CDHO Advisory | Hypothyroidism
COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY
ADVISORY TITLE
Use of the dental hygiene interventions of scaling of teeth and root planing including
curetting surrounding tissue, orthodontic and restorative practices, and other invasive
interventions for persons1 with hypothyroidism.
ADVISORY STATUS
Cite as
College of Dental Hygienists of Ontario, CDHO Advisory Hypothyroidism, 2011-02-01
INTERVENTIONS AND PRACTICES CONSIDERED
Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and
restorative practices, and other invasive interventions (“the Procedures”).
SCOPE
DISEASE/CONDITION(S)/PROCEDURE(S)
Hypothyroidism
INTENDED USERS
Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies
ADVISORY OBJECTIVE(S)
To guide dental hygienists at the point of care relative to the use of the Procedures for
persons who have hypothyroidism, chiefly as follows.
1.
2.
3.
4.
1
Understanding the medical condition.
Sourcing medications information.
Taking the medical and medications history.
Identifying and contacting the most appropriate healthcare provider(s) for medical
advice.
Persons includes young persons and children
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5. Understanding and taking appropriate precautions prior to and during the Procedures
proposed.
6. Deciding when and when not to proceed with the Procedures proposed.
7. Dealing with adverse events arising during the Procedures.
8. Record keeping.
9. Advising the patient/client.
TARGET POPULATION
Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged, 80 and over
Male
Female
Parents, guardians, and family caregivers of children, young persons and adults with
hypothyroidism.
MAJOR OUTCOMES CONSIDERED
For persons who have hypothyroidism: to maximize health benefits and minimize adverse
effects by promoting the performance of the Procedures at the right time with the
appropriate precautions, and by discouraging the performance of the Procedures at the
wrong time or in the absence of appropriate precautions.
RECOMMENDATIONS
UNDERSTANDING THE MEDICAL CONDITION
Nomenclature of hypothyroidism
Resources consulted
 Hypothyroidism, Thyroid Foundation of Canada
 Hypothyroidism, Mayo Clinic
 Hypothyroidism, MedlinePlus
 Hypothyroidism  Overview, University of Maryland Medical Center
1. Adult hypothyroidism, alternative name for hypothyroidism.
2. Borderline hypothyroidism, also called compensated hypothyroidism, a common
condition that cannot be accurately diagnosed clinically without blood tests, in which
the
a. thyroid-stimulating hormone is elevated
b. thyroid hormone levels are normal or only slightly subnormal.
3. Congenital hypothyroidism, also called neonatal hypothyroidism, a condition in infancy
or early childhood induced by genetic or environmental factors, in which in-utero
thyroid hormone deficiency results from
a. missing thyroid
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4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
b. faulty development of the thyroid during pregnancy
c. development of the thyroid in the wrong anatomical place which thus fails to
function.
Cretinism, a congenital condition also called congenital myxedema, cretinoid dysplasia
a. caused by thyroid hormone deficiency during fetal development
b. characterized in childhood by
i. dwarfed stature
ii. mental retardation
iii. dystrophy of the bones
iv. low basal metabolism.
Goiter, also called goitrous hypothyroidism or compensatory goiter, in which the thyroid
is enlarged because of constant stimulation.
Hashimoto thyroiditis, also called autoimmune thyroiditis, the most common cause of
hypothyroidism, an autoimmune disorder in which thyroid cells are destroyed by
various cell-mediated and antibody-mediated immune processes.
Hyperthyroidism, (CDHO Advisory) a condition which
a. is caused by overproduction of thyroid hormone
b. raises thyroid hormone in the blood to excessive levels, which adversely affects
various tissues of the body
c. causes an abnormally increased rate of metabolism.
Hypothyroidism, a condition in which the body lacks thyroid hormones.
Myxedema, also called advanced hypothyroidism, is
a. caused by decreased activity of the thyroid in adults
b. characterized by dry skin, swellings around the lips and nose, mental
deterioration, and a subnormal basal metabolic rate
c. rare but may be life-threatening; the most severe form, called myxedema coma,
is a medical emergency.
Neonatal hypothyroidism, decreased or, rarely, absent thyroid hormone production.
Postpartum thyroiditis, also called subacute thyroiditis, a transient form of
hypothyroidism.
Secondary hypothyroidism, the thyroid is normal but not producing enough hormones
because of a problem in the pituitary or hypothalamus.
Thyroid gland, makes and stores hormones that help regulate the heart rate, blood
pressure, body temperature, and metabolism.
Thyroid hormone deficiency, the consequence of hypothyroidism.
Thyroid hormones
a. are controlled by the hypothalamus which, according to the blood level of
thyroxine and triiodothyronine, stimulates the pituitary to produce thyroidstimulating hormone, which regulates the thyroid’s production of thyroid
hormones
b. include
i. thyroxine, which
1. is the body’s main metabolic hormone
2. regulates
a. the rate of oxygen use by cells
b. the generation of body heat
3. promotes glucose metabolism
ii. free thyroxine, which is
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1. the amount of the free (unbound) active thyroxine circulating in the
blood
2. measured by specific laboratory procedures
iii. triiodothyronine, which
1. is the most active thyroid hormone and affects all body processes
2. helps regulate growth and development
3. helps control metabolism and body temperature
4. by negative feedback, acts to inhibit the secretion of thyroidstimulating hormone by the pituitary gland
5. circulates in blood almost completely bound to carrier proteins
iv. free triiodothyronine, the free (unbound) portion of triiodothyronine, that
is believed responsible for the biological action
v. calcitonin, which regulates the amount of calcium in the blood.
16. Thyroiditis, inflammation (not infection) of the thyroid, of which there are several types.
Overview of hypothyroidism
Resources consulted
 Congenital Hypothyroidism, HEALTHLinkAlberta
 Hypothyroidism, Mayo Clinic
 Hypothyroidism, MedLinePlus
 Hypothyroidism, MyThyroid.com
 Hypothyroidism  Overview, University of Maryland Medical Center
 Hypothyroidism, Thyroid Foundation of Canada
 Management of hypothyroidism during pregnancy, Canadian Medical Association Journal
 Screening for Congenital Hypothyroidism, The Canadian Task Force on the Periodic Health

Examination
Thyroid Problems and Pregnancy, endocrineweb
Hypothyroidism
1. affects
a. women most commonly
i. especially in the age range above 50
ii. as many as ten percent have some degree of thyroid hormone deficiency
b. adults generally
c. children, including babies and teenagers
d. about two percent of the population
e. many or even all body functions
2. affects reproduction and pregnancy
a. is the most common thyroid disorder occurring before, during or after
pregnancy
b. may occur because of the development during pregnancy of antibodies that
neutralize the woman’s thyroid
c. impairs fertility through
i. interference with ovulation resulting from low levels of thyroid hormone
ii. autoimmune disorder, which also may be linked to the hypothyroidism
iii. menstrual irregularities, such as
1. heavy periods
2. amenorrhea
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iv. decreased libido
d. if left untreated is linked to
i. increased incidence of birth defects
ii. lower IQs in neonatal hypothyroidism
iii. miscarriage
iv. preeclampsia
v. premature delivery
e. may be overlooked because of confusion with common conditions in pregnancy,
such as
i. fatigue
ii. excessive weight gain
f. may be treated with synthetic hormones, which
i. are generally considered safe because the chemical structure is nearly
identical to that of the natural hormones
ii. may require the dose to be increased during pregnancy for women with
previously treated hypothyroidism
3. is caused by
a. defects in the thyroid arising from or associated with
i. autoimmune disorders, such as
1. Hashimoto thyroiditis, autoimmune thyroiditis, which
a. is a common thyroid gland disorder
b. occurs at any age, but is most often seen in middle-aged
women, especially with a family history of the disease
c. is caused by a reaction of the immune system against the
thyroid gland
d. affects between 0.1 and 5 percent of all adults in Western
countries
2. thyroiditis, which may have causes other than autoimmune disorder
3. type I diabetes (CDHO Advisory), in association with which
a. hypothyroidism occurs more commonly in women than
men
b. hypothyroidism seems to be particularly common in
teenage girls
ii. medical conditions
1. goitrous hypothyroidism
2. atrophic thyroid, small thyroid
3. birth defects
b. side-effects of treatment
i. surgery for
1. hyperthyroidism (CDHO Advisory)
2. cancer of the thyroid
3. other conditions of the thyroid involving removal of all or part of
the thyroid
4. cancer of the head and neck involving surgery with or without
radiation exposure to the neck
ii. radiation of the
1. thyroid
2. head and neck
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iii. medications
1. specific medications
2. radioactive iodine used in the treatment of hyperthyroidism
c. diet
i. iodine deficiency
ii. iodine excess
d. abnormalities of the pituitary or hypothalamus, in which
i. pituitary does not release enough hormone to stimulate the thyroid,
possibly because of a benign tumour
ii. disorder of the hypothalamus
4. seldom creates problems in the early stages but the slowing of metabolism over time, if
untreated, may result in
a. medical conditions or complications, such as
i. obesity
ii. joint pain
iii. heart disease
b. non-specific symptoms and signs in various systems
i. general
1. fatigue
2. weakness
3. sluggishness
4. intolerance to cold
5. poor appetite
6. puffiness of the face
7. constipation
8. weight gain, likely because of some combination of
a. fluid retention
b. reduced ability to burn calories
c. increased levels of hormones that drive hunger
d. difficulty losing weight
ii. mental health conditions
1. difficulty concentrating
2. memory impairment
3. depression
4. sleep disorders
5. irritability
iii. musculature
1. aches
2. tenderness
3. stiffness
4. cramps
5. weakness
iv. joints
1. pain
2. stiffness
3. swelling
v. skin and hair
1. pale, cold, dry, coarse, rough or scaly skin
2. thickening of the skin and underlying tissues, myxedema
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3. hair
a. coarse, dry, brittle
b. lost
4. brittle fingernails
vi. hoarseness of voice
vii. changes in cholesterol levels that increase the risk of heart disease,
primarily because an underactive thyroid may raise the level of lowdensity lipoprotein (LDL) cholesterol
c. specific signs
i. absence of thyroid on palpation
ii. slow reflexes
iii. slow heart rate
5. occurs in children, including babies and teenagers
a. infants born with neonatal hypothyroidism owing to absence or dysfunction of
the thyroid
i. at birth
1. may show few indications, which is why routine thyroid screening is
advocated for newborns
2. or may exhibit
a. jaundice
b. frequent choking
c. large, protruding tongue
d. puffiness of the face
ii. with the progression of the hypothyroidism, are likely to be subject to
1. feeding problems
2. failure to grow and develop normally
3. constipation
4. poor muscle tone
5. excessive sleepiness
b. older children may variously exhibit the signs and symptoms that occur in
adults, plus
i. delayed deciduous dentition (see oral health considerations)
ii. dwarfism
iii. yellow, dry, thick skin
iv. obesity, to some degree
v. thick lips and tongue
vi. short hands with thick fingers
vii. mental retardation
viii. delayed puberty
ix. slow movement
6. is associated with risk factors, including
a. female gender
b. age over 50 years; increased in the elderly
c. previous radiation treatment to the neck or upper chest
d. obesity
e. thyroid surgery
f. a close relative, such as a parent or grandparent, with an autoimmune disease
g. previous treatment with radioactive iodine or anti-thyroid medications
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h. untreated thyroid disease in mothers, which increases the risk of birth defects
in their babies: the prognosis is good for the baby if the condition is detected
within the first few months of life
7. is diagnosed by accurate thyroid function tests, specifically with
a. thyroid-stimulating hormone, which
i. provides an important initial screening test
ii. provides a critically important test for the confirmation of borderline
hypothyroidism, for which diagnosis is otherwise extremely difficult
because
1. symptoms may be vague or absent
2. once treatment is started it usually continues for life and is difficult
to stop
b. thyroid hormones, when showing low levels of thyroxine and triiodothyronine
in the blood
8. is treated with synthetic thyroid hormones, which are usually simple, safe and effective
once the appropriate dosage is established
9. usually progresses if left untreated, which may result though rarely in severe
a. life-threatening depression (CDHO Advisory)
b. heart disease
c. myxedema coma.
Multimedia and images
Hypothyroidism
Thyroid gland
Comorbidity, complications and associated conditions
Comorbid conditions are those which co-exist with hypothyroidism but which are not
believed to be caused by it. Complications and associated conditions are those that may
have some link with it. Distinguishing among comorbid conditions, complications and
associated conditions may be difficult in clinical practice.
Resources consulted
 Thyroid Disease and Mental Disorders: Cause and Effect or Only Comorbidity?: Hypothyroidism,



Medscape (free service, requires registration)
Psychiatric comorbidity and medication use in autism: a community survey, Psychiatric Services
Medical Comorbidity in Bipolar Disorder: Implications for Functional Outcomes and Health
Service Utilization, Psychiatric Services
Effect of anemia and comorbidity on functional status and mortality in old age, Canadian Medical
Association Journal
1. Mental health conditions are associated with hypothyroidism even though most
hypothyroid patients do not meet the criteria for a mental disorder; the associated
conditions include
a. diminished cognition, slow thought process, slow motor function, and
drowsiness
b. depression (CDHO Advisory); even subclinical hypothyroidism may affect mood
c. bipolar symptoms
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CDHO Advisory | Hypothyroidism
2.
3.
4.
5.
6.
7.
8.
9.
d. may involve specific conditions, such as
i. Alzheimer's disease, especially in women
ii. autism.
Myxedema, which is associated with severe mental disorders including psychoses, and
which may manifest as myxedema coma, which is
a. a medical emergency that occurs when the body's level of thyroid hormones
becomes extremely low
b. treated with
i. intravenous thyroid hormone replacement and steroid medications
ii. supportive therapy (oxygen, breathing assistance, fluid replacement) and
intensive-care nursing, as required
Immune system disorders which may, in rare cases, be associated with
a. chronic thyroiditis
b. other endocrine disorders such as
i. adrenal insufficiency
ii. type 1 diabetes (CDHO Advisory).
Infections; subacute thyroiditis
a. results in inflammation of the thyroid gland
b. may be a complication of an upper respiratory infection
Diabetes (CDHO Advisory)
Heart disease
Obesity
Goiter, goitrous hypothyroidism
Infertility
Oral health considerations
Resources consulted
 Management of patients with thyroid disease Oral health considerations, Journal of the

American Dental Association
Diabetes and Other Endocrine Disorders, Colgate-Palmolive Company
The dental hygienist should be aware of the
1. oral and systemic manifestations of hypothyroidism so as to be able to
a. recognize the need for medical advice about
i. the possibility of hypothyroidism in an undiagnosed patient, and the need
to defer oral healthcare pending medical advice
ii. a diagnosed patient/client relative to
1. the degree to which the hypothyroidism is controlled
2. complications
iii. a diagnosed patient/client who has for some time been taking
medications, and who is now experiencing symptoms of increased thyroid
activity which may be but should not be attributed to the stress of oral
healthcare, such as
1. palpitations
2. restlessness or shakiness
3. sweating
4. and, on questioning, acknowledges rapid weight loss
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b. take the medical history of a diagnosed patient relative to the
i. hypothyroidism
ii. complications
iii. comorbidities
iv. current treatment
2. oral health aspects of hypothyroidism
a. children with hypothyroidism may have
i. malocclusion
ii. delayed tooth eruption
iii. protruding tongue
iv. swollen gums
v. increased risk of decay and periodontal disease
vi. poorly shaped teeth
b. adults with hypothyroidism may have
i. enlarged tongue
ii. delayed tooth eruption
iii. variable or poor periodontal health
iv. delayed wound healing
v. changed taste sensitivity
vi. rapid and severe periodontal disease
vii. weakened oral and facial bones
3. the importance of cardiovascular associated with hypothyroidism, because medical
advice may be required prior to the Procedures relative to
a. risk of infective endocarditis and the need for antibiotic prophylaxis
b. atrial fibrillation, in regard to requirement for
i. antibiotic prophylaxis
ii. coagulation tests to assess hemostasis when anticoagulation medication
is used by the patient
c. caution regarding the use of epinephrine for patients who have cardiovascular
disease
d. potential for harm from stress in the course of oral healthcare for hypothyroid
patients receiving treatment for heart disease that may increase energy
consumption cardiac function, and therefore the load on the heart
4. the significance of lethargy and slowing of respiratory rate in diagnosed and medicated
hypothyroidism patients may, during treatment, signal aspiration risk.
MEDICATIONS SUMMARY
Sourcing medications information
1. Adverse effect database
 Health Canada’s Marketed Health Products Directorate
toll-free 1-866-234-2345
 Health Canada’s Drug Product Database
2. Specialized organizations
 US National Library of Medicine and the National Institutes of Health Medline Plus
Drug Information
 WebMD
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3. Medications considerations
All medications have potential side effects whether taken alone or in combination with
other prescription medications, or as over-the-counter (OTC) or herbal medications.
4. Information on herbals and supplements
 US National Library of Medicine and the National Institutes of Health Medline Plus
Drug Information All Herbs and Supplements
Treatment of Hypothyroidism
Resources consulted
 Hypothyroidism, Thyroid Foundation of Canada
 Hypothyroidism treatment, Mayo Clinic
 Hypothyroidism, MedlinePlus
Medications
1. Treatment with thyroxine or its synthetic equivalent is continued for life and must not
be stopped because the cause of the thyroid failure is likely to be progressive and
permanent.
2. The dose may have to be altered for major stress or illness, which can sometimes
increase the need for thyroid hormone.
3. For patients with heart disease, in older patients, or patients with co-existing or
suspected heart disease, treatment is started with a low dose of thyroxine or synthetic
equivalent to avoid aggravating conditions such as angina or other forms of heart
disease.
Synthetic equivalent of thyroxine
levothyroxine (Synthroid®, Eltroxin®, Levothroid®, Levoxyl®, Unithroid®)
Side effects of medications
See link above.
THE MEDICAL AND MEDICATIONS HISTORY
The dental hygienist in taking the medical and medications history-taking should
1. focus on screening the patient/client prior to treatment decision relative to
a. medications considerations, including over-the-counter medications, herbals
and supplements
b. contraindications
c. complications
d. comorbidities
2. explore the need for advice from the primary or specialized care provider(s)
3. inquire about
a. pointers in the history of significance to hypothyroidism, such as the oral health
aspects of hypothyroidism in children
b. symptoms indicative of problematic control of hypothyroidism, such as
symptoms that could indicate that the medication dose is too high
c. the patient/client’s understanding and acceptance of the need for oral
healthcare
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d. medications considerations, including over-the-counter medications, herbals
and supplements
e. problems with previous dental/dental hygiene care
f. problems with infections generally and specifically associated with
dental/dental hygiene care
g. the patient/client’s current state of health
h. how the patient/client’s current symptoms relate to
i. oral health
ii. health generally
iii. recent changes in the patient/client’s condition.
IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE
Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain
medical or other advice pertinent to a particular patient/client
The dental hygienist should
1. record the name of the physician/primary care provider most closely associated with
the patient/client’s healthcare, and the telephone number
2. obtain from the patient/client or parent/guardian written, informed consent to contact
the identified physician/primary healthcare provider
3. use a consent/medical consultation form, and be prepared to fax the form to the
provider
4. include on the form a standardized statement of the Procedures proposed, with a
request for advice on proceeding or not at the particular time, and any precautions to
be observed.
UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS
Infection Control
Dental hygienists are required to keep their practices current with infection control policies
and procedures, especially in relation to
1. the Recommendations published by the Centers for Disease Control and Prevention
(a frequently updated resource)
2. relevant occupational health and safety legislative requirements
3. relevant public health legislative requirements
4. best practices or other protocols specific to the medical condition of the patient/client.
DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED
1. There is no contraindication to the Procedures.
2. With an otherwise healthy patient/client whose symptoms are under control and whose
treatment is proceeding normally, the dental hygienist should implement the
Procedures, though these may be postponed pending medical advice, which is likely to
be required if the patient/client has
a. symptoms or signs of exacerbation of the medical condition
b. comorbidity, complication or an associated condition of hypothyroidism
c. not recently or ever sought and received medical advice relative to oral
healthcare procedures
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d. recently changed significant medications, under medical advice or otherwise
e. recently experienced changes in his/her medical condition such as medication
or other side effects of treatment
f. deep concerns about any aspect of his or her medical condition.
DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES
Dental hygienists are required to initiate emergency protocols as required by the College of
Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of
the patient/client.
First-aid provisions and responses as required for current certification in first aid.
RECORD KEEPING
Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2), for a
patient/client with a history of hypothyroidism, the dental hygienist should specifically
record
1. a summary of the medical and medications history
2. any advice received from the physician/primary care provider relative to the
patient/client’s condition
3. the decision made by the dental hygienist, with reasons
4. compliance with the precautions required
5. all Procedure(s) used
6. any advice given to the patient/client.
ADVISING THE PATIENT/CLIENT
The dental hygienists should
1. urge the patient/client to alert any healthcare professional who proposes any
intervention or test that he or she
a. has a history of hypothyroidism
b. is taking medication for hypothyroidism
2. should discuss, as appropriate
a. the importance of the patient/client’s
i. self-checking the mouth regularly for new signs or symptoms
ii. reporting to the appropriate healthcare provider any changes in the
mouth
b. the need for regular oral health examinations and preventive oral healthcare
c. oral self-care including information about
i. choice of toothpaste
ii. tooth-brushing techniques and related devices
iii. dental flossing
iv. mouth rinses
v. management of a dry mouth
d. the importance of an appropriate diet in the maintenance of oral health
e. for persons at an advanced stage of the condition or who are debilitated
i. regimens for oral hygiene as a component of supportive care and
palliative care
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ii. the role of the family caregiver, with emphasis on maintaining an
infection-free environment through hand-washing and, if appropriate,
wearing gloves
iii. scheduling and duration of appointments to minimize stress and fatigue
f. comfort level while reclining, and stress and anxiety related to the Procedures
g. medication side effects such as dry mouth, and recommend treatment
h. mouth ulcers and other conditions of the mouth relating to disorders of the
adrenal gland, comorbidities, complications or associated conditions,
medications or diet
i. pain management.
BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS
POTENTIAL BENEFITS
1. Promotion of health through
a. oral hygiene for persons who have hypothyroidism
b. early detection of inadequately controlled hypothyroidism
c. recognition of complications that require medical advice prior to the
Procedures.
2. Recognizing the possibility of undiagnosed hypothyroidism, and referring the
patient/client for medical advice.
3. Reducing the risk that oral health needs are unmet.
POTENTIAL HARMS
1. Causing risk to the patient/client by proceeding with oral healthcare without
appropriate advice about a cardiovascular condition associated with the
hypothyroidism.
2. Performing the Procedures at an inappropriate time, such as
a. when the control of the patient/client’s hypothyroidism is problematic
b. in the presence of complications for which prior medical advice is required
3. Disturbing the normal dietary and medications routine of a person with hypothyroidism.
4. Inappropriate management of pain or medication.
CONTRAINDICATIONS
CONTRAINDICATIONS IN REGULATIONS
Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III.
DATE OF LAST REVIEW
2011-02-01
ADVISORY DEVELOPER(S)
College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists
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SOURCE(S) OF FUNDING
College of Dental Hygienists of Ontario
ADVISORY COMMITTEE
College of Dental Hygienists of Ontario, Practice Advisors
COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY
Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of
Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA
Lisa Taylor
RDH, BA, MEd
ACKNOWLEDGEMENTS
The College of Dental Hygienists of Ontario gratefully acknowledges the Template of
Guideline Attributes, on which this advisory is modelled, of The National Guideline
Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality
(AHRQ), U.S. Department of Health and Human Services.
Denise Lalande
Final layout and proofreading
COPYRIGHT STATEMENT
© 2011 College of Dental Hygienists of Ontario
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