The Promise of Stem Cells in Dentistry Obesity Effects on Periodontal Disease Drug Abuse Aware and Prepared Office-Based Anesthesia ...

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The Promise of Stem Cells in Dentistry Obesity Effects on Periodontal Disease Drug Abuse Aware and Prepared Office-Based Anesthesia ...
March/April 2018

•   The Promise of Stem Cells in Dentistry
•   Obesity Effects on Periodontal Disease
•   Drug Abuse Aware and Prepared
•   Office-Based Anesthesia

                                             March/April 2018 The Dental Assistant PG 1
The Promise of Stem Cells in Dentistry Obesity Effects on Periodontal Disease Drug Abuse Aware and Prepared Office-Based Anesthesia ...
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 PG 2 The Dental Assistant March/April 2018
The Promise of Stem Cells in Dentistry Obesity Effects on Periodontal Disease Drug Abuse Aware and Prepared Office-Based Anesthesia ...
March/April 2018                                      Volume 87. No. 2

                  ADAA President                                        Natalie Kaweckyj, LDARF, CDA, CDPMA, COA,
                                                                                          COMSA, CPFDA, CRFDA,
                                                                                          MADAA, BA

                  Executive Director                                    John E. Kasper, PhD, CAE

                  Managing Editor                                       Angela Hickman
                                                                        877-874-3785 X220

                  Advertising Sales Manager                             John E. Kasper, Jr.
                                                                        877-874-3785 X214

                  Editorial Review Board                                Jan DeBell, CDA, MS, BS
                                                                        Ronda Lane, CDA, RDA
                                                                        Cathy Roberts, EFDA, MADAA, CDA-Emeritus,
                                                                                       CDPMA-Emeritus, COA-Emeritus,
                                                                                       CPFDA-Emeritus
                                                                        Robynn Rixse, AS, CDA, EFDA, FADAA

                                                                        The Dental Assistant Journal
                                                          140 N. Bloomingdale Road, Bloomingdale, IL 60108-1017
                                                           General inquiries 877-874-3785 • fax 630-351-8490
                                                          e-mail: publications@adaausa.org • www.adaausa.org

To obtain a copy of our Writer’s Submission Guidelines or the Editorial Calendar, please go to the ADAA website, www.adaausa.org.
Copyright 2018 by the American Dental Assistants Association. Reproduction in whole or in part without permission is prohibited.
DISCLAIMER: “Authors and advertisers are solely responsible for the accuracy of any and all material provided to The Dental
Assistant. Authors and advertisers are also solely responsible for checking that any and all material relevant to dental care in a
clinical setting meets OSAP standards. The information and opinions expressed or implied in articles and advertisements that appear
in The Dental Assistant are strictly those of the authors and advertisers. They do not necessarily represent the opinion, position or
official policies of the American Dental Assistants Association.”
                                                                                     March/April 2018 The Dental Assistant PG 3
The Promise of Stem Cells in Dentistry Obesity Effects on Periodontal Disease Drug Abuse Aware and Prepared Office-Based Anesthesia ...
FEATURES
9    Research: The Promise of Stem Cells in Dentistry
     By Anderson Benavides and Diana Macri, RDH, BSDH, MEd
     Although not all procedures done with stem cells have succeeded, the rapid advances have
     shown many positive and beneficial outcomes. Stem cells have the potential to revolutionize the
     field of dentistry.

12   Research: Obesity Effects on Periodontal Disease
     By Annie Chitlall, RDH, BS
     Obesity and periodontists continuously affect more people in the world, and a link between obesity
     and periodontal disease has been scientifically established. It’s important for dental professionals to
     understand how obesity can affect the practice of dentistry.

16   Drug Abuse Aware and Prepared
     By Cris Zimmerman, RDH, BS
     The opioid problem is affecting all areas of the workforce, including the dental profession. It’s a
     harsh reality for those in management positions who are trying to maintain a safe and a profes-
     sional work environment. There are many indicators that you can watch for to reveal if a person is
     abusing drugs.

18   Office-Based Anesthesia: How Dental Assistants Ensure Safe Patient Care
     By Martha Peters
     Training for excellence in office-based anesthesia requires leadership, preparation, and simulation.
     Learn how dental assistants can contribute to the effectiveness of the surgical team.

20   From the Archives: “Can Decay of the Teeth Be Prevented?”
     In 1938, Walter T. McFall, DDS discussed how preventing tooth decay is a cooperative effort between
     patient and dentist.

DEPARTMENTS
6    Editor’s Desk                           26    Trustee News
7    President’s Page                        29    Member Spotlight
22   News Briefs

The Dental Assistant (lSSN-1088-3886) is published bi-monthly (every other month). Non-member subscriptions are $30. Allow 6-8 weeks
for subscription entry. Publisher is the American Dental Assistants Association, 140 N. Bloomingdale Road, Bloomingdale, IL 60108-1017

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The Promise of Stem Cells in Dentistry Obesity Effects on Periodontal Disease Drug Abuse Aware and Prepared Office-Based Anesthesia ...
Editor’s Desk
                                  Angela Hickman
                                  Managing Editor
                                  The Dental Assistant

New Research and Everyday Advice

W
           elcome to the March/April issue of The Dental      effects of obesity on the progression of PD is significant,
           Assistant. This research-heavy edition offers      and oral health care professionals need to be able
           some important information on everything           to understand that obesity can also affect the dental
from stem cells to the relationship between obesity           process of care,” she writes.
and periodontal disease. In each issue, we seek to               Shifting gears, this issue also takes a look at a
strike a balance between offering new research                topic that is the subject of daily news stories. The
and sharing everyday advice from practicing dental            opioid problem has become a nationwide epidemic,
assistants and other professionals in the office, as well     affecting people from all walks of life and in virtually
as educators and outside experts.                             every profession. The dental field is not immune. “It’s
     This issue’s lead story discusses the promise of stem    a harsh reality for those in management positions
cells for dentistry. While stem cells for regenerative        who are trying to maintain a safe and a professional
therapy have largely been used in patients with               work environment,” writes Cris Zimmerman, RDH, BS.
leukemia and lymphoma, stem cells show enormous               She notes a number of indicators of drug abuse and
potential for regenerating alveolar bone, periodontal         points out that blood tests are far from fail proof in
ligament, pulp, dentin, and enamel. In fact, some             determining whether a suspected employee has a drug
suggest such treatments could become a reality in as          problem. “An impaired dental assistant puts herself, the
little as 5 years. “The encouraging data coming from          practice, and the patient at risk,” Zimmerman writes.
trials done on animals have made stem cells a popular         “The onus is on managers to be aware of opioid and
topic in dentistry since people care more about health        other drug abuse and have systems in place to identify
and aesthetics than they ever did,” write authors             employees who may be at risk or already abusing
Anderson Benavides and Diana Macri, of Eugenio                drugs.”
Maria de Hostos Community College. “Although not                   This issue also discusses the importance of dental
all procedures done with stem cells have succeeded,           assistants as part of the team delivering office-based
the rapid advances have shown many positive and               anesthesia. “Office-based anesthesia privileges are vital
beneficial outcomes. Stem cells will revolutionize            to the livelihood of all dental practices that administer
medicine and are poised to have a massive impact in           anesthesia and sedation,” writes Martha Peters, CDA.
dentistry as well.”                                           Because the dental team must deliver quality office-
     Another research manuscript in this issue discusses      based ambulatory anesthesia, training for dental
the relationship between obesity and periodontal              anesthesia assistants—staff members who work
disease. Today, about half of American adults over the        under the care of dentists who administer anesthesia
age of 30 have chronic periodontitis; in fact, 38 percent     and sedation—is critical. “Raising the bar by creating
have moderate to advanced stages of the disease. “Oral        anesthesia training standards and protocols for your
health disparities, such as periodontal disease and           office will lead the way for successful management of
dental caries related to obesity, affect 3.9 billion people   office emergencies,” she says.
worldwide,” writes Annie Chitlall, RDH, BS, of the New             Don’t miss this issue’s introduction to ADAA
York City College of Technology and Eugenio Maria de          members in Member Spotlight. Learn what inspires and
Hostos Community College. Chitlall suggests dentists          motivates your peers every day.
and oral health care professionals should consider
implementing the measurement of BMI index as part
of routine dental screening. “The dental professional              Interested in writing an article for
can use the BMI index to determine if treatment                               the journal?
modification will be necessary and to predict any                   Email the Managing Editor at abrady@adaausa.org.
possible complications related to the treatment. The

PG 6 The Dental Assistant March/April 2018
The Promise of Stem Cells in Dentistry Obesity Effects on Periodontal Disease Drug Abuse Aware and Prepared Office-Based Anesthesia ...
President’s Page
                                     Natalie Kaweckyj, LDARF, CDA, CDPMA, COA,
                                     COMSA, CPFDA, CRFDA, MADAA, BA
                                     President 2017-2018
                                     American Dental Assistants Association

Pride, Passion and Professionalism:
Are You Doing YOUR Part?
                                                           and independent streak that makes us passionate about
“If passion drives you, let reason hold the reins”         doing things we have set our mind on, even if we are
                                    – Benjamin Franklin    told not to. That’s what passion is about. Employers
                                                           are continually looking for people with passion and

T
       hree words—pride, passion and                       dedication to be added to their dental teams.
       professionalism—mean different things to               So what can you do? Get involved! For some, this
       different people. In late February, the Chicago     may sound scary because you may not know anyone.
Dental Society held its annual Midwinter Meeting,          For others, time commitment may play a factor in
https://www.cds.org/meetings-events/midwinter-             participation. At ADAA, we value the participation and
meeting, with just this theme: Pride, Passion, and         opinion of all dental assistants, whether you are a
Professionalism. ADAA had an opportunity to present        student, in mid-career, or a career veteran with so many
education in the main catalog to two sold out sessions.    tips of the trade to share that you could write a book.
Our title, Dental Assisting: A Mixture of Pride, Passion   How do you get involved enough to make a difference?
and Professionalism, focused on a variety of areas         By participating in progress and giving feedback to
important in the daily life of a dental assistant. The     questions asked. Pride comes with the realization
intent of the three-part lecture was to inspire dental     that you do indeed make a difference. Everyone does,
assistants at all stages of their careers. So often
through my travels, I encounter dental assistants who
do not value their true worth to the profession, or who               At ADAA, we value the
feel that they contribute very little. Honestly, we all
make a difference. Collectively, we could have a huge
impact. It is time for some action.
                                                               participation and opinion of all
    At some point in our careers, most of us have been
hit with that pit-of-the-stomach, Monday-morning               dental assistants, whether you
moment of questioning: “OMG, do I really have to
go to work?” For some of us, this feeling may begin           are a student, in mid-career, or a
mid-afternoon Sunday, ruining the remainder of the
weekend and setting you up for anxiety-filled dreams in       career veteran with so many tips
the night to come. For others, it may happen regularly
and with some frequency. So what is missing? Our
drive for being a top dental professional is a positive
                                                                of the trade to share that you
emotional connection to our career and often our most
energy-consuming quest. However, with soul searching,                   could write a book.
planning, action, and support, you can redirect your
career to incorporate what truly excites and invigorates   whether you think so or not. We make a difference to
you in dental assisting.                                   our team, our patients, students, and our colleagues.
    We come into this world with so much passion for       Participate in the progress of the professional
so many different things. We love our food, our toys,      association by first becoming a member, and secondly
and those people close to us who play a role in our        by getting involved and giving feedback, demonstrating
lives. We are passionate about new experiences and         your eye for detail and your desire to contribute to
repeating old experiences that we particularly like. We    improvement. Take pride in the fact that you have a
like security, but at the same time, we have a stubborn    voice in professional matters.

                                                                        March/April 2018 The Dental Assistant PG 7
The Promise of Stem Cells in Dentistry Obesity Effects on Periodontal Disease Drug Abuse Aware and Prepared Office-Based Anesthesia ...
President’s Page
continued

   Be a positive force in the field. We all know someone
who has the tendency to be the “Debbie downer” at
everything that is proposed or suggested. Be aware and
demonstrate a keen sense of being positive at work and
within your profession. Embrace your organization’s
history, culture, and vision of the future. We will
celebrate our centennial in a few years. There are some

ADAA staff Peter Kasper (front left) and Jay Kasper (back right)
and President Natalie Kaweckyj and President-Elect Jan DeBell
at the Chicago Dental Society Midwinter Meeting in February.

state associations of ADAA that are already celebrating
their centennials. What a milestone! What dedication
the members had to keep things moving forward to
reach 100 years! Your environment is what you make
it; take pride in being a positive force at work and in            Newly appointed ADAA 1st District Trustee Nancy Leary (back
your association. Engage with positive-minded people               left) and President Natalie Kaweckyj (back right) at the Yankee
and invest in building positivity around you and in your           Dental Congress with students enrolled in the dental assisting
personal and professional environment. Remember                    program.
what you achieved and what the future holds for the                best to identify them early on, course correct, and create
profession. Take pride in that joint achievement. On               future plans by very clearly avoiding such individuals.
the flip side, steer clear of negative influences, people,            Every professional organization has seen failures
and ex-employees’ sub-standard practices. If you skew              or a time of low member morale. It happens in cycles.
towards negativity, then you are clearly in the wrong              ADAA has seen its share of changes through the years,
place.                                                             as well as struggles of reestablishing itself within the
     Those who demonstrate lack of pride are easy                  dental community. Although change is difficult for
enough to identify—being non-participative, keeping                many, it is needed to keep moving a profession forward.
their heads down and not giving feedback even when                 Are you doing your part? We are continually looking
asked. When things do go south, as they do from time               for members to become more involved. It is a great
to time, these folks are the first to point fingers. From a        learning experience and comes with mentoring and
management perspective, the signs are all there. Why               the opportunity to serve on the local, state or national
would anyone want someone like this on their team? It’s            levels. The time is now: Get involved!

PG 8 The Dental Assistant March/April 2018
The Promise of Stem Cells in Dentistry Obesity Effects on Periodontal Disease Drug Abuse Aware and Prepared Office-Based Anesthesia ...
Research: The Promise of Stem Cells in Dentistry
Although not all procedures done with stem cells have succeeded, the rapid
advances have shown positive and beneficial outcomes

By Anderson Benavides and Diana Macri, RDH, BSDH, MEd

R
      ecently, scientists have made new discoveries
      regarding stem cells that can potentially
      revolutionize the field of dentistry. Regenerative
medicine started in 1998 with the discovery of human
embryonic stem cells, which are easier to manipulate
and obtain.1 In regenerative therapy, stem cells are
mostly being used in patients with leukemia and
lymphoma. Since regenerative medicine has not
been around for long, the topic of stem cells is not
often discussed among dental assistants. Stem cells
have self-renewing abilities and can differentiate into
multiple cell lineages.1 This process shows enormous
potential for regenerating alveolar bone, periodontal
ligament, pulp, dentin, and enamel. Thus far, stem cell
treatments have only been tested on animals such              • Stem Cells from Apical Papilla (SCAPs)—mesenchymal
as dogs, pigs, and mice. More research is needed in             stem cells (MSCs) found in the apical papilla of
order to receive approval from the Food and Drug                incompletely developed permanent teeth.
Administration to begin research on human subjects.           • Dental Follicle Progenitor Cells (DFPCs)—extracted
                                                                from dental follicle surrounding tooth germ in early
Stem Cell Basics                                                tooth formation, DFPCs have shown the greatest
Stem cells can divide to repair damaged tissues and             results in the regeneration of the bone.
have the ability to develop into distinct types of cells
                                                              Current Standard of Care
in the human body. There are two types of stem cells:
                                                              Most of the research done on stem cells has focused
embryonic stem cells, from embryos (fertilized egg)
                                                              on regeneration of damaged tooth related structures.3
and non-embryonic stem cells, also known as adult
                                                              Diseases of the oral cavity include dental caries and
stem cells.2 It is important to note that embryonic stem
                                                              periodontal disease. The Centers for Disease Control
cells are fertilized in vitro and not inside a woman’s
                                                              (CDC) estimates that periodontal disease affects
body. Researchers carefully cultivate a controlled
                                                              47 percent of the population, to varying degrees
environment that allows embryonic stem cells to
                                                              (mild, moderate, severe), sometimes causing severe
differentiate into cell types such as muscle, nerve, and
                                                              inflammation and irreversible loss of bone tissue.4
blood cells. Adult stem cells are found in mature tissue
                                                              However, the irreversible nature of this condition may
such as bone marrow. Stem cells can be instructed
                                                              be a thing of the past. Researchers have been evaluating
to become any type of cell in the body, including
                                                              different methods to reverse or find an alternative
osteoblasts, which are responsible for bone formation.
                                                              solution to the effects of periodontitis. Unfortunately,
    There are five types of stem cells that can be obtained
                                                              these methods have not yet achieved a successful full
from the structures of the oral cavity:3
                                                              restoration of the periodontium. However, there are
• Dental Pulp Stem Cells (DPSCs)—mesenchymal type             current treatments available in the market that can
  of cells found inside dental pulp tissue.                   repair periodontium and replace missing teeth.
• Stem Cells from Human Exfoliated Deciduous Teeth                Bone and tissue grafts and flap surgery are some
  (SHEDs)—found in deciduous teeth, these cells show          of the most popular treatments available to treat
  greater proliferation and differentiation than bone         periodontitis. Both methods help treat inflammation,
  marrow stem cells (BMSCs).                                  but bone and tissue grafting recover lost periodontal
• Periodontal Ligament Stem Cells (PDLSCs)—exhibit            tissue and bone. Gingival grafting is a procedure that
  properties similar to mesenchymal stem cells (MSCs),        uses synthetic material or tissue from another area of
  the most widely studied adult stem cells.                   the mouth to cover exposed roots.5 Treating periodontal
                                                              disease with flap surgery is recommended for people

                                                                          March/April 2018 The Dental Assistant PG 9
The Promise of Stem Cells in Dentistry Obesity Effects on Periodontal Disease Drug Abuse Aware and Prepared Office-Based Anesthesia ...
The Promise of Stem Cells in Dentistry
continued

with moderate to severe periodontitis. In this procedure,      created from stem cells and successfully transplanted to
the gingiva (free gingiva and attached gingiva) is             a human. The patient appeared in various news reports
separated from the underlying alveolar bone in order to        saying how well he felt after the procedure. There were
debride root surfaces that are too deep to be accessed         many legal and ethical issues presented, especially when
with traditional methods.6 Once the areas have been            the patient died two years after the procedure. Other
thoroughly debrided, the gingival is reattached. This          reasons that might have influenced the death of the
process effectively reduces pocket depth to allow both         patient are still unclear.
patient and dentist to have better access to the affected          Realizing the incredible potential of stem cells to heal,
area. It is also used to facilitate placement of dental        there now exists the possibility of banking stem cells.
implants.                                                      People can save their biomaterial to use in the future for
   While effective in allowing access to previously            regenerative therapy, and that service can be provided
unreachable areas, these methods have some                     in the dental office.10 Dental stem cells are found in
disadvantages because they are not efficient in repairing      teeth with “healthy pulp.” Often these teeth are seen
bone and soft tissue loss. In gingival grafting, the “new”     as waste because they are the wisdom teeth, which are
gingiva does not adhere completely, which leaves deep          usually extracted, or deciduous teeth.
pockets that can accumulate bacteria if not properly           Conclusion
maintained. Another downside to these treatments is            Dr. Rena D’Souza, from the University of Utah School of
that the body can reject the transplant (i.e. graft), which    Dentistry, believes that treatment using stem cells will
will lead to more surgery to remove the implant.6 If           become a reality within 5-10 years.11 The encouraging
stem cell treatment is perfected, transplanting tissue         data coming from trials done on animals have made
from a different part of the mouth will not be necessary.      stem cells a popular topic in dentistry since people
Successful Regeneration on Animals                             care more about health and aesthetics than they
For stem cell treatment to become a reality, it first          ever did. Although not all procedures done with stem
needs to be approved for testing on human subjects             cells have succeeded, the rapid advances have shown
by the Food and Drug Administration. While there               many positive and beneficial outcomes. Stem cells
is no data regarding human subjects, successful                will revolutionize medicine and are poised to have a
generation of biological tooth crowns and roots has            massive impact in dentistry as well.
been accomplished in animals.7 Japanese researchers
                                                               Anderson Benavides is a senior student in the dental
have been able to form a whole tooth from stem cell
                                                               hygiene program at Eugenio Maria de Hostos Community
in mice.8 A study on pigs using bone marrow fluid and
                                                               College. Diana Macri is an assistant professor in the Dental
mesenchymal stem cells was successful as researchers
                                                               Hygiene Unit, Allied Health Department, at Eugenio Maria
were able to grow a whole tooth after 40 weeks of
                                                               de Hostos Community College.
implantation.7 The downside of this experiment,
however, and one that many scientists are finding,
may also be the main reason why trials in humans
have not been yet conducted. Issues involving the
shape determination, size control, and eruption of the
tooth need to be solved.8 Because stem cells obtained
from the oral cavity have a specific role in the formation
of the tooth, scientists are trying to pinpoint the stage of
tooth development in which stem cells become active,
and at which point they stop this activation.
    A few years ago, the pressing problem was how to
stop stem cells from growing when trying to create
certain organs or tissues. Recently, a trachea was

PG 10 The Dental Assistant March/April 2018
The Promise of Stem Cells in Dentistry
continued

References                                                     6. Zuhr O, Baumer D, Hurzeler M. The addition of soft tissue
 1. Mudda J, Bajaj M. Stem cell therapy: A challenge to           replacement grafts in plastic periodontal and implant
    periodontist. Indian Journal of Dental Research. 2011;        surgery: critical elements in design andexecution. Journal
    22:132-139.                                                   of Clinical Periodontology. 2014; 41 (Suppl. 15): S123–S142.
 2. NIH Stem Cell Information Home Page. In Stem Cell          7. Nadig R. Stem cell therapy–Hype or hope? A review.
    Information [World Wide Web site]. Bethesda, MD:              Journal of Conservative Dentistry. 2009; 12:131-138.
    National Institutes of Health, U.S. Department of Health   8. Chen Y, Yu Y, Liu L, et al. Human Umbilical Cord
    and Human Services, 2016. Cited January 30, 2018.             Mesenchymal Stem Cells: A New Therapeutic Option for
    Available at https://stemcells.nih.gov/info/basics/1.htm      Tooth Regeneration. Stem Cells International. 2015; 2015:
 3. Park Y, Cha S, Park Y. Regenerative Applications              Article ID 549432, 11 pages. Available at http://dx.doi.
    Using Tooth Derived Stem Cells in Other Than                  org/10.1155/2015/549432.
    Tooth Regeneration: A Literature Review. Stem Cells        9. Tzong-Fu K, Hsin-Chi L, Hao-Hueng C, et al. Bone Marrow
    International. 2015; 1-12.                                    Combined with Dental Bud Cells Promotes Tooth
 4. American Dental Association. Study Estimates Nearly           Regeneration in Miniature Pig Model. Artificial Organs.
    Half of American Adults Have Periodontal Disease.             2011; 35:113-121.
    Published September 27, 2012. Accessed January 30,         10. Majeski J. Dental Stem Cells in Research and Practice.
    2018.                                                          Access. 2009; 23:24-26.
 5. National Institute of Dental and Craniofacial Research.    11. YouTube. http://www.youtube.com/watch?v=_
    Periodontal (Gum) Disease: Causes, Symptoms, and               Gyv-BVniAw. Published October 9, 2013. Accessed April
    Treatments. https://www.nidcr.nih.gov/OralHealth/              3, 2017.
    Topics/GumDiseases/PeriodontalGumDisease.htm
    Published 2013. Updated December 8, 2014. Accessed
    January 30, 2018.

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                                     to work for you and your colleagues.          Assistants Association
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                                         VOLUNTEER AND GET INVOLVED                        Bloomingdale, IL 60108-1017
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                                                                          March/April 2018 The Dental Assistant PG 11
Obesity Effects on Periodontal Disease
Oral health care professionals need to understand how obesity affects the
dental process of care

By Annie Chitlall, RDH, BS

T
       he public and health-care providers have              Background
       shown increasing interest regarding the link          In 1977, the first association between PD and obesity
       between oral and systemic health. Obesity and         appeared after interesting changes were observed in
periodontitis continuously affect more people in the         the periodontium of obese rats. The rats accumulated
world, and a link between obesity and periodontal            biofilm, which produced severe periodontal
disease has been scientifically established.1                inflammation and destruction of alveolar bone.1 The
Periodontal disease (PD) is a bacterial-induced chronic      inflammatory process in obesity is similar to the disease
inflammatory disease that releases endotoxins.2              process in periodontal disease because inflammation
The endotoxins in PD activate the pro-inflammatory           releases cytokines in both disease processes.2 Obesity
cytokines interleukin (IL)1– and tumor necrosis factor       is a systemic condition capable of exacerbating the
alpha (TNF-a), which destroys the periodontal ligament       severity and advancement of periodontal disease.5 As
and causes resorption of the alveolar bone.3 A               a result of the systemic chronic inflammatory process
general dentist or a periodontist is responsible for         that occurs in obesity, there is an increased production
making a clinical diagnosis of PD.4 Several variables,       of reactive oxygen species resulting in an aerobic
such as tooth loss, recession, clinical attachment           environment; the oxidative environment alters the host
loss, periodontal probing depths, tooth mobility, and        immune system and increases vulnerability to various
radiographic evidence of bone loss are used to make a        infections.6
clinical diagnosis of periodontal disease.5                  Obesity and Oral Health
    Approximately 50 percent of American adults over         Globally, the most prevalent oral health condition is
the age of 30 have chronic periodontitis, and 38 percent     untreated dental caries in children.10 Approximately
have moderate to advanced stages of the disease.3            621 million children have dental caries in deciduous
Overweight individuals are predisposed to high bacterial     teeth.9 The leading causes of increased dental diseases
cells in subgingival plaque, and oral bacteria may           are excessive sugar intake and improper oral hygiene.11
increase metabolic efficiency when transferred through       A diet high in fermentable carbohydrates is associated
the gastrointestinal tract.6 An obese individual is more     with diseases of the oral cavity.8 A sugary diet fosters the
susceptible to infections because obesity alters the host    development of other non-communicable conditions,
immune response.7 Globally, obesity is the most notable      such as diabetes, chronic kidney disease, and obesity.7
public health problem, affecting 34 percent of adults in     Obesity, weight gain, and increased waist circumference
the United States alone.3                                    may contribute to the development of periodontal
    Oral health disparities, such as periodontal disease     disease.1,4
and dental caries related to obesity, affect 3.9 billion        Additionally, obesity impairs healing related to
people worldwide.8 Oral health professionals are             maxillofacial surgical procedures.4,11 Obesity makes third
responsible for assessing the degree to which a              molar extractions difficult with complicated post-surgical
patient’s risk factors outweigh the protective factors       healing.6 The total time for extraction increased in
and provide recommendations to tip the balance               overweight patients with 50% of the surgeries in obese
toward health. Patients typically have more trust in the     patients categorized as very difficult.11 Approximately
recommendations of their oral health care provider and       3.9 billion people worldwide are affected by periodontal
will be more accepting of treatment recommendations          disease and dental caries related to obesity.12
given by a dentist or dental hygienist regarding the state
of their periodontal health and body weight.9 Dental         Etiology of Periodontal Disease
and systemic diseases are both the byproducts of a high      The exact cause of periodontal disease has not been
carbohydrate diet.8 Some suggest that dental diseases        definitely identified; however, augmented secretion
are early indicators of diabetes, obesity, and coronary      of pro-inflammatory cytokines is assumed to be a
heart disease.9 This article explores the links between      contributing factor.1 The mildest form of periodontal
oral hygiene status, periodontal health and obesity.         disease is gingivitis. Gingivitis is an inflammation of the
                                                             gingival tissue induced by the pathogens residing in

PG 12 The Dental Assistant March/April 2018
Obesity Effects on Periodontal Disease
continued

dental plaque around the gingival margin and sulcus.13        gluconeogenesis, which elevates the triglycerides
The bacteria in the gingival sulcus foster the progression    levels because of high numbers of free fatty acids.6 In
of periodontal disease, which results in apical loss of       men, obesity is parallel to an increase in abdominal
epithelial attachment along with loss of hard and soft        and visceral fat.7 In women, fat is distributed by an
periodontal tissues.14 Gingivitis is reversible by removing   enlargement of subcutaneous and visceral fat along with
the etiological factors; however, if left untreated,          a modest amount of fat in the gluteofemoral region.12
gingivitis progresses to irreversible periodontal disease.5   Prevalence of Obesity
   There are 400 species of bacteria found in                 Increased sedentary lifestyles and a high caloric diet
subgingival plaque. However, the bacteria most                created a worldwide epidemic of obesity.15 According
frequently associated with the progression of PD is           to the CDC, one in every three adults is obese, and
Porphyromonas gingivalis, a particularly pathogenic           61 percent of overweight children aged 5 to 10 years
organism, which initiates an inflammatory response            have one or more risk factors for chronic diseases.16
that destroys alveolar bone, facilitates ulceration of        The prevalence of obesity worldwide has doubled in
the epithelium, and exposes the connective tissue.14          North America, the United Kingdom, Eastern Europe,
In periodontitis, a vast number of cytokines mediate          the Middle East, the Pacific Islands, Australia, and
the inflammatory mechanisms that occur during tissue          China.11 By 2015, approximately 2.3 billion adults will be
destruction.6 Bacteria are the prime etiological factor in    overweight, and more than 700 million will be obese.10
periodontitis; however, bacteria alone are insufficient       In 2007 to 2008, in the United States, the overall obesity
to advance the disease process. Various risk factors,         rates reached 24.1 percent, making it the country with
such as stress, genetics, and systemic health outweigh        the highest obesity index amongst all high-income
the effects of bacterial metabolism in the development        countries.2,10
of periodontitis.5 Porphyromonas gingivalis activates
host cells, which results in the release of cytokines and     Risk Assessment for Obesity and Periodontal Disease
tumor necrosis factor.14 The pro-inflammatory process         Obesity is suggested as the second risk factor after
in periodontal disease is similar to the release of           smoking for the inflammatory process that destroys
cytokines and hormones from adipose tissue in obesity.2       tissue in periodontal disease.11 Additionally, in an obese
In PD, the cytokines are part of the circulation system.12    individual, there is increased clinical attachment loss
Porphyromonas gingivalis is also a risk factor for various    and deeper periodontal pockets.11 Obesity is a state
systemic diseases, including obesity. There is substantial    of low-grade inflammation due to the increase in the
evidence linking periodontal disease to atherosclerosis,      release of tumor necrosis factor- a and interleukin 6
Type 2 diabetes, and obesity.14                               (IL-6).17 The state of low-grade inflammation is fueled
                                                              by cytokines that adjudicate inflammation.15 Obesity
Etiology of Obesity                                           increases the chance of destructive periodontal disease
Obesity is the abnormal or excessive accumulation of          by 35 percent.12
fat.15 Obesity has a wide range of etiological factors,
including genetic, biological, social, and behavioral         Pathophysiology of Obesity and Periodontal Disease
factors, which all combine and eventually lead to an          The primary cause of obesity and periodontal disease
imbalance between energy intake and expenditure.15            is inflammation. Human fat cells secrete 12 types of
The measuring tool used to classify an individual as          inflammatory cytokines, including interleukin-6 and
obese or overweight is the body mass index (BMI).2 The        TNF-a, which alters the metabolic mechanism of the
BMI is calculated using a person’s weight in kilograms        cytokines in the body and fosters low-grade systemic
divided by the square of height in meters.16 According        inflammation.9 For each unit increase in BMI, there
to the World Health Organization, a person with a BMI         was a 5% increase in the progression of alveolar bone
equal to or more than 30 kg is considered to be obese.10      loss13, and for every one-centimeter increase in waist
In obesity, adipose tissue is an inactive organ used for      circumference, there was a 1% to 2% increase in the
storage of triglycerides.2 The liver of an overweight         progression of probing depth and clinical attachment
person decreases the uptake of insulin and increases          loss.18 An obese patient who presents with periodontal

                                                                          March/April 2018 The Dental Assistant PG 13
Obesity Effects on Periodontal Disease
continued

disease becomes high risk for cardiometabolic illnesses    Conclusion
compared with individuals with a healthy weight.17         Obesity is a contributing risk factor for periodontal
Gingivitis scores decreased by one-third when there was    disease separate from other risk factors, such as age,
a moderate decrease in high carbohydrate diet.9            gender, race, and ethnicity.17 Inflammation related
Treatment of Periodontal Disease                           to obesity is a contributor to periodontal disease
The traditional approach to periodontal therapy            progression.17 Adipose tissue secretes inflammatory
is scaling and root planing (SRP) with manual and          markers, which increase gingival inflammation and
ultrasonic scalers.19 Scaling and root planing is a        enhance the spread of bacteria.1 The disease process
simple and affordable method of eliminating microbial      in periodontitis also influences the production of pro-
deposits which favors optimal periodontal health.6         inflammatory cytokines, which stimulate various chronic
There are also various other methods of non-surgical       metabolic diseases, including obesity.1 While men are
adjunctive periodontal treatment, such as lasers and       at a higher risk for developing PD than women, the
locally delivered controlled-release antimicrobials,       hormonal changes occurring in women can also increase
which promote reductions in pocket depths.19 In            gingival inflammation and create susceptibility to
the United States, locally delivered, control-released     periodontitis.1,25 The influence of sex on the association
antimicrobial products are tetracycline, chlorhexidine     between overweight/obesity and development of
chip, doxycycline gel, and minocycline microspheres.20     periodontitis is inconclusive.24
                                                               In the presence of obesity, younger adults,
Periodontal Therapy and Obesity                            women, and non-smokers experienced greater
Periodontal therapy has been shown to have positive        epithelial attachment loss and increased prevalence
effects on the inflammatory markers in patients with       of periodontal disease.24 Dentists and oral health
obesity and other systemic diseases.6 Obese patients       care professionals should consider implementing the
with periodontal disease responded clinically to           measurement of BMI index as part of the routine dental
periodontal therapy similar to normal weight patients      screening. The dental professional can use the BMI
with PD.21 As inflammation decreases, there is decrease    index to determine if treatment modification will be
in the release of cytokines in the gingival crevicular     necessary and to predict any possible complications
fluid following periodontal therapy.22 Obese patients      related to the treatment. The effects of obesity on the
presented with good clinical scores and consistent         progression of PD are significant, and oral health care
levels of adipocytokines and high-density lipoprotein      professionals need to be able to understand that obesity
serum.21 Research shows there was an increased risk        can also affect the dental process of care.
for future cardiovascular disease in individuals who did
not respond well to periodontal treatment.23 Successful                    Annie Chitlall, RDH, BS, is an adjunct
periodontal therapy may influence the progression of                       lecturer in the dental hygiene department
subclinical cardiovascular disease.23 The periodontal                      at New York City College of Technology
parameters in both overweight and healthy weight                           and the dental hygiene unit at Eugenio
patients had significant improvements in periodontal                       Maria de Hostos Community College,
therapy.22 Periodontal treatment resulted in significant                   both in New York City. In addition to
reduction of serum leptin and C-reactive protein levels,                   teaching, Chitlall also works as a clinical
which demonstrated that periodontal therapy produced                       hygienist in two private practices.
beneficial outcomes in patients with obesity and chronic
periodontitis.4 Periodontal treatment is a simple
and cost-effective method of eliminating microbial
deposits favoring optimal periodontal health. It is safe
to conclude that periodontal treatment is effective
in altering the progression of inflammation in obese
patients.4

PG 14 The Dental Assistant March/April 2018
Obesity Effects on Periodontal Disease
continued

References                                                         12. Pasquali, R. The hypothalamic-pituitary-adrenal axis
1. Keller A, Rohde J, Raymond K, Heitmann B. Association               and sex hormones in chronic stress and obesity:
   between periodontal disease and overweight and obesity:             Pathophysiological and clinical aspects. Annals of The New
   a systematic review. Journal of Periodontal Research 2015;          York Academy of Sciences 2012; 1264, 20–35.
   86:766-776.                                                     13. Bhatt S, Garrison C, Johnson Y, Patel S. Periodontal
2. Fearing Tornwall R, Chow A. The association between                 Screening: Patient Attitudes and Clinical Care Decision
   periodontal disease and the systemic inflammatory                   Making. Journal of California Dental Hygienists’ Association
   conditions of obesity, arthritis, Alzheimer’s and renal             2014; 30:6-13.
   diseases. The Canadian Journal of Dental Hygiene 2012;          14. Boyd L, Giblin L, Chadbourne D. Bidirectional relationship
   46:115-123.                                                         between diabetes mellitus and periodontal disease: State
3. De Pergola G, Abbinante A, Cagiano R, et al. The bad                of the evidence. The Canadian Journal of Dental Hygiene
   association: obesity, periodontal disease, inflammation             2012; 46:93-102.
   and insulin resistance. Review and personal findings.           15. Khosravi, R., et al. Tumor necrosis factor-a and
   Nutritional Therapy & Metabolism 2014; 32:53-60.                    interleukin-6: Potential inter organ inflammatory
4. Types of gum disease. American Academy of                           mediators contributing to destructive periodontal
   Periodontology. Available at: http://www.perio.org/                 disease in obesity or metabolic syndrome. Mediators of
   consumer/types-gum-disease.html. Accessed January 28,               Inflammation 2013, 1–6.
   2018.                                                           16. Centers for Disease Control and Prevention. 2015, May
5. Mosley M, Offenbacher S, Phillips C, Granger C, Wilder R.           15 body mass index (BMI). Available at: http://www.cdc.
   North Carolina Cardiologists’ Knowledge, Opinions and               gov/healthyweight/assessing/bmi/index.html. Accessed
   Practice Behaviors Regarding the Relationship between               January 28, 2018.
   Periodontal Disease and Cardiovascular Disease. Journal of      17. Hein, C., & Batista, L. E., Jr. Risk assessment for obesity and
   Dental Hygiene 2014; 88:275-284.                                    periodontal disease. Decisions in Dentistry 2017, 1–12.
6. Gurav AN. The association of periodontitis and metabolic        18. Gorman A, Kaye E, Apovian C, Fung T, Nunn M, Garcia
   syndrome. Dental Research Journal 2014; 11:1-10.                    R. Overweight and obesity predict time to periodontal
7. Papageorgiou S, Reichert C, Jäger A, Deschner J. Effect of          disease progression in men. Journal of Clinical
   overweight/obesity on response to periodontal treatment:            Periodontology 2012; 39:107-114.
   systematic review and a meta-analysis. Journal of Clinical      19. Zammit E. Comparison of Er: YAG laser debridement
   Periodontology 2015; 42:247-261.                                    versus conventional scaling and root planing. The
8. Meier T, Deumelandt P, Christen O, Stangl G, Riedel K,              Canadian Journal of Dental Hygiene 2012; 46:183-186.
   Langer M. Global Burden of Sugar-Related Dental Diseases        20. Finkelman R, Polson A. Evidence-Based Considerations for
   in 168 Countries and Corresponding Health Care Costs.               the Clinical Use of Locally Delivered, Controlled-Release
   Journal of Dental Research 2017; 96:845-854.                        Antimicrobials in Periodontal Therapy. The Journal of
9. Watterson, D. G. The role of diet in oral disease                   Dental Hygiene 2013; 87:249-264.
   prevention. RDH Magazine 2013; 79–81. Available at: http://     21. Duzagac E, Cifcibasi E, Cintan S, et al. Is obesity associated
   www.rdhmag.com/articles/print/volume-33/issue-10/                   with healing after non-surgical periodontal therapy?
   features/the-role-of-diet-in-oral-disease-prevention.html.          A local vs. systemic evaluation. Journal of Periodontal
   Accessed January 28, 2018.                                          Research 2016; 51:604-612.
10. World Health Organization. 2009 fact sheet on unhealthy        22. Nair V, Bandyopadhyay P, Kundii D, Das S. Elucidating
    diets and physical inactivity report 2009. Available at:           the Role of Non-Surgical Therapy on GCF Interleukin-18
    http://www.who.int/nmh/publications/fact_sheet_diet_               Levels in Indian Population with Periodontal Disease.
    en.pdf. Accessed January 28, 2018.                                 International Medical Journal 2016; 23:21-25.
11. Yuan J, Lee D, Afshari F, Galang M, Sukotjo C. Dentistry and   23. Holmlund A, Lampa E, Lind L. Poor Response to
    obesity: a review and current status in U.S. Predoctoral           Periodontal Treatment May Predict Future Cardiovascular
    dental education. Journal of Dental Education 2012;                Disease. Journal of Dental Research 2017; 96:768-773.
    76:1129-1136                                                   24. AlJehani, Y. A. Risk factors of periodontal disease: Review
                                                                       of the literature. International Journal of Dentistry 2014,
                                                                       1–10.

                                                                                March/April 2018 The Dental Assistant PG 15
Drug Abuse Aware and Prepared
The opioid crisis brings a new risk to today’s dental practices,
including patients and employees

By Cris Zimmerman, RDH, BS

T
       he opioid problem has become a nationwide
       epidemic, affecting every generation, gender,
       race, income level, and profession. The opioid            It is disheartening to see what any
problem is affecting all areas of the workforce,
including the dental profession. It’s a harsh reality                form of addiction can do to a
for those in management positions who are trying to
maintain a safe and a professional work environment.             wonderful person and competent
   There are many indicators that you can watch for to
reveal if a person is abusing drugs. And, it’s important
to know that the recommended urine or blood tests are
                                                               employee. Any number of devastating
not fail-proof resources for determining if a suspected
employee may have a drug abuse problem.                         issues can contribute to drug abuse.
   Consider some lessons I’ve learned in my own
work as a dental hygienist and in discussions with                However, it’s important for dental
professional peers.
   One manager shared her experience with an                      practices to be aware of the risks.
employee who started to show a decline in her work
skills and personal appearance. This staff member was
a great employee when she was first hired. However,         the results would indicate whether an employee was
the manager started to notice a rapid change in her         abusing narcotics. After sending an employee for two
appearance and work ethic. Furthermore, her behavior        separate drug tests, and knowing from other employees
became peculiar; she hid things where no one else           that this person was in fact abusing narcotics, the
would even think to look for them. She was fidgety          employee passed both tests. The manager knew
and appeared nervous. She tried very hard to come           from my other sources that one of his employees was
across as confident with a leadership desire but the        snorting pain killers along with other drugs and bragging
actions didn’t line up with her words. She began to         about it to other co-workers. He needed proof in order
develop sores on her face that she claimed was a form       to fire the employee. He contacted the lab and asked
of acne, but the manager knew it was nothing like           if the employee’s tests were supervised because he
the acne she had experienced or seen. A number of           figured he must have taken someone else’s urine with
people approached the manager with genuine concern          him. She assured the manager that the second test
and compassion for this individual, including patients      was supervised. The manager then inquired further on
who genuinely cared for the employee in question but        how someone could pass a urine test when they are
had also noticed alarming changes. The manager was          likely abusing drugs. He was told that if someone has
unaware these issues were indicators of a drug problem      a prescription for Adderall or similar drug, which is a
until it was brought to her attention.                      methamphetamine, the lab looks at the prescription
   Ultimately, the manager used her state’s online          history and automatically gives a pass on anything in
substance abuse reporting system to check the               that category. This would have been the same result if
employee’s history of narcotic prescriptions, a resource    he had sent him for a blood test, which costs more, and
typically used by medical practices to protect themselves   was his next course of action.
from drug-seeking patients. Unfortunately, the manager          It is disheartening to see what any form of addiction
found a need to check out an employee, especially after     can do to a wonderful person and competent employee.
she had requested pain medications from the practice.       Any number of devastating issues can contribute to drug
The manager was shocked at how many prescriptions           abuse. However, it’s important for dental practices to be
for controlled substances had been prescribed to the        aware of the risks. Patients trust in our care and should
employee and her husband from the practice.                 feel confident that the employer will hire the capable
   In another instance, a manager indicated that he         team to deliver the standard of care they need and
assumed if he sent an employee for drug testing,            deserve.

PG 16 The Dental Assistant March/April 2018
Drug Abuse Aware and Prepared
continued

    An impaired dental assistant puts herself, the
practice, and the patient at risk. The onus is on
managers to be aware of opioid and other drug abuse
and have systems in place to identify employees who          Interested in writing an article
may be at risk or already abusing drugs. The North                  for the journal?
Carolina Controlled Substance Reporting website is an
excellent resource: www.nccsrsph.hidinc.com. Bear
in mind, there are strict rules for how the site can be
                                                                       Email the Managing Editor at
utilized. Generally, drug problems begin with pain                       abrady@adaausa.org
medications, but when that becomes too costly and
difficult to continue, abusers seek out heroin and other
dangerous drugs. Medical/dental professionals are
catching on and monitoring the amount of prescription
drugs they prescribe. Dentists are now required to take
at least an hour of continuing education on controlled
substance prescribing. North Carolina dentists will
soon be required to be listed on the North Carolina
site and required to look up any patient before they
provide a controlled substance and also document that
prescription in the patient’s chart.
    Be aware of what is going on in your community
and workplace at all levels. Please be sure to look
further into the rules of employment within your local
employment security commission and remember that
you can’t single out one employee for drug testing.            PARTNERSHIP.
    At my own practice, it has become our policy that
all employee candidates are drug screened prior to             INTEGRITY.
employment, although, as noted, these tests aren’t
without flaws. I have adopted a policy that was given          INNOVATION.
to me from a mentor: Be slow to hire and quick to
fire. Obviously, we aren’t going to fire unless there is       Working hard to deliver the very best in
reasonable, documented cause, but always act in the            patient experience and practice lifestyle.
best interest of the work environment for patients and
                                                               At Patterson Dental, we are proud to connect you with
the rest of the team.                                          innovative tools and resources so that you can focus on
                                                               providing expert dental care.
Cris Zimmerman, RDH, BS, is a dental hygienist and             Let us be your partner in providing everything you need
office manager in Jacksonville, NC. Reach her at               to excel at dentistry.
christinecrannie@yahoo.com.
                                                               CONTACT YOUR LOCAL BRANCH
                                                               800.873.7683 | PATTERSONDENTAL.COM

                                                           18P0687c (1/18)

                                                                         March/April 2018 The Dental Assistant PG 17
Office-Based Anesthesia
How Dental Assistants Ensure Safe Patient Care

By Martha Peters, CDA

O
         ffice-based anesthesia privileges are vital to the   skills used in anesthesia administration. Frequently
         livelihood of all dental practices that administer   providing the dental team with opportunities to expand
         anesthesia and sedation. The ability to provide      knowledge through hands-on training and evaluation
effective pain and anxiety management to patients in a        is an effective way to master skills. Recognition and
safe environment is a need that has always existed.           management of office emergencies are essential to
    Because the dental team must deliver quality office-      successful outcomes. Recognizing and responding to
based ambulatory anesthesia, a critical need exists           emergency situations are fundamental skills that must
to properly validate training for dental anesthesia           be mastered.
assistants—staff members who work under the care of               A number of resources are available for training and
dentists who administer anesthesia and sedation. The          developing the dental anesthesia team for excellence:
validation of this training and skillset continues to be      • The DAANCE (Dental Anesthesia Assistant National
under scrutiny because of the importance of patient             Certification Examination), developed by AAOMS
safety when administering anesthesia. Anesthesia                (American Association of Oral and Maxillofacial
and sedation administration is a right earned by many           Surgeons), is a core educational curriculum geared
dentists through intensive training and is a privilege that     towards training the dental anesthesia assistant
must be held to the highest standards and delivered             for office-based anesthesia and sedation assisting.
with safety, confidence, and effectiveness.                     DAANCE is also offered to all dental specialty
    Training for excellence in office-based anesthesia          anesthesia assistants where sedation and anesthesia
requires leadership, preparation, and simulation. A             are administered in offices that hold valid anesthesia
comprehensive training plan starts with the dentist’s           permits.
vision for the practice to build, lead, and engage
                                                              • The Anesthesia Assistants Review Course (AARC),
the team, encouraging them to weave purpose,
                                                                sponsored by AAOMS, is a comprehensive live,
commitment, and passion into every aspect of patient
                                                                in-person review course that emphasizes essential
care. Leadership from the surgeon is a key component
                                                                anesthesia protocols/guidelines for the dental
to attracting and retaining top quality staff that will
                                                                anesthesia assistant. A condensed version is also
engage in training and support the practice vision.
                                                                available online. AARC also prepares the assistant for
Dentists who expect excellence will get excellence.
                                                                the DAANCE examination.
    Staff will respond to a dentist who clearly
communicates the expectations and provides support,           • The Anesthesia Assistants Skills Lab (AASL) for
as well as sharing knowledge. While dental anesthesia           AAOMS allied staff provides hands-on training with
assistants don’t administer anesthesia and sedation,            anesthesia administration, airway management,
they play an important role in supporting the dentist           dysrhythmia recognition, and medical emergency
as he administers anesthesia. Teachable and trainable           management.
moments elevate the practice. Constant immersion              • AAOMS also recently offered its members an
in training is the single-most important element to             upcoming live in-person course on Advanced
emergency preparation and management. Skills are                Protocols for Medical Emergencies that discusses
mastered with confidence through in-depth knowledge,            emergencies encountered in the OMS office setting
understanding, and frequent performance. Training for           and the participation of the assistant in these
excellence prepares staff for the unexpected. Skills are        situations. Upcoming AAOMS webinars on preparing
improved through constant review of our proficiencies           staff to handle an office emergency are also available.
and deficits. Identifying the gap between what we have        • ACLS (Advanced Cardiac Life Support) and PALS
mastered and what we need to master is critical. Part of        (Pediatric Advanced Life Support) certification provide
the training plan needs to fill that gap.                       a systemic approach to advanced resuscitation
Training Opportunities                                          efforts through recognition and evaluation of
Training for excellence in office-based anesthesia              algorithms, airway management, and pharmacology
includes teaching, practicing, and demonstrating                administration.

PG 18 The Dental Assistant March/April 2018
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