oxygen and
nitrous tanks found within the facility.
Lead facilitator until Fire Personnel arrive.
Coordinate evacuation of patients/staff.
Gather SDS binder, ensure all doors are closed and patient/staff evacuation
complete before turning off lights and evacuating building.
Notify ROA in the event of Fire/Evacuation.
Responsible for facilitating annual fire drill and review of fire safety protocol.
Dentists, Hygienists, and Assistants
Responsible for evacuating patients safely from each operatory.
Priority assistance should be given to children, elderly, disabled adults in a
wheelchair.
Front Desk Staff
Responsible for evacuating guests located in reception area.

Fire Extinguisher Usage
Use fire extinguisher only if fire is very small, using the PASS method.
P: Pull the pin. It is there to prevent accidental discharge.
A: Aim low at the base of the fire. This is where the fuel source is.
S: Squeeze the lever above the handle. Release to stop the flow.
S: Sweep from side to side. Move toward the fire, aiming low at its base.
Sweep until flames are extinguished. Watch for re-igniting. Repeat as
necessary.
A fire extinguisher needs to be recharged following any discharge.

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Medical Waste Management & Amalgam Recycling Protocol

Developing a Waste Management plan
The majority of waste products generated by dental offices are either general
office (non-hazardous) or medical waste (regulated). The handling and
disposal of hazardous waste is regulated by a complex set of federal and state
laws. In compliance with the Medical Waste Regulatory Act of 1990 and the
Bloodborne Infectious Disease Rules of 1993, it is important to develop
protocols to handle these materials.
A medical waste management plan should be developed to educate and
prepare staff for when they handle and dispose of infectious medical waste.
These plans should consider all aspects of waste in the dental environment.

Medical Waste Management by Category
Dental clinics generate the following categories of regulated waste or medical
waste as defined by state Medical Waste Regulatory Acts and Bloodborne
Infectious Disease Rules:

 SHARPS:
o Includes dental injection needles, anesthetic carpules, scalpels, suture

needles, and burs. (This includes contaminated and non-contaminated
sharps).

 PATHOLOGICAL WASTE:
o Includes human tissue, extracted teeth, and fluids removed during dental

procedures and not fixed in formaldehyde.

 LIQUID WASTE:
o Includes blood and saliva diluted by water or other irrigating solutions

generated from oral surgery procedures and evacuated into the canister of
a portable suction device.

 CONTAMINATED ITEMS:
o Includes materials that would release blood or saliva in a liquid or semi-

liquid state if compressed, such as blood soaked gauze and items caked
with dried blood or saliva which are capable of releasing these contents
during handling, such as blood-caked gauze.

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Segregation and Handling Procedures

 SHARPS

o After they are used, in proximity to their point of generation, sharps
are to be placed into the Biohazard-labeled, rigid, puncture-proof
containers located in each operatory.

o No materials other than sharps or broken anesthetic carpules are to be
placed into these sharps containers.

o When the containers are full, they are sealed according to the
manufacturer’s directions. The containers are stored in the regulated
medical waste storage repository until removal by commercial
medical waste hauler Stericycle. Each clinic is on a 90-day waste
disposal program.

o Employees are required to use all necessary Personal Protective
Equipment (PPE) when disposing of sharps and transporting full
sharps to storage repository.

 PATHOLOGICAL WASTE:

o Waste generated from oral or periodontal surgical procedures is
collected and flushed down a drain connected to a sanitary sewer.

o Grinding of the waste is unnecessary due to the small amounts
generated. Larger pieces are to be collected in a container labeled
with a biohazard symbol and released to the commercial medical
waste hauler Stericycle.

o Extracted Teeth without amalgam are to be sterilized in autoclave and
disposed of in general office trash once labeled: DECONTAMINATED
MEDICAL WASTE (include DATE).

o Extracted Teeth containing amalgam are to be recycled in the
amalgam recycling storage container. This to be further discussed in
amalgam recycling section.

o Employees are required to use all necessary PPE when disposing of
pathological waste.

 LIQUID WASTE:

o Waste generated from oral or periodontal surgical procedures and
collected in a portable suction container is flushed down a drain
connected to a sanitary sewer.

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o Employees are required to use all necessary PPE when disposing of
liquid waste.

 CONTAMINATED ITEMS:

o Blood/saliva soaked disposable items or items caked with dried
blood/saliva are placed in a container labeled with a biohazard label
and released to commercial medical waste hauler Stericycle.

o An alternative is to autoclave these contents and dispose in general
office trash once labeled: DECONTAMINATED MEDICAL WASTE
(include DATE).

o Blood or saliva stained items are NOT regulated as infectious waste
and may be discarded into operatory wastebaskets with ordinary
unregulated trash.

o Employees are required to use all necessary PPE when disposing of
contaminated waste.

Storage of Medical Waste

 When sharps containers are full, prior to collection by the commercial
waste hauler, Stericycle, containers of sharps are sealed according to the
manufacturer’s directions and then placed in a sturdy cardboard box
lined with a polyethylene bag to prevent leakage and spilling of waste.
This box is stored in the mechanical room.

 Full Biohazard bags are also sealed and stored in this box in the
mechanical room awaiting transport.

Decontamination Methods

 Onsite: Decontamination is accomplished through autoclaving. The
container is then labeled “DECONTAMINATED MEDICAL WASTE”
prior to disposal with non-regulated waste.

 Off-site: Medical waste is transported for incineration by a regulated
commercial disposal service. Please see waste manifest documents.

Team Training on Medical Waste Issues

All employees who may be exposed to infectious agents through the
process of handling medical waste will receive initial training on standard
operating procedures for medical waste management.

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 All records will be stored in a Training Support or HR Department.
 Additional training provided when operating procedures change or

annual updates are provided.
 The medical waste management training program will ensure that all

employees handling regulated medical waste:
o Understand which waste items need special handling as medical waste

and which items may be disposed of as non-regulated waste,
according to the Michigan Medical Waste Regulatory Act.
o Understand the measures they should use to minimize exposure to
infectious agents during the handling and disposal of medical waste,
including standard operating procedures for processing medical
waste, the use of PPE, and the use of environmental devices.
o Understand the requirements for waste management, including the
workplace standard operating procedures for segregating and
packaging each category of medical waste generated.
o Know the meaning of the universal biohazard warning symbol, as well
as how a container of medical waste must be labeled.
o Understand the waste management requirements for each category of
medical waste generated, including workplace standard operating
procedures for waste storage, decontamination, collection, and
disposal.
o Understand that regulated medical waste may not be stored in a
generating facility for more than 90 days.
 The clinic safety coordinator is responsible for managing the handling
and disposal of infectious medical waste.
 The written medical waste management protocol will be reviewed and
updated as necessary by HR department.

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Amalgam Waste Management & Recycling

Mercury Containing Dental Waste
Amalgam/Mercury waste is defined as both non-contact and contact amalgam and
products, amalgam dental traps, sludge from traps and vacuum pump filters,
extracted teeth with amalgam fillings, empty amalgam capsules, mercury clean up
materials that contain mercury amalgam, batteries, and light bulbs containing
mercury. The dental office is responsible for properly segregating, packaging, and
labeling of regulated medical waste and adheres to manufacturer guidelines for
packaging and mail back process.

Amalgam Compliance Measures – Evacuation Systems
It is recommended to use only pre-capsulated amalgam alloy. Each office should
store all dental amalgam waste in an enclosed and structurally sound container
until a sufficient amount has been collected for shipment to a reclamation facility
or recycler or at a minimum, recycled annually. This service can be contracted
with an amalgam recycling mail service for proper disposal.
At the chairside, disposable traps are utilized in each operatory to retain amalgam
waste and are to be changed weekly.
At the vacuum pump, filters are utilized and changed per manufacturer guidelines.
Many states and communities now require each office to be served by an ISO-
certified amalgam separator installed in accordance with standards published by
the International Organization for Standardization in ISO test 11143. Staff are to
follow the manufacturer’s directions for collection and maintenance of the
separator. Filters are changed annually and recycled through the manufacturer.
In the event of a mercury spill, each clinic is to utilize nitrile gloves and a mercury
spill kit.

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Best Management Practices for Handling Dental Waste

Waste Description Management Practices
Sharps
 Needles  All sharps are stored in a Sharps Container-
Pathological  Burs disposed of every 90 days by Stericycle
Waste  Scalpels

Liquid Waste  Broken anesthetic carpules
Contaminated
Items  Extracted Teeth ( without amalgam)  Extracted teeth are decontaminated in
 unfixed tissue autoclave and labeled “Decontaminated
Scrap Amalgam Medical Waste” or provided to patient per
their request.

 Small amounts of tissue are stored in
biohazard bag and disposed of every 90 days
by Stericycle.

 Blood or saliva  Flush into sewer system

 Blood/saliva soaked items (gauze)  Stored in biohazard bag and disposed of
every 90 days by Stericycle.
 Items stained with blood/saliva are NOT
considered contaminated and can be  Decontaminated in autoclave and labeled
disposed in regular trash “Decontaminated Medical Waste”

 Non-contact amalgam (excess mix left  Collect with other amalgam waste and mail
over at end of dental procedure) to amalgam recycler

Contact  Amalgam that has been in contact with  Collect with other amalgam waste and mail
Amalgam patient’s blood/saliva to amalgam recycler

Chair-Side Traps  Dental unit traps that collect contact  Change disposable traps weekly and collect
amalgam during procedures with other amalgam waste and mail to
amalgam recycler

Vacuum Pump  Filters that collect amalgam and sludge  Collect disposable filters and send back to
Filters at the vacuum pump manufacturer or store with other amalgam
waste and mail back to amalgam recycler
Amalgam  Captures amalgam and mercury from
Separator the dental office waste stream  Annual maintenance with filter changes and
Extracted Teeth recycled through manufacturer
 Extracted teeth with amalgam fillings
Lead Aprons  Provided to the patient per their request
 Aprons used as protective barriers
during digital film exposure  Collect with other amalgam waste and mail
to amalgam recycler

 Replaced every three years and disposed of
through hazardous waste hauler as needed.

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References
Michigan Dental Association. Waste Management and Recycling for Michigan
Dental Office. HHR Update, Journal of the Michigan Dental Association, March
1996
Chadzynski, L. Medical Waste Management in Michigan: An Update, Journal of
the Michigan Dental Association 1991: (73) 9:24-25
U.S. Department of health and Human Services, Centers for Disease Control.
Guidelines for Infection Control in Dental Health Care Settings. Morbidity and
Mortality Weekly Report 2003; 52(RR-17): 1-68
ADA Guidelines on Amalgam Accumulations in Dental Office Plumbing
http://www.ada.org/prof/resources/positions/statements/amalgam_plumbing
_guidelines.pdf
Best Management Practices for Amalgam Waste, October 2007
http://www.ada.org/prof/resources/topics/topics_amalgamwaste.pdf
The State of Michigan Department of Environmental Quality website
http://www.michigan.gov/deq/0,160,7-135-3307_29693_4175-11753--
,00.html

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Recruitment and Hiring Process

Recruiting: It is important to be in compliance with federal and state
employment laws. Each state will have its own laws, and it is important to be
aware of the unique requirements and regulations. As a generic best practice to
recruitment, this outline is offered as a starting point for the facility and human
resources.

 A facility that needs a position filled must make a request to the appropriate
administrative staff. In the MCDC organization this requires the completion of a
Position Request Form which is returned to the Talent Support and Recruiting
Department (TSR).

 Once the request is submitted to Human Resources or TSR, and approved by
Operations, recruiting will begin.

 Depending upon the organization, open positions can be communicated to
current staff and made available for three days.

 The next suggested step would be a classified ad placed in the local newspaper
of the appropriate clinic for a minimum of four days unless requested otherwise.

 The appropriate administrator will pre-screen all candidates and forward all
qualified candidates to the clinic for consideration.

Interviewing:

 Interviews should be conducted at the clinic at which the employee will be
working.

 The interview should be conducted by an office administrator and any other
appropriate clinic staff members. The involvement of the doctors should always
be welcomed, but the Office Administrator/Manager should take the lead in the
process.

 Once the interviews are completed, each candidate interviewed should have
some form of an Applicant Tracking Form completed.

 The Applicant Tracking Form should be returned, along with the application
and resume, to Human Resources within three business days following the
interview.

Making Job Offers:

 All job offers should be made by the Human Resources, or TSR department,
after the background and reference checks are completed.

 All start dates and work schedules must be approved by Operations and will
be communicated to the candidate during the job offer.

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