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1 Persons includes young persons and children

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with gastroesophageal reflux disease.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Gastroesophageal Reflux Disease, 2016-10-01

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

G a s t r o e s o p h a g e a l r e f l u x d i s e a s e

INTENDED USERS

Advanced practice nurses Dental assistants Dental hygienists Dentists Denturists Dieticians Health professional students

Nurses Patients/clients Pharmacists Physicians Public health departments Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have gastroesophageal reflux disease, chiefly as follows. 1. Understanding the medical condition.2. Sourcing medications information.3. Taking the medical and medications history.4. Identifying and contacting the most appropriate healthcare provider(s) for medical

advice.

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5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.

6. Deciding when and when not to proceed with the Procedures proposed. 7. Dealing with adverse events arising during the Procedures. 8. Keeping records. 9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years) Adolescent (13 to 18 years) Adult (19 to 44 years) Middle Age (45 to 64 years) Aged (65 to 79 years) Aged 80 and over Male Female

Parents, guardians, and family caregivers of children, young persons and adults with gastroesophageal reflux disease.

MAJOR OUTCOMES CONSIDERED

For persons who have gastroesophageal reflux disease: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory

Resources consulted Gastroesophageal Reflux Disease: Medscape Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease

(GERD): National Digestive Diseases Information Clearinghouse Management of gastro­oesophageal reflux disease in general practice: British Medical

Journal (payment required for full article)

Gastroesophageal reflux disease (GERD) is a severe, ongoing form of gastroesophageal reflux, in which food and digestive fluids, such as hydrochloric acid, that constitute the stomach contents 1. leak backwards from the stomach into the esophagus 2. irritate the esophagus, causing heartburn, among other symptoms.

Other terminology is as follows.

1. Acid indigestion, an alternative term for heartburn, a common symptom of gastroesophageal reflux disease and gastroesophageal reflux.

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2. Acid reflux, alternative term for gastroesophageal reflux. 3. Acid regurgitation, alternative term for gastroesophageal reflux. 4. Atopic asthma, linked with allergic reactions, hence non­atopic asthma, asthma for

which no allergies have been identified and the cause of the airway inflammation is unclear (CDHO Advisory).

5. Gastroesophageal reflux, which is common, occurs when stomach contents leak backwards from the stomach into the esophagus, which

a. occurs when the lower esophageal sphincter opens spontaneously, for varying periods of time, or does not close properly, so that stomach contents pass into the esophagus

b. causes digestive fluids, such as hydrochloric acid, to pass into the esophagus. 6. Gastroesophageal reflux disease is a more serious, ongoing form of gastroesophageal

reflux, in which stomach contents back up a. in adults, usually producing heartburn that occurs more than twice per week b. in children under 12 years, often producing not heartburn but

i. dry cough ii. asthma symptoms (CDHO Advisory)

iii. trouble swallowing c. leading eventually to more serious problems.

7. Globus sensation, persistent or intermittent painless sensation, occurring between meals, of a lump or foreign body in the throat.

8. Heartburn, a burning pain in the chest, starting behind the sternum and moving up to the neck and throat, lasting up to two hours.

9. Hiatal hernia, when part of the stomach moves above the diaphragm. 10. pH, a measure of acidity. 11. Reflux esophagitis, alternative term for gastroesophageal reflux disease. 12. Scleroderma, a connective tissue disease that

a. involves changes in the skin, blood vessels, muscles, and internal organs b. is a type of autoimmune disorder.

Overview of gastroesophageal reflux disease

Resources consulted Gastroesophageal Reflux Disease: eMedicineHealth Gastroesophageal Reflux Disease: Medscape Gastroesophageal Reflux in Children and Adolescents: National Digestive Diseases

Information Clearinghouse Gastroesophageal Reflux in Infants: National Digestive Diseases Information

Clearinghouse GERD: Canadian Digestive Health Foundation GERD: Mayo Clinic Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease

(GERD): National Digestive Diseases Information Clearinghouse Management of gastro­oesophageal reflux disease in general practice: British Medical

Journal (payment required for full article)

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Occurrence Gastroesophageal reflux disease 1. is experienced by as many as one third of the Canadian population 2. occurs in

a. adults b. children c. during pregnancy (CDHO Advisory).

3. is associated with persistent acid reflux, which may damage the esophagus 4. negatively affects well­being and quality of life

a. on measures of pain, mental health, and social function b. creating consequences that constitute one risk factor that is taken into account

in treatment decisions; physical complications comprise the other 5. may be related to sleep apnea (CDHO Advisory), a potentially dangerous condition.

Cause

1. Gastroesophageal reflux disease a. may be linked to

i. genetic factors, through a family history of upper gastrointestinal disease associated with gastroesophageal reflux disease

ii. lifestyle factors iii. immune system response

b. appears to result from the action of the lower esophageal sphincter, which i. separates the esophagus from the stomach

ii. fails to close sufficiently thereby allowing reflux, a dysfunction which sometimes occurs in conjunction with hiatus hernia

2. Heartburn and gastroesophageal reflux may be caused or exacerbated by a. pregnancy (CDHO Advisory) b. medications, such as

i. anticholinergics for bronchodilation in asthma ii. beta­blockers for high blood pressure or heart disease

iii. calcium channel blockers for high blood pressure iv. dopamine­active drugs for Parkinson's disease v. progestin for abnormal menstrual bleeding or birth control

vi. sedatives for insomnia or anxiety vii. tricyclic antidepressants.

Risk factors

Gastroesophageal reflux disease and gastroesophageal reflux risk factors include 1. alcohol, though the link is not yet fully established 2. hiatal hernia 3. obesity 4. pregnancy 5. scleroderma 6. Smoking.

Signs and symptoms

Signs and symptoms of gastroesophageal reflux disease and gastroesophageal reflux 1. are associated with those that

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a. are described as heartburn, which i. is most common or more severe at night

ii. is variously increased by bending, stooping, lying down, or eating iii. is relieved by antacids iv. may be less effective as the basis for a question in history­taking aimed

at identifying gastroesophageal reflux disease than a direct question regarding ‘a burning feeling rising from the stomach or lower chest up towards the neck’

b. recur persistently c. are chiefly caused by reflux of acid, such as hydrochloric acid, against which the

esophagus is not as well protected as the stomach d. may be described as fluid or food with a sour taste regurgitated into the mouth,

experienced or exacerbated when bending over or lying down e. may less commonly be described by adults with gastroesophageal reflux disease

as i. difficult or painful swallowing manifested by a feeling that food is

lodged behind the sternum ii. heartburn

iii. hiccups iv. hoarseness v. nausea after eating

vi. persistent dry cough vii. persistent sore throat

viii. tightness in the throat, as if a piece of food is stuck ix. uncomfortable fullness after meals x. unexplained chest pain

xi. wheezing, asthma f. are unrelated to physical activity.

2. may resemble those of myocardial infarction (CDHO Advisory). Medical investigation

Medical investigation of gastroesophageal reflux disease and gastroesophageal reflux 1. is required if symptoms

a. worsen or do not improve with lifestyle changes or medication. b. are severe or frequent c. cause the person to seek relief more than twice per week, from over­the­

counter medications for heartburn d. involve

i. appetite, loss ii. bleeding

iii. choking, coughing, shortness of breath iv. fullness feeling, develops rapidly during eating v. hoarseness

vi. swallowing, difficult or painful vii. vomiting, frequent

viii. weight loss 2. in children involves an important distinction between normal physiological reflux and

gastroesophageal reflux disease, which

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a. may be indicated if regurgitation continues past the first year of age b. has as its most common symptoms repeated vomiting, coughing, and other

respiratory problems c. may be signaled by irritability or arching of the back, often during or

immediately after feeding d. may be overlooked or confused with

i. repeated regurgitation ii. dyspepsia i. nausea

ii. heartburn iii. coughing iv. laryngitis v. wheezing, asthma, or pneumonia

e. may lead to feeding problems that impair growth. 3. lacks a single, accurate and specific test, and so variously requires tests such as

a. barium swallow radiograph to detect i. hiatus hernia

ii. esophageal strictures iii. ulcers

b. endoscopy, to directly inspect the inner surface of the esophagus c. biopsy d. pH monitoring over 24 to 48 hours to track when and how much acid is

regurgitated and the relation with i. eating

ii. respiratory symptoms triggered by reflux e. measurement of the pressure inside the lower part of the esophagus f. stool occult blood test to detect bleeding originating with the irritation in the

esophagus, stomach, or intestines. Treatment

Gastroesophageal reflux disease and gastroesophageal reflux treatment 1. commonly includes self­treatment with antacids or other over­the­counter acid­

suppressing medications 2. in most persons requires long­term management, the success of which is largely judged

by changes in symptoms 3. begins with lifestyle and dietary changes, which may help the person to avoid specific

foods and beverages that provoke heartburn and be of benefit to health generally a. but these

i. rarely remove the need for acid suppression ii. have little or no effect on the gastroesophageal reflux disease itself

b. include i. avoiding

1. coffee and alcohol beverages 2. foods, such as

a. chocolate b. citrus fruits and juices c. fatty and fried foods d. garlic and onions

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e. pepper, mustard, and vinegarf. peppermint and mint flavouringsg. spicy foodsh. tomato­based foods, like spaghetti sauce, salsa, chili,

and pizza3. large portions at mealtime; smaller and more frequent meals

may better control symptoms4. lying down immediately after eating5. eating within two to three hours before bedtime

ii. elevating the head of the bed four to six inchesiii. losing weightiv. stopping smoking

4. may require medications, whicha. suppress or neutralize gastric acid secretion, but do not treat the reflux itself, a

continuing challengeb. may be used to substantiate a diagnosis of gastroesophageal reflux diseasec. to maintain symptom control may require

i. increasing dosage over timeii. change of medication

d. should avoid aspirin and NSAIDs for pain management5. may require anti­reflux surgery, such as fundoplication.

Prevention Prevention of gastroesophageal reflux disease and gastroesophageal reflux relies on the same measures used for the prevention of heartburn.

Prognosis The prognosis of gastroesophageal reflux disease and gastroesophageal reflux 1. is good in that most persons respond to lifestyle changes and medications, though

a. many persons need to continue taking drugs to control their symptomsb. as the conditions progress, some persons may require surgery to correct the

anatomical defect at the gastroesophageal junction that affects the loweresophageal sphincter

2. may be adversely affected by serious complications.

Social considerations Gastroesophageal reflux disease creates social considerations in the care of children because of 1. the important distinction between normal physiological reflux and gastroesophageal

reflux disease2. need for careful advice to parents concerned about a child’s symptoms.

Multimedia and images

Digestive system Gastroesophageal reflux disease Upper gastrointestinal system

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Comorbidity, complications and associated conditions

Comorbid conditions are those which co­exist with gastroesophageal reflux disease but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice.

Comorbid conditions, complications and associated conditions for gastroesophageal reflux disease 1. include serious complications, such as

a. esophagitis, resulting from too much stomach acid in the esophagus, which may lead to bleeding or ulcers in the esophagus

b. strictures, which may narrow the esophagus and interfere with swallowing c. Barrett’s esophagus, severe damage to the cells lining the lower part of the

esophagus, which may increase the risk of esophageal cancer, for which surveillance endoscopy may be recommended

d. exacerbating or contributing to asthma (CDHO Advisory), chronic cough, and pulmonary fibrosis.

2. may be signalled by symptoms, such as a. typical symptoms

i. adults: heartburn ii. children under 12 years

1. dry cough 2. asthma symptoms 3. swallowing difficulties

b. atypical symptoms, such as i. dysphagia

ii. globus sensation iii. non­cardiac chest pain iv. dyspepsia v. abdominal pain

c. symptoms or signs originating outside the esophagus that i. are attributed to gastroesophageal reflux disease following

investigation ii. may improve in response to treatment of the gastroesophageal reflux

disease, such as 1. dental erosion 2. sleep apnea (CDHO Advisory); treatment of gastroesophageal

reflux disease may reduce sleep disorders, snoring, and daytime sleepiness

3. hoarseness or sore throat, or both iii. sinusitis iv. otitis media v. chronic cough

vi. laryngitis or polyps on the vocal cords, or both vii. non­atopic asthma (CDHO Advisory), which may be associated with so­

called ‘silent aspiration’ of 1. neutralized stomach acid refluxed into the esophagus, lungs,

mouth or nasal cavities

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2. other caustic agents, including bile, pepsin and digestive enzymes

viii. recurrent aspiration or pulmonary fibrosis, or both d. symptoms associated with lifestyle factors, such as

i. alcohol use (CDHO Advisory) ii. obesity, with its association with dietary factors that increase the risk of

reflux, such as the consumption of larger meals and rich, energy­dense foods (CDHO Advisory)

iii. smoking. Oral health considerations

Resources consulted Dental Erosion in Gastroesophageal Reflux Disease: Canadian Dental Association Journal What Is the Critical pH and Why Does a Tooth Dissolve in Acid?: Canadian Dental

Association Journal

1. Dental erosion a. may be the first sign of gastroesophageal reflux disease; the patient/client may

well be aware of symptoms but unaware of their significance. b. when recognized during oral healthcare, apparently for the first time, the

patient/client should be i. referred to the primary care provider for further investigation into the

possibility of gastroesophageal reflux disease or other medical conditions

ii. offered 1. oral healthcare, such as

a. plaque control b. therapies for remineralization of enamel

2. advice on a. oral hygiene b. lifestyle and diet

iii. referred for dental advice c. if not recognized by the time of adolescence, the progressive loss of hard dental

tissues caused by a chemical process not involving bacterial action may lead to damage that, in early adulthood, is more severe and more difficult to treat

d. is governed by the critical pH below which enamel dissolves, which i. is inversely proportional to the concentrations of calcium and

phosphate in the saliva and plaque fluid ii. means that teeth

1. with early subsurface caries lesions can be remineralized 2. that have suffered acid erosion cannot be remineralized.

2. Pain management, which should a. avoid NSAIDs such as

i. aspirin ii. ibuprofen (Advil®, Motrin®)

iii. naproxen (Aleve®, Naprosyn®) b. consider acetaminophen (many brand over­the­counter versions).

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MEDICATIONS SUMMARY

Sourcing medications information

1. Adverse effect databases Health Canada’s Marketed Health Products Directorate toll­free 1­866­234­2345 Health Canada’s Drug Product Database

2. Specialized organizations US National Library of Medicine and the National Institutes of Health Medline Plus

Drug Information WebMD

3. Medications considerations All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over­the­counter (OTC) or herbal medications.

4. Information on herbals and supplements US National Library of Medicine and the National Institutes of Health Medline Plus Drug Information All Herbs and Supplements

5. Complementary and alternative medicine National Center for Complementary and Alternative Medicine

Types of medications

Neither over­the­counter nor prescription medications slow or prevent the progression of gastroesophageal reflux disease because they do not treat the reflux itself.

Pain management should avoid the use of aspirin and NSAIDS.

Approaches to medication for gastroesophageal reflux disease include 1. over­the­counter antacids, often tried initially as self­medication, which

a. provide rapid short­term or partial relief from, but do not prevent heartburn b. signal the need for advice from the primary care provider if they continue to be

taken for more than three weeks c. comprise various combinations of magnesium, calcium, and aluminum as the

hydroxide or bicarbonate d. may have side effects such as diarrhea and constipation e. include Alka­Seltzer® Gas Relief Maximum Strength Softgels® Gaviscon® Maalox® Mylanta® Pepto­Bismol® Riopan® Rolaids® Titralac® Tums®

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2. proton pump inhibitors, which a. block an enzyme necessary for production of stomach acid b. are the most effective medications in blocking stomach acid c. include esomeprazole (Nexium®) lansoprazole (Prevacid®) omeprazole (Prilosec®, Losec®) pantoprazole (Pantoloc®) rabeprazole (AcipHex®, Pariet®)

3. H2­receptor antagonists, which a. block histamine’s stimulation of production of acid by certain cells of the

stomach b. are considered safe but less efficacious than proton pump inhibitors c. include

i. prescription only cimetidine (Tagamet®) famotidine (Pepcid®) nizatidine (Axid®) ranitidine (Zantac®)

ii. over­the­counter low­dose versions of prescription­only H2­receptor antagonists.

Side effects of medications

Resources consulted Long­term Proton Pump Inhibitor Therapy and Risk of Hip Fracture: Journal of the

American Medical Association Use of proton pump inhibitors and risk of osteoporosis­related fractures: Canadian

Medical Association Journal 1. Long­term proton­pump medications, particularly at high doses, are associated with an

increased risk of hip fracture associated with osteoporosis. 2. The advisability of suppressing a physiological function as fundamental as stomach acid

production is contested by some experts. 3. Up to 40 percent of patients taking a proton pump inhibitor once daily develop

refractory gastroesophageal reflux disease, leading to dissatisfaction of some patients with their medications, though poor compliance may be a factor.

See the links above to the specific medications.

THE MEDICAL AND MEDICATIONS HISTORY

The dental hygienist in taking the medical and medications history­taking should 1. focus on screening the patient/client prior to treatment decision relative to

a. key symptoms b. medications considerations c. contraindications d. complications

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e. comorbidities f. associated conditions

2. explore the need for advice from the primary or specialized care provider(s) 3. inquire about

a. symptoms indicative of inadequate control of gastroesophageal reflux disease, such as heartburn

b. dental erosion c. the patient/client’s understanding and acceptance of the need for oral

healthcare d. medications considerations, including over­the­counter medications, herbals

and supplements e. problems with previous dental/dental hygiene care f. problems with infections generally and specifically associated with

dental/dental hygiene care g. the patient/client’s current state of health h. how the patient/client’s current symptoms relate to

i. oral health ii. health generally

i. recent changes in the patient/client’s condition.

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

The dental hygienist should 1. record the name of the physician/primary care provider most closely associated with

the patient/client’s healthcare, and the telephone number 2. obtain from the patient/client or parent/guardian written, informed consent to contact

the identified physician/primary healthcare provider 3. use a consent/medical consultation form, and be prepared to fax the form to the

provider 4. include on the form a standardized statement of the Procedures proposed, with a

request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to 1. the CDHO’s Infection Prevention and Control Guidelines (2019) 2. relevant occupational health and safety legislative requirements 3. relevant public health legislative requirements 4. best practices or other protocols specific to the medical condition of the patient/client.

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DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

In an otherwise healthy patient/client with well controlled symptoms there is no contraindication to the Procedures.

The dental hygienist may postpone the Procedures pending medical advice if the patient/client 1. appears insufficiently aware of the significance of protracted symptoms of

gastroesophageal reflux disease 2. appears debilitated 3. has recently changed significant medications, under medical advice or otherwise 4. has recently experienced changes in his/her medical condition such as medication or

other side effects of treatment 5. is deeply concerned about any aspect of his or her medical condition.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s , and as appropriate for the condition of Standards of Practicethe patient/client.

First­aid provisions and responses as required for current certification in first aid.

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of gastroesophageal reflux disease, the dental hygienist should specifically record 1. a summary of the medical and medications history 2. any advice received from the physician/primary care provider relative to the

patient/client’s condition 3. the decision made by the dental hygienist, with reasons 4. compliance with the precautions required 5. all Procedure(s) used 6. any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The dental hygienist should 1. urge the patient/client to alert any healthcare professional who proposes any

intervention or test a. that he or she has a history of gastroesophageal reflux disease b. to the medications he or she is taking

2. should discuss, as appropriate a. referral for medical advice if the dental hygienist believes that dental erosion

indicates unrecognized gastroesophageal reflux disease b. lifestyle and dietary changes, including the need for regular oral health

examinations and preventive oral healthcare c. the importance of the patient/client’s

i. self­checking the mouth regularly for suspicious signs or symptoms

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ii. reporting to the appropriate healthcare provider any changes in themouth indicative of suspicious lesions

d. the need for regular oral health examinations and preventive oral healthcaree. oral healthcare in the home for family caregivers with childrenf. oral self­care including information about

i. choice of toothpasteii. tooth­brushing techniques and related devices

iii. dental flossingiv. mouth rinsesv. management of a dry mouth

g. comfort level while reclining, and stress and anxiety related to the Proceduresh. medication side effects such as dry mouth, and recommend treatment.i. mouth ulcers and other conditions of the mouth relating to gastroesophageal

reflux disease, comorbidities, complications or associated conditions,medications or diet

j. pain management.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

1. Promoting health through oral hygiene for persons who have gastroesophageal refluxdisease.

2. Reducing the adverse effects, such as progressive loss of hard dental tissues bya. early detection of dental erosion, especially in childrenb. oral healthcare, such as plaque controlc. generally increasing the comfort level of persons in the course of dental hygiene

interventionsd. using appropriate techniques of communicatione. providing advice on scheduling and duration of appointments.

3. Reducing the risk that oral health needs are unmet.

POTENTIAL HARMS

1. Failing toa. recognize dental erosionb. consider gastroesophageal reflux disease and advise the patient/client

appropriately.2. Performing the Procedures at an inappropriate time, such as in the presence of

complications for which prior medical advice is required.3. Disturbing the normal dietary and medications routine of a person with

gastroesophageal reflux disease.4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

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ORIGINALLY DEVELOPED

2010­07­15

DATE OF LAST REVIEW

2012-02-01; 2016­10­01

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow MD, MHSc, MBA, DTM&H, CHE, CCFP, DABPM, LFACHE, FCFP, FACPM, FRCPC

Lisa TaylorRDH, BA, MEd

Roula Anastasopoulos RDH, BEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande Final layout and proofreading

COPYRIGHT STATEMENT

© 2010, 2012, 2016 College of Dental Hygienists of Ontario