Alcohol and Drug Abusers

Disease/Medical Condition

SUBSTANCE USE DISORDER Date of Publication: June 20, 2019

(also known as “SUD”, “drug use disorder”, and “substance-related disorder”1; includes “drug or alcohol dependency” [also known as “drug addiction or alcoholism”, “chemical dependence”, and “chemical dependency”] and “drug or alcohol abuse” [also known as “substance abuse”])

Is the initiation of non-invasive dental hygiene procedures* contra-indicated? No, unless:

― the patient/client displays behavioural signs/symptoms that pose a risk to himself/herself or the dental hygienist during procedures (e.g., extreme restlessness or aggression); or ― the patient/client is intoxicated or “high” and therefore is incapable of giving informed consent.  Is medical consult advised? — Yes, if undiagnosed substance use disorder (abuse or dependence) is suspected. The patient/client’s primary physician may be able to assist with access to a treatment program or an addiction treatment specialist. ― Yes, if poor response to substance abuse/dependence treatment is suspected.2

Is the initiation of invasive dental hygiene procedures contra-indicated?** Yes, if drug or alcohol dependency is of a type or extent that may affect the appropriateness or safety of scaling and root planing, including curetting surrounding tissue (as per Ontario Regulation 501/107).

 Is medical consult advised? ...... See above. Additionally, before aggressive nonsurgical (or surgical) periodontal therapy is undertaken, the patient/client’s physician should be consulted to confirm there is no immunosuppression or significant liver or kidney damage. Also, pain control should be coordinated with the primary care physician for patients/clients recovering from substance abuse/dependence.  Is medical clearance required? — Yes, if drug or alcohol dependency meets the proscribed initiation criteria of O. Reg. 510/107. — Yes, if the patient/client has history of intravenous (IV) drug abuse. — Yes, if there is a bleeding disorder (e.g., caused by thrombocytopenia resulting from alcoholism or habitual cocaine use).  Is antibiotic prophylaxis required? ...... Possibly, if the patient/client has a history of intravenous drug abuse.3  Is postponing treatment advised? — Yes, in most circumstances where the patient/client has “self-medicated” with drugs of abuse or alcohol prior to the dental/dental hygiene appointment. If the patient/client is “high” or intoxicated, procedures should be deferred until the patient/client is not mentally impaired and not at undue risk of significant myocardial ischemia, cardiac arrhythmia, or other serious medical sequelae in the operatory (particularly with use of cocaine or methamphetamine). Patients/clients “high” on methamphetamine should not receive dental treatment for at least 8 hours (and ideally at least 24 hours) after last administration of the drug. ― Yes, if patient/client is medically unstable. An overdose of an abused substance requires immediate medical attention. Alcohol poisoning is a medical emergency. ― Yes, if the patient/client has untreated alcoholic liver disease. Elective, outpatient dental/dental hygiene care should be deferred pending assessment by a physician regarding bleeding risk, etc. ― Yes, until medical assessment has occurred regarding possible antibiotic prophylaxis in patients/clients with history of intravenous drug abuse. — Yes, if the patient/client is unwilling or unable to comply with treatment. When recovery from addiction is further progressed, the patient/client may be more receptive to dental hygiene care.

1 “Substance-related disorder” also encompasses “substance-induced disorders” including intoxication, withdrawal, and other substance/ medication-induced mental disorders. These conditions are also addressed to some degree in this fact sheet. 2 Behavioural and pharmacologic treatments are used to treat drug or alcohol addiction. Medications used to treat depression and anxiety disorders are also used to treat patients/clients with addictive behaviour disorders. For alcoholism, alcohol sensitizing agents (e.g., disulfiram and citrated calcium carbamide), anti-craving agents (such as naltrexone), and antiemetic agents (such as ondansetron) may be employed. For patients/clients with addiction to heroin or narcotic painkillers, methadone (an opioid agonist) or buprenorphine (a partial opioid agonist/antagonist) can be used. Naloxone is an opioid antagonist used to block or reverse the effects of opioids, particularly for opioid overdoses. 3 Many IV drug users develop venous thrombosis and organic valvular heart disease. In particular, damage to the tricuspid valve is often associated with IV substance abuse. As well, IV drug use can result in endocarditis caused by Staphylococcus aureus on nonsterile needles.

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Disease/Medical Condition

SUBSTANCE USE DISORDER

(also known as “SUD”, “drug use disorder”, and “substance-related disorder”; includes “drug or alcohol dependency” [also known as “drug addiction or alcoholism”, “chemical dependence”, and “chemical dependency”] and “drug or alcohol abuse” [also known as “substance abuse”])

Oral management implications

 Patients/clients who are dependent on alcohol or drugs or who are receiving treatment for substance abuse pose complex issues for the dental hygienist related to preventive oral healthcare. In addition to poor self-care, there are numerous potential oral manifestations of substance abuse.  History-taking should include explicit questions about “recreational drugs” and “alcohol”, in addition to “prescribed medications”, “drugs”, and “over-the-counter medications”. Chemically dependent patients/clients should be identified to avoid interactions between drugs used in the dental office and abused substances.  Patients/clients with substance abuse issues typically seek dental care only when they are in severe pain. Furthermore, the oral health problem is often in an advanced state, because of neglect or because pain sensation has been blunted by the use of drugs. Chemically dependent patients/clients may also experience tolerance to analgesics and sedatives.  Red flags for suspicion of substance abuse in a patient/client include: frequently misses appointments; careless appearance and poor hygiene; lapses in concentration and/or memory; smell of substance on breath, body, or clothes; slurred speech; rapid mood swings; needle marks on arms; abnormal pupillary constriction or dilatation; wears sunglasses in operatory (to cover dilated or red pupils, red eyes, or blank stare); wears long clothes on a hot day (to cover needle marks); continually sniffs nose and uses tissues; hacking cough; tremors of hands or head; frequently requests specific medication for pain; and high tolerance to analgesics and sedatives.  The dental hygienist should determine if the patient/client has “self-medicated” with alcohol or drugs prior to the dental/ dental hygiene appointment. If so, then the care plan may need to be modified or cancelled to avoid any substance- associated behavioural problems, drug interactions (e.g., with local anaesthetics or nitrous oxide), or other safety issues. Drugs that depress brain activity ― such as opioids, benzodiazepines, and antihistamines ― can enhance the effects of local anaesthetics.  Because some drug-abusing patients/clients may seek dental/dental hygiene treatment to obtain prescriptions for abused substances, prescription pads should be kept out of sight and be inaccessible.  Multiple short appointments may be necessary to manage anxiety or emotional instability in drug-dependent patients/clients.  Blood pressure and pulse should be monitored during appointments for cocaine and methamphetamine abusers. Such patients/clients are at elevated risk for cardiac arrhythmias, myocardial infarction, and stroke.  Malnutrition is common in substance abusers, and thus nutritional counselling and dietitian referral may be indicated.  Methamphetamine users tend to consume large amounts of soft drinks, which compounds the problems of “meth mouth”. The remaining dentition is often unsalvageable, with extractions being the only viable option.  Patients/clients who are in recovery programs may seek long-neglected oral healthcare as part of their recuperation efforts. However, recovering addicts may be very reluctant about taking any type of medication, thus complicating efforts to control pain during scaling and root debriding. Pain control should be coordinated with the primary physician.  If a chemically dependent patient/client requires sedation with nitrous oxide or benzodiazepines for dental treatment, he/ she should be referred to practitioners experienced in treating such patients/clients. Persons with a significant substance abuse history and needing extensive dental treatment may require care in a hospital or operating room.  Opioid analgesics and other addictive substances should be avoided if possible in patients/clients with drug/alcohol abuse or dependence. If prescribed, the patient/client should be monitored to ensure proper medication use. A “pain contract” outlining specific pain management strategies may be indicated, and engagement of the patient/client’s primary physician in this process should be considered. In most circumstances, nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for post-procedure pain to avoid addiction issues posed by opioids.  Epinephrine should be avoided for 24 hours after the last use of cocaine or methamphetamine.  Excessive bleeding may occur secondary to liver disease in alcoholism; lab tests may be needed for confirmation.  Complex oral procedures should only be performed when the patient/client is in a stable condition in the context of the substance use disorder.  Realistic goals for oral self-care should be set for both active drug abusers and recovering addicts. A daily fluoride rinse regimen is often appropriate, particularly if the patient/client has a moderate to high caries risk. Fluoride therapy is important for heroin addicts enrolled in a methadone program, because daily methadone is typically administered in a sugary syrup.  Fluoride and antimicrobial rinses recommended to patients/clients with alcoholism should be nonalcoholic in composition to avoid contributing to their addiction. Furthermore, even tiny amounts of alcohol ingested by a patient/client taking alcohol- sensitizing drugs (e.g., disulfiram) can cause severe gastrointestinal distress and hypotension.

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Disease/Medical Condition

SUBSTANCE USE DISORDER

Oral manifestations

 Substance abuse may result in xerostomia, increased caries rate, enamel erosion, periodontal disease, and impaired tissue healing.  Tremors of the tongue can occur during alcohol withdrawal.  Localized tissue necrosis may result from placement of drugs directly in the vestibule or sublingually. In particular, gingival lesions and recession may result from cocaine placement, as may dental erosion (particularly of the facial aspects of the maxillary teeth from persistent rubbing of powder over these surfaces).  Buccal cervical caries can result from ingestion of large quantities of sweets and carbohydrates, as often craved by alcohol and drug abusers.  Oral candidiasis can result from immunosuppression and/or nutritional deficiencies.  Glossodynia can result from malnutrition and immunosuppression.  Bruxism often occurs in persons using cocaine or methamphetamine, resulting in flat cuspal planes on the molars and premolars.  Bruxism and jaw clenching occur with MDMA4 (“ecstasy”) use (for which some “ravers” use pacifiers).  Angular cheilitis, glossitis, and loss of tongue papillae can result from nutritional deficiencies in patients/clients with chronic alcoholism. Furthermore, spontaneous gingival bleeding and mucosal ecchymoses and petechiae can result from vitamin K deficiency, impaired hemostasis, portal hypertension and splenomegaly (causing thrombocytopenia). A musty, sweet odour to the breath is associated with liver failure, as is jaundice of the mucosal tissue.  Sialadenosis5 is a common finding in patients/clients with cirrhosis of the liver, which can result from alcoholism.  Risk of oral squamous cell carcinoma is elevated with long-term alcohol use (potentiated by smoking tobacco) or chronic smoking of cannabis. High-risk sites include the lateral border of the tongue and the floor of the mouth.  “Meth mouth” results from smoking acidic methamphetamine. It is characterized by rampant caries, xerostomia, gingival inflammation, advanced periodontal disease, and poor oral hygiene. In methamphetamine-induced caries, damage begins at the gingiva with attack on the buccal smooth surfaces of posterior teeth and the interproximal spaces of anterior teeth, progressing to destruction of the coronal tooth structure. Vomiting also contributes to rampant caries and dental erosion in meth abusers.  Halitosis occurs with long-term use of anabolic steroids.  Methadone treatment for opioid addiction can adversely affect oral health due to the high sugar content and acidity of the syrup. Complications include caries, erosion, and xerostomia.

Related signs and symptoms

 Substance use disorder6 is a significant problem in Canada, involving legal (e.g., alcohol) and prescribed psychoactive substances (e.g., certain opioids) as well as illegal psychoactive substances. More than 19% of Canadians aged 12 and older (or about 5.8 million people) are considered heavy drinkers7, with males more likely to report heavy alcohol use than females. As well, opioid addiction (often involving prescription narcotics) is an increasingly recognized area of concern in Ontario and Canada.

4 MDMA = 3,4-methylenedioxymethamphetamine 5 Sialadenosis is bilateral, painless hypertrophy of the parotid glands. 6 In contradistinction to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-4, published in 1994), DSM-5 (published in 2013) combines the DSM-4 categories of substance abuse and substance dependence into “substance use disorder” measured on a continuum from mild to severe. 7 Heavy drinking refers to males who report having 5 or more drinks, or women who report having 4 or more drinks, on one occasion at least once a month in the past year.

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Disease/Medical Condition

SUBSTANCE USE DISORDER

Related signs and symptoms

 Substance abuse is a pattern of self-administered drug use that may lead to drug addiction and psychologic and physiologic dependence.8 Routes of administration vary amongst substances of abuse, and they include oral ingestion, injection (intravenous, intramuscular, or subcutaneous), snorting, inhalation, smoking, and rectal administration.  Denial is often an integral part of substance use disorder, which is an impediment to treatment and recovery and a precipitating factor for relapse.  Drug abuse occurs at elevated rates in dental office personnel compared with the general population due to ready access to opioid analgesics, sedative-hypnotic drugs, and nitrous oxide.  A person who has developed physiologic drug dependence will go through drug withdrawal upon cessation of drug use. Withdrawal signs/symptoms may include sweating, anxiety, vomiting, diarrhea, cramps, high blood pressure, headaches, and seizures.  Drugs that are often abused include the following9:

Drug Drug Effects and Health Consequences

Alcohol Short-term use: reduced inhibitions; decreased anxiety; slowed reactions; slurred speech; impaired decision-making; unconsciousness Long-term use: liver damage (including hepatitis and cirrhosis); increased risk of breast, colorectal, and stomach cancers; heart failure; dementia

Depressants (including barbiturates [“downers”], benzodiazepines, Lowered inhibitions; slowed pulse and breathing; lowered blood and flunitrazepam) pressure; poor concentration; confusion; impaired memory, judgement, and coordination; slurred speech; dizziness

Opioids (including codeine, morphine, fentanyl, carfentanil, Euphoria; drowsiness; respiratory depression; nausea; constipation; oxycodone, hydrocodone, hydromorphone, meperidine, and heroin) confusion; sedation; unconsciousness

Stimulants Stimulants amphetamines (“uppers”) Feelings of exhilaration and energy; increased heart rate, blood pressure, and metabolism; irregular heart rhythm; reduced appetite; weight loss; heart failure cocaine (“coke” or “crack”) Similar effects to amphetamines; increased temperature; chest pain; respiratory failure; stroke; seizures; malnutrition methamphetamine (“meth”) Similar effects to amphetamines; aggression; psychotic behaviour; memory loss; impaired memory and learning; cardiac and neurologic damage

8 Drug addiction is a compulsive and chronic need to use drugs despite causing physical harm to the user. Psychologic dependence relates to the user’s belief that the drug is needed to maintain a state of well-being. Physiologic dependence results from biologic alteration of the user’s brain from continual drug use, and drug tolerance ensues whereby increasingly large doses are required to produce the same effects obtained earlier with smaller doses. Withdrawal signs/symptoms occur upon abstinence from a habitually used substance. 9 Table modified from tables in 1/ Darby M (ed.) and Walsh M (ed.). Dental Hygiene: Theory and Practice (4th edition). St. Louis: Elsevier Saunders; 2015 and 2/ Little JW, Falace Da, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (8th edition). St. Louis: Elsevier Mosby; 2013.

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Disease/Medical Condition

SUBSTANCE USE DISORDER

methylphenidate Similar effects to amphetamines; increased or decreased blood pressure; psychosis; digestive problems

Cannabinoids (including cannabis [marijuana], hashish, and Short-term use: relaxation; euphoria; confusion; poor coordination; sinsemilla) bloodshot eyes; hunger; difficulty with concentration, learning, and memory; sensory distortions; dilated pupils; tachycardia; bronchial hyperactivity

Long-term use: elevated risk of chronic obstructive pulmonary disease and lung cancer (when smoked); chronic use can result in withdrawal symptoms

Hallucinogens lysergic acid (LSD) Short-term use: hallucinations; sensory distortions; extreme emotions from panic to euphoria; increased blood pressure and heart rate; hyperthermia; acute anxiety Long-term use: paranoia; delusions of grandeur; depression; psychosis; flashbacks

Mescaline (“buttons” or peyote) Hallucinations; hyperthermia; increased blood pressure; sweating; impulsive behaviour; rapid shifts in emotion

Anabolic steroids Short-term use: enhanced athletic performance; increased muscle mass; aggression; weight gain

Long-term use: shrinkage of testicles; breast development (in males); cessation of menses; facial hair (in females); acne; depression and mood swings; hypertension; liver damage; increased risk of injury to muscles, tendons, and ligaments

Inhalants volatile solvents (including airplane glue, spray paint, hair spray, Short-term use: reduced inhibitions; excitement; euphoria; paint thinner, and gasoline) irritability; slurred speech; dizziness; drowsiness

Long-term use: confusion; delirium; emotional instability; impaired thinking; psychomotor impairment; damage to brain/nervous system, liver, kidney, lung, and bone marrow

Systemic effects: respiratory arrest; asphyxia; cardiac arrhythmia; suicide volatile nitrites (including amyl nitrite and room deodorizers) Short-term use: relaxation of smooth muscles; altered consciousness; enhanced sexual pleasure Long-term use: headaches; dizziness; giddiness; shock; loss of consciousness; nitrite poisoning; damage to nervous system; impaired perception, reasoning, and memory; altered muscular coordination anaesthetics (nitrous oxide) Short-term use: euphoria; giddiness Long-term use: addiction; frostbite of nose and vocal cords from direct inhalation from pressured tank; peripheral nerve damage; brain damage due to oxygen deprivation

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Disease/Medical Condition

SUBSTANCE USE DISORDER

Dissociative Drugs phencyclidine (PCP or “angel dust”) Short-term use: reduced inhibitions; sensory deprivation; reduced pain Long-term use: combative behaviour; confusion, paranoia, and agitation; inability to speak; amnesia Systemic effects: severe hypertension; respiratory depression; catatonia; seizures; coma; flashbacks10 ketamine Elevated blood pressure and heart rate; memory loss; nausea and vomiting; impaired motor function; delirium; depression ; respiratory depression and arrest

Club Drugs

MDMA Mild hallucinogenic effects; increased tactile sensitivity; reduced inhibitions; anxiety; sweating; muscle cramping; impaired memory; (3,4-methylenedioxymethamphetamine or “ecstasy”) hyperthermia; depression

GHB (gamma-hydroxybutyrate) Drowsiness; nausea; headache; disorientation; decreased coordination; memory loss; unconsciousness; seizures

Flunitrazepam (Rohypnol) Sedation; muscle relaxation; confusion; memory loss; dizziness; impaired coordination

 Agitation or extreme depression may indicate a drug overdose.  A variety of cutaneous lesions may indicate parenteral drug abuse. These include skin “tracks” (chronic inflammation from repeated injections)11, cellulitis, and thrombophlebitis. Subcutaneous abscesses can result from “popping” of heroin.  Burns and scars on the thumb of the dominant hand may result from repeated use of a disposable lighter for smoking crack cocaine.  Nosebleeds and significant nasal damage can result from snorting or inhaling drugs.  Tremors of the hands and eyelids may be signs of alcohol withdrawal.  Extraoral facial signs of alcohol abuse include: ― red facial skin and spider angiomas (from dilated blood vessels) on the nose; ― yellow facial skin from jaundice caused by liver disease; ― red or swollen eyes; and ― angular cheilitis caused by vitamin B deficiency.  Nausea, vomiting, abdominal pain, and hypotension result if alcohol is ingested while a person is being treated with an alcohol sensitizing agent.  Infections with human immunodeficiency virus (HIV), hepatitis B, hepatitis C, and hepatitis D occur at elevated rates in patients/clients with a history of intravenous drug use.  Lung disease (including chronic obstructive pulmonary disease [COPD] and lung cancer) can result from abuse of inhaled or smoked drugs.

10 PCP is retained in fat cells for several months after use, and it can be released during exercise, fasting, or in stressful situations. 11 Skin tracks typically appear as linear or bifurcated lesions, which become hyperpigmented and indurated.

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Disease/Medical Condition

SUBSTANCE USE DISORDER

Related signs and symptoms (cont’d)

 Long-term alcohol abuse can cause liver, kidney, heart, pancreas, brain, and reproductive system damage, in addition to affecting motor coordination. Malnutrition associated with alcoholism can lead to anemia due to dietary deficiencies in vitamin B12 and folic acid. Alcoholic liver disease can lead to bleeding tendencies, unpredictable metabolism of certain drugs, and risk for spread of infection. Alcoholic cirrhosis may be accompanied by ascites12, ankle edema, jaundice, and hemorrhage from esophageal varices. Consumption of alcohol during pregnancy can lead to fetal alcohol spectrum disorder.  Schizophrenia can be triggered by cannabis use in adolescents.  Drug and alcohol abuse can lead to homelessness, crime, unemployment, impaired driving, violence, stress, and child abuse.

References and sources of more detailed information

 College of Dental Hygienists of Ontario http://www.cdho.org/Advisories/CDHO_Advisory_Substance_Use_Disorder.pdf  Khocht A, Schleifer SJ, Janal MN, Keller S. Dental Care and Oral Disease in Alcohol Dependent Persons. J Subst Abuse Treat. 2009;37(2):214-216. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760312/  Shekarchizadeh H, Khami MR, Mohebbi SZ, et al. Oral Health of Drug Abusers: A Review of Health Effects and Care. Ira J Public Health. 2013;42(9):929-940. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4453891/  Priyanka K, Maheswarappa Sudhir K, Sekhara Reddy V, et al. Impact of Alcohol Dependency on Oral Health ― A Cross- sectional Comparative Study. J Clin Diagn Res. 2017;11(6):ZC43-ZC46. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5535480/  Ministry of Health and Long-Term, Government of Ontario http://health.gov.on.ca/en/pro/programs/opioids/  ConnexOntario https://www.connexontario.ca (Access to Addiction, Mental Health, and Problem Gambling Services)  Centre for Addiction and Mental Health https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/cocaine https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/ecstasy  Government of Canada https://www.canada.ca/en/health-canada/services/substance-use/problematic-prescription-drug-use/opioids.html https://www.canada.ca/en/health-canada/services/substance-use/problematic-prescription-drug-use/opioids/responding- canada-opioid-crisis.html https://www.canada.ca/en/services/health/campaigns/cannabis/health-effects.html https://www.canada.ca/en/health-canada/services/publications/drugs-health-products/is-cannabis-safe-use-facts- youth.html  Statistics Canada https://www150.statcan.gc.ca/n1/en/pub/82-625-x/2017001/article/14765-eng.pdf?st=zPPhD0dD (Health Fact Sheets: Heavy Drinking, 2015)  Canadian Cancer Society http://www.cancer.ca/en/prevention-and-screening/reduce-cancer-risk/make-healthy-choices/limit-alcohol/some-sobering- facts-about-alcohol-and-cancer-risk/?region=on#ixzz5X2OIL5tu  Canadian Centre on Substance Use and Addiction http://www.ccdus.ca/Eng/Pages/Addictions-Treatment-Helplines-Canada.aspx

12 Ascites is abnormal accumulation of fluid in the abdominal (i.e., peritoneal) cavity. cont’d on next page... 7

Disease/Medical Condition

SUBSTANCE USE DISORDER

References and sources of more detailed information (cont’d)

 National Institute on Drug Abuse, National Institutes of Health https://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts  MedlinePlus https://medlineplus.gov/ency/patientinstructions/000494.htm (Health risks of alcohol use)  Decisions in Dentistry http://decisionsindentistry.com/article/addiction-oral-health-care/print/  American Psychiatric Association https://www.psychiatry.org/.../DSM/APA_DSM-5-Substance-Use-Disorder.pdf  WebMD https://www.webmd.com/mental-health/addiction/what-is-methadone#1  The Ohio State University Wexner Medical Center https://wexnermedical.osu.edu/mental-behavioral/addiction-drugs (Addiction to Drugs or Alcohol)  Darby M (ed.) and Walsh M (ed.). Dental Hygiene: Theory and Practice (4th edition). St. Louis: Elsevier Saunders; 2015.  Ibsen OAC and Phelan JA. Oral Pathology For The Dental Hygienist (6th edition). St. Louis: Elsevier Saunders; 2014.  Regezi JA, Sciubba JJ, and Jordan RCK. Oral Pathology: Clinical Pathologic Correlations (6th edition). St. Louis: Elsevier Saunders; 2012.  Little JW, Falace Da, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (8th edition). St. Louis: Elsevier Mosby; 2013.  Malamed SF. Medical Emergencies in the Dental Office. St. Louis: Elsevier Mosby; 2015.

* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.

** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.

Date: December 2, 2018