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CDHO Advisory: Sjögren Syndrome

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CDHO ADVISORY

SCOPE

RECOMMENDATIONS

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

CONTRAINDICATIONS

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 Sjögren syndrome.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Sjögren syndrome, 2020-05-04

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)

Sjögren syndrome

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 Sjögren syndrome, 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.
  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. Record keeping.
  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 or guardians of children and young persons with Sjögren syndrome.

MAJOR OUTCOMES CONSIDERED

For persons who have Sjögren syndrome: 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

Nomenclature of Sjögren syndrome

Adapted from

Sjögren syndrome

  1. is an autoimmune disorder
  2. commonly presents with the sicca symptoms
    1. xerostomia
    2. xerophthalmia
  3. is defined as one of two forms, which occur with equal frequency, and which may be difficult to distinguish
    1. primary Sjögren syndrome, which exists in the apparent absence of any other autoimmune disorder, and which 
      1. is characterized by progressive decrease of gland function leading to
        1. xerostomia
        2. xerophthalmia
      2. may be associated with various conditions that occur in tissues other than glands, including
        1. abnormally low white cell count
        2. anemia (CDHO Advisory)
        3. arthritis (CDHO Advisory)
        4. enlargement of lymph glands
        5. gastrointestinal disease
        6. joint pain 
        7. lymphoma (CDHO Advisory)
        8. muscle pain
        9. peripheral nerve disorders
        10. pulmonary disease
        11. Raynaud’s phenomenon
        12. renal tubular acidosis
        13. vasculitis
    2. secondary Sjögren syndrome
      1. when it arises secondarily to an autoimmune disorder such as
        1. rheumatoid arthritis (CDHO Advisory)
        2. systemic lupus erythematosus (CDHO Advisory)
        3. scleroderma
      2. is accompanied by xerostomia and xerophthalmia though these may be less severe than in primary Sjögren’s syndrome.

Other terminology includes

  1. Angular cheilitis, angular stomatitis. Painful condition of the corners of the mouth, associated with wrinkled or fissured epithelium, which
    1. does not involve the mucosa
    2. is caused by inflammation that may be associated with candidiasis.
  2. Autoantibodies. Abnormal antibodies that 
    1. are associated with autoimmune disorders
    2. erroneously attack specific tissues or organs of the body
    3. fail to distinguish ‘self’ from ‘non-self’.
  3. Autoimmune hepatitis. A condition in which the immune system attacks liver cell causing inflammation of the liver. 
  4. Candidiasis, oral candidiasis, thrush. Infection of the mouth caused by the Candida fungus, which is also known as yeast.
  5. Erythematous. Pertaining to erythema, redness of the skin, caused by capillary congestion, among many things.
  6. Epstein-Barr virus. A common virus that 
    1. remains dormant in most people
    2. causes infectious mononucleosis
    3. has been associated with lymphoma (CDHO Advisory).
  7. Fibrosis. The formation of excessive fibrous tissue, also known as scar tissue.
  8. HIV/AIDS. A disease called acquired immunodeficiency syndrome (AIDS) caused by the human immunodeficiency virus (HIV).
  9. Hyposalivation. Reduction in salivary output causing dry mouth associated with 
    1. advancing age
    2. medications
    3. various systemic diseases, including Sjögren syndrome.
  10. Mucosal sloughing. Dead cells peeling off from the mucosa.
  11. Mumps. A disease caused by a virus that 
    1. usually spreads through saliva 
    2. can infect the
      1. parotid glands
      2. other parts of the body.
  12. Raynaud’s phenomenon. A condition of fingers and/or toes that 
    1. arises from abnormal spasm of the blood vessels, which diminishes the blood supply to the local tissues after 
      1. exposure to changes in temperature
      2. emotional events 
    2. is characterized by a particular sequence of skin discolorations: on exposure to cold temperature the digit(s) involved successively
      1. turn white because of diminished blood supply
      2. turn blue because of prolonged lack of oxygen
      3. turn red because the blood vessels reopen, causing a local flushing.
  13. Rheumatoid factor. A specific antibody that is
    1. measurable in the blood
    2. able to bind to other antibodies.
  14. Saliva’s protective role includes
    1. inhibiting dental caries and retarding calculus formation by 
      1. reducing dental demineralization
      2. promoting remineralization
      3. maintaining a physiological oral acidity
    2. maintaining the coating and lubrication of the oral mucosa, which facilitates
      1. speech
      2. mastication and swallowing
      3. taste perception and, indirectly, nutritional status (CDHO Advisory) 
    3. combating infection with salivary enzymes
    4. forming the salivary pellicle
    5. facilitating the effectiveness of sublingually administered medications.
  15. Salivary pellicle. A thin, naturally occurring biofilm formed from salivary proteins that
    1. forms on 
      1. dentures
      2. mucosal surfaces in the oral cavity
      3. restorations
      4. teeth
    2. provides
      1. a physical barrier for protecting the underlying structures
      2. lubrication to facilitate oral functions
    3. reforms within minutes when brushed away 
    4. lubricates and protects the underlying surface
      1. for teeth
        1. protects enamel
        2. provides a base for plaque formation
        3. is associated with staining
      2. of other parts of the oral cavity
    5. is impaired when salivary secretion is diminished, which deprives the teeth and oral cavity of protection, causing vulnerability to
      1. mucosal allergies to various foods, beverages, dental hygiene products and dental materials 
      2. traumatic ulcers, especially of the tongue and cheeks, because of lack of lubrication
      3. various chemical and microbiological threats
      4. increased dental caries.
  16. Sedimentation rate, erythrocyte sedimentation rate, ESR. Common blood test used to detect and monitor inflammation in the body. 
  17. Scleroderma. A group of autoimmune disorders characterized by fibrosis in the skin and organs of the body.
  18. Sialadenitis. Infection, often recurrent, of the salivary glands caused by oral bacteria which migrate into the salivary glands because of diminished salivary flow.
  19. Sialogogue. A medication that stimulates the flow of saliva.
  20.  Sicca syndrome. A term reserved for the combination of dryness of the mouth and eyes, regardless of cause. 
  21. Thyroiditis. Inflammation of the thyroid gland.
  22. Vasculitis. A general term for a group of uncommon diseases characterized by inflammation in and damage to the walls of various blood vessels.
  23. Xerophthalmia. Abnormal dryness of the conjunctiva and cornea of the eyes.
  24. Xerostomia. Abnormal dryness of the mouth resulting from decreased secretion of saliva; has various causes apart from Sjögren syndrome.

Overview of Sjögren syndrome

Adapted from

Sjögren syndrome

  1. Is the second most common autoimmune rheumatic disorder, which
    1. in the combined primary and secondary forms is estimated to affect 
      1. up to one percent of the population in the United States
      2. up to 430,000 Canadians
    2. predominantly affects women, who account for about 90 percent of diagnoses 
    3. occurs at all ages, but typically between 30 and 50 years of age.
  2. In both its primary form and secondary form exhibits
    1. xerostomia, the symptoms and signs of which include
      1. frequent use of water, chewing gum and candy for sucking
      2. burning mouth, often associated with candidiasis 
      3. dental decay
      4. gingivitis
      5. periodontitis
      6. halitosis
      7. discomfort with dentures
      8. mouth sores
      9. recurrent sialadenitis
      10. tongue problems, such as
        1. clicking during speaking
        2. discomfort and pain
      11. lips that
        1. are dry
        2. stick to the teeth
      12. swallowing and chewing difficulty, sometimes severe, associated with
        1. dry food unaccompanied by liquid
        2. intolerance of certain foods and beverages
        3. changes in taste
      13. fissures at the angles of the mouth
    2. xerophthalmia, the symptoms and signs of which
      1. include
        1. diminished tear production
        2. dryness requiring artificial tears at least 3 times a day
        3. sensation of gravel or foreign body on the conjunctiva
        4. eyelids that are
          1. stuck together on waking from sleep
          2. exhibit crusting and debris among the eyelashes
          3. adhere to the cornea
        5. conjunctival and corneal
          1. infection
          2. abrasion
        6. discomfort with 
          1. bright light
          2. air drafts
      2. are related to
        1. eye gland destruction
        2. diminished response to nerve impulses
    3. may involve
      1. digestive organs
      2. vagina
    4. may exhibit swelling of the parotid gland, which can 
      1. be
        1. recurrent
        2. painful
        3. persistent
      2. be associated with
        1. stones
        2. infection.
  3. In its secondary form behaves as an associated condition.
  4. Is differentiated from the type of xerostomia that is not caused by Sjögren syndrome, a type that
    1. affects about one in 50 persons
    2. is caused by or associated with 
      1. advancing age
      2. medication side effects
      3. radiation therapy (CDHO Advisory) to the head and neck which irradiates the salivary glands
      4. dehydration
      5. anxiety (CDHO Advisory)
      6. unexplained causes.
  5. Is of unknown cause, although increasing evidence implicates genetic factors because
    1. it occurs with increased frequency in families whose members have other autoimmune disorders, such as 
      1. systemic lupus erythematosus (CDHO Advisory)
      2. autoimmune thyroid disease (CDHO Advisory)
      3. type 1 diabetes (CDHO Advisory)
    2. it may reflect a genetically determined reaction to viruses that attack the parotid gland, including the viruses of
      1. Epstein Barr
      2. HIV /AIDS
      3. mumps.
  6. Is identified by
    1. dryness of the mouth, including
      1. lips that are dry and peeled
      2. oral mucosa that
        1. appears dry
        2. appears erythematous
        3. may evidence mucosal sloughing
    2. enlargement, hardening and tenderness of the salivary glands
    3. change in taste or smell
    4. salivary gland tests
    5. biopsy, often of the salivary gland in the lower lip
    6. blood tests for 
      1. autoantibodies 
      2. rheumatoid factor
      3. thyroid antibodies (CDHO Advisory)
      4. anemia (CDHO Advisory)
      5. sedimentation rate
    7. xerophthalmia
  7. Lacks a cure; is treated 
    1. for conditions in the particular areas of the body that are involved, including the
      1. mouth, teeth and nose
        1. infections of the mouth and teeth 
        2. dental hygiene
        3. diligent dental care
        4.  increased fluid intake
        5. humidified air
        6. enhancement of saliva flow
        7. saline nasal for dryness in the nasal passages
        8. medications
      2. eyes
        1. dryness, with
          1. artificial tears
          2. eye-lubricant ointments at night
          3. minimization of the use of hair dryers
          4. surgical closure of the tear duct to reduce drainage
          5. medications
        2. conjunctivitis
    2. for its comorbidities, complications and associated conditions.

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with Sjögren syndrome 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. 

Sjögren syndrome

  1. complications include infections, such as those in the
    1. lining of the respiratory airways 
    2. vagina
  2. contributes through xerostomia to the high prevalence of geriatric malnutrition   
  3. co-exists or is associated with conditions such as
    1. rheumatoid arthritis (CDHO Advisory) and joint pain
    2. autoimmune hepatitis
    3. autoimmune thyroiditis which can lead to abnormal thyroid hormone levels (CDHO Advisory)
    4. chronic pneumonia, leading to fibrosis of the lung
    5. debilitating fatigue
    6. gastroesophageal reflux disease (CDHO Advisory)
    7. lymph-node enlargement and pain
    8. lymphoma (CDHO Advisory), the most serious associated condition, which usually develops only after many years with Sjögren syndrome
    9. non-Hodgkin’s B-Cell Lymphoma (CDHO Advisory), which affects as many as 10 percent of persons with Sjögren Syndrome
    10. damage to peripheral nerves
    11. primary biliary cirrhosis, an immune disease of the liver that leads to scarring of the liver tissue
    12. Raynaud’s phenomenon
    13. vasculitis of the skin
  4. is secondary to conditions which, in up to 25 percent of patients, later develop Sjögren syndrome, including
    1. rheumatoid arthritis (CDHO Advisory)
    2. scleroderma
    3. systemic lupus erythematosus (CDHO Advisory)

Oral health considerations

Adapted from

Sjögren syndrome is an important challenge for oral healthcare professionals because

  1. it often remains unrecognized and untreated and, even when treated, the average time to diagnosis is reportedly 3.5 to 7 years
  2. the patient/client affected by it may turn first to oral healthcare for help with the xerostomia which, with the ageing of the population, is likely to be encountered with increasing frequency in oral healthcare
  3. its effects are 
    1. common, extensive and severe
    2. associated with a
      1. significant burden of illness relative to
        1. oral health, with increased likelihood of
          1. dental caries
          2. oral infections
        2. health generally
        3. mental health, especially from depression
        4. quality of life
        5. social function
      2. rate of dental-care utilization that tends to be
        1. high
        2. costly
  4. its early recognition may
    1. assist early diagnosis, in particular of serious comorbidities, complications and associated conditions
    2. help distinguish it from hyposalivation associated with
      1. aging
      2. medications
    3. promote prevention and oral healthcare for a troublesome disorder that undermines general health and quality of life
  5. its management requires 
    1. awareness of the
      1. nature and functions of saliva, such as 
        1. the concept of the salivary pellicle
        2. its protective role 
      2. impact of the loss of salivary protection, such as
        1. vulnerability to harm from
          1. physical, chemical and microbiological attacks
          2. traumatic ulcers, especially of the tongue and cheeks
          3. contact allergies to foods, beverages, dental hygiene products and dental materials
        2. erosion of enamel
    2. particular attention to
      1. infections of the mouth and teeth, which should be addressed promptly and aggressively
      2. dental caries and the adequacy of preventive measures generally; factors for consideration include
        1. oral healthcare visits, for optimum
          1. coordination between dental and dental hygiene visits
          2. frequency of dental hygiene visits
          3. collaboration between the dental hygienist, dentist, ophthalmologist, rheumatologist, primary care physician, nurse, family caregiver and, where appropriate, psychiatrist
        2. fluoride toothpastes, mouth rinses, gels or varnishes to reduce tooth decay, especially in children and adolescents
        3. appropriate dietary advice
        4. the importance of regular fluoride treatments 
        5. increased mucosal sensitivity and the choice of toothpastes
      3. treatment of oral candidiasis 
      4. enhancement and restoration of salivary output
      5. hydration
      6. monitoring of salivary output and disease progression.

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements

Types of medications

Warnings

Individual medications may be subject to important warnings, which

  1. change from time to time
  2. may affect the appropriateness, efficacy or safety of the Procedures
  3. are accessible via the links to the particular medications listed below or through the specialized organizations listed above
  4. through the links, should be viewed by dental hygienists in the course of their familiarizing themselves about a medication or combination of medications identified in the patient/client’s medical and medications history.

Medications for

  1. Angular cheilitis 
    • nystatin (Mycostatin®, Nystat-Rx®, Nystop®, Pedi-Dri®) 
    • clotrimazole cream (Fungoid® Solution, Gyne-Lotrimin®, Lotrimin®, Mycelex® Troche)
  2. Artificial saliva preparations and mouthwashes (OTC)
    • Biotene
    • Oralbalance
  3. Caries prevention
    • topical flourides
  4. Enhancement of saliva flow
    1. physiological stimulation
      • sugar-free candies, to reduce caries-producing effect of sugar
      • citrus-free candies, to reduce demineralising effect of citrus juice
      • chewing gum
    2. pharmacological stimulation
  5. Immunosuppression for serious complications, such as vasculitis
  6. Infection control; inhibition of the development of dental plaque and gingivitis 
    1. antibacterial mouthwash 
    2. appropriate antibiotics
  7. Oral candidiasis
    1. treatment
      • nystatin (Mycostatin®, Nystat-Rx®, Nystop®, Pedi-Dri®)
    2. for soaking removable prostheses
  8. Reduction of inflammation to improve the function of tear glands
  9. Relief of mouth sores
  10. Xerostomia sialogogues

Side effects of medications

  1. See the links above for the individual medications.
  2. Medications are the most common cause of xerostomia, such medications include
    1. over 500 types
    2. anticholinergics
    3. antidepressants
    4. antihypertensives. 

THE MEDICAL AND MEDICATIONS HISTORY

The medical  and medications history-taking should 

  1. Focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions.
  2. Explore the need for advice from the appropriate primary care provider(s).
  3. Inquire about
    1. the patient/client’s understanding and acceptance of the need for oral healthcare
    2. indications of inadequate control of the symptoms of Sjögren syndrome, especially xerostomia
    3. medications considerations, including over-the-counter medications, herbals and supplements
    4. problems with previous dental/dental hygiene care
    5. problems with infections generally and specifically associated with dental/dental hygiene care
    6. how the patient/client’s state of health is at this moment
    7. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. 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

  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 securely send 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 (2022)
  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.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

As appropriate, the dental hygienist should consult with the treating physician or specialist to obtain advice about implementing or clearance for implementing the Procedures. 

Medical clearance should be obtained if the patient/client is being treated with medications associated with immunosuppression +/- increased risk of infection (e.g., corticosteroids [e.g., prednisone], methotrexate, cyclosporine, azathioprine, mycophenolate, cyclophosphamide, and rituximab).

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 Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid 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 Sjögren syndrome, 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 patient/client is urged to alert any healthcare professional who proposes any intervention or test that he or she has a history of Sjögren syndrome.

As appropriate, discuss 

  1. The importance of a good diet in the maintenance of oral health.
  2. The need for regular oral health examinations and preventive oral healthcare. 
  3. Home oral hygiene including information about 
    1. choice of toothpaste, tooth-brushing devices, dental flossing, mouth rinses and use of saliva substitutes
    2. preventive strategies for xerostomia for
      1. home care regimens for the patient/client
      2. the family caregiver.
  4. The role of the family caregiver for persons at an advanced stage of the condition, with emphasis on maintaining an infection-free environment, and advice on wearing gloves. 
  5. Medication side effects such as xerostomia, and recommend treatment.
  6. Mouth ulcers and other conditions of the mouth that occur with Sjögren syndrome, comorbidities, medications or diet.
  7. Pain management.
  8. The importance of avoiding tobacco and alcohol with attention to a diet that does not promote tooth decay.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promotion of health through oral hygiene for persons who have Sjögren syndrome.
  2. Reduction of the adverse effects of delay in recognition of Sjögren syndrome, by
    1. promptly consulting with medical or other healthcare providers when xerostomia and xerophthalmia coexist
    2. generally increasing the comfort level of persons in the course of dental hygiene interventions 
    3. using appropriate techniques of communication
    4. providing advice on scheduling and duration of appointments.
  3. Reduction of risk of oral health needs being unmet.

POTENTIAL HARMS

  1. Causing harm by failing to recognize the need for medical advice for the patient/client in the early stages of a comorbid, co-existing or associated condition.
  2. Performing the Procedures at an inappropriate time, such as 
    1. when medical advice is required for the patient/client’s Sjögren syndrome 
    2. in the presence of comorbidities, complications and associated conditions for which medical advice is required
    3. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person with Sjögren syndrome.
  4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

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

ORIGINALLY DEVELOPED

2010-03-25

DATE OF LAST REVIEW

2020-05-04

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 COMITTEE

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 Taylor
RDH, BA, MEd

Kyle Fraser
RDH, BComm, BEd, Med

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

© 2010, 2020 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children.