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202Chapter 8 – Profession of Dental HygieneThe College of Nurses of Ontario has an extensive medication standardsreference list on conscious sedation and analgesia, in addition to itsmedication standards of practice. 45HPRAC has been told that the CDHO would establish one or more standardsof practice for conscious sedation in consultation with the CPSO, theRCDSO and the Ontario College of Pharmacists. The expectation is that theCDHO would adapt the CRDHA qualification requirements for registereddental hygienists to meet certification requirements in Ontario. Theproponents have indicated they have had discussions with the OntarioMinistry of Training, Colleges and Universities for support to any changesneeded in the Ontario dental hygienist curriculum in order to comply withthe National Competencies. 46 These changes could be ready within 18months to two years.Injection of AnaestheticsLocal anaesthetic, with almost no resulting side-effects, is commonly usedin dentistry, and patients refer to the procedure as “freezing”. The injectionof the local anaesthetic is sometimes preceded by a numbing gel, sopatients do not feel the needle slide into their gums.Anxiety-induced events are the most common adverse reaction associatedwith local anaesthetics in dentistry, the most common of which is syncope.In addition, other symptoms, including hyperventilation, nausea, vomitingand alterations in heart rate or blood pressure may be noted. 47 Allergicreactions may also be common, including signs such as urticaria, edemaand bronchospasm.The training required for the injection of local anaesthetics includes notonly expertise in the drugs that may be injected, but also the site ofadministration, the speed of injection and maximum dose calculations thatare appropriate to the patient. The patient’s medication history andpossible drug interactions must be taken into account.During the process of dental anaesthesia, including infiltration anaesthesiaas well as mandibular anaesthesia, oral bacteria can enter the tissuefollowing perforation of the mucous membrane by the needle injection. 48Dental local anaesthesia may therefore lead to suppurative local infectionsor odontogenic bacteraemia, as has been shown to occur in other dentalsurgery interventions. These circumstances have raised the issue of routineantibiotic prophylaxis in oral surgery. 4945College of Nurses of Ontario. Practice Standard: Medication. Revised 2008. Available:http://www.cno.org/docs/prac/41007_Medication.pdf.46HPRAC meeting with proponents.47Haas, Daniel A. An Update on Local Anaesthetics in Dentistry. Journal de l’Association dentairecanadienne, October 2002. Vol. 68.9.Available: http://www.cda-adc.ca/jadc/vol-68/issue-9/546.pdf.48Gräf, 1965; Streitfeld & Zinner, 1958; Winther & Praphailony, 1969.49Rahn, 1989; Roberts et al., 1998.HPRAC Critical Links January 2009
203Chapter 8 – Profession of Dental HygieneExtensive education, including knowledge of drugs and their interactions,potential responses to interventions, the need for antibiotic prophylaxisand clinical practice training is essential to the administration of oral localanaesthetics.ConclusionsAdministration of Drugs by Injection and InhalationAs a result of its review, including an examination of current competencies ofthe profession, a jurisdictional review, examination of accreditation criteria,educational programs and the depth of knowledge of pharmacotherapeuticswithin the profession of dental hygiene, HPRAC is not prepared torecommend that dental hygienists be authorized to independentlyadminister substances by injection or inhalation. Current dental hygieneeducation programs in Ontario do not have the course content needed toprepare new practitioners to perform these activities; no related standardsof practice have been developed, and no continuing competence or bridgingprograms to train existing practitioners are in place today.HPRAC sees value in the expansion of dental hygienists’ independentpractice into urban and rural communities. HPRAC has heard fromproviders in long-term care homes and home care that on-site oral hygieneservices provide value for their residents, patients and clients. Nonetheless,when people who can benefit from oral hygiene care need painmanagement, it should be provided in a context of total physical care andnot as an isolated intervention.Request for Prescribing, Dispensing and CompoundingSeveral organizations and individuals have raised concerns about thecompetencies of dental hygienists to prescribe drugs.HPRAC heard particular concerns from members of the dentistry professionabout inconsistencies in dental hygiene training programs and deficienciesin quality assurance programs that have been put in place by the CDHO torequire educational bridging programs and “gap training” forinternationally-trained graduates. Others voiced concerns about CDHO’squality assurance programs and their exactitude in defining and measuringprescribing competencies. 50 The Ontario Dental Association told HPRACthat dental hygienists at present do not have the comprehensive trainingand education needed to prescribe prescription drugs.HPRAC heard from numerous professionals, regulators and professionalassociations of concerns about dental hygiene education in the areas ofanatomy, biochemistry and physiology that would qualify members of theprofession to prescribe drugs for patients. A number of stakeholders50HPRAC meetings and interviews with key stakeholders. November and December 2008.HPRAC Critical Links January 2009
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