Health inclusivity is defined as: “The process of removing the personal, social, cultural, and political barriers that prevent individuals and communities from experiencing good physical and mental health, and a life fully realized.”¹ Based on the second stage report, the United States ranks fourth out of 40 countries, with Australia, Sweden, and the United Kingdom in the top three.

Evaluations are based on a set of indicators across three main domains:

Health in Society. This assesses how highly a nation values the health of its people and whether it considers health across all government policies. This accounts for the social determinants of health (SDOH) such as education, housing, and income. See the article in this issue of Dimensions regarding SDOH factors in oral and overall health (page 32).

Inclusive Health Systems. This measures the strength and scope of a nation’s healthcare system, including its accessibility, responsiveness, and whether cost is a barrier to accessing services.

People and Community Empowerment. This evaluates efforts to ensure that healthcare services are designed to be inclusive, accessible, and tailored to individuals and their preferences, including vulnerable groups. This domain often focuses on factors such as health literacy and community members’ ability to engage with their own health (self-care).

Here is what the HII’s assessment of the US system implies about oral health issues:

1. Cost is a major barrier to accessing health services in the US. This is acutely visible in oral health. Because dental care is separate from medical care, a significant portion of the population has no or inadequate dental coverage. Furthermore, preventive care is delayed or avoided, turning easily treatable conditions into severe, expensive, and debilitating ones.
2. The US has wide health disparities. The data show that caries and periodontal diseases disproportionately affect specific groups such as low-income adults and racial and ethnic minorities (Black, Hispanic, and Native American). These individuals have greater difficulty accessing care.
3. ­The US system, by separating medical and dental care, lacks integration of services. This impacts overall health as we know that untreated periodontal diseases are linked to serious systemic conditions like diabetes and heart disease.

In short, while the HII doesn’t isolate dental statistics, its assessment of the US system’s affordability and equity issues provides a clear explanation for why conditions, such as tooth decay and periodontal diseases, remain major, inequitable public health crises in this country. Even in 2026, we have far to go.

Reference

1. Health drives wealth: the economic impact of health inclusivity. Economist Impact. Available at https://impact.economist.com/ projects/ health-inclusivity-index/documents/health_inclusivity_index_phase3_report.pdf?v=2025. Accessed December 15, 2025.

From Dimensions of Dental Hygiene. January/February 2026; 24(1):6

Sterilization monitoring is a cornerstone of infection control and prevention in dental settings. Spore testing, also known as biological monitoring, is considered the gold standard for verifying the efficacy of sterilization processes. Oral health professionals must routinely verify that their sterilizers are working properly, including performing spore tests at the frequency recommended by the United States Centers for Disease Control and Prevention (CDC) and required by the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. The two most common types of spore testing used in dental practices are in-office incubation and mail-in.

Regulatory Background

According to the CDC’s Guidelines for Infection Control in Dental Health-Care Settings, sterilization procedures should be monitored using biological indicators (spore tests) at least weekly and with every load that contains implantable devices, such as titanium or ceramic zirconia implants.¹ OSHA reinforces this recommendation under the Bloodborne Pathogens Standard (29 CFR 1910.1030), which mandates that employers ensure proper functioning of sterilization equipment as part of their exposure control plan.²

Importance of Sterilization in Dentistry

Sterilization of dental instruments is a critical component of infection prevention in dental practices. Instruments used during patient care come into contact with blood, saliva, and other potentially infectious materials, posing a risk of cross-contamination if not properly sterilized.¹ Failure to adequately sterilize instruments can result in the transmission of pathogens.³

The Spaulding classification system is a widely accepted framework for determining the level of disinfection or sterilization required for medical and dental instruments. The Spaulding classification categorizes instruments into three levels based on the risk of infection associated with their use: critical, semicritical, and noncritical.¹

Critical items are instruments that penetrate soft tissue or bone (eg, scalers, surgical instruments). These must be heat sterilized after each use. Semi-critical items are instruments that contact mucous membranes but do not penetrate soft tissue (eg, mouth mirrors, reusable impression trays). These should also be heat sterilized after each use. Noncritical items are instruments or devices that only contact intact skin (eg, blood pressure cuffs, X-ray tube head).¹ These require intermediate or low-level disinfection depending on the level of contamination.

Sterilization protects both patients and oral health professionals by ensuring that instruments are free from all forms of microbial life, including spores. This process must be consistent, validated, and documented as part of a comprehensive infection control program.^1,2 Effective sterilization reassures patients about the safety of dental care and fulfills the legal and ethical responsibility of the provider.

Sterilization Monitoring

The CDC provides clear guidance on sterilization monitoring in dental practices to ensure patient safety and prevent disease transmission. Three types of monitoring are recommended by the CDC and required by the OSHA Bloodborne Pathogens Standard as a comprehensive quality assurance system for sterilization procedures.^1,2 Monitoring includes mechanical, chemical, and biological monitoring.

Mechanical monitoring includes observing or visually verifying the gauges on the sterilizer including time, temperature, and pressure readings, which should be conducted during each sterilization cycle.¹ Some new sterilizers include technology that prints out mechanical monitoring results on a tape roll or through removable USB devices, wireless internet connection, or cloud storage. New technology can eliminate the need for visual monitoring, improving staff efficiency.

Chemical monitoring includes the use of chemical indicators (CI), which should be used with every package processed, including both external and internal indicators, to visually verify that sterilization conditions were met. CIs are designed to react to one or more parameters of the sterilization process, typically time, temperature, and presence of steam or gas.^1,4,5 These indicators provide immediate visual confirmation that the sterilization cycle has reached the required conditions for efficacy, although they do not prove microbial kill like a biological spore test.

CIs are located on sterilization pouches, which turn color when the parameters are reached or as indicator strips, known as integrators, are placed inside of a cassette, pouch, or bag. CIs should be used in every package, tray, or load to provide immediate feedback on whether sterilization parameters were met. When used consistently with biological monitoring, CIs enhance patient safety and support compliance with infection prevention protocols.

Biological monitoring should be performed at least weekly (as a minimum) and whenever a sterilizer is newly installed, repaired, or relocated.^1,5 The CDC also emphasizes the importance of documenting the results of each spore test, maintaining records in compliance with OSHA, and taking immediate corrective action in the event of a failed test result. Results of all monitoring should be recorded and documented for compliance.^1,2

While biological indicators (BIs), or spore tests, are the most reliable method for monitoring sterilization, CIs also play a vital role in daily sterilizer performance checks. Used alongside BIs, CIs offer additional layers of assurance and are essential for maintaining quality control in sterilization procedures. Table 1 outlines the six types of CIs.

The CDC also recommends that dental practices develop and follow written policies and procedures for recording and documenting results of sterilization monitoring and for sterilization processes, including response protocols for positive BI tests (failed spore tests).^1,4

Instruments should not be used until a passing spore test confirms sterilizer performance.^4,6,7 Failure to remove a malfunctioning sterilizer, or to recall and reprocess potentially contaminated instruments, may result in significant health risks and regulatory penalties.⁴

Types of Sterilizers Used in Dentistry

Several types of sterilizers exist, each designed to meet specific needs based on instrument load, material type, and workflow. Oral health professionals must understand the instructions for use (IFU) for each sterilizer machine used in the practice setting, as each machine operates differently. Consulting the manufacturer’s IFU for loading and operating instructions vs relying on previous experience or legacy errors is prudent. The manufacturer’s IFU will also outline the recommended types of chemical and biological monitoring products to use, guiding the user on compatibility features. Therefore, understanding the sterilizer specifics will guide the user on best practices with chemical and biological monitoring in their setting. Common types of sterilizers are:⁴

1. Steam Sterilizers (Autoclaves)

• Use pressurized steam to achieve sterilization
• Fast, effective, and compatible with most dental instruments; common in dentistry
• Available in gravity displacement and pre-vacuum (high-speed) models

2. Dry Heat Sterilizers

• Use high temperatures without moisture to sterilize instruments
• Suitable for instruments that may corrode or dull with steam
• Require longer cycle times than steam sterilizers

3. Chemical Vapor Sterilizers

• Use a mixture of chemicals heated under pressure to sterilize
• Less corrosive than steam; appropriate for heat- and moisture-sensitive instruments
• Require adequate ventilation due to chemical emissions

4. Unsaturated Chemical Vapor Sterilizers and Gas Plasma

• Used less frequently in dentistry
• Effective for delicate, heat-sensitive items

Sterilizer choice depends on factors, such as instrument compatibility, sterilization time, environmental controls, and cost. Regardless of type, all sterilizers must be maintained, calibrated, and monitored using mechanical, chemical, and BIs to ensure optimal performance.^1,2

Biological monitoring evaluates whether a sterilization cycle effectively kills highly resistant microorganisms, typically bacterial endospores from Geobacillus stearothermophilus or Bacillus atrophaeus.¹ This form of testing can detect failures in the sterilization process that may not be identified by mechanical means or CIs alone. Two methods are commonly used in dental offices: in-office testing kits and mail-in biological monitoring services. Table 2 outlines the process for conducting both methods of spore testing.

Spore Testing

In-office spore testing kits allow dental practices to incubate and read BIs on-site. These kits typically consist of spore strips or self-contained vials and an incubator. The turnaround time for results is faster, typically within 24 to 48 hours, allowing immediate identification of sterilization failures.⁴ Newly developed ultra-rapid incubators can provide results within 20 to 60 minutes. Ultra-rapid BI testing uses advanced detection methods, such as bioluminescence, to provide rapid results vs slower culture methods.⁸

The advantages of in-office spore testing include immediate feedback and rapid results. The user determines when testing and incubation occurs, making it convenient and controllable. The initial kit includes a one-time incubator purchase. Spore testing vials are the only supply that is needed after the initial purchase. Long-term, this method can be cost effective.

Some of the disadvantages of in-office spore testing include time and training. Staff training is required initially to understand the process of adherence to incubation protocols. Therefore, there is a risk of human error during processing or interpretation. It is crucial to maintain the incubator and monitor the temperature accurately.

Mail-in testing involves sending BIs to a laboratory for incubation and result reporting. A control and an exposed spore strip are enclosed in a special envelope provided by a vendor and mailed in. The process is generally outsourced to third-party vendors who provide detailed reporting and quality assurance services.

The advantages of mail-in spore testing include low cost and ease of use. Mail-in envelopes, including the control strip and the spore strip, are provided and are relatively inexpensive. The user places the strip into the sterilizer in a challenging area, and it is run through a regular sterilization cycle.

Challenging areas include the center of a gravity displacement steam sterilizer, or near the door of a pre-vacuum steam sterilizer. Once completed, the strip is placed back into the envelope, the envelope is labeled and mailed to the vendor for laboratory incubation. This method reduces in-office workload and eliminates the need for an incubator. The spore testing is performed by trained laboratory personnel upon arrival. Results are documented and reported back to the office after 48 hours of incubation.

Some of the disadvantages of mail-in spore testing include delayed results and the risk of getting lost in the mail. The slower mail-in method might delay results for up to 7 days. The risk of an unknown delayed spore test failure could result in contaminated instruments being used, forcing an instrument recall or worst-case scenario of contacting patients.

Regardless of the testing method used, documentation and recordkeeping are essential for OSHA compliance.² Sterilizer monitoring records must be maintained for 1 to 3 years depending on state regulations and should include date, sterilizer used, type of test, results, and actions taken if results indicate failure.² The CDC recommends maintaining records for 3 years.¹ Dental practices should develop written policies that outline procedures for biological monitoring and corrective actions in the event of sterilization failure. Figure 1 outlines the steps and corrective action needed when a spore test fails.

The CDC does not specify a preferred method (in-office vs mail-in) but emphasizes the need for regular weekly testing and proper documentation.¹ Practices must also verify that spore test strains, incubation methods, and result interpretations follow manufacturer instructions and scientific standards.

Best Practices for Spore Testing

Several best practices are needed to ensure compliance with biological monitoring. First, a trained staff member or infection control coordinator should be designated to oversee sterilization monitoring. Having one or two staff members responsible for this important task eliminates human error and enhances correct safety procedures.

Biological monitoring should be performed at least weekly (at a minimum) and whenever a sterilizer is newly installed, repaired, or relocated.^1,4 Second, a method for biological monitoring should be chosen that aligns with the practice’s size, volume, and workflow. High-volume practices with rapid instrument turnover might consider in-office methods for quicker results. Third, perform and log results at least weekly, or more often depending on the practice volume, as well as after sterilizer repairs or failures. It is vital to keep backup indicators and supplies available. Finally, immediately investigate and document any positive test results (failed spore tests) and take corrective action. Failed spore tests happen and are often a result of human error such as overloading the sterilizer.

Conclusion

Sterilization is non-negotiable in dental settings and spore testing is an essential component of verifying sterilizer effectiveness. Both in-office incubation and mail-in methods have merits and limitations. Dental practices must choose the most appropriate option based on workflow, resources, and compliance needs. Consistent monitoring, accurate documentation, and staff training are crucial.

References

1. United States Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings—2003. MMWR Recomm Rep. 2003;52(RR-17):1–61.
2. Occupational Safety and Health Administration. 29 CFR 1910.1030 – Bloodborne Pathogens. Available at osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030. Accessed December 16, 2025.
3. United States Centers for Disease Control and Prevention. COVID-19 Guidance for Dental Settings. Available at cdc_88256_DS1.pdf. Accessed December 16, 2025.
4. United States Centers for Disease Control and Prevention. Best Practices for Sterilization Monitoring in Dental Settings. Available at cdc.gov/dental-infection-control/hcp/dental-ipc-faqs/sterilization-monitoring.html. Accessed December 16, 2025.
5. Association for the Advancement of Medical Instrumentation (AAMI). Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Available at https://array.aami.org/doi/book/10.2345/9781570208027. Accessed December 16, 2025.
6. Sasaki J, Imazato S. Autoclave sterilization of dental handpieces: A literature review. J Prosth Res. 2020;3: 239-242.
7. Patiño-Marín N, Villa García L, Aguirre López E, et al. Sterilization and disinfection: ensuring infection control in dental practices. Cureus. 2025;17:e79041.
8. Rams TE, Sautter JD, Lee AH, van Winkelhoff AJ. Evaluation of a rapid biological spore test for dental instrument sterilization. J Contemp Dent Pract. 2022;23:279-283.

From Dimensions of Dental Hygiene. January/February 2026; 24(1):9-12

Lasers have traditionally been used for excisional procedures, but over the past two decades, important nonsurgical applications have emerged. Novel modifications in laser technology now allow their use to accelerate healing, reduce inflammation, and diminish pain — all noninvasively.

This approach is termed photobiomodulation or photobiomodulation therapy and is defined as the targeted application of light for therapeutic purposes at a level below that associated with cutting of tissue or damage to structural proteins. The concept was introduced in 1971 and has been thoroughly researched since that time.^1,2

Photobiomodulation delivers photons of light to the affected area and can be generated by a variety of lasers. The lasers that can develop these photons can be differentiated by the wavelength of light generated and the depth of penetration of the energy produced. Early generations of these devices could only deliver power sufficient to penetrate superficial tissues. This low-powered process is most frequently termed low-level laser therapy (LLLT). These lasers, by definition, produce 0.5 watts or less of power, which limits the depth of tissue penetration. The wavelengths produced by these devices range from 390 to 600 nm. More powerful lasers can deliver light energy to deeper tissues, a process termed high-intensity laser therapy (HILT), and generate wavelengths ranging from 810 to 1,064 nm. Both LLLT and HILT are noninvasive, with minimal negative side effects and both positively affect numerous cellular processes.

Of greatest clinical significance is the energy absorbed by molecules in the tissue called chromophores. This is because it leads to the production of energy, which results in many of the positive responses seen following photobiomodulation. Some energy may also be transmitted through the tissue, while other photons can be scattered and yet others are reflected thus diminishing the positive effects of therapy (Figure 1). When energy is absorbed, it produces photochemical effects, including increasing cellular adenosine triphosphate (ATP) production by targeting mitochondrial chromophores (Figure 2).³

HILT is able to produce high peak power (in the kilowatt range) and short pulses with a low duty cycle (0.1% to 0.01%), ensuring sufficient cooling of tissues between emissions. Unlike high-power lasers (HPL) that operate with higher duty cycles (10% to 100%) and lower peak power, HILT uniquely induces the photomechanical effects through the generation of photoacoustic waves.

These waves directly impact the extracellular matrix and cytoskeleton, triggering cascades of biological responses that promote tissue regeneration and repair.⁴ Additionally, HILT can be adjusted to longer pulses for controlled photothermal effects,^5,6 which propagate thermal energy through tissue to activate cellular heat shock proteins (HSPs), such as HSP47 and HSP72. These proteins play critical roles in tissue remodeling, particularly in fibrotic conditions.⁶

Photobiomodulation can induce photochemical effects across all laser types. Both HPL and HILT are capable of producing combined photochemical and photothermal effects. However, HILT induces all three effects: photochemical, photothermal, and photomechanical (Figure 3). This unique capability makes HILT suitable for applications requiring deep tissue penetration and more comprehensive biological modulation. To achieve these tailored therapeutic outcomes, careful consideration of laser parameters is essential.

The photothermal effect results in vasodilation. Clinically, HILT has been shown to stimulate blood flow through angiogenesis and extracellular matrix synthesis that can lead to more rapid healing times for oral wounds.⁷ Another important part of stimulating the healing process is the effect of photobiomodulation on susceptible stem cells and progenitor cells as well as its potential to enhance cell differentiation, all of which, in turn, improve the rate of healing.⁸ Multiple studies have reported that stem cell proliferation is improved by photobiomodulation, including the production of gingival fibroblasts. Its effect on dental pulp stem cells extracted from permanent teeth, and exfoliated deciduous teeth has also been studied.⁹

Photobiomodulation can also be used to stimulate the immune response. Near infrared wavelengths (HILT) increase the production of nitric oxide, a compound that aids in healing cells and increases blood flow. Nitric oxide regulates the activation, proliferation, and differentiation of immune cells. White blood cells release nitric oxide when detecting a threat, so increasing nitric oxide levels that can stimulate the immune system, regulate blood pressure, and reduce inflammation.¹⁰

Dental Applications

Photobiomodulation has been used in dentistry for decades. Until recently, the majority of applications employed LLLT. Early studies on the use of LLLT to treat temporomandibular joint problems had mixed results but subsequent research using HILT frequently reduced pain, increased range of motion, and decreased disability compared to LLLT.¹¹

Photobiomodulation can also reduce dental pain, be used to induce dental anesthesia,¹² reduce dental hypersensitivity,¹³ and diminish pain following orthodontic band placement.¹⁴ A meta-analysis of pain relief using photobiomodulation demonstrated that laser phototherapy was very efficacious in relieving pain.¹⁵

The effect of photobiomodulation on orthodontic tooth movement has been studied extensively. One review of wavelengths between 780 and 830 nm showed an increase in the speed of tooth movement vs controls by 24%.¹⁶ Another group that received HILT had accelerated tooth movement during molar uprighting compared to controls.¹⁷ A recent review concluded that photobiomodulation can effectively reduce orthodontic treatment time and produce anesthesia and anti-inflammatory effects. A concern of the reviewers was a lack of consistency among photobiomodulation protocols.¹⁸

Of clinical significance is this therapy’s effect on the healing of bone. Photobiomodulation has been shown to accelerate healing in extraction sockets in both animal and human models.^19-21 It has also been shown to speed bone healing around dental implants. One study of bone deposition around dental implants in rabbit tibia using HILT concluded that laser photobiomodulation accelerated bone healing around these devices compared to controls.²² In one animal study, photobiomodulation was found to accelerate bone healing by stimulating blood flow, activating osteoblasts, and diminished osteoclastic activity when used in extraction sites augmented with hydroxyapatite biomaterial.²³ One study of dental implants placed into rat femurs and treated with either 660 nm or 808 nm lasers, found increased bone tissue matrix production compared to controls.²⁴

A number of studies have looked at the effect of photobiomodulation therapy on treating erosive lichen planus. The majority indicate that higher intensity levels reduce or remove the necessity for more aggressive forms of therapy, making laser therapy the safer alternative. Specifically, HILT has been found to be superior to surgical removal of these lesions²⁵ and has also been shown to reduce pain associated with these lesions.²⁶ Using HILT often eliminates the need for corticosteroid therapy, thus reducing the possible systemic problems associated with this form of therapy.

Conclusion

Photobiomodulation is safe and effective. Applications using LLLT are best reserved for superficial tissues such as gingiva. It seems reasonable that the use of longer wavelengths produced by HILT will have a more profound effect and thus work better for most hard tissue applications. One drawback to the use of photobiomodulation is the lack of specific wavelengths and settings for specific therapeutic applications. Unfortunately, the studies on this topic are heterogeneous, and further study is needed to gain more specificity. Research is ongoing to specifically find the type of laser and the settings for that laser for each individual dental application. It is undoubtedly true that this technology will advance with our knowledge of more directed applications and thus be beneficial for many of our patients.

Acknowledgment

The authors would like to thank Damiano Fortuna, DVM, and 
Kathryn Mootz, MBA, for their help with this manuscript.

References

1. Mester E, Ludany G, Selyei M, Szende B, Total GJ. The stimulating effect of low power laser rays on biological systems. Laser Rev. 1968;3:12-14.
2. Rodriguez Salazar DY, Malaga Rivera JA, Laynes Effio JE, Valencia-Arias A. A systematic review of trends in photobiomodulation in dentistry between 2018 and 2022: advances and investigative agenda. F1000Res. 2023;12:1415.
3. Zati A, Valent A. Physical therapy: new technologies in rehabilitation medicine (translated to English). Edizioni Minerva Medica. 2006;2006:162-185.
4. Fortuna D, Masotti L. The HILT domain by the pulse intensity fluence (PIF) formula. Energy for Health. 2010;5(5):12-19.
5. Farivar S, Malekshahabi T, Shiari R. Biological effects of low level laser therapy. J Lasers Med Sci. 2014;5:58-62.
6. Cronshaw M, Parker S, Grootveld M, Lynch E. Photothermal effects of high-energy photobiomodulation therapies: an in vitro investigation. Biomedicines. 2023;11:1634.
7. da Silva Neves FL, Silveira CA, Dias SB, et al. Comparison of two power densities on the healing of palatal wounds after connective tissue graft removal: randomized clinical trial. Lasers Med Sci. 2016;31:1371-1378.
8. de Freitas LF, Hamblin MR. Proposed mechanisms of photobiomodulation or low-level light therapy. IEEE J Sel Top Quantum Electron. 2016;22:2561201
9. Fernandes AP, Junqueira Mde A, Marques NC, et al. Effects of low-level laser therapy on stem cells from human exfoliated deciduous teeth. J Appl Oral Sci. 2016;24:332-337.
10. Barolet AC, Litvinov IV, Barolet D. Light-induced nitric oxide release in the skin beyond UVA and blue light: red & near-infrared wavelengths. Nitric Oxide. 2021;117:16-25.
11. Ekici O, Dundar U, Buyukbosna M. Effectiveness of high-intensity laser therapy in patients with myogenic temporomandibular joint disorder: A double-blind, placebo-controlled study. J Stomatol Oral Maxillofac Surg. 2022;123:e90-e96.
12. Poli R, Parker S. Achieving dental analgesia with the erbium chromium yttrium scandium gallium garnet laser (2780 nm): a protocol for painless conservative treatment. Photomed Laser Surg. 2015;33:364-371.
13. Cattoni F, Ferrante L, Mandile S, Tete G, Polizzi EM, Gastaldi G. Comparison of lasers and desensitizing agents in dentinal hypersensitivity therapy. Dent J (Basel). 2023;11:11030063.
14. Sfondrini MF, Vitale M, Pinheiro ALB, et al. Photobiomodulation and pain reduction in patients requiring orthodontic band application: randomized clinical trial. Biomed Res Int. 2020;2020:7460938.
15. Kate RJ, Rubatt S, Enwemeka CS, Huddleston WE. Optimal laser phototherapy parameters for pain relief. Photomed Laser Surg. 2018;36:354-362.
16. Dominguez Camacho A, Montoya Guzman D, Velasquez Cujar SA. Effective wavelength range in photobiomodulation for tooth movement acceleration in orthodontics: a systematic review. Photobiomodul Photomed Laser Surg. 2020;38:581-590.
17. Murakami-Malaquias-Silva F, Perim Rosa E, Malavazzi TCS, et al. Photobiomodulation increases uprighting tooth movement and modulates IL-1beta expression during orthodontically bone remodeling. J Biophotonics. 2023;16:e202300013.
18. Goncalves A, Monteiro F, Brantuas S, et al. Clinical and preclinical evidence on the bioeffects and movement-related implications of photobiomodulation in the orthodontic tooth movement: A systematic review. Orthod Craniofac Res. 2025;28:12-53.
19. Daigo Y, Daigo E, Hasegawa A, Fukuoka H, Ishikawa M, Takahashi K. Utility of High-intensity laser therapy combined with photobiomodulation therapy for socket preservation after tooth extraction. Photobiomodul Photomed Laser Surg. 2020;38:75-83.
20. Daigo Y, Daigo E, Fukuoka H, Fukuoka N, Ishikawa M, Takahashi K. Wound healing and cell dynamics including mesenchymal and dental pulp stem cells induced by photobiomodulation therapy: an example of socket-preserving effects after tooth extraction in rats and a literature review. Int J Mol Sci. 2020;21:21186850.
21. Amaroli A, Colombo E, Zekiy A, Aicardi S, Benedicenti S, De Angelis N. Interaction between laser light and osteoblasts: photobiomodulation as a trend in the management of socket bone preservation-a review. Biology (Basel). 2020;9:9110409.
22. Lopes CB, Pinheiro AL, Sathaiah S, Da Silva NS, Salgado MA. Infrared laser photobiomodulation (lambda 830 nm) on bone tissue around dental implants: a Raman spectroscopy and scanning electronic microscopy study in rabbits. Photomed Laser Surg. 2007;25:96-101.
23. Dalapria V, Marcos RL, Bussadori SK, et al. LED photobiomodulation therapy combined with biomaterial as a scaffold promotes better bone quality in the dental alveolus in an experimental extraction model. Lasers Med Sci. 2022;37:1583-1592.
24. da Fonseca G, Cavalcanti M, de Souza Maior JD, et al. Laser-photobiomodulation on titanium implant bone healing in rat model: comparison between 660- and 808-nm wavelength. Lasers Med Sci. 2022;37:2179-2184.
25. Tarasenko S, Stepanov M, Morozova E, Unkovskiy A. High-level laser therapy versus scalpel surgery in the treatment of oral lichen planus: a randomized control trial. Clin Oral Investig. 2021;25:5649-5660.
26. Khater MM, Khattab FM. Efficacy of 1064 Q switched Nd:YAG laser in the treatment of oral lichen planus. J Dermatolog Treat. 2020;31:655-659.

From Dimensions of Dental Hygiene. January/February 2026; 24(1):14-16

Artificial intelligence (AI) is taking dentistry by storm, impacting many aspects of the profession including diagnostics, treatment planning, and business operations.¹ One subset of AI, computer vision, is emerging as an innovative approach to improve ergonomics. Adding to dentistry’s AI arsenal, this image-processing technology can support oral health professionals in reducing musculoskeletal disorders (MSDs) in the workplace.

Oral health professionals are at increased risk for MSDs due to the need for static and awkward postures, repetitive motions, and vibrating equipment.² With MSDs affecting an estimated 78% of oral health professionals, effective interventions are critical.² Through computer vision use in ergonomic assessments, dentistry can leverage this technology to respond to its MSD challenge.

Ergonomic Assessments

To fully understand AI’s impact on ergonomics, the foundations of an ergonomic assessment must be reviewed. Ergonomic assessments involve observing and analyzing the subject’s body mechanics; they are performed to address risk factors for MSDs. Ergonomic professionals facilitate these assessments, which can be conducted on working individuals or for research purposes.^3,4

The most widely used ergonomic assessment tools are the rapid upper limb assessment (RULA) and rapid entire body assessment (REBA).³ RULA quickly measures risk by analyzing body posture, force, and repetition concentrating on the neck, trunk, and upper extremities. Scores range from one to seven, with one designating acceptable posture. A score of seven indicates immediate investigation of posture and that changes are needed. REBA looks at the whole body and is commonly used in manual work, healthcare, and service industries. REBA scores range from one to 15, with one being low risk and 15 being very high risk.^3,4

Ergonomic assessment tools, such as RULA and REBA, allow for a measured evaluation of body alignment and are often used within the dental profession.⁵ A recent pilot study by Partido et al⁶ used RULA to examine the impact of an alternating seating-standing protocol on posture for dental hygiene students. While not statistically significant, results showed that the RULA scores of the students alternating seating and standing during scaling were lower than the control group that remained seated.

Traditionally, ergonomic evaluations are done through human observation, but this method is prone to user error and bias and is time consuming.⁷ An alternative is to have the subject use wearable devices to measure posture. While accurate, this technique can be cumbersome and it limits the natural movement of the subject.⁸ Incorporating computer vision into assessments may reduce the limitations that traditional methods face.

Computer Vision Artificial Intelligence

Ergonomic AI technology uses computer vision, which processes and analyses visual content such as images or videos. By translating an image into numbers, the computer can process the data into useful applications. With vast applicability, its uses vary from simple to complex, including facial and object recognition, self-driving cars, and sports performance analysis.

Within the ergonomics field, computer vision identifies an individual’s posture (joint angles), speed, and force used. From the data collected, AI can quickly calculate ergonomic scores such as REBA and RULA. Other applications include a comparison of before and after ergonomic interventions, calculations of large data sets, and prediction of subjects’ future movements.

Computer vision for ergonomics has been validated for accuracy and comes with many benefits.⁷ A systematic review of computer vision use in ergonomics found that it costs less than wearable device methods, is noninvasive, holds the potential for automatic features, and can be used in a variety of environments.⁷

One of the main challenges noted in the review was obstacle occlusion, or a physical object blocking part of the subject’s body. Another limitation was the limited amount of real-world application research conducted thus far, potentially affecting accuracy and data-set benchmarks. However, computer vision technology is gaining in popularity. As is the nature of AI, the more data available to the technology, the more it can learn, improving precision and application.⁷

Ergonomic computer vision has been employed in various professions such as construction, healthcare, administration, agriculture, and transportation.⁷ In a recent narrative review of computer vision use among cardiothoracic surgeons, the benefits included the ability to provide feedback on the surgeon’s technique and the potential to investigate the link between aspects of procedures and patient outcomes.⁹ It was also noted that computer vision allows for movement tracking in the operating room without the use of special equipment or markers.⁹

Use of Ergonomic Artificial Intelligence

With many other professions now using AI for ergonomics, dentistry should consider doing the same. The following examples show applications within the dental field by using an ergonomic AI program facilitated by an ergonomic specialist. In Figure 1, a color-coded skeleton overlay of the clinician illustrates the risk for MSDs. Green indicates low risk with joint angles within normal range. Yellow demonstrates moderate risk and red indicates high risk.

Figure 1 shows a screenshot of a video recording taken of a dental hygienist hand scaling in the 9 o’clock position. Using computer vision, data, such as joint angles, joint speed, and time spent in each respective risk category ,were quickly obtained. Table 1 shows the average postural angle of each joint attained during the duration of the video (15 seconds) and the respective risk denoted by color. For  example, the clinician’s right wrist flexion measured 27.9° and is categorized within the red, high-risk range. Within the ergonomic AI program, REBA and RULA scores can also be generated. For this example, the REBA score was 10, indicating high risk, requiring immediate intervention.

Based on the data collected, ergonomic interventions can then be recommended by an ergonomic specialist. Potential solutions to decrease risk and improve ergonomics include but are not limited to modifications in patient-operator positioning to achieve neutral posture and a saddle stool to improve forward flexion of the trunk.

Not only are the data from the assessments insightful, but the visual feedback for oral health professionals can also be impactful.^10-12 With the addition of video and the skeleton overlay showing risk, clinicians can receive constructive feedback to improve their ergonomics. As demonstrated by a recent study conducted with surgeons utilizing a computer vision ergonomic AI app, residents were able to reduce their percentage of time spent in an unsafe neck joint angle by 61%.¹³ Adopting similar ergonomic AI approaches in dentistry could provide comparable outcomes. While more research is needed, the potential for improved neutral posture for oral health professionals is compelling.

Another benefit of ergonomic AI technology is the ability to quickly compare ergonomic interventions. Figure 2 shows a dental hygiene student wearing standard safety glasses (A) in contrast to ergonomic deflection loupes (B). The safety glasses resulted in an average neck flexion of 25.8°, while deflection loupes reduced neck flexion to an average of 7°.

When using computer vision AI with video recording, clinicians must protect patient and provider privacy, comply with Health Insurance Portability and Accountability Act regulations, and ensure all recordings are handled securely.

Conclusion

AI use in ergonomics is rising, allowing for quantitative and objective evaluations that support data-driven solutions. The dental profession can take advantage of this emerging technology to address its struggle with ergonomics and MSDs. Whether it’s to help individual clinicians, students, or for future research, AI technology will bring exciting developments to ergonomics in dentistry.

References

1. Xie B, Xu D, Zou XQ, Lu MJ, Peng XL, Wen XJ. Artificial intelligence in dentistry: A bibliometric analysis from 2000 to 2023. J Dent Sci. 2024;19:1722-1733.
2. Lietz J, Kozak A, Nienhaus A. Prevalence and occupational risk factors of musculoskeletal diseases and pain among dental professionals in Western countries: a systematic literature review and meta-analysis. PloS One. 2018;13:e0208628.
3. Joshi M, Deshpande V. A systematic review of comparative studies on ergonomic assessment techniques. International Journal of Industrial Ergonomics. 2019;74:102865.
4. Kee D. Systematic comparison of OWAS, RULA, and REBA based on a literature review. Int J Environ Res Public Health. 2022;19:595.
5. Danylak S, Walsh L, Zafar S. Measuring ergonomic interventions and prevention programs for reducing musculoskeletal injury risk in the dental workforce: a systematic review. J Dent Educ. 2024;88:128-141.
6. Partido B, Henderson R, Lally M. Impact of a seated-standing protocol on postures and pain among undergraduate dental hygiene students: a pilot study. J Dent Hyg. 2021;95:70-78.
7. Egeonu D, Jia B. A systematic literature review of computer vision-based biomechanical models for physical workload estimation. Ergonomics. 2025l68:139-162.
8. Sabino I, Maria, Cepeda C, et al. Application of wearable technology for the ergonomic risk assessment of healthcare professionals: A systematic literature review. International Journal of Industrial Ergonomics. 2024;100:103570-103570.
9. Constable MD, Hubert, Clark S. Enhancing surgical performance in cardiothoracic surgery with innovations from computer vision and artificial intelligence: a narrative review. J Cardiothorac Surg. 2024;94:19.
10. Mills M, Smilyanski I, Giblin‐Scanlon L, Vineyard J. What are the effects of photographic self‐assessment on students’ risk for musculoskeletal disorders using rapid upper limb assessment. J Dent Educ. 2020;84:749-754.
11. Partido B, Henderson R, Kennedy M. Improving the awareness of musculoskeletal disorder risks among dental educators. J Dent Educ. 2019;83:e1-e8.
12. Partido B, Henderson R. Reducing the risks for musculoskeletal disorders utilizing self-assessment and photography among dentists and dental hygienists. J Dent Hyg. 2021;95:36-41.
13. Barbara C.S. Hamilton, Dairywala MI, Highet A, et al. Artificial intelligence based real-time video ergonomic assessment and training improves resident ergonomics. Am J Surg. 2023;226:741-746.

From Dimensions of Dental Hygiene. January/February 2026; 24(1):18-20

Dental caries remains the most common, chronic, preventable disease impacting children globally.¹ A multifactorial condition, early childhood caries (ECC) is characterized by the presence of one or more decayed, missing or filled (DMF) teeth in the primary dentition of children younger than age 6.^1,2

Any smooth surface cavitated lesion is considered severe early childhood caries (S-ECC) among children younger than age 3.² In 2019, an estimated 43% (514 million) of children ages 1 to 9, across the globe, had dental caries in primary teeth.³ In the United States, between 2017 and 2020, nearly half (46%) of children ages 2 to 19 had untreated or restored dental caries. Among children ages 2 to 5, 22% had untreated or restored dental caries, and this prevalence increased with age.⁴ Moreover, children from households with a federal poverty level (FPL) less than 350% had a higher prevalence of untreated or restored dental caries than those living above 350% of the FPL.⁴

ECC can impact a child’s oral health-related quality of life (OHRQoL), which is the impact of oral disease on an individual’s physical functioning and psychological and social well-being.^5-7 A recent systematic review demonstrated that higher DMF scores were related to greater impact on a child’s OHRQoL and increased visits to the emergency department for dental problems.⁷

When compared to children without ECC, children with ECC exhibit a significantly greater likelihood of developing caries in their permanent dentition and are more susceptible to adverse health and social outcomes, including school absenteeism, sleep disturbances, anemia and infections, impaired physical growth and development, reduced quality of life, and social isolation.^8-11

Determining a Successful Approach to Early Childhood Caries Prevention

The multifactorial risks associated with ECC must be considered prior to birth. The biological mechanisms of oral health, including the microflora, host and teeth, and diet, are connected to modifiable risk factors that encompass family-level, community-level, and child-level influences. This complex system influences children’s oral health outcomes, specifically, ECC.^1,12

Conversations related to oral health behaviors and practices should begin during the gestational period. This period is an ideal time to provide dental care and education regarding dental caries prevention for the expectant mother to protect both her oral health and that of the child.¹³ Communication strategies, such as motivational interviewing (MI), are effective in reducing dental caries among children.^14-16 Furthermore, the American Academy of Pediatric Dentistry (AAPD) promotes collaborative efforts for preventive practices among healthcare professionals and caregivers as a strategy to decrease ECC among children, which minimizes the burden on the child, family, and society.⁸

The Impact of Dietary Behaviors on Early Childhood Caries

Dietary behaviors are at the core of ECC and occur prior to the birth of the child through familial behaviors.¹ The mother, caregivers, and family establish dietary habits for the child. Therefore, providing dietary counseling to caregivers is essential to promote healthier behaviors in children and serves as a key preventive measure against ECC.⁸

Aligning the nutrition of foods, the timing of intake, and the frequency of consumption is also a large part of nutritional guidelines for children with ECC. Nutritional recommendations to caregivers should include advising against cariogenic foods/sugary drinks near bedtime, assessing the consumption of sugar in food and drinks, evaluating sticky foods and children’s gummy multivitamins, and educating caregivers on the importance of avoiding foods that can remain in the pits and fissures of primary molars.¹⁷ The caregiver may want to track the frequency of cariogenic foods and beverages, as these cause an acidic pH in the mouth, further contributing to ECC.

The Influence of Oral Health Behaviors on Early Childhood Caries

Prevention of dental caries in children is cost effective and relates to decreased treatment needs. Early establishment of a dental home by age 1 is a sustained national recommendation by the AAPD.^18,19 Moreover, establishing a collaborative relationship between dentists and physicians at the community level can support primary care providers recommending a dental visit for children by age 1, based on risk assessment.²⁰

Guidelines for ECC prevention include community water fluoridation, specifically for vulnerable communities, and a minimum of 1,000 to 1,500 ppm fluoride toothpaste used twice daily for all children.^1,8 A smear of toothpaste should be used for children younger than age 3 and a pea-sized amount for children ages 3 to 6.^6,21

Effective at-home oral hygiene is essential, especially for children in dental care shortage areas who face transportation barriers to in-office care. Recent data from a cross-sectional study of the geographic distribution of accessibility to US dental clinics indicated that 24.7 million people live in a dental care shortage area, which is defined as less than one dental office per 5,000 residents.²²

Strategies for Effective Management of Early Childhood Caries

The management of ECC should be based on caries risk assessment, parent/caregiver participation in oral self-care, age and current oral health status.⁵ In 2020, a scoping review critically evaluated global guidelines, policies, and guidance for the treatment of ECC.⁵ Inclusion criteria were studies from 2011-2018 written in English and ranged from the US, United Kingdom, Malaysia, Brazil, Chile, Argentina, European Academy of Paediatric Dentistry, and the British Society of Paediatric Dentistry. Fifty-two studies were assessed, with 22 meeting criteria for inclusion in the scoping review.

Interestingly, the studies reviewed indicated that the approach for incipient lesions differed from the approach for cavitated carious lesions (Table 1). For incipient caries, a watch approach was indicated, and the application of fluoride varnish (5% professional NaF) or brushing with a nonprescription fluoride toothpaste at home was recommended. This approach is appropriate only when the child has strong parent/caregiver support. Additionally, sealants on occlusal surfaces or composite resin on interproximal surfaces were recommended.

The authors found minimally invasive 38% silver diamine fluoride (SDF) recommended for both cavitated and noncavitated carious lesions.⁵ A systematic review within the scoping review further concluded and supported SDF’s ability to arrest cavitated and noncavitated lesions.²³ The World Health Organization also supports this recommendation.¹

Role of the Dental Hygienist in the Prevention and Management of Early Childhood Caries

Oral health professionals must be knowledgeable of the risk, prevention, and management strategies for ECC. Integrating caries risk assessment tools, such as the Caries Management by Risk Assessment (CAMBRA), will help clinicians assess a patient’s biological and environmental risk factors, such as familial decay history and protective factors, among children ages 0 to 6.²⁴

Dental hygienists, in partnership with healthcare professionals, are instrumental in providing oral hygiene education to caregivers to decrease the risk of ECC. Regular preventive care should be emphasized and related to overall health.²⁵

Motivational interviewing (MI) should be used to promote positive oral health behavior change in patients that can be modeled to their young children. Brief MI, an alternative approach to MI with shorter 5- to 15-minute sessions, works best with the time constraints of dental hygiene appointments.²⁶ While a single session of brief MI may be insufficient to produce behavior change, successive sessions can build on and facilitate long-term improvements in oral health outcomes.

Finally, supporting professional autonomy, expanded scope of practice, and consistent national standards for dental hygienists may help reduce barriers such as limited access to dental care and transportation challenges. Expanding direct access to dental hygienists across the country may promote improved oral and overall health, while reducing dental emergencies.²⁵

Conclusion

ECC is a preventable oral disease experienced by young children. Prevention strategies, such as caries risk assessment, dietary counseling, motivational interviewing, and anticipatory guidance, should be considered for pregnant women and caregivers of young children. Oral health professionals can keep up to date on ECC by reviewing evidence-based literature and attending continuing education courses on best practice for prevention and management.

References

1. World Health Organization. Ending childhood dental caries: WHO implementation manual. Available at who.int/publications/i/item/ending-childhood-dental-caries-who-implementation-manual. Accessed December 11, 2025.
2. American Academy of Pediatric Dentistry. Definition of Early Childhood Caries (ECC). Available at aapd.org/assets/1/7/d_ecc.pdf. Accessed December 11, 2025.
3. World Health Organization. Global Oral Health Status Report: Towards Universal Health Coverage for Oral Health by 2030. Available at who.int/publications/i/item/9789240061484. Accessed December 11, 2025.
4. Stierman B, Afful J, Carroll MD, et al. National Health and Nutrition Examination Survey 2017–March 2020 prepandemic data files—Development of files and prevalence estimates for selected health outcomes. Natl Health Stat Report. 2021;14:10.15620.
5. Corrêa-Faria P, Viana KA, Raggio DP, Hosey MT, Costa LR. Recommended procedures for the management of early childhood caries lesions—a scoping review by the Children Experiencing Dental Anxiety: Collaboration on Research and Education. BMC Oral Health. 2020;20:75:1-11.
6. Tinanoff N, Baez RJ, Diaz Guillory C, et al. Early childhood caries epidemiology, aetiology, risk assessment , societal burden, management, education and policy: global perspective. Int J Paediatr Dent. 2019;29:238-248.
7. Zaror C, Matamala-Santander AM, Ferrer M, et al. Impact of early childhood caries on oral health-related quality of life: a systematic review and meta analysis. Int J Dent Hyg. 2022;20:120-135.
8. Policy on Early Childhood Caries: Classifications, Consequences and Preventive Strategies. The Reference Manual Of Pediatric Dentistry. Chicago: American Academy of Pediatric Dentistry; 2020:79–81.
9. Bagis EE, Derelioglu SS, Sengül F, et al. The effect of the treatment of severe early childhood caries on growth-development and quality of life. Children (Basel, Switzerland). 2023;10:411.
10. McGrath C, Broder H, Wilson-Genderson M. Assessing the impact of oral health on the life quality of children: implications for research and practice. Community Dent Oral Epidemiol. 2004;32:81-85.
11. Rodrigues do Amaral M, Freire-Maia J, Bittencourt JM, et al. Early childhood caries and its consequences impact sleep in preschool children. J Dent Child (Chic). 2024;91:25-30.
12. Fisher-Owens SA, Gansky SA, Platt LJ, et al. Influences on children’s oral health: A conceptual model. Pediatrics. 2007;120:e510-520.
13. National Maternal and Child Oral Health Resource Center. Oral Health Care During Pregnancy Consensus Statement. Available at: mchoralhealth.org/PDFs/OralHealthPregnancyConsensus.pdf. Accessed December 11, 2025.
14. Colvara BC, Faustino-Silva DD, Meyer E, Hugo FN, Celeste RK, Hilgert JB. Motivational interviewing for preventing early childhood caries: A systematic review and meta-analysis. Community Dent Oral Epidemiol. 2021;49:10-16.
15. Jahanshahi R, Amanzadeh S, Mirzaei F, Moghadam SB. Does motivational interviewing prevent early childhood caries? a systematic review and meta-analysis. J Dent (Shiraz). 2022;23:Suppl:161–168.
16. Manek S, Jawdekar AM, Katre AM. The effect of motivational interviewing on reduction of new carious lesions in children with early childhood caries: a systematic review and meta-analysis. Int J Clin Pediatr Dent. 2023;16:112–123.
17. Ma S, Ma Z, Wang X, et al. Relationship of dietary nutrients with early childhood caries and caries activity among aged 3-5 years- a cross sectional study. BMC Pediatr. 2024:24:506.
18. Chen J, Meyerhoefer, CD, Timmons E. The effects of dental hygienist autonomy on dental care utilization. Health Econ. 2024;33:1726-1747.
19. American Academy of Pediatric Dentistry. Policy on the Dental Home.Available at https://www.aapd.org/media/policies_guidelines/p_dentalhome.pdf. Accessed December 11, 2025.
20. Krol DM, Whelan K, Section On Oral Health. Maintaining and improving the oral health of young children. Pediatrics. 2023:151):1.
21. Drury TF, Horowitz AM, Ismail AI, Maertens MP, Rozier RG, Selwitz RH. Diagnosing and reporting early childhood caries for research purposes. J Public Health Dent. 1999; 59:192-197.
22. Rahman MS, Blossom JC, Kawachi I, Tipirneni R, Elani HW. Dental clinic deserts in the US: spatial accessibility analysis. JAMA Netw Open. 2024;7:e2451625.
23. Schmoeckel J, Gorseta K, Splieth CH, Juric H. How to intervene in the caries process: early childhood cares—a systematic review. Caries Res. 2020;54:102-112.
24. Featherstone JD, Crystal YO, Alston P, et al. A comparison of four caries risk assessment methods. Front Oral Health. 2021;2: 657518.
25. Hammond S. Missed Potential: How Expanding Dental Hygienists’ Roles can Bridge America’s Oral Health Gaps. Available at adha.org/advocacy/adha-white-papers. Accessed December 11, 2025.
26. Koerber A. Brief interventions in promoting health behavior change. In: Ramseier CA, Suvan JE. Health Behavior Change in the Dental Practice. Hoboken, New Jersey: John Wiley & Sons; 2011:93-112.

From Dimensions of Dental Hygiene. January/February 2026; 24(1):22-26

A clean, well-organized utility room supports the longevity of dental equipment. Dental office down days will tragically affect your schedule, budget, and salaries. This is why preventive maintenance should be top of mind. Even minor issues, such as dust and debris buildup, can restrict airflow and force systems to work harder than necessary, ultimately shortening their lifespan. This is why routine inspection and maintenance are essential to reducing equipment failure and minimizing the risk of compromised dental procedures.

For example, poor maintenance may result in clogged filters and vacuum lines, which can severely restrict the performance of dental equipment. Ignoring regular upkeep not only hampers efficiency but also compromises the safety of both patients and staff. Inadequate maintenance can also lead to moisture in the air compressor, which can affect bonding agents, leading to premature failure in dental procedures and handpieces.

Safety and Infection Prevention

Dental compressors and vacuum systems play a critical role in infection control and directly impact infection prevention. If these systems are not properly maintained — and if chemicals are stored in these areas — moisture, which leads to bacterial growth, and chemical vapors can accumulate and migrate into the operatory, compromising air quality. In addition, reduced suction efficiency can increase aerosol spread during clinical procedures.

Managing the utility room also influences environmental safety. To keep mercury and other dangerous substances out of the water system, the United States Environmental Protection Agency (EPA) says that amalgam separators must be used. To follow EPA and occupational safety rules, the amalgam separator and other important parts must work properly. If these systems aren’t maintained, they can go into bypass mode, which lets dangerous waste pass through without being treated. To stay compliant and keep working at their best, these separator filters need to be replaced on a regular basis, usually once per year.

Keeping written records of how and when to service this equipment lowers liability and is in line with guidelines for preventing and controlling infections.

Daily Discipline That Pays Off

Utility room maintenance doesn’t need to be overwhelming. A consistent checklist can make a big impact. At a minimum, suction lines should be cleaned daily with a nonfoaming cleaner, such as CleanStream from Air Techniques; traps need to be inspected weekly; and compressor systems monitored for moisture and air pressure changes. Amalgam separator filters should be checked regularly and replaced according to usage, but at least annually.

By keeping these systems in top condition, dental practices ensure smooth clinical workflows, protect staff and patient health, and avoid costly repairs or downtime. Maintaining the utility room is not an extra task, it is a basic one.

It wasn’t until later in my career that I realized how much the utility room impacts not just the functionality of equipment, but patient care, clinician safety, and practice operations. Early on, I didn’t know how much was at stake behind that closed door. Like many, I was more focused on the treatment room. But when the utility room fails, everything stops.

Consistent maintenance of this area can improve every part of clinical treatment, from helping to prevent infections to protecting the environment to making equipment last longer. To ensure safe, effective, and uninterrupted patient care, dental teams should include regular checks of utility rooms in their overall maintenance and compliance plans.

Air Techniques
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800-AIR TECH (247-8324)

From Dimensions of Dental Hygiene. January/February 2026; 24(1):27

Sickle-cell disease (SCD) refers to a group of genetic blood disorders that impact hemoglobin — an oxygen-carrying protein in red blood cells (RBCs) — leading to multisystem morbidity and reduced life expectancy. One of the most common severe genetic disorders worldwide, SCD affects about 100,000 people in the United States.^1,2 SCD occurs in approximately one out of every 365 Black or African American births and one out of every 16,300 Hispanic American births.²

While the disease can exist in people of all races and ethnicities, it is particularly common among those whose ancestry originates where malaria is or was common, including Sub-Saharan Africa, South America, the Caribbean, Central America, Saudi Arabia, India, and Mediterranean countries. ^2,3 The prevalence of SCD is highest in Sub-Saharan Africa, with an estimated 230,000 affected children born each year compared to 2,600 and 1,300 affected births in North America and Europe.^1,2

SCD is an umbrella term encompassing several forms of the disease with the most common being homozygous hemoglobin SS, also known as sickle cell anemia (SCA). Other forms of SCD are heterozygous conditions, commonly referred to as sickle cell trait (Table 1).^1,3

The homozygous and heterozygous forms of SCD are starkly different diseases. SCA is severely disabling, while heterozygous forms are mostly benign. The mutation that causes SCD may confer partial protection against severe malaria.^3-5 Compared to those with normal hemoglobin, individuals with sickle cell trait have a 50% to 90% reduction in parasite density.⁴

Three pathophysiological processes are associated with SCD: sickle hemoglobin (HbS) polymerization, vaso-occlusion, and hemolysis-mediated endothelial dysfunction. The HbS mutation alters the physiology and rheology of RBCs.^1,2,4-7 Vaso-occlusion can cause acute systemic vaso-occlusive crisis (VOC), or sickle cell crisis.^1,7,8 Approximately 1% of patients have more than six VOC episodes per year while 39% have none.⁸ VOCs have no specific cause, but triggers may include infection, dehydration, extreme temperatures, hypoxia, stress, and menstruation.

VOC is characterized by intense pain and organ injury caused by hemolysis and sickling, leading to impaired blood flow. Hemolysis and sickling also increase plasma viscosity. Cycles of intermittent periods of reduced blood flow can lead to inflammatory stress and tissue injury, also known as ischemia-reperfusion injury. Ischemia-reperfusion injury can lead to chronic inflammation.^1,7-11

Hemolytic anemia is precipitated by the rupture of RBCs, causing the release of hemoglobin into surrounding plasma. Free plasma hemoglobin may contribute to nitric oxide resistance, leading to vasoconstriction and impaired blood flow. Hemolytic anemia may cause symptoms in SCD patients including fatigue, anemia, and progressive vasculopathy.^1,8,10

Systemic Complications

The chronic impact of hemolytic anemia and VOCs may result in systemic complications involving multiple organs, with symptoms appearing in the first 6 months of life.^7-9

Cerebrovascular accidents are a major complication of SCD. Patients with SCD have a 200-fold increase in stroke risk compared to typical populations and once stroke has occurred, the risk of reoccurrence is more than 60%.^1,8 SCA is also one of the most common causes of stroke in children due to vasculopathy. In 1 year, for every 100 patients with SCD, about one will experience his or her first stroke between the ages of 2 and 5, and 11% may have had a stroke by the age of 20.^1,12 Vasculopathy may be detected early by transcranial doppler scanning.

Acute chest syndrome (ACS) is a lung injury that affects both children and adults with SCD. It is the leading cause of death and hospitalization among this patient population. ACS may appear radiographically as an alveolar pulmonary infiltrate involving at least one lung segment and presents with signs such as fever, chest pain, cough, or dyspnea.^1,7,8,12,13 ACS is triggered by infection, fat embolism, vaso-occlusion of the pulmonary vasculature, and surgical procedures.^1,7,13 Treatment may include broad-spectrum antibiotics, bronchodilators, oxygen, or mechanical ventilation.

Pulmonary hypertension occurs in approximately one third of patients with SCD and is a strong predictor of morbidity.^1,12,13 Pulmonary pressures rise acutely during VOCs, and even more during acute chest syndrome. Risk factors for pulmonary hypertension include hypoxemia, sleep apnea, pulmonary thromboembolic disease, restrictive lung disease, left ventricular systolic and diastolic dysfunction, severe anemia, and iron overload. Left heart disease may occur secondary to pulmonary hypertension and affects about 13% of adults with SCD.^1,13 Patients with both diastolic dysfunction and pulmonary vascular disease are at an increased risk of death.¹

The kidneys are particularly vulnerable to vaso-occlusive events, making renal damage almost unavoidable in SCD. Appearing early in life, renal dysfunction can cause impaired tubular function, limited urine output, and increased dehydration. Progressive renal injury may lead to chronic renal failure, most frequently occurring in the third or fourth decade of life.^1,8,14 Among adults with SCD, approximately 30% develop chronic renal failure, which contributes to the mortality of the disease.

Management

Long term management of SCD focuses on preventing infection and organ damage. As such, patients with SCD should receive vaccinations against meningococcus, pneumococcus, Hemophilus influenza B, and SARS-CoV-2.^14,15

Several therapeutic approaches to manage acute complications of SCD have been approved by the United States Food and Drug Administration including hydroxyurea, L-glutamine, crizanlizumab-tmca, voxelotor, exagamglogene autotemcel, and lovotibeglogene autotemcel (Table 2). Hydroxyurea is an antimetabolite that increases fetal hemoglobin expression, which may decrease the severity of SCD complications. L-glutamine protects sickled RBCs from hemolysis and oxidative damage and may lower incidence of hospitalization, chest crisis, and VOCs. Crizanlizumab-tmca is a humanized, anti-P-selectin monoclonal antibody administered intravenously to prevent VOCs by impeding RBCs, white blood cells, and platelets from forming aggregates and adhering to blood vessel walls. Voxelotor inhibits HbS polymerization and RBC sickling by modifying hemoglobin’s affinity for oxygen, which may reduce inflammation and improve complications. Exagamglogene autotemcel is an autologous gene therapy and may increase fetal hemoglobin. L ovotibeglogene autotemcel is an anti-sickling gene therapy that may produce a modified hemoglobin that reduces or eliminates the sickling of red blood cells, and may reduce VOCs.^9,14,16

Erythrocyte transfusion is used to treat acute and chronic complications of SCD by reducing the occurrence of stroke, ACS, and VOCs. Approximately 90% of adults with SCD will receive at least one transfusion.¹² Indications for erythrocyte transfusion include stroke, ACS, acute exacerbation of anemia, and perioperative conditions. Alloimmunization to RBC antigens is a major complication associated with transfusions in patients with SCD. In the US, approximately 0.5% to 1.5% of the general population experiences alloimmunization, compared to 18% to 76% of patients with SCD.¹² Iron overload is another serious complication of transfusion and may cause many systemic complications including oxidative stress which can result in the dysfunction of the liver, heart, and endocrine organs.¹⁷

Hemopoietic stem cell transplantation (HSCT) is the only cure for SCD currently available. Treatment success is contingent on donor compatibility, recipient age, and disease severity.^1,9,14 Stem cells are sourced from a matched related donor to avoid complications such as graft-vs-host disease. Management of HSCT related complications remains a significant challenge and is an area of ongoing research.

Oral Implications

Several oral manifestations of SCD may affect tooth structure, oral mucosa, periodontal tissues, and bone. The most common are paleness of the oral mucosa (pallor), delayed tooth eruption, enamel and dentin mineralization disorders, papillary atrophy of the tongue, mandibular osteomyelitis, nerve damage, orofacial pain, pulpal necrosis of healthy teeth, and malocclusion in children and teens.^8,15,18,19

Pallor of the oral mucosa is the most common oral manifestation.¹⁹ The mucosa may appear yellowish due to hemolysis and commonly appears on the soft palate and floor of the mouth. Also common is papillary atrophy of the tongue, which may affect the entire surface, causing it to appear reddish and smooth. Sudden onset of pulpal necrosis or pain in healthy teeth occurs 8.33 times more among patients with SCD patients compared to patients without it due to vascular occlusive events in the pulpal microvasculature.^8,15,19-21

Bone manifestations of SCD include bone pain and osteomyelitis of the jaws. Chronic anemia may induce bone marrow hyperplasia, which can impede blood flow, leading to bone ischemia, necrosis, and episodes of bone pain.^13,19 Due to decreased immune function, osteomyelitis occurs 200 times more frequently in patients with SCD than the typical population.⁸ Other triggers of bone pain may include periods of hypoxia, dehydration, general anesthesia, stress, or surgery. Bone pain occurs more frequently in mandibular bone, particularly in posterior regions due to a less developed vascular network in this area. Bone necrosis can be observed radiographically in the mandible, maxilla, and throughout the skeleton, appearing as small radiolucent lesions.¹⁹ Osteomyelitis in the posterior mandibular region may be managed with sequestrectomy, curettage, debridement, corticotomy and resection of mandible and affected muscles.¹⁵

Vascular infarction of the mental nerve or its branches may lead to loss of sensation in the chin and lower lip, also known as numb chin syndrome (NCS). It can be triggered by VOCs, which cause ischemia, painful crises in mandibular bone, hypoesthesia, paresthesia, or pain in the chin and lower lip. Nerve damage may also affect tooth sensation, resulting in false negative tooth vitality testing. Neuropathy of the mental nerve occurs 2.2 times more in patients with SCA than the general population.¹⁹ Currently no treatment exists for NCS, however, management includes resolution of VOCs, and sensation may eventually return after several months.^19,20,22

Data are inconclusive regarding the incidence of caries among patients with SCD. This patient population may be at increased risk due to enamel hypomineralization and decreased oral hygiene due to frequent hospitalizations. Certain medications used to treat SCD, including hydroxyurea, may also alter salivary pH and flow, and others contain sucrose.^16,18,23 Many patients with SCD frequently use prophylactic antibiotics such as penicillin which may decrease colonization by Streptococcus mutans, impacting caries risk.²¹

SCD is also a risk factor for moderate to severe dental malocclusion due to resultant changes in the craniofacial bones.^8,21,24 Increased demand for erythropoiesis may cause compensatory bone marrow expansion, leading to pathologic changes which can be observed radiographically. The most common craniofacial bone abnormalities in SCD include maxillary protrusion with flaring of maxillary incisors, overjet, overbite, retrusion or thin border of the mandible, increased prominence of zygomatic and parietal bones, large trabecular bone, and frontal bossing.^21,24 Among patients with SCD, 30.1% required orthodontic treatment compared to 2.7% of controls.¹⁵

Conflicting evidence exists about the link between SCD and periodontitis. Many studies demonstrate no correlation, while others suggest a potential association through shared inflammatory pathways.^17,25,26 Inflammation is a core component of the pathophysiology of both periodontitis and SCD, and can precipitate VOC. Iron overload, a complication of blood transfusion used to manage SCD, may also play a role in the development of periodontal diseases. Iron plays a role in periodontal health as a growth factor and regulator of periodontal pathogens. Essential for normal differentiation of human periodontal ligament stem cells, iron in excess may negatively impact alveolar bone remodeling.¹⁷

Dental Management

Prevention is the best approach for patients with SCD. Oral health screening should occur every 6 months and include evaluation of pulp, detection of dental infection, periodontal evaluation, and orthodontic evaluation.^10,15,26 Pulpal necrosis is common among this population, so routine evaluation of pulp is recommended.

Detecting dental infections and subsequent treatment are critical because they may precipitate a VOC or exacerbate an existing crisis.¹ A strict periodontal screening regimen should be implemented to assess oral hygiene and detect periodontal inflammation. The importance of good oral hygiene must be emphasized, especially during periods of hospitalization.^10,25,26 Malocclusion may require orthodontic treatment, which needs to incorporate rest periods to minimize pain. Close monitoring of bone response and pulpal health is needed to avoid SCD complications.¹⁵

Stress is a well-established trigger for sickle cell crisis, therefore minimizing stress during dental appointments is key. An anxiety assessment at the initial visit is prudent. Profound local anesthesia is suggested to reduce stressful events that may trigger VOC.¹⁹ Conscious sedation using an equimolar mixture of oxygen and nitrous oxide (MEOPA) is preferred to general anesthesia due to fewer complications; however, 100% oxygen should be administered for 4 to 5 minutes when the MEOPA is stopped to avoid hypoxia, which may induce VOC.^19,24 Patients with mild anxiety may be prescribed anxiolytics or sedatives. Barbiturates and narcotics should be avoided as they may cause respiratory suppression, leading to VOC.²⁴ Patients with severe anxiety or multiple dental or surgical procedures may require intravenous sedation or general anesthesia and should be referred to a hospital with hematology expertise to ensure the patient remains hydrated, warm, and receives oxygen therapy throughout the procedure.^15,24

Patients with SCD may experience serious side effects from medications so post-operative pain management must be approached with caution. Acetaminophen or acetaminophen with codeine is most often recommended.^15,22 Steroidal anti-inflammatory drugs are contraindicated, while nonsteroidal anti-inflammatory drugs may be used at the lowest effective dose and for the shortest duration, especially for patients with renal, gastrointestinal, and cardiovascular risks.^19,24

The literature is evolving on the use of aspirin as a treatment option; however, decreased platelet function, increased bleeding, acidosis, and bone marrow suppression are all possible risks.^15,24 Patients with SCD are often mistakenly perceived by healthcare professionals as drug seekers, but pain is a significant characteristic of the disease.

Conclusion

SCD is a complex genetic blood disorder that affects multiple organ systems and significantly reduces quality of life and life expectancy. It is associated with several comorbidities and oral manifestations that impact the provision of dental care. Effective management requires preventive strategies and multidisciplinary care. By recognizing oral implications of SCD, oral health professionals can improve both the oral and overall health of affected individuals.

References

1. Rees DC, Williams TN, Gladwin MT. Sickle-cell disease. Lancet. 2010;376:2018-2031.
2. United States Centers for Disease Control and Prevention. Data and Statistics on Sickle Cell Disease. CDC.Available at cdc.gov/sickle-cell/data/index.html. Accessed November 24, 2025.
3. GBD 2021 Sickle Cell Disease Collaborators. Global, regional, and national prevalence and mortality burden of sickle cell disease, 2000–2021: a systematic analysis from the Global Burden of Disease Study 2021. Lancet Haematol. 2023;10:e585‑e599.
4. Archer NM, Petersen N, Clark MA, et al. Resistance to Plasmodium falciparum in sickle cell trait erythrocytes is driven by oxygen-dependent growth inhibition. Proc Natl Acad Sci U S A. 2018;115:7350–7355.
5. Esoh K, Wonkam A. Evolutionary history of sickle-cell mutation: implications for global genetic medicine. Hum Mol Genet. 2021;30:R119-R128.
6. Ancillotti LHDSF, Abreu MHNG, Marinho AMCL, Santos MPAD. Validating evidence for the knowledge, management and involvement of dentists in a dental approach to sickle-cell disease. Braz Oral Res. 2024;38:e026.
7. Sundd P, Gladwin MT, Novelli EM. Pathophysiology of sickle cell disease. Annu Rev Pathol. 2019;14:263-292.
8. da Fonseca M, Oueis HS, Casamassimo PS. Sickle cell anemia: a review for the pediatric dentist. Pediatr Dent. 2007;29:159-169.
9. Barak M, Hu C, Matthews A, Fortenberry YM. Current and future therapeutics for treating patients with sickle cell disease. Cells. 2024;13:848.
10. Manwani D, Frenette PS. Vaso-occlusion in sickle cell disease: pathophysiology and novel targeted therapies. Blood. 2013;122:3892-3898.
11. Barshtein G, Pajic-Lijakovic I, Gural A. Deformability of Stored Red Blood Cells. Front Physiol. 2021;12:722896.
12. Chou ST. Transfusion therapy for sickle cell disease: a balancing act. Hematology Am Soc Hematol Educ Program. 2013;2013:439-446.
13. Wang MX, Pepin EW, Verma N, Mohammed TL. Manifestations of sickle cell disease on thoracic imaging. Clin Imaging. 2018;48:1-6.
14. Conway O’Brien E, Ali S, Chevassut T. Sickle cell disease: an update. Clin Med (Lond). 2022;22:218-220.
15. Mulimani P, Ballas SK, Abas AB, Karanth L. Treatment of dental complications in sickle cell disease. Cochrane Database Syst Rev. 2019;12:CD011633.
16. Brandão CF, Oliveira VMB, Santos ARRM, et al. Association between sickle cell disease and the oral health condition of children and adolescents. BMC Oral Health. 2018;18:169.
17. Costa SA, Moreira ARO, Costa CPS, Carvalho Souza SF. Iron overload and periodontal status in patients with sickle cell anaemia: A case series. J Clin Periodontol. 2020;47:668-675.
18. Fernandes ML, Kawachi I, Corrêa-Faria P, Pattusi MP, Paiva SM, Pordeus IA. Caries prevalence and impact on oral health-related quality of life in children with sickle cell disease: cross-sectional study. BMC Oral Health. 2015;15:68.
19. Chekroun M, Chérifi H, Fournier B, et al. Oral manifestations of sickle cell disease. Br Dent J. 2019;226:27-31.
20. Schlosser BJ, Pirigyi M, Mirowski GW. Oral manifestations of hematologic and nutritional diseases. Otolaryngol Clin North Am. 2011;44:183-vii.
21. Ralstrom E, da Fonseca MA, Rhodes M, Amini H. The impact of sickle cell disease on oral health-related quality of life. Pediatr Dent. 2014;36:24-28.
22. Bedrouni M, Touma L, Sauvé C, et al. Numb chin syndrome in sickle cell disease: a systematic review and recommendations for investigation and management. Diagnostics (Basel). 2022;12:2933.
23. Yue H, Xu X, Liu Q, et al. Association between sickle cell disease and dental caries: a systematic review and meta-analysis. Hematology. 2020;25:309-319.
24. Kawar N, Alrayyes S, Yang B, Aljewari H. Oral health management considerations for patients with sickle cell disease. Dis Mon. 2018;64:296-301.
25. de Carvalho HL, Thomaz EB, Alves CM, Souza SF. Are sickle cell anaemia and sickle cell trait predictive factors for periodontal disease? A cohort study. J Periodontal Res. 2016;51:622-629.
26. Sari A, Ilhan G, Akcali A. Association between periodontal inflamed surface area and serum acute phase biomarkers in patients with sickle cell anemia. Arch Oral Biol. 2022;143:105543..

From Dimensions of Dental Hygiene. January/February 2026; 24(1):28-31

The dental­­­ hygiene diagnosis (DHDx) was introduced to the dental hygiene process of care in the early 1990s.¹ According to the American Dental Hygienists’ Association (ADHA), DHDx is “the identification of an individual’s health behaviors, attitudes, and oral health care needs for which a dental hygienist is educationally qualified and licensed to provide.”² Dental hygienists use assessment data to determine the DHDx and care planning to support improved health outcomes.

In 2015, a model for creating the DHDx was introduced composed of four main categories: assessment, examples of dental hygiene diagnoses, examples of contributing factors, and examples of dental hygiene care planning including treatment, education, counseling and referrals.³ This model was updated in 2018 to include the current periodontal classification.⁴ Today, the emphasis is on social determinants of health (SDOH), which have been incorporated into the Dental Hygiene Diagnosis Model.

Healthy People 2030 defined SDOH as “the conditions in the environment where people are born, live, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks.”⁵ Additionally, Healthy People 2030 included objectives based on SDOH needs in the domains of economics, education, healthcare, neighborhoods and communities. While progress is being made in some of these areas, other areas are declining, such as dwindling community connections. Many individuals do not have the social support of friends and family to share health concerns, which may increase physical and mental health problems.⁶

Food insecurity and hunger are also growing issues. Adequate access to nutritionally sound foods improves health outcomes for both adults and children and can improve school performance in children.⁷ Dental hygienists need to be aware of the correlation between a lack of healthy foods and an increase in unmet dental care needs.⁸ Food deserts, areas where residents lack access to healthy, affordable food, are disproportionately located in communities of low-income, minority populations.⁹

Individuals may present every day in practice that fit these descriptions of unmet SDOH needs and yet clinicians may be unaware. Associating SDOH with general health and oral disease is key for recognizing unmet needs and improving health outcomes.

Unmet Needs

Dental hygienists understand how periodontal diseases can negatively impact systemic conditions such as diabetes mellitus, cardiovascular diseases, and obesity.¹⁰ Additionally, diabetes has a bidirectional relationship with periodontal diseases, meaning each condition can increase the severity of the other. Patients with SDOH are at increased risk for these systemic conditions.

Patients with lower socioeconomic status are more likely to develop type 2 diabetes and have more complications related to the disease. The incidence of diabetes and mortality rate are higher among individuals who have not completed high school. Lack of employment increases the risk of developing both prediabetes and type 2 diabetes. For those who have unstable housing, eating nutritionally, getting adequate exercise, and gaining access to medications and testing supplies needed for those with diabetes can be difficult.¹¹

Many SDOH factors are related to cardiovascular disease and obesity.^12,13 Socioeconomic status, lack of adequate employment, neighborhoods that are unsafe for outdoor exercise, limited access to grocery stores and healthy food, lower education levels, and lack of social support systems, all increase the risk of developing and dying from cardiovascular diseases.¹² Further, individuals with higher SDOH needs have a higher prevalence of obesity.¹³

Periodontal diseases are not the only oral maladies to be impacted by unmet SDOH needs. Patients with oral cancer who have unmet SDOH experience poorer health outcomes. They present with more advanced cancer at the time of diagnosis, are less likely to have surgery, and experience poorer survival rates.^14,15

Dental caries risk and prevalence are higher in patients with food insecurity, lower socioeconomic status, and lower oral health literacy.^8,16 Children of non-English speaking parents are less likely to understand the need for regular dental visits and preventive measures and are more likely to have limited access to dental insurance. These SDOH factors increase the burden of disease in these individuals.¹⁶

Clinicians might not know if a patient has SDOH needs unless they ask. The screening process can be quick and easy with a short questionnaire, and then the DHDx related to SDOH unmet needs can be determined.

Diagnostic Categories

SDOH has been incorporated into the Dental Hygiene Diagnosis Model to reflect examples of experiences that may impact oral healthcare. The diagnostic categories are derived from SDOH screening tools that examine various SDOH domains, including Health-Related Social Needs Screening Tool,¹⁷,the Social Needs Screening Tool,¹⁸ the Protocol for Responding to and Assessing Patient Assets, Risks, and Experience tool,¹⁹ and the Health Begins tool.²⁰ Each tool is briefly described to help clinicians identify which instrument might be most appropriate for their dental hygiene practice setting.

The Health-Related Social Needs Screening Tool includes 10 items categorized into five domains: housing instability, food insecurity, transportation problems, utility help needs, and interpersonal safety. Supplemental domains within this tool address financial strain, employment, family and community support, education, physical activity, substance use, mental health, and disabilities. The tool includes 26 items and is meant to be used for individuals, parents or caregivers, and clinicians.¹⁷

The Social Needs Screening Tool was developed by the American Academy of Family Physicians to improve health equity in every community. This tool includes 15 items across 10 domains such as housing, food, transportation, utilities, childcare, employment, education, finances, personal safety, and assistance.¹⁸

The Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences tool was created by the National Association of Community Health Centers. This 21-item tool addresses five SDOH domains: personal characteristics, family and home, money and resources, social and emotional health, and optional additional questions.¹⁹

The Health Begins instrument captures social and behavioral domains that impact the opportunity to have a safe, healthy place to live, work, eat, sleep, learn and play. Fourteen domains are included in the 15-item screening tool including education, employment, social connection and isolation, physical activity, immigration, financial strain, housing insecurity, food insecurity, dietary pattern, transportation, exposure to violence, stress, and civic engagement.²⁰

Based on the domains identified in the four screening tools described above, the updated Dental Hygiene Diagnosis Model (Table 1) examines SDOH domains including community/social support, cultural influences, economic stability, educational, food security, health care system, language, and physical/environment/safety. Examples of DHDx might include, but are not limited to communication barriers, education barriers, financial strain (employment), food insecurity, health literacy barriers, housing barriers, insufficient social support, personal safety concerns, and transportation barriers.

Contributing factors leading to these diagnoses relate to bereavement, cost concerns, cultural or religious beliefs, English as a second language, homelessness, inadequate access to care, loneliness, signs of or reported abuse or neglect, and transportation difficulties. Once the SDOH DHDx is determined, the care plan might include the need for an interpreter or personalized oral health education. Referrals could be indicated for mental health counseling, physician care, dentists for abuse evaluation, senior citizen’s center, or social services. In cases of suspected or reported abuse, referral to the appropriate local or state agency is warranted.

Community Resources

The national findhelp.org website provides resources for SDOH needs.²¹ On findhelp.org, local resources can be found for food, housing, goods, transit, health, money, care, education, work, and legal services. Oral health professionals can identify local resources within their communities and create a handout that is readily available and relevant for their practice.

Person-Centered Care

The following case studies provide an opportunity to assess individuals for SDOH and determine related DHDx. Each case represents different types of SDOH that may present in the dental office.

Case Study A. Colette is a 35-year-old single mom with two preschool-age children. She struggles to feed her children and to find safe childcare for them. Currently, she is employed full-time at a minimum wage job that provides no health benefits. Her children are on state Medicaid health and dental plans, but there is a wait list to find a dental provider willing to accept Medicaid. When the dental hygienist takes Colette’s blood pressure, the results are 159/90 mmHg.

Per Table 1, the SDOH DHDx relevant for this case are food insecurity, insufficient social support (childcare), and financial strain (insufficient wages and no health benefits). By using the findhelp.org website and her zip code, Colette and/or the dental hygienist can search for local resources in the categories of childcare, employment, finances, food, and social support.

Case Study B. Carl is a full-time college student with anxiety and depression who does not have a stable place to live. He is not working and is without family support. He has no medical or dental insurance. When he is able, he accesses the food pantry and clothes closet at his college. He tried to schedule a dental appointment because he has a toothache, but he has no money to pay for it. He ends up in the emergency department for help with the pain. The dental hygienist employed by the hospital evaluates the patient and determines there is a dental abscess with suppuration, and realizes the patient is at risk for a tooth extraction and further infection.

The SDOH DHDx for Carl are financial strain, food insecurity, housing barriers, personal safety concerns, and insufficient social support. Referrals to the findhelp.org website, a mental health counselor, a local dentist or dental therapist, and social services are appropriate.

Although the cases presented above focused specifically on SDOH needs, the DHDx Model offers a comprehensive list of DHDx in multiple assessment categories . The individuals in the previous cases would also have DHDx in other categories. For example, in Case A, Colette would also have a DHDx of risk for emergency due to uncontrolled hypertension, requiring a referral to a physician for evaluation. In Case B, Carl would have a DHDx of patient reported excessive anxiety and depression, requiring the care plan to include stress reduction protocols along with the referrals.

Importance of Addressing Social Determinants of Health

Integrating SDOH into dental hygiene practice is a critical step toward providing comprehensive and person-centered care. Understanding and addressing SDOH allows dental hygienists to identify barriers to optimal oral health, develop targeted interventions, and connect patients with essential community resources. The practical implementation of SDOH assessment and diagnosis in dental hygiene practice is not only feasible but also essential for fostering improved health outcomes.

A key strategy for incorporating SDOH into routine dental hygiene care is the integration of SDOH-related questions into the health history assessment. By adding a brief but effective screening tool to health history forms, dental hygienists can systematically identify individuals with unmet social needs that impact their general and oral health. This screening process does not need to be time-consuming; many of the validated tools discussed previously contain concise questions that can be quickly reviewed by the dental team.

The successful implementation of SDOH screening requires collaboration among the entire dental team, including dental assistants, front office staff, and billing personnel. Office staff can assist individuals in completing the screening tools, while dental hygienists review responses and determine appropriate DHDx based on SDOH factors. Training the entire dental team on the importance of SDOH and how unmet needs influence oral health outcomes is vital to ensure consistency in implementation. Staff education sessions can highlight the connections between SDOH and common oral health conditions.

Once SDOH-related barriers are identified, dental hygienists can work to develop individualized care plans that include tailored education, referrals, and support services. Utilizing readily available community resources enables dental professionals to connect those in need with food assistance programs, transportation services, housing support, and mental health resources. Maintaining a list of local resources available in multiple languages ensures the practice meets its patients’ needs.

Financial concerns are a common barrier to accessing dental care. The dental billing coordinator can play a significant role in assisting individuals with understanding their insurance benefits, exploring financial assistance programs, and setting up payment plans when necessary.

Conclusion

By making small but impactful changes in how social factors are assessed and addressed, oral health professionals can bridge the gap between systemic and oral healthcare. Implementing SDOH screening and intervention are not just theoretical concepts, they are a practical and essential component of modern dental hygiene practice that ensures all individuals receive the comprehensive, person-centered care they deserve.

References

1. Gurenlian JR. Diagnostic decision making . In: Woodall I, ed. Comprehensive Dental Hygiene Care. 4th ed. St. Louis: Mosby; 1993:361–70.
2. American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene Practice. Available at adha.org/education-resources/standards/. Accessed December 1, 2025.
3. Swigart DJ, Gurenlian JR. Implementing dental hygiene diagnosis into practice. Dimensions of Dental Hygiene. 2015;13(9):56-59.
4. Gurenlian JR, Swigart DJ. Components of dental hygiene diagnosis. Dimensions of Dental Hygiene. 2018;16(12):36-39.
5. United States Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2030. Available at https://odphp.health.gov/ healthypeople/ priority-areas/social-determinants-health. Accessed December 1, 2025.
6. United States Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2030, Health Communication. Available at https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/health-communication/increase-proportion-adults-who-talk-friends-or-family-about-their-health-hchit-04. Accessed December 1, 2025.
7. United States Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2030, Economic Stability. Available at: https://health.gov/healthypeople/objectives-and-data/browse-objectives/economic-stability. Accessed December 1, 2025.
8. Wiener RC, Sambamoorthi U, Shen C, Alwhaibi M, Findley P. Food security and unmet dental care needs in adults in the United States. J Dent Hyg. 2018;92:14-22.
9. Beaulac J, Kristjansson E, Cummins S. A systematic review of food deserts, 1966-2007. Prev Chronic Dis. 2009;6:A105.
10. Chapple I, Genco R. Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on periodontitis and systematic diseases. J Periodontol. 2013;84;S106-S112.
11. Hill-Briggs F, Adler NE, Berkowitz SA, et al. Social determinants of health and diabetes: A scientific review. Diabetes Care. 2020;44:258–279.
12. Javed Z, Haisum Maqsood M, Yahya T, et al. Race, racism, and cardiovascular health: Applying a social determinants of health framework to racial/ethnic disparities in cardiovascular disease. Circ Cardiovasc Qual Outcomes. 2022;15:e007917.
13. Javed Z, Valero-Elizondo J, Maqsood MH, et al. Social determinants of health and obesity: Findings from a national study of US adults. Obesity (Silver Spring). 2022;30(2):491-502.
14. Agarwal P, Agrawal RR, Jones EA, Devaiah AK. Social determinants of health and oral cavity cancer treatment and survival: A competing risk analysis. Laryngoscope. 2020;130:2160-2165.
15. Tellez M, Zini A, Estupiñan-Day S. Social determinants and oral health: an update. Curr Oral Health Rep. 2014;1:148–152.
16. Ramos-Gomez F, Kinsler JJ. Addressing social determinants of oral health, structural racism and discrimination and intersectionality among immigrant and non-English speaking Hispanics in the United States. J Public Health Dent. 2022;82(Suppl 1):133-139.
17. Centers for Medicare and Medicaid Services. The accountable health communities health-related social needs screening tool. Available at: cms.gov/priorities/ innovation/files/worksheets/ahcm-screeningtool.pdf. Accessed December 1, 2025.
18. American Academy of Family Physicians. Social Needs Screening Tool. Available at aafp.org/dam/AAFP/documents/ patient_care/everyone_project/hops19-physician-form0sdoh.pdf. Accessed December 1, 2025.
19. National Association of Community Health Centers Inc. PRAPARE: Protocol for Responding to and Assessing Patients’ Assets, Rsks and Experiences. Available at https://prapare.org/ wp-content/uploads/2024/04/PRAPARE-English.pdf. Accessed December 1, 2025.
20. Manchanda R, Gottlieb L. Upstream risks screening tool and guide V2.6. Health Begins. Available at medchi.org/Portals/18/Files/Practice%20Services/SDoH%20Screening%20Tool.pdf?ver=2023-08-10-131750-180. Accessed December 1, 2025.
21. Findhelp. Help Is Available in Your Neighborhood. Available at: findhelp.org. Accessed December 1, 2025.

From Dimensions of Dental Hygiene. January/February 2026; 24(1):32-35

Neurological and/or cognitive issues, such as depression, delirium, dementia, and Alzheimer disease (AD), are common among older adults. While they may appear to have similar presentations, they can typically be diagnosed more definitively. Accurate diagnosis is essential to developing an effective treatment plan.¹ Oral health professionals need to be knowledgeable about AD and its impact on systemic and oral health in order to provide high-quality patient care.

AD is anticipated to impact more than 12 million people worldwide by 2050.² The disease, known for its initial effect on neuro/cognitive functioning, is caused by the presence of neurofibrillary tangles in the brain that cause brain synapses and neuron death.² While post-mortem examination remains the definitive diagnostic method, AD can now be diagnosed with validated clinical criteria and biomarker evidence.

The progression of AD comes in three stages (Table 1).³ In the early or mild stage, the individual is able to function independently but begins to notice memory challenges. These memory lapses are often noticed, not only by the individual, but family and friends as well. In the second stage, moderate dementia, memory becomes worse. Assistance completing tasks associated with personal hygiene and food preparation may be needed in this stage. The final, or severe, stage requires around-the-clock care and includes the inability to complete activities of daily living.⁴

Impact of Systemic Conditions

Depression,^5,6 gastrointestinal disease,^7,8 cardiovascular disease,^9-11 and type 2 diabetes^12,13 often go hand in hand with AD. Comorbidities that occur simultaneously with AD increase the level of physiological dysfunction.¹⁴ The correlation between AD and other chronic conditions stems from the central mechanism of inflammation.¹⁵

The presence of systemic conditions may complicate the treatment of AD, especially as the disease progresses and dementia becomes apparent. The successful treatment of comorbidities may improve patient outcomes. Oral health professionals should be aware of any systemic conditions impacting their patients with AD in order to provide the most effective care and help patients and their families support long-term oral health.

In patients with AD, depression is more commonly experienced early in the diagnosis and is linked to the location of plaques in the brain. Antidepressants may be prescribed to support quality of life.⁶

Patients with AD may experience bowel habit changes, including constipation or diarrhea. Either can be triggered by changes in diet, medications, and behavioral changes.^7,8 Providing fluids and nutrient-dense food, as well as encouraging mobility can minimize gastrointestinal irritation.

Cardiovascular disease in patients with AD is linked to hypertension and inflammation, especially in mid-life prior to the AD diagnosis. Noting these conditions early provides a window of opportunity to address diet, smoking, stress modification, and inflammation to improve patient quality of life.^9,10

Current evidence indicates a link between AD and type 2 diabetes; specifically linking early onset of diabetes with dementia.^11,12 Research is now examining the connection with a controlled, stable glucose level and AD.

Periodontal Pathogens

Periodontal diseases are among the most prevalent chronic inflammatory conditions, affecting two in five adults (42.2%) in the United States. Among those age 65 and older, the prevalence increases to nearly 60%.¹⁶ While periodontal diseases are localized oral conditions, evidence suggests their systemic implications extend far beyond the periodontium.

A possible correlation exists between periodontal diseases and the onset and progression of AD, with inflammation and periodontal pathogens playing recognized roles.¹⁷ Both conditions share common inflammatory pathways, particularly the involvement of cytokines such as interleukin (IL)-1β, IL-6, and tumor necrosis factor-α.¹⁸ These mediators contribute to tissue destruction including alveolar bone loss in periodontal diseases and neuronal degeneration in AD, suggesting a potential bidirectional relationship between oral and neurodegenerative health.¹⁹

More than 700 bacterial species are contained within the human oral microbiota, with each exhibiting different grades of pathogenicity toward the host.^17,20 The microbiota form plaque and preferentially colonize on different surfaces in the oral cavity, forming a complex biofilm.¹⁷ In a healthy state, Gram-positive bacteria dominate the composition of plaque. As the biofilm matures, a progressive shift occurs from Gram-positive to predominately Gram-negative, anaerobic bacteria.^20,21 

These pathogenic bacteria, including Porphyromonas gingivalis, Treponema denticola, Tanerella forsythia, Aggregatibacter actinomycetemcomitans, Prevotella intermedia, and Fusobacterium nucleatum, release pro-inflammatory mediators that can travel to the bloodstream and cause cerebral inflammation, contributing to systemic inflammation.^18,20,22 Interestingly, not all individuals with these bacteria will develop periodontal diseases, the virulence of each species alone is low and cooperation between the bacteria and an overzealous host-immune response is necessary for disease progression.²⁰

The severity of periodontal diseases is influenced by host immune competence, genetic susceptibility ,and external factors including lack of proper oral hygiene, malnutrition, and chronic illness.²³ This dysbiosis increases the risk for chronic inflammation, which may accelerate systemic pathologies such as AD.

Miklossy and McGeer²⁴ showed a seven times higher density of oral bacteria in the brain tissue of post-mortem patients with AD compared to those without AD. Studies have detected elevated levels of P. gingivalis, F. nucleatum, and P. intermedia in patients with AD.^17,25 However, results have been mixed and there is not currently a consistent association between specific bacterial species and AD pathology.^26,27

Given the potential for periodontal inflammation to influence systemic disease through the diffusion of inflammatory mediators, routine periodontal maintenance should be viewed not only as a preventive strategy for oral health but as critical in reducing the risk and progression of AD. Early and consistent periodontal intervention may help lower systemic inflammatory burden, providing a valuable adjunct to the neurodegenerative disease.

Oral Health Concerns

Patients with AD are more likely to have substandard oral hygiene and poor oral health compared to individuals without cognitive impairment.²⁸ This is largely due to the progressive neurogenerative nature of AD, affecting memory, motor skills, judgement, and problem solving. With the progression of the disease, patients may forget to perform daily oral hygiene tasks, lose the ability to perform these tasks, or may not recognize the importance of daily self-care.

Ming et al²⁹ suggests that patients with AD have a reduced ability to identify pain or discomfort associated with periodontal diseases, gingival bleeding, or decay, and may not report oral health concerns. As a result, undiagnosed oral maladies may be present.

A high plaque index may be noted as individuals with AD often have irregular brushing habits.²⁹ A meta-analysis looked at 22 observational studies to determine the association between oral health and AD.²⁷ Individuals with AD had more significant periodontal disease markers, including high plaque index, increased gingival bleeding, higher probing depths, and greater loss of attachment compared to those without AD. Additionally, the number of proinflammatory biochemical mediators related to periodontal diseases was noticeably higher.^27,28

Xerostomia, a common side effect of malnutrition and polypharmacy, can further impair oral health. Medications prescribed to manage AD include antihypertensives, antidepressants, and antipsychotics, which all contribute to a reduced salivary flow. Xerostomia can lead to increased biofilm accumulation, caries, periodontal diseases, fungal infections, candidiasis, and masticatory discomfort.³⁰

Saliva substitutes or encouraging frequent sips of water may help alleviate symptoms and improve oral function. Xerostomia can also be related to burning mouth syndrome, reduced food intake, impaired salivary cleansing, and dysphagia, all impacting patient quality of life.¹⁶

Partial or full edentulism is a common occurrence among older adults with dementia, and may be due to a bidirectional relationship between diseases.²² Studies have shown that individuals with significant tooth loss may have an increased risk of cognitive decline, though the relationship is likely multifactorial and may reflect shared risk factors.²⁹ Brain degeneration caused by AD can reduce sensation of smell and taste, appetite, and motor function, which impairs mastication.³¹ This can lead to reduced nutritional intake, increase malnutrition, worsening dementia symptoms, and diminished quality of life.³²

Partnering With the Caregiver

As AD progresses, individuals lose the ability to maintain oral hygiene independently and must rely on a caregiver.³³ Oral health professionals must recognize caregivers as key partners in managing care. The Alzheimer’s Association provides a vast array of resources to help the patient, caregiver, and healthcare professional access information pertinent to optimizing the standard of care for patients with AD.³⁴

Partnering with the caregiver involves actively including them in all stages of oral healthcare such as shared decision-making, education, and demonstrating daily oral hygiene practices.

For individuals with AD, the caregiver and oral health professional should consider the longevity of treatment, maintenance, and further progression of disease. Care plans should be realistic, minimally invasive, and tailored to the patient’s long-term disease trajectory. The clinician must pay attention to verbal and nonverbal communication as individuals with AD may have difficulty expressing discomfort or fear. Effective communication with the patient and caregiver may include shorter appointment times, gentle and patient conversations, and the tell-show-do technique.³⁵ Reduced cognition and dexterity may mean patients cannot recognize or report pain.

Oral health professionals should recommend specific aids, such as adaptive toothbrush handles or electric brushes, for caregivers.²² Caregivers can then be educated on techniques to help the patient with daily oral hygiene. Table 2 provides practice recommendations for partnering with caregivers of patients with AD.

By creating a strong partnership with the caregiver, oral health professionals can better address the complex oral health needs of patients with AD. Providing caregivers with the knowledge, tools, and clear communication will improve quality of care and quality of life for the patient.

Conclusions

AD presents significant challenges not only for affected individuals but also for their caregivers. As the disease progresses, the need for comprehensive and personalized care becomes even more crucial. Dental health, often overlooked, plays a vital role in the overall health and quality of life of patients with AD. By understanding the specific oral health challenges these individuals face, oral health professionals can develop tailored, evidence-based strategies to address these concerns effectively.

Collaboration with caregivers is essential in ensuring proper care, as they are often directly involved in assisting with oral hygiene routines. By focusing on the unique needs of patients with AD and using a team-based approach, oral health professionals can help enhance the comfort, health, and dignity of individuals living with AD. Dental hygienists are in a unique position to advocate for and implement care strategies that preserve dignity and quality of life.

References

1. Meiner SE, Yeager JJ. Gerontologic Nursing. 6th ed. St. Louis, Missouri: Elsevier; 2019.
2. Touhy T, Jett K. Toward Healthy Aging. 11th ed. Elsevier; 2023.
3. Alzheimer’s Association. Help & Support. Available at alz.org. Accessed December 3, 2025.
4. Touhy T, Jett K. Ebersole and Hess’ Gerontological Nursing and Healthy Aging. 6th ed. St. Louis, Missouri: Elsevier Health Sciences; 2022.
5. Ownby RL, Crocco E, Acevedo A, John V, Loewenstein D. Depression and risk for Alzheimer disease: systematic review, meta-analysis, and metaregression analysis. Arch Gen Psychiatry. 2006;63:530–538.
6. Alzheimer’s Society. About Dementia. Available at alzheimers.org.uk/about-dementia. Accessed December 3, 2025.
7. National Institute on Aging. Caregiving. Available at nia.nih.gov/health/caregiving. Accessed December 3, 2025.
8. Lynch SV, Pedersen O. The human intestinal microbiome in health and disease. N Engl J Med. 2016;375:2369–2379.
9. Saeed A, Lopez O, Cohen A, Reis S. Cardiovascular disease and Alzheimer’s disease: The heart-brain axis. J Am Heart Assoc. 2023;12:9
10. Petrovitch H, White L, Masaki KH, et al. Influence of myocardial infarction, coronary artery bypass surgery, and stroke on cognitive impairment in late life. Am J Cardiol. 1998;81:1017–1021.
11. Bunch TJ, Weiss J P, Crandall BG, et al. Atrial fibrillation is independently associated with senile, vascular, and Alzheimer’s dementia. Heart Rhythm. 2010;7:433–437.
12. Janson J, Laedtke T, Parisi JE, O’Brien P, Petersen RC, Butler PC. Increased risk of type 2 diabetes in alzheimer disease. Diabetes. 2004;53:474–481.
13. Janson J, Laedtke T, Parisi JE, O’Brien P, Petersen RC, Butler PC. Increased risk of type 2 diabetes in Alzheimer disease. Diabetes. 2004;53:474–481.
14. Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: implications for understanding health and health services. Ann Fam Med. 2009;7:357-363.
15. Alzheimer’s Association. Healthy Brain Initiative Road Map. Available at alz.org/professionals/public-health/models-frameworks/hbi-road-map. Accessed December 3, 2025.
16. National Institutes of Health. Periodontal Disease in Adults (Age 30 or Older). Available at nidcr.nih.gov/research/data-statistics/periodontal-disease/adults. Accessed December 3, 2025.
17. Dioguardi M, Crincoli V, Laino L, et al. The role of periodontitis and periodontal bacteria in the onset and progression of alzheimer’s disease: a systematic review. J Clin Med. 2020;9:495.
18. Gehrig JS, Shin DE. Foundations of Periodontics for the Dental Hygienist. 6th ed. New York: Lippincott; 2024.
19. Nicholson JS, Landry KS. Oral dysbiosis and neurodegenerative diseases: correlations and potential causations. Microorganisms. 2022; 10:1326.
20. Borsa L, Dubois M, Sacco G, Lupi L. Analysis the link between periodontal diseases and alzheimer’s disease: a systematic review. Int J Environ Res Public Health. 2021;18:9312.
21. Brogden KA, Guthmiller JM, eds. Polymicrobial Diseases. Washington, DC: ASM Press; 2002.
22. Gao SS, Chu CH, Young FYF. Oral health and care for elderly people with alzheimer’s disease. Int J Environ Res Public Health. 2020;17:5713.
23. Soni J, Sinha S, Pandey R. Understanding bacterial pathogenicity: a closer look at the journey of harmful microbes. Front Microbiol. 2024;15:1370818.
24. Miklossy J, McGeer PL. Common mechanisms involved in Alzheimer’s disease and type 2 diabetes: a key role of chronic bacterial infection and inflammation. Aging (Albany NY). 2016;8:575-588.
25. Wu H, Qiu W, Zhu X, et al. The periodontal pathogen fusobacterium nucleatum exacerbates alzheimer’s pathogenesis via specific pathways. Front Aging Neurosci. 2022;14:912709.
26. Sparks Stein P, Steffen MJ, Smith C, et al. Serum antibodies to periodontal pathogens are a risk factor for Alzheimer’s disease. Alzheimers Dement. 2012;8:196-203.
27. Hamza SA, Asif S, Bokhari SA. Oral health of individuals with dementia and Alzheimer’s disease: A review. J Indian Soc Periodontol. 2021;25:96-101.
28. Gao SS, Chen KJ, Duangthip D, Lo ECM, Chu CH. The oral health status of Chinese elderly people with and without dementia: A cross-sectional study. Int J Environ Res Public Health. 2020;17:1913.
29. Ming Y, Hsu SW, Yen YY, Lan SJ. Association of oral health-related quality of life and Alzheimer disease: A systematic review. J Prosthet Dent. 2020;124:168-175.
30. Holt E. Oral care for patients with Alzheimer disease. Decisions in Dentistry. 2023;9(4):30-33.
31. Elsig F, Schimmel M, Duvernay E, et al. Tooth loss, chewing efficiency and cognitive impairment in geriatric patients. Gerodontology. 2015;32:149-56
32. Alessandro GD, Costi T, Alkhamis N, Bagattoni S, Sadotti A, Piana G. Oral health status in Alzheimer’s disease patients: A descriptive study in an Italian population. J Contemp Dent Prac. 2018;19:48-489.
33. Hugo FN, Hilgert JB, Bertuzzi D, Padilha DM, De Marchi RJ. Oral health behaviour and socio-demographic profile of subjects with Alzheimer’s disease as reported by their family caregivers. Gerodontology. 2007;24:36-40.
34. Healthy People 2030. Social Determinants of Health. Available at https://health.gov/healthypeople/objectives-and-data/social-determinants-health. Accessed December 3, 2025.
35. Chavez EM, Wong LM, Subar P, Young DA, Wong A. Dental care for geriatric and special needs populations. Dent Clin N Am. 2018;62:245-267.

From Dimensions of Dental Hygiene. January/February 2026; 24(1):36-39

Dental hygienists are not just practitioners, they are experts and invaluable allies in the pursuit of optimal oral health. As trusted authorities on effective dental hygiene interventions, dental hygienists make critical clinical decisions that directly impact patient care. The responsibility of planning, implementing, and evaluating the oral-facial aspects of a comprehensive patient care plan is not taken lightly, and the American Dental Hygienists’ Association (ADHA) Standards for Clinical Hygiene Practice play a pivotal role (Table 1).¹

Revisions to the standards were made in 2025, amplifying the importance of a comprehensive dental hygiene care plan while ensuring that every patient feels understood and valued. While traditional methods of preventive care, such as toothbrushing and flossing, remain fundamental to oral hygiene, integrating these age-old practices with innovative technologies and advanced self-care solutions is imperative.

When dental hygienists take the time to understand patients’ cultural beliefs, especially those related to oral health and personal hygiene practices, they positively influence patients’ perceptions of self-care and the value of continued oral hygiene visits. Dental hygienists worldwide are learning about the cultures and specific beliefs of individuals regarding oral hygiene practices, the value placed on preventive-reparative care, and patients’ tolerance levels associated with dental procedures, which can influence how patients respond to treatment.² By recognizing these beliefs, dental hygienists can tailor their communication and comprehensive dental hygiene care plans in a way that respects patients’ perspectives, helping to alleviate anxiety and build trust.

A miswak stick is not just a dental self-care aid but a cultural symbol reflecting oral hygiene practices steeped in tradition. As globalization continues to connect diverse cultures, individuals are increasingly drawn to practices that resonate with their heritage or those that promote a sense of authenticity in their self-care routines.

The rise of the wellness movement has also encouraged many to seek holistic approaches to health, including oral care. The miswak stick aligns with this philosophy, appealing to individuals looking for natural solutions that work in harmony with their lifestyle and beliefs. Incorporating patients’ cultural practices into oral health discussions can enhance patient-clinician relationships and improve self-care behaviors. Oral health professionals who educate patients about the benefits and limitations of miswak may find it a valuable addition to their preventive care strategies.

History and Application

Before the invention of nylon-bristle toothbrushes, people relied on a variety of methods to maintain their oral hygiene, including chewing sticks, tooth sticks, and teeth-cleaning twigs.³ The chewing stick is the original toothbrush.⁴ The exact origins of chewing sticks for cleaning teeth are somewhat unclear, but historical evidence suggests their use can be traced back to around 3500 BC in different parts of the world.⁵

Among the numerous plant species employed as chewing sticks, estimated to be around 182, one of the oldest and most popular that remains in use today is the miswak.⁶ It is derived from the roots or slender branches of the Salvadora persica.⁷ A small tree that grows in arid environments, Salvadora persica is native to countries such as Egypt, Saudi Arabia, India, and Nigeria.^8,9

The miswak has gained recognition not only for its effectiveness in cleaning teeth but also for its health benefits. It serves as a natural oral hygiene aid, exhibiting antibacterial, anti-caries, and anti-periopathogenic properties.¹⁰ In many countries, particularly in regions where the toothbrush tree is grown, the miswak stick is favored because it is readily available, inexpensive, and easy to use.

Additionally, religious beliefs and cultural practices significantly contribute to the continued use of miswak. Islamic scripture recommends performing the siwak (the act of using the miswak stick) a few times daily.^11,12 The term “miswak” is an Arabic word meaning a tooth-cleaning stick.

Miswak sticks can be made from both the roots and branches of the Salvadora persica tree, and each part has distinct characteristics and potential differences. The roots have a softer texture, making them easier to chew and form fibers than the branches. Research indicates that the roots generally contain a higher concentration of antibacterial properties.¹³ However, harvesting the roots may have a greater impact on the tree’s sustainability.

Conversely, branches can provide a firmer fiber because they are tougher and may last longer. Softening the fibers of the miswak may require more chewing for an extended period. Additionally, harvesting branches may be more convenient due to their availability. Both the roots and branches of the Salvadora persica tree offer effective options for oral hygiene. The choice between roots and branches often comes down to personal preference, availability, and the preferred texture. Understanding these differences can help users select the most suitable miswak for their oral hygiene needs (Figures 1 and 2).

To use a miswak effectively, the length of the miswak is essential. One study found that an ideal miswak stick should be about 6 inches long and roughly 1/3 of an inch in diameter to make it easy to hold and carry.¹⁴

Benefits and Limitations

A vital component of the Standards for Clinical Dental Hygiene Practice emphasizes the importance of integrating current research and best practices into clinical decision-making. In this context, both the benefits and limitations of using miswak must be explored.

The therapeutic advantages of the Salvadora persica tree primarily come from an alkaloid known as Salvadorine, which has potent bactericidal properties. Its naturally bitter taste can help stimulate saliva production. Additionally, Salvadora persica is rich in several beneficial extracts, including sulfur, vitamin C, and sodium bicarbonate. In addition, the tree’s roots contain an oil composed of benzyl nitrate and benzyl isothiocyanate, which serve as chemopreventive agents.¹⁵

Research indicates that these extracts exhibit strong antibacterial effects against various bacteria, including Streptococcus mutans, Lactobacillus acidophilus, and Porphyromonas gingivalis.^16,17 Furthermore, some patients may incorporate extracts from Salvadora persica, into various oral care products such as toothpaste, chewing gum, mouthrinses, and lozenges.^18,19 Consumers seeking organic or natural dental care products may utilize these products, and dental hygienists must understand the therapeutic mechanisms behind their effectiveness in comparison to conventional dental hygiene practices.

The therapeutic effectiveness of antibacterial properties can be limited by several factors, particularly the concentration and variability of these properties in different parts of the harvested tree. For instance, roots may exhibit different antibacterial qualities compared to branches, which can significantly impact their therapeutic potential. Additionally, the environmental conditions in which the trees are grown play a crucial role in determining their effectiveness.

The miswak is biodegradable and eco-friendly, offering cleaning advantages similar to conventional toothbrushes. Additionally, the miswak is convenient because its use does not require toothpaste. In a randomized controlled trial involving 50 dental students, researchers compared the effectiveness of miswak sticks to conventional toothbrushes, focusing on changes in plaque and gingival indeces.²⁰ The results showed that the group using miswak sticks experienced a significant reduction in plaque levels compared to the group using conventional toothbrushes. However, neither the miswak nor the toothbrush group showed a significantly different reduction in gingival inflammation.

One limitation of the miswak stick is that its use requires proper technique, including applying the correct amount of pressure, frequency of use, brushing duration, and quality of the stick’s working end.²¹ Some users may accidentally cause trauma or injury to their teeth and gingiva by excessively scrubbing in an uncontrolled motion. Signs of gingival irritation from toothbrushing trauma may include redness, scuffing, or small punctate lesions.

The fibers of the miswak stick often lack uniformity in texture and size. Consistent miswak use over time can increase the user’s risk of gingival recession, just as misusing a toothbrush can.²² A 2025 systematic review found that excessive or improper use of miswak may contribute to gingival recession. The authors emphasized the importance of careful patient assessment and noted that current evidence is insufficient to establish a clear, direct link between miswak use and a higher prevalence of gingival recession.²³

Any improper or traumatic toothbrushing, whether with conventional toothbrushes or miswak sticks, can directly harm the teeth and supporting structures of the gingiva. Dental hygienists should demonstrate proper brushing technique to their patients.

Comprehensive Dental Hygiene Care Plan

The ADHA Standards for Clinical Dental Hygiene Practice play a crucial role in shaping the modern practice of dental hygiene by emphasizing the importance of integrating cultural practices into oral healthcare. This shift represents a significant evolution in the healthcare field, as it moves toward a more inclusive approach that prioritizes patient-centered care.

Research suggests that culturally competent care is associated with improved health outcomes and higher patient satisfaction.²⁴ When dental hygienists are aware of and respect cultural differences, they can provide care that resonates with patients on a deeper level. This connection not only enhances the effectiveness of the care provided but also fosters a strong relationship between the clinician and the patient.

By inviting patients to share their cultural perspectives and personal experiences related to their oral hygiene, dental hygienists can cultivate an environment where open communication thrives. Patients are more likely to express their concerns and preferences when they feel understood and respected, which can lead to a patient-centered, comprehensive dental hygiene care plan and improved overall oral health.

A tangible example of this integration is the miswak stick. Used for centuries as a natural toothbrush with deep cultural and historical significance, the miswak stick can be introduced by dental hygienists to encourage patients to explore their own cultural practices in relation to oral health. However, dental hygienists must also adhere to evidence-based practice. This knowledge enables dental hygienists to effectively weigh the benefits against any potential limitations.

Integrating the components of the ADHA Standards for Clinical Hygiene Practice into the creation of the comprehensive dental hygiene care plan fosters a culture of continuous improvement within the profession. It encourages dental hygienists to stay updated with the latest advancements, best practices, and evidence-based approaches. This commitment to professional development not only enhances individual skills but also raises the overall standard of care within the dental hygiene community.

Conclusion

By incorporating the Standards of Clinical Hygiene Practice, the miswak, and a comprehensive dental hygiene care plan, dental hygienists can enhance patient interactions, boost satisfaction, and, ultimately, improve health outcomes. Engaging patients in dialogue about their cultural beliefs and practices related to oral care can lead to more effective and respectful treatment approaches, which benefits both patients and dental hygienists alike.

References

1. American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene Practice. Available at adha.org/ education-esources/standards/?_zs+B19OU1&_zl. Accessed December 2, 2025.
2. Aliyu TK, Titus OS, Bernard OT, Alade OT, Ehizele AO, Foláyan MO. Cultural themes related to oral health practices, beliefs, and experiences in nigeria: a scoping review. Oral. 2025;5(2):23.
3. Darout IA. The natural toothbrush “Miswak” and the oral health. Int J Life Sci Biotech Pharma Res. 2014;3:1.
4. Elemi A, Selim MA, Mussa SM, et al. From tradition to evidence: a review of the therapeutic and preventive benefits of Miswak. Exp Clin Med Georgia. 2025;4:69-74.
5. Aboul-Enein BH. The miswak (Salvadora persica L.) chewing stick: Cultural implications in oral health promotion. Saudi J Dent Res. 2014;5:9-13.
6. Qureshi AA, Qureshi AA, Dohipoide A, Jamadar NN. Effects of miswak-Salvadora Persica on oral health. Al Ameen J Med Sci. 2016;9:215-218.
7. Farag M, Abdel-Mageed WM, El Gamal AA, Basudan OA. Salvadora persica L.: Toothbrush tree with health benefits and industrial applications – An updated evidence-based review. Saudi Pharm J. 2021;29:751-763.
8. Khan AL, Latif A, et al. Decoding first complete chloroplast genome of toothbrush tree (Salvadora persica L.): insight into genome evolution, sequence divergence and phylogenetic relationship within Brassicales. BMC Genomics. 2021;22:312.
9. Iyenger E, Patolia J, Chikara J. A useful plant for coastal saline soils. Wastelands News. 1992;32:50-51.
10. Ahmad H, Ahamed N. Therapeutic properties of meswak chewing sticks: A review. Afr J Biotechnol. 2012;11(83):14850-14857.
11. Fauzi A. Contextualizing the meaning of the Siwak Hadith through Fazlur Rahman’s hermeneutic approach (a substantive-philosophical understanding). J Hadith Stud. 2018;1:135-152.
12. Ramli H, Mohd-SAid S, Ismall AM, Dom TM. Siwak as a prophetic and evidence-based oral hygiene tool: a qualitative study among Islamic scholars. Islamiyyat. 2023;45(2):77-92.
13. Ibrahim MM, Al Sahli AA, Alaraidh IA, Al-Homaidan AA, Mostafa EM, El-Gaaly GA. Assessment of antioxidant activities in roots of Miswak (Salvadora persica) plants grown at two different locations in Saudi Arabia. Saudi J Biol Sci. 2015;22:168-175.
14. Batwa M, Bergstrom J, Batwa S, Al-Otaibi MF. The effectiveness of chewing stick miswak on plaque removal. Saudi Dent J. 2006;18:125-133.
15. Haque MM, Alsareii SA. A review of the therapeutic effects of using miswak (Salvadora persica) on oral health. Saudi Med J. 2015;36:530-543.
16. Halawany HS. A review on miswak (Salvadora persica) and its effect on various aspects of oral health. Saudi Dent J. 2012;24:63-69.
17. Almas A, Almas K. Miswak (Salvadora persica chewing stick) and its role in oral health: An update. J Pak Dent Assoc. 2013;22:255-264.
18. Nordin A, Bin Saim A, Ramli R, Abdul Hamid A, Mohd Nasri NW, Bt Hj Idrus R. Miswak and oral health: An evidence-based review. Saudi J Biol Sci. 2020;27:1801-1810.
19. Hussein EF, Abdelgadir WA, Osman RM, Waddad AY, Abdelgadir AA. Formulation and antimicrobial evaluation of Miswak (Salvadora persica L.) chewing stick aqueous extract lozenges. Drug Des Open Access. 2021;10:1-6.
20. Malik AS, Shaukat MS, Qureshi AA, Abdur R. Comparative effectiveness of chewing stick and toothbrush: A randomized clinical trial. N Am J of Med Sci. 2014;6:333-337.
21. Al-Hammadi AA, Al-Rabai NA, Togoo RA, Zakirulla M, Alshahrani I, Alshahrani A. Knowledge, attitude, and behavior related to use of miswak (chewing stick): a cross-sectional study from aseer region, Saudi Arabia. Contemp Clin Dentistry. 2018;9(Suppl 1):S64-S68.
22. Ramli, H, Mohd-Dom TN, Mohd-Said S. Clinical benefits and adverse effects of siwak (S. persica) use on periodontal health: a scoping review of literature. BMC Oral Health.2021:21:618.
23. Suleman N, Sidrak M, Noussair J, et al. The prevalence of gingival recession among miswak (Salvadora persica L.) chewing stick users: a systematic review. J Herbal Med. 2025;51:101003.
24. Theodosopoulos L, Fradelos EC, Panagiotou A, Dreliozi A, Tzavella F. Delivering culturally competent care to migrants by healthcare personnel: a crucial aspect of delivering culturally sensitive care. Soc Sci. 2024;13:530

From Dimensions of Dental Hygiene. January/February 2026; 24(1):40-45

According to the Council on Disability Income and Awareness, approximately 25% of today’s 20-year-olds will become disabled before they reach retirement age.¹ Chronic conditions are the most common cause of disability, with 25% a result of muscle and bone disorders such as back problems, joint pain, and muscle pain.¹ Musculoskeletal disorders (MSDs) are one of the most common reasons for disability claims.^2,3 Dental hygienists are especially at risk for MSDs due to the repetitive work and compromised posture for prolonged periods when treating patients.

Disability insurance may be prudent for dental hygienists because the right policy can replace your after-tax income if an injury or illness leaves you suddenly unable to work. It can be especially important if you have dependents who rely on your income.

There are three types of disability insurance: short-term, long-term, and accident-only. Short-term disability policies typically provide coverage for 3, 6, or 12 months after a short waiting period. Long-term disability insurance has a typical waiting period of 90 days, after which benefits are paid for anywhere from 2 years to retirement. The accident-only insurance pays benefits if there is a disability due to an accident. Most oral health professionals choose long-term disability as it can replace your income for years — even up until  retirement age if you can never work again.

Factors to consider when deciding on disability insurance are the likelihood of a hand-related disability and emergency savings. Carpal tunnel syndrome, repetitive strain injuries, or other hand-related conditions are common risks for dental hygienists. If a policy covers these, it could be worth the investment. In addition, evaluate if you have enough savings to cover 3 or more months of living expenses in case you cannot work. If not, disability insurance might serve as a critical backup.

Dental hygienists rely heavily on their physical health, especially their hands, neck, and back. If an injury or illness prevents you from working, disability insurance provides a means to protect your income. Many disability insurance policies for healthcare professionals, including dental hygienists, offer specialized coverage called “own-occupation” coverage. This means you will receive benefits if you are unable to perform the specific duties of a hygienist, even if you could work in another capacity. Lastly, even with the 3-month waiting period, receiving a payout after that time can prevent financial strain during a long-term disability and provide financial peace of mind.

On the other hand, disability insurance premiums can be expensive, particularly for policies with good coverage and short elimination periods. The cost may outweigh the coverage provided. Additionally, the 3-month waiting period means you will need to rely on savings or another income source for short-term disabilities.

If you are considering purchasing disability insurance, make sure you carefully read the policy details and consult an insurance broker or financial advisor who specializes in healthcare professionals. They can help you assess whether the policy is appropriate for your risks and needs. A good disability insurance policy will protect you financially even if you are unable to work for years. Compare quotes from multiple disability insurance providers including those provided by your national professional association.

References

1. Council for Disability Income Awareness. Chances of Disability. Available at disabilitycanhappen.org/overview. Accessed November 20, 2025.
2. Integrated Benefits Institute. Health and Productivity Benchmarking 2019 Short-Term Disability, All Employers. Condition-Specific Results. Available at ibiweb.org/research-resources/leave-benchmarking-publications. Accessed November 20, 2025.
3. Integrated Benefits Institute. Health and Productivity Benchmarking 2019 Long-Term Disability, All Employers. Condition-Specific Results. Available at https://www.ibiweb.org/research-resources/leave-benchmarking-publications. Accessed November 20, 2025.

From Dimensions of Dental Hygiene. January/February 2026; 24(1):46