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Readers' Forum

July 1, 2003
I want to commend Dr. Doniger for an excellent and timely article on sun exposure, as well as add some important reference Web sites to her list.

Be ever vigilant against skin cancer

Dear RDH,
I want to commend Dr. Doniger for an excellent and timely article on sun exposure, as well as add some important reference Web sites to her list. The first is, which was developed by my husband as a memorial tribute to our 26-year-old son, Dan, who lost his life to melanoma on October 10, 1998. The Web site has had more than 400,000 visitors in the four years it has been online. In 1999, it was personally e-mailed to every college in this country and has since evolved into a high school health curriculum used by over 75 high schools in Massachusetts where we reside.

With it, readers can receive a very thorough lesson in checking their own skin to detect skin cancer at its earliest and most curable stage.

I must reiterate Dr. Doniger's statistics. Melanoma is the highest rising cancer in young people under age 30, and there are more new cases diagnosed annually (53,000 predicted this year) than new cases of HIV-Aids infections (50,000). As health-care professionals, we usually see our patients more often than they see their primary care physicians. Therefore, we should alert them to any changes we notice in moles on any exposed body parts — the face, neck, hands, and sometimes arms and legs. We should discourage tanning and refer our patients to, a very informative site about safe tanning alternatives such as sunlesss bronzers and mist-on tanning.I also recommend a contemporary clothing catalog company, Sun Solutions, in Falmouth, Mass., devoted entirely to apparel that is very tightly woven and has SPF built in. The online address is www.sunsolutionscloth

Finally, I would like to make one correction to Dr. Doniger's definition of UVA and UVB rays. UVA are the more deeply penetrating ultraviolet rays found in tanning lamps. UVB (B for burn) are those that cause sunburns. Not the other way around as was described. In any case, we want to avoid red (from sunburn) or brown ( from tan) on our skin if we want this organ, the largest in the body, to stay healthy.

Gail Sandler Fine, RDH, BS
Stephen A. Fine, PhD
President, Melanoma Education Foundation
Peabody, Massachusetts

Examples of EBDM questioned

Dear RDH:
An article published in the May 2003 issue of RDH titled, "Solving Puzzling Clinical Questions," by Denise Bowen, RDH, MS, and Jane Forrest, RDH, EdD, intended to demonstrate the use and discuss the benefits of "Evidence-Based Health Care" (EBHC). The article intended to encourage "evidence-based decision making" (EBDM) by illustrating a method of scientific searches using "oscillating vs. sonic toothbrushes" as an example. Five times within the text of the article references were made to Braun Oral B; however, manufacturers of other toothbrushes were never mentioned.

The article suggests that practitioners should use EBHC as "scientific evidence to make decisions that maximize the potential of successful patient care outcomes." The use of a model developed by the National Center for Dental Hygiene Research for EBDM demonstrated a method known as Patient or Problem, Intervention, Comparison, and Outcomes (PICO) using an online literature search via PubMed. The PICO model aids in finding "credible information" to make decisions regarding new technologies, treatment modalities, and oral health products.

The following example was used to demonstrate EBDM using the PICO method via PubMed: "For patients with dental deposits and periodontal disease [P], do oscillating (Oral B) [I] as compared to sonic [C] toothbrushes better reduce deposits and periodontal disease [O]?" Key words or phrases and limitations are used in conducting such online searches. The search was based on the following key words, "powered toothbrushes AND oscillating or sonic AND dental deposits AND periodontal disease," and limited to the past six years, the English language, humans, and randomized controlled trials.

The authors state that six abstracts and bibliographic references appeared directly answering the example question. When closely reviewing the six abstracts, only one study reflects a comparison between oscillating and sonic toothbrushes. That study was a crossover design evaluating calculus and gingivitis, which may not be the most appropriate design in evaluating a gingival health measure and calculus. Another study had only eight subjects. A sample size of eight subjects is too small to make scientific evidence based decisions regarding the validity of a product's performance. Another study (Zimmer et al) compared ultrasonic and manual toothbrushes, which are neither oscillating nor sonic. The other studies were comparisons between two different sizes of brush heads for a sonic toothbrush, and studies comparing powered toothbrushes and manual toothbrushes, some which are not valid for making a decision between the two toothbrushes.

Care needs to be taken when conducting such searches and interpreting the results. Depending on the key words or phrases and limitations selected for searches can drastically affect the outcome of the search. For example, if the key words/phrase "dental deposits" was deleted and the key words/phrase "periodontal disease" was replaced with "periodontal health," the search would have produced different abstracts than those listed in the article comparing oscillating and sonic toothbrushes. Searching for key words/phrases not included in the abstract will not include pertinent articles.

When conducting such searches, care needs to be given in the use of logic terms — terms that connect keywords/phrases, such as AND, OR, or NOT. The use of connecting words can have a direct effect on the outcome of the search. The more limits and specifications used, the more narrow the search. Searching for articles is only as good as the key words/phrases and logic terms used in the search.

Another consideration is interpreting the results of the search. In reviewing research articles for EBDM, some important elements to consider are:

• The number of subjects enrolled in the study (should be sufficient to produce valid results)
• The study design (should be appropriate to evaluate the research question)
• Controlling factors to reduce bias (subjects randomized to treatment, the examiner blinded to treatment, all groups given equal training, etc.)
• The results (should show statistical significance and clinical relevance)

The authors also made reference to the Cochrane Collaboration, which publishes evidence-based reviews in all areas of health care including oral health. Recently, the Cochrane Group published a review of manual vs. powered toothbrushes using a meta-analysis. The authors made a statement that meta-analysis is the highest and most credible form of evidence. Meta-analysis is simply the analysis of statistical analyses and is only as good as the studies that are analyzed.

After reviewing the Cochrane review, the authors of the RDH article compare their findings to the Cochrane review and conclude similar results. Indeed, the two research questions are distinctly different (oscillating /sonic comparison vs. powered toothbrush/manual comparison) thus invalidating any comparison of the results.

Using evidence in support of decision-making remains the goal of the health-care community, including the dental professional. Let's be certain, however, that we are applying a thorough examination of the evidence, and that valid results aren't being discarded from our analysis. The results of Internet searches should be interpreted and used with care. Dental professionals should recommend powered toothbrushes to patients based not only on published studies but also on improved oral health and hygiene, increased patient compliance and satisfaction, and clinical expertise as demonstrated by their personal experience.

Katherine Ortblad, RDH, MHA
Director of Clinical Research
Philips Oral Healthcare, Inc.
Snoqualmie, Washington

More information about needlestick rules

Dear RDH:
After reading "The Point" in the May 2003 issue, I felt I should respond in order to save dental offices additional stress and headaches. As a health and safety consultant who assists employers in many OSHA areas, it is important to make a clarification. The authors discussed some of the aspects of the new Needlestick Safety and Prevention Act, which was signed into law on Nov. 6, 2000, and was included in the modification to OSHA's revised Bloodborne Pathogens Standard that took effect on April 18, 2001.

As with many of OSHA's rules, one needs to read all areas of a standard that are referenced in the main text. The new revisions to the Bloodborne Pathogens Standard include information in the Non-mandatory Appendix A to Subpart B for Partially Exempt Industries. Employers are not required to keep OSHA injury and illness records for any establishment classified in the partially exempt industries, dental offices and dental labs being in this category. The Standard Industrial Code (SIC) for dental offices is 802 and dental laboratories is 807. The exemption also may apply if the employer has 10 or less employees. If at any time during the calendar year the employee count is above 10, then the employer must document injuries and illnesses on the appropriate 300 series forms that went into effect in January 2002.

With that being said, if employers are exempt from record-keeping, they are also exempt from maintaining a sharps injury log. This does not preclude them from annually researching and documenting the research results for safer devices, and the justifications for their decisions. Even though employers may be exempt from all of this extra work, I would still recommend that injuries (including needlesticks) be recorded as a source of information for the employer and employee. Any problems arising from an injury or illness can best be covered under Workers' Compensation and health insurance when armed with complete documentation.

Most employers are required to maintain the injury and illness logs for five years. Exempt employers may be contacted by mail, usually during the month of October each year, by OSHA requesting documentation of injuries and illnesses for the coming calendar year. Whether or not an employer is contacted, maintaining records for your office helps determine if there are trends of injuries or illnesses that indicate a need for attention.

A comment that I take issue with in this article referred to OSHA as being the "enemy." In OSHA's defense, I would hope that all employees realize that OSHA is on their side, and only exists to protect employees. All of the standards that are promulgated have been done so based on historic information on injuries and illnesses. The standards are developed to address problems that have occurred nationally. OSHA's mission is to ensure safe and healthy workplaces in America. Since the agency was created in 1971, workplace fatalities have been cut in half and occupational injury and illness rates have declined 40 percent. At the same time, U.S. employment has doubled from 56 million workers at 3.5 million work sites to 111 million workers at 7 million work sites. The rules are developed for a reason. The office staff written about in this article was surprised that they had a say in researching and choosing better devices. OSHA has always encouraged employee participation, and this rule change reflects that.

Hopefully, this information is useful to all of the offices out there trying to meet their compliance responsibilities.

Sharon Roman, RDH
President, Regulatory Compliance Consultants, Inc.
Sylvania, Ohio

About the cover
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Deborah Sparks is busy celebrating a couple of 20-year anniversaries this year. The most important one is coming up in December — 20 years with her husband, Gene. But the Phoenix resident also waxes nostalgic about the other anniversary, which occurred last month — "practicing clinical hygiene for 20 continuous years," as she puts it.

In fact, if any former classmates from those final days at Foothill College in Los Altos Hills, Calif., in June 1983 are still around, feel free to drop her a line at deb [email protected]. In the meantime, we'll fill you in on the details. Her marriage nixed some dreams for a dental hygiene adventure in Switzerland, so she practiced for 11 years in northern California before the family relocated to Arizona. For the last six years, she has practiced in the offices of Dr. Dale Steiner in the Phoenix suburb of Chandler. Currently, she works two days a week and devotes the rest of the time to activities involving her two sons, Daniel, 13, and Kevin, 10.

"Though I now spend as much time volunteering at my children's schools as I practice hygiene, I have acheived harmony in the balance between my professional life and being a Mom."

She still enjoys traveling, going to Paris with her mother last year and to New York City with her family this summer. The Sparks crew also spends many weekends camping and hiking in nearby Arizona parks.

"I know that one day I would like to once again volunteer my hygiene skills, or maybe finally work abroad. Either way, my career still offers me much to look forward to."

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