The patient with special needs in the traditional private practice dental office: Q&A with Diane Flanagan, AAS, RDH.
How do we define a patient with special health care needs?
The American Academy of Pediatric Dentistry's definition of special health care needs (SHCN) includes:
"Any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs."
Using this definition, individuals with SHCN can experience health conditions ranging from asthma or hypertension to severe mental and physical disorders. Health care service needs for individuals with SHCN can range from prescription medication to around-the-clock skilled nursing care. The 2010 U.S. Census Bureau report indicates there are approximately 36.3 million Americans with a disability. It is estimated that 1 in 5 U.S. households with children have at least one child with SHCN.
Is a traditional private practice dental office equipped to serve patients with special needs?
Each day, the traditional private practice dental office serves many patients with a SHCN. In addition, dental facilities are required to comply with the Americans with Disabilities Act (ADA) to ensure a barrier-free environment. A checklist is available on the ADA website to determine if a dental facility meets barrier-free guidelines (see box).
Standard dental equipment used with adaptive techniques is adequate to treat the majority of individuals with SHCN. Even though the physical structure of the traditional private practice dental office is adequately equipped to serve patients with SHCN, the practitioners may not be equipped with the skills to provide care to individuals with severe or complex conditions. In these circumstances, the practitioners have an obligation to act in an ethical manner by making a referral to an appropriate facility to ensure the health of the patient.
What is the role of the health history in treating a patient with special needs?"
An accurate and thorough health history is essential to providing appropriate treatment planning and care to all patients. The health history provides the necessary information the dental hygienist needs to assess the patient's health and the impact a special need can have on the patient's general health as well as their oral health. The dental hygienist also needs to obtain a signed informed consent for dental treatment. The health history and informed consent must be signed by the patient or by an individual who is legally authorized to provide this service on their behalf.
What are the unique dental treatment considerations for patients with special health care needs?
All patients need to feel they are accepted and valued and that their unique needs will be met in a safe and nonthreatening environment. The dental hygienist treats the patient as a whole by considering the patient's general physical, emotional and oral conditions. Individuals or families with children who have SHCN may have neglected their oral health or feel that it is less important in light of the demands of their condition. The dental hygienist can play a pivotal role in the patient's acceptance of treatment and prevention strategies.
Prevention and maintenance of oral health are the cornerstones of the dental hygiene treatment plan for SHCN. Adaptive techniques and preventive care instructions provided to the patient or caregiver need to be delivered in a manner that the patient or caregiver understands and is able to perform. Adaptive clinical techniques may include the use of a sign language interpreter, extra-oral finger rests during instrumentation, mouth prop, non-flavored prophy paste and behavior guidance methods. Adaptations to daily oral care may include the use of social stories, floss holders, adaptive toothbrushes and caregiver instruction on toothbrushing guidance, and patient positioning techniques. The dental hygienist needs to take into consideration the patient's sensory, intellectual, developmental or mental conditions when determining the appropriate treatment and daily oral care techniques. Patient needs and success of adaptations should be reviewed with the patient or caregiver at each appointment.
Are there different standards of oral health care for people with special needs?
The standard of oral health care for people with special needs is the same as that for all patients. The difference lies in the method of service delivery and informed consent. Dental hygienists utilize their professional skills to assess and treat patients with SHCN so they can achieve the best oral health possible. Standards of care also include accurate recording of patient records including preventive care recommendations and oral health prognosis.
What is the role of the dental hygienist in coordinating care with the other health care professionals who serve the patient with special needs?
The oral health needs of the individual with SHCN are best met in a dental home that resides within a medical home. The patient-centric medical home includes the provision of health services by a variety of health care professionals coordinated by the primary care medical provider. Speech, occupational and physical therapists; school nurses; residential medical center staff and dental team may be among the health care professionals who are part of the medical home for the individual with SHCN. As examples, the dental hygienist may consult with a patient's speech therapist to develop an oral desensitization plan or work with an occupational therapist to identify an adaptive toothbrush. When communicating with other health care professionals, the dental hygienist must adhere to the patient's privacy rights by complying with the Health Insurance Portability and Accountability Act (HIPAA).
What resources are available to assist the dental hygienist in working with patients with special health care needs?
Free online courses and publications are available to the dental hygienist to improve their skills in working with individuals with SHCN (see box) Clinical experience working with individuals with SHCN can be acquired by volunteering for the Special Olympics Special Smiles oral health screenings. Additional experience may be available by providing oral health training to group home staff and residents in your community.
Rachel Stryjak, RDH Practice of Dr. Russell Pollina, Mt. Prospect and Barrington, Illinois
Our practice specializes in pediatrics and patients with special needs, aged from 18 months to well into their 20s. Some of our special needs patients, however, are now grown adults as old as 40 and still in our active recall system.
The types of disabilities are really too numerous to list. Our patients can have Asperger's, autism, cerebral palsy, Marfan syndrome, attention deficit disorder or other sensory disorders--each case is unique. These patients are often wheelchair bound and seen without removing them from the comfort of their own chairs. Each patient needs extra time, understanding and to be treated as an equal.
I provide oral health care instructions to parents or care providers as, often, I am unable to communicate effectively with the individual patients. Some cerebral palsy patients are GI tube fed and cannot tolerate mouthwash or effectively rinse the oral cavity. Instructions vary from demonstrating proper brushing and flossing technique to emphasizing the benefits of power brushes. Often, caregivers fear their loved ones will hurt their (caregivers') fingers in protest of regular care. I suggest the handle of a toothbrush as a mouth prop, or simply finding the most relaxed part of the patient's day in an attempt to relieve some of the "fight" involved in effective daily plaque removal. Often, parents will add brushing to the patient's bath time. In patients with Asperger's or autism, consistency is key. Performing the same routine at the same time each day often helps. I have several patients with special needs that report a love for the toothbrush, which helps tremendously.
Dr. Pollina and I have tried to make sure that individual patients with special needs see the same provider at each appointment to establish a rapport. This consistency allows the patient to become familiar with our individualized methods in performing prophylaxis and other preventive services such as sealants and fluoride treatments. Patients who seem noncognitive will eventually recognize the practitioner and actually begin to communicate. The first few visits are always hard, but as the years pass, we all become friends, although it must be noted that some type of restraint is typical during most dental visits.
I have a patient whose mother passed away in 2006, leaving his father as the sole provider. Shawn's father is not really comfortable brushing his grown son's teeth. I first saw Shawn in January 2010. He had a reputation for combative behavior, but I have never experienced anything other than mild protest during any of his visits. He enters the operatory on his own, while his dad usually sleeps in one of the waiting room chairs. He always wears a Mickey Mouse sweater his mom gave him. Shawn is 37 years old, probably 240 pounds and stands at five feet, four inches. His stocky build and deep voice may give the impression he is aggressive, but he's a big sweetheart, and needless to say, I think he is adorable! Last year, I saw Shawn and his father while I was Christmas shopping for my daughter. We spoke briefly, and I wished him a Merry Christmas. For the duration of my shopping spree that day, Shawn was just a few feet away. I'm sure he was not shopping for Barbies as I was. I was delighted at the possibility that he might like me as much as I liked him!
The first time I saw him, his oral hygiene was really nonexistent. He had heavy plaque, food debris, heavy bleeding and heavy tenacious calculus. I always ask him if he has been brushing at home, but Shawn cannot effectively communicate on that subject thus far. Our first visit was difficult for both of us. Shawn's anxiety caused him to clench his mouth shut, forcing me to use a mouth prop. He was very verbal but not conversational, shouting randomly and raising his hands frequently. He is too large for restraint of any kind. I remember just trying to wait it out. The more time that passed as I sat beside him, the more he began to realize I was only trying to help. Perfect scaling was next to impossible. A cavitron was out of the question. I feared that he and his father would never return to the office, or any other dental office, if I upset him too much. The appointment lasted over an hour, and we were both exhausted when it was over. Shawn had always been on a four-month recall. I suggested we see him every three months. His father reluctantly complied, and Shawn has been returning for regular recall visits every three months now for three years.
Shawn's improvement has been remarkable. His tolerance, communication and tissue quality have improved. The last time I treated Shawn, I was able to use the cavitron, record periodontal probings and take a panorex. Unfortunately, during that visit, Dr. Pollina discovered two molars requiring extractions.
The day of the extraction, Shawn came to the office chanting repeatedly, "Cleaning?"
"No Shawn," I answered. "Next month! Have you been brushing at your house?"
"A-huh," he replied. Well I hope so!
LeeAnn Chastain, RDH, BS Practice of Dr. Michael Edenfield, Chattanooga, Tennessee
Our office is designed to accommodate individuals with special needs ranging from very mild to severe intellectual, developmental and physical disabilities. Some examples are Down's syndrome, significant seizure disorders, mild to severe autism and cerebral palsy.
Individuals with special needs have self-esteem just like you and I do. Unfortunately, these individuals are looked at as second-class citizens in our society. Our biggest concern is to treat them like we would treat anyone else. We greet them by name, shake their hands, give them hugs, ask them questions about their lives, joke with them, and make sure their dental visit is comfortable. They look forward to coming to our office, and I look forward to seeing them. We have seen great transformations in attitudes when patients are proud of the way they look.
The majority of our patients are on a four-month recall due to the fact that they or their caregiver can't give the best oral hygiene possible. Most of our patients are very cooperative with their recall appointments, but we do have some whose mental conditions do not allow for cooperation. We are able to treat these individuals with conscious IV sedation.
I have a patient who is 45 years old who has severe autism and cerebral palsy. When he first started coming to our office, he was not very compliant. His dad would repeat everything I told him to do so he would actually do it. It's been three years since his first visit, and he now comes back by himself and is very easy to work with. He needed a restoration, and due to his severe anxiety disorder, his family requested that we sedate him for the procedure. When he was waking up, I went in to check on him. He slowly lifted his hand to his shirt pocket and gave me a hand-printed letter. It reads, "Dear LeeAnn, socks feet shoes sack feet" over and over, but at the bottom it says "love you" and his name. While the letter makes no sense, it touches my heart. Here is a man who needed his father to tell him every move to make, and now he is not only following my instructions but expressing friendship toward me.
Working with special needs can be very difficult, but it can also be very rewarding. It takes a lot of patience, persistence, care and love. My experience has shown me that when I give those patients the attention they deserve, they become some of my favorite patients. Don't be afraid to touch them, pat their shoulder or shake their hand. Give them a hug! Just have fun! Some of them greet me with a hug so big that I have to push them off before they choke me. Some greet me with a kiss on the cheek. It's those patients that make me so grateful for the opportunity to treat people with special needs. At the end of the day, those patients are more of a blessing to me than I could ever be to them.
Rebecca McKeough, C.R.D.H. Barnes and McDonnell Pediatric Dentistry, Ormond Beach and Port Orange, Florida
I work in a pediatric dental office that specializes in those with special medical and developmental needs. We have numerous special needs patients.
One patient in particular that I see is an adolescent who has severe cerebral palsy. He is bound to a wheelchair specifically designed for his condition, and he has a G-Tube that delivers nutrition directly to his stomach. His medication list consists of various types of antiseizure medications that put him at risk for gingival hyperplasia.
I started seeing this patient in my office at a very young age. In the beginning, he was so small that the visits only required one hygienist performing the prophylaxis, while one assistant would stabilize the patient's head and hold the mouth prop. The mother would help stabilize his arms. We would tough it out during these visits since the patient only presented with slight amounts of calculus.
As the patient got older and stronger, it became difficult for his mother to maintain his oral hygiene at home. Since the muscles in his mouth do not function, and he does not chew, the calculus started building up more readily. We started having him come in for a prophylaxis every three months, only completing one quadrant at a time. At these visits, we were needing one hygienist and three assistants to help stabilize the patient.
As the prophylaxis appointments became too stressful and traumatic for the patient, we decided to start performing all necessary procedures under our in-office IV sedation with our anesthesiologist. Although this makes it easier to control the patient during the procedure, there is now another set of concerns. While doing the prophylaxis using IV sedation, it is important for me to keep the airway open at all times, while maintaining complete dryness in the mouth so the patient does not aspirate anything into his lungs. All of this is done under the close supervision of the dentist and the anesthesiologist.
Although special needs patients like this are very difficult to treat, it is also very rewarding to know that you are helping improve their quality of life.
Kylee Carpenter, RDH, BS Dentures and Dental Services, Denton, Texas (former position)
The residents from the Denton State Supported Living Center visited our office for dental needs. Being the sole hygienist, I saw all of the patients who were in for a prophy/scaling. Most of the patients had severe ADHD, paranoia, bipolar disorder, Alzheimer's and other mental disorders along with being physically unable to take care of themselves.
My patients had Down syndrome, blindness, cerebral palsy, muscular dystrophy, and other disorders, and some were confined to wheelchairs following a stroke or other severe trauma. Some of my patients had multiple disabilities.
I was extremely patient with these patients. I often asked them questions about their life so I could know them on a personal level. This made the patients feel very comfortable and it often made the quiet ones a little more outgoing. I made the patients comfortable in the dental chair, and they actually looked forward to coming back.
I had a patient who was mentally handicapped for not getting enough oxygen when being born. He came in and was very shy. When I leaned the chair back, he started to get frightened, so I touched his shoulder and reassured him that everything was going to be okay. We got past the leaning of the chair and ended up having a discussion about random things for the hour that he was in my chair. He told me he loved Michael Jackson, and when we were finished, he stood up and started to moonwalk. That's what I call a great and progressive dental appointment! Working with special needs patients taught me how to be a more patient and caring dental hygienist. It was a very rewarding experience!
Laura Healy, RDH Mobile Care 21J, Overland Park, Kansas (headquarters)
I am the hygienist for the Greater St. Louis and bi-state area, known as Resi-Dent. I live in St. Louis and travel to a different nursing home or care facility daily, about 100 locations. My patients have a variety of special needs: pacemakers, joint replacements, cancer, HIV-AIDS, hepatitis C, deafness, blindness, varieties of heart and lung conditions and medication-induced side effects such as xerostomia. Some have mental disorders
including Alzheimer's, dementia, schizophrenia and depression. Many are wheelchair bound, many have limited use of their hands and arms. If a condition is associated with age, it is certain that each patient will have at least a few of these special needs. I also work with a few facilities serving those with developmental retardation or who are no longer able to care for themselves due to injuries.
These patients are no different than you or I, except that they need just a little more time, patience and understanding. Each facility has a chart showing each patient's medical history that is updated monthly. Each visit, I check the chart and medications to make appropriate decisions regarding how to scale, whether they have a pacemaker or COPD limiting scaling to hand rather than ultrasonic, or if they might need antibiotic premedication prior to their cleaning.
Many of my patients are wheelchair bound and unable to move to a reclining chair. These patients remain in their wheelchair or sit in a seat beside me. It compromises my posture, but is best for the patients. Many of my patients need a lot of handholding or explanation of what they are having done. Many of my dementia/Alzheimer's patients need reminding every few moments that they are having their teeth cleaned and they are ok. For the most part, those conditions are the only ones that require some adjustment on my part. Those who are afraid or apprehensive, I sing to--or with, since many love to sing. There is something very calming in music.
My patients' biggest needs are related to education and troubleshooting. It would be best if the facilities' nurses, aids and technicians were able to brush for them; however, many are overworked and unable to take a few moments to help with oral care, and some do not have the education. Occasionally, I am able to present an in-service to the staff on how to care for someone else's oral hygiene.
My patients are better able to help themselves if I can troubleshoot a few modifications with them. About half the patients have dentures and/or partials and need help learning proper cleaning techniques. If squeezing a tube of toothpaste is too difficult, I recommend squeezing the entire tube into a small container so they can swipe a dab onto their brush. If they can't reach a sink to rinse, I suggest using bedside commodes or emesis trays. Many of these things are not pretty or pleasant, but my patients who are desperate to help themselves in any way that they can appreciate the alternatives to a sink. Some patients cannot tolerate a toothbrush or lose them to "theft" by a roommate, so I recommend they use a washcloth--anything to get the job done.
I had a patient whose husband brought her into the treatment area, and I asked her how she was and who was with her. Her husband told me, "She is unable to speak. The first 60 years of our marriage, all she did was talk and talk and I just wanted her to be quiet sometimes, but since her stroke a year ago, all I want is to be able to hear her talk again."
One of my patients was a gentleman with a girlfriend who lived at the same facility. He said that people often asked him why he was her boyfriend, because he was so happy and she was so grumpy. I asked if he thought she was grumpy, and he said "not as much as other people think."
My patients are incredibly wonderful, even those who are grouchy regularly. They very much want and need someone to talk to about their day, what they like and don't like, about what life was like before they were placed in a home, their families. They need to feel like someone cares for them and is concerned with their well-being. I take time to chat with them and make sure they are happy--or at least a little happier than when they entered the treatment room. And I encourage them to do their best to help each other, those they live with, to be happy.
Dental Treatment in Chronically Ill Adults in Last Year of Life
A study conducted at the University of North Carolina, Chapel Hill was the first to examine the dental treatment provided to chronically ill long-term care residents in the last year of life. Researchers found that although oral health was poor in the 197 patients retrospectively evaluated, more than half of those examined received no dental care leading up to death. However, of those who did receive treatment, 62.9 percent received usual care instead of limited care focusing on pain and infection. Researchers also found that having dental insurance significantly increased the likelihood of a patient's receiving dental care before death. There was no correlation between patients' oral health conditions and how much care they received.
The dying process can linger up to a year or longer in patients with chronic diseases or advanced frailty. During this process, severe dry mouth, oral pain and oral infection may substantially affect quality of life. Poor oral hygiene and oral infection may also cause severe, sometimes fatal, systemic complications such as aspiration pneumonia. Impaired chewing function and swallowing disorders can further aggravate malnutrition and accelerate terminal decline.
Among subjects who did receive dental treatment prior to death, nearly two-thirds received comprehensive treatment that would be expected in a healthy elderly patient, including restorations, extractions and/or new denture treatment. More than 60 percent of those patients had their treatment completed within the last three months of life, leading the researchers to question whether those patients benefited from treatment or may have even suffered unnecessary pain or increased risk of related systemic complications.
The study was published in the November 2013 issue of the Journal of the American Dental Association. Full text is available at http://jada.ada.org/content/144/11/1234.full.
Source: UNC School of Dentistry
Foundation for the NIH Launches Bone Quality Project
The Foundation for the National Institutes of Health (FNIH) Biomarkers Consortium has announced the launch of a three-year study to track the progression of osteoporosis more precisely and pave the way for more effective treatments. The study, which uses data from existing academic and clinical trials, is designed to establish the validity of specific imaging and biochemical markers for bone health.
Approximately 9 million adults in the U.S. suffer from osteoporosis and, with the aging of the population, the numbers continue to rise. Recent concerns have prompted regulatory agencies to review the safety of antiresorptive drugs for osteoporosis, while these same concerns among patients and physicians are decreasing the use of this particular class of drugs.
The FNIH Biomarkers Consortium Bone Quality Project will evaluate the effectiveness of two types of biomarkers that measure bone strength: 1) Quantitative Computed Tomography, a state-of-the-art imaging technology, and 2) biochemical markers of bone turnover, defined as biomarkers of bone formation or resorption. Both measures have been included in existing clinical trials in small subsets of patients with some relevant analyses previously performed. However, analytic methods have varied greatly among the existing analyses, and this, together with small sample sizes, has limited the ability to draw definitive conclusions about their utility. For more information about this project, visit www.fnih.org.
Source: PR Newswire Association
Periodontal Disease Treated with 'Homing Beacon' to Bring Immune Cells to Inflamed Area
Periodontal disease could be effectively treated by beckoning the right kind of immune system cells to the inflamed tissues, according to a new animal study conducted by researchers at the University of Pittsburgh. The findings, published in Proceedings of the National Academy of Sciences, offer a new therapeutic paradigm for the disease.
According to the researchers, current strategies for managing periodontal disease fail to address the overreaction of the immune system that causes a "needlessly aggressive" response to the presence of oral bacteria. In many people, the chronic bacterial overload sets up the immune system to stay on red alert, harming oral tissues while it attempts to eradicate germs.
Evidence suggests that the diseased tissues lack sufficient regulatory T-cells, so the researchers found a way to call the T-cells to the inflamed area. They developed a system of polymer microspheres to slowly release a chemokine, or signaling protein, called CCL22 that attracts regulatory T-cells, and placed tiny amounts of the paste-like agent between the gums and teeth of animals with periodontal disease. The team found that even though the amount of bacteria was unchanged, the treatment led to improvements of standard measures of periodontal disease, including decreased pocket depth and bleeding, reflecting a reduction in inflammation as a result of increased numbers of regulatory T-cells. MicroCT-scanning showed lower rates of bone loss.
Next steps include developing the immune modulation strategy for human trials.
Source: University of Pittsburgh Medical Center
This feature was compiled by ADHA staff from responses to a Facebook post.
Model of HIV Protein Provides New Insight
Weill Cornell Medical College and the Scripps Research Institute have released an atomic-level structural model of the HIV envelope protein, a breakthrough the collaborators say will mean better opportunities to develop the elusive HIV vaccine.
HIV, which infects 34 million people annually, has long stymied scientists searching for a cure due to the complex, tripartite structure of its envelope protein known as "Env."
Currently, afflicted patients must rely on retroviral drugs to treat the disease's symptoms. Weill Cornell and Scripps' effort was the first to undertake the task of mapping the protein as a whole rather than piecemeal, an approach that they hope will allow immunologists to identify and exploit as yet unnoticed weaknesses in the virus structure.
The Env trimer has already been put to work; researchers have begun studying the antibodies released by animal immune systems when in contact with the protein. The group published their findings over two papers in Science's online edition Science Express in October 2013.
Source Weill Cornell Medical College
Printing a Better
Brush 3D printing is a rapidly growing technological field, allowing anyone with a specialized device and a blueprint to "print" real, functioning objects with a wide range of applications, in everything from spare parts for the International Space Station to fully functioning cars.
Now the company Blizzident is using 3D printing to revolutionize the way that people brush their teeth with their uniquely designed 3D toothbrush. Patients visit their dentist for either a bite impression or a direct scan, Blizzident creates a digital model of their mouth, and then creates a customized "toothbrush" that resembles a full mouthguard with bristles.
The company claims that the brush cuts down on user error, and can remarkably clean the whole mouth in six seconds. Though the relatively high cost compared to traditional brushes may keep the average consumer away, its once-a-year replacement requirement may appeal to the kind of buyer looking to shave a few minutes off of the daily brushing routine. More information can be found at www.blizzident.com Source: Blinuient
RELATED ARTICLE: Online Courses and Publications
The Americans with Disabilities Act: Checklist for Readily Achievable Barrier Removal
Dental Professionals Toolkit
Patients with Special Needs: Resources for Patients and Health Care Professionals
Practical Oral Care for People with Developmental Disabilities (2 credits)
Special Care: An Oral Health Professional's Guide to Serving Young Children with Special Health Care Needs (4 credits)
Organizations American Academy of Pediatric Dentistry
Special Care Dentistry
RELATED ARTICLE: 2012-2013 Donor Honor Roll
This revised portion of the Honor Roll of Donors reflects the complete contributions of the following donors to the Institute from July 1, 2012 through June 30, 2013.
Donors of $1,000-$2,499
Ester C. Ball, RDH, BS
Karen L. Neiner, RDH, MBA
Lynn M. Ramer, LDH
Donors of $750-$999
Tammy L. Filipiak, RDH, MS
Donors of $500-$749
Esperanza Garza, RDH, BS
Donors of $300-$499
* Kimberly A. Hickman-Bowen, RDH, BSDH, MA
Victoria E. Richards, RDH, BS
Donors of $150-$299
Ann O'Kelley Wetmore, RDH, MSDH
Carolyn D. Roberton, BSDH, RDH
Cynthia A. Crisler, RDH
Denise B. Frank, RDH, BS
Emma E. Violante, RDH
Jackie L. Sanders, RDH
Jamie N. Woods, RDH
Kristen R. Potts, RDH
LeeAnn Katherine Winkler, RDH, BSDH
Lisa Ann Goss, RDH, BS
Marilynn L. Rothen, RDH, MS
Maryann Cugini, RDH, MHP
Maureen R. Titus, RDHAP, BS
Patricia Lynn Aylward, RDH
Rebecca L. Alles, LDH
Ronald Jaecks, MD, FACS
* Sandra L. Tesch, RDH, MSHP
Donors of $75-$149
Christine M. Farrell, RDH, BSDH, MPA
Colleen Gaylord, RDH
Deborah Kappes, RDH, MPH
Elizabeth Ann Nies, RDH, BS
Elizabeth L. Kelley-Miyashiro, RDH, BS
Jeanna Kay Secrist, RDH
* Joan Kenney Fitzgerald, RDH, BS
Karen S. Sealander
Lisa E. Stillman, RDH
Michele E. Braerman, RDH, BS
Patricia H. Parker, RDH
Sue Meyers, RDH
Susan L. Melton, RDH
Vicki L. Munday, RDH
* ADHA Board of Trustees Member
For a full list of the Institute for Oral Health 2012-2013 Donor Honor Roll, please visit: http://pubs.royle.com/publication/?i=180431&p=28
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|Title Annotation:||Clinical Feature|
|Date:||Jan 1, 2014|
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