Diana Macri

	The sister profession of public health continues to provide dental hygienists with opportunities for professional growth and information regarding the behaviors associated with poor health. Most pertinent of all these includes poverty and its lingering effects on the health of Americans.

 by an outdated standard developed in the 1960s.

	47 million Americans (this includes 15.5 million children) live in a cycle of poverty and poor health that is difficult to break. 105 million live close to poverty, with incomes less than two times that of their poverty thresholds.

Related: Dentistry and the Federal Government

	As of 2014, the national poverty rate was at 14.8 percent with clear distinctions seen between whites and people of color: 26.2 percent of African-Americans and 23.6 percent of Latinos are poor, compared with 10.1 percent of whites. Poverty now, as always, is not equally distributed among racial groups.

	Those who live in poverty are at an increased risk of getting ill because of poor nutrition and stress-the harsh realities of which may make risking their health a necessity in order to keep the family safe. Poor health, in turn, increases the chances of poverty, reducing a family’s work productivity and often necessitates the use of desperate measures such as the selling of assets in order to keep the family safe.

Read more about dentists and poverty: Horizontal approaches to improving oral health in rural communities

	What are the social determinants of health?

. Poverty contributes to a greater phenomenon, socioeconomic status (SES), which more accurately paints a picture of the effects of poverty. SES includes not just material wealth (or lack of material wealth) but a multitude of different social, economic and cultural factors including education and social prestige. 

The US Department of Health and Human Services

 recognizes that SES affects a person’s health and has highlighted the importance of addressing these Social Determinants of health which include:

 Is there clean and safe water and air? Is housing safe and not overcrowded? Is there good sanitation? What are levels of crime like? How safe are roads? Are there jobs with decent working conditions?

 Have you inherited a greater likelihood of certain illnesses?

 Is there access to healthy food? Is healthy food being regularly consumed?

 Going to school improves many health outcomes.

 Strong support networks improve all health outcomes.

 People who are excluded or denied access to social forums experience poorer health.

 Are services and providers available nearby?

 Includes exercise, eating habits and social habits such as smoking/excessive drinking of alcohol. 

	Up next: The effects of low SES and your role

	Parental socioeconomic status has been shown to affect cognitive functions in children. These children whose parents experience low SES show gradual declines in mental, motor and socioemotional development compared to children whose parents have higher levels of SES.

	One of the primary reasons for the decline is due to the effects of chronic stress. Repeated exposures to adverse childhood experiences, or ACEs, mold a child’s developing brain, particularly in the prefrontal cortex, which is in charge of executive function and differentiating between good and bad, and the hippocampus, which handles memories and learning. Children who experience ACEs are not ready for kindergarten, so they fall behind quickly and have difficulties learning to read which impairs working memory.

Related article: Hey dental hygienists, it's time to stop blaming the victim

	Chronic stress can interact with other toxins like air pollution, or genetic predispositions with consequences including cognitive deficits and emotional disorders. Kids who grow up with higher levels of violence as a backdrop in their lives, based on MRI scans, have weaker real-time neural connections and interaction in parts of the brain involved in awareness, judgment, and ethical and emotional processing. As they age, these children exhibit impaired brain function and emotional problems as adults. In short, learning, behavioral, mental health and physical health problems are seen at higher rates among those who were raised in poverty. These deficiencies persist into adulthood.

	Thankfully, because the brain is very adaptable, the effects of stress can be combatted through nurturing relationships and consistent feelings of safety. Additionally, some research on poverty alleviation (i.e. cash transfer programs) has supported the reversal of the neurobiological effect of poverty.

Related: Chicago Dental Society Foundation opens free dental clinic

	We cannot improve the oral health of Americans without first resolving the greater, more pressing issue of poverty. All oral health care providers adhere to a Code of Ethics which recognizes our responsibility in sharing our knowledge and skills in order to improve health. In every way, let’s try to acknowledge the challenges a large portion of Americans face, provide them with resources and professional care, promote healthy lifestyles in our own communities and advocate legislatively for programs with proven records of effectiveness.

http://www.nytimes.com/2012/07/29/opinion/sunday/why-cant-we-end-poverty-in-america.html

www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

journals.plos.org/plosone/article?id=10.1371/journal.pone.0080954

http://www.citylab.com/housing/2013/10/how-crummy-run-down-housing-harms-children-who-live-it/7345/

Income, Poverty, and Health Insurance Coverage in the United States: 2014

Income and Poverty in the United States: 2014

Kim et al. Effects of childhood poverty and chronic stress on emotion regulatory brain function in adulthood. PNAS (2013). 110 (46); 18442-18447.

Articles

A summary of the effects of socioeconomic status, showing all health care professionals the daunting task they have in tackling poverty.

Poverty and the healthcare professional

	This past summer the Associated Press (AP) raised holy hell with their assertion, based upon information retrieved from systematic reviews, that flossing is useless and serves no purpose. The ADA, ADHA, AAP, OHA and most oral health professionals have called the AP to task, supporting the importance of flossing and equating lack of flossing with all manner of poor hygiene, including an especially crude comparison to the wiping of one's arse.

	Media naturally favors sensational stories that catch the public’s eye and interest, which in turn attracts advertisers and, consequently, money. Science is neither eye-catching nor interesting to most people. This creates a conflict of interest and angers many 

. Media coverage of science can be broken down into three categories: the wacky, the scary and the “breakthrough” science stories. Stories like these are ridiculous and writers are to blame for their proliferation.

	Daily, we are all exposed to media misrepresentation of science. Magazines and websites are abundant with ads about “super foods”, which are often just exotic fruits. Weight loss, skin treatment and hair restoration products all make exaggerated claims of their benefits; media only increases the hype. Every year around Christmas and Easter, articles are published by mainstream media on the reported health benefits of chocolate. There is little scientific research to back these claims up, but the media, doing what it does best, is able to play on people’s emotions. Of course people would like to believe chocolate is good for you; it’s delicious. In this way, media uses warped science to exercise its will; people like to read what makes them feel good, and what can make someone feel better than thinking chocolate is scientifically proven to be healthy.

Trending article: Is the Associated Press right? Response to the AP regarding the benefits of flossing

	Media sensationalism is often applied to scare stories as well. The MMR scare and widespread anti-vaccination sentiment is a perfect example. More recently, mass hysteria was created when Ebola entered the United States. 

 ran an article on the Ebola overreaction at the height of the epidemic. Their analysis included a survey in which two-thirds of participants feared an epidemic within the United States-despite there being only eight documented cases on American soil. 3,000 to 49,000 people died from a flu-related death during the years 1976-2007, yet no one seems to be rushing out for seasonal flu vaccines. The culprit of this madness: media.

	Mainstream writers are ill-equipped to handle the relaying of scientific data and findings to the public. Journalists just don’t feel the need to back their claims up with evidence; they just need sensational stories to attract readers for advertisers. They understand that people usually only need conviction to be convinced. Whereas the learned members of a scientific community need facts, the public does not need nor even want them. Who has time to sit and analyze table after table and statistic after statistic? The public pressures media into misrepresentation of science. Before you know it, and by no fault of anyone’s, science is skewered to make it understandable.

Trending article: To floss or not to floss?

	In science, the pursuit of truth, of facts, is accomplished through the use of the scientific method. It is “

best way yet discovered for winnowing the truth from lies and delusion

” and from individual biases which cloud our judgment. In dentistry, this inquiry is called Evidence Based Decision Making/Evidence Based Dentistry (EBDM/EBD) and is the subject of a significant number of articles in every peer reviewed journal. The ADA has devoted 

 to it; there is even an entire organization dedicated to the pursuit of evidence based dental practice named, aptly enough, the 

. It should go without saying, and should not require constant reminders, that the decisions we make as healthcare providers ought to be based on facts. These facts come to us not only through in vivo and in vitro research but through the acquisition of empirical evidence-the kind espoused by Albert Einstein, “All knowledge of reality starts from experience and ends in it.” Hence, the more experience a clinician has in treating patients, the more evidence she has to draw upon.

	When asking someone what they think science is, their answer is usually something along the lines of a laboratory filled with men in lab coats or a scene from Star Trek. The failed experiments, painstaking work, vast amount of supporting or disproving data and gradual baby steps in progress go unrecognized by most. All things considered, media does science no favors. Facts, evidence and data are often neglected to spur public interest using sensationalism, and for this media is directly responsible for spreading misinformation. The full scope of and relationship between the public and scientific communities needs to be considered; that is, how media is controlled by the public, vice-versa, and how science is often the unlucky victim of the human condition.

The media's unsubstantiated coverage of medical and scientific issues could be dangerous to the general public's health.

How the mainstream media is crippling oral health

	In March of this year, the Centers for Disease Control and Prevention released a Summary of Infection Prevention Practices in the Dental Setting which is a synopsis of the recommendations made in their more extensive document, Guidelines for Infection Control in Dental Health-Care Settings-2003.

	There is nothing in the summary which is new, it is just a shortened document which condenses the material in the 2003 document. Still, it’s a 44-page summary and takes some time to sift through. Every dental health care professional should be aware of all these recommendations, but for those who need a refresher 

	We've made it a printable document so you can post this in your practice as a way to remind everyone of proper infection control standards. 

Diana Macri, RDH, has sifted through a 44-page summary from the CDC to give you a handy checklist of what you should and shouldn't be doing in your dental practice

Printable list of infection control do's and don'ts for the dental practice

		For a variety of reasons (including lack of motivation, dexterity and/or resources) many patients struggle with maintaining proper mechanical plaque removal regimens.

		Additionally, mechanical plaque removal does not eliminate the plaque biofilm, which remains on the soft tissues (the lips, buccal mucosa, attached/free gingiva, the tongue, the floor of the mouth, etc.), which comprise approximately 80 percent of the oral cavity. To remedy these shortcomings, the American Dental Association (ADA) recommends that oral rinses be incorporated into daily oral hygiene practices.

		Oral rinses are used for cosmetic purposes to freshen breath or to whiten teeth, and therapeutic purposes to help prevent or control tooth decay and gingivitis, and to reduce plaque biofilm.

		A bacterium is protected from its environment by a membrane on the bacterial wall, the integrity of which is essential to survival of the bacterium. This membrane consists of basic compounds such as phospholipids and lipopolysaccharides. The bacterial wall is important, as this confers rigidity and differs considerably between gram-positive and gram-negative bacteria. This diversity leads to great variation in the potency of antimicrobial agents.  

		Plants contain fragrant components that protect the plant in continually changing internal and external environments. The International Organization for Standardization defines an essential oil (EO) as a product made by distillation of these components with either water or steam.

 EOs are antibacterial, antiviral, antifungal and antimicrobial, hence their efficacy in combating oral pathogens. They are also known to have anti-inflammatory and anti-oxidative (oxidation is the loss of at least one electron when two or more substances interact; this causes damage to the cell) properties

, and few side effects which add to their ease of use. EOs also possess high specificity (effective against many different bacteria), but low substantivity (duration of antimicrobial action). The active ingredients in Listerine are a combination of three EOs: thymol 0.063%, eucalyptol 0.091%, and menthol 0.042%, along with other ingredients (i.e., methyl salicylate 0.0660%).

		These are a class of chemical compounds, including chlorhexidine, with strong antibacterial properties. The mechanism of action is to bind strongly to bacterial cell membranes, increasing the cell permeability, thus initiating leakage of intracellular components. Furthermore, bis-biguaides reduce pellicle formation and hinder the adsorption of bacteria onto the tooth structure. Chlorhexidine is a broad-spectrum agent effective against gram-positive and gram-negative bacteria, fungi, yeasts and some viruses. It has high substantivity, over seven to 12 hours after rinsing. It is considered the gold standard, the most potent of all chemotherapeutic agents. Disadvantages include brown staining of the teeth, tongue and restorations, alteration of taste perceptions, strong, bitter taste and increased calculus formation. There is some discrepancy regarding using a dentifrice containing sodium lauryl sulfate with some researchers finding no difference in efficacy when combining the two and others finding that SLS reduced the antimicrobial action of CHX. Without a clear distinction, the recommended procedure has been to use the SLS-containing dentifrice at least 30 minutes and preferably two hours after CHX rinsing.

		
		Quaternary ammonium compounds (QACs) irreversibly bind to the phospholipids and proteins of the membrane, thereby impairing permeability. The capacity of the bacterial cell to absorb such molecules influences sensitivity; the agent becomes bound to the wall proteins and is thus able to enter and destroy the membrane. Cetylpyridinium chloride is an example of a QAC and is found in Crest Pro-Health. CPC shares some of the adverse effects of CHX, including tooth staining, burning and increased calculus formation and does not have high substantivity.

		Asian countries have used traditional herbal medicines to treat infectious diseases for thousands of years. Many herbal extracts have proven to be powerful antimicrobials including pomegranate, Acacia nilotica, clove, Cinnamum zeylanicum, acacia, Araucaria bidwilli Hook, rosemary, evergreen, Sappan Lignum, S. flavescens, garlic, turmeric, and Psoraleae Semen.

  Sanguinaria canadensis (bloodroot) has particularly high substantivity and its effectiveness as an antimicrobial has been well studied and documented.

 Studies have shown that usage of herbal mouthwashes compared to chlorhexidine resulted in a significant reduction in plaque indices scores, gingival indices scores and gingival bleeding index scores.

		Chlorhexidine was found to be more effective on aerobic and anaerobic micro-organisms. Well documented side effects of chlorhexidine like tooth staining, taste alteration, and development of resistant microorganisms limits its use, especially in children. Therefore, oral rinses which incorporate herbal extracts can serve as an alternative in patients with special health care needs. The problem with these herbal rinses is that they are not regulated by the Food and Drug Administration (other oral rinses such as Listerine, Pro-Health and Peridex are approved by the FDA) so one cannot be sure of the percentage of the extract that is actually in the rinse.

		Boasting a 100-year safety record, sodium hypochlorite (common household bleach) is one of the most potent antiseptic and disinfectants available, effectively killing bacteria, fungi and viruses. Because it is present naturally (in neutrophils, monocytes and macrophages) is causes no allergic reactions and is not a teratogen or a carcinogen. It also doesn’t produce any side effects such as staining, does not cause irritation to mucosal tissues, does not erode tooth structures or titanium implants.

 The American Dental Association Council on Dental Therapeutics has long supported sodium hypochlorite as an antiseptic mouthrinse.

 Patients should be instructed to rinse with two tsps of 6% household bleach diluted in one cup of water for 30 seconds two to three times per week.

		The antiseptic action of salt on the skin and mucous membranes has been documented for over 2500 years. Egyptians used salt to make laxatives and anti-infectives, Hippocrates created a mixture of salt and honey to clean bad ulcers, and was the first to discover the antiinflammatory effects of inhaling steam from salt-water. The antiseptic and bactericidal qualities of dental salt (sea salt) come from its ability to increase the pH balance of saliva, creating an alkaline environment which make survival difficult for pathogenic bacteria. Add half a teaspoon-to one teaspoon of salt to a cup of warm water and rinse for approximately 20 seconds a couple of times a day.

		Triclosan, a bis-phenyl, is a very effective, broad-spectrum antimicrobial agent. Its judicious use in hospital settings by trained healthcare providers is undisputed. However, it has been implicated in a variety of harmful health effects including endocrine disruption, impaired muscle contraction, developmental and reproductive toxicity and carcinogenesis.

		Environmental effects on aquatic ecosystems include severely limiting microbial diversity which leads to adverse effects in species higher up the food chain, not to mention the potential numbers of microorganisms who become resistant to the drug (contributing to the serious problem of antibiotic resistance). It is available in the product Colgate Total Plax. Interesting to note that Colgate-Palmolive removed triclosan from its soap products yet still utilizes it for its toothpaste, Colgate Total Care.

		Stannous fluoride has anticariogenic and antibacterial properties. The use of stannous fluoride as an antibacterial is limited due to its instability and side effects. Amine fluoride stabilizes stannous fluoride and formulations including the two have been shown to be comparable to CHX in reducing oral bacterial accumulations. The negative effects of stannous fluoride include staining and a bitter, metallic taste. Iodine and its derivatives are the broadest spectrum and potent antiseptics available, and are also able to kill the Herpes virus. There are few negative side effects, it has low financial cost, does not encourage bacterial resistance and any stains it produces can be easily removed. Those allergic to iodine, pregnant/nursing women and those with thyroid dysfunction should not use it. A 10% PVP-iodine solution was shown to be a useful irrigant following periodontal debridement and root planing with great success: Five weeks after nonsurgical periodontal therapy (including root planing) 44 percent of treated sites revealed pathogen reduction of 95 percent or more.

		Gram negative bacteria are highly sensitive to active oxygen. Hydrogen peroxide breaks down into water and oxygen and effectively kills bacteria. Oxygenating agents such a hydrogen peroxide have been used for many years to disinfect oral tissues. Researchers tested Ardox-X, formulated with peroxyborate and specific carriers such as glycerol and cellulose, and reported a significant microbial shift in composition of oral bacterial species such as Streptococcus and Veillonella. These agents also produce the added benefit of bleaching on teeth. Peroxide, however, is unstable and difficult to store thus limiting its use. Long-term studies have shown a lack of adverse effects to the soft tissues of the mouth in when used in low concentrations (<2%)

.In high concentrations (>30% solution) soft tissues may exhibit erythema or mucosal sloughing, inflammation or hyperplasia.

1. International Organization for Standardization. http://www.iso.org/iso/home/store/catalogue_tc/catalogue_detail.htm?cs number=51017
		2. Adorjan, Barbara, and Gerhard Buchbauer. "Biological properties of essential oils: an updated review." Flavour and Fragrance Journal; 25.6 (2010)
		3. Asadoorian, J. “CDHA Position Paper on Commercially Available Over-the-Counter Oral Rinsing Products”. Canadian Journal of Dental Hygiene; 40.4 (2006)
		4. Yim et al. “Screening of aqueous extracts of medicinal herbs for antimicrobial activity against oral bacteria”. Integrative Medicine Research; 2.1 (2013)
		5. Lee, S. “Antimicrobial effects of herbal extracts on Streptococcus mutans and normal oral streptococci”. Journal of Microbiology; 51.4 (2013)
		6. Salam et al. “Antimicrobial activity of medicinal plant for oral health and hygiene”. International Journal of Natural and Social Sciences; 2.1 (2015)
		7. Mali et al. “Comparative evaluation of 0.1% turmeric mouthwash with 0.2% chlorhexidine gluconate in prevention of plaque and gingivitis: A clinical and microbiological study”. Journal of Indian Society of Periodontology; 16.3 (2012)
		8. Dabholkar, C. S., Shah, M., Kathariya, R., Bajaj, M., & Doshi, Y. (2016). Comparative Evaluation of Antimicrobial Activity of Pomegranate-Containing Mouthwash Against Oral-Biofilm Forming Organisms: An Invitro Microbial Study. Journal of Clinical and Diagnostic Research: JCDR, 10(3), ZC65.
		9. Eley, B. “Antibacterial agents in the control of supragingival plaque - a review”. British Dental Journal; 186.6 (1999)
		10. Slots, JÃ¸rgen. "Low-cost periodontal therapy." Periodontology 2000 60.1 (2012): 110-137.
		11. American Dental Association. “Accepted dental therapeutics”. Chicago IL: American Dental Association, 1984, p. 326
		12. Yueh et al. “The commonly used antimicrobial additive triclosan is a liver tumor promoter”. Proceedings of the National Academies of Sciences; 111.48 (2014)
		13. Halden, R. “On the Need and Speed of Regulating Triclosan and Triclocarban in the United States”. Environmental Science and Technology; 48 (2014).
		14. Business Insider. Colgate-Palmolive removed this potentially harmful chemical from its soap products -but it’s still in your toothpaste. http://www.businessinsider.com/triclosan-cancer-causing-ingredient-in-colgate-toothpaste-2014-8
		15. Hang et al. Povidone-iodine as a periodontal pocket disinfectant. Journal of Periodontal Research; 38 (2003)
		16. Mostajo et al. “Effect of an oxygenating agent on oral bacteria in vitro and on dental plaque composition in healthy young adults”. Frontiers in Cellular and Infection Microbiology; (2014)
		17. Walsh, L. “Safety issues relating to the use of hydrogen peroxide in dentistry”. Australian Dental Journal; 45.4 (2000)

For a variety of reasons (including lack of motivation, dexterity and/or resources) many patients struggle with maintaining proper mechanical plaque removal regimens. To remedy these shortcomings, the American Dental Association (ADA) recommends that oral rinses be incorporated into daily oral hygiene practices.

What you need to know about oral rinses

	Antimicrobial resistance is compromising our ability to treat infectious diseases, and fostering the rise of superbugs, bacteria that have become resistant to all known therapies. Antibiotic resistance refers specifically to bacteria’s resistance to antibiotics.

	Antimicrobial resistance is a broader term, referring to other microbes’ resistance to drugs used to treat infections. These include parasites (e.g. malaria), viruses (e.g. HIV) and fungi (e.g. 

). More than two million people in the United States develop antibiotic-resistant infections, and at least 23,000 of them die as a result each year. This has caused several world and national health organizations to create guidelines to control the unnecessary use of antibiotics.

	Both the World Health Organization (WHO) and the Centers for Disease Control (CDC) emphasize that infection prevention and limiting inappropriate antibiotic use are the most effective practices for controlling antibiotic resistance.

More from Diana Macri: How can you prevent violations of health and safety in the dental industry?

	Every oral health care professional should be practicing standard precautions to protect themselves and their patients. The 

		Handwashing- The single most effective means of stopping disease transmission; should be done for 15 seconds, every time gloves are removed and before gloves are placed on the hands. Hands should also be washed whenever they have touched a contaminated surface

		Use of personal protective equipment (PPE)- Mask, gloves, gown (or lab coat) and protective eye wear are to be worn EVERY time a provider treats a patient

		 Strict adherence to appropriate sterilization and disinfection protocols

		Vaccinations- recommendations include HepB, MMR, Varicella, Tdap, meningococcal and annual influenza

	And by all means, if you’re sick, stay home!

Trending article: Some of the worst infection control mistakes we've heard

	All health care workers must strive to preserve the power of antimicrobial therapies and that includes preventing inappropriate prescribing and dispensing practices. According to WHO, “...staff lack up-to-date information, cannot identify the type of infection, [and/or] yield to patient pressure to prescribe antibiotics or benefit financially from supplying the medicines.” It is estimated by the 

 that half of antibiotics prescribed in the US are unnecessary or inappropriate for the symptoms reported. In 2014 the American Dental Association presented the findings of a panel of experts (the 2014 Panel) convened by the American Dental Association Council on Scientific Affairs. The panel “developed an 

evidence-based clinical practice guideline

 (CPG) on the use of prophylactic antibiotics in patients with prosthetic joints who are undergoing dental procedures. This CPG is intended to clarify the 

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-based Guideline and Evidence Report

 which was developed and published by the American Academy of Orthopaedic Surgeons and the American Dental Association (the 2012 Panel).” Their findings:

The current best evidence failed to demonstrate an association between dental procedures and prosthetic joint infection (PJI). In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection. The practitioner and patient should consider possible clinical circumstances that may suggest the presence of a significant medical risk in providing dental care without antibiotic prophylaxis, as well as the known risks of frequent or widespread antibiotic use.

Trending article: Dental care linked to risk of respiratory infections in ICU patients

	Antibiotic premedication is reasonable for patients with:

		Prosthetic cardiac valve or prosthetic material used for cardiac valve repair

		A cardiac transplant that develops cardiac valvulopathy

		The following congenital (present from birth) heart disease: a unrepaired cyanotic congenital heart disease, including palliative shunts and conduits

		  A completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure

		Any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device (that inhibit endothelialization)

	In my own office, I often have patients who are still pre-medicating for conditions such heart murmurs, knee replacements and mitral valve prolapse. Often, the only reason they are pre-medicating is because they are used to it and not because their orthopedist or cardiologist prescribed it. Even more troubling is the practice of dentists taking it upon themselves to premedicate a patient without consulting with the patient’s surgeon. Whether or not a patient needs to premedicate prior to dental procedures should be made by the patient’s surgeon and not the dentist.

Related reading: Hand sanitizer vs. handwashing: What dental professionals need to know

	Dental hygienists often recommend the use of antimicrobial/antiseptic rinses to prevent oral diseases such as dental caries and periodontal disease. Antimicrobial mouth rinses reduce the bacterial count and inhibit the bacterial activity in dental plaque; their efficacy has been well documented. The active ingredients in over the counter rinses are cetylpyridium chloride, essential oils (combinations of thymol, menthol, eucalyptol and methyl salicylate) and stannous fluoride. Many practices utilize chlorhexidine, a powerful antimicrobial, as an adjunct to manual biofilm/calculus removal therapies.

	Chlorhexidine ruptures the bacterial cell membrane and binds salivary mucins, which reduces pellicle formation and is widely used in medicine, as well as dentistry, due to its broad activity spectrum, acceptable tolerability and favorable safety record. However, there is increasing concern that bacteria are forming a resistance to it.

Conceivably, the use of chlorhexidine to combat oral disease may be contributing to this increase in resistance. In their systematic review, Jangid et al.

 reported comparable efficacy between herbal mouthwashes compared to chlorhexidine in preventing gingivitis. Interestingly, in their systematic review, Van Leeuwen et al.

 reported chlorhexidine was significantly better at controlling plaque but there was no significant difference with respect to reduction of gingivitis. Both studies concluded that herbal mouthrinses were a reliable alternative to chlorhexidine in reducing gingivitis (which is the first stage of periodontal disease).

	Antimicrobial resistance is a serious global threat. As with all matters regarding public health, the concerted efforts of all will be necessary in order to preserve the potency of antimicrobials. Health care providers, including all oral health professionals, have taken on the responsibility of caring for the health of the population. Adhering to infection control guidelines and utilizing good judgment alongside sound scientific evidence will help to stop the spread of disease and, by extension, the unnecessary use of antimicrobials.

1. Horner, C., Mawer, D., & Wilcox, M. (2012). “Reduced susceptibility to chlorhexidine in staphylococci: is it increasing and does it matter?”Journal of Antimicrobial Chemotherapy. doi: 10.1093/jac/dks284

2. Jangid, K., Doraiswamy, J., Saji, V., Malaiappan, S. (2014). “Efficacy of Herbal Mouthwashes Compared to Chlorhexidine in Gingivitis-A Systematic Review”. International Journal of Ethnobiology and Ethnomedicine. 1 (1): 1-12.

3. Van Leeuwen, M. P. C., D. E. Slot, and G. A. Van der Weijden. (2011)."Essential oils compared to chlorhexidine with respect to plaque and parameters of gingival inflammation: a systematic review." Journal of Periodontology. 82 (2): 174-194.

Antimicrobial resistance is compromising our ability to treat infectious diseases, and fostering the rise of superbugs, bacteria that have become resistant to all known therapies. Antibiotic resistance refers specifically to bacteria’s resistance to antibiotics.

The importance of battling antimicrobial resistance

	The practice of dentistry has evolved from its humble origins when barbers were the only “professionals” providing oral health care. Today, there are eight dental specialities (endodontist, orthodontist, periodontist, prosthodontist, pediatric dentist, general dentist, oral surgeon and oral pathologist) tasked with restoring dentition to a healthy status. Dental hygienists, in contrast, are primarily disease-prevention specialists. Through patient education and calculus removal techniques, they work to maintain a healthy periodontium, the foundation of the dentition. Together, these professionals are responsible for the oral health of Americans. Traditionally, as with most careers, dentistry was a male-dominated profession. However, the modern dental workforce is overwhelmingly female.

	The first American woman to earn a degree in dentistry was Lucy Hobbs Taylor, and she did so in secrecy. The year was 1865 and, having been denied entry into Eclectic College of Medicine because she was a woman, Lucy obtained her dental education from the dean of the Ohio College of Dental Surgery privately. She did not receive a degree upon completion. After an apprenticeship with a male dentist, she ventured out on her own and opened a practice in Cincinnati in 1861. The practice quickly became successful, and, in 1865, The Iowa State Dental Society granted her membership, stating, “the profession has nothing in its pursuits foreign to the instincts of women.” She received her degree in 1866 from Ohio College of Dental Surgery. Lucy was, by all accounts, a powerful lady. She was a suffragist, advocate and educator, having trained her own husband to become a dentist. By the turn of the 20th century, there were 1,000 women dentists.

Related reading: Dental Products Report's Top 25 Women in Dentistry for 2015

	The dental hygiene profession originated from the mind of Dr. Albert C. Fones, a Connecticut dentist who realized that proper oral hygiene was the key to preventing dental disease. He wrote a textbook, “Mouth Hygiene: a course of instruction for dental hygienists,” in which he details the techniques he created to secure “extreme cleanliness.” After training his cousin, Irene Newman, in plaque and calculus removal techniques, she became the world’s first dental hygienist. Dedicated to his vision, Dr. Fones, working against organized dentistry (they highly disapproved of dental hygienists), opened his own school in a carriage house behind his private practice. In 1914, 27 women graduated from the Fones Clinic for Dental Hygienists.

		185,000 dental hygienists and 186,000 dentists in the United States.

		96 percent of dental hygienists and 47 percent of dentists are female.

		That means of 373,000 dental care providers, 264,000 are women.

elated reading: How the role of women in dentistry has come a long way

	The implications of these numbers are unknown, but some trends regarding dentists are evident:

		Women are less likely than men to own their own practices (54 percent vs. 74 percent, respectively).

		Women are less prominent in organized dentistry and leadership roles.

		Women work less hours (89 percent of male dentists worked full-time vs. 75 percent of women dentists).

		Women are more likely to treat oral disease conservatively.

		Female health care providers are perceived as more empathetic than male providers (empathy is crucial to positive patient outcomes).

	In academia and publication status, women still lag behind. In a recent study examining the gender differences in the number and rate of publications, only 13

percent of first authors and 9 percent of last authors were women. Although women are more likely than men to pursue academic careers (this is assumed to be due to women’s desire to work less hours to balance family and career), they only account for one-third of the full time faculty in dental teaching institutions. Women report significant gender disparities in the world of academia; men are predominant in positions of tenure, deanship and scholarly activity. Strong efforts have been made by leading organizations, such as the American Dental Association and the American Dental Education Association, to provide women with the training and opportunities necessary to close the gap.

Related reading: The significance of Dental Products Report's Top 25 Women in Dentistry award

	Women are also beginning to earn more visible leadership positions. The president of the American Dental Association, the American Dental Hygienists Association, the American Academy of Periodontology, the American Academy for Oral Systemic Health and the American Dental Assistants Association are all women. In fact, the entire board of the ADAA is female! Women are also strongly represented in the sister profession of public health. Fourteen percent of the presidents of the American Association of Public Health Dentistry were female, and there has been a significant increase of female authorship in the Journal of Public Health. 

	The effects of all this feminization are yet to be seen. I like to think the tenderness and compassion inherent of women will positively affect the practice of dentistry. Current trends in public policy and science support the need for a holistic approach to health, which produces better outcomes (healthier, happier people) and reduces cost. In my own experience, I’ve noticed differences in the way women care for their patients. While I can’t attest to differences in quality of care (I have worked with excellent clinicians both male and female), there are noticeable differences in delivery of care. Women take more time and pay less attention to the profits. Patients appreciate this, and studies show they are more likely to adopt healthy behaviors when cared for this way. Dr. Lynn Carlisle discusses this more in-depth and makes a final observation.

Related reading: The best and worst states for female professionals

	“The current generation of women dentists will be a bridge generation that deals with the many challenges of being pioneers in the way women practice dentistry,” she says. “Hopefully, the current bridge generation of women in dentistry will integrate the feminine and masculine into a more humane, holistic, caring, relationship-based dental profession. Hopefully, they will add to the rich tradition of women as healers and men as healers.”

Diana Macri is an assistant professor in the dental hygiene department at Hostos Community College. She obtained a bachelor’s degree from the University of Bridgeport and a master’s degree in higher education administration from Baruch College

“The current generation of women dentists will be a bridge generation that deals with the many challenges of being pioneers in the way women practice dentistry.”

Why women dentists in the current generation are indeed pioneers

	I recently co-authored a manuscript on patient compliance, discussing the different theories/methods that dental hygienists may use in order to motivate their patients to improve their oral hygiene behaviors.

	The first step to writing such a thing is to do a thorough review of the literature (articles written by experts) and get as much good, solid information from good, solid researchers who have devoted themselves to getting to the bottom of things. That's what a good scientist does - forms a hypothesis then tests it and honestly reports the results. We, as the readers, are left to make our own judgments regarding the scientists' success or failure at proving their hypotheses.

	In doing the literature review, I quickly became depressed. There were words in those articles that were foreign and unpleasant such as cognitive dissonance, cognitive behavioral interventions, reasoned action, social cognition models, and operationalization.

More from the author:	How can you prevent violations of health and safety in the dental industry?

	My motivation for writing the manuscript came from my own experiences in private practice and realizing that my patients were no more dedicated to homecare practices now than they were 20 years ago when I first became a hygienist. Regardless of my enthusiasm, dedication, knowledge, or approach, they do not adopt my recommendations for the long term. Honestly, it’s frustrating!

	So I looked to find the latest theories and the most effective methods I can use, according to the experts, to get my patients to do what I think is best for them. Additionally, I have the added responsibility of passing that knowledge on to my students via lectures and getting them to become really good at it as they work with patients in

Read more of her frustrations and solutions on the next page...

	The problem is that any student would need a solid background in psychology in order to even begin to understand the terminology, let alone effectively use the techniques with their patients in the clinic. Let’s not forget this has to be done simultaneously as they are learning instrumentation, radiography, treatment planning, etc.

	Often I see articles about how “the dental hygiene visit is the ideal time to” discuss teeth whitening, do sleep apnea screening, diabetes screening, oral cancer screening, and HIV screening. Because, you know, dental hygienists have plenty of time to provide care (obtaining vital signs, scaling/root planing, polishing, CAMBRA, treatment planning, FM probing, exposing radiographs, patient education, expose a PAN, apply sealants and 

, desensitize, pain management, check occlusion, discuss TMJ disorders, dietary counseling, etc.), so adding in these “little” things would only take a few minutes and would provide a valuable service to our patients. Other authors have alluded to how “compassion leads to compliance” (in fact, all the evidence clearly points out that the patient’s intrinsic motivation is the only thing that can lead to compliance and that our jobs as clinicians is not to “compassion” our patients over the head but to be persistent in our educational efforts) and, my newest favorite, salivary diagnostics.

If I did an HIV screening on a client and the results were positive, what training do I have (even with a master’s degree) to properly support that patient at that moment?

Who’s going to pay for the fancy salivary diagnostic kit? My socioeconomically stable patients who have low incidence of disease or the socioeconomically 

 patients who have no insurance benefits? Because we clearly know the people who need us most are those who are poor and uneducated.

Approximately 1 out of 11 Americans have 

are prediabetic and don’t know it. You need only ask physicians and nurses how successful they are at getting patients to comply with their medications/dietary recommendations to understand that this is an multifactorial epidemic and screening for it in a dental environment will barely make a dent in its resolution.

HOT READ: July's 20 bets tweets about dental hygienists

	What ends up happening when we keep piling on all these responsibilities to the dental hygiene appointment is that the really important work, that of education and disease prevention, falls by the wayside. Regarding oral diseases, periodontitis and caries, researchers have stated repeatedly and unequivocally:

The importance of sugars as a cause of caries is underemphasized and not prominent in preventive strategies. This is despite overwhelming evidence of its unique role in causing a worldwide caries epidemic. Why this neglect? One reason is that researchers mistakenly consider caries to be a multifactorial disease; they also concentrate mainly on mitigating factors, particularly fluoride. The long-standing failure to identify the need for drastic national reductions in sugars intakes reflects scientific confusion partly induced by pressure from major industrial sugar interests.

Periodontitis affects more than 50% of the adult population and its severe forms affect 11% of adults, making severe periodontitis the 6th most prevalent disease of mankind. Chronic gingival inflammation in response to microbial biofilms is considered the key risk factor for the onset of periodontitis, or its progression in treated patients. A preventive approach to care requires diagnosis, education and motivation towards behaviour change, with patients taking greater responsibility for their own health under the guidance of and with support from the oral care team.

	I would like to see all dental hygienists, in every capacity in which they work (writers, clinicians, educators, consultants, speakers, etc.) remember that our responsibility is primary to prevent oral disease and that we have very clear evidence as to how best to do that. It has long since been the time for dental hygiene to be a Bachelor’s level degree and I stand behind any efforts that promote that. But as long as we have two short years to educate dental hygienists, disease prevention must remain our focus in practice.


	1. Sheiham, A., and W. P. T. James. "Diet and Dental Caries The Pivotal Role of Free Sugars Reemphasized." 

	2. Tonetti, Maurizio S., et al. "Primary and secondary prevention of periodontal and peri-implant diseases." 


	Diana Macri is an assistant professor in 

the dental hygiene department at Hostos Community Colleg

e. Previously, she was as an adjunct lecturer at 

, both in New York City. Within these programs she taught both clinical and didactic courses. Currently, she teaches three core courses: Dental Hygiene Practice I and II and Ethics, Jurisprudence and Practice Management. In addition to her teaching duties, she has presented lectures at professional conferences locally and nationally. She serves as a trustee on 

the National Board of the Hispanic Dental Association

 and is the chair of the Communications Committee. Additionally, she has been appointed to the Minority Affairs Advisory Committee of the 

n. She is involved in many advocacy efforts, specifically those which seek to resolve oral health disparities seen in the Hispanic population. Prof. Macri obtained a bachelor's degree from the 

 and a master's degree in higher education administration from 

. She happily resides in New York City with her three sons.

I recently co-authored a manuscript on patient compliance, discussing the different theories/methods that dental hygienists may use in order to motivate their patients to improve their oral hygiene behaviors.
The first step to writing such a thing is to do a thorough review of the literature (articles written by experts) and get as much good, solid information from good, solid researchers who have devoted themselves to getting to the bottom of things.

I'm a dental hygienist, not a therapist (or social worker … or saleswoman … or psychiatrist … or detective)

In 2013, investigators on a routine inspection of an oral surgery practice in Tulsa, Okla., discovered numerous violations of health and safety laws and major violations of the state dental act.

Among the findings in the office of W. Scott Harrington, DMD, was medication with long past due dates (1993!) and equipment that was rusted and not properly sterilized. State health officials immediately initiated screenings of the dentist’s 7,000 patients when it was further discovered the practice included a high volume of patients with infectious diseases such as HIV or hepatitis.
	
	Like many others in the dental industry I was disgusted to learn of such egregious violations of basic protocol. As a practicing dental hygienist, and being intimate with the inner workings of dental offices for more than 20 years, my attention immediately turned to the many assistants and dental hygienists who, through the years, had been complicit in the dereliction of duty. I lament, I sympathize and I ponder: How can we, collectively, prevent such episodes from recurring?

Philosophers have long studied ethics, usually in the greater context of discovering its role in leading a meaningful, fulfilling life. Modern medicine is still greatly influenced by the work of the Greek philosophers. Aristotle, pupil of Plato, spent decades studying humanity’s greater purpose. He introduced the idea of eudaimonia, what he believed to be the purpose of the human race and what we refer to as “happiness.” Living  a virtuous life, characterized by temperance and courage, will ensure eudaimonia.

The most recognized of all Greek contributions to ethical behavior in medicine is the 

. Found in the Corpus Hippocraticum, a body of manuscripts that embody a code of principles for the teachers of medicine and their students, the oath dictates the obligations of physicians in caring for their patients and their students. Contemporary versions keep alive the humble vision of a physician as caretaker and heale--a noble profession practiced only by the most virtuous members of society.
	
	In health care and elsewhere, ethical behavior is the result of perceiving an action as either right or wrong. According to famed psychologist 

, the foundations of moral (ethical) behavior are forged in childhood and adolescence, reinforced by the practices of our parents and those around us. In adulthood, people behave morally mostly out of an understanding of the need to keep order in society. Few reach the highest levels of moral reasoning where ethical decisions are based on respect for oneself and for the rights of others.

Dental hygiene programs have long recognized the need to incorporate at least some ethical education into their curricula. However, most scholars agree it is not enough to keep up with the pace of a world that is changing so quickly.

Ethics education programs that are not grounded in a community context fail to produce significant moral development. For true character to develop, a community that nurtures and supports moral action must exist. Legislators dutifully pass laws and create governmental departments tasked with the duty to enforce moral conduct. Although ethics and the law are closely related, they are not the same. Ethical obligations may-and often do-exceed legal duties. The drawback of relying on rules (i.e. laws and government) to ensure people behave ethically is that while it is probably a good defense against the actions that contributed to the last crisis, they are not effective against preventing newer crises from occurring.

The burden, then, is on the strongest amongst us to take the lead. Ethical leadership consists of taking seriously the notion that each of us has great power and great influence-that the seemingly small actions we perform every day can and do affect others positively (and, conversely, negatively).

By placing less emphasis on monetary gains and more on strong character, we can ensure incidents such as the one in Tulsa do not happen again. I have previously written about the use of personal mission statements in maintaining a strong ethical perspective. Many professional organizations  now offer continuing education courses devoted to the topic. 

 offers an excellent course on practical ethics, and various other MOOCs (massive open online courses) are available through higher education institutions such as 

In 2012, prior to the incident in Tulsa, news broke of an oral surgeon who had agreed to discontinue practicing dentistry after it was discovered that, in addition to prescription fraud, he had reused needles and syringes on more than 8,000 patients at two of his dental practices. While news of the voluntary surrender of his license in Colorado is of little satisfaction to me, what IS of great satisfaction is the knowledge that, in that case, authorities were prompted to investigate due to the report of an employee. The employee notified authorities Dr. Stein was ordered drugs under patients’ names.

Whoever she is and wherever she is, I thank her and commend her actions-Not just because she saved so many others from danger but because I know that I was not the only one who was inspired by her strong character.


Diana Macri is an assistant professor in the dental hygiene department at Hostos Community College. Previously, she was as an adjunct lecturer at 

, both in New York City. Within these programs she taught both clinical and didactic courses. Currently, she teaches three core courses: Dental Hygiene Practice I and II and Ethics, Jurisprudence and Practice Management. In addition to her teaching duties, she has presented lectures at professional conferences locally and nationally. She serves as a trustee on the National Board of the Hispanic Dental Association and is the chair of the Communications Committee. Additionally, she has been appointed to the Minority Affairs Advisory Committee of the 

n. She is involved in many advocacy efforts, specifically those which seek to resolve oral health disparities seen in the Hispanic population. Prof. Macri obtained a bachelor's degree from the 

 and a master's degree in higher education administration from 

 In 2013, investigators on a routine inspection of an oral surgery practice in Tulsa, Okla., discovered numerous violations of health and safety laws and major violations of the state dental act.