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2020 Dental Hygienist Renewal Bundle Back to Course Index






The course includes multiple lessons in one document.  It is not timed and you can come and go as you please.  You must complete the quiz at the bottom which covers all of the lessons for credit.  Completing this one quiz will grant you the full credits of the course (24).  You can take the quiz as many times as needed.  If you do not receive a passing score the quiz will tell you what section you need to review before retaking it.

If you prefer to take the courses with separate quizzes, for example, if you purchased the bundle but only want to take one or two lessons during this renewal period, email us at [email protected] and we can break the lessons apart.

This course includes lessons on:

Medical Errors Prevention in Dentistry 
Domestic Violence
Patient Compliance and Its Effects on Oral Health
Dental Anxiety
Human Trafficking 
Tooth Whitening
Counseling and Treating Bad Breath
Medical Emergencies




As a dental health care professional, you have a responsibility to be aware of the risk of medical errors as well as learn strategies to minimize that potential risk. Medical errors can occur at any point in treatment, even in preventive care, and do not always result in patient injury or death. Dental professionals who suspect the occurrence of an adverse reaction to a drug or dental device have an obligation to communicate that information to the broader medical and dental community, including, in the case of a serious adverse event, the Food and Drug Administration (FDA). 

Alarming Statistics

The shocking figures frequency and of what medical errors cost the US economy prompted a major co-initiative among federal bureaus, such as agencies within the Department of Health and Human Services, with the IOM to reduce medical errors and improve patient safety in federally funded health care programs, and by example and partnership, in the private sector. The Patient Safety and Quality Improvement Act was signed into law on July 29, 2005, with the purpose of establishing patient safety organizations that would collect, aggregate, and analyze confidential information reported by health care providers, identify failure patterns, and propose measures to eliminate patient safety risks and hazards. The Act is part of the IOM’s vision for improving health care delivery and developing a first-rate, patient responsive, 21st-century health care system across the country.

Understanding Key Terms

Patient safety involves the prevention of healthcare errors and the elimination or mitigation of patient injury caused by healthcare errors. The National Patient Safety Foundation further defines Healthcare Error as An unintended healthcare outcome caused by a defect in the delivery of care to a patient. Healthcare errors may be errors of:

  • Commission doing the wrong thing
  • Omission not doing the right thing
  • Execution doing the right thing incorrectly.

Medical malpractice is a broad and obscure term that is often subjective to personal experience and opinion. However, there are certain parameters that have been set in order to recognize when it is present. These factors include:

  • Failure to communicate the diagnosis
  • Formulating an inaccurate diagnosis
  • Lacking informed consent from the patient or the immediate legal family
  • Surgical errors
  • Mistakes in the prescription of medication
  • Neglect.

When using sharp instruments on sensitive areas such as oral tissue, the difference between safe practices and a damaging accident may be only millimeters, turning a careless mistake, at a crucial moment, into an undesired medical error. Although harm does not result from medical error 100% of the time, reducing incidents of improper commission, omission and execution avoids preventable accidents and improves the healthcare outcome.

Medical errors are either active or latent. A latent error refers to an error in the planning, organization, training, or maintenance which leads to operator errors. The effects typically lie dormant in the system for lengthy periods of time. An active error pertains to an error in execution, occurring at the level of the front line operator where effects are felt almost immediately. Latent errors occur due to poor design, incorrect installation, faulty maintenance, bad management decisions, and poorly structured organizations, which may then lead to active errors such as administering the wrong medication or incorrect charting notes.

Active Errors  dent2

Surgical Errors

Adverse events related to surgery accounted for two-thirds of all adverse events and 1 of 8 deaths in a study at Colorado and Utah hospitals in 1995 as reported in JAMA, the Journal of the American Medical Association.

Dr. Stanley Malamed, the author of Medical Emergencies in the Dental Office, indicates a medical consultation is indicated before any treatment that involves a degree of hemorrhage (e.g., periodontal surgery, oral surgery) if the patient is currently receiving anticoagulant or antiplatelet therapy. The doctor should take precautions to prevent postoperative hemorrhage from occurring. Possible steps include a haemonstatic dressing placed within the socket, multiple sutures in the surgical area, intraoral pressure packs, extraoral icepacks, the avoidance of mouth rinses, and a soft diet for 48 hours following the procedure.

Dr. Malamed also advises dentists to verify that adequate analgesic has been administered prior to the surgery to ensure the patient feels no pain, and for the dentist to aid in the postoperative control of pain and anxiety in the patient. After surgery, the dentist should:

  • Be available by telephone 24 hours a day
  • Monitor pain control and prescribe analgesic medication as needed
  • Prescribe antibiotics if a possibility of infection exists
  • Prescribe anti-anxiety agents, if in the doctor’s opinion they may be required by the patient
  • Prescribe muscle-relaxant agents after prolonged therapy or following multiple injections into one area (such as inferior alveolar nerve block).

Providing a patient with adequate medical and moral support after surgery should be a standard practice in dentistry because the medical procedure ends when the patient feels better, not as soon as he or she is out of the surgical room or dental office.

Medication Errors

Healthcare practitioners see many patients monthly who suffer from different ailments. This can be stressful and confusing. Carefully noted medical charts and records remind dental professionals of each patient’s specific condition.

Before administering a drug, a dentist must always ask whether the patient is allergic and consult the patient’s chart to see if he or she is taking any medication or has a condition that may cause an adverse reaction. Dental professionals must also be careful when writing the prescription, verify the right drug and dosage, and advise the patient to take it correctly.

With regards to anesthesia, Dr. Malamed comments, Dosage is a highly significant factor. Within the clinical dosage range for most local anesthetics, there is a linear relationship between dose and maximal blood concentration. The larger the dose of local anesthetic injected, the higher the ultimate blood level of the drug will be.

Dr. Malamed also points out that it has been reported with increasing frequency that certain individuals possess genetic deficiencies that alter their responses to certain drugs. He provides an example of the genetic deficiency in the enzyme serum cholinesterase. Produced in the liver, this enzyme circulates the blood and is responsible for the biotransformation of two important drugs: succinylcholine and the ester type of local anesthetics. Thus due to individual patient physiology, a dentist should take precautions not to administer a drug that may have adverse results.

Diagnostic Inaccuracies

A correct diagnosis is the primary requisite for accurate and effective procedures, treatment, and prescriptions. A misdiagnosis may endanger a patient by delaying treatment or prescribing an ineffective medicine or unnecessary procedure. Inexperience with a technically difficult diagnostic procedure can affect the accuracy of the results and be costly or invasive.

The Council of State Governments issues a pamphlet titled State Regulatory Policies: Dentistry and the Health Professions. Dentistry means the healing art which is concerned with the examination, diagnosis, treatment planning and care of conditions within the human oral cavity and its adjacent tissues and structures. Dental practitioners are expected to have a thorough understanding of these fundamentals and be alert to early warning signs of possible disease.

Latent Errors

System Failures

Systemic factors contribute significantly to preventable adverse events, and in fact, medical errors may result most frequently from faults in the organization of health care delivery and the way resources are provided to the delivery system. Efforts to reduce medical errors in an organization require changes to the system design, including the possible reorganization of resources by top-level management.

With the continual development of technology, the practice of medicine both improves and deteriorates. More complex treatments and dental procedures often allow more room for errors. Often understaffed and not adequately trained, dental offices and other dental care facilities experience serious technical difficulties. Advanced technology has made dental equipment efficient and reliable, but all are human-operated and thus imperfect. Training dental staff to understand and operate dental equipment is crucial, but so is maintaining the equipment and checking it on a regular basis to maintain its safety.

Patient Errors dent4

Human Error

All professionals are prone to make mistakes. Although most cases of dental malpractice involving human errors are not intentional, they must still be reported and properly addressed. The IOM reports the following factors may endanger patient safety:

  • Fatigue: due to working long hours
  • Use of alcohol or other drugs by medical staff, often caused by the high stress of the profession and easy access to medications
  • Illness: coming to work when not well jeopardizes the medical employees’ health as well as the health of the patient under his or her care
  • Inattention/Distraction: a noisy, busy dental office makes it difficult to concentrate on one patient’s care, especially when others are waiting
  • Emotional states: anger, anxiety, boredom or fear can all impair job performance
  • Communication problems: lack of clear and friendly communication among the staff or between health providers and patients
  • Equipment design flaws: training and experience with equipment are key to avoiding errors
  • Hard-to-read handwriting: dentists must write legibly on prescriptions and reports
  • Unsafe working conditions: poor lighting or slippery floors, as well as a disorganized working environment, can lead to chaos.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) notes two common factors contributing to medical errors include: 1) multiple procedures performed during a single visit and 2) unusual time pressure which speeds up procedures.

The National Patient Safety Partnership, spearheaded by the Veterans Administration, released a list of 16 best practices for medication safety in 1999. Some valuable tips for healthcare professionals to help ensure patient safety include:

  • Educate patients
  • Put allergies and medications on patient records
  • Stress dose adjustment in children and older persons
  • Limit access to high hazard drugs
  • Avoid abbreviations
  • Standardize drug packaging, labeling, and storage.

A Properly Trained Staff in Case of Emergency

Without any doubt the most important step in the preparation of a dental office for medical emergencies will be the training of all office personnel, including non-chair side personnel such as receptionists and laboratory employees, says Dr. Malamed. All dental personnel needs adequate training in administering cardio-pulmonary resuscitation (CPR), and advanced cardiac life support (ACLS). Although medical emergencies are rarely seen in dental offices, every care facility must be ready in case one occurs; a trained staff can save a patient’s life.

The dental team should also have a plan in case of an emergency, designating different employees to carry out certain tasks. For example, one employee should provide basic life support and stay with the victim, while another retrieves the emergency kit, and a third will monitor vital signs and keeps records of the incident.

Videotapes are a useful learning tool that provides dental staff with visual examples of what can take place during an emergency situation. They can exhibit the best procedures to implement. Emergency telephone numbers should be clearly displayed by all dental office phones. These should include immediate contact information for ambulance service, nearby hospital emergency room, or local emergency medical services (EMS).

Emergency Phone Numbers and Drug Kit

Aside from emergency phone numbers, emergency drug kits are also valuable. Although there are many commercial brands of drug kits, Dr. Malamed suggests the most desirable approach is for the doctor to prepare a kit that is individualized to meet his or her special requirements and capabilities. This is true in the sense that the dental emergency kit need not, and should not, be complicated since complexity in adversity breeds chaos.

According to Dr. Malamed, there are three points that dental professionals should keep in mind when it comes to emergency medication:

  • Drugs are not necessary for the immediate management of most emergencies
  • Primary management of all emergency situations is basic life support (BLS)
  • When in doubt, never medicate.

Patient Safety Tool Kit

The American Dental Association (ADA) reported in 2008 the Agency for Healthcare Research and Quality (AHRQ) has created 17 ways to help health care providers and patients improve communications, enhance patient safety, and reduce medical errors. These toolkits, available online and free of charge, include a variety of evidence-based training materials, medication guides, and checklists which help to reconcile the discharge of a patient from one facility to another. They are adaptable to many health care settings from emergency departments to intensive care units to outpatient facilities and have been equally intended for dentists, physicians nurses, hospital managers, and others providing safe, quality health care at any point in the health care process. For a complete list of topic areas or to access toolkits online, log on to the Agency for Healthcare Research and Quality (AHRQ) at

Error Prevention and Reduction

Preventing Medication Errors

Most of the time the medications people take are beneficial, or at least they cause no harm, but on occasion, they do injure those taking them. Some of these Adverse Drug Events, or ADEs , are inevitable: the more powerful a drug is, the more likely it is to have harmful side effects, but sometimes the harm is caused by an error in prescribing or taking the medication, and these damages are not inevitable. To aid in decreasing medication errors, the IOM recommends:

  • Enhance doctor/patient communication
  • Suggest steps patients should take to protect themselves
  • Improve packaging, naming, and labeling of drugs to reduce confusion
  • Key in prescriptions electronically
  • Create easy to understand drug information resources for the patient.

Improving Patient Safety

Studies funded by the AHRQ, an agency of the U.S. Department of Health and Human Services, have indicated three computerized methods which reduce reliance on human memory and have shown promise in helping to reduce errors while raising efficiency: computerized ADE monitoring, computer-generated reminders for follow-up testing, and standardized protocols.

  • Computerized ADE Monitoring Although determined less accurate than chart review and voluntary identifying of adverse drug events, it saves five times the personnel time in tracking drug errors
  • Computer-Generated Reminders for Follow-up Testing Have reduced the number of patients subject to unnecessary repeat testing and reduced the time until appropriate treatment could be administered
  • Standardized Protocols Have increased survival rates of patients in intensive care and may raise the efficiency of decision support systems.

Preventive Methods

Prevention attempts to eliminate an error before it happens. Risky situations exist in the dentistry field, such as infections and the spread of HIV and other viruses, but proven steps can prevent and control them. The human oral cavity is home to over 500 different strains of bacteria at any given time and infections are one of the main concerns of dental professionals.

Research shows that protection against infection and cross-contamination is an important preventive measure. Over 65 percent of the adult U.S. population is treated at a dental facility each year. Thus, the dental staff has a professional and ethical duty to protect patients from blood and fluid borne pathogens.

Some preventive methods to control infection and cross-contamination are:

  • Hand-washing is a standard and common practice between dental employees
  • Use of personal barriers such as gloves, eye shields, facemasks and disposable gowns by dental staff
  • Properly dispose of these items after use following hazardous waste guidelines
  • Clean office equipment that may be contaminated during a procedure, such as lamp handles, bracket handles on tables and trays, hoses and handles, switches and chair controls, and patient X-rays and charts.

Many microbial pathogens, from HIV to tuberculosis, can possibly survive from 2 hours to 8 months on the surface of contaminated equipment. Thus, disinfecting these surfaces should be accomplished between patients using an approved medical disinfectant. Another important guideline to avoid the spread of deadly diseases such as the HIV virus is the correct handling of sharp objects. Some reminders are:

  • Needles should never be recapped
  • All “sharps” must be disposed of in approved, one-way depository containers and should be clearly marked as BIOHAZARDOUS WASTE
  • “Sharps” containers should be disposed of properly when 3/4 full.

Another important factor to remember is that certain physical conditions in the patient may complicate certain medical procedures. For example, the introduction of any prosthetic device, whether joint implant, pacemaker, or heart valve, increase patient risk for focal infection; implants provide a healthy medium for bacterial colonization and infection.

In the case of a patient with joint replacements, the ADA recommends a course of prophylactic antibiotic treatment to prevent risks of bacterial build-up. In these particular cases, the dentist should consider treatment on an individual basis and consult with the patient’s physician or orthopedic surgeon to evaluate the risks of joint infection in that patient.

A bite to the inside of the cheek, lip or tongue can provide an easy route for transmission of oral bacteria into the bloodstream of the soft tissues. Thus, dentists are responsible for treating these lesions first and forming a diagnosis of whether these lesions signal a more serious disease such as HIV or oral cancer.

Also keep in mind that prior to performing routine, elective, or invasive dental procedures, oral care practitioners may prescribe a regimen of antibiotic medication as dictated by the patient’s condition. Amoxycillin, ampicillin, erythromycin, and penicillin are among the prescribed medications that have proven effective in oral bacteria.

Root Cause Analysis

Evidence-based risk assessment instruments can prevent future errors from happening by determining the cause of the problem. This is the concept behind Root Cause Analysis or RCA. The JCAHO defines the process as identifying the basic or causal factor or factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. The objectives of a Root Cause Analysis are:

  • First, find out first what happened
  • Second, why did it happen
  • Third, what factors contributed to the event
  • Finally, what can be done to prevent it from recurring

Two essential factors leading to the success of an RCA are:
1) striving to maintain the highest degree of impartiality possible
2) not approaching the case with pre-existing judgment.

According to the National Center for Patient Safety, a thorough RCA must include:

  • Determination of human and non-human factors.
  • Determination of related processes and systems.
  • Analysis of underlying cause and effect systems through a series of WHY questions.
  • Identification of risks and their potential contributions.
  • Determination of potential improvement in processes or systems.

The results of RCAs commonly point to system failures, risk management flaws, and substance abuse by healthcare professionals; as the cause of the error.

Risk Management

Stress on both the patient and the dental staff can cause procedural errors with unfavorable consequences. Emergency situations in dental offices may develop quickly with a failure to follow protocol. Flaws within a dental practice, such as poor communication between staff, health care providers and patients have contributed to the recurrence of errors. Dentists routinely manage these and other risks in daily practice. Risk management strategies encompass the application of risk assessment and communication, plus workplace issues of anti-discrimination, record keeping, privacy, security, fraud, and abuse.


For the ten year period between 1997 and 2007, the Physicians Insurer Association of America (PIAA) reported the average indemnity payment for claims against dental practices and practitioners doubled, from $63,000 to $138,000 per claimant. This is faster than the rise in payments to primary and specialty care providers, although the figures are half that of the indemnity claims against physicians. In fact, most claims closed with much smaller payouts to the patient.

Common malpractice claims dental practices encounter include:

  • Failures to diagnose, such as periodontal disease or oral cancer
  • Carrying out an inappropriate or unnecessary procedure
  • Neglecting informed consent
  • Failure to refer for additional care
  • Operations on the wrong tooth.

Insurance Purchasing

When seeking liability coverage for a practicing professional or dental practice, an oral healthcare provider should consider the reputation and solvency of the insurance carrier. A reputable carrier should be authorized to do business in multiple states; if the practitioner relocates, it is easy to adjust the policy, rather than attempt a new coverage application. The carrier should show a measure of financial stability. This can be determined by checking with industry rating agencies such as AM Best and Standard & Poors. The practitioner should also be concerned with the carrier’s litigation philosophy and history. Companies that vigorously defend against malpractice suits are more desirable to retain than those that quickly close cases in favor of the plaintiff.

Practitioners must also weigh the affordability of policies with the cost and likelihood of particular malpractice claims. Large dental practices may subsidize practitioner’s liability insurance costs. States which have enacted tort reform laws have put caps on the damage amounts in liability claims and are friendly to the healthcare provider. Tort reform has limited claims for non-economic damage in some states, that is, amounts awarded for incidences of pain & suffering, lost wages, and future dental care. Without tort reform, a practitioner might consider carrying higher insurance limits; although such liability amounts should be comparable to others in the workplace, no one should become a lightning rod in a malpractice suit!

Risk Communication

All members of a dental practice should be experienced in patient communications, thus mitigating malpractice risk with house policies that ensure patients understand both the risks of care and their financial obligations before giving informed consent. Especially in the case of cosmetic dental procedures, the dentist and staff should accurately assess the patient’s expectations for positive outcomes. Documenting not only treatment procedures and results but also patient interactions, such as conversation and even body language, can be beneficial should an incident of malpractice arise. Establishing more efficient teamwork between dental employees and more personal respectful relationships between dentists and patients can only lead to better oral health outcomes and business practice results.

Charitable Immunity Protection

Oral care providers who volunteer their services may have some liability protection under state and federal laws. Many states have enacted charitable immunity laws that offer some legal protection to health care volunteers. The Federal Volunteer Protection Act protects certain volunteer clinicians from claims of simple negligence. The ethical responsibilities of participating dentists must also be considered when analyzing the applicability of immunity laws. Risk management planning should involve an assessment of applicable laws and the impact on the potential liability of the society and volunteers.

Legal Considerations

As in the case of medical malpractice, there are specific factors that determine a case of dental malpractice. These four factors are a breach of duty, the duty of care, proximate cause, and injury:

  • Breach of duty – the dentist did not provide competent dental care
  • Duty of care – the dentist had an obligation to provide competent dental care
  • Proximate cause – the patient’s injury was a result of the dentist’s breach of duty
  • Injury – the patient was injured while undergoing dental procedures.

There is a kind of law meant to protect patients that have been victims of malpractice. It is called personal injury law and according to the legal website, The Dentalaw Group at, it is an area of law that seeks to recover damages (compensation) for victims of physical or mental injury that has occurred due to the action (or inaction) of another.

Personal injury law protects patients who have been victims of malpractice. From the Dentalaw Group, a dental malpractice resource center at, [this] area of law seeks to recover damages (compensation) for victims of physical or mental injury that has occurred due to the action (or inaction) of another. and personal injury cases can be filed by the victim, or loved ones, on three bases: negligence, strict liability, and intentional wrong. These are situations which all dental professionals should be aware of and avoid:

  • Negligence – this type of personal injury case includes those injuries that allegedly occur due to the inaction of another (failing to follow safety regulations, etc.)
  • Strict Liability – this type includes injuries that allegedly occur due to a defective product
  • Intentional Wrong – this type of case includes injuries allegedly inflicted upon the victim intentionally.

Examples of Dental Malpractice

In addition to the aforementioned common malpractice claims dentists experience, there are four more examples:

  • Failure to advise the patient of the diagnosis
  • Improper diagnosis
  • Lack of informed consent
  • Dental procedure error resulting in injury to the patient
  • Medication errors.

According to the Dentalaw Group, “there are several cases of dental damage that can take place while a patient is undergoing medical treatment.” These may include:

  • Nerve injury to the jaw, lips, and tongue
  • Anesthesia injury – this also includes anesthesia deaths
  • Injury to the bones of the jaw
  • Injury to the teeth or gums from a faulty crown or bridge
  • TMJ Dysfunction Syndrome resulting from orthodontic treatment
  • Injuries or infections resulting from the use of dental products.

Actual Dental Malpractice Cases

Though many times not publicized, accidents happen in the dental profession and are many times overlooked. There have been some notorious instances of both negligence and malpractice in the dentistry field.

Such is the case of a 40-year-old part-time Florida nursing student and housewife with negligence in crown and bridge treatment prior to periodontal treatment resulting in periodontal surgery and new crowns. This case was settled prior to trial for $47,500 and was disclosed to the Dentalaw Group:

The plaintiff, a 40 year old part-time nursing student and housewife was examined by the defendant’s associate who told her that she needed many of her teeth capped but that she first had to have periodontal treatment. At the next visit, the plaintiff was seen by the defendant who started to prepare her teeth to be capped and told her that her periodontal condition wasn’t so bad. During treatment the patient requested that the defendant cap all of her teeth for aesthetic considerations and he complied. A few months after all of the crowns and bridges were cemented the patient visited a new dentist for routine cleaning and was told to run, not walk, to the nearest periodontist. Upon examination by the periodontist, the patient learned that she needed four quadrants of periodontal surgery which she promptly had performed. Following the surgery, the gingival margin occupied a healthier position which was now 1-3 millimeters away from the metal margin of the crowns which was then visible and unsightly. Thus, the plaintiff had to have all the crowns cut off and replaced. Specials (new crowns and periodontal surgery) were $9,000.

Another actual account found on this legal site is that of a 30-year-old Florida man who needed a root canal due to a temporary bridge coming loose. The case settled for $7,000.00 at a mediation conference::

Plaintiff was a 30 year old pressure cleaning mechanic who underwent the construction of a three unit dental bridge by the defendants general dentist. The temporary bridge came loose shortly before the permanent bridge was to be cemented and the plaintiff walked around without the temporary for a few days. During that interval, the teeth shifted and when the plaintiff returned to the defendant for the final cementation of the bridge, the bridge wouldn’t fit.

The defendant attempted to machine out the inside of the molar crown of the bridge and ground down the molar, which significantly traumatized the nerve. The bridge was eventually cemented but the patient was in extreme pain. The subsequent treating dentist had to do a root canal on the molar which relieved the patients pain.

Once he was out of pain, the patient quit the subsequent treater, complaining that his fees were too high. He began seeing another subsequent treater but never returned to have the bridge finished, by either of his two subsequent treating dentists.

Legal and Financial Consequences

Aside from the physical and emotional suffering, an erroneous diagnosis can cause a patient, the dentist is also adversely affected. Even if a case is settled and the dentist does not lose their practicing license, settlement fees can be high and medical reputations ruined, thus diminishing clientele base and possibly ending a successful dental career.

The high settlements against healthcare professionals for medical malpractice suits make it a necessity to pay increasingly higher premiums for malpractice insurance. Many view it as a vicious cycle: the higher the insurance premium the dentist has to pay yearly, the more he or she is pressured to work and make a profit, and the more room there is for error in the dental office.

Healthcare Professionals on Trial

Once an event happens, you cannot rewind the tape, erase it or do it over. A fraction of a second can be the difference between a successful medical procedure and a suffering patient. When malpractice has already taken place and there is nothing to be done to prevent it, often what follows is a complex legal and emotional trial.

Malpractice trials are economically and emotionally draining for both the patient plaintiff and the dental professional defendant. Know your rights and responsibilities. The risk management department of your dental liability insurance carrier is equipped to answer questions related to liability issues and malpractice events. Use them as your first resource.

McClellan (p.4) states, the author of Medical Malpractice: Law, Tactics, and Ethics, that during a trial:

The defendant physician is subjected to piercing cross-examination in an environment that is unfamiliar and potentially hostile. In this environment, the doctor’s ego, competence, and knowledge are challenged and scrutinized in a manner to which he is unaccustomed. Physicians live and work in a social structure that encourages them to act as if they are in control and indeed demands that they do so. The legal system, on the other hand, turns the defendant into a passive participant who must rely on others to play the dominant roles in resolving the dispute.

Trials are economically and emotionally draining for both the patient (plaintiff) and the dental professional accused of malpractice (defendant). However, the legal process is inevitably linked with the dental profession, especially when it comes to malpractice and knowing some of the legal terms and procedures involved in these cases is an essential part of any dental professional’s training.

Conclusion dent3

Although remarkable advances have been made in the field of dentistry, it remains a practice of both art and science and greatly depends on the skills of its practitioners. Practicing dentistry requires an innate love for humankind and the act of healing others.

Dental professionals are expected to have an ethical and professional understanding of their responsibilities to their patients. Since human suffering can result from errors, both for the patient and the dental professional, oral health practitioners must continually improve techniques to ensure patient safety and to minimize medical errors. In turn, this will assure a sound risk management program and protect practitioners against malpractice suits, the worst consequences resulting from medical error.



Tooth whitening continues to be the number one cosmetic procedure requested by patients of all ages. Americans are spending over 1.4 billion annually on over the counter tooth whitening products. Professional tooth whitening is safe, effective, desired by our patients and the most conservative cosmetic treatment we can offer.

Tooth color is determined by several factors. Both the enamel and the dentin play roles in the determination of what color is seen in the oral cavity. Both the enamel and the dentin are formed by millions of tiny crystals in a lipid/protein matrix.

Enamel is the hardest substance in the body. The thickness of healthy enamel varies by tooth. Enamel is thinnest on incisors (about 2 mm) and thickest on molars (2.5 to 3 mm).

It is composed primarily (about 95%) of calcium phosphate molecules that are packed so tightly together that they are known as apatite crystals. Apatite crystals have often been called hydroxyapatite, which means it has attached oxygen and hydrogen groups, however pure hydroxyapatite does not really exist. Tooth mineral is more like contaminated carbonated hydroxyapatite.

If fluoride ions replace some of the oxygen and hydrogen ions in the crystal, it becomes fluorapatite. Fluorapatite forms a stronger crystalline lattice and is more resistant to acid attack.

All these crystals in the matrix line up into a cluster that is perpendicular to the tooth surface and is known as enamel rods. There are tiny spaces between the crystals and fluids that fill the spaces (protein, lipids, and water) between the rods. Although these spaces are too small for bacteria to enter, other ions such as oxygen, hydrogen, fluoride, and calcium phosphate can enter. If the enamel is demineralized, it provides a more porous area for the carious process.

The natural color of the teeth comes from both the enamel and the underlining dentin. This color can range from a yellowish-white to grey. The color of the dentin is a major contributor to overall tooth color. Genetically determined, dentin color ranges from yellowish-white to grayish-white.

Dentin is the largest tooth structure. It is calcified with tubules filled with plasma-like fluid, much like the enamel. As living tissue, dentin conducts thermal sensitivity and pain from enamel to the nerve root, resulting in hypersensitivity.

Changes in tooth color can occur through several different means. They can be extrinsic or exogenous due to things such as food, drinks, tobacco, and drugs. They usually adhere to the tooth deposits but can also adhere to the tooth structure itself.

Intrinsic, or endogenous stains can also cause color changes within the tooth. These include staining from aging, oral disease, trauma, medications, systemic conditions, and heredity.

As teeth grow older, the pulp shrinks and the dentin becomes thicker, which can cause teeth to look more yellow. Oral diseases, such as exposed root surfaces from gingival recession or restorations, also affect tooth color.

During trauma, vital pulp tissue can die. If a trauma does not destroy the tooth, bleeding into tooth structures can occur causing darkening over time. Enamel defects can result from trauma during tooth formation or inherited dental disorders, such as amelogenesis imperfecta.

Medications taken during tooth formation can result in enamel defects. A common cause is an antibiotic tetracycline. Fluorosis, or excess fluoride consumption, can also cause mottled and spotted teeth, as shown here.

If a patient wants to make them brighter and whiter, this can be achieved. There are several options to choose from in the office, from the office and over the counter (OTC).

The OTC industry has seen the evolution of gels, strips, rinses and chewing gum. The OTC products have produced oral health concerns resulting from undiagnosed or underlying oral health problems. Faders such as dental restorations, extremely dark stains, tooth sensitivity, non-uniform single tooth color difference, cavities, periodontal (gum) problems, exposed tooth-root surfaces, prior root canals, and antibiotic influenced internal colors have all contributed to the varying success of the expended whitening results. The incidence and varying degrees of tooth sensitivity may depend on the bleaching material quality, operator, and applied techniques. Since consumers rarely report adverse problems to the FDA, the American Dental Association advises patients interested in bleaching to consult with their dentist prior to bleaching to help determine the most appropriate method, based on desired results and safety.

In-office whitening (bleaching) materials are typically hydrogen peroxide-based, while some products are carbazide peroxide based. The strength of the in-office bleaching product range typically 3-5 times more concentrated than at-home bleaching materials. Regarding the sensitivity of teeth while using the products, mild to high tooth sensitivity can occur in up to two-thirds of users during the early stages of treatment, with the duration of sensitivity individual. The occurrence and severity of tooth sensitivity and gum irritation may depend on the material brand, quality, technique, duration of applications, and chemical concentrations of products.

As a general consideration of bleaching. patients should begin with a general dental examination that includes health and dental history, along with radiographs. If there is discoloration of teeth, due to favors such as trauma and/or staining resulting from prolonged use of antibiotics, such as tetracycline, the whitening expeditions of the patient may be unachievable without cosmetic
restorative treatment. Past history of tooth sensitivity and allergies, such as ingredients found in the bleaching materials, are all factors to bleaching. Cracks in tooth enamel exposed root surfaces that resist bleaching (and may increase sensitivity), the translucency of the teeth edges, tooth anatomy and alignment, teeth grinding/clenching habits and diets are also considerations that will influence the whitening outcome. if dental restorations are present, the expense and risks related to the replacement of fillings and/or crowns to match post-treatment colors should be recognized and discussed before treatment begins. Smoking and
red wine consumption will influence the duration and outcome of the whitening experience. Age is also a consideration, as teeth typically darker as we get older.

With tray bleaching, the desired color change is normally seen in the 3 days to 6-week range.  Although brown, beige, and light yellowed teeth may respond well to bleaching, white discolorations and grey tooth shades may remain difficult to change. The “background” of the white spots may be lightened to make the white areas less noticeable. Nicotine stained teeth and tetracycline influenced grey teeth may take months to see a color change. Tray systems available from a dental office may have longer-lasting results, safer regarding concentrations of materials, and more control of bleaching gels than OTC tray systems.

With in-office bleaching, proper isolations of soft tissue, such as gums and tongue, is very important. Post-treatment sensitivity is unpredictable. There are some studies that have suggested pulp irritation and tooth sensitivity may be higher with the use of bleaching lights or procedures involving applying heat. Some
studies suggest heat and light application may initially increase whitening appearance due to tooth dehydration, which usually reverses with time. Some studies suggest that the average number of in-office visits for whitening is three, with the range of 1-6 treatments. A tray may be made for take home completion of this process.

Presently, all non-internal tooth bleaching products remain unclassified by the FDA, These products include all in-office peroxide-based products, at-home dentist dispensed products, OTC products, as well as materials used in nondental stores (such as retail stores). Tooth whitening products are developed and marketed under U.S. “cosmetic” regulations.

While there are some side effects mentioned above from teeth whitening, most conventional whitening treatments are fairly safe to use as long as the product’s directions or procedures are followed.

Tooth Whitening has become easy, rewarding, and profitable.  New systems are being brought to market at a dizzying pace so it is important to stay up on current methods and industry knowledge.




Domestic Violence is an inclusive term gathering into itself several other related terms such as domestic abuse, spousal abuse, battering, family violence, dating abuse, and Intimate Partner Abuse (IPA). The definition of domestic violence is A pattern of abusive behaviors including a wide range of physical, sexual, and psychological maltreatment used by one person in an intimate relationship against another to establish power unfairly or maintain that person’s misuse of power, control, and authority. It is typically viewed as a pattern of antisocial behaviors that can take many forms, including physical aggression or assault (hitting, kicking, biting, shoving, restraining, slapping, throwing objects, battery), or threats thereof; sexual abuse; emotional abuse; controlling or domineering; intimidation; stalking; passive/covert abuse (e.g., neglect); and economic deprivation. Domestic violence and abuse are not limited to obvious physical violence. It can also mean endangerment, criminal coercion, kidnapping, unlawful imprisonment, trespassing, harassment, and stalking.

The awareness, perception, definition, documentation, and treatment of domestic violence differ (slightly) from region-to-region in the United States. For example, studies indicate that it is tolerated more in the South than in other regions. Also, the laws pertaining to domestic violence vary by country. While it is generally outlawed in the Western World, this is not the case in some Middle East countries. For instance, some Arab countries allow a man to physically discipline his wife and children. The social acceptability of domestic violence also differs by country. While in most developed countries domestic violence is considered unacceptable by most people, in many areas of the world the views are different: according to recent studies, the percentage of adult women think that a husband is justified in hitting or beating his wife under certain circumstances is over 70% in Afghanistan, Jordan, and in the Central African Republic. Refusing to submit to a husband’s wishes is a common reason given for justification of violence.              

Domestic violence is largely thought to be male against female; however, the term includes any intimate relationship husband against wife, wife against husband, brother against brother, uncle against nephew, grandchild against grandparent, and roommate against a roommate. Wikipedia, The Free Encyclopedia states that domestic violence occurs when a family member, partner or ex-partner attempts to physically or psychologically dominate another. The encyclopedia goes on to say that domestic violence often refers to violence between spouses, or spousal abuse but can also include cohabitants and non-married intimate partners. Domestic violence occurs in all cultures; people of all races, ethnicities, religions, sexes, and classes can be perpetrators of domestic violence. Domestic violence is perpetrated by both men and women.

Also from Wikipedia, domestic violence can be criminal and includes physical assault (hitting, pushing, shoving, etc.), sexual abuse (unwanted or forced sexual activity), and stalking. Although emotional, psychological and financial abuse is not generally criminal behaviors in some legal systems, they are forms of abuse and can lead to criminal violence. There are a number of dimensions including:

  • Mode: physical, psychological, sexual and/or social.     
  • Frequency: on/off, occasional and chronic.
  • Severity: in terms of both psychological or physical harm and the need for treatment. Injuries may vary from mild to moderate to severe up to homicide.
  • Transitory or permanent

An important component of domestic violence, often ignored is the realm of passive abuse, leading to violence. Passive abuse is covert, subtle and veiled. This includes victimization, ambiguity, and neglect, spiritual and intellectual abuse.

Recent attention to domestic violence began in the women’s movement, particularly feminism and women’s rights, in the 1970s, as concern about wives being beaten by their husbands gained attention. Estimates are that only about a third of cases of domestic violence are actually reported in the United States. According to the Centers for Disease Control, domestic violence is a serious, preventable public health problem affecting more than 30 million Americans. Popular emphasis has tended to be on women as victims of domestic violence. However, with the rise of the men’s movement, and particularly men’s rights, there is now advocacy for men victimized by women. In a special report on violence-related injuries by the US Department of Justice hospital emergency room visits pertaining to domestic violence indicated that physically abused men represent just under one-sixth of the total patients admitted to the hospital reporting domestic violence as the cause of their injuries. The report highlights that significantly more men than women did not disclose the identity of their attacker. Insignificant numbers, males are the batterers and females are the sufferers of domestic violence. However, that is not always the case. Fewer men report incidents.

Domestic violence has been an increasing health concern in America for the past 25 years; consequently, communities are developing strategies to slow the violence and provide more protective mechanisms for women, men, and children who are battered. Researchers estimate that approximately 90 percent of the violence is against females and that over 3 million experience some form of violence each year. Also, most have been attacked by a family member or a person they are acquainted with. However, domestic violence is a family problem that devastates every sector of society, overwhelming our courts and hospitals, spilling over into our streets, and filling our morgues. We must all be a part of the solution if we are to address the death toll this epidemic is taking. Every community is touched, yet the pervasive problem of domestic violence continues to be a problem that most individuals struggle with at the time of witnessing an event that seems as though it is pushing the envelope of just an argument. When do you call the police? When do you get involved? Do you look away?

Domestic violence was one of the leading causes of injury to women at the start of the 21st century and continues to the present time. It results in more injuries than muggings, stranger rapes, and auto accidents combined. Researchers estimate that some form of domestic violence occurs in approximately one-third of marriages in the United States and has a significant impact on the health care cost as the victims spend nearly 125,000 days in hospitals, make 40,000 emergency room visits, and 70,000 trips to the doctor every year.   Also, about one-half of homeless women and their children are fleeing from domestic violence situations. Also, over 4 million children witness or are involved in acts of domestic violence every year. The risk of psychological and behavioral problems increases dramatically for these children and they are more likely to attempt suicide and/or abuse alcohol, tobacco, and other drugs. They start their early life with a significant handicap (due to no fault of their own) and frequently never completely overcome it. In essence, it’s a heavy load on children who either witness domestic violence or are victims themselves.



 Researchers predict that over five million Americans will be victims of domestic violence per annum. Almost one in three women will be assaulted by their partner, at least once. Even with those daunting figures, experts agree that the actual numbers are higher because many feel too ashamed or fearful of their perpetrator to report the incident. According to the American Psychological Association Task Force on Violence and the Family, this type of violence is the leading cause of injury to women age 15 to 44 in the US and represents a national epidemic of violence in the home. 

Although much can be predicted about the pattern after the abuse has begun, little can predetermine with validity who will abuse. Race and or socio-economic levels are not significant risk factors meaning that domestic violence occurs across all racial and socio-economic levels. African-American women experience more domestic violence than White women in the age group of 20-24. However, Black and White women experience the same level of victimization in all other age categories. Hispanic women are less likely to be victimized than non-Hispanic women in every age group.

Research suggests a high correlation between aggression and the use of alcohol and other drugs. Not necessarily in that, there is a correlation that suggests alcohol and other drugs cause abuse, but rather their presence can exacerbate the level of violence. Alcohol and other drug use lower inhibitions, affect judgment and often increase emotions.



Researchers have found that over 40% of battering men came from male-dominated homes where the male was either violent or controlling or both. Typically, family members were afraid of the dominant male because of threats or frequent violence acts generally directed at his mate or the children. Although men are more likely to be victims of violent crime overall, a recent study by the U.S. Department of Justice reports that “intimate partner violence is primarily a crime against women. Of those victimized by an intimate partner, approximately 90% are women and 10% are men. In other words, women are considerably more likely than men to be victimized by an intimate partner. Even when men are victimized, 10% are assaulted by another man. In contrast, only 2% of women who are victimized are assaulted by another woman. With these statistics, it is important to note that women are more likely to report violent incidents. Only about half of domestic violence incidents are reported to the police. There is growing skepticism regarding the quality of police response which is grounded in reality. For example, a recent study by D.C. Metropolitan Police Department concluded that only 17% of the victims were asked about a restraining order, and 83% were provided no printed information with contact information or resources which is a department standard. This may or may not be indicative of service across the country, but it is an alarming discovery. As noted previously, Domestic abuse occurs when one person in a relationship or marriage tries to dominate and/or control the other person. The abuser may use fear, guilt, shame, or intimidation to gain an advantage over the victim. He or she may threaten the victim or their family (including their children). When abuse turns violent (physical attacks) it is called domestic violence. Victims of domestic abuse/violence may be men or women, although women are more commonly victimized. Domestic abuse/violence occurs among heterosexual couples as well as in same-sex relationships. Domestic abuse/violence does not discriminate except for gender (women are predominately the victims). Also, it occurs across all ages, ethnic backgrounds, and social/economic levels.

Heterosexual males (in relationships) are the most frequent domestic violence offenders. However, researchers have found that women are equally likely to hit or physically harm a partner. Also, an average man is larger and more capable of defending himself against physical assaults; consequently, they do not have the same reaction to violence directed at them. It is equally wrong regardless of who does the abusing, as no one should have to tolerate being abused by another person. In any case, the female is more likely to sustain a serious injury than the male counterpart. Also, a man’s reaction to a woman’s violence is usually less emotionally than a woman’s reaction to a man’s violent acts. The man’s reaction is usually categorized in the annoyance, anger and self-righteousness categories whereas the reaction for women is more traumatic, often involving varying amounts of fear or terror. When a 200-lb man hits a 120lb woman, the impact is going to be greater for her than if the roles were reversed due to physical size, training, and mindset. If either the man or woman hits a young child the results can be devastating.



Despite a common myth, domestic violence is not due to the abuser’s loss of control over his emotions and behavior. Researchers have concluded that their violence is a deliberate choice made by the abuser in order to control the victim. Some of the more obvious observations to support this conclusion are:

  • The perpetrator does not batter other individuals-the supervisors who treat him unfairly or the restaurant server who spills food.  He waits until there are no witnesses and abuses the person he says he loves.
  • In most cases, the perpetrator can stop when the police arrive at the scene.  It’s amazing how quickly he can regain his composure and look calm, cool and collected and she is the one who may look hysterical.  If he were truly “out of control” he would not be able to stop himself when it is to his advantage to do so.
  • The incident generally escalates from pushing and shoving to hitting in places where the bruises and marks don’t show. An out of control perpetrator would not be able to direct or limit where he kicks or punches the victim.



In most states, only the physical acts of domestic violence are actionable under law. This is generally interpreted as the use of physical force or threats to control or intimidate a victim. Certainly, there are many relationships between people that are dysfunctional in which one or both people are emotionally abusive to the other. But if there’s no battering (threat of violence or overwhelming control of that person’s life) then we’re simply talking about a bad relationship in which either party can choose to remove themselves; and not one in which a person feels threatened of serious harm if they leave. Another legal issue to consider is the mandatory arrest policies in which police are required to make an arrest if there is probable cause that a person has committed domestic violence. Passage of these laws was advocated by domestic violence experts to address the inadequate response to domestic violence victims by law enforcement. When officers arrive at the scene of domestic violence crime, they often cite evidence that both partners have engaged in some aggressive behavior, and arrest both. This “dual arrest” strategy fails to take into account which of two people is primarily responsible for the aggression and which one is responding out of self-defense, and can have devastating effects, particularly if there are children involved in the relationship. To counteract this problem, some departmental or statewide policies now provide guidelines for an officer to determine who the primary aggressor is in a violent incident. For example, the California Commission on Peace Officer Standards and Training publish a guidebook for officers responding to domestic violence, discouraging “dual arrests” and outlining several factors to consider when determining who is the primary aggressor in a domestic violence situation. The primary aggressor is defined as “the person determined to be the most significant, rather than the first, aggressor.” Factors to consider include the history of domestic violence between the people involved, the threats and fear level of each person, and whether either person acted in self-defense. These are appropriate considerations when determining who the primary aggressor is, and therefore which of the two parties should be arrested.



 Acts of domestic violence generally fall into one or more of the following categories:        

  • Physical battering includes bodily attacks or aggressive behavior. This type of behavior is what most people think of when they hear the term domestic violence. Physical violence ranges from pushing or shoving to bruising (while restraining) to punching, kicking, biting to serious injury up to and including death. Most experts agree that without some type of intervention physical violence escalates with time. It starts with a relatively minor incident, which is excused as trivial such as pushing someone or throwing keys, and then escalates over time into more frequent and serious attacks.
  • Psychological or emotional abuse is the deliberate undermining of someone’s sense of safety and well-being. This type of abuse includes repeated criticisms, humiliation, name-calling, extreme jealousy, harassment, threats of suicide, and isolation from friends and family. Isolation occurs to undermine the support system and reduce the negative feedback about the relationship someone might receive from family and friends.
  • Sexual violence is unwanted or coerced sexual contact of any kind. Married or not, a person has the right to say no.
  • Intimidation is defined in this context as the act of deterring or making someone fearful by threats of violence to manipulate or control behavior. The abuser inhibits the victim’s behavior by threatening to hurt or kill them or their friends and family, including blackmail and threats to abduct children. This category often includes physical violence against property such as breaking into an individual’s home and wrecking it or displaying weapons in such a way that a threat is implied.
  •  Parallel violence is when an abuser acts against another person the intended victim cares about or a pet in order to control the partner.
  • Economic abuse is often used to control a victim’s ability to leave a relationship. It involves restricting access to money or to other financial resources. Keeping a partner’s income or preventing them from earning an income is included in this type of abuse.



Some of the psychological/personality characteristics common in abusers (in addition to their propensity to use physical violence) are:

  • Dominance or type A personality: Most perpetrators have a domineering personality with a strong need to be in charge of those around them. They like to tell people what to do and when to do it and for their orders to be followed. They have a tendency to direct most family activities.
  • Humiliation tendencies: A perpetrator will do almost anything to embarrass a victim. His objective is to make the victim feel bad or feel defective in some manner. The abuser’s objective is to make the victim believe they are worthless and of no value to anyone else. Also, the victim’s self-esteem is eroded through insults, name-calling, shaming, and put-downs.
  • Isolationism: This trait is used to increase the victim’s dependence on the perpetrator. The perpetrator will limit transportation, money and other items to isolate a victim from family and friends. In severe cases, this may extend to work and school activities.
  • Threats: Threats are used to keep a victim from leaving or to scare them into dropping charges. The threats are generally related to the physical realm and may include a threat to harm children, other family members or pets. He may also threaten to harm himself.
  • Intimidation: A perpetrator may use threatening looks or gestures, damage personal property, drive-bys, injure your pets or display guns to scare a victim into submission. The message is that if you don’t obey, there will be violent consequences.
  • Denial and blame: Perpetrators blame their violent behavior on a bad childhood, trouble at work, bad neighborhood, a bad day, family or anything else that will shift the responsibility for the abuse to someone or something else. The perpetrator will also minimize his role or deny that it occurred. He will commonly shift the responsibility for his violence onto you as if somehow it’s your fault.



Emotional Abuse

  • Put-downs (erodes victims self-esteem)
  • Name Calling/personal insults
  • Playing the psycho game (make someone think they are going crazy)
  • Humiliation (public reprimand; exploit/exaggerate any mistake in public)
  • Causing guilt (false accusations)

Economic Abuse

  • Limit job opportunities (outside the home)
  • Denying a person money or access to money
  • Limit how much a person can spend (allowance)
  • Taking the other person’s money

Coercion and Threats

  • Making or carrying out threats to do something to hurt the other person.
  • Threatening to leave the other person, to commit suicide, report the other person to law enforcement
  • Making the other person do illegal things


  • Making the other person afraid by using looks, gestures, or actions
  • Smashing things
  • Abusing pets
  • Displaying weapons

Using Children

  • Making the other person feel guilty about the children
  • Using visitation to harass the other person
  • Threatening to take the children away

Abusing Privileges

  • Treating the other person like a slave
  • Making all the decisions  



Many theories have been developed to explain ongoing violence in intimate relationships. Some have named family dysfunction, inadequate communication skills, stress, chemical dependency, and financial distress as theories. These problems may be associated with domestic violence but they are not the cause. Removing the factors that perpetuate anger will not end violence. Domestic violence is about power and control. Power and control over one or a select few. Power and control is the primary factor in this kind of conduct. The violence begins and continues because it is an effective method for gaining and keeping control over another person, frequently with few negative consequences.

Much can be predicted about the pattern that exists within the abusive relationship. Batterers typically externalize blame, explaining their violence is due to stress, the partner’s behavior, alcohol, etc. Poor self-esteem, feeling inadequate and feeling powerless in the world are frequent attributes of those that abuse. They take these feelings of inadequacy and lack of power over the outside world out on those that are on the inside and intimate. Often, their chief source of identity and ego gratification depends on their being able to exert control over their partner.

Often blame is placed on those who stay in abusive relationships. On the surface, the situation seems obvious. However, the barriers to leaving an abusive relationship are plentiful. Survivors of abuse typically experience shame, guilt, embarrassment, and isolation. How many men want to admit they are being physically abused? How many would make jokes about a man explaining he was forced to have unwanted sex? Homelessness in women is a leading outcome of leaving violent marriages. The threat of losing children is a terrifying nightmare. At the very least, leaving means a loss of income, the difficulties associated with single parenting, frequently harassment at work. Friends and family will not always believe the victim.

There is also the very real emotional pull that comes from the fact that most violent relationships are not violent at all times. The human spirit is full of hope. Abusers can be every bit as loving as they can be cruel. One of the most important points to remember is that leaving is dangerous.

Violent relationships frequently develop into cycles of violence

 The cycle begins with Phase One: Escalating or Tension Building. In this phase, the batterer is in a low stage of anger. They degrade, humiliate, and verbally harass the victim. They are easily irritated and agitated. Often a husband will have a growing fear that his wife will leave and he has an increased degree of surveillance of her behavior and a higher degree of jealousy. There is a definite increase in stress and anxiety. The victim does everything they can to keep the peace. They often place blame on outside stressors.

Characteristics/interactions of this phase include:

  •   Abuser begins to get irritable and begins verbal attacks; generally is in continuous hostile/anger mood
  •   Abuse may begin; may initially be minor; may include threats to the victim, other family members, friends, and others; may include a threat to commit harm self)
  •   There is generally a breakdown of effective communication; loss of trust; may become protective of joint property and joint financial resources
  •   The abuser may attempt to limit victims outside contacts with family and friends
  •   The victim feels the need to keep the abuser calm
  •   The victim feels they are walking on eggshells
  •   Tension increases to the critical/explosive stage

The second is Phase Two: Acute battering. In this phase, there is a violent discharge of tension or rage. The batterer appears to have impaired awareness and lacks control. Often batterers in treatment say, “she knew just what to do to push my buttons; she did it on purpose”. This can be explained by the victim in this phase as they often feel a passive acceptance and a belief that it’s futile to try to escape. In some instances they know if they get through the incident the next phase will come. The victim is isolated, depressed and often suffers from an emotional collapse after the violence.   The characteristics/interactions of this phase include:

  • The abuser physically and emotionally attacks the victim; may attack other family members or friends; may inflict physical and/or emotional harm to the victim.
  • The abuser may appear to lose awareness of his surroundings and loss of control of his actions (researchers have concluded that most abusers know what they are doing at all times).
  • Alcohol and or other drugs may increase the risk of severe injury
  • The abuser will generally isolate the victim and limit their communication
  • The abuser may restrain the victim
  • The abuser may leave the scene with children (victim is emotionally stressed by the absence of children and fear that they may be harmed)
  • Police are generally involved; parties are generally separated until they regain their composure and request reconciliation
  • Restraining/protective court orders may be required

The third is Phase Three: The Honeymoon Phase. The batterer loves and asks for forgiveness. They promise never again. They are dependent on the victim’s acceptance and validation. The victim experiences guilt and responsibility for the batterer. They have hope that this is the last time until the behaviors begin again in phase one. The characteristics/interactions of this phase include:

  •   Abuser acts as if the incident never happened
  •  The abuser may apologize and be very remorseful (generally temporary); promises that it will never happen again; attempts to explain away the incident
  •   The abuser may shower the victim with gifts and affection
  •   The victim may hope that abuse is over

The cycle can happen several times in an abusive relationship. Each stage lasts a different amount of time in each relationship. The cycle can take anywhere from a few hours to a year or more to complete. It is important to remember that not all domestic violence relationships fit the cycle.



Most authorities on the subject of domestic violence agree that it is an issue of power and control rather than simply anger. Batterers can be characterized as using violence as a strategy to gain power and control over others. The following list defines qualities that are many experts have compiled that are frequently, but not always, present in batterers:

  •        Male
  •        Dependent, inadequate personalities
  •        Violent family of origin
  •        History of violence
  •        Abusive of alcohol or other drugs
  •        Easily frustrated
  •        Poor control of impulses
  •        Rigid beliefs
  •        Mood swings


Risk Factors for Abuse

Abuse occurs in all socioeconomic groups, all genders, all religions, all races, all educational backgrounds, all ages, and all sexual orientations. In a national survey of over 6,000 American families, 50% of the men who frequently assaulted their wives also frequently abused their children. The following factors are areas of increased risk for abuse:

  •  Female between the ages of 19 to 29
  •  Pregnancy
  •  Individuals who come from abusive homes or have had previously abusive relationships
  •  Women who are single and under 35 are more likely to report the abuse


Barriers to Leaving a Violent Relationship

The most crucial reason to stay is leaving is dangerous. The most dangerous time in a violent relationship is when the victim is attempting to end the relationship. Men and women alike are frequently embarrassed to admit they have been physically abused. Often leaving means continued and escalated harassment. In an attempt to control the individual leaving, threats are frequently made concerning finances and child custody.

There is also a mixed emotion for love and hope along with the manipulation, intimidation, and fear. Often the abusers will threaten to hurt themselves or other loved ones if the victim does not stay.

Support systems often become weaker once the threat is increased and pointed at them, as well. A friend who offers a friend a safe place to stay can become threatened and scared. Clergy and secular counselors are often trained to see only the goal of saving the marriage. Financial institutes do not want to get involved in family issues.


Preparing Health Care Professionals to Screen for Domestic Violence

Less than 10% of primary care physicians screen for domestic violence on a routine basis during regular office visits. In emergency rooms, less than 3% of female patients disclosed or were screened for domestic violence by a nurse or physician, yet an estimated 17% to 27% of the injuries that bring women to the emergency room were caused by their partner. Using protocols to identify and treat those in the population that is at increased risk of domestic violence and any others who meet certain criteria increases the identification rate to 30%. The National Institute of Justice and the Centers for Disease Control indicated that women make almost 700,000 health care visits due to injuries resulting from physical assault and that most of these are inflicted by intimate partners. All women and men who present with injure and implausible explanations should be evaluated with abuse in mind.

Injuries are not the only symptom of domestic violence. Many chronic health care problems, such as alcoholism and other substance abuse issues, depression, and other mental health problems are also caused by this type of violence.

According to The Family Violence Prevention Fund, all females over the age of 14 should be asked questions concerning the topic of domestic violence. Their publication has a set of clinical guidelines for routine screening for domestic violence in health care settings. They recommend these guidelines be utilized in all primary care, urgent care, obstetrics/gynecology, family planning, mental health, and residential settings. Screening should be a part of all initial intake forms, including prenatal visits. The number one most prevalent time in a woman’s life to be battered is during pregnancy.

The following is a checklist that could be utilized as a tool for health care providers:

Does your partner:

___Put you down, embarrass or make fun of you in front of others?

___Make fun of your goals or discourage you?

___ Intimidate or attempt to control you?

___ Tell you that you are nothing without them?

___Attempt to make all of the decisions?

___Treat you rough-grab, push, pinch, shove or hit you?

___Make you feel bad about yourself?

___Call you several times a night or show up to make sure you are where you said you would be?

___Blame you for how they feel or act?

___Blame alcohol or other drugs for how they act?

___Pressure you sexually?

___Are you ever afraid of them?

___Are you afraid they will hurt themselves or someone else if you leave the relationship?

___Do you find yourself attempting not to make them angry at all costs?

To ensure the effectiveness of the screening, health care providers should be educated about the dynamics of domestic violence, the safety and autonomy of abused patients, and the cultural aspects of this type of violence. These screeners should be trained in asking about abuse and in intervening with abuse victims. This screening should be conducted in a private setting and under the best of circumstances should be done in person. A nonjudgmental approach is essential.

As a medical professional it is important for you to know how to build rapport and ask the appropriate questions.

Questions can be in the form of general framing questions such as:

  • Violence against women is becoming such a prevalent problem in our society that I have begun to include it in all of my assessments. Can you tell me about your experiences?
  • I’m concerned about how your injuries were caused.  Are you comfortable telling me how they occurred?

Questions can be direct such as:

  • Does your partner threaten you, attempt to control you, push or hit you?
  • Are you or have you ever been concerned for your safety?

If, as a medical professional, you are concerned for a patient who is not currently admitting to abuse or is not ready to leave the relationship you can refer them to counseling and or give them telephone numbers to shelters and protective agencies. Sometimes discussing the safety of children and pets motivates them to get the help they need.


Recognizing Domestic Violence in the Dental Chair

  • Injuries to the teeth, soft tissue, jaw, face head or neck
  • Soft and hard palate bruises or abrasions from implements of penetration
  • Abscessed or lost nonvital teeth caused by blows to an area of the face or from traumatic tooth fractures
  • Torn frenum due to trauma
  • Fractured teeth, nose, mandible, maxilla, and signs of healing fractures on radiographs
  • Signs of strangulation
  • Bite marks
  • Hair loss (especially  in patches)
  • Difficulty eating
  • Dental neglect
  • Fear of dental care


Battering in Special Populations

Teen relationships follow the same pattern and have the same undercurrent, as do the relationships of adults. Young individuals are often struggling with self-esteem, gender roles, sexual activities they are comfortable with and those they are not. Even in the best of relationships, this is a time when individuals do not have assurance in who they are and what they want or need. Self-esteem can often easily be manipulated, isolation from family is often already occurring as the teen develops independence. Many times when a boyfriend displays extreme possessiveness it is taken as he must really love and care about me.

The elderly represent a population that often does not have a voice to defend themselves with. Special consideration should be given to screening for abuse in this population.

Understanding cultural issues are paramount in investigating domestic violence. Understanding how and why domestic violence occurs is impossible without taking into account the varying religious and cultural beliefs and practices. In many countries, society is permissive of violence. Popular songs, movies, even the nightly news and literature all normalize violence as a common, almost every day experience.

The patriarchal structure of the family is traditional in many countries with the husband’s authority unquestioned. Often in many cultures, there is a major emphasis on compliance and not speaking out. Laws in many cultures are designed to protect the male, head of the household’s right to make decisions about the family. A female who stands up to her husband or protests a beating causes the family, and herself, shame and embarrassment.

A few fundamental religions and cults promote keeping women and children in line with advice from the pulpit to beat unruly wives and children.

Because America is a melting pot of cultures it is necessary to keep these statistics and cultural aspects in mind. It is important to recognize that these situations are, by families of these cultures standards, not considered wrong. If you question a female from that culture if someone has done something out of line the answer will be no. They will often not report violence, as they do not see it as a reportable concern.

To intervene successfully in all these cultures, it will be necessary to change both men’s and women’s socialization patterns and establish a new definition of authority.


Impact of Domestic Violence 

Every American suffers from the effects of domestic violence. Although women are who you predominately think of when discussing domestic violence, men are also frequent victims. Conservative estimates are that between 3.3 and 4.3 million children every year witness domestic violence, with devastating results. Pets are also frequently abused as part of the pattern.

An estimated three to five billion dollars every year are lost due to this problem. Lost wages, lower productivity, sick day usage, medical expenses, and legal expenses combine to drain the national economy.

When discussing domestic violence the issue of homelessness is brought to the surface. Statistic figures indicate that domestic violence is a factor in approximately 50% of homeless women and children. For women alone, estimates range from 17 to 24%.


Legal and Social Resources

There are many options to give those in need. As a health care provider, it is essential you are prepared with the resources and suggestions.

If a person is not prepared to immediately leave an abusive relationship, it is critical that they develop safety plans. While in a violent relationship, a victim needs to be prepared to leave if physically threatened. If it is safe to do so, they should be prepared to call for help, by phone or by yelling. If a confrontation is occurring, the advice is given to stay close to an exit, avoid being in the bathroom, kitchen, or near any weapons. The potential target of violence should consider in advance what the safe ways to quickly exit the house are. They need to determine which doors, windows, stairways, etc. are quickest and safest to use, and where they will be when they have exited. In some cases, it is a good idea to get spare keys to their vehicles made and placed in an accessible place. Keys are often taken from them in an argument.

Belongings are not a factor in the face of violence. Getting to a safe place is far more important. In the event of ongoing abuse, if safe, advice can be given to keep a bag of clothing and essentials at the residence of a friend. Neighbors need to be identified who are aware of the violence and they should be encouraged to call the police if they hear a disturbance. The development of a code to be used with children, friends, and a neighbor when help is needed is advised.

If a person is already preparing to leave a violent relationship, additional elements of a safety plan can be considered. Separate savings account with a safe address is sometimes recommended, when safe. Money, spare keys, important documents, and extra clothing can be left with a friend so that leaving can occur quickly. Arrangements for where a victim will stay can be made in advance. Arrangements for pets in danger can also be made. A calling card and the number of the closest emergency shelter should be kept on hand at all times. The most dangerous period of time is when someone is leaving a violent relationship.

Upon leaving a dangerous relationship, additional locks, different routes to and from work, sometimes informing employers is necessary and an unlisted phone number should be obtained. A safety plan for the children when the parent is not with them needs to be developed. Daycare centers and schools need to be clearly informed about who can and cannot pick up the children. If the person has obtained a restraining order, they should keep a copy on their person at all times. All threatening phone messages should be documented, tapes of threats should be retained, and all instances of violating a protective order should be reported.

There are many domestic violence programs that can offer assistance and help in obtaining a civil protection order and for a referral to a lawyer who can be helpful in pursuing criminal prosecution. Laws vary widely in different cities, counties, and states. In most jurisdictions, judges can issue protective orders, order abusers to leave the home, award temporary custody and order temporary child support. Unfortunately, a court order offers little protection against a determined abuser.

In the past, police have traditionally regarded domestic violence as a family dispute in which they did not get involved beyond stopping the immediate incident. The system is changing and frequently both parties are arrested and left to the court system to untangle. In many areas, the arrest of the alleged batterer is mandatory. Even if victims withdraw charges due to fear or emotional confusion, the perpetrator of the violence will still be prosecuted. Victims are not able to drop charges.

Many communities generally offer some sort of shelter and services for battered women and their children. The addresses and telephone numbers of shelters are kept as secret as possible. Under most circumstances, the police have these numbers and can make a referral.

Most court systems recommend domestic violence counseling. Individual therapy for victims generally focuses on assisting them to look at and correct distorted thinking and to deal with the terror of long-term abuse, anger, and anxiety that they experience. Many victims love their abusers. This is a time of confusion and loneliness. Building rapport, establishing a support system for the survivor, helping them to recognize and correct the distorted belief systems are critical components of treatment. Many will fall into similar types of relationships without personal growth. Violence, feelings of guilt, the inability to make decisions for them are normal, what is strange and different is a healthy relationship. Helping them explore their history of relationship patterns can enable them to seek out positive relationships the next time. Individuals need to deal with any family of origin issues and any reasons they stayed in an abusive relationship so that they do not repeat the same decisions in future relationships.

Group therapy can be very effective in this issue. This therapeutic mode of treatment allows individuals to build a support network and hear the stories of others in similar situations. As they offer support to others, as well, they become more confident in their abilities. They begin to recognize that they were not responsible for their partner’s behavior. Well, if she wasn’t pretty enough, together enough, a good enough mother, a good enough cook; then no one could be for him Group therapy is also helpful to show the effects of domestic violence on children.

Dentists in all states must report child and adult abuse if a patient assessment indicates injuries are due to violence,
abuse, or neglect. Adult patients need a safe environment for assessment and intervention if they are injured due to
domestic violence. The dentist must determine if a pediatric patient requires further assessment or intervention.

Dentists, dental hygienists, and dental assistants can play an important role to stop the cycle of abuse. Domestic violence is a very sensitive subject, and reporting suspected abuse is a serious matter for dental professionals. In accordance with state and federal law and each state’s dental board, consistent protocols and best practice policies should be reviewed yearly.




Dentinal hypersensitivity (DH) is a general term for sharp oral pain of short duration in response to stimuli at sites with exposed dentin, which cannot be explained by any other condition. It is a common dental problem that is frequently encountered yet it is often under-reported by patients or misdiagnosed by clinicians. This lesson will address the etiology, prevalence, and diagnosis of dentinal hypersensitivity as well as review clinical evidence behind common treatments.

We will explore the etiology of the condition commonly referred to as “dentinal hypersensitivity,” “dentine sensitivity,” “root sensitivity” or “tooth sensitivity.” We will review the prevalence and diagnosis of the condition as well as reviewing clinical evidence behind various popular home care products and in-office treatment options.


Dentinal hypersensitivity (DH) is a global oral health issue and a significant challenge for most dental professionals. Symptoms of dentinal hypersensitivity are generally reported by the patient and are difficult to describe and challenging to accurately diagnose because other dental diseases have to be ruled out first, such as dental caries, cracked-tooth syndrome, and defective restorations, among others. The most common symptom reported is a short, sharp transient pain arising from exposed dentin responding to one of several different stimuli: thermal, chemical, tactile, evaporative and osmotic (Figure 1).

Figure 1. A pictorial display of origin of pain associated with sensitive teeth.
Image: Origin of pain associated with sensitive teeth.

The prevalence of dentinal hypersensitivity has been reported over the years in a variety of ways: 3.8% to 74.0% depending upon the population, study setting and study design, 14.3% of all dental patients, between 8% and 57% of adult dentate population, and up to 30% of adults at some time during their lifetime. Among periodontal patients, the frequency is much higher (60%-98%).

Dentinal hypersensitivity has been shown to peak in 20 to 30-year-olds and then rise again when in their 50s.  A more current study conducted in India by Sood et al, with 2051 subjects, found that the highest prevalence of DH occurred in the 40-49-year-old age group and the age group of 60-69 years showed minimum hypersensitivity.  These results further demonstrate the difficulty of diagnosing the condition and accurately reporting prevalence. The condition generally involves the facial surfaces near the cervical aspect of teeth and is very common in premolars and canines.  Patients undergoing periodontal treatment are particularly susceptible to this condition, as mentioned above, because of the recession following periodontal surgery or loss of cementum following non-surgical periodontal therapy.  In addition, periodontal disease and improper brushing habits can also result in gingival recession accompanied by sensitive teeth. Dentinal hypersensitivity has been researched extensively through the years and many authors express an agreement that dentinal hypersensitivity is either under-reported by the dental patient population or under-diagnosed, and excludes the underserved population when estimating the prevalence of the condition.


A variety of theories have been suggested to help explain the mechanism involved in the etiology of dentinal hypersensitivity.  The transducer theory, the modulation theory, the “gate” control and vibration theory, and the hydrodynamic theory have all been presented and discussed throughout the years. The latter, “hydrodynamic theory,” developed in the 1960s and based upon two decades of research, is now widely accepted as the cause of tooth sensitivity.  Before explaining the “hydrodynamic theory” it is important to point out that none of these mechanisms full explain dentin hypersensitivity, indicating unexplained mechanisms are possibly responsible. The widely accepted hydrodynamic theory asserts that when the fluid within the dentinal tubules, absent of a smear layer, is subjected to thermal, chemical, tactile or evaporative stimuli, the movement of the fluid stimulates the mechanical receptors which are sensitive to fluid pressure, resulting in the transmission of the stimuli to the pulpal nerves (Figure 2) ultimately causing the pain response.

Figure 2. Depiction of Brannstrom’s Hydrodynamic Theory.
Image: Brannstrom’s Hydrodynamic Theory

Berman describes this reaction as:

“The coefficient of thermal expansion of the tubule fluid is about ten times that of the tubule wall. Therefore, heat applied to dentin will result in expansion of the dentinal fluid, and a cold stimulus will result in contraction of the fluid, both creating an excitation of the ‘mechano-receptor’.”

Based on the hydrodynamic theory, dentinal hypersensitivity is transient tooth pain. In order to exhibit a response to the stimuli, the tubules would have to be open at the dentin surface as well as the pulpal surface of the tooth. Anatomically, the tubules in the area closest to the pulp chamber are wider, and the number of tubules per unit area increases almost two-fold from the outer surface to the pulp.

The most important variable affecting the fluid flow in dentin is the radius of the dentinal tubules. If the radius is reduced by one-half, the fluid flow within the tubules falls to one-sixteenth of its original rate. Consequently, the creation of a smear layer or the occlusion of the tubules will significantly reduce sensitivity.


The reason(s) for tubules to be exposed or open should be assessed during a visual examination of the teeth. Additionally, a detailed dietary history should be taken. Useful diagnostic tools are the air/water syringe (thermal), dental explorer (touch), percussion testing, bite stress tests, and other thermal tests such as an ice cube, and assessment of occlusion. Since dentinal hypersensitivity is essentially diagnosed by exclusion, a comprehensive dental examination will ultimately rule out other underlying conditions for which sensitivity may be a symptom such as a cracked tooth, fractured restoration, chipped teeth, dental caries, gingival inflammation, post-restorative sensitivity, marginal leakage and pulpitis. Excessive intake of dietary acids such as citrus juices and fruits, carbonated drinks, wines, and ciders have been identified as potential risk factors for dental hypersensitivity.  The dietary history provided by the patient will assist in identifying the risk factors the patient may have for tooth sensitivity. Erosion is one of the most common causes of irreversible enamel loss.

In addition, other risk factors should be ferreted out during an examination such as toothbrush abrasion (Figure 3), chemical erosion (Figure 4), thin enamel, gingival recession, exposed dentin, and eating disorders such as bulimia. The patient will be able to assist in diagnosis by identifying the pain-inciting stimuli, i.e., thermal, tactile, etc., as well as describing the pain. The response to stimuli varies from patient to patient. Factors such as individual pain tolerance, emotional state, and environment can contribute to the variety of responses between and among patients.

Figure 3. Tooth Abrasion.
Image: Teeth showing a tooth abrasion.
Figure 4. Tooth Erosion.
Image: Teeth showing tooth erosion.
Images courtesy, Dr. Beatrice Gandara, University of Washington, School of Dentistry

The most commonly cited reason for exposed dentinal tubules is the gingival recession (predisposing factor).  Chronic exposure to bacterial plaque, toothbrush abrasion, gingival laceration from oral habits such as toothpick use, excessive flossing, crown preparation, inadequate attached gingiva, an inadequate labial plate of the alveolar bone and gingival loss secondary to disease or surgery are some but not all causes of gingival recession.  Gingival recession is the reduction of the height of the gingival margin to a location apical to the CEJ. Recessed areas may become sensitive due to the loss of cementum, ultimately exposing dentin. Probing depths, recessed areas (areas of gingival recession), and sensitivity reported by the patient must be accurately recorded and monitored to provide a reference for the patient’s disease activity over time.


Treating dentinal hypersensitivity can be challenging for the dental professional because of the difficulty related to measuring the pain response as the response can often vary from patient to patient. In addition, if the dentin exposure is due to personal habits, it may be difficult for patients to change their behavior(s). If the diagnosis confirms dentinal hypersensitivity in the absence of underlying diseases or structural problems of the tooth, then the following steps can be initiated: (1) remove the risk factors by educating the patient about dietary acids and other oral care habits; (2) recommend different toothbrushing methods, if appropriate; (3) initiate treatment by recommending a desensitizing agent for home use; and/or (4) applying topical desensitizing agents in-office.

In 1935, Grossman addressed the requirements for an ideal desensitizing agent as rapidly acting with long-term effects, non-irritating to the pulp, painless and easy to apply without staining the tooth surface. These requirements still exist today when considering an ideal solution to dentinal hypersensitivity.  There are various ways to classify treatments: first, they can be categorized based on their ingredients and/or mechanism of action.  There are two common approaches to treating dentinal hypersensitivity, nerve stabilization, and tubule occlusion. Furthermore, treatment options can be classified as either invasive or non-invasive in nature. Examples of invasive procedures administered in-office include gingival surgery, application of resin adhesive materials such as dentin bonding agents, or a pulpectomy. Dentifrices and other products for home use are non-invasive. Finally, treatments can be categorized based on whether they can be applied by the patient (over-the-counter) or require professional application. For the purposes of this CE course, the focus is on first-line over-the-counter products as well as popular in-office treatments.

Over-the-Counter Products

Over-the-counter products for the treatment of tooth sensitivity are considered to be a simple and cost-effective first line of treatment for most patients.  The primary at-home non-invasive treatment option has historically been anti-sensitivity dentifrices. The two most common ingredients are potassium nitrate, which interferes with the transmission of the nerve impulse, and stannous fluoride, which blocks dentinal tubules by forming a smear layer at the surface.

Potassium Nitrate Dentifrice

Potassium nitrate is known to interfere with the nerve impulse and is commonly found in desensitizing toothpaste.  Potassium nitrate products raise the extracellular potassium ion concentrations and affect polarization. When the concentration is sustained over time, the synapse between nerve cells is blocked, the nerve excitation is reduced and the tooth is less sensitive to the stimuli. A number of studies, published since the early seventies, have investigated the use of potassium nitrate (KNO3) as an effective active ingredient in treating dentinal hypersensitivity.

A four-week exposure time is widely used in these clinical trials because results have shown that this time is needed for 5% KNO3 to exert its desensitizing effect.  The use of a broadly accepted positive or negative control toothpaste formulation or product has been increasingly used over the years in comparative trials because the condition itself can appear to be self-resolving within the time scale of the study. Over time, investigators have chosen various methods to capture subjective responses; controlled reproducible stimuli and objective measurements are preferred.

Figure 5. Illustration of the Yeaple Probe.
Image: Yeaple Probe.

In 2006, the Cochrane Collaboration published a systematic review of potassium nitrate toothpastes for the treatment of dentinal hypersensitivity based on clinical trials conducted up to the year 2005 involving KNO3 toothpaste compared to non-KNO3 toothpaste. This review focused on studies that incorporated similar methods in order to determine if KNO3 is an effective agent in reducing dentinal hypersensitivity. The results were obtained by measuring tactile (Figure 5), thermal, and air blast stimuli as well as patients’ subjective assessment of pain during everyday life. The exposure periods ranged from six to eight weeks, reporting outcome measurements as a mean change from baseline.

The meta-analysis included six studies, and all showed a significant effect on sensitivity assessed by air blast and tactile methods at the 6 to 8-week follow-up. However, there was no significant effect observed at the 6 to 8-week follow-up for the subjective assessment. The authors concluded the support for the efficacy of potassium nitrate toothpaste for dentinal hypersensitivity was based on very small sample size, thus evidence of the effectiveness of KNO3 is not clear, suggesting more clinical trials need to be conducted and published. There is no current research published to support a different conclusion than what is stated above even though new product lines are being marketed.

Some products that contain potassium nitrate include Sensodyne ProEnamel®, Crest® Sensitivity, Crest Sensi-Relief Plus Scope Toothpaste, Colgate® Sensitive Pro-Relief Enamel Repair Toothpaste, Arm & Hammer® Advanced Whitening Sensitive, Tom’s of Maine Maximum Strength Sensitive and Opalescence Whitening Sensitivity Relief Toothpaste.

Stannous Fluoride

Stannous fluoride has been shown to be effective in the prevention of dental caries, reduction of plaque formation, control of gingivitis and the suppression of breath malodor. Research also shows stannous fluoride is effective against dentinal hypersensitivity.   The ADA has recognized the desensitizing properties of stannous fluoride by granting the ADA Seal of Acceptance to a non-aqueous stannous fluoride gel formulation (Gel-Kam) for the therapeutic prevention of sensitivity and caries as well as to Crest® PRO-HEALTH® toothpaste.

In situ research shows root dentin treated with stannous fluoride exhibits tubule occlusion at the surface by the formation of a smear layer (Figure 6).  When the tubules are blocked, fluid flow is limited and the stimulation of the mechanoreceptors does not occur, thus preventing the pain response.

Figure 6a. Open tubules following treatment with non-sensitivity fluoride toothpaste.
Image: Open tubules.
Figure 6b. Closed tubules following treatment with SnF2 dentifrice.
Image: Closed tubules.

Stannous fluoride has been delivered via a mouth rinse, dentifrice, and gel for some time. Research by Thrash et al.  in the 1990s suggested there is a gradual decrease in sensitivity starting at two weeks and continuing throughout the 16-week period from initiation of treatment. Thrash and colleagues conducted a two-phase experimental design study comparing a 0.4% stannous fluoride gel to an aqueous 0.717% fluoride solution and a placebo to evaluate the effect of the products on hypersensitivity tooth pain and to determine the precise time of onset of any effect on dentinal hypersensitivity. Sensitivity to thermal stimuli was assessed prior to the first application and then at 2, 4, 8, and 16-week intervals after the initial application. The results indicated subjects who applied the 0.4% stannous fluoride gel reported significantly less sensitivity during the four to eight week period. The stannous fluoride gel resulted in the lowest mean threshold temperature compared to the other products.

Historically, one limitation to the use of stabilized stannous fluoride has been the potential for temporary extrinsic tooth staining associated with the long-term use of these products. Due to advances in dentifrice technology, this occurrence has been mitigated by incorporating sodium hexametaphosphate, advanced tartar control, and whitening ingredient, in the formulation marketed as Crest® PRO-HEALTH® toothpaste.

In two randomized, double-blind clinical trials, this stabilized stannous fluoride toothpaste significantly reduced thermal and tactile sensitivity versus a negative control.   More recently, He et al, demonstrated in two different randomized controlled clinical trials that twice-daily brushing with the stabilized stannous fluoride dentifrice provides superior dentinal hypersensitivity improvement versus a marketed sodium fluoride dentifrice, and a dentifrice containing 8.0% arginine, calcium carbonate, and sodium monofluorophosphate.  The stannous fluoride dentifrice provided some relief after the first brushing relative to each control, with the benefit growing larger over the study period with twice-daily use. When compared to sodium fluoride/triclosan dentifrice, there was a similar outcome, superior dentinal hypersensitivity improvement with significant greater relief after two weeks and a larger benefit at eight weeks with twice-daily brushing.   In separate clinical research, this unique dentifrice provided significant extrinsic whitening relative to the positive control.

In addition to the product mentioned above, a 2-step system that includes stannous fluoride dentifrice as the first step and hydrogen peroxide whitening gel at the second step has been shown to provide significantly better sensitivity relief than potassium nitrate sodium fluoride dentifrice.

Bioactive Glass

Dentifrices containing desensitizing agents have been the most popular first-line treatment for sensitive teeth, but there are some drawbacks. It typically takes time (approximately 4 weeks) to experience relief and on-going use is required to maintain the benefit.

One such product is NovaMin, a synthetic mineral composed of calcium, sodium, phosphorus and silica releases deposits of crystalline, hydroxyl-carbonate apatite which is structurally similar to tooth mineral composition. NovaMin is technically described as sodium calcium phosphosilicate.

Method of Action

The formation of bioglass reacts with the saliva in the mouth to form a protective layer of hydroxyapatite on the tooth, thereby, occluding dentin tubules. This layer prevents the discomfort that is tooth sensitivity.

A number of clinical studies (5) investigating the efficacy of NovaMin for four and six weeks have been conducted. A product name you may be familiar with is Sensodyne Repair and Protect. An overview of the clinical evidence for the use of NovaMin to treat dentinal hypersensitivity was addressed by Gendreau et al. Clinical evidence supports the effectiveness of the 5% and 7.5% product twice daily brushing for pain relief from this malady.

In-office Treatments

Professional treatments are available for sensitivity cases that cannot be managed using over-the-counter products. Some in-office treatments include fluoride varnishes, prophylaxis pastes, and laser treatments.

Fluoride Varnishes

The most popular in-office treatment is fluoride varnish, a resin-based fluoride. Various types are available. Fluoride varnish is primarily used to prevent tooth decay by entering the tooth enamel and making the tooth surface impenetrable. The mode of action involves calcium fluoride being deposited on the tooth surface with the formation of fluorapatite.  The varnish is applied after cleaning and drying the tooth surface. For caries protection, fluoride varnish is painted onto the tooth surfaces with a small brush. The varnish forms a sticky covering over the tooth and becomes hard as soon as saliva in the mouth touches it. Fluoride varnish prevents new cavities from forming and slows down or stops decay from progressing.

Many practitioners have begun using fluoride varnish as a desensitizing agent by applying the varnish to the exposed area to seal the dentin surface. Pashley et al., evaluated a series of commercial cavity varnishes and reported that all cavity varnishes tested decreased dentin permeability by 20 to 50%.   In 2012, Camilotti et al. conducted a randomized, split-mouth clinical trial in 42 patients (252 teeth) presenting with dentin hypersensitivity to thermal changes in the mouth. The treatment groups were 4 fluoride varnishes (Duraphat, Fluorniz, Duofluorid Xii, and Fluorphat), a neutral fluoride (Flutop), a potassium oxalate gel (Oxa-gel) and a placebo which were all applied 3 different times with a time interval of one week between applications. Sensitivity reduction using air blast and clinical probing was evaluated at the end of 1 week, 2 weeks, 3 weeks and 30 days after the last application. The 4 fluoride varnish groups and the oxalate gel group had significantly lower pain scores compared to placebo at the 30-day reassessment; there were no significant differences between the 5 groups. The neutral fluoride group was not significantly different from the placebo, nor was it significantly different from Fluoriniz, Duoluorid XII, or Oxa-gel.

Fluoride varnish is easy to apply, low-cost and generally safe to use in the mouth, but should not be used if there is an allergy to one of the ingredients in the varnish.

Prophylaxis Pastes

Prophylaxis pastes with desensitizing agents are another professional treatment used for the relief of sensitivity. One example is paste containing 8% arginine (Pro-Argin), calcium carbonate, and 1450 ppm fluoride as sodium monofluorophosphate (Colgate Sensitive Pro-Relief). Arginine, an amino acid naturally present in saliva, is reported to work in conjunction with calcium carbonate and phosphate to occlude dentinal tubules.

Results from a 12-week clinical trial showed that 8% arginine-containing prophylaxis paste was statistically significantly more effective in reducing dentinal hypersensitivity than a control pumice prophylaxis paste (NuPro) immediately the following application and after 4 weeks. No statistically significant differences were noted between treatment groups post-scaling and after 12 weeks.

In some markets outside the US, arginine is available in over-the-counter dentifrice and mouth rinse products.

Another prophylaxis paste for hypersensitivity relief contains sodium-calcium phosphosilicate, marketed under the name of NovaMin®.  Sodium calcium phosphosilicate occludes the dentinal tubules by forming a protective hydroxyapatite-like layer on the dentin surface. A number of clinical studies investigating the efficacy of NovaMin® for the relief of dentinal hypersensitivity have been conducted.

Neuhaus et al. conducted a randomized, controlled, double-blind, parallel study with three treatment groups – sodium-calcium phosphosilicate prophylaxis paste, with and without fluoride, and a control group – in 151 subjects meeting dentinal hypersensitivity entrance criteria.  Tactile and air blast assessments were completed at baseline and day 28. The results indicate that after a single professional application of sodium-calcium phosphosilicate prophylaxis paste, hypersensitivity was significantly reduced immediately and 28 days after scaling and root planing procedures. The effect was independent of the presence of fluoride in the paste.


Four different kinds of light amplification by stimulated emission of radiation (lasers) have been used for the treatment of dentinal hypersensitivity with effectiveness ranging from 5.2 to 100%, depending on the laser type and parameters used. The most common are: Nd-YAG (neodymium:yttrium-aluminum-garnet), GaAIas (gallium/aluminum/arsenide) and Erbium-YAG (yttrium-aluminum-garnet) lasers.  The mechanism of action of lasers in treating hypersensitivity is not very clear, but it has been proposed that the lasers coagulate the proteins inside the tubules and block the movement of fluid.

A 2011 systematic review of lasers for the treatment of sensitivity found only 3 randomized clinical trials for inclusion. The authors concluded that laser therapy can reduce dentinal hypersensitivity-related pain, but there is only weak evidence for its effectiveness and the placebo effect has to be taken into account.


Dentinal hypersensitivity is a common problem that affects many dental patients. When a patient presents with dentinal hypersensitivity symptoms, they should be examined and informed of the treatment options available to alleviate the problem. The patient plays a role in this process since their daily habits may be contributing to the problem, and if not changed the condition may persist.

The initial cause of dentinal hypersensitivity, in the majority of cases, is recessed gingiva with the exposure of dentinal tubules. Once the tubules are exposed the patient is susceptible to pain in response to thermal, tactile, or osmotic stimuli. Desensitizing treatments should be delivered systematically.

Prevention and over-the-counter treatments, including desensitizing toothpastes, are a good place to start and can later be supplemented with in-office treatments if needed.

Evidence suggests that hypersensitivity reactions, particularly Type III and IV, may be involved in the pathogenesis of periodontal disease.





What happens in the dental chair only accounts for a small portion of oral care.  Patients play a large role in the overall health of their teeth and gums.

Compliance with health-related behaviors and recommendations are crucial to the overall effectiveness of a treatment program.



John hasn’t been to the dentist in two years. He knows that every passing month will make the inevitable visit that much worse. He just can’t bring himself to make the appointment because after all, he isn’t experiencing any pain. Going to the dentist costs money and it is embarrassing because although his teeth are fine in appearance he knows he doesn’t brush or floss as often as he should.



A dental chair can combine the sum of all fears pain, needles, doctors, confined-spaces, and loud and annoying noises. Outside of the chair itself, the brushing, flossing, making time for appointments and then paying for them isn’t at the top of anyone’s list of favorite things to do either. It’s no big surprise so many people fall short of compliance with treatment recommendations.

Patient noncompliance, which refers to the non-adherence or only partial adherence to healthcare behaviors and recommendations, is a well-recognized problem, and it continues to be a major obstacle to appropriate care that ensures patients’ health and well-being.

Given the recent associations between oral disease and systemic diseases such as cardiovascular disease, renal disease, and diabetes, it has become increasingly essential to obtain patient cooperation with dental conditions.

How we go about doing this involves looking at why noncompliance exists. Obviously, taking care of our health takes effort. Good oral hygiene involves habit, education and a few good tools.

Compliance isn’t just important to the dentist or the hygienist though. How compliant patients are with their own oral care recommendations affect outcomes across all disciplines, including restorative, periodontal and orthodontic care. Examples of cross-specialty issues with compliance include decalcification, which is a common condition arising from poor oral hygiene. During orthodontic treatment, calcification has been associated with longer treatment duration. Noncompliance with smoking cessation recommendations places patients at increased risk for many medical conditions, as well as oral cancer, periodontal disease, and poor periodontal therapy outcomes. These and many other examples shine a light on the importance of treatment compliance with the dental industry.

Factors that Effect Noncompliance

There are many factors, both external and internal that affect compliance with dental recommendations. From the most basic of brushing your teeth after every meal to flossing, regular check-ups and cleanings to taking care of more serious issues that arise, it is more common than not that someone will attempt to avoid these behaviors in spite of how important they are. It seems that unless there is more pain associated with not doing these than there is with doing them, they won’t get done regularly. Let’s explore some of these factors.


Internal Factors

  • Fear of Pain
  • Anxiety
  • Fear of Needles
  • Lack of Understanding
  • Poor Communication
  • Apathy
  • Perceived or Real Lack of Time
  • Lifestyle
  • Age
  • Health
  • Perceived Unimportance of Treatment or Oral Care
  • Physical or Psychological Health
  • Self Esteem
  • Embarrassment

More than 50% of the overall population has been estimated to suffer from dental anxiety. The industry as a whole has done a great deal to lessen this, however, if your patient hasn’t been to the dentist in the last five years they may not be aware of this. Even if they get past the anxiety involved and make an appointment then show up, there are still many internal factors that play a part in them following through with recommendations made during the first visit. It is quite normal for someone to have a healthy dose of fear regarding pain and needles. Many patients have put off going for so long that they are embarrassed with the state of their teeth and gums. Apathy can play a part also when nothing is hurting. It is difficult to motivate someone to spend a great deal of money on something that they aren’t experiencing a perceived physical need.  “If it ain’t broke don’t fix it.”

The issue of the perceived unimportance of treatment or oral care, in general, is largely an education and habit issue. If parents don’t model good oral care, kids won’t learn good oral care. These things need to be taught. Everyone has heard that it is important to brush after every meal and floss daily, but nationwide, the average population brushes their teeth 1.1 times a day. The average person spends only 17 seconds each time they brush their teeth! Just 17 seconds! 


External Factors

  • Poor Communication by Providers
  • Stress
  • Community Influences
  • Socioeconomic Status
  • Physical Issues
  • Sounds
  • Actual Pain

External factors can include poor communication or involvement by those providing professional oral care. Education, again, is crucial to motivating patients to take care of their teeth and gums and make the time for follow up procedures.

When exploring the socioeconomic factor it is important to explore two issues at work.   One is affordability. Nobody likes to spend money on dentistry. Someone can usually think of a much more enjoyable way to spend their money. Some have minimal or no insurance coverage. Sometimes good enough has to be the way when the best is not within reach.

The other issue is value. Not everyone places a high value on their dental health. It can be a lot to spend if an individual needs major work. It can be difficult to justify the expense when there isn’t anything they notice at risk.

For many the overall experience of holding their mouth open is uncomfortable and the sounds are irritating and loud. Some have very sensitive gag reflexes that make x-rays difficult and embarrassing. Very few appreciate leaving the office to finish their day with part or all of their mouth completely numb. Many times this causes embarrassment and/or lip and cheek injuries.


Addressing the internal and external factors affecting noncompliance will result in better oral care, increased and enhanced professional care and improved home care. As professionals, we can work toward better patient communication and education, behavioral modification techniques, psychological help, pharmaceutical interventions, and improved home care regimens. Providing treatments that alleviate patient’s concerns about pain, needles and time, and creating home care regimens that mitigate noncompliance factors, many also remove some obstacles to care.

Communication and Education

Poor communication between providers and patients can be a large source of frustration, fear and cause noncompliance. This lack of communication may be the result of infrequent or abbreviated communication; giving patients too few facts or conversely, too many facts; complicated information; or poor communication styled. It is essential that the dental professional provides the patient with an appropriate amount of information at an appropriate level and at the appropriate moment. For this to be effective, a good rapport is essential. The patient should be given enough information to learn and understand, but not so much that it is overwhelming. At subsequent visits, more information can be offered.

The amount of information a patient can absorb and apply will depend upon the individual patient. Learning and applying new information or techniques can be achieved by building on the previous set of information. Poor communication and education results in confusion and misunderstanding over treatment and care, which can result in poorer patient compliance with recommended care.


Behavioral Techniques

  • Behavioral strategies used by dental professionals include:
  • Positive Reinforcement (e.g. praising the patient)
  • Use of Non-Threatening/Non-embarrassing Language
  • Tell-Show-Do Techniques.

The tell-show-do technique was originally developed for use in pediatric dentistry, but can also be used with nervous adult patients. The technique involves verbal explanations of procedures in easy-to-understand language (tell), followed by demonstrations of the sights, sounds, smells, and tactile aspects of the procedure in a non-threatening way (show), followed by the actual procedure (do).

More specialized behavioral treatments include teaching individuals relaxation techniques, such as:

  • Diaphragmatic Breathing: deep breathing from the abdomen that is done by contracting the diaphragm.
  • Progressive Muscle Relaxation:  alternately tensing and relaxing different muscle groups working the way through the body.   
  • Cognitive Restructuring: a set of techniques for becoming more aware of our thoughts and for modifying them when they are distorted or are not useful. This approach does not involve distorting reality in a positive direction or attempting to believe the unbelievable.  Rather, it uses reason and evidence to replace distorted thought patterns with more accurate, believable, and functional ones.  
  • Guided Imagery: directed thoughts and suggestions that guide the imagination toward a relaxed, focused state.

Both relaxation and cognitive strategies have been shown to significantly reduce dental fear. One example of a behavioral technique is systematic desensitization, a method used in psychology to overcome phobias and other anxiety disorders. This is also sometimes called graduated exposure therapy or gradual exposure. For example, for a patient who is fearful of dental injections, the therapist first teaches relaxation skills to the patient, then gradually introduces the feared object (in this case, the needle and/or syringe) to the patient, encouraging the patient to manage his/her fear using the relaxation skills previously taught. The patient progresses through the steps of receiving a dental injection while using the relaxation skills until the patient is able to successfully receive a dental injection while experiencing little to no fear. This method has been shown to be effective in treating fear of dental injections. Cognitive restructuring, when applied in a non-threatening situation, might be a useful alternative as a first step after years of avoidance of dental care and less threatening than immediate exposure to the feared stimuli.

Certain aspects of the physical environment also play an important role in alleviating the negative connotations surrounding the dental industry. For example, getting rid of the smells traditionally associated with dentistry, the dental team wearing non-clinical clothes, or playing music in the background can all help patients by removing and replacing stimuli which can trigger feelings of fear. Some anxious patients respond well to more obvious distraction techniques such as listening to music, watching movies, or even using virtual-reality headsets during treatment.


Pharmacological Techniques 

Pharmacological techniques to manage dental fear range from mild sedation to general anesthesia, and are often used by dental professionals in conjunction with behavioral techniques. One common anxiety-reducing medication, as a dental professional you are surely familiar with, is nitrous oxide, which is inhaled through a mask worn on the nose and causes feelings of relaxation and dissociation. Dentists may prescribe an oral sedative, such a benzodiazepine like temazepam (Restoril), alprazolam (Xanax), diazepam (Valium, or trazolam (Halcion).  While these sedatives may help people feel calmer and sometimes drowsy during dental treatment, patients are still conscious and able to communicate with the dental staff. Intravenous sedation uses benzodiazepines administered directly intravenously into a patient’s arm or hand. An IV sedation is often referred to as conscious sedation as opposed to general anesthesia (GA). In IV sedation, patients breathe on their own while their breathing and heart rate are monitored and are still responsive to a dentist’s prompts. In GA, patients are more deeply sedated and unable to breathe on their own and are not responsive to verbal or physical prompts.

Behavioral Change Methodology for Home Care

Compliance with home care is one of the greatest issues in dental care. The majority of patients are noncompliant to some degree with home oral care regimens.   A further problem in assessing patient compliance is the disparity between self-reported compliance, which is generally already poor compliance and actual compliance.

In the home care setting, both manual and powered brushes are known to be effective. The time and attention a patient pays to brush and interdental cleaning influence the results.

Any instrument or device that will lengthen the brushing or improve its effectiveness is going to have a positive impact. Using electric toothbrushes and water flossing units can have benefits. Electric toothbrushes can reduce the effort and time required to achieve compliance. Novelties items such as toothbrushes that have musical elements or beeps have been shown to lengthen the time spent brushing.

Patients are notoriously noncompliant when it comes to flossing. More than half of dental hygienists in one survey reported that less than one-third of their patients flossed daily. This may be due to the time required, the technique required or the perceived unimportance of interdental cleaning; also, as interdental plaque is not visible, it may not be socially unacceptable. Compliance can be improved through educating on the importance of flossing, as well on different types of floss. One-handed flossing aids can also help to alleviate difficulty with flossing. Interdental oral hygiene devices include interdental brushes and cleaners, floss and powered brushes with interdental heads. Interdental brushes offer an alternative that may be easier than flossing and has been shown to be at least as effective. A number of interdental brushes are available including slim designs for narrower interdental spaces. Nonetheless, a second step required in addition to brushing, for noncompliant patients, can be a barrier.

One study found improvement in-home care regimens for dental care through the strengthening of patients’ self-esteem. Self-care behavior can be influenced by concrete planning of care, with very specific directions about where, when and how to perform oral hygiene procedures.

However, it is also known that, over time, even patients who have been trained in oral hygiene care revert to old habits. Therefore, any gains in adherence to appropriate home care must be repeatedly reinforced. Patients also have been found to revert to old habits once the novelty effect of a powered brush has worn off.


Compliance with Office Visits

Going to the dentist’s office for most conjures up the image of the drill, fill and bill. This perception of discomfort and fear of pain and needles contributes to reduced visits. Beyond this problem, patients who do attend may be noncompliant with treatment recommendations. Utilizing technology and techniques that help prevent or reduce discomfort and pain and help improve the patient experience is key to helping patients accept treatment.

The office environment and staff can also make a difference. A staff that is warm and friendly can make a patient feel more at ease. As mentioned earlier, the sounds and smell of the office can also become a deterrent to office visits.

In-office topical fluorides are an important component of prevention programs. Options available include tray-applied gels and foams, as well as fluoride varnishes. The fluoride therapy selected may influence patient compliance, particularly in children and teens. Traditionally tray-applied gels and foams have been used in the United States and have been found to reduce caries. An alternative treatment of 5% sodium fluoride varnish also reduces caries. Unlike the tray-applied gels and foams, no tray is required with varnish. The varnish is applied using a disposable applicator such as a micro brush, or in the case of unit doses, using the applicator that comes with the unit dose. Since a tray is not required and the application is quick and simple, the patient will not experience the gagging that may be associated with tray use, and the procedure is less messy. This allows for increased patient comfort and may help patients avoid the embarrassment and distress that results from gagging. Using a white or clear varnish may also help patient compliance by removing the objection of applying a yellow color to teeth. Fluoride varnish can be used in all age groups; it minimizes the ingestion of fluoride and lowers blood plasma fluoride levels following application when compared to the use of gels. As with all products, use is contraindicated in patients with allergies to ingredients in the product (in the case of varnish, allergy to colophony).

Sedation may also be helpful if used appropriately for fearful patients receiving dental treatment.

Fun Dental Facts

AAPs recent Consumer Survey found:

50% of Americans consider the smile the first facial feature they notice

80% are not happy with their smile

32% of Americans cite bad breath as the least attractive trait

73% of Americans would rather go grocery shopping than floss

Adults with post-high-school degrees had an average of three more teeth than those without a high school diploma.

Smokers remain three times more likely than non-smokers to lose all their teeth.

The average woman smiles about 62 times a day.

A man?  Only 8!

People who drink 3 or more sugary sodas daily have 62% more dental decay, fillings and tooth loss

78% of Americans have had at least 1 cavity by age 17 

90% of systemic disease have oral manifestations. 

51 Million school hours per year are lost because of dental-related illness.

Dentistry is affordable:
Dentistry:  $50 Billion
Pet food:  $50 Billion
Haircare:  $100 Billion
Gambling (legal): $300 Billion





Human trafficking is the trade of humans, most commonly for the purpose of forced labor, sexual slavery, or commercial sexual exploitation for the trafficker or others. This may encompass providing a spouse in the context of forced marriage or the extraction of organs or tissues, including for surrogacy and ova-removal.  Human trafficking can occur within a country or trans-nationally. Human trafficking is a crime against the person because of the violation of the victim’s rights of movement through coercion and because of their commercial exploitation. Human trafficking is the trade in people, especially women and children, and does not necessarily involve the movement of the person from one place to another.

According to the International Labor (ILO), forced labor alone (one component of human trafficking) generates an estimated $150 billion in profits per year.  

Human trafficking is thought to be one of the fastest-growing activities of trans-national criminal organizations.

Human trafficking is condemned as a violation of human rights by international conventions. In addition, human trafficking is subject to a directive in the European Union.



The Trafficking Victims Protection Act of 2000, (TVPA) 

As a result of the 2000 Trafficking Victims Protection Act (TVPA), law enforcement was given the ability to protect international victims of human trafficking through several forms of immigration relief, including Continued Presence and the T visa. Continued Presence allows law enforcement officers to request temporary legal status in the U.S. for a foreign national whose presence is necessary for the continued success of a human trafficking investigation. The T visa allows foreign victims of human trafficking to become temporary U.S. residents, through which they may become eligible for permanent residency after three years. The TVPA also established a law requiring defendants of human trafficking investigations to pay restitution to the victims they exploited. 


The Justice for /victims of Trafficking Act  of 2015, ( JVTA)

The Justice for Victims of Trafficking Act (JVTA)of 2015 is a positive step forward in ensuring the perpetrators of human trafficking are held accountable.

The JVTA includes important provisions that will enhance the capacity of the U.S. government to tackle human trafficking and will further empower survivors in the context of criminal proceedings, especially in the area of restitution. The bill codifies important provisions related to training for law enforcement personnel on the identification and investigation of human trafficking. The JTVA will also improve law enforcement reporting on the incidence of trafficking across the United States—an essential step for determining the scope of this crime and for designing effective policies to tackle it. 

The JVTA works to fight human trafficking by reducing demand for sex trafficking, providing more services for victims, depriving convicted offenders of criminal assets and using forfeited assets to satisfy restitution orders for victims and giving law enforcement more and better tools to fight sex trafficking.




Sex Trafficking


Sex trafficking affects 4.5 million people worldwide. Most victims find themselves in coercive or abusive situations from which escape is both difficult and dangerous.

Trafficking for sexual exploitation was formerly thought of as the organized movement of people, usually women, between countries and within countries for sex work with the use of physical coercion, deception, and bondage through forced debt. However, the Trafficking Victims Protection Act of 2000 (US), does not require movement for the offense. The issue becomes contentious when the element of coercion is removed from the definition to incorporate the facilitation of consensual involvement in prostitution. For example, in the United Kingdom, the Sexual Offenses Act 2003  incorporated trafficking for sexual exploitation but did not require those committing the offense to use coercion, deception or force so that it also includes any person who enters the UK to carry out sex work with consent as having been “trafficked.”  In addition, any minor involved in a commercial sex act in the US while under the age of 18 qualifies as a trafficking victim, even if no force, fraud or coercion is involved, under the definition of “Severe Forms of Trafficking in Persons” in the US Trafficking Victims Protection Act of 2000.

Sexual trafficking includes coercing a migrant into a sexual act as a condition of allowing or arranging the migration. Sexual trafficking uses physical or sexual coercion, deception, abuse of power and bondage incurred through forced debt. Trafficked women and children, for instance, are often promised work in the domestic or service industry, but instead are sometimes taken to brothels where they are required to undertake sex work, while their passports and other identification papers confiscated. They may be beaten or locked up and promised their freedom only after earning – through prostitution – their purchase price, as well as their travel and visa costs.       


Labor Trafficking

Labor trafficking is the movement of persons for the purpose of forced labor and services. It may involve bonded labor, involuntary servitude, domestic servitude, and child labor. Labor trafficking happens most often within the domain of domestic work, agriculture, construction, manufacturing and entertainment; and migrant and indigenous people are especially at risk of becoming victims.



Trafficking for Organ Trade

Trafficking in organs is a form of human trafficking. In some cases, the victim is compelled into giving up an organ. In other cases, the victim agrees to sell an organ in exchange of money/goods, but is not paid (or paid less). Finally, the victim may have the organ removed without the victim’s knowledge (usually when the victim is treated for another medical problem/illness – real or orchestrated problem/illness). Migrant workers, homeless persons, and illiterate persons are particularly vulnerable to this form of exploitation. Trafficking of organs is organized crime, involving several offenders:

  • the recruiter
  • the transporter
  • the medical staff
  • the middlemen/contractors
  • the buyers

Trafficking for organ trade often seeks kidneys. Trafficking in organs is a lucrative trade because in many countries the waiting lists for patients who need transplants are very long.


Bonded Labor or Debt Bondage

Bonded labor or debt bondage is probably the least known form of labor trafficking today, and yet it is the most widely used method of enslaving people. Victims become “bonded” when their labor, the labor they themselves hired and the tangible goods they bought are demanded as a means of repayment for a loan or service in which its terms and conditions have not been defined or in which the value of the victims’ services is not applied toward the liquidation of the debt. Generally, the value of their work is greater than the original sum of money “borrowed.”


Forced Labor

Forced labor is a situation in which victims are forced to work against their own will under the threat of violence or some other form of punishment; their freedom is restricted and a degree of ownership is exerted. Men are at risk of being trafficked for unskilled work, which globally generates 31 billion USD according to the International Labor Organization.  Forms of forced labor can include domestic servitude, agricultural labor, sweatshop factory labor, janitorial, foodservice, and other service industry labor, and begging. Some of the products that can be produced by forced labor are clothing, cocoa, bricks, coffee, cotton, and gold.

The International Organization for Migration (IOM), the single largest global provider of services to victims of trafficking, reports receiving an increasing number of cases in which victims were subjected to forced labor. A 2012 study observes that “… 2010 was particularly notable as the first year in which IOM assisted more victims of labor trafficking than those who had been trafficked for purposes of sexual exploitation.”


Child Labor

Child Labor is a form of work that may be hazardous to the physical, mental, spiritual, moral, or social development of children and can interfere with their education. According to the International Labor Organization, the global number of children involved in child labor has fallen during the past decade – it has declined by one third. 



Human exploitation is the unethical, selfish use of human beings for the satisfaction of personal desires and/or profitable advantage. There are several areas where individuals are exploited including the trafficking mentioned above and additionally media exploitation, pornography, and bullying.

Media exploitation can involve the over-sexualized pictures in vogue as well as using sites, such as Facebook and Twitter to attack others. Media exploitation can also involve the use of propaganda to persuade people’s attitudes, beliefs, and behaviors.

Exploitation infests the production of pornography. Exploitation also pervades the consumption of pornography. The production and promotion of pornography can very easily and usually do exploit the individuals involved.

Bullying on every level is a form of exploitation.   The very definition of bullying is to use superior strength or influence to intimidate (someone), typically to force him or her to do what one wants.


People Smuggling

Human trafficking differs from people smuggling which involves a person voluntarily requesting or hiring another individual to covertly transport them across an international border, usually because the smuggled person would be denied entry into a country by legal channels. Though illegal, there may be no deception or coercion involved. After entry into the country and arrival at their ultimate destination, the smuggled person is usually free to find their own way.

According to the International Center for Migration Policy Development (ICMPD), people smuggling is a violation of the national immigration laws of the destination country and does not require violations of the rights of the smuggled person. Human trafficking, on the other hand, is a crime against a person because of the violation of the victim’s rights through coercion and exploitation. Unlike most cases of people smuggling, victims of human trafficking are not permitted to leave upon arrival at their destination.

While smuggling requires travel, trafficking does not. Trafficked people are held against their will through acts of coercion and forced to work for or provide services to the trafficker or others. The work or services may include anything from bonded or forced labor to commercial sexual exploitation. The arrangement may be structured as a work contract, but with no or low payment, or on terms which are highly exploitative. Sometimes the arrangement is structured as debt bondage, with the victim not being permitted or able to pay off the debt.



Vulnerable groups that are at risk of becoming trafficked, include migrant workers, migrant women, new immigrants, at-risk youth and those who are socially or economically disadvantaged. This latter group might include youth, teenage runaways or those who may have been lured to urban centers or who have gone of their own free will with the hopes of bettering their lives. Recent convictions for human trafficking for the purpose of sexual exploitation demonstrate that Canadian girls and women are often victims.



Human traffickers use violent methods such as coercion, extortion, violence, including both physical and emotional abuse, but they also use subtle methods, such as blackmail or even seduction of the victim. Most often, they establish direct contact with the person or members of his/her family through impersonation as a prospective employer or a love interest, or through misleading ads that promise jobs and opportunities to earn money. It is not rare for victims to be recruited via the Internet.


Why don’t people who are affected by trafficking escape:

  • The threat of violence against family
  • Restrictions on freedom of movement: traffickers remove passport/identity documents
  • Fear of authorities: trafficked person scared of being imprisoned or deported
  • Debt bondage: trafficked person owes money to trafficker or his/her family
  • Isolation: the trafficked person does not know the language of the country or how to get around
  • Emotional attachment: the trafficked person may have an emotional attachment to a trafficker (boyfriend or only person feeding them)



Traffickers can be lone individuals or part of extensive criminal networks. What they have in common is the desire to exploit people for profit. A wide range of criminals, including individual pimps, family operations, small businesses, loose-knit decentralized criminal networks, and international organized criminal operations, can be human traffickers. Based on human trafficking cases that have been identified by the National Human Trafficking Resource Center, examples of traffickers may include:

  • Brothel and fake massage business owners and managers
  • Employers of domestic servants
  • Gangs and criminal networks
  • Growers and crew leaders in agriculture
  • Intimate partners/family members
  • Labor brokers
  • Factory owners and corporations
  • Pimps
  • Small business owners and managers



  • Physical and sexual violence signs of abuse, such as unexplained bruises, black eyes, cuts, or marks. 
  • Exhibit behaviors including fear, anxiety, depression, submission, tension, and/or nervousness.
  • Exhibit “hyper-vigilance” or paranoid behavior.
  • Sexually exploited children and youth often express interest in or are in relationships with, adults or older men.
  • Evidence of controlling or dominating relationships, including repeated phone calls from a “boyfriend” and/or excessive concern about displeasing partner.
  • Unexplained shopping trips or possession of expensive clothing, jewelry, or a cell phone could indicate the manipulation of an exploiter. 
  • Not in control of their own money.
  • Use of lingo or slang from “the life” among peers, or referring to a boyfriend as “Daddy.” 
  • Secrecy about whereabouts.
  • Unaccounted for time, vagueness concerning whereabouts, and/or defensiveness in response to questions or concern.
  • Keeping late-night or unusual hours.
  • A tattoo that he or she is reluctant to explain may the result of tattooing or branding by a pimp. Pimps and other sexual exploiters often tattoo or brand children and youth, particularly girls.  Youth are commonly branded with their exploiter’s name tattooed on the neck, chest, or arms.
  • Wearing sexually provocative clothing can be an indicator of sexual exploitation.  But it should be noted, so as not to rely on stereotypes, that not all children in the commercial sex industry wear such clothing. Sexually provocative clothing is not a warning sign in and of itself.  Wearing new clothes of any style, or getting hair or nails done with no financial means to this independently, is a more general indicator of potential sexual exploitation.
  • Most sexually exploited children have been trained to lie about their age.  Sometimes a child’s appearance and/or actions can contradict the information they give.  Be sensitive to clues in behavior or appearance that could indicate that a child is underage. 
  • Personal information such as age, name, and/or date of birth – might change with each telling of his or her story, or the information given might contradict itself.
  • Has no identification or is not in control of his or her identification documents.



The following was developed by the National Human Trafficking Resource Center and contains questions that can be used to assess a client for potential signs that she or he has been a victim of human trafficking. The suggestions and indicators below are not exhaustive or cumulative in nature and each question taken alone may not indicate a potential trafficking situation. Assessment questions should be tailored to your program and client’s specific needs.

As with any assessment of a victim of crime, there are some general points to be aware of when evaluating a client’s needs. Listed below are general tips for conducting an assessment with a potential victim of trafficking.

The term “controller” is used generally to describe the potential

trafficker or the person(s) who maintain(s) control over the potential victim(s).

Assessment Environment and Tone

  • Conduct the assessment in a comfortable and safe environment. If you are in a police station or in a place where the physical space/conditions are limiting, attempt to create an environment that is as calming and positive as possible.
  • Provide the individual with space when speaking with them.
  • Be relaxed and use an approachable tone, demeanor, and body language. Ask yourself the question “To what degree does my present posture communicate openness and availability to the client”?
  • Use empathic listening. Empathic listening centers on being attentive, observing, and listening in order to understand the client’s situation without making judgments.
  • While you engage in empathic and reflective listening make sure you are maintaining good eye contact with the client. Good eye contact is another way of conveying “I want to hear what you have to say”. 
  • If at all possible, try not to take notes and instead engage in active listening and write your notes immediately following the meeting with the client. If note-taking is necessary, let the individual know why you need to write notes and for what purposes they may be used.
  • Be clear about your role and goals, and about the services that your agency can and cannot provide.
  • Explain why you care about the individual’s situation and that you have worked with and assisted other individuals in situations that may be similar to his/her own. Explaining who you are and why you are there is particularly important to correct any misperceptions of your role.


Assessment of Language and Questions

  • When appropriate, attempt to engage in casual conversation about lighter topics and ask questions to try to get the individual to open up, even if it’s not about their trafficking situation or service needs.
  • Although the client might be confused, scared and/or distracted, engaging in casual conversation before the assessment helps to build trust and set the tone for effective, non-defensive communication.
  • In your initial assessment, try to focus predominantly on assessments of their service needs, but weave in other questions naturally and when appropriate.
  • It is often useful to start with questions that ascertain the lesser degrees of control before moving onto the more severe methods of control.

Example: Inquiring about living or working conditions may be an easier topic to tackle initially than directly inquiring about physical or sexual abuse that the victim may have sustained.

  • Be conscious of the language that you use when speaking with a potential victim of trafficking. Mirroring the language that the potential victim uses can be a helpful first step.

Example: If the potential victim refers to her controller as her boyfriend, referring to that person as a “pimp” or a “sex trafficker” may have a negative impact. Although these are terms that can be used for controllers in the commercial sex industry, the potential victim may not identify this person in this way.

  • The phrasing of all questions included in this assessment should be changed, amended or revised to fit the client and context you are in.
  • It is also important to conduct assessments in a potential victim’s native language whenever possible.
  • Use trained interpreters sensitive to the nature of the crime and who are not in any way tied to the potential victim or the potential trafficker’s community of origin.
  • Ensure that the interpreter is introduced and their role is fully explained.


Important Dynamics For Your Assessment

  • Keep in mind that many victims do not self-identify as “human trafficking victims” due to a lack of knowledge about the crime itself and the power and control dynamics typically involved in human trafficking situations.
  • Be conscious of the fact that an individual in a trafficking situation has typically been conditioned by their trafficker not to trust law enforcement and/or service providers.
  • Be aware of power dynamics when a third party is accompanying or interpreting for a potential victim. Try to speak to the potential victim alone or secure an outside interpreter.
  • Be aware that canned stories are common and that the true story may not emerge until trust has been built with the potential victim after multiple meetings.
  • Each client is going to tell his/her story differently and no client will present all of the elements of their trafficking situation in a neat package.
  • It is imperative that the assessor remain flexible and prioritize the client’s needs and safety as the primary reason for the assessment.


Safety Check

Be sure to conduct a safety check if the individual has recently exited the situation or if they are still in the situation.

  • Is it safe for you to talk to me right now? How safe do you feel right now? Are there times when you don’t feel safe?
  • Do you feel like you are in any kind of danger while speaking with me at this location?
  • Is there anything that would help you to feel safer while we talk?

If speaking with the individual over the phone:

  • Are you in a safe place? Can you tell me where you are?
  • Are you injured? Would you like for me to call 911/an ambulance?
  • If someone comes on the line, what would you like for me to do?  Hang up? Identify me as someone else, a certain company/person/friend?
  • Also, remind the individual to feel free to hang up at any point during the conversation if they believe that someone may be listening in.
  • How can we communicate if we get disconnected? Would I be able to call you back/leave a message?
  • Would you prefer to call me back when you are in a safe place?


General Trafficking Assessment Questions

The following questions could be applicable to both situations of sex and labor trafficking. Please note that the order listed is not intended to indicate the order in which the questions should be asked. The type and order of questions should be tailored to a given situation and should be amended to react effectively and supportively to the client.


Fraud Questions

  • How did you meet this person/find out about your job?
  • What were you told about the job before you started/what promises were made about the relationship?
  • Did your experience meet your expectations?
  • Do you feel you were ever deceived about anything related to your job/your relationship?
  • Did anything surprise you about this job/relationship?
  • Did the conditions of your job/relationship change over time?
  • Did you feel like you understand your rights in this job/situation?


Domestic Servitude Questions

  • Did you have days off? Were you able to leave the house on your days off? Were you ever expected to complete work on your days off (still provide childcare, complete household chores before leaving, etc.)?
  • Were you ever able to leave the home to run errands, transport children to school or go to church? Were you monitored or timed when you left the home for these things?
  • Did you have your own room in the home? Where did you sleep?
  • Did you have consistent access to food? Were you ever made to go without food?
  • Did you have access to medical care while you lived in the home?
  • What were your tasks in the home (childcare, cleaning, cooking, etc.)? How many hours did you work during the day or at night?
  • Were you allowed to communicate with your family/friends while you lived in the home?
  • Are you afraid that your controller might harm your family back in your hometown?
  • Did the controller ever force you to engage in sexual acts against your will at any time they requested it? What did you think would happen if you refused to do this?
  • Did your partner/family member ever ask you to engage in commercial sex acts in order to “help the relationship/the family”?
  • Did your partner/family member ever force you to engage in commercial sexual acts with friends or business associates for favors/money?
  • Did your partner/family member ever force you to engage in commercial sex through online sites, escort services, street prostitution, strip clubs, truck stops, fake massage businesses or residential brothels?
  • Did your partner/family member ever threaten you or abuse you if you indicated that you did not want to engage in commercial sex or did not do what this person asked of you?
  • Did your partner/family member ever withhold financial support or restrict access to your children?



Human trafficking is abuse so the rules for mandatory reporting are the same for human trafficking. If you are licensed by the division of quality medical assurance you need to report suspected trafficking. The need doesn’t end there though. Everyone has a role to play in combating human trafficking.

If you suspect or know of human trafficking activity please contact your local police, the National Human Trafficking Resource Center at 1-800-96-ABUSE or Homeland Security at 802-872-6199.

Do not attempt to confront a suspected trafficker directly or alert a victim to your suspicions. Your safety, as well as the victim’s safety, is paramount. 

You can also submit a tip at  Highly trained specialists take reports from both the public and law enforcement agencies on more than 400 laws enforced by ICE HSI, including those related to human trafficking.

By identifying victims and reporting tips, you are doing your part to help law enforcement rescue victims, and you might save a life. Law enforcement can connect victims to services such as medical and mental health care, shelter, job training, and legal assistance that restore their freedom and dignity. The presence or absence of any of the indicators is not necessarily proof of human trafficking. It is up to law enforcement to investigate suspected cases of human trafficking.



Once emergency needs are met (safety, food, and clothing), other needs that present themselves in the short- and long-term are housing (transitional and permanent for adults, and foster care or permanent placement for minors), legal assistance (e.g., help in understanding legal rights, legal representation and, for international victims, assistance with filing T-visa applications, and immigration petitions), and advocacy (e.g., assistance retrieving identification documents, completing applications, attending appointments, and navigating the different systems, including criminal justice, child welfare, immigration, human services, transportation, etc.).

Most victims also need health screening (tuberculosis, sexually transmitted diseases, pregnancy), vaccinations/immunizations, medical treatment for physical injuries, and dental care. Other service needs include child care (for both adults and minors with children), education (GED assistance, enrollment in school, technical training/certification), life skills training (including assisting some international victims with operation of basic household appliances, using public transportation, using a telephone, mailing a letter, etc.), job training, finding employment, financial management, and where appropriate, family reunification or repatriation.

A number of studies have identified the serious and often complex mental health needs of victims of human trafficking. The majority of research related to the mental health needs of this population focuses on the significant levels of post-traumatic stress disorder (PTSD). Victims of human trafficking have often experienced, witnessed, or been confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and their response to these events frequently involves intense fear, helplessness, or horror.  This exposure and common reaction are two of the main criteria for PTSD.  While there is some evidence that preexisting conditions related to social supports, history, childhood experiences, personality variables, and preexisting medical disorders can factor in the diagnosis of PTSD, exposure to trauma is the most important feature in the development of PTSD.

In addition to PTSD, victims of human trafficking have been found to suffer from other anxiety and mood disorders including panic attacks, obsessive-compulsive disorder, generalized anxiety disorder, and major depressive disorder.

Substance-related disorders are often found to be co-morbid in victims of human trafficking. While a few victims of trafficking reported prior substance addictions, the majority of victims who reported alcohol and drug use said they began using after they were in their trafficking situations. Some victims reported using alcohol and drugs to help them deal with their situations; however, others reported being forced or coerced to use drugs or alcohol by the traffickers.

While victims of human trafficking can suffer from a range of mental health problems, the most prominent and those for which there is significant research documenting their presentation tend to be anxiety disorders, mood disorders, dissociative disorders, and substance-related disorders. 



Treatment for trauma is a crucial part of a victim’s recovery.  In trauma-informed care, treatment is guided by the practitioner’s understanding of trauma and trauma-related issues that can present themselves in victims. 

While there are numerous therapy approaches, the purpose of all trauma-focused therapy is to integrate the traumatic event into the person’s life, not subtract it. Many therapists combine different types of therapies.  Although you are not in the counseling field note the types of approaches used:


Pharmacotherapy is the use of medications to manage disruptive
trauma reactions. Medications have been shown to be helpful with the following classes of reactions/symptoms:

  • Intrusive symptoms
  • Hyperarousal
  • Emotional reactivity
  • Heightened arousal
  • Irritability
  • Depression

Taking medication does not make someone’s trauma reactions and pain evaporate. Medications can only help make the symptoms less intense and more manageable.

Behavior Therapy

The most common form of behavior therapy is exposure. In exposure therapy, one gradually faces one’s fears–for example, the memories of a traumatic event–without the feared consequence occurring.

Often, this exposure results in the individual learning that the fear or negative emotion is unwarranted, which in turn allows the fear to decrease.

Exposure therapy has been found to reduce anxiety and depression, improve social adjustment, and organize the trauma memory. There are various forms of exposure therapy:

  • Imaginal exposure: An individual imagines the feared event as vividly as possible.
  • In vivoexposure: The exposure occurs in the therapy.
  • Systematic desensitization: The individual is exposed to successively more fear-inducing situations. This exposure is paired with relaxation.

Exposure therapy is a highly effective treatment for post-traumatic stress (PTSD).

Another form of behavior therapy is Stress Inoculation Training (SIT), also known as relaxation training. Stress Inoculation Training teaches individuals to manage stress and anxiety.

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is grounded in the idea that an individual must correct and change incorrect thoughts and increase knowledge and skills. Common elements of cognitive-behavioral therapy trauma therapy include:

  • Teaching individuals how to breathe in order to manage anxiety and stress
  • Educating individuals on normal reactions to trauma
  • Exposure therapy
  • Identifying and evaluating negative, incorrect, and irrational thoughts and replacing them with more accurate and less negative thoughts

Eye Movement Desensitization and Reprocessing (EMDR)

Therapists who perform EMDR first receive specialized training from an association such as the EMDR Institute or the EMDR International Association.  An EMDR session follows a preset sequence of 8 steps or phases. Treatment involves the person in therapy mentally focusing on the traumatic experience or negative thought while visually tracking a moving light or the therapist’s moving finger. Auditory tones may also be used in some cases. The debate regarding whether eye movements are truly necessary exists within the field of psychology, but the treatment has been shown to be highly effective for the alleviation and elimination of symptoms of trauma and other distress.


There is no one guiding principle for hypnotherapy.   In general, a hypnotherapist guides the individual in therapy into a hypnotic state, then engages the person in conversation or speaks to the person about certain key issue. Most hypnotherapists believe that the emotions and thoughts that an individual comes into contact with while under hypnosis are crucial to healing.

Psychodynamic Therapy

The goal of psychodynamic trauma therapy is to identify which phase of the traumatic response the individual is stuck in. Once this is discerned, the therapist can determine which aspects of the traumatic event interfere with the processing and integration of the trauma. Common elements of psychodynamic therapy include:


  • Taking the individual’s developmental history and childhood into account

  • Placing emphasis on understanding the meaning of the trauma

  • Looking at how the trauma has impacted the individual’s sense of self and relationships, as well as what has been lost due to the traumatic event

Group Therapy

There are a variety of different groups for trauma survivors. Some groups are led by therapists, others by peers. Some are educational, some focus on giving support, and other groups are therapeutic in nature.   Groups are most effective when they occur in addition to individual therapy. It is important for a trauma survivor to choose a group that is in line with where one is in the healing journey.

Due to the fairly new development of anti-human trafficking activities and initiatives and the recent recognition of the phenomenon of human trafficking in the field of mental health, there is little evidence-based research on the treatment of victims of human trafficking.  These treatments for PTSD and trauma are the current approach.



Close to 37,000 Americans will be diagnosed with oral or pharyngeal cancer this year. It will cause over 8,000 deaths, killing roughly 1 person per hour, 24 hours per day. Of those 36,000 newly diagnosed individuals, only slightly more than half will be alive in 5 years. (Approximately 57%). This is a number that has not significantly improved in decades. The death rate for oral cancer is higher than that of cancers we hear about more routinely such as cervical cancer, Hodgkin’s lymphoma, or skin cancer (malignant melanoma).

Oral cancer is part of a group of cancers called head and neck cancers. Oral cancer can develop in any part of the oral cavity or oropharynx, which is the oral part of the pharynx that reaches from the Uvula to the level of the hyoid bone.

Oral cancer is very common and can frequently be avoided through lifestyle choices. Excessive intake of alcohol and cigarettes and other forms of tobacco should be avoided. Oral cancer is a major global threat to public health, causing great morbidity and mortality rates.

There are many forms of oral cancer. It can involve the tongue, lips, throat and other parts of the mouth. In all cases, the disease involves an abnormal growth process, which if left untreated, can result in death. Common names for it include oral cancer, pharyngeal cancer, mouth cancer, tongue cancer, and throat cancer.



Understanding the causative factors of cancer will contribute to the prevention of the disease. As a dental professional you are on the front lines for recognizing oral cancer so familiarizing yourself with the risk factors, signs and symptoms of this disease can make a big impact on the fight against oral cancer.

The number one cause of oral cancer is tobacco, both inhaled and smokeless. Patients who smoke cigarettes, cigars, pipes or other inhaled products are at increased risk.

Smokeless tobacco products, such as snuff, are also very detrimental. Approximately 80% of people with oral cancers use tobacco. The risk increases with the amount and length of tobacco use.

Age is also frequently named as a risk factor for oral cancer, as historically it occurs in those over the age of 40. The age of diagnosed patients may indicate a time component in the biochemical or biophysical processes of aging cells that allows malignant transformation, or perhaps, immune system competence diminishes with age. With this being stated, data acquired within the last three years have indicated that the fastest-growing segment of the oral cancer population is non-smokers under the age of fifty, which would indicate a paradigm shift in the cause of the disease, and in the locations where it most frequently occurs in the oral environment.

The anterior of the mouth (tobacco and alcohol-associated) cancers have declined along with a corresponding decline in smoking. Posterior of the oral cavity sites (associated with the HPV16 viral causes) are increasing. However, it is likely that the accumulative damage from other factors, such as tobacco use, alcohol consumption, and persistent viral infections such as HPV, are the real culprits. It may take several decades of smoking, for instance, to precipitate the development of cancer. Having said that, tobacco use in all its forms, as noted, is still number one on the list of risk factors in individuals over 50. When tobacco use is combined with heavy alcohol use, the risk is significantly increased, as the two-act synergistically. Those who both smoke and drink, have a 15 times greater risk of developing oral cancer than others. It does not appear that the HPV16 viral causes act synergistically with tobacco or alcohol, and represent a completely unique and independent disease process.

Tobacco and alcohol are essentially chemical factors, but they can also be considered lifestyle factors since we have some control over them.

Besides these, there are physical factors such as exposure to ultraviolet radiation. This is a causative agent in cancers of the lip, as well as other skin cancers. Cancer of the lip is one oral cancer whose numbers have declined in the last few decades. This is likely due to the increased awareness of the damaging effects of prolonged exposure to sunlight, and the use of sunscreens for protection.

Another physical factor is exposure to x-rays. Radiographs were regularly taken during examinations, and at the dental office, they are safe, but remember that radiation exposure is accumulative over a lifetime. It has been implicated in several head and neck cancers.

Biological factors include viruses and fungi, which have been found in association with oral cancers. We briefly touched on the human papillomavirus, particularly HPV16, which has been definitively implicated in oral cancers, particularly those that occur in the back of the mouth. (Oropharynx, the base of the tongue, tonsillar pillars and crypt, as well as the tonsils themselves.) HPV is a common, sexually transmitted virus, which infects about 40 million Americans today. There are over 130 strains of HPV, most thought to be harmless. Most Americans will have some version of HPV in their lifetimes, and even be exposed to the oncogenic / cancer-causing versions of it.   Only approximately 1% of those infected, have a lack of immune response to the HPV16 strain which is the primary causative agent in cervical cancer (with HPV18), cancers of the anus and penis, and now also oral cancer, as well.

Infection with even a high-risk HPV virus does not mean that an individual will develop oral cancer. Most people’s immune systems will clear the infection before a malignancy has the opportunity to occur.

There are other minor risk factors, which have been associated with oral cancers but have not yet been definitively shown to participate in their development. These include lichen planus, an inflammatory disease of the oral soft tissues, and genetic predispositions. 

There are also suggested causative links in individuals who use conventional “smokeless” chewing or spit tobacco. Promoted by some as a safer alternative to smoking, it has in actuality not proven to be any safer when referring to oral cancers.

From a gender perspective, for decades this has been cancer that affected 6 men for every woman. That ratio has now become 2 men to 1 woman.

Oral cancer is the 6th most common cancer in men and the 14th most common cancer in women. Oral cancer is most common in men, African Americans, Native Americans, adults over age 40, smokers, and heavy alcohol drinkers. However, one out of four cases occurs in non-smokers and people under age 30. Oral cancer is the most common cancer among men in India, mainly due to the habit of using smokeless tobacco.



One of the real dangers of this cancer is that in its early stages, it can go unnoticed. It can be painless, and little in the way of physical changes may be obvious. As a dental professional, when you know what to look for, you may see or feel the precursor tissue changes, or actual cancer while it is still very small, or in its earliest stages long before the patient is aware.

It may appear as a white or red patch of tissue in the mouth, or a small indurated ulcer that looks like a common canker sore.

Because there are so many benign tissue changes that occur normally in the mouth, and some things as simple as a bite on the inside of the cheek may mimic the look of a dangerous tissue change, it is important to pay close attention to any sore or discolored area of the mouth, which does not heal within 14 days.

Other signs /symptoms include:

  •         a lump or mass which can be felt inside the mouth or neck
  •         pain or difficulty in swallowing, speaking or chewing
  •         wartlike mass
  •         any numbness in the oral/facial region
  •         Unilateral persistent earache
  •         Swelling, thickening or roughness on the tongue, cheek or on the floor of the mouth
  •         White patches along the side of the tongue or on the lip.
  •         Unexplained bleeding in the mouth or throat.
  •         Soreness in the back of the mouth or in the throat
  •         Hoarseness or changes in the voice
  •         chronic sore throat
  •         Persistent sores in the lips, tongue, palate or throat
  •         Skin lesion, lump, or ulcer that do not resolve in 14 days


Additional symptoms that may be associated with this disease:

  •         Tongue problems
  •         Swallowing difficulty
  •         Mouth sores
  •         Pain and paraesthesia are late symptoms

Common areas for oral cancer to develop in the anterior (front) of the mouth are on the tongue and the floor of the mouth. Individuals that use chewing tobacco, are likely to have them develop in the sulcus between the lip or cheek and the soft tissue (gingiva) covering the lower jaw (mandible) where the plug of tobacco is held repeatedly. There are also a small number of cancers that are unique to the salivary glands, as well as the very dangerous melanoma.

While the occurrence of these is dwarfed by the other oral cancers, they are responsible for a small percentage of the total incidence rate. In the US, cancers of the hard palate are uncommon, though not unknown. The base of the tongue at the back of the mouth, the oropharynx (the back of the throat) and on the pillars of the tonsils, and the tonsillar crypt and the tonsil itself, are other sites where it is now more commonly found, particularly in young non-smoking individuals.

If anything suspicious is found it is best to do a biopsy of the area. It is important to have a firm diagnosis as early as possible. The biopsy is usually completed by a specialist.



The death rate associated with this cancer is high not because it is hard to discover or diagnose, but rather due to the cancer being routinely discovered late in its development.  There is not a comprehensive program in the United States to opportunistically screen for the disease, and without that; late-stage discovery is more common.

Another obstacle to early discovery is that the contributing HPV 16 virus incidences many times do not produce visible lesions or discolorations that have historically been the early warning signs of the disease process.

Cancer screenings can be a regular part of an annual visit. Screening involves examination for early stages in the development of the disease even though there are no apparent symptoms.

Studies show that dentists and dental hygienists may be the most thoroughly trained and the most sensitive to early, subtle changes in the mouth that could signal trouble later on.

When the diagnosis of oral cancer is made, surgical excision is the treatment of choice. Fortunately, if this is performed early, survival is often assured. Unfortunately, early detection is sometimes not made, and the survival rate is low.



Oral cancer is curable. Treatment depends on the type and location of cancer, as well as the extent of its spreading. When detected early, treatment tends to be more conservative, producing fewer complications.  

After a definitive diagnosis has been made and cancer has been staged, treatment may begin. Treatment of oral cancers is ideally a multidisciplinary approach involving the efforts of surgeons, radiation oncologists, chemotherapy oncologists, dental practitioners, nutritionists, and rehabilitation and restorative specialists. The actual curative treatment modalities are usually chemotherapy with concurrent radiation, oftentimes combined with surgery. Early-stage cancers that are limited to the oral cavity may be treated by surgery alone.

Chemotherapy while able to kill cancer cells itself is currently not used as a monotherapy for oral cancers. Added to decrease the possibility of metastasis, to sensitize the malignant cells to radiation, to reduce the size of any malignancy prior to surgery, or for those patients who have confirmed distant metastasis of the disease, it is a powerful component of treatment.

Prior to the commencement of curative treatment, it is likely that other oral health needs will be addressed. The purpose is to decrease the likelihood of developing post therapeutic complications. Teeth with poor prognosis from periodontal problems, caries, etc. may be extracted. This avoidance of post-radiotherapy surgery is important as it can sometimes induce osteonecrosis, a condition that can develop when tissue damaged by radiation exposes the underlying bone and remains chronically non-healing. The bone, which has lost its ability to efficiently repair itself due to reduced blood supply, from radiation exposure, yields a chronic and difficult to treat the situation. Thorough prophylaxis or cleaning will likely be done as well prior to beginning treatments.

Whether a patient has surgery, radiation, and surgery, or radiation, surgery, and chemotherapy, is dependent on the stage of development of cancer. Each case is individual. Patients with cancers treated in their early stages may have little in the way of post-treatment disfigurement. For those whose cancer is caught at a later stage, the results of surgical removal of the disease may require reconstruction of portions of their oral cavity or facial features. There may be adjunctive therapy required to assist in speech, chewing and swallowing of foods, the problems associated with the lack of salivary function, as well as the fabrication of dental or facial prostheses.

This form of cancer is one of the most expensive forms to treat, with an advanced case costing upward of $200,000.

Unfortunately, patients with oral cancer have a poor prognosis, and the 5-year survival rate of approximately 50% has remained unchanged for the past 50 years. Perhaps the single most important reason for this is the fact that oral cancers continue to be diagnosed in advanced stages.



What are HIV and AIDS  

The Human Immunodeficiency Virus, which is commonly referred to as HIV, is a virus that directly attacks certain human organs, such as the heart or kidneys, as well as the human immune system.   The immune system is made up of cells, which work to protect the body from infections and some cancers. HIV attacks the cells, which are required for a proper immune system function. When HIV destroys enough of these cells there is a failure of the immune system to protect the individual from certain opportunistic infections.

Acquired Immunodeficiency Syndrome or AIDS refers to an individual who has very advanced HIV disease and their immune system has incurred significant damage.

According to The Centers for Disease Control the conditions that mark a progression from HIV disease to AIDS are:

*Certain infections, such as repetitive pneumonia

*Certain cancers, such as cervical cancer, Kaposi sarcoma, and central nervous system lymphoma

*CD4+ count less than 200 or 14% of lymphocytes

Symptoms of HIV Infection

The only way to determine for sure whether someone has HIV/AIDS is to be tested for the HIV infection. Someone cannot rely on symptoms to know whether or not they are infected with HIV. Many people who are infected with HIV do not have any symptoms at all for many years. The potential symptoms include:

  • rapid weight loss 
  • dry cough
  • recurring fever or profuse night sweats
  • profound and unexplained fatigue
  • swollen lymph glands in the armpits, groin, or neck (lymphadenopathy)
  • diarrhea that lasts for more than a week
  • white spots or unusual blemishes on the tongue, in the mouth, or in the throat (thrush)
  • pneumonia
  • red, brown, pink, or purplish blotches on or under the skin or inside the mouth, nose, or eyelids (Kaposi Sarcoma)
  • memory loss, depression, and other neurological disorders


HIV and AIDS remain a persistent problem for the United States and countries around the world. While great progress has been made in preventing and treating HIV, there is still much to do. According to the Center for Disease Control (CDC) as of June 2016, 17 million people living with HIV were receiving medicines to treat HIV, called antiretroviral therapy (ART). 

Advances in HIV have led to dramatic declines in AIDS deaths and slowed the progression from HIV to AIDS. Better treatments have led to a rise in the number of people in the United States who are living with AIDS. This growing population represents an increasing need for better understanding, empathy, support, continued HIV prevention services, and treatment.

The Infection    

While there are treatments that help people survive some of the diseases they get as a result of losing their immunity, there is no cure for AIDS. Although scientists have yet to find a cure or an effective vaccine, AIDS, unlike many other life-threatening illnesses, is completely preventable. We have the knowledge, technology, and resources to halt the spread of the epidemic. We know how HIV is and is not spread. Educating everyone about how to protect him or herself is the only way we can halt the spread of this disease. Prevent HIV infection and you will prevent AIDS.

Medical tests detect antibodies to HIV. These antibodies are in the bloodstream and are an attempt of the immune system to eliminate the virus. Antibodies are generally detectable 6 to 12 weeks after infection with HIV. When antibodies are present in someone’s blood, that person is said to be HIV-positive. Generally, in an untreated HIV-infected person, symptoms serious enough to constitute an AIDS diagnosis begin to appear eight to ten years after infection.

Before highly active antiretroviral therapy became available, most people who contracted HIV eventually progressed to AIDS and had some AIDS-related complications such as deterioration of the immune system functioning and an increased risk of infection and cancers. Presently, most HIV-positive people live normal, active lives for several years after infection.

A number of factors can affect how rapidly HIV progresses, some that can be controlled, and some that cant. An individual who takes better care of himself or herself, which improves the immune system, and following the doctors’ advice slows the progression of HIV disease to AIDS. An infection by a virulent strain of HIV, having a higher viral load, older age, and the abuse of alcohol and other drugs may cause the HIV progression to AIDS to be more rapid.


As we continue to research how to control and eventually eradicate this disease, our efforts have focused on the identification of the ways in which HIV can be transmitted.

According to The Centers for Disease Control and Prevention:

HIV is transmitted by:

* Sexual contact with an infected person

* Sharing needles and/or syringes with someone who is infected.

* Less commonly (and now very rare in countries where blood is screened for HIV antibodies), through transfusions of infected blood or blood clotting factors.

* Babies born to HIV-positive women may become infected before or during birth or through breastfeeding after birth.

* In health care settings, workers have been infected after being stuck with needles containing HIV-infected blood.

* Less frequently, workers have been infected after HIV-positive blood gets into a worker’s open cut or a mucous membrane (eyes or inside of the nose).


The first step in controlling HIV is to prevent new infections.

There are three key things that can be done to help prevent all forms of HIV transmission. Promoting widespread awareness of HIV and how it can be spread; counseling and testing, and providing antiretroviral treatment. This treatment enables people living with HIV to enjoy longer, healthier lives, and as such, it acts as an incentive for people to volunteer for HIV testing. It also brings people into contact with health care workers who can deliver prevention messages and interventions.

Out of these three key components, we will look at specific protocols and recommendations based on the route of transmission.

Prevention of Occupational Exposure

There are many strategies that can be used to reduce the risk of occupational exposure.

The primary means of preventing the health care worker’s occupational exposure to HIV and other blood-borne pathogens is to follow infection control precautions with the assumption that the blood and other body fluids from all patients are potentially infectious. These precautions include:

  • Routinely using barriers (such as gloves and/or goggles) when anticipating contact with blood or body fluids
  • Immediately wash hands and other skin surfaces after contact with blood or body fluids.
  • Carefully handling and disposing of sharp instruments during and after use.
  • Safety devices also have been developed to help prevent needle-stick injuries.

If used properly, these types of devices may reduce occupational HIV exposure risk. Furthermore, because many percutaneous injuries are related to sharps disposal, strategies for safer disposal, including safer design of disposal containers and placement of containers, are being developed.

Although the most important strategy for reducing the risk of occupational HIV transmission is to prevent occupational exposures, plans for post-exposure management of health care workers should be in place. The administration of antiretroviral drugs as post-exposure prophylaxis (PEP) should be considered. Using zidovudine as PEP has been shown to be safe and associated with decreased risk for occupationally related HIV infection. Newer antiretrovirals also may be effective, although there is less experience with their use as PEP. CDC recently issued guidelines for the management of HCW exposures to HIV and recommendations for PEP. These guidelines outline a number of considerations in determining whether or not an HCW should receive PEP and in choosing the type of PEP regimen. The recommendations will be updated if ongoing data collection and analysis show increased the effectiveness of newer drug treatments.

As mentioned, all health care workers should use universal precautions. These precautions should include the routine use of gloves and or goggles when contact with blood or body fluids is possible, washing hands and other skin surfaces immediately after contact with blood or body fluids and using extra care when handling or disposing of sharp instruments.

Precautions Regarding Sex

To reduce the transmission of HIV the CDC recommends abstinence, monogamy with a safe, tested the significant person or at a minimum the use of latex or polyurethane condoms.

Injectable Drug Use

Abstinence from IV drug use is also a necessary component of the reduction in the transmission of HIV. If drug use is an issue, the user should only use clean needles and syringes and seek the aid of a substance abuse rehabilitation program.

Perinatal Transmission of HIV

The perinatal transmission of HIV each year in the United States by approximately 6,000 to 7,000 HIV-infected women giving birth, results in 280 to 370 new perinatal infections. Approximately 40% of the HIV infected women who pass their HIV to their child never knew they were HIV infected or were never tested for HIV during their pregnancy.

Effective prevention of mother-to-child transmission (PMTCT) requires a three-fold strategy.

  • Preventing HIV infection among prospective parents
  • Avoiding unwanted pregnancies among HIV positive women
  • Preventing the transmission of HIV from HIV positive mothers to their infants during pregnancy, labor, delivery, and breastfeeding.

The last of these can be achieved by the use of antiretroviral drugs, safer feeding practices, and other interventions.

For HIV-positive women in well-resourced countries, the advice from national health agencies is straightforward: they should avoid breastfeeding altogether because the risk of HIV transmission far outweighs the risks associated with replacement feeding.

Many women do not know that perinatal transmission of HIV is preventable. Only about 33% of all hospitals offer rapid HIV testing to women in labor and only 50% of them have policies to test women whose HIV status is unknown.


The strongest weapon against HIV is education. As a society and each individual must conquer the fear through knowledge and education rather than allowing the fear to postpone testing and take part in unsafe practices such as unprotected sex.

 The CDC provides the following to dispel popular misconceptions:

* There is no known transmission of HIV by contact with an environmental surface. (Public accommodations, transportation, etc.)

* There is no evidence of HIV transmission through mosquitoes or other insects.

* There is no known risk of HIV transmission to co-workers, clients or consumers from contact in industries such as food-service establishments.

* Casual contact through closed-mouth kissing is not a risk for transmission of HIV.

* The CDC recommends engaging in French or open-mouth kissing, although the risk of acquiring      HIV during this practice is believed to be very low.

* Contact with saliva, tears, or sweat has never been shown to result in the transmission of HIV.

* Natural membrane condoms have been shown to allow viruses to pass through them. For condoms to provide maximum protection, they must be latex or polyurethane, be used every time and correctly.

HIV Testing

The Centers for Disease Control and Prevention has recommended that HIV testing and HIV screening be part of routine clinical care in all health care settings. The CDC also has stated it suggests that the patient’s right to refuse be preserved in order to facilitate a good working relationship between patient and doctor. The following summarizes the HIV testing recommendations from the CDC.

Patients in all Health-Care Settings

  • HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening).
  • Persons at high risk for HIV infection should be screened for HIV at least annually.
  • Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient and imply consent for HIV testing.
  • Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings.

Pregnant Women  

  • HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women.
  • HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines (opt-out screening).
  • Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient for HIV testing.
  • Repeat screening in the third trimester is recommended in certain areas with elevated rates of HIV infection among pregnant women.

There are 3 primary tests for HIV.

  • Elisa
  • Western Blot
  • PCR (Viral Load)

The tests to determine if a person has been infected with HIV really do not test for the actual HIV virus. Instead, these tests detect proteins that circulate in the body when a person has been infected with HIV. Two of these antibody blood tests are used to detect HIV antibodies in the bloodstream while the third detects HIV proteins.

This is the first portion of the HIV test. This test detects the presence of HIV antibodies in the blood. If the test is negative then the person is determined not to be HIV infected. If the test is positive the second portion of the test is run to confirm the results.

Western Blot
This test is used to confirm a positive Elisa test. The Western Blot test detects specific protein bands that are present in an HIV infected individual.

In combination with a positive Elisa, a positive Western Blot is 99.9% accurate in detecting HIV infection.

PCR detects specific DNA and RNA sequences that indicate the presence of HIV in the genetic structure of anyone HIV infected. After one is infected with HIV, RNA, and DNA from the HIV virus circulating in the blood. The presence of this DNA and RNA “pieces” indicates the presence of the HIV virus.

Getting tested earlier than 3 months may result in an unclear test result, as an infected person may not yet have developed antibodies to HIV. The time between infection and the development of antibodies is called the window period. Some test centers may recommend testing again at 6 months.

It is also important that an individual is not exposed to further risk of getting infected with HIV during the window period. The test is only accurate if there are no other exposures between the time of possible exposure to HIV and testing.

If an individual’s test is negative at six months and they have not had unprotected sex or shared needles again in the meantime, it means that they do not have HIV, and will not, therefore, go on to develop AIDS.

HIV Treatment  

The importance of testing and diagnosis is ever increasing with significant progress being made regarding the treatment of HIV. Antiretroviral medications can slow and even stop the damage occurring to the body. Medical compliance is crucial to slowing the progression of HIV to AIDS.

The Initiation of Treatment

  • Antiretroviral therapy is recommended for all patients with AIDS-defining illnesses or symptomatic HIV infection regardless of CD4 count or HIV Viral Load.
  • Antiretroviral therapy is recommended for asymptomatic patients with a CD4 count < 200.
  • Those asymptomatic patients with CD4 counts of 201 – 350 should be offered treatment.
  • Most experienced clinicians will defer treatment for those asymptomatic patients with CD4 counts > 350 and viral loads > 100,000.
  • HIV Treatment should be deferred for those patients with a CD4 count > 350 and a viral load of < 100,000.


Under most circumstances, HIV testing is voluntary. Unless there are special circumstances, most states require a person to give informed consent before he or she can be tested for HIV. Many options are available for anonymous testing at clinics and at home. Most states have laws that protect the confidentiality of HIV testing and diagnosis.

Confidentiality is a complex issue. The need for confidentiality is paramount to further the efforts of testing and treatment. However, most if not all states carry the requirement of disclosing HIV status to a prospective sexual or needle-sharing partner. In some states, failure to do so is a misdemeanor; in others, it is a felony.   The challenge lies in defining an identifiable sexual or needle-sharing partner while respecting the rights of the HIV-infected individual to confidentiality.

Reporting HIV and AIDS in Florida

As part of informed consent, it is important to verbalize and put in writing your responsibilities as a professional prior to beginning assessments and treatment. Also, should a situation arise where you are unsure it is always best to seek supervision through a supervisor and mentor in your field. 

HIV/AIDS cases should be reported to the local county health department within 2 weeks of diagnosis, per FL Statutes. Cases may be reported ONLY by MAIL or by TELEPHONE.

The Centers for Disease Control and Prevention (CDC) published its first surveillance case definition for Acquired Immune Deficiency Syndrome (AIDS) in September of 1982. Starting in 1983, Florida designated AIDS as a reportable disease and an AIDS surveillance program was instituted. Reporting at that time, however, was voluntary and it was not until 1986 that the mandatory reporting of AIDS became incorporated into Florida Statues (s.384, F.S.). Currently, an HIV positive patient age 13 or older meets the CDC surveillance case definition of AIDS if they have a CD4 T-lymphocyte count less than 200/ul or 14%. They also meet the criteria if they have any one of 26 opportunistic infections. Florida Administrative Code 64D directs that all AIDS cases, as defined by CDC, be reported to the local county health department by physicians who diagnose or treat AIDS.

AIDS surveillance data has provided critical information necessary for tracking this disease and targeting both prevention and treatment resources. In recent years, however, AIDS surveillance data has been less reflective of the epidemic due to the success of antiretroviral therapy. Individuals infected with HIV are doing better and the progression from HIV to AIDS is much longer. People are living longer, healthier lives. Consequently, the number of AIDS cases has dropped. With fewer cases and longer progression from HIV to AIDS, it is difficult to know where new infections are occurring and where to target resources.

In 1996 legislation was passed, amending s.384, F.S., and 64D, F.A.C., authorizing the Department of Health to establish rules to require both laboratory and physician reporting of positive HIV infections. Effective July 1, 1997, HIV infection became reportable by name in the State of Florida. Laboratories are required to report within 3 working days from the date of receipt of test results and physicians are required to report within 2 weeks of diagnosis. Only confidential positive tests that diagnose HIV infection are reportable. Examples of tests, previously noted, to diagnose HIV infection are antibody-based testing systems such as repeat ELISAs followed by a Western Blot, and antigen tests such as p24 antigen or polymerase chain reaction (PCR), when these are used for confirmatory purposes. Tests to determine viral load are not reportable unless done to diagnose HIV infection. Under Florida Law there is no retroactive reporting; only positive results obtained from specimens collected on or after July 1, 1997, are reportable.

HIV reporting in the state of Florida was implemented, not only to have a more accurate picture of the epidemic but also to link patients to services. Under Florida Law, a health department representative will contact the reporting physician for permission to contact the patient. This contract is for the purpose of offering and initiating follow-up services. Examples of follow-up services are post-test counseling for persons who did not return for test results, referral for medical evaluation, case management services, and voluntary partner notification. This linking of seropositive patients to services is one reason that patient names are necessary on the reports. Another reason names are needed is to prevent duplication. Eliminating duplicates prevents the inflation of statistics and ensures that the data are as accurate as possible.

For those patients not wishing to be reported if positive, Florida Law requires that anonymous testing be readily available in all counties of the state through the county health department. Persons who test positive for HIV through the anonymous testing system will not be reported. All persons being offered an HIV test are required by law to be informed about These locations are mandated by law to give equal opportunity to use or enjoy the public accommodation of goods, services, or facilities.

HIV/AIDS-related illnesses are also covered under the Family & Medical Leave Act. This allows eligible employees to take off up to 12 work weeks in any 12 month period to care for themselves or a family member with a serious health condition.

Working with Patients with HIV/AIDS

The patient with HIV/AIDS is facing not only a life-threatening and often fatal illness but also with the social stigma, public fear and concerns of transmitting the illness to loved ones. They often face isolation, discrimination, loss of career and in many circumstances abandonment by family and friends. They are financially threatened by medical expenses and fear for their benefits. In many situations, they also are faced with grief and loss from friends and loved ones who have died from AIDS. Medical professionals must address the psychological, biological and social aspects of this illness.

With the advances made in treatment, HIV-positive clients should not be treated as hospice patients. Many HIV-infected clients live normal lives for years to come. For this reason, it is important to help the client to establish coping mechanisms for the long term well being.

The treatment plan should address medical compliance and social services should develop a plan including issues relating to prejudice, support issues, concerns about relationships, depression, anxiety, and suicide risk assessment and education.

Universal precautions should be used with HIV positive clients, just as they should be used with all patients.

HIV Positive Personnel

Twenty years ago, returning to work with HIV was not an issue. It was not an issue because people were too sick or died soon after their diagnosis. But today, with the advent of powerful HIV drugs, people are living long productive lives. People are feeling well and want to resume their normal lives…lives that include family, relationships, and employment. While going back to work is a positive thing, there are things you must know before returning to the workplace to avoid problems after taking the job.

Unless your HIV disease affects your ability to perform your job you are under no legal obligation to disclose your HIV status. And because HIV is not transmitted by casual contact, your HIV infection does not put any of your coworkers in danger of being infected.

Employers should proactively develop comprehensive personnel policies to address the broad-spectrum HIV-related issues that can arise at the worksite. The ever-expanding scope of the HIV epidemic essentially guarantees that all employers will be confronted with the human relations issues related to HIV infection.

The “hands-on” nature of health care creates specific challenges in drafting scientifically sound personnel policies. While employment and personnel policies frequently reflect societal attitudes on a number of issues, health care employers must base HIV policies on scientific facts rather than misinformation and/or in response to political/social pressures.

Personnel policies should create a maximally safe and healthful environment for all workers.

Legal topics discuss HIV infection reporting and the availability/location of anonymous test sites. A list of anonymous test sites in your area can be obtained from your local county health department. However, once a person meets the CDC defined AIDS criteria they are reportable, regardless of whether or not they tested anonymously. Furthermore, because AIDS is still a reportable disease a new report needs to be filed for all HIV reported persons who later meet the AIDS criteria.


HIV & AIDS Reporting Guidelines

Reportable in Florida if:

  • Patient tests positive for any test to diagnose and/or
    confirm HIV diagnosis on or after July 1997

    -Tests such as Western Blot
    PCR qualitative testing
    PCR quantitative*

* (ONLY if used for diagnostic purposes)

Reportable in Florida if:

   Patient has a documented AIDS-defining Opportunistic Infection
at any time


  Patient has a documented
CD4 <200 or <14% at
any time



Legal Protection for the HIV-infected Person

The Americans with Disabilities Act (ADA) gives federal civil rights protections to individuals who are diagnosed with HIV/AIDS. Persons with HIV, both symptomatic and asymptomatic are protected by law against discrimination and are entitled to equal opportunity in public accommodations, employment, and transportation. Additionally, individuals who are discriminated against because they associate with an HIV-infected person are also protected by the ADA.

This protection prohibits all private employers with 15 or more employees, as well as all public entities, regardless of their size from discriminating in employment against qualified individuals with disabilities. This includes hiring, firing, as well as job application procedures such as interviewing, job assignments, training, promotions, wages, benefits, leave and all other employment-related activities. An example of this protection could include a hospital that discharged a mental health technician due to their HIV-positive status. Customer or co-worker attitudes do not constitute just cause for discharge.

The ADA mandates that an employer may not ask or require a job applicant to take a medical examination before making a job offer. It cannot make any pre-offer inquiry about a disability or the nature or severity of a disability. An employer may inquire as to whether a candidate is able to perform the duties of the job.

The ADA requires that medical information be kept confidential. Medical information must be kept in a separate file apart from an individual’s personnel file. All licensing boards have very strict guidelines for the maintenance of client files. Most require that client files be maintained in a locked file cabinet in a locked room. Only authorized staff is allowed to review charts. Again, it is stressed that the policy for confidentiality is best clearly defined in informed consent.

A public accommodation is also a legally protected issue. Public accommodation relates to a private entity that owns, operates, leases or leases to a place of public accommodation. This would include places such as restaurants, shopping malls, medical practices, as well as others.

Post Exposure to BBP

Although not a primary means of HIV transmission, occupational exposure to HIV has resulted in documented cases of HIV seroconversion among health care workers in the United States.

Although as discussed in the prevention section of this course, preventing exposures to blood and body fluids is the primary means of preventing occupationally acquired HIV infection, it is also appropriate to look at post-exposure management as an important element of workplace safety.

If you experienced a needlestick or sharps injury or were exposed to the blood or other body fluid of a patient during the course of your work, immediately follow these steps:

  • Wash needle sticks and cuts with soap and water
  • Flush splashes to the nose, mouth, or skin with water
  • Irrigate eyes with clean water, saline, or sterile irrigants
  • Report the incident to your supervisor
  • Immediately seek medical treatment

Any incident of exposure should be reported to your supervisor immediately.





This lesson is designed to provide dental professionals with practical strategies to facilitate the discussion and treatment of oral malodor in the dental office.

This course describes a useful communication model specifically aimed at discussing potentially sensitive issues. 


Bad breath is a common problem that can cause significant psychological distress.
There are a number of potential causes and treatments available.


Only a dental or medical professional can determine whether halitosis is the result of bad oral habits or something more serious.  The production of bad breath, known as oral malodor and/or halitosis is caused by several factors that may involve both oral and non-oral sources.   

Bacterial putrefaction of proteins by gram-negative and some gram-positive anaerobic bacteria particularly those residing on the posterior dorsum of the tongue utilize sulfur-containing amino acids, primarily cysteine and methionine, to produce volatile sulfur compounds (VSCs). Although other organic components (e.g., organic acids, indole/skatole, putrescine, cadaverine) may be involved in the production of halitosis, hydrogen sulfide (H2S), methyl mercaptan (CH3SH), and dimethyl sulfide [(CH3)2S] have been identified as the predominate VSCs responsible for oral malodor.   While the tongue is considered the primary source of VSC production, other dental problems can generate these offensive gases.

Dental sources of breath odor include gingivitis, periodontal disease, gross carious lesions, and poor oral hygiene. However, when dental disease is the source of oral malodor, treatment of the condition will often eliminate the problem.  The tonsils have also been reported as a possible source of halitosis.   Likewise, transient breath problems from eating spicy foods, smoking, and drinking certain beverages will most often disappear shortly after their use is discontinued.  However, while eliminating these sources can successfully treat the majority of patients who suffer from bad breath, some individuals continue to have chronic breathing problems.  

Non-oral sources of breath odor would include pathologic conditions outside the mouth such as nasal, paranasal, laryngeal regions, the pulmonary or upper digestive tract (non-blood-borne extra-oral halitosis). An example of an extra-oral, blood-borne odor is cirrhosis of the liver. In this example, the odor is emitted via the lungs but its origin is from the liver. Conditions such as type 2 diabetes, kidney disorders, and pulmonary disease may also contribute to offensive breath odor.  Serious diseases such as some cancers, and conditions such as metabolic disorders can cause bad breath as a result of the chemicals they produce in the body. These conditions should not go undiagnosed, and a dentist will be able to rule out other potential causes of halitosis and determine if an individual should visit a doctor to get screened for cancer or other diseases.  

Medications, especially those that reduce salivary flow such as antidepressants, antipsychotics, narcotics, decongestants, antihistamines, and antihypertensives can exacerbate breath odor. These non-oral sources of breath odor have been well reviewed in the literature. However, while systemic conditions and medications can contribute to breath problems, most authorities seem to agree the majority of bad breath originates in the oral cavity.  As mentioned, the primary source for oral malodor is the tongue, home to bacteria stored inside all of its grooves and cracks. When particles of food aren’t completely removed from the mouth, they collect bacteria on the tongue and around the gums.  These bacteria feed on the food and protein material in the mouth, as well as their byproducts.  A possible result–bad breath.

The foods individuals eat affect how the breath smells because what is eaten affects the air that is exhaled.  After being absorbed into the blood stream, some of the components of foods are transferred into the lungs, where they’re expelled when someone breathes. Ingredients such as garlic, for example, contribute to bad breath odor.  The objectionable odors may linger until the body naturally eliminates those foods’ components.

There are other reasons why oral malodor can occur. Chronic dry mouth can cause oral malodor because saliva is necessary to clean the mouth and remove particles that may cause bad breath.  Bad breath may also be caused by a medical condition, such as respiratory infections, diabetes, or gastrointestinal disturbance.


  • Poor oral hygiene
  • Periodontal disease
  • Tongue coating
  • Food impaction
  • Unclean dentures
  • Faulty crowns, bridges, and fillings
  • Tobacco
  • Medications (several drugs produce dry mouth as a side effect)
  • Diet
  • Systemic illness, including gastrointestinal disorders

It has been estimated that up to 25% of the population suffers from bad breath on a regular basis in spite of having good physical and oral health and after the elimination of offensive foods and beverages.   It is these patients that most need our expertise. While there are many new products and emerging information regarding the treatment of oral malodor, the dental professional also needs to feel comfortable sharing this information and these products with their patients.


Here are some key points about bad breath. 

  • Bad breath is estimated to affect 1 in 4 people globally
  • The most common cause of halitosis is bad oral hygiene
  • If particles of food are left in the mouth, their breakdown by bacteria produces sulfur compounds
  • There are a number of common causes of bad breath, including smoking, tooth decay, and alcohol consumption
  • Keeping the mouth hydrated can reduce mouth odor
  • Bad breath in children is often due to a trapped item in the nasal cavity
  • Rarer causes of bad breath include bowel obstruction, ketoacidosis and aspiration pneumonia 
  • The best treatment for bad breath is regular brushing, flossing, and hydration
  • Crash diets can cause bad breath because of the build-up of ketones.


Not everyone is that honest!  Telling someone they have bad breath is awkward.  Regardless of the source of oral malodor, chronic breathing problems can be detrimental to one’s self-image and confidence causing social, emotional, and psychological anxiety. The problem of assessing and treating oral malodor is exacerbated by the personally sensitive nature of the topic. Even in close relationships, people are often reluctant to inform others their breath is offensive. Asking a trusted confidant or experienced health professional is considered the most reliable method of confirming a chronic breath odor problem. This, however, can be awkward and embarrassing for both the patient and the dental professional, who historically has been hesitant to broach the subject. Since the dental office is the most logical place to assess and treat oral malodor, it is important to develop the communication skills and knowledge base that will enable dental professionals to respond to our patients who seek information about and treatment for bad breath.

Since oral malodor can be related to certain medical conditions or medications, taking a comprehensive medical/dental history, including questions pertaining to breath concerns, can lay the groundwork for open dialogue about breathing problems. When patients initiate a dialogue about their breath concerns, dental professionals need to be comfortable with explaining the etiology of and treatments for oral malodor. 


The P-LI-SS-IT System

As a professional in this situation it is critical that you approach the issue with knowledge and sensitivity.  This course introduces a communication model that has been used successfully by people in a range of helping professions when providing sexuality-related information, also sensitive in nature. The model is J.S. Annon’s P-LI-SS-IT system.   The acronym stands for the model’s four progressive levels:

  • Permission
  • Limited Information
  • Specific Suggestions
  • Intensive Therapy

This lesson discusses how the P-LI-SS-IT model may be applied to the dental setting for discussing the personally sensitive topic of breath odor concerns with patients. The P-LI-SS-IT system is flexible and adaptable to many settings and to whatever amount of time is available. The model allows for a range of treatment choices geared to the level of competence of the individual clinician.

Before introducing the P-LI-SS-IT model, let’s go over general interviewing skills and counseling techniques.

Before an effective clinician/patient dialogue can take place, it is important that the dental professional feel secure about their own knowledge level regarding the etiology and interventions available for treating breathing problems. A strong knowledge base enables the clinician to personalize the treatment plan to the particular problem of an individual patient and rely less on standardized techniques and “one size fits all” regimens. Furthermore, it is important to be familiar with interviewing and counseling techniques that encourage open communication, reduce anxiety and establish rapport.

The more knowledge of the etiology and treatment of oral malodor a clinician has, the more confidence they will experience when interviewing and counseling patients about breath odor. Beyond this course, several sources of information are available to expand one’s knowledge base regarding oral malodor.

Armed with the basics and more it is also very important to know basic interviewing skills to gather information and explore your patient’s possible causes.  Most of us have heard the adage “It’s not what is said but how it’s said that makes a difference.” This is particularly true when discussing subjects that are inherently sensitive. What follows are specific suggestions for interviewing and counseling patients:

The Setting

It is very important the clinician and patient have some degree of privacy when discussing personally sensitive issues. Patients are typically reluctant to share sensitive information that might be overheard by others. For this reason, if you can offer a patient privacy, it’s best to do so. When privacy is limited, it is best to postpone discussions until the clinician is alone with the patient and to speak in a low volume.

The Initial Approach

Time is typically a consideration. If the clinician does not have time available to talk in-depth about the patient’s concern, she/he can give limited information (following the P-LI-SS-IT model discussed in this article) and make another appointment for the patient as soon as practical. This way the patient does not leave feeling as though their needs were not addressed.

When initiating conversations regarding oral malodor, it is important to use statements the clinician feels comfortable with. For example, after reviewing a patient’s medical history or oral examination, one might begin by using one of the following questions:

“Do you have any other dental concerns or problems regarding yourself or a family member’s oral health?”

“What dental products are you currently using on a regular basis?”

“Do you have questions regarding dental products you’ve seen advertised or heard about?“

If the patient says they do not have any concerns, it is recommended to accept this answer and do not press further. Let it be known that if in the future he or she does have concerns that they feel free to contact you at the office. Suppose the patient does have a concern, what does the clinician do?


The most common and serious mistake made by most clinicians is failing to really listen to what the patient has to say without interrupting. It is important we don’t jump in with suggestions before hearing the patient out.



With the advent of so many “bad breath” remedies and standardized regimens available for sale to patients, it is important for dental professionals to keep in mind the treatment procedures and/or products we recommend should be based on an individualized assessment. Otherwise, there is no point in performing a comprehensive assessment if all patients go through the same treatment program. Furthermore, it is important to keep in mind we have a professional responsibility to follow The Code of Professional Conduct for the Dental Profession.

The code of ethics reminds dental professionals to preserve the inherent trust in the dentist-patient relationship.  It also stresses the importance of verifying the accuracy of claims made by manufacturers and distributors about product safety and efficacy before inducing patients to purchase products or undergo procedures.  “The dentist has an independent obligation to inquire into the truth and accuracy of such claims and verify that they are founded on accepted scientific knowledge or research.”  

In the Ethics portion of the American Dental Hygiene Association’s Policy Manual states that “The American Dental Hygienists Association (ADHA) opposes misleading advertising and unsubstantiated claims connected with oral care products and services.

We have an ethical responsibility to base our clinical recommendations on sound scientific evidence. This practice of integrating the most current knowledge into clinical decision-making is referred to as Evidence-Based Decision Making (EBD). One way that we can be assured of using EBD in our product recommendations to patients is to endorse products that have undergone the rigorous evaluation by the ADA Council on Scientific Affairs’ and have received the ADA Seal of Approval.


The P-LI-SS-IT System

As mentioned earlier, the P-Li-SS-IT model that has been used successfully by school counselors, social workers, nurses, clergymen, and health aides when counseling persons with sexuality concerns and problems. The P-LI-SS-IT system is flexible and adaptable to many settings and to whatever amount of time is available.

The model allows for a range of treatment choices geared to the level of competence of the individual clinician. The first three levels involve “brief therapy,” and most patients bad breath problems can be successfully resolved at these levels. The fourth and final level involves “intensive therapy” and is reserved for those patients whose problems require more complex therapy. At this level, it is important the clinician has the appropriate training and experience to provide a highly individualized therapeutic program. This may include a referral for either medical assessment or psychological counseling.

This information discusses how the P-LI-SS-IT model may be applied to the dental setting for discussing the personally sensitive topic of breath odor concerns with patients. Let’s return to the scenarios presented earlier and outline some helpful responses using the P-LI-SS-IT model.


The dental professional should enter the conversation by gaining the patient’s permission to discuss the topic.  “Do you have any other concerns you would like to discuss?”  “Many of my clients like to ask questions about how flossing and dental hygiene can effect breath issues. Some like to ask what products are preferred for cavity prevention?  Would you like to discuss those or any other concerns?”

The goal is to open up communication and ensure the client feels comfortable.



In this phase of the conversation it is important to let the patient know what are the possible causes, discussed above, and show that as a professional you have information to offer them, but not to overwhelm them.  “So it sounds like you experience bad breath only in the mornings.  This is usually caused by a lack of saliva through the night and bacteria.”

The application of this second level is a continuation of the first level of approach, permission. At the permission level, the patient is made to feel comfortable and encouraged to share their concerns. The clinician is primarily concerned with reassuring the patient that she/he is normal. At the limited information level, the patient is given specific factual information directly relevant to their specific problem. Typically, the information provided at this level can be incorporated into existing schedules and does not require additional appointment time.

If giving limited information is not sufficient to resolve the patient’s concern, there are two options available to the clinician at this point. The patient may be referred for appropriate treatment elsewhere or, providing the clinician

has the appropriate setting, knowledge, skills, and experience, he or she can proceed to the third level of treatment: specific suggestions.


Once you have gathered all of the information from the patient, listening carefully and completely, you can present specific suggestions based on a full evaluation of the presenting problem.

When providing specific suggestions, clinicians may wish to supplement verbal instruction with appropriate readings; resources include published articles, patient education brochures, and Internet websites. Reading materials provide both non-intimidating information sources as well as being time-saving, Image result for animated toothbrush giffor both the clinician and the patient.

While it may be possible to incorporate the information provided at this level into existing appointments, it may also be necessary to schedule additional appointment time(s). The fees charged for these procedures will be determined by individual offices and will be based on the time involved, the expertise of the clinician, and the products provided to the patient.

There may be times when the specific suggestions that have worked for others do not work for a particular patient’s problem. When a clinician believes they have done as much as they can from within the “brief therapy” framework, then it is time for highly individualized intensive therapy.


Intensive therapy involves an in-depth assessment of the patient’s specific situation in order to develop a highly individualized comprehensive therapeutic program unique to them. Clinicians with appropriate training in the etiology of and treatment modalities for oral malodor could initiate such treatment. Otherwise, this is the point at which you would refer patients for appropriate treatment elsewhere. The important point to keep in mind is we have an ethical responsibility to first try to resolve patients’ problems from within the brief therapy approach.

It is important to keep in mind that while the brief therapy part of the model may be sufficient to resolve many of our patients’ oral malodor problems, it is not intended to resolve all bad breath problems. If we don’t have the expertise in our office, we have an ethical responsibility to identify and refer patients to those who do.



As mentioned breath odor can have an oral origin, medical issue or be related to other factors such as the food someone eats.  When other factors are ruled out diagnostic tests can utilize X-rays and computed tomography (CT) scanning for cross-sectional views.   Rhinoscopy can be performed to examine the nasal passage.  In addition, clinicians can utilize clinical symptoms such as pain and palpation or pain while leaning ther head forward to diagnose a sinus pathology.  The ADA considers tools, equipment, and all instruments for measuring breath odor as secondary tests; organoleptic judging is the primary test.  There are generally only a few different instruments regularly used in the US for the general clinic.  One is called the Halimeter equipped with electrochemical sensor and the Breathtron described as a portable monitor with a zinc-oxide think film semiconductor sensor specific to VSC’s.  Gas chromatography (GC) equipment can also detect and discern gasses in the breath.  some dental offices now have equipment that can detect VSC levels in the breath.

The introral, paranasal, ear, nose and throat examination involves the observation of all types of surface abnormalities, including color, texture, and palpation in areas of interest.  A hand-held pen light is suitable for a quick analysis, but lamps or head lights should be used for thorough investigations.  

Oral examinations begin with a visual examination, then proceed to palpation.  All hard and osft tissues are observed.  Lumps, bumps, lesions, and discolorations need to be noted.  All teeth, including third molars and implants, need to be examined for pericoronitis and periimplantitis.  

Oftentimes, oral malodor is multifactorial.  Places harboring bacteria a detained food, damaged hard and soft tissues are all sites or oral malodor production that may not show on an x-ray.  The odor that is emanating from the marginal opening of a crown, inside of which could have unchecked decay and debris leaking out.  It is not only crowns beneath which pathogenic bacteria, decay, and odor can seep, but also beneath all types of faulty restorations where plaques can accumulate and not be cleaned.  

Ulcerations, surgical wounds, gignival and periodontal disease, TC and even pericoronitis can be culprits that should be investigated during the examination. 

Observing the tongue and making assessments about the depth and breadth of a tongue’s coating is one method of making a gross judgment about potential malodor.

Scientists have developed indexes to record various conditions including tongue coating.  Judging the tongue’s coating is considered one useful method of detecting oral malodor.  There is a strong correlation between a thick tongue coating and halitosis.                                                                                    

Since chronic bad breath causes severe repercussions, suffers are anxious to find a cure. Halitosis treatment products have spurred a billion-dollar industry.   The most popular means of combating chronic halitosis, after eliminating other medical causes for bad breath, include toothbrushes, mouthwash, and tongue scrapers.  Brushing and flossing play an important role in oral hygiene. 

Tongue scraping, together with proper oral hygiene is the most effective “common” treatment against the causes of halitosis. 

Other Recommendations for Reducing Oral Malodor: 

  • Remove dentures at night and clean to get rid of bacterial buildup from food and drink.
  • Drink plenty of water and swish cool water around in the mouth. This is especially helpful to freshen “morning breath.”
  • Brush after every meal and floss, preferably twice a day.
  • Replace the toothbrush every two to three months.
  • Arrange regular dental checkups and cleanings.
  • Chew a handful of cloves, fennel seeds, or aniseeds. Their antiseptic qualities help fight halitosis-causing bacteria.
  • Chew a piece of lemon or orange rind for a mouth- freshening burst of flavor. (Wash the rind thoroughly first.) The citric acid will stimulate the salivary glands—and fight bad breath.
  • Chew a fresh sprig of parsley, basil, mint, or cilantro. The chlorophyll in these green plants neutralizes odors.
  • Suggest a 30-second mouthwash rinse that is alcohol-free. Mix a cup of water with a teaspoon of baking soda (which changes the pH level and fights odor in the mouth) and a few drops of antimicrobial peppermint essential oil. Do not swallow (Yields several rinses.)

Bad breath can be a serious issue. Surveys have shown that people find the oral odor to be a major turn-off, even more so than having stains on clothes, being bald, having yellow teeth or acne. In some cases, it is a sign of a serious health issue.  As a dental professional it is important to gain the skills necessary to notice the signs, have the ability to have an open conversation about and to treat this serious issue.




You are watching your 8-year-old son playing little league baseball and in the middle of the game, the pitcher is knocked over with a ball right to his chest. Will you know what to do? Many of us, every day, are witness to trip and fall accidents, car crashes and other medical emergencies. This course will serve as a refresher course on what a first responder is, how are they protected, what constitutes a medical emergency, what to do for many common emergencies, how medical emergencies should be transported, advice on psychological trauma and the emotional toll on responders, themselves.

Information in this lesson is designed as a refresher course, not a recommendation or full training, and is not meant to usurp medical training or personal judgment.

 What is a First Responder?

A certified first responder is a person who has completed a course, through a recognized organization such as the American Heart Association or Red Cross and has received certification in providing pre-hospital care for medical emergencies. They have more skill than someone who is trained in basic first aid but they are not a substitute for advanced medical care rendered by emergency medical technicians, emergency physicians, nurses, or paramedics. The term “certified first responder” is not to be confused with “first responder”, which is a generic term referring to the first medically trained responder to arrive on the scene (police, fire, EMS). Without being too concerned with titles, it is important for anyone who is willing to help in an emergency. The help may be with keeping the victim calm, calling 911 or initiating Cardio Pulmonary Resuscitation (CPR).

Many people who do not fall into the category of medical technicians, emergency physicians, nurses, or paramedics seek out or receive Certified First Responder training through their employment because they are likely to be first on the scene of a medical emergency, or because they work far from medical help.

Some of these non-traditional first responders include:

  • Park rangers
  • Utility workers
  • Teachers, childcare workers, and school bus drivers
  • Designated industrial workers in a large facility (industrial plant) or at a remote site (fish-packing plant, commercial vessel, oil rig)
  • Police Officers
  • Security guards
  • Bodyguards
  • General aviation pilots and commercial flight attendants
  • Sports coaches and Athletic trainers
  • Hunting and fishing guides
  • Search and rescue personnel
  • Campus Responders and campus police
  • Lifeguards/Ski Patrollers
  • Camp counselors
  • Boy Scouts and Girl Scouts and leaders
  • Community Emergency Response Team (CERT) members (varies by jurisdiction).

What Is An Emergency and What is Not? 

It iRelated images critical to know how to recognize the signs of a medical emergency. Correctly interpreting and acting on these signs could make a real difference in a true emergency. Many people under-report the symptoms of a medical emergency, such as a heart attack or stroke. They sometimes want to see if the symptoms will go away on their own. They delay seeking care right away out of denial, fear, financial concerns or for a myriad of other reasons. For many medical emergencies, time is of the essence, and delays in treatment can often lead to more serious consequences.

Emergency physicians believe it is the responsibility of every individual to learn to recognize the warning signs of a medical emergency. The following signs and symptoms and are not intended to represent every kind of medical emergency, but rather to provide examples of common issues.

What To Do In A Medical Emergency

The following is refresher information on how to handle common emergency medical conditions. This section does not contain all the signs or symptoms of medical emergencies, and the advice is not intended to be a substitute for consulting with a medical professional specializing in the symptoms the victim is reporting. Someone who is experiencing a medical emergency should seek immediate medical attention.

Adverse Drug Reactions     

Side effects are a normal occurrence with many drugs. Some are minimal and some can be very serious and can trigger life-threatening reactions both allergic and non-allergic.  Also, some medicines interact with other medications and cause adverse drug reactions. An adverse drug reaction is an expression that describes harm associated with the use of given medications at a normal dose. People who take three or four medications each day are more likely to have reactions to drugs. In addition, the use of herbal supplements and alternative medicines can interact with certain drugs and cause health issues.

Adverse drug reactions can occur within minutes or within hours of exposure. They are a leading cause of death in the United States, resulting in more than 100,000 deaths each year.

The most common symptoms of allergic reactions to drugs are:

  • Skin rash or hives
  • Itchy skin
  • Wheezing or other breathing problems
  • Swelling
  • Diarrhea or constipation

Penicillin is a frequent culprit for adverse drug reactions. Antibiotics, sulfa drugs, barbiturates, and insulin also can cause problems. Some medicines trigger a response from the immune system in people with drug hypersensitivity. The body’s immune system perceives the substance as attacking the body, so it attacks the system.

More than 90 percent of adverse drug reactions do not involve an allergic immune system response. Instead, these reactions may produce a range of symptoms involving almost any system or part of the body – which often makes them difficult to recognize.

Reactions to drugs may range from mild, such as upset stomach or drowsiness, to severe, life-threatening conditions, such as anaphylaxis. These reactions can occur with prescription medications, over-the-counter medications, and supplements or herbal remedies.

Everyone with known sensitivity should always tell their doctor if they have adverse reactions to medications and they should wear an identifying bracelet or jewelry that alerts rescuers to their condition.

Asthma and Allergies

Although asthma and allergies are two separate conditions – asthma is a chronic disease of the bronchial air tubes, whereas allergies involve an overreaction of the body’s disease-fighting immune system – the two conditions can be intertwined and often overlap. 

For example, because most people with asthma also have allergies, asthma attacks, sometimes referred to as “exacerbations”, can be triggered by exposure to allergens, such as pollen, mold or animal dander. This type of asthma is known as allergic asthma, and it is one of several types of asthma.

In addition, asthma and certain allergic conditions, such as hay fever and peanut allergy, share the potential to be life-threatening. Allergies can be life-threatening when they lead to anaphylaxis. Asthma can be fatal when a severe asthma attack does not respond to inhaled bronchodilators and leads to symptoms of respiratory failure, a condition known as “status asthmaticus.”

Finally, since many of the symptoms of asthma are the same as they are for allergies, physicians may use some of the same medications to treat both.

Asthma is a chronic lung disease that results in 1.8 million emergency visits and about 4,000 deaths each year. There are several types of asthma, and although the disease can be controlled, there is not yet a cure, which means that asthma patients must manage their condition on a daily basis. Moreover, it is estimated that about half of asthma sufferers do not have their condition under control, making it more likely that these patients will end up in an emergency department as a result of an asthma attack. When poorly controlled, asthma is potentially life-threatening.

The characteristics of asthma include inflammation (swelling and irritation) of the airways and bronchoconstriction (tightening of the muscles surrounding the airways). Often worse at night, these problems shrink the airways, making it more difficult to breathe. The often-missed warning signs of poorly controlled asthma are:

  • Waking at night wheezing and/or coughing
  • Requiring a quick-relief inhaler more than twice a week
  • Missing school or work
  • Being unable to participate in everyday activities
  • Requiring emergency or urgent care in order to breathe properly

Respiratory infections, such as the common cold or flu, are common triggers of asthma exacerbations, (which is why persons with asthma are advised to get a flu shot each fall when the vaccine becomes available). Other triggers include exercise, laughing or crying hard, cold air and irritants, such as poor air quality (e.g., Code Red ozone pollution days in the summer), chemicals, smoke, perfume, and air fresheners. Some allergens also can serve as triggers. Common inhaled allergens include dust, pollen, mold or animal dander.

The symptoms of asthma include:

  • Difficulty breathing
  • Tightness in the chest
  • Coughing and wheezing

Asthma attacks that appear to be severe or that do not respond to the patient’s normal medication require immediate medical attention. Less serious attacks or an increased frequency of asthma attacks should be evaluated by a visit to one’s doctor. In some cases, the patient may seek the advice of an asthma care specialist – such as an allergist or pulmonologist.

Asthma patients should go to the emergency department if they have severe asthma symptoms, especially if these symptoms are accompanied by severe sweating, faintness, nausea, panting, rapid pulse rate, and pale, cold, moist skin. (These may be signs of shock or a potentially life-threatening drop in blood pressure.) These patients may be experiencing a potentially fatal asthma attack, known as “status asthmaticus.”

Seek immediate medical attention for the following symptoms and warning signs associated with this potentially life-threatening condition:

Persistent shortness of breath or breathlessness experienced even while lying in bed.

  • An asthma attack that is not relieved by a usually effective rescue inhaler.
  • Lips or fingernails are turning blue (or gray in persons with dark complexions).
  • Straining to breathe or the inability to complete a sentence without pausing for breath.
  • A feeling of chest tightness.
  • Feelings of agitation, confusion or an inability to concentrate.
  • Hunching of shoulders, straining of abdominal and neck muscles or sitting or standing to breathe more easily

These are all signs of impending respiratory system failure, a potentially fatal condition. Be aware also that fatal asthma attacks often occur with few warning signals, and that they can come on quickly, leading rapidly to asphyxiation and death. Fatal asthma attacks are more common among persons who have poor control of allergens or asthma triggers in their daily environments and an infrequent history of using peak flow monitors and inhalers as aids in controlling their asthma.

Finally, it is important to note that extremely severe, potentially fatal asthma attacks may not feature more wheezing and coughing – thus making such symptoms unreliable in judging the severity of asthma attacks. In such cases, the breathing airways have become so restricted that there is not enough air going in and out of the lungs to cause wheezing or coughing. In addition, wheezing also can be a sign of other health conditions, such as respiratory infection and heart failure, so it is important to seek prompt medical attention if these other serious conditions are suspected.

Emergency department treatment of asthma typically includes oxygen, inhaled bronchodilators (such as albuterol), and systemic corticosteroids (such as prednisone). Long-term asthma treatment includes inflammation “controllers,” such as inhaled corticosteroids, and symptom “relievers” such as inhaled bronchodilators.

Since the key to preventing asthma attacks is controlling them, it is important to seek out proper medical care, take medication as directed and become educated as to how best avoid previously described “asthma triggers.”

Allergies involve an overreaction of the body’s immune system, which is responsible for fighting infections. There are many types of allergies, including seasonal allergies, which involve allergic reactions to pollens, grasses, and weeds, perennial allergies, which last for 9 or more months out of the year, chronic allergies to allergens such as dust and mold, food allergies, medicine allergies, insect venom allergies, and animal allergies, among others. In addition, some people develop a potentially life-threatening allergy to latex, which is found in rubber gloves, while others can become “sensitized” to substances they have been repeatedly exposed to at work, a condition is known as “occupational allergy.”

Allergic responses range from mild to life-threatening. Common mildly annoying allergy symptoms include sneezing, congestion, runny nose, watery eyes, headache and fatigue. However, exposure to some allergens, such as peanuts, shellfish, insect stings, medications, and latex can quickly progress to severe life-threatening reactions or anaphylaxis. For that reason, seek emergency care right away if you experience a mix of some of the following symptoms:

Difficulty breathing

  • Wheezing (along with high-pitched breathing sounds)
  • Confusion
  • Anxiety, fear, apprehension
  • Slurred speech
  • Swelling of the face, eyes, tongue or extremities
  • Trouble swallowing
  • Severe sweating
  • Faintness, light headedness, dizziness
  • Heart palpitations (feeling one’s heartbeat)
  • Nausea and vomiting
  • Diarrhea
  • Abdominal pain, cramping
  • Panting
  • Rapid or weak pulse rate
  • Pale, cold, moist skin or skin redness
  • Blueness of skin, including lips or nail beds (or grayish for darker complexions)
  • Loss of consciousness

Additional Precautions and Prevention

Individuals with allergies and asthma, which as noted earlier are often related, should always carry medications with them and ask their doctors about wearing medical alert bracelets or jewelry.

More specifically, individuals with asthma should always carry a quick-relief inhaler (bronchodilator), such as albuterol, and avoid known asthma triggers when possible. Individuals at risk of anaphylaxis, for whom a doctor has prescribed self-injectable epinephrine (such as an EpiPen or TwinJect), should carry it at all times and know how to use it in an emergency. If you are helping someone having an asthma attack you might have to get the inhaler for them.

Injectable epinephrine should not be used on persons other than the person for whom it has been prescribed (e.g., asthmatics or persons allergic to insect venom). Some people may have underlying health conditions that could be adversely affected by this drug. If the individual you are helping is having difficulty with their injectable, in many states, it is illegal for you, unless you are licensed to administer prescription medications, to inject them with a prescription medication, you can, however, assist them by getting the device for them or assisting them with them giving it to themselves. Under new American Heart Association and American Red Cross first-aid guidelines, first-aid providers may help victims who are experiencing a bad anaphylactic reaction use a prescribed epinephrine auto-injector – as long as the first-aid provider is trained to do so, the state law allows it and the victim is unable to self-administer the epinephrine, however, it is best to simply assist them in giving it to themselves unless you have received specific training and know your state laws.

Anaphylaxis is a severe, life-threatening, multisystemic allergic reaction that is triggered by common substances, such as foods, insect stings, medications, and latex.

About half of all anaphylaxis episodes are caused by such foods as peanuts, tree nuts (e.g., walnuts, pecans, almonds, and cashews), fish, shellfish, cow’s milk, and eggs. Bees, wasps, hornets, yellow jackets and fire ants are the cause of about 500,000 allergy-related emergency visits and at least 50 deaths each year. Medications can cause anaphylaxis, particularly drugs in the penicillin family. Other commonly used medications and pain relievers that can trigger anaphylaxis include aspirin, ibuprofen, anesthetics, and antibiotics. People who have had one or more previously mild episodes of anaphylaxis may be at risk for more severe future episodes. Repeat exposure to allergens, such as latex, may also increase the risk of developing anaphylaxis.

Anaphylaxis symptoms can develop quickly, in some cases within minutes or hours after exposure to an allergen. In some cases, the symptoms can abate and then return hours later. The most dangerous symptoms of anaphylaxis affect the respiratory system (breathing) and/or cardiovascular system (heart and blood pressure). Specific symptoms may include:

  • Difficulty breathing due to narrowing of airways and swelling of the throat
  • Wheezing or coughing
  • Unusual (high-pitched) breathing sounds
  • Confusion
  • Anxiety
  • Slurred speech
  • Difficulty swallowing
  • Swelling of the tongue, throat and nasal passages (nasal and throat congestion)
  • Localized edema (or swelling), especially involving the face
  • Itchiness and redness on the skin, lips, eyelids or other areas of the body
  • Skin eruptions and large welts or hives
  • Skin redness
  • Bluish skin color, especially the lips or nail beds (or grayish in darker complexions)
  • Nausea, stomach cramping, vomiting/diarrhea
  • Heart palpitations (feeling the heart beating)
  • Weak and rapid pulse
  • Drop in blood pressure
  • Dizziness, fainting or loss of consciousness, which can lead to shock and heart failure.

If you see someone with the symptoms of anaphylaxis it is important to take action quickly. You can respond by:

  • If the person is having anaphylaxis, call 911 immediately.
  • If the person is unconscious, lay him or her flat and elevate the feet.

         If available, help the victim get their self-injectable epinephrine (e.g., EpiPen, TwinJect) and help them administer it.  These should be carried by all persons who know they are at risk for anaphylaxis. As noted earlier, under new American Heart Association and American Red Cross first-aid guidelines, first-aid providers may help victims who are experiencing a bad anaphylactic reaction use a prescribed epinephrine auto-injector – as long as the first-aid provider is trained to do so, the state law allows it and the victim is unable to self-administer the epinephrine. However, you should know your individual state laws. Also, check for a medical tag, bracelet or necklace that may identify anaphylactic triggers.

Cardio-Pulmonary Resuscitation (CPR)

Cardio-Pulmonary Resuscitation (CPR) saves lives.  CPR is a combination of rescue breathing and chest compressions delivered to victims thought to be in cardiac arrest.  When cardiac arrest occurs, the heart stops pumping blood.  CPR can support a small amount of blood flow to the heart and brain to buy time until normal heart function is restored.  A quick response is crucial to a positive outcome. CPR should be started within 3 minutes of when the heart stops pumping.

The tips provided below are based on procedures recommended by the American Heart Association (AHA) and are not a substitute for formal training in CPR. Everyone with the ability to move the chest wall should take a course and should have their CPR skills tested at least every two years.

The use of Automated External Defibrillators (AEDs) goes hand in hand with CPR. Rescuers, both professional and lay, can be trained to operate these small, portable, computerized devices used to apply electric shock to restart a heart that has developed a chaotic rhythm called ventricular fibrillation, the most common cause of sudden cardiac arrest. Survival is directly linked to the amount of time between the onset of sudden cardiac arrest and the treatment with an electric shock to stop the abnormal heart rhythm. There is a major push for public access to these devices.

To perform CPR remember the ABCs of CPR: Airway, Breathing, and Circulation. This acronym is used to help you remember the steps to take when performing CPR.


  • If a person has collapsed, determine if the person is unconscious. Gently prod the victim and shout, Are you okay? If there is no response, shout for help. If someone is available ask them to call 911 or your local emergency number and go get an AED if one is nearby.
  • Open the person’s airway by lifting up the chin gently with one hand while pushing down on the forehead with the other to tilt the head back. If the person may have suffered a neck injury, in a diving or automobile accident, for example, open the airway using the chin-lift without tilting the head back. If the airway remains blocked, tilt the head slowly and gently until the airway is open.
  • Once the airway is open, check to see if the person is breathing.
  • Take five to 10 seconds (no more than 10 seconds) to verify normal breathing in an unconscious adult, or for the existence or absence of breathing in an infant or child who is not responding.
  • If opening the airway does not cause the person to begin to breathe, it is advised that you begin providing rescue breathing.

Breathing (Rescue Breathing)

  • Pinch the person’s nose shut using your thumb and forefinger. Keep the heel of your hand on the persons forehead to maintain the head tilt. Your other hand should remain under the person’s chin, lifting up.
  • Inhale normally (not deeply) before giving a rescue breath to a victim.
  • Immediately give two full breaths while maintaining an air-tight seal with your mouth on the person’s mouth. Each breath should be one second in duration and should make the victims chest rise. (If the chest does not rise after the first breath is delivered, perform the head tilt-chin lift a second time before administering the second breath.) Avoid giving too many breaths or breaths that are too large or forceful.

Circulation (Chest Compressions)

  • After giving two full breaths, if the victim is not coughing, moving or gasping (obvious signs of circulation) begin chest compressions.
  • Kneel at the person’sns side, near his or her chest.
  • With the middle and forefingers of the hand nearest the legs, locate the notch where the bottom rims of the rib cage meet in the middle of the chest.
  •  Place the heel of the hand on the breastbone (sternum) next to the notch, which is located in the center of the chest, between the nipples. Place your other hand on top of the one that is in position. Be sure to keep your fingers up off the chest wall. You may find it easier to do this if you interlock your fingers.
  • Bring your shoulders directly over the person’s sternum. Press downward, keeping your arms straight. Push hard and fast. For an adult, depress the sternum about a third to half the depth of the chest. Then, relax pressure on the sternum completely. Do not remove your hands from the person’s sternum, but do allow the chest to return to its normal position between compressions. Relaxation and compression should be of equal duration. Avoid interruptions in chest compressions (to prevent the stoppage of blood flow).
  • Use 30 chest compressions to every two breaths (or about five cycles of 30:2 compressions and ventilations every two minutes) for all victims (excluding newborns). You must compress at the rate of about 100 times per minute.
  • Continue CPR until advanced life support is available.

Using an AED in conjunction with CPR:

  • AEDs are voice prompted and walk the responder through the process. The first step is to turn the device on. If possible, continue to perform CPR while a second responder turns the AED on and places the pads. You would stop CPR when the machine verbalizes not to touch the victim.
  • If using an AED on a one-year-old to an eight-year-old child, use a pediatric adapter or pediatric pads if available. However, do not use child pads or a child adapters with an adult in cardiac arrest because the smaller dose may not defibrillate adults properly.

CPR for Infants (Up to One Year Old)


  • With infants, be careful not to tilt the head back too far. An infant’s neck is so pliable that forceful backward tilting might block breathing passages instead of opening them.


  • Do not pinch the nose of an infant who is not breathing. Cover both the mouth and the nose with your mouth and breathe slowly (one to one and a half seconds per breath), using enough volume and pressure to make the chest rise. 
  • With a small child, pinch the nose closed, cover the mouth with your mouth and breathe at the same rate as for an infant. Rescue breathing should be done in conjunction with chest compressions.

Chest Compressions on Infants 

  • If alone with an unresponsive infant, give five cycles of CPR (compressions and ventilations) for about two minutes before calling 911 or your local emergency number.
  • Use only the tips of the middle and ring fingers of one hand to compress the chest at the sternum (breastbone), just below the nipple line, as described in the table below. The other hand may be slipped under the back to provide firm support. (However, if you can encircle your hands around the chest of the infant, using the thumbs to compress the chest, this is better than using the two-finger method.)
  • Depress the sternum between a third to a half the depth of the chest at a rate of at least 100 times a minute.
  • Two breaths should be given during a pause after every 30 chest compressions (a 30:2 compression-to-ventilation ratio or two breaths about every two minutes) on all infants (excluding newborns).
  • Continue CPR until emergency medical help arrives.

Small Children (ages one to eight)

  • Give five cycles of CPR (compressions and ventilations) for about two minutes before calling 911.
  • Use the heel of one or two hands, as needed, and compress on the breastbone at about the nipple line.
  • Depress the sternum about a third to half the depth of the chest, depending on the size of the child. The rate should be 100 times per minute.
  • Give two breaths for every 30 chest compressions (30:2 ratio) or two breaths about every two minutes.
  • Continue CPR until emergency medical help arrives.


Choking is signaled by an inability to speak, cough or breathe, and may result in a loss of consciousness and death. Avoid using excessive force in employing an abdominal thrust to avoid injury to the ribs or internal organs. Given the potentially life-or-death nature of the situation, use your best judgment.

In the event of choking, the American Heart Association offers the following guidelines:

 Conscious Adult

  •  In the event of choking, rescuers should take action if they see signs of severe airway obstructions (including poor air exchange and increased breathing difficulty, a silent cough, cyanosis or if the person is unable to speak or breathe).
  • To differentiate between mild airway obstruction and severe airway obstruction, the rescuer should ask, “Are you choking?” If the victim nods yes, assistance is needed. Choking also often is indicated by the Universal Distress Signal (hands clutching the throat).
  • If the person can speak, cough or breathe, do not interfere.
  • If the person cannot speak, cough or breathe, give abdominal thrusts.
  • To employ abdominal thrusts, reach around the person’s waist. Position one clenched fist above the navel and below the rib cage. Grasp your fist with your other hand. Pull the clenched fist sharply and directly backward and upward under the rib cage 5 times quickly, repeat as needed.
  • In case of obesity or late pregnancy, give chest thrusts.
  • Continue uninterrupted until the obstruction is relieved or advanced life support is available. In either case, the person should be examined by a physician as soon as possible.

Unconscious Adult

  •  Position the person on his or her back, arms by side.
  • Shout for help. Call 911 or the local emergency number.
  • Look inside the victim’s mouth to see if you can locate the obstruction. If you can see the object and believe that you can remove it you can perform a finger sweep. Only remove an object you can see and easily extricate.
  • Attempt two rescue breaths reopening the airway by tilting the head if you do not see chest rise and fall with your breaths.
  • Place the heel of your clasped hands on the center of the chest on the nipple line and perform 30 compressions, approximately 2 inches deep.
  • Repeat sequence: look in the mouth to see if you can locate the object, attempt rescue breathing, perform compressions, until successful.
  • Continue uninterrupted until the obstruction is removed or advanced life support is available. When successful, have the person examined by a physician as soon as possible.
  • After the obstruction is removed, continue CPR, if necessary.

Conscious Infant (Under one year old)

  • Support the head and neck with one hand. Place the infant face down over your forearm, head lower than the torso, supported on your thigh.
  • Deliver up to five back blows, forcefully, between the infant’s shoulder blades using the heel of your hand.
  • While supporting the head, turn the infant face up, head lower than the torso.
  • Using two or three fingers, deliver up to five thrusts in the sternal (breastbone) region. Depress the sternum to 1 inch for each thrust. Avoid the tip of the sternum.
  • Repeat both back blows and chest thrusts until the foreign body is expelled or the infant becomes unconscious.
  • Do not perform blind finger sweeps or abdominal thrusts on infants.

Unconscious Infant (Under one year old)

  •  Shout for help. Call 911 or the local emergency number.
  • Perform the tongue-jaw lift. (Grip on the jaw by placing your thumb in the infant’s mouth and grasping the lower incisor teeth or gums; the jaw then lifts upward.) If you see the foreign body and you believe you can remove it attempt to do so.
  • Attempt two rescue breaths reopening the airway by tilting the head if you do not see chest rise and fall with your breaths.
  • Using two or three fingers, deliver up 30 compressions in the sternal (breastbone) region. Depress the sternum to 1 inch for each thrust. Avoid the tip of the sternum.
  • Repeat the sequence.
  • If the foreign body is removed and the infant is not breathing, continue CPR.

Conscious Child (Over one-year-old)

To dislodge an object from the airway of a child:

  • Perform abdominal thrusts as described for adults. Avoid being overly forceful in order to avert injury to ribs and internal organs.

Unconscious Child (Over one-year-old)

  •  If the child becomes unconscious, continue as for an adult.

If you are choking and are alone:

  •  Do not panic; if possible, take slow breaths.
  • Call 911 or the local emergency number immediately (even if you cannot speak); the dispatcher should be able to recognize that an emergency is occurring. If you are using a land-line, in some (but not all) areas, he or she may then be able to trace the call and send emergency personnel to you. (Cell phone calls may not be traceable to an exact location.)
  • If you are able go to the front door, unlock and open the door so first responders will be able to locate you and see the issue.
  • If available, lean over the back of a chair and press hard on your abdomen and chest to expel the object or attempt to use your fists to give yourself abdominal thrusts.
  • Continue uninterrupted until the obstruction is expelled or advanced life support is available. In either case, you should be examined by a physician as soon as possible.

Cuts and Abrasions    

Most cuts can be treated by cleaning with soap and water and applying a clean bandage. You also may want to treat the cut with an antibiotic ointment. If you delay care for only a few hours, even a minor wound can build enough bacteria to cause a serious infection and increase the risk of a noticeable scar.

Puncture wounds may not seem very serious, but because germs and debris are carried deep into the tissues, a physician evaluation may be needed. In addition, antibiotics or a tetanus shot may be required. Do not remove the object that caused the puncture if it is still impaled in the wound. Think of a water balloon with a nail in it. What is going to occur if you remove the nail?

Seek medical attention for a cut or a wound that shows any of the following signs:

  • Long or deep cuts that need stitches
  • Cuts over a joint
  • Cuts from an animal or human bite
  • Cuts that may impair the function of a body area, such as an eyelid or lip
  • Cuts that remove all the layers of the skin, like slicing off the tip of a finger
  • Cuts caused by metal objects or puncture wound
  • Cuts over a possible broken bone
  • Cuts that are deep, jagged or “gaping” open
  • Cuts that have damaged underlying nerves, tendons or joints
  • Cuts that have foreign materials, such as dirt, glass, metal or chemicals embedded in them
  • Cuts that show signs of infection, such as fever, swelling, redness, a pungent smell, pus or fluid draining from the area
  • Cuts that include problems with movement or sensation, or increased pain 

Seek emergency care if:

  • The wound is still bleeding after a few minutes of steady, firm pressure with a cloth or bandage
  • Signs of shock occur
  • Breathing is difficult because of a cut to the neck or chest
  • There is a cut to the eyeball
  • There is a cut that amputates or partially amputates an extremity
  • There is a deep cut to the abdomen that causes moderate to severe pain


Diabetic Emergencies  

Diabetics may experience life-threatening emergencies from too much or too little insulin in their bodies. Too much insulin can cause a low sugar level (hypoglycemia), which can lead to insulin shock. Not enough insulin can cause a high level of sugar (hyperglycemia), which can cause a diabetic coma. 

Symptoms of insulin shock include: 

  • Weakness, drowsiness
  • Rapid pulse
  • Fast breathing
  • Pale, sweaty skin
  • Headache, trembling
  • Odorless breath
  • Numbness in hands or feet
  • Hunger

Symptoms of diabetic coma include:

  • Weak and rapid pulse
  • Nausea
  • Deep, sighing breaths
  • Unsteady gait
  • Confusion
  • Flushed, warm, dry skin
  • Odor of nail polish or sweet apple
  • Drowsiness, gradual loss of consciousness

First aid for both conditions is the same:

  •  If the person is unconscious or unresponsive, call 911 or your local emergency number immediately.
  • If an unconscious person exhibits life-threatening conditions, place the person horizontally on a flat surface, check breathing, pulse and circulation, and administer CPR, if needed while waiting for professional medical assistance
  • If the person is conscious, alert and can assess the situation, assist him or her with getting sugar or necessary prescription medication.
  • If the person appears confused or disoriented, give him or her something to eat or drink and seek immediate medical assistance.


Drowning occurs most often among small children and people who can’t swim, but even experienced swimmers may be susceptible, depending on weather conditions, water currents, their health, and other circumstances.

In the United States, it is the second leading cause of death, after motor vehicle crashes, in children 12 and younger. Children have drowned in wading pools and even bathtubs. It only takes a few seconds for a child to drown.

  • If a person appears to be drowning (e.g., is flailing in the water, yelling for help, coughing or going under, or appears to be unconscious or floating in the water), call or have someone call 911 or your local emergency number. In addition:
  • Do not attempt to rescue a drowning person while in the water yourself unless you are trained to do so and have lifesaving equipment. People who are drowning may panic and pull you underwater with them; dangerous circumstances – such as strong currents or rip tides – may also endanger you.
  • If possible, reach out with or throw an object that floats to the person from a secure out-of-water position, such as a boat, a swimming pool ladder or a dock.
  • For a person pulled from the water, tilt the head back, lift the chin and check for breathing and other signs of life. Expel fluid or other objects from the mouth.
    • If the person is not breathing, give two slow rescue breaths. If you see chest rise and fall with your breaths, begin CPR. If rescue breaths do not go in, reposition the airway and reattempt.
    • If the person is still not breathing after rescue breaths are administered, see Unconscious Choking.


Electrical Injury/Shock 

An electric shock occurs upon contact of a human body with any source of voltage high enough to cause sufficient current through the muscles or hair.

Causes of electrical injury and shock include accidental exposure to household or appliance wiring, arcs from power lines, the severing of an electrical cord or sticking of foreign objects into an outlet, typically in the case of a young child, faulty machinery and occupational accidents.

Symptoms of electrical injury or resulting shock may include:

  • Skin burns
  • Numbness, tingling
  • Weakness
  • Muscle contraction or pain
  • Bone fractures
  • Headache 
  • Hearing impairment
  • Seizures
  • Irregular heart rhythms
  • Cardiac arrest
  • Respiratory failure
  • Unconsciousness

Whether a person survives an electric shock depends on the type of circuit (AC or DC current), level of the voltage, level of amperage, the way in which the current entered the body, the duration of exposure, the victim’s general health, and the timing and adequacy of treatment. Seeking immediate emergency assistance is vital in such situations.

To assist someone with an electrical injury:

Check to see if the person is still in contact with the electric current. If so, don’t touch the person, and find another way to shut off the power, such as at the circuit or breaker box. A victim in contact with an AC current (household current) may not be able to let go of the point of contact because their muscles contract strongly in response to the electricity.

  • Check breathing and pulse.
  • Call 911 or emergency number.

Head Injury  

A head injury is any trauma that leads to injury of the scalp, skull, or brain. The injuries can range from a minor bump on the skull to serious brain injury.

If a person loses consciousness after a head injury, then the person has had a “concussion,” which may be serious because it means there has been a temporary loss in brain function. Some people with concussions do not lose consciousness, and brain injuries can occur without a loss of consciousness.

Danger Signs – Adults

Severe head injuries can involve bruising, fracture, swelling, internal bleeding or a blood clot. Seek emergency care if you notice any of these signs of severe head injury:

  • Headaches that worsen, despite over-the-counter pain medications.
  • Weakness, numbness or decreased coordination.
  • Repeated vomiting.
  • Loss of consciousness for more than one minute.
  • The person is unconscious or cannot be awakened.
  • Sleepiness.
  • Unequal pupil sizes – one pupil (the black part in the middle of the eye) is larger than the other.
  • Convulsions or seizures.
  • Slurred speech.
  • Increased confusion or agitation.

You do not need to prevent a person with a head injury from sleeping as a safeguard against going into a coma; this concept is a myth. If the person has neck pain, try to prevent any movement of the neck.

Danger Signs – Children

Seek emergency medical assistance if the child:

  • Exhibits any of the danger signs listed for adults.
  • Won’t stop crying.
  • Can’t be consoled.
  • Refuses to eat or nurse.
  • In infants, exhibits bulging in the soft spot on the front of the head. 
  • Shows any sign of skull trauma or obvious abnormality of the skull, such as bruising on the scalp or a depressed area at the location of the injury.

Heart Attack

Heart attack, or myocardial infarction, remains the leading killer of both men and women in the United States. More than 400,000 Americans die from heart attacks each year. Getting emergency medical help immediately can dramatically increase the chances of survival and recovery.

A heart attack is not always a sudden, deadly event. Often it is an evolving process during which a clot forms in an artery of the heart, depriving the heart of blood and oxygen. The longer the heart attack process continues, the more permanent damage is done to otherwise healthy heart muscle.

Many people ignore the warning signs of a heart attack or wait until their symptoms become unbearable before seeking medical help. Others wait until they are absolutely sure it’s a heart attack because they worry they will look foolish if it is a false alarm. These reactions can result in dangerous delays.

People often will experience some, but not all, of the following symptoms, which may come and go:

  • Uncomfortable pressure, fullness, squeezing sensation or pain in the center of the chest, lasting more than a few minutes, or it goes away and comes back.
  • Pain that spreads to the shoulders, neck, jaw, arms or back.
  • Chest discomfort accompanied by lightheadedness, fainting, sweating, nausea or shortness of breath.

Some less common warning signs of heart attack that should be taken seriously, especially if they accompany any of the above symptoms, include:

  • Shortness of breath and difficulty breathing.
  • Abnormal chest pain (angina), stomach, or abdominal pain. (Symptoms may feel like indigestion or heartburn.)
  • Nausea or dizziness.
  • Unexplained anxiety, weakness, or fatigue.
  • Palpitations, cold sweat or paleness.

As with men, women’s most common heart attack symptom is chest pain or discomfort. Women are more likely than men to experience shortness of breath, nausea/vomiting, and back or jaw pain.

If you suspect someone is having a heart attack: 

  • Call 911 or your emergency services number immediately. Stay with the person until the ambulance arrives. Do not attempt to drive the person to the hospital; if his or her condition should worsen, there is nothing you can do to help while driving.
  • After 911 is called, the EMS dispatcher will likely give pre-arrival instructions (when appropriate) for the administration of aspirin (not acetaminophen, ibuprofen or naproxen) and nitroglycerin (if prescribed) while emergency-response units are en route to the scene The ideal aspirin dose in such instances is two to four baby aspirin or one full or extra-strength tablet (325 or 500mg), and chewing helps get the aspirin into the bloodstream faster than swallowing it whole. (The patient should not be given aspirin if his or her physician has advised otherwise, e.g., because of allergies or possible harmful interactions with other medications or known disease complications).
  • If the person is conscious, keep the person calm and help him or her into a comfortable position. The victim should stop all physical activity, lie down, loosen clothing around the chest area, and remain calm until the ambulance arrives.
  • If the person becomes unconscious, make sure they are lying on his or her back.  Clear the airway and loosen clothing at the neck, chest, and waist.  check for breathing and pulse; if the victims not breathing begin rescue breathing, it they do not have a discernible pulse or they are not coughing, gasping or moving then begin cardiopulmonary resuscitation (CPR). 

Heat-Related Illnesses  

Heat-related illness can be caused by overexposure to the sun or any situation that involves extreme heat. Young children and the elderly are most at risk, but anyone can be affected.

Heat Cramps

Symptoms include muscle spasms, usually in the legs and stomach area.

  • To treat, have the person rest in a cool place and give small amounts of cool water, juice or a commercial sports liquid. (Do not give liquids if the person is unconscious.)
  • Gently stretch and massage the affected area.
  • Do not administer salt tablets.
  • Check for signs of heatstroke or exhaustion.

Heat Stroke and Exhaustion

Symptoms of early heat exhaustion symptoms include cool, moist, pale or flushed skin; headache; dizziness; weakness; feeling exhausted; heavy sweating; nausea; and giddiness.

Symptoms of heatstroke (late stage of heat illness) include flushed, hot, dry skin; fainting; a rapid, weak pulse; rapid, shallow breathing; vomiting; and increased body temperature of more than 104 degrees. 

  • People with these symptoms should immediately rest in a cool, shaded place and (if conscious) drink plenty of non-alcoholic, non-caffeinated fluids.
  • Apply cool, wet cloths or water mist while fanning the person.
  • Seek immediate medical attention by calling 911 or your local emergency number for symptoms that include cool, moist, pale skin, rapid pulse, elevated or lowered blood pressure, nausea, loss of consciousness, vomiting or high body temperature.
  • For late-stage heatstroke symptoms, cool the person further by positioning ice or cold packs on wrists, ankles, groin, and neck and in armpits.
  • Administer CPR if the person becomes unconscious.

Neck or Back Injury  

Trauma to the neck and back can lead to spinal cord injury and permanent disability. When someone has a head or neck injury, he or she should not be moved because movement may cause further damage to spinal cord nerves, which carry messages between the brain and body, resulting in possible paralysis below the site of the injury.

The symptoms of serious neck or back injury include:

  • Head or body contorted in an unnatural or unusual position
  • Numbness or tingling sensations that radiate through an arm or a leg
  • Weakness in back, neck or limbs
  • Difficulty standing or walking
  • Inability to move arms or legs
  • Loss of bladder or bowel control
  • Shock (pale, clammy skin; blue or gray lips, fingernails; dazed or semi-conscious appearance)
  • Unconsciousness
  • Neck pain, stiff neck or headache that won’t go away

If any of the above causes or symptoms are involved, assume that the person has a spinal cord injury, and take the following steps:

  • Call 911 or the local emergency number.
  • Immobilize the head, neck and shoulder area to prevent movement.
  • Do not attempt to reposition, bend or twist the neck or body; and do not move or roll the person unless he or she is in danger (e.g., he or she is in a burning vehicle).

o If you must roll the person, do so only if he or she is vomiting or choking on blood, or because you must check that the person is still breathing.

o Rolling a person requires two people, with one person stationed at the head and the other along the victim’s side. The person’s head, neck, and back should be kept in line while rolling occurs.

o If the person is wearing a helmet, do not remove it.

        o If the person is not breathing, begin rescue breathing and CPR, if necessary. Do not move or tilt the head back
         when attempting to open the airway; instead, position your fingers on each jaw along the side of the head and lift
          the jaw open or forward.


A stroke is an interruption of the blood supply to any part of the brain by a clogged or burst artery. The interruption deprives the brain of blood and oxygen and causes brain cells to die. Seek emergency care immediately if a stroke is suspected.

Stroke symptoms in general include:

  • Sudden numbness, weakness or paralysis and drooping of the face, arm or leg, especially on one side of the body.
  • Suddenly blurred or decreased vision in one or both eyes.
  • Loss of balance or coordination.
  • Headache, frequently abrupt onset.

Stroke symptoms that last for only a few minutes and then subside may indicate a “mini-stroke,” or a transient ischemic attack (TIA). TIAs are serious medical events and require treatment; they are also a warning sign that a more dangerous stroke may occur in the future.

It is important to know that stroke often goes unrecognized; people often wait to see if their symptoms improve and unknowingly put themselves in greater danger. However, because stroke can incapacitate or kill within minutes, doctors recommend treating a suspected stroke as a medical emergency and seeking immediate medical care. To help someone with the symptoms of a stroke call 911 and have the victim lie down and stay with them.

Should You Drive or Call an Ambulance?        

If you answer “yes” to any of the following questions about a person experiencing a medical emergency, or if you are unsure, it’s best to call an ambulance, even if you think you can get to the hospital faster by driving yourself.

  • Does the person’s condition appear life-threatening?
  • Could the person’s condition worsen and become life-threatening on the way to the hospital?
  • Could moving the person cause further injury?
  • Does the person need the skills or equipment employed by paramedics or emergency medical technicians?
  • Would distance or traffic conditions cause a delay in getting the person to the hospital?

If you drive to the hospital, know the location and the fastest route to the nearest emergency department. In addition:

  • Don’t delay care by driving to a more distant hospital emergency department.
  • If necessary, a patient may be transferred to a hospital with special capabilities, such as a regional trauma or pediatric center.

If you call an ambulance, keep in mind that even though the 911 system was introduced in 1968, the network still does not completely cover some rural areas of the United States and Canada. When traveling, check for local EMS numbers in the areas where you will be, so you have this information before you begin your journey.

Also, be aware it is important for people calling 911 from wireless phones to tell the emergency operator the location of the emergency because a cell tower provides only very general information about the location of a caller. Some cars now are equipped with “smart” technologies that use global positioning system satellites and cellular technology to link vehicles to direct emergency help, but many are not.

When you call for help, remember to:

  • Speak calmly and clearly.
  • Give the name, address, phone number, and location of the person in need and describe the nature of the problem.
  • Don’t hang up until the dispatcher tells you to. The dispatcher may need more information.
  • Teach children how to place an emergency call.

Managing Intense Emotions

When people are first faced with disaster intense emotions are often present and appropriate. They are a result of intense fear, uncertainty, and apprehension.

Communicate Calmly:

  • Get to their level.
  • Lean forward.
  • Eye contact.
  • Relax.

Communicate Warmth:

  • Use a soft tone.
  • Smile.
  • Use open and welcoming gestures.
  • Allow the person you are talking with to
    dictate the distance between you.

Establish a Relationship:

  • Introduce yourself if they do not know you.
  • Ask the person what they would like to be called.
  • Do not shorten their name or use their first
    name without their permission.

Use Concrete Questions to Help the Person

  • Use closed-end questions.
  • Explain why you are asking the question.

It is also an important note to remember your emotional needs, as well. In the flurry of an emergency things happen very quickly. Many times the ambulance arrives and they whisk away the victim and you are left with the aftermath of never even knowing what happened next. It is important to talk to someone about what occurred and how you feel.

In Case of Emergency (ICE)

 A cell phone can become a source of information for paramedics and other emergency personnel responding to accidents, crimes, and disasters when individuals add ICE (In case of emergency) to the contact list or address book on the phone. Medical professionals use this information to notify the person’s emergency contacts and to obtain critical medical information if a patient arrives unconscious or unable to answer questions.


Knowing what constitutes an emergency, where to get help and what to do while you’re waiting for help can save a life. You are never expected to do more than you are trained to do. Do your part by staying up to date on how to respond.



Dental fear refers to the fear of dentistry and of receiving dental care. This can be quite severe when diagnosed as dental phobia, odontophobia, dentophobia, or dentist phobia or less severe when describing as generalized anxiety.

A phobia is traditionally defined as an irrational severe fear that leads to avoidance of the feared situation, object or activity. Exposure to the feared stimulus provokes an immediate anxiety response, which can take the form of a panic attack. The phobia causes a lot of distress, and impacts on other aspects of a person’s life, not just oral health. Dental phobics will spend a great deal of time thinking about their teeth or dentists or dental situations, or else spend a lot of time trying NOT to think of teeth or dentists or dental situations.  


Dental anxiety is feeling nervous about or being fearful of, visiting a dentist. It can sometimes be a barrier to people getting dental treatment.

This lesson will explore:

  • Dental anxiety
  • Types of anxiety
  • Methods to reduce anxiety

About Dental Anxiety 

Dental anxiety is common and affects people of all ages. As noted, there are different levels of dental anxiety, ranging from slight nervousness to severe phobia. It is estimated that as many as 75% of adults in the United States experience some degree of dental fear, from mild to severe. Approximately 5 to 10 % of adults are considered to experience dental phobia and as such avoid dental care at all costs. Many fearful individuals will only seek dental care when they have a dental emergency, such as a toothache or dental abscess. Many individuals who are very fearful of dental care often experience a cycle of avoidance, in which they avoid dental care due to fear until they experience a dental emergency requiring invasive treatment, which can reinforce their fear of dentistry.

Women tend to report more dental fear than men, and younger people tend to report being more fearful than older individuals. Individuals tend to report being more fearful of more invasive procedures, such as oral surgery, as than they are of less invasive treatment, such as professional dental cleanings, or prophylaxis.

Phobia of dental care is sometimes diagnosed using a fear measurement instrument like Corah’s Dental Anxiety Scale or the Modified Dental Anxiety Scale. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), lists diagnostic criteria of specific phobia to include:

  • a marked and persistent fear of the specific object or situation that is excessive or unreasonable,
  • an immediate anxiety response upon exposure to the feared stimulus, which may take the form of a panic attack,
  • recognition that the fear is excessive or unreasonable,
  • avoidance of the anxiety-producing situation,
  • the phobia interferes with normal functioning or causes marked distress.

Common Areas that Induce Anxiety

Dental anxiety is most commonly caused by traumatic dental experiences, although there can be other causes, as well. Children are often influenced by their parents’ fears and attitudes towards dental treatment. Dental anxiety may involve fear of dentists, dental procedures, a specific fear of needles, teeth, or objects and situations which remind the sufferer of the phobic situation. The dentist’s drill is often a major factor in these fears.

  • The embarrassment of Bad Teeth, Gagging, Crying
  • Loss of Control
  • Sights, Sounds & Smells
  • Pain
  • The Drill
  • Needles
  • Fear of Fainting
  • Sexual Abuse
  • Can’t Get Numb
  • Bad Reaction to Local Anesthetic
  • Choking
  • Cost
  • Extensive Treatment
  • Unnecessary Treatment


However nervous or fearful someone is of having dental treatment, there are a number of things that can be done to help overcome the anxiety.

Many people hate the feeling of being tipped back in the chair, and/or lying down as it makes them feel exposed, defenseless and helpless. If this is the case for your patient perhaps offering to leave the chair in a more upright position could ease the anxiety.

Many people complain that their childhood dentists never explained to them what they were doing or why. They were treated like a set of teeth rather than like a living, breathing person with feelings and emotions. While these types of dentists exist, most dental professionals view their patients as partners in their care.

As a professional in the dental industry, you should explain the treatment in advance, how they are done, what a procedure involves from the patient’s point of view, what the alternatives are, and what the pros and cons of the various options are. The patient has to give their informed consent before any treatment is started.

If the patient needs more time to make the decision, for example, because they need to think it over or they want to read up more on suggested options, this should be accommodated.

Many dental professionals use the Tell-Show-Do technique with patients with anxiety. This technique involves telling the patient about the procedure, showing them the tools they are going to use and demonstrating the procedure beforehand. Many people fear a loss of control like being informed in this way. It removes the element of unpredictability which many people dread.

Some individuals are less anxious with their eyes closed so they don’t have to see the instruments. If they still prefer to know the procedure a dentist can perform a demonstration on their hand without them needing to see the tool.

A stop signal is a signal that a patient and dental professional has agreed upon which will signal the professional that the patient needs a break. Some examples of stop signals include:

  • Raised arm
  • Raised leg
  • Devise that emits a noise such as a dog clicker/noisemaker

Stop signals must be followed by the dentist or hygienist or trust will be damaged. Also, the patient must be able to give the stop signal when needed. Some individuals will get too fearful to be able to make the motion.

Another really useful strategy is called structured time. It involves talking with the patient to first determine the likely length of treatment and agree to take breaks at fixed intervals (for example, 5 minutes). This way the patient does not suffer in silence afraid to interrupt. This is a great way of establishing trust.


A patient may find treatment easier if they have some form of sedation. This relieves anxiety and helps them to relax. The patient will still be awake but will probably not be able to remember much about the procedure afterward. There are three main types of sedation used in dentistry.

Oral sedation

The dentist may prescribe medicine, such as temazepam or diazepam, to help reduce anxiety. The patient will take this as a tablet, usually about an hour or two before the appointment. The patient must take these medicines exactly as directed by the dentist.

Inhalation sedation

This is also known as ‘gas and air’. It’s a mixture of nitrous oxide and oxygen. The patient breathes it in through a mask placed over the nose. The patient should be able to understand what the dentist or hygienist is saying throughout the treatment, but the sedation should reduce the anxiety.

When the treatment is finished, the sedation will wear off after a few deep breaths and the gases will soon leave the body. However, the patient may be asked to stay in the clinic for up to 30 minutes for the effects of the sedation to wear off fully.

Intravenous sedation

If a patient has intravenous sedation, a medicine will be injected through a fine plastic tube (cannula) into a vein (usually on the back of the hand). The medicine will make the patient feel relaxed, but they will still be able to talk and listen to the dentist (although they may not remember any of it afterward).

In this situation, the patient should have someone accompany them to and from the dental appointment. Sedation temporarily affects co-ordination and reasoning skills, so they must not drive, drink alcohol, operate machinery or sign legal documents for 24 hours afterward.

General anesthesia

Occasionally, people who have severe dental phobia, young children and people with special needs may need general anesthesia in a hospital to have dental treatment. However, all possible alternatives should be explored first.

Distraction Techniques

 A patient may find that distracting their attention away from the dental treatment helps them to relax. For example, they may like to try:

  • listening to music or audiobooks
  • watching a video or DVD 
  • concentrating on relaxing each part of their body in turn
  • thinking about something they’re looking forward t

Sometimes it is the little things that make the difference. Try to look at the situation from the patient’s point of view.  Arriving for a first appointment and having to sit around for ages waiting is every nervous patient’s nightmare. So if possible set up your practice systems so that new patients coming to see you who are nervous are identified in advance and wherever possible offer a time slot where you are most likely to be on time. For example, the first appointment of the day, after a break or after lunch.

It is true that you only get one chance to make a good first impression. There are many ways of doing this including simply walking out to your waiting room, introducing yourself to your patient and making polite chat on the way to the dental chair.

You really need to listen harder than ever before to the patient as they tell you their story, in it will be all the clues you need to help them, their fears, their triggers, and what things you need to find a way around to stop from scaring them half to death. By asking questions you are showing that you are interested in what the patient has to say and as such are more likely to act on it. Resist the temptation to jump in with solutions as they come to mind, just take notes and let the patient talk out all of their fears.

Finally, recognize that working with nervous patients who have recently joined your practice can be seriously hard work. But, like so many things in life, by giving first without expecting to receive, you will be pleasantly surprised when your early efforts are repaid. And if you help a patient overcome their fear you have a patient for life and someone who is very likely to tell their friends about your care.

It is critical that every nervous patient receives your very best efforts. It is truly wonderful to see the personal growth that often follows when someone resolves a long-standing dental fear.


Communication and Support  

Before any strategy can be employed, the dental professional and patient need to communicate. Sometimes an initial visit can consist solely of an interview to ask questions and get to know the office staff and environment. Items to discuss can include

Timing. Letting the patient know that you will go at their pace. For example, the patient might choose to just have an examination at their first appointment, or even just sit in the chair. Once the first stage doesn’t frighten them anymore, you can move on to the next. This way they may be able to overcome their anxiety gradually.

Control. Talk to the patient about the fact that they have control over the amount of treatment they’re getting. It’s important that they don’t feel pushed further or faster than they can cope with. They may feel more in control if they have a signal (raising their hand, for example) that lets you know that they would like you to stop.

Specific concerns. If there are particular things that they are worried about, or if they have had a traumatic experience in the past this gives them an opportunity to discuss this without being in the dental chair already feeling vulnerable.

Choice. There are a number of treatment options that may help them to relax. Explain which options may be most suitable for them.