What constitutes dental hygiene practice in Nova Scotia?

Only individuals who hold a CDHNS practising licence may engage in the practice of dental hygiene in Nova Scotia, whether as a volunteer or for renumeration.

Section 22 of the Dental Hygienists Act provides details regarding dental hygiene scope of practice. In conjunction with the Regulations (including Sections 25 and 26:Scope of Practice), the practice of dental hygiene is defined. The practice of dental hygiene includes registrants who act as clinicians, educators, researchers, administrators, managers, health promoters, and/or consultants. This may include positions like dental supply company sales rep, infection prevention and control consultant, and dental hygiene department manager. All positions count towards accumulation of practice hours and all positions require a CDHNS practising licence.

 

Can I treat my spouse/partner in my dental hygiene practice?

Currently, dental hygienists may provide dental hygiene care to spouses/partners in Nova Scotia. There is presently no legislation, standards of practice, or ethical principles in Nova Scotia which restrict dental hygienists from providing dental hygiene care to a spouse/partner.

The concerns that exist around treatment of spouses/partners is the potential imbalance of power and vulnerability that may occur. This is less pronounced in the dental hygienist and client relationship, at least where there is a well-established relationship that pre-exists the professional relationship.

While treating a spouse/partner, the dental hygienist must provide dental hygiene care in accordance with the CDHNS Standards of Practice and Code of Ethics, just like a dental hygienist would for any other client. If a dental hygienist believes that their professional judgment and ability to provide safe and ethical dental hygiene care is affected by the personal relationship with the spouse/partner, the dental hygienist must refer the client to another dental hygienist.

The ability to treat a spouse or partner does not prevent an individual from making a complaint to the CDHNS about a regulated member. That complaint would be addressed through the CDHNS complaints process.

I am trying to minimize the generation of AGPs unless necessary. What about polishing teeth for stain removal?

Perform AGPs when the anticipated benefits outweigh the risks to the client, the health professional, and the greater community. 

It is up to each clinician to determine the appropriate procedure(s) needed for each client. As a regulated professional, you must use your professional judgement and clinical evaluation to construct and implement a client-specific treatment (care) plan that addresses their oral health needs.  The decision around which specific oral health services to provide must be based on individual client need i.e., client centred care. The decision to perform Aerosol Generating Procedures (AGPs) versus Non-Aerosol Generating Procedures (NAGPs) is another client-specific decision. Consider acceptable NAGP treatment options over AGP procedures.

As we are re-evaluating our in-office practices to ensure that we are continuing to safely and effectively provide care, we are provided with another opportunity to evaluate some of the routine “processes” in our offices that may not actually align with best practices or current standards of care. One example is performing routine prophylaxis (teeth polishing). This procedure will generate aerosols, regardless of the type of paste selected. The decision to perform this procedure should be made when it is deemed appropriate, after weighing all of the factors above.

Consider these facts about 'routine prophylaxis' (polish):

  • There is no therapeutic value to a prophylaxis. It is strictly a cosmetic concern, not a pathological condition. You are removing extrinsic stain or other removable discolorations on the teeth.
  • It is contraindicated on newly erupted and deciduous teeth.
  • Consider the particle impact, particularly immediately after periodontal debridement, when tissues may be irritated.
  • Most individuals do not require a prophy in the absence of stain.
  • There may be other dental/dental hygiene procedures which require a form of prophylaxis to be performed e.g., sealants, certain orthodontic procedures.  
  • Consider other methods to remove biofilm – particularly a method that has a lower risk for generating aerosols.
  • Educate your clients on the risks versus benefits associated with “routine polishing” so that they can make an informed decision about their care.

This response emphasizes the intent of the June 17, 2020 presentation of the four Oral Health Regulators and provides a few more additional details for clarity.  It draws on concepts outlined in the CDHNS Protocols (Tab 1) of the Joint RTW Guidelines for NS Oral Health Professions. The concepts about appropriate use of Aerosol Generating Procedures (AGPs) versus Non-Aerosol Generating Procedures (NAGPs) is woven throughout the entire document – particularly sections 2.2 and 2.3 of the CDHNS Protocols. The use of “slow-speed handpiece in the presence of water/saliva” is listed as an AGP. Polishing, within the context of this question, falls within this bullet.

Should I treat clients who present with a 'cold sore' (i.e., active primary or recurrent herpetic lesions)?

No, do not provide clinical oral health care services if the client has potentially contagious lesions in or near the mouth, whether from primary herpetic gingivostomatitis or from recurrent oral herpes simplex. Provide oral health care once the vesicles/ulcers have completely healed. There is a risk of transmission of the virus to other head and neck areas of the client or to the dental hygienist.

Mode of transmission: HSV-1 is primarily transmitted via contact with the saliva of carriers, resulting in oral herpes. Transmission may also occur through contact of active cold sores on the lips of carriers or via contact with other active herpetic lesions. Transmission of HSV-2 is usually via sexual contact and causes genital herpes. However, oral-genital, oral-anal or anal-genital contact means that HSV-1 and HSV-2 may be transmitted to various sites, and the historical distinction between the two types of HSV in terms of site of infection is now blurred. After the initial infection, the virus becomes dormant in the sensory ganglia of the face (or genital area); reactivation of the virus causes cold sores of the mouth (or genital sores, if the primary infection was in the genital area).

Considerations:

  1. Dental hygienists must not treat clients while the lesions are present.
  2. Dental hygienists have an ethical responsibility to educate their clients about the significance of their diseases, the potential for recurrence, and the risk of infection of others.
  3. Not only are resulting lesions to the dental hygienists' fingers and thumbs a possibility (e.g., herpetic whitlow), but the virus is also shed in the saliva which means that splatter during treatment can be risky.
  4. Clients may become upset if rescheduling is required. This is another reason that education is key.
  5. Developing a clear office policy regarding rescheduling clients until lesions are healed will ensure consistent messaging and approaches in your office.

References: 1. Bowen, D., & Pieren, J. (2020). Darby and Walsh Dental Hygiene, 5th Edition. Elsevier. 2. Centers for Disease Control and Prevention (USA). (2017, Aug 28). CDC Herpes Facts and Brochures. Retrieved Aug 12, 2020, from Herpes - CDC Fact Sheet: https:// www.cdc.gov/std/herpes/stdfact-herpes.htm#:~:text=It%20is%20also%20possible%20 to,silverware%2C%20soap%2C%20or%20towels. 3. CDHO. Advisories. (May 2014). CDHO Factsheet Herpes Simplex. Retrieved Aug 4, 2020 at: https://www.cdho.org/Advisories/CDHO_Factsheet_Herpes_Simplex.pdf

What are the protocols I am required to follow when treating a client who presents with a new serious medical condition?

As a regulated health professional, it is your professional responsibility to use your professional judgement to ensure safe and effective care is provided. This includes the responsibility to complete a comprehensive health history at each visit, and to consult with the appropriate individual in a client’s health care team, if necessary. 

If a client has a medical condition that is listed in Section 28 of the Dental Hygienists Regulations, e.g., a recent heart attack, stroke, or other medical condition that the dental hygienist is unfamiliar with,  a written clearance from the client’s medical doctor or nurse practitioner is required before an RDH proceeds to scale or root plane - each case is client specific and dependent on a number of factors. While it may be safe to proceed, the consultation and written clearance must occur before proceeding. See below for the legislation in NS that outlines this requirement:

The NS DH legislation outlines the expectations for this process – most are outlined in Section 28 of the Dental Hygienists RegulationsContra-indications to performing scaling teeth and root planing. This section is highlighted in the CDHNS document on our website entitled Self-Initiation Best Practices Section 3, page 6., provides further explanations:   

CONTRAINDICATIONS: The following health issues/conditions are listed in the CDHNS Regulations and are referred to in the [Dental Hygienists] Act as contraindications. They require consultation and a written clearance before proceeding with dental hygiene care [scaling and root planing].

“All of the following are prescribed as contra‐indications under clause 23(1) of the Act, and a dental hygienist must not, on their own initiative, perform scaling teeth or root planing nor continue scaling teeth or root planing for a client when any of the following conditions are reported or known to be present in the client, or if the dental hygienist is in doubt as to the accuracy of the medical or oral health history of the client, unless there is a relevant, current and documented clearance as provided for in subsection (2).”

As a dental hygienist, it is your legislated responsibility to refrain from providing scaling or root planing until a written clearance is obtained from an appropriate health professional. The legislation lists the client’s physician, nurse practitioner, or dentist [found in Section 28 (1)] as potential individuals who may provide written clearance. However, when obtaining written clearance, the RDH must decide who is the most appropriate health professional of the three options listed to obtain written clearance. This decision depends on the individual case and conditions of the client. For example, if it was a dental issue and a complication occurred, a dentist may be the appropriate choice. In the case of a medical condition, like a stroke that occurred within the last few months, or a client who is undergoing chemotherapy, it is the client’s physician (general physician or oncologist in our examples) or nurse practitioner that the RDH must obtain written clearance before proceeding.  

Section 28 (2) also goes on to say that “the conditions outlined in subsection (3) are not contra-indications under clause 23(1)(b) of the Act if there is a relevant, current and documented clearance for the client.”

“Clearance” must follow these three conditions - relevant, current, and documented:

  1. Is it relevant and current?
    1. Are you proposing to perform any new scaling or root planing procedures that would be contraindicated due to any of the client’s medical or oral health conditions that are listed in Section 28?
    2. Has anything changed in the client’s medical or oral health history/conditions, that may apply to the contraindications in this Section of the Regulations?
  2. Is it documented?
    1. The original clearance must be written by the specific health care professional. RDHs can’t just write “consulted with Dr. XXX, physician, and he said it is ok to move forward with scaling and root planing”. If it’s not a written clearance from one of those identified practitioners, it doesn’t meet the legislated requirement.
    2. Any subsequent decisions to proceed linked to the original relevant, current clearance, must also be documented by the RDH. This is important so that the decision-making process that the RDH completed is clear. For example, the RDH must write something like “current, relevant documented clearance on file. Therefore, no contraindications to proceed with scaling and root planing”, so that it is clear why they did not obtain another written clearance before proceeding.
Does a dental hygienist need a “prescription” from a dentist before they can proceed with teeth whitening procedures (chairside or take-home products)?

No. It is not a legislated requirement that an RDH obtains a prescription prior to performing teeth whitening.

Decisions around the scope of practice for dental hygiene are determined by the CDHNS, in alignment with Dental Hygienist Legislation, and any further policies that are developed by the CDHNS around specific areas. This includes teeth whitening. As such, in October 2012, CDHNS Council passed a Practice Protocol on the Use of Tooth Bleaching/Whitening*. In 2013, Council issued two other documents that also provided further clarity on teeth whitening — May 2013, Council issued their Position statement on Teeth Whitening; and in Sept 2013, the CDHNS Council issued the Practice Protocols for Laser Use in Dental Hygiene Practice*, which included use of lasers for teeth whitening and periodontal therapy.

As with all competencies/scopes of practice, the individual dental hygienist must be competent to perform it.

CDHNS Practising registrants performing teeth whitening for their clients must

  • Practice within the Code of Ethics adopted by the CDHNS. Certain ethical considerations can arise around the use of bleaching/whitening. These usually involve respect for the client’s personal values, and informed consent.
  • Make evidence-based decisions regarding implementation of new techniques, technology or research before incorporating them into practice. It is the registrant’s responsibility to understand the processes involved in tooth whitening.
  • Be competent in the procedures, and have appropriate education on the use of the product and equipment
  • Assess the client for contraindications to teeth whitening procedures (e.g., bleaching), apply appropriate selection criteria and knowledge of contraindications
  • Provide client education on the nature of the stain or discoloration of the teeth, including discussion on the expectations of results and other ramifications of bleaching, including possible adverse effects
  • Consider preventive measures to reduce any possible sensitivity.
  • Obtain written informed consent.
  • Use the product and equipment according to the manufacturer’s direction.
  • Practice collaboratively to determine that the planned procedure aligns with the overall treatment plan for the client.

*Note: Both the CDHNS Whitening and Laser Polices are targeted for an update/review

 

Do clients have to remove insulin pumps before radiographs are taken?

No. It is not necessary to remove insulin pumps when taking dental radiographs. However, ensuring that the pump is covered by a lead apron is an added precaution that could be taken.

Thank you to Kim Haslam (Assistant Professor, Dalhousie University School of Dental Hygiene) and Dr. Anthea Senior (Associate Professor, Associate Chair, DDS Clinical Education, School of Dentistry, Edmonton, Alberta) for their input.

Can I use Best Topical Ever and TAC 20% (compounded anaesthetics) in my practice?

These products are not to be used in Canada. Products like the ones listed above are customized compounded anaesthetics that are being used in the dental field. The products above are produced and marketed in the USA. In the USA, there is concern about compounded topical anaesthetics – partially because these types of products are not really approved by the United States Food and Drug Administration (FDA). The products that are used to compound them are approved, but not the actual finished product. These products contain high concentrations of local anaesthetics and use should be evaluated on a client-by-client basis. They are not supposed to be sold on a “bulk basis” to dental/dental hygiene practices; but are compounded for a specific client. They are not intended for office wide use, like the non-compounded topical anaesthetics approved by Health Canada. “Because compounded agents can include various FDA approved drugs, there are infinite possible combinations and concentrations (Patel, 2019).” Additionally, there is no known toxic level for these customized products. Packaging for compounded substances is unmetered. As a result, inaccurate dosing can easily occur, which can put clients at risk for systemic intoxication. (Kravitz, 2007) Furthermore, both of these compounded products combine amides and esters, which put a variety of clients at risk. All dental hygienists must remain current regarding the use or recommendation of topical and injectable anaesthetic agents.

References: Kravitz, N. D. (2007). The use of compound topical anesthetics: a review. J AM Dent Assoc (138), 1333-1339. doi: https://doi.org/10.14219/jada. archive.2007.0048 Patel, T. J. (2019, May 9). Update on Dental Topical Anesthetics. Retrieved from The Journal of Multidisciplinary Care: Decisions in Dentistry: https:// decisionsindentistry.com/article/update-on-dental-topical-anesthetics/

 

 

Do I have to use the CDHNS certificate of attendance for all courses I attend?

No. You are only required to use this form if the course provider does not provide their own certificate of attendance or other document that verifies successful completion of the course. As per the CDHNS CCP Requirements, in addition to the items listed on the CDHNS certificate template, you must also provide the following additional information for all courses that are not offered through the CDHNS, CDHA, Dalhousie University, or a Study Club registered through the CDHNS: presenter name and qualifications (if not included in the attendance form), session summary (detailed course outline) and learning objectives, subject matter of the activity, and documentation that supports the length of the presentation e.g., agenda that includes all major breaks.

 

 

How often can we do a fluoride varnish on a client per year? Or, how many weeks/months apart should fluoride varnish be applied?

There are no 'set' protocols about how often fluoride varnish can be applied. It depends on the individual needs of the client.

  • It depends on caries risk factors: diet, poor oral hygiene, low salivary flow, medications, past history of caries, deep pit & fissures on occlusal surfaces, clinical or radiographic signs of carious lesions.

For example: 

  • A client with high caries risk may have professional fluoride varnish more frequently than a client with low caries risk.
  • A client with radiation caries would need fluoride varnish applications more frequently than a client with incipient (code 1) caries.

As always, the practitioner should read the manufacturer's instructions. 

https://www.iccms-web.com/content/resources/elearning

*Response provided by Kim Haslam, RDH

 

 

Is Orofacial Myofunctional Therapy within the DH scope of practice in Nova Scotia?

Myofascial Release Therapy/Orofacial Myofunctional Therapy (OMT) is not within the scope of practice of dental hygiene in Nova Scotia. Accordingly, registrants of the CDHNS are not authorized to provide Myofascial Release Therapy or OMT services as a RDH. RDHs that provide Myofascial Release Therapy or OMT must clearly advise clients that these are not dental hygiene services. Further, RDHs cannot offer these services as part of their dental hygiene practice.   

The CDHNS is in the middle of reviewing Myofascial Release Therapy and OMT and has not yet determined if these services are within the scope of dental hygiene practice in Nova Scotia. If a decision is made that these services are within the scope of DH practice in NS, it may also include any restrictions or requirements for delivery of these services. This review has been ongoing for awhile, but it is important that a comprehensive analysis is completed, prior to making a final decision. As soon as a decision is made, we will circulate this out to all CDHNS registrants.

Please note any hours you practice Orofacial Myofunctional Therapy or Myofascial Release Therapy cannot be counted as practice hours for the purpose of licence renewal with the CDHNS. Further, please note that your DH professional liability insurance may not cover you for these services.

What is the difference between cultural safety and cultural humility when it comes to Indigenous populations? How can this be applied in dental care when it comes down to client care?

The Indigenous Health Primer that was published by the Royal College of Physicians and Surgeons of Canada in 2019 describes how it is the patient who decides whether a culturally safe space has been created. This can be fluid and can change over time. You may have one interaction that a patient considers to be healthy and safe, but another interaction that the same patient would consider unsafe. Cultural safety is an outcome and the end goal.

We can maximize our chances of creating culturally safe spaces through the practice of cultural humility. Cultural humility is an ongoing process whereby we develop an honest assessment of who we are and how this impacts our interaction with others. This is achieved through active reflection and can be further honed through formal and informal feedback from those around us. This information must be applied to change the way we see and relate to the world. In the context of Indigenous people, this requires ongoing interrogation of power, privilege, and racism. Some appreciation of cultural difference is necessary, but cultural humility is centred largely on gentle curiousity, respect, and empathy for the human experience.

*Response provided by Dr. Brent Young

I was just authorized by the CDHNS to perform orthodontic procedures (or permanent restorative procedures). Do I have to reapply to keep performing these after Nov 1, 2022?

No, like all other CDHNS authorizations specific to a certain 'scope of practice', e.g., local anaesthetic administration, you must remain authorized to perform those procedures as long as you hold a practising licence with the CDHNS, unless advised differently by the CDHNS. At all times, as per section 23 (2) of the Dental Hygienists Act, you are expected to restrict yourself to only performing procedures that you are individually competent to perform, regardless of authorization.

I heard Safety Code 30 has recently been updated. What are the major changes and could you provide me with more details?

Update: Radiation Protection in Dentistry:  Safety Procedures for the Installation, Use, and Control of Dental X-Ray Equipment Safety Code 30 (2022)

In 2019, I wrote an article for the UNISON, 'I Don't Want Radiographs' based on the 1999 Health Canada's Radiation Protection, Safety Code 30. This document has now been revised. While most of the recommendations remain the same, there are some significant changes, regarding collimation, protection, and handheld devices.

Radiation Protection in Dentistry-Recommended Safety Procedures for the Use of Dental X-Ray Equipment-Safety Code 30 (2022) can now be accessed at Health Canada.ca/en/ health-canada/services/environmental-workplace-health/ reports-publications/radiation/radiation-protectiondentistry-recommended-safety-procedures-use-dentalequipment-safety-code-30.html

When reading the document, be aware of the words 'must' and 'should'.

- 'Must' is used to indicate essential radiation protection requirements.

-'Should' indicates a recommendation to be implemented, where possible. 

Must Statements

- Rectangular colllimation of the X-ray beam must be used, except when exposing occlusal images. For most X-ray units, there are attachable collimation units that are attached to the end of the position indicating device (see page 9 of the Fall 2022 Newsletter).

- A client's clinical record must contain details of all radiographic examinations carried out, including indications and findings.

- The operator must be able to observe the client.

- X-ray units must have pre-settings for the client's size (adult/child) and anatomical indications (bitewings, anterior) or have a chart with the settings located near the control panel.

Should Statements

- Radiographs should only be taken after a clinical examination.

- A receptor holder with an alignment device (e.g., Rinn Kit) for the X-ray beam should be used. 

- A long cone ( 30 cm or longer) should be used. 

Protection

- Thyroid Shields

Clients must be provided with a thyroid shield for all exposures except:

  • panoramic exposures,
  • when it interferes with obtaining a diagnostic image.

- Lead Aprons

  • Are not required except when exposing Cone Beam Computed Tomography (CBCT)
  • May be used to aid in client comfort regarding fear of radiation.

Handheld Units

- Must only be used in exceptional situations, due to the location where imaging is being undertaken and/or the conditions of the client, where it is not reasonably feasible to use a device that is wall-mounted or mobile/transportable that permits the operator to initiate X-ray exposures from a distance of at least 2 m from the device.

- Must only be held by hand when it is not reasonably feasible for it to be supported on a stand and used remotely with the corded or remote irradiation switch.

- For at least the first year of operation where the device is routinely held by hand, each operator must wear a personal dosimeter until a baseline annual radiation dose is established.

-If you are using a handheld device, please refer to Safety Code 30 for additional information.

(To reference the handheld radiation device, go to page 9 of the Fall 2022 Newsletter.)

Other Important Information

 Prescribing Information

- Prescribing radiographs is within the scope of practice for Dental hygienists registered and licensed with the CDHNS.

- Please see the following Safety Code 30 recommended prescribing guidelines:

  • Dental Radiographic Examinations: Recommmendations for Patient Selection and Limiting Radiation Exposure (American Dental Association/Food and Drug Administration), on), https://www.fda.gov/media/84818/download

Quality Assurance Program

- Please refer to Safety Code 30, especially if you are the owner of a dental hygiene practice.