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Evidence-Based
Oral Surgery

A Clinical Guide for the General

Dental Practitioner
Elie M. Ferneini
Michael T. Goupil
Editors

123
Evidence-Based Oral Surgery
Elie M. Ferneini · Michael T. Goupil
Editors

Evidence-Based Oral
Surgery
A Clinical Guide for the General Dental
Practitioner
Editors
Elie M. Ferneini Michael T. Goupil
Beau Visage Med Spa, Division of Oral & Maxillofacial Surgery
Greater Waterbury OMS University of Connecticut School of Dental
Cheshire, CT Medicine
USA Farmington, CT
USA
Division of Oral and Maxillofacial Surgery
University of Connecticut
Farmington, CT
USA

ISBN 978-3-319-91360-5    ISBN 978-3-319-91361-2 (eBook)

https://doi.org/10.1007/978-3-319-91361-2

Library of Congress Control Number: 2018965193

© Springer International Publishing AG, part of Springer Nature 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
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The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword

Evidence-based dentistry integrates a practitioner’s clinical expertise and judgment,

the needs, desires, and preferences of the patient, and current, clinically relevant
evidence. The intersection of these domains is a critical component of an effective,
patient-centered approach to care. The American Dental Association defines
evidence-based dentistry (EBD) as “an approach to oral healthcare that requires the
judicious integration of systematic assessments of clinically relevant scientific
evidence, relating to the patient’s oral and medical condition and history, with the
dentist’s clinical expertise and the patient’s treatment needs and preferences.” Since
introduced at McMaster University in the 1980s to improve the quality of healthcare
delivery by closing the gap between scientific-based knowledge and commonly
found practice patterns, evidence-based dentistry has continued to advance and is
now widely accepted as a best practice.
This text is intended to provide the general dentistry community with clear,
concise, focused guidance on the delivery of evidence-based, patient-centered
surgical management and care. Drs. Goupil and Ferneini are leaders in the practice
of evidence-based oral and maxillofacial surgery, with extensive experience in
academic, military, and private practice settings. The text covers a spectrum of
topics pertaining to oral and maxillofacial surgery, including patient assessment,
exodontia, pain management, oral pathology, trauma, temporomandibular joint
dysfunction, and implant therapy—all of which are discussed using the principles
and parameters of evidence-based healthcare. Collaborating with over twenty
authors, they have developed the quintessential guide for general dentists to apply
translational science and knowledge into everyday clinical practice. All general
dentists will find information in Evidence-Based Oral Surgery: A Clinical Guide for
the General Dental Practitioner to be of great value and relevance to their practice.

Farmington, CT, USA Steven M. Lepowsky

v
Contents

Part I Patient Assessment

1 Evidence Based Dentistry: What, Why, How������������������������������������������   3
Michael T. Goupil and Linda Elder
2 Office Environment������������������������������������������������������������������������������������ 23
Melissa E. Ing and Peter Arsenault
3 Medical Assessment of the Oral and Maxillofacial Surgery Patient ���� 49
Steve R. Ruiz, Steven Halepas, Jeffrey Bennett, and Elie M. Ferneini
4 Dental Radiography���������������������������������������������������������������������������������� 67
Aditya Tadinada
5 Complementary and Alternative Medicine���������������������������������������������� 91
Stephan Goupil and Michael T. Goupil
6 Medicolegal and Ethical Considerations in
Oral Surgery by the General Dentist ������������������������������������������������������ 103
Eric R. Bernstein and Zita Lazzarini

Part II Principles of Exodontia

7 Local Anesthetics in Dentistry������������������������������������������������������������������ 129
Christy Lottinger
8 Uncomplicated Exodontia ������������������������������������������������������������������������ 151
Roger S. Badwal and Andrew Emery
9 Complicated Exodontia ���������������������������������������������������������������������������� 173
Stuart Lieblich
10 Unerupted and Impacted Teeth: A Guide for
Assessment and Treatment������������������������������������������������������������������������ 183
Leon A. Assael
11 Surgical Complications������������������������������������������������������������������������������ 205
Christine Niekrash and Michael T. Goupil

vii
viii Contents

12 Acute Pain Management �������������������������������������������������������������������������� 223

Joseph F. Piecuch

Part III Management of Oral Pathology

13 Odontogenic Infections������������������������������������������������������������������������������ 239
Gabe Hayek, Morton H. Goldberg, and Elie M. Ferneini
14 Osteonecrosis���������������������������������������������������������������������������������������������� 263
Johanna M. Hauer, Mo Banki, and Elie M. Ferneini
15 Evidence-Based Principles of Antibiotic Therapy���������������������������������� 283
Thomas R. Flynn
16 Preprosthetic Surgery�������������������������������������������������������������������������������� 317
Riccardo I. Ambrogio and Daniel Beauvais
17 Soft Tissue Oral Pathology������������������������������������������������������������������������ 333
Easwar Natarajan and Michael T. Goupil
18 Dentoalveolar Trauma ������������������������������������������������������������������������������ 383
Richard T. Zhu, Frank Paletta, and Douglas L. Johnson

Part IV Advanced Oral Surgery

19 Disturbances of the Temporomandibular Joint Apparatus�������������������� 399
M. Franklin Dolwick and Danielle Freburg-Hoffmeister
20 Congenital Facial Deformities������������������������������������������������������������������ 423
Jeff Marschall Green, Eric D. Bednar, and Lewis C. Jones
21 Dental Implants������������������������������������������������������������������������������������������ 433
Martin A. Freilich, David M. Shafer, and Steven Halepas
22 Forensic Odontology���������������������������������������������������������������������������������� 461
Kevin Rand Torske

Part V Illustrative Case Reports

23 Case 1: Diagnostic Dilemma - White and Red lesion������������������������������ 479
Easwar Natarajan
24 Case 2: Diagnostic Dilemma - Crusty Lips���������������������������������������������� 485
Easwar Natarajan
25 Case 3: Diagnostic Dilemma - White Patch �������������������������������������������� 491
Easwar Natarajan
26 Case Studies Evidence-Based Treatment Planning�������������������������������� 495
Michael T. Goupil
Contributors

Riccardo I. Ambrogio Department of Oral and Maxillofacial Surgery,

The University of Connecticut School of Dental Medicine, Farmington, CT, USA
New York University College of Dentistry, New York, NY, USA
OMFS, Private Practice, Wethersfield, CT, USA
Peter Arsenault Division of Operative Dentistry, Department of Comprehensive
Care, Tufts University School of Dental Medicine, Boston, MA, USA
Leon A. Assael University of California San Francisco, San Francisco, CA, USA
Roger S. Badwal Division of Oral and Maxillofacial Surgery, Department of
Surgery, Western Connecticut Health Network, Danbury Hospital, Danbury, CT, USA
Division of Oral and Maxillofacial Surgery, University of Connecticut School of
Medicine, Farmington, CT, USA
Private Practice, Danbury, CT, USA
Mo Banki Artistic Contours and MSL Surgery, Warwick, RI, USA
Department of Surgery, Clinical Faculty, Warren Alpert Medical School of Brown
University, Providence, RI, USA
Division of Oral and Maxillofacial Surgery, Clinical Faculty, University of
Connecticut, Farmington, CT, USA
Daniel Beauvais Department of Oral and Maxillofacial Surgery, The University of
Connecticut School of Dental Medicine, Farmington, CT, USA
Eric D. Bednar Department of Orthodontics, University of Louisville, Louisville,
KY, USA
Jeffrey Bennett Indianapolis, IN, USA
Eric R. Bernstein University of Connecticut School of Dental Medicine,
Farmington, CT, USA
M. Franklin Dolwick Department of Oral and Maxillofacial Surgery, UF College
of Dentistry, University of Florida, Gainesville, FL, USA
Linda Elder Foundation for Critical Thinking, Santa Barbara, CA, USA

ix
x Contributors

Andrew Emery University of Connecticut School of Dental Medicine, Farmington,

CT, USA
Elie M. Ferneini Beau Visage Med Spa, Greater Waterbury OMS, Cheshire, CT,
USA
Division of Oral and Maxillofacial Surgery, University of Connecticut,
Farmington, CT, USA
Thomas R. Flynn Private practice (retired), Reno, NV, USA
Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine,
Boston, MA, USA
Danielle Freburg-Hoffmeister Department of Oral and Maxillofacial Surgery,
UF College of Dentistry, University of Florida, Gainesville, FL, USA
Martin A. Freilich Reconstructive Sciences, University of Connecticut School of
Dental Medicine, Farmington, CT, USA
Morton H. Goldberg Division of Oral and Maxillofacial Surgery, University of
Connecticut School of Dental Medicine, Farmington, CT, USA
Michael T. Goupil Division of Oral and Maxillofacial Surgery, Emeritus Faculty,
University of Connecticut School of Dental Medicine, Farmington, CT, USA
Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT,
USA
Stephan Goupil Department of Family Medicine, University of Massachusetts,
Worcester, MA, USA
Jeff Marschall Green Oral and Maxillofacial Surgery, University of Louisville,
Louisville, KY, USA
Steven Halepas University of Connecticut School of Dental Medicine, Farmington,
CT, USA
Johanna M. Hauer Department of Oral and Maxillofacial Surgery, University of
Connecticut School of Dental Medicine, Farmington, CT, USA
Gabe Hayek Division of Oral and Maxillofacial Surgery, Department of
Craniofacial Sciences, University of Connecticut School of Dental Medicine,
Farmington, CT, USA
Melissa E. Ing Division of Operative Dentistry, Department of Comprehensive
Care, Tufts University School of Dental Medicine, Boston, MA, USA
Douglas L. Johnson Private Practice, St. Augustine, FL, USA
University of Florida Shands, Jacksonville, FL, USA
Lewis C. Jones Department of Oral and Maxillofacial Surgery, University of
Louisville, Louisville, KY, USA
Contributors xi

Zita Lazzarini Community Medicine and Health Care, University of Connecticut,

Farmington, CT, USA
Stuart Lieblich University of Connecticut, Farmington, CT, USA
Avon Oral and Maxillofacial Surgery, Private Practice, Avon, CT, USA
Christy Lottinger Department of Oral and Maxillofacial Surgery, University of
Connecticut School of Dental Medicine, Farmington, CT, USA
Easwar Natarajan Section of Oral and Maxillofacial Pathology, University of
Connecticut School of Dental Medicine, Farmington, CT, USA
Christine Niekrash Frank H. Netter MD School of Medicine, Quinnipiac
University, North Haven, CT, USA
Frank Paletta Private Practice, MSL Facial & Oral Surgery, Warwick, RI, USA
Department of Surgery, Warren Alpert Medical School of Brown University,
Providence, RI, USA
Joseph F. Piecuch Division of Oral and Maxillofacial Surgery, University of
Connecticut School of Dental Medicine, Farmington, CT, USA
Steve R. Ruiz Division of General Dentistry, Department of Craniofacial Sciences,
University of Connecticut, Farmington, CT, USA
David M. Shafer Division of Oral and Maxillofacial Surgery, University of
Connecticut School of Dental Medicine, Farmington, CT, USA
Aditya Tadinada Oral and Maxillofacial Radiology, Oral Health and Diagnostic
Sciences, University of Connecticut School of Dental Medicine, Farmington, CT,
USA
Kevin Rand Torske Oral Pathology and Forensic Dentistry, Naval Medical Center,
Portsmouth, VA, USA
Richard T. Zhu Warren Alpert Medical School of Brown University, Providence,
RI, USA
 Part I
Patient Assessment
Evidence Based Dentistry:
What, Why, How 1
Michael T. Goupil and Linda Elder

“Now we will take another line of reasoning. When you follow

two separate chains of thought, you will find some point of
intersection which should approximate the truth.”
Sherlock Holmes in—The Disappearance of Lady Frances Carfax

Abstract
The concept of evidence-based medicine {EBM} and evidence-based dentistry
(EBD) is not new. EBM traces its origins back to the 1980s when the evidence-
based process was developed at McMaster University, Ontario, Canada. This
concept should be commonplace with the current generation of graduating den-
tists. Yet there continues to be barriers to fully implement EBD. This chapter
focuses on the what, why, and how of EBD.

1.1 Introduction: What Is EBD

The American Dental Association defines evidence-based dentistry as “an approach

to oral health care that requires the judicious integration of systemic assessments of
clinically relevant scientific evidence, relating to the patient’s oral and medical con-
dition and history with the dentist’s clinical expertise and the patient’s treatment
needs and preference” (Sakaguchi 2010). In other words dentists are expected to
provide the best possible health care for their patients as possible.

M. T. Goupil (*)
Division of Oral and Maxillofacial Surgery, Emeritus Faculty, University of Connecticut
School of Dental Medicine, Farmington, CT, USA
Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT, USA
e-mail: [email protected]
L. Elder
Foundation for Critical Thinking, Santa Barbara, CA, USA
e-mail: [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 3

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_1
4 M. T. Goupil and L. Elder

The concept of EBD can best be demonstrated through a Venn diagram consist-
ing of three intersecting circles of equal value (Fig. 1.1). The circles represent (1)
the current clinical situation of the patient and the patient’s values, (2) current and
relevant scientific evidence, and (3) the clinical experience and judgment of the
dental provider. The area where all three of the circles intersect represents evidence-
based dentistry or more aptly labeled evidence-based practice. There is a miscon-
ception that evidence-based dentistry is based solely on the dental or medical
literature. Rather all three areas need to be considered, and depending on the
circumstance of a specific situation or patient, each of these areas may take on more
or less importance. There are a number of factors that need to be considered in each
of these domains.

1.2 The Patient

First consider the clinical patient circumstances. Obviously this includes an appro-
priate hard and soft tissue examination of the head and neck region. But one also
needs to consider the patient’s past dental history including past and current oral
hygiene practices and opportunities. Equally important is the past and current medi-
cal health history including past and current medications. Several questions need to
be addressed. How might the medical history have contributed to the patient’s oral
health? Will the patient’s medical status have an impact on any planned treatment?
Does the patient have any physical impairment that might affect the delivery of the
proposed treatment, and equally important, are there impairments in the patient’s
ability to maintain her or his oral health? (See Chap. 3.) Once the physical data have

Fig. 1.1 Venn diagram

demonstrating the
components of evidence-
based dentistry [EBD]
Patient Pertinent
Condition Literature
Values

Dentist
Abilities
Values
1 Evidence Based Dentistry: What, Why, How 5

been obtained, treatment plan options can be formulated for the patient, which
addresses their oral health in context with their more general medical health.
Next consider the patient’s preferences and their values. What is the patient’s
overall perception of oral health and its impact on general, overall health? Does he
or she eat to live or live to eat? What kind of esthetic concerns does the patient have?
Is a bright, white smile with straight teeth necessary? What is the patient’s financial
situation, and what time and financial investments do they want to make toward
their oral health?
There needs to be a recognition and acknowledgment that the patient’s value sys-
tem and the dental practitioner value system may be worlds apart. This does not mean
that the provider shouldn’t try to influence the patient’s value system through educa-
tion, but in the final analysis, it is the patient’s preferences that should drive the final
treatment choices. These preferences and values may change over time and need be
reassessed periodically. How patients view the world when they are young and on the
dating scene may be very different than when they are in their later years and enjoying
a few final pleasures like eating. From an ethical point of view, the dental provider is
not required to provide treatment that is not in the best interest of the patient just
because the patient wants a certain treatment plan, for example, the young adult
patient with a reasonable healthy and easily restored dentition that wants a full-mouth
extraction and complete dentures to avoid going to the dentist in the future. This is
really not a justifiable and ethical option despite the patient’s preference.

1.3 Scientific Evidence

As treatment plans are developed, it is paramount to consider what the literature

states about current materials and methods. Technology continues to advance
rapidly, providing ever-expanding options for providing health care. The literature
must be evaluated both critically and carefully, and especially for applicability,
before changing tried and true methods.
The notion of a “universally true” concept in dentistry is myth. Depending on
when an individual has graduated from dental school, some of the concepts that
were taught and “written in stone” have not survived the test of time. These
“universally true” concepts should be reassessed periodically in light of advanced
and advancing understandings of disease and the human condition.
The clinician should look for the best scientific literature available that represents
the clinical situation as closely as possible. This literature then needs to be evaluated in
a systematic fashion to assess both its value and applicability to the patient.

1.4 The Dental Provider

Lastly but equally important is the clinician’s experience and judgment. The scien-
tific literature is frequently based on looking at the results of an intervention on a
reasonably homogenous population. The results of a study must be assessed in the
6 M. T. Goupil and L. Elder

context of how closely a specific patient matches the population studied. As a

clinician gains more experience she/he is better able to make predictions on how
successful the treatment might be in a given situation.
Not all clinicians have an equal ability to perform certain specific tasks, although
there usually is an acceptable minimum standard that needs to be met. Frequently
one hears and perhaps even says “in my hands this works in such and such a way.”
That is a very important concept in assessing both the results in the literature and the
formulated treatment plan. Dental providers should accurately assess and honestly
face the results of their skills on a periodic basis. Treatment outcome assessments
should be part of every practice to ensure oral health care is provided at the highest
level. These outcome assessments can then be compared to current literature results.
In summary there are at least three components to evidence-based dentistry:
(1) the patient’s needs and desires, (2) what good current scientific literature states,
and (3) what the clinician knows that works well in her/his hands. Each of these
components is important and must be considered if one wants to deliver evidence-
based care. The relative importance of each of these components may change based
on circumstances for a specific patient. The influence of each of these components
may change and must be adjusted for each individual patient. The influence of the
literature may vary based on what is available and how applicable the literature is to
a specific patient. The clinician’s influence should improve over time, based on
experience and continuing education. Evidence-based dentistry entails using the
current literature within the context of one’s own expertise and applying this
knowledge to provide the best possible health care to dental patients.

1.5 Why Do EBD?

Evidence-based decision-making is the best approach to dentistry because it offers

the best chance at successfully helping our patients achieve reasonable goals in
terms of their dental care. The practitioner should continually ask the questions—
“What would I want if I were facing these dental issues?” “What would I want for
my family member?” One does need to be cautious though when applying this
dictum to specific patients. As mentioned, part of the evidence-based dentistry
model entails respecting the desires and values of the patient.
Oral health values are based on education and previous clinical experience and
modified by the practitioner’s own personal value system. This may lead the
practitioner to believe that a certain treatment plan is the “best” or the “ideal
treatment plan” and, indeed, the proposed plan may be the best for the provider, but
it may not be the best for the patient. The practitioner needs to again consider the
patient’s value system. As mentioned above the best procedure may be able to
modify the patient’s choice through education. In any case, the provider needs to be
mindful that current ethical philosophy focuses on patient autonomy, as opposed to
the “doctor knows best” paternalism of the past.
Another way of looking at evidence-based dentistry is that it represents or is part
of the informed consent process. Informed consent is a process that evolves over
1 Evidence Based Dentistry: What, Why, How 7

time through an open dialogue with the patient. Components of the informed
consent process include the patient’s condition as well as potential methods for how
this condition may best be addressed. What are the best treatment options, including
possibly no treatment at all? What risks and benefits of each of the reasonable
treatment options exist—including no treatment? How competent is the provider
ability to deliver these options?
In today’s litigiousness society, a recurrent theme is lack of informed consent.
Probably one of the best ways to avoid these legal consequences is to apply the
evidence-based dentistry model, incorporate EBD into the informed consent
process, and then, of course, document the process.

1.6 How Can EBD Be Accomplished?

In certain regards, evidence-based decision-making within dentistry can be imple-

mented relatively easily. In most cases the patient’s condition can be assessed
through the clinical examination and a review of the medical history that has been
captured earlier through questionnaires and verified through patient dialogue.
Directed questions to the patient to determine what he or she is looking for in terms
of health in general, and oral health more specifically, will help assess the patient’s
desires and personal values. Initial evaluation inferences may change, when various
treatment options are discussed with the patient as part of the informed consent
process. Individual practitioners are aware of their own experiences and expectations,
and they should realize, as mentioned previously, that these experiences and
outcomes must be evaluated objectively. Given the inherent problem of intellectual
arrogance in all human thought, it must be remembered that a provider’s success
rate may not be as high as one perceives it to be. Ideally, expectations change over
the course of time based on further experience, developed skills, and continuing
education. Periodic objective clinical practice outcome assessments should be part
of any EBD-based practice.
Incorporation of the scientific literature can be a little more complicated, but,
hopefully, with practice this need not be overly time-consuming. The scientific
evidence is limited to given research in reputable journals. But other essential infor-
mation is relevant to evidence-based dentistry. To name a few information sources
relevant to EBD (in addition to those already mentioned):

• Formal as well as informal learning and training through dental programs

and dental degree programs
• Discussions with colleagues
• Given Standards of Dental Societies
• Community Standards
• Professional Meetings
8 M. T. Goupil and L. Elder

None of these sources, in and of themselves, should be considered to offer defini-

tive “facts” and instead must be evaluated using a systematic critical thinking
approach.
To some, evaluation of the scientific evidence may be the most intimidating; but
there are ways to make the process less daunting. First and foremost, one should
already be taking an active approach to keep abreast of the current, as well as classic,
scientific literature. Most states and hospital organizations already require mandatory
continuing education hours, to encourage this process (ADA n.d.). There are
hundreds of medical/dental journals available, and in fact it is impossible to keep
abreast of all of them. For general dentists in the United States, the journal considered
by most scholars in the field to be required reading is the Journal of the American
Dental Association. This journal contains frequent updates on important changes in
the standards of the dental profession. We also recommend Dental Abstracts, a
journal that supplies easy-to-read summaries of potentially relevant articles from a
wide variety of journals that, in all likelihood, are not part of one’s routine reading.
Accordingly Dental Abstracts may offer exciting, new, and innovative ways of
thinking about dentistry and therefore can help keep you on the cutting edge of our
field.
In reviewing a patient’s medical history, the odds are that several disease entities
and/or medications will crop up where one’s knowledge base may be weak. A quick
Google Scholar search and a few minutes time in all likely will answer the
question—“Will this disease or medication have a modifying effect on the treatment
I am contemplating?” It would be beneficial to make a quick note in the patient’s
chart on the conclusions. An annotation of the information source and date is also
advisable. Again, remember that your conclusions may change with the development
of further information, given that, considered from one point of view, dentistry is
still in its infancy in terms of its potential.
As one considers an individual patient, certain key questions should also come to
mind:

• Is this the best treatment option?

• Is there another way?
• Is there a better way?
• How long will this last?
• Why didn’t that treatment work?
• Is there a more efficient way?
• Is there a more cost-effective way?

To effectively and efficiently address these questions, one needs to consider the
type of answer desired. Are we looking for generalities and opinion or, more likely,
specific, concrete information that will answer our questions and help direct the
patient’s care?
One method that is widely proposed is the use of the acronym PICO or more
commonly called the PICO statement. This method narrows the question and
1 Evidence Based Dentistry: What, Why, How 9

therefore should guide you to a more precise search of the literature, hopefully
resulting in the most relevant and significant articles, focused on the specific
information you are seeking.
“P” stands for the patient, problem, and the population with whom we are con-
cerned. Rather than looking for “What is the success rate of dental implants?”, the
search needs to be narrowed and focused on a specific relevant population, articu-
lated in a specific question, such as: “What is the success rate of dental implants in
a young, healthy male population?” “What is the success rate of dental implants in
a geriatric partially edentulous patient, with Type II diabetes, who is being treated
for osteoporosis?” You should be able to appreciate the differences in the responses
of search engines to each of these questions. The generalized question potentially
will return hundreds of responses, whereas the other two questions may only return
very few, but more relevant, articles.
“I” stands for intervention. What treatment options are you contemplating?
“C” stands for comparison. This is an optional component to the PICO state-
ment. Are reasonable alternative treatment options available?
“O” stands for outcomes, which refers to anticipated results for treatment option
options.

Example of a PICO Statement

P: For patients undergoing the removal of impacted third molars,
I: does the use of prophylactic antibiotics,
C: as opposed to no antibiotics,
O: help prevent postoperative complications, i.e. infection, alveolar osteitis

A variety of scientific sources are available for beginning to find answers.

Primary sources, such as research articles in scientific literature, are usually consid-
ered to have the best answers for EBD. A hierarchy exists in terms of value of the
literature; meta-analysis of randomized controlled trials (RCTs) is considered to be
at the top of the pyramid. Other significant and relevant sources of information
should be also considered. Textbooks, lectures, and input from colleagues may also
be utilized, providing a critical analysis and assessment of the information are
performed.
The more specific the question, the better the literature search is likely to answer
the question at the heart of the clinical process. The downside of an overly specific
question is that search engines might not find any literature that can answer the
question.
The type of question and the kind of information required will determine the best
place to start the search. When dealing with questions concerning the medical his-
tory of a client, a drug app on a smartphone may be all that is needed. A simple
Internet search, entering only the drug name or medical condition, will frequently
provide sufficient information. Even Wikipedia may provide the relevant answer,
but of course one must always use caution in using this source.
10 M. T. Goupil and L. Elder

The University of Texas at San Antonio has championed evidence-based practice

in a real practice environment for a number of years, and consequently they
developed the medical literature search engine SUMSearch [sumsearch.uthscsa.
edu]. SUMSearch 2 {http://sumsearch.org/} is now hosted by the University of
Kansas. The University of South Carolina hosts an evidence-based dentistry search
engine [http://musc.libguides.com/EBD/searching] that is designed to readily
accept your PICO question.
If the question at issue doesn’t readily adapt to using the PICO method, another
way of formulating questions is the use of WIN-, WIS-, and WIR-type questions
that are used in problem-based learning pedagogy. These stand for “What is the
nature of____________? What is the significance of_________? What is the
relation of_____________? Using this process entails selecting the most applicable
question and filling in the blank with the information relevant to the clinical case.
These questions can be easily used with other search engines.
PubMed is a frequently used and readily available search tool. Another search
engine to be considered is the Trip database [www.tripdatabase.com]. This database
will provide you with established practice guidelines which can help in the deci-
sion-making process.
Part of the acquisition of the evidence is ensuring that the source of the informa-
tion is reliable. It must be clear that any information acted upon will be in the best
interest of the patient. If the information is outdated or not from a trusted source,
there is significant potential that the information is no longer valid.
There are a couple of choices though that need to be made as part of the search
process. Some of the search engines noted previously should accommodate these
choices. One of the choices is “Do you want to select a specific journal?” Some
ranking systems attempt to assign a score to indicate the potential value of an
article found in a specific journal. One method commonly used is the “impact fac-
tor.” The impact factor (IF) is calculated on the number of times each article in a
journal is cited by authors for other articles. The impact factor is based on this
calculation over a 2-year period and obviously may change from year to year. One
implication is that the higher the IF, the more important is the value of an article
published in that journal. Thus, one would expect a journal like Cancer to have a
higher IF value than a throw away journal like Dental Economics. Remember
though this is a guideline and should be used with caution. Depending on the infor-
mation you are seeking, an obscure information source with a lower IF value may
be more relevant to a specific patient condition. The top five dental journals with
consistently high impact factors are the Journal of Dental Research, Journal of
Clinical Periodontology, Clinical Oral Implants Research, Dental Materials, and
Periodontology 2000 (Sillet et al. 2012).
A more recent method for ranking scientific journals is the Eigenfactor. In
this method the journal is still evaluated by the number of citations for each
article, but now the citations are weighted based on the relative importance of
where the citation is being used. The top five journals in this ranking system
have now changed to the Journal of Dental Research; Journal of Periodontology;
1 Evidence Based Dentistry: What, Why, How 11

Journal of Oral and Maxillofacial Surgery; Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology, and Endodontology (quad O and E); and Dental
Materials. The Journal of the American Dental Association, which has an
impact factor of 1.9 and ranks #24 now moves to #14 using the Eigenfactor
(Sillet et al. 2012).
Just as journals may differ in relative value or significance, so may individual
articles within a specific journal. As mentioned previously a hierarchy exists of
study design or clinical evidence which is commonly described as “levels of
evidence,” ranking from Level 1 studies which contain the strongest evidence to
Level 5 which contain the weakest (Fig. 1.2). Level 5 entails editorials or opinions,
and Level 4 contains case reports; Level 3, case-controlled studies; Level 2, cohort
studies; and Level 1, randomized controlled trial and/or meta-analysis systematic
reviews. Several of the previously mentioned search engines can be judged according
to the level of evidence required. Obviously, one would prefer to have Level 1
evidence answer the question; but in many, if not most instances, this type of
evidence may not be available to answer the question. In most situations the provider
will have to settle for the best information currently available, at whatever level this
exists.
Cochrane reviews are an excellent source of high-level, comprehensive, clini-
cal-based literature. Their evaluations are designed to provide both the practitio-
ner and the patient relevant information for making informed health-care decisions
(Sandhu 2012).

Fig. 1.2 Hierarchy of

levels of evidence

Meta
Analysis

Randomized

Controlled

Cohort Studies

Case-controlled Studies

Case Series, Case Reports

Editorials or Expert Opinion

12 M. T. Goupil and L. Elder

Another choice that must be decided upon is how far back in the literature to go.
In most cases probably no more than 5 years would be appropriate. Decisions should
be made on the best and most current literature that is available.
Just because something is in print doesn’t necessarily make it true. A statistic to
keep in mind is that studies that have a significant difference are more likely to be
published than studies that don’t have a significant difference (Smyth et al. 2011).
Thus when reviewing the literature, be mindful that what is being read already
contains some form of bias. A critical evaluation of the information is of paramount
importance.
When reading a scientific article, there are a couple of things need to be checked
in the method section. Is the sample size large enough to truly indicate whether the
statistical difference is truly valid? Was a power analysis conducted to ensure that
the sample size is appropriate? Unfortunately, this is frequently missing in the
dental literature. Also note, if the test groups are compared over time, was the time
interval long enough? A difference noted may initially be found to be “statistically
significant,” but when followed for a longer more appropriate period of time, this
difference may in fact disappear, with the end result that indeed there was no
difference in the intervention being studied.
The p-value or statistical significance should be assigned before the study is
conducted. In most dental literature, a p-value of 0.05 is used to indicate significance.
A term creeping into the literature is “the results are approaching significant.” An
outcome is either significant or not. Significant results may also be indicated by a
confidence level (CL) that implies the probability that the true result falls within a
defined interval.
A large and varied body of literature is available, dealing with critical thinking.
Critical thinking is now required in the curriculum in all US dental schools. In the
field of dentistry, the concepts critical thinking and evidence-based dentistry are
essentially being used synonymously. However, while evidence is a significant part
of critical thinking, it represents only one part.
Further, some people believe that critical thinking is confined to given sub-
jects such as literature and the humanities. However this would be incorrect.
Critical thinking is in fact relevant to all subjects and disciplines in which peo-
ple reason, including dentistry; critical thinking can and should be applied to all
facets of life where best decisions need to be made and issues need to be rea-
soned through.
There isn’t a single definition capturing all components and complexities of criti-
cal thinking. According to Dr. Richard Paul, a world-renowned authority on this
subject, “critical thinking is thinking about your thinking while you are thinking in
order to improve your thinking.” This offers just one simple way into the concept.
In the remainder of this chapter, we will attempt to provide the basic format of the
Paul-Elder Critical Thinking Model™ (Fig. 1.3). It is up to dental professionals to
apply this method to our continuing education seminars and professional meetings
and even to other interpersonal interactions.
1 Evidence Based Dentistry: What, Why, How 13

Fig. 1.3 The Paul-Elder Critical thinkers routinely apply intellectual standards
Critical Thinking Model™ to the elements of reasoning In order to develop
(Paul and Elder 2015) Intellectual tralts.
The Standards
Clarity Precision
Accuracy Significance
Relevance Completeness
Must be
Logicalness Fairness applied to
Breadth Depth

The Elements
Purposes Inferences
Questions Concepts
As we learn Point of view Implications
to develop Information Assumptions

Intellectual Traits
Intellectual Humility Intellectual Perseverance
Intellectual Autonomy Confidence in Reason
Intellectual Integrity Intellectual Empathy
Intellectual Courage Fairmindedness

1.7 Paul-Elder Approach to Critical Thinking

The Paul-Elder Framework for Critical Thinking™ offers a unique approach to analyz-
ing an article, lecture, case study, patient interaction, etc. into eight component parts. The
eight component parts are based on reasoning and are as follows: purpose, key question,
point of view, assumptions, information, concepts, inferences, and implications (Fig. 1.4).
It is important to realize that there is no hierarchy to the eight parts of reasoning;
they all are open to analysis; and they function in a dynamic relationship with one
another in the mind of all humans. Therefore the provider need not analyze reasoning
(either one’s own or a patient’s) in a specific order. From a practical point of view
though, it may be easier to conduct the analysis in the order given above. Consistent
use in this order will ensure that all eight components have been considered when
reasoning through a given issue. An advantage of using this mode of analysis for
most peer-reviewed literature is that at least half of the components can usually be
identified in the article’s abstract.
This analysis is useful in analyzing any form of reasoning in any context—a
lecture, an article, a book, and a conversation. The use of the Checklist for Clinical
Reasoning taken from The Thinker’s Guide to Clinical Reasoning (Hawkins et al.
2010) simplifies the process (Fig. 1.5). The following helpful diagrams from this
guide illustrate the analysis and assessment process in clinical practice.
14 M. T. Goupil and L. Elder

Fig. 1.4 Elements of To Analyze Thinking We Must Learn to Identify and

critical thinking (Elder Question its Elemental Structures
and Paul 2010)
8 1

to answer a Whenever
question of we think
7 solve a we think for a 2
problem. purpose

based on
concepts and within a
theories point of view
Universal
Structures
6 of Thought 3
to make based on
inferences and assumptions
judgements

We use leading to
data, facts, implications and
and experiences consequences.

5 4

8 1

What is the What is my

key question I fundamental
7 am trying to purpose? 2
answer?
What is the What is my
most basic point of view
concept in the with respect to
the issue?
question? Universal
Structures
6 What are my of Thought 3
What
most fundamental assumptions am
inferences of I using in my
conclusions? What What reasoning?
information are the
do I need to implications
answer my of my reasoning
question? (if I am collect)?

5 4
1 Evidence Based Dentistry: What, Why, How 15

A Checklist for Clinical Reasoning A Checklist for Clinical Reasoning (cont.)

1 All clinical reasoning has a PURPOSE. 5 All clinical reasoning is based on DATA, INFORMATION, and EVIDENCE.
To what extent is your reasoning supported by relevant data?
Can you state your purpose clearly?
Do the data suggest explanations that differ from those you have given?
What is the objective of your clinical reasoning?
How clear, accurate, and relevant are the data to the clinical
Dose your reasoning focus throughout on your clinical goal?
question at issue?
Is your clinical goal realistic?
Have you gathered data sufficient to reach a valid conclusion?

2 All clinical reasoning is an attempt to figure something out, to settle 6 All clinical reasoning is expressed through, and shaped by,
some QUESTION, to solve some PROBLEM. CONCEPTS and THEORIES.
What clinical question are you trying to answer? What key concepts and theories are guiding your clinical reasoning?
Are there other ways to think about the question? What alternative explanations might be possible, given these
Can you divide the question into sub-questions? concepts and theories?
Is this a question that has one right answer or can there be more Are you clear and precise in using clinical concepts and theories in
than one reasonable answer? your reasoning?
Dose this question require clinical judgment rather than facts alone? Are you distorting ideas to fit your agenda?

7 All clinical reasoning contains INFERENCES or INTERPRETATIONS

3 All clinical reasoning is based on ASSUMPTIONS.
by which we draw CONCLUSIONS and give meaning to data.
What assumptions are you making? Are they justified?
To what extent do the data support your clinical condusices?
How are your assumptions shaping your point of view?
Are your inferences consistent with each other?
Which of your assumptions might reasonably be questioned?
Are there other reasonable inferences that should be considered?
4 All clinical reasoning is done from some POINT OF VIEW. All clinical reasoning leads somewhere, that is, has IMPLICATIONS
8
What is your point of view? What insights is it based on? What are and CONSEQUENCES.
its weaknesses? What implications and consequences follow from your reasoning?
What other points of view should be considered in reasoning If we accept your line of reasoning, what implications or
through this problem? What are the strengths and weaknesses of consequences are likely?
these viewpoints? Are you fairmindedly considering the insights What other implications or coclsequences are possible or probable?
behind these viewpoints?

Fig. 1.5 Checklist for clinical reasoning (Hawkins et al. 2010)

1.8 Reasoning Through the Logic of This Chapter

We can take the eight elements of reasoning and use them to figure out the logic of
this chapter we are writing for this book, as follows:
Purpose—What is the author trying to accomplish? For instance, the purpose of
this chapter is to give the dental practitioner a reasonable and defensible rationale
behind evidence-based dentistry and suggested ways to easily accomplish this goal.
Key Question—What essential question does this chapter, article, or lecture
address? For instance, a key question in writing this chapter was: What is a feasible
approach to addressing implementation of EBD?
Point of View—From what direction is the question being viewed and
answered? What are you looking at and how are you seeing it? Focusing on point
of view can help define potential bias when one is evaluating a piece of research,
lecture, or interaction. One of the authors [MG] has been a dentist for the past 40
plus years and in this capacity has provided direct patient care as an oral and
maxillofacial surgeon; for the past 15 years, he has been involved in teaching
critical thinking skills to dental students. The other author [LE] has made
16 M. T. Goupil and L. Elder

teaching of critical thinking her life’s work and is the one of the developers of
Paul-Elder Framework for Critical Thinking™. Each author therefore brings a
different point of view to this chapter, and both viewpoints enhance the other. To
take a different example, when considering the point of view in the context of
EBD, one must consider not only how a dental provider is looking at an issue but
very importantly how the patient may view the same issue; in many situations,
there also must be a consideration of how a third-party payer may be looking at
the same issue.
Assumptions—What is being, or should be, taken for granted in the clinical
context? One assumption being made by the authors of this chapter is that the
readers want to be more facile in applying evidence-based dentistry to their prac-
tice and therefore would see this chapter as useful and valuable. The readers, in
turn, should assume that the authors have been vetted and are therefore suffi-
ciently expert in their fields to write intelligently about the issues in this
chapter.
Information—What data is being used in the article or chapter? The informa-
tion used in this chapter offers the basics of what, why, when, and how of EBD. It
also offers a rich conception of critical thinking for the reader, through which EBD
can be best implemented.
Concepts—Concepts are the rules, laws, and principles used to interpret the
information in order to ultimately derive a conclusion. The primary concepts used
in this chapter include our idea of what constitutes EBD and how it may be reason-
ably understood in the dental field. This chapter also introduces the Paul-Elder
Framework for Critical Thinking™, as a primary conceptual tool for engaging in
EBD.
Conclusions—What primary conclusions do the authors of this chapter want the
reader to accept? At the end of this chapter, our expectation is that the reader will
conclude that evidence-based dentistry has value and that there are powerful
conceptual tools available for engaging in effective EBD.
Consequences—What happens if one acts or fails to act on the conclusions
offered in this chapter? A desired consequence of this chapter is that the reader will
incorporate critical thinking, not only throughout their practice in client care but
also in their daily life. If EBD is considered valuable, then as a result of using EBD,
one will be in a better position to make reasonable and sound decisions—based on
fact and not myth. If the concepts of EBD and critical thinking are not accepted by
the reader, the reader may not see the value of progressing as a thinker in dental care
and hence keep doing the same thing year after year, never advancing as a dental
provider.

1.9  nalyzing and Assessing Clinical Research Using

A
the Tools of Critical Thinking

The essence of this textbook entails the idea that the best treatment option for a
patient should be supported by the best available scientific data. The eight parts
of reasoning are very useful in analyzing and assessing research in the field of
dentistry (Fig. 1.6).
1 Evidence Based Dentistry: What, Why, How 17

Analyzing & Assessing Clinical Research

Use this template to assess the quality of any
clinical research project or paper.
1) All clinical research has a fundamental PURPOSE and goal.
Research purposes and goals should be clearly stated.
Related purposes should be explicitly distinguished.
All segments of the research should be relevant to the purpose.
All research purposes should be realistic and significant.
2) All clinical research addresses a fundamental QUESTION, problem or issue.
The fundamental question at issue should be clearly and precisely stated.
Related questions should be articulated and distinguished.
All segments of the research should be relevant to the central question.
All research questions should be realistic and significant.
All research questions should define clearly stated intellectual tasks that, being
fulfilled, settle the questions.
3) All clinical research identifies data, INFORMATION, and evidence relevant to its
fundamental question and purpose.
All information used should be clear, accurate, and relevant to the fundamental
question at issue.
Information gathered must be sufficient to settle the question at issue.
Information contrary to the main conclusions of the research should be explained.
4) All clinical research contains INFERENCES or interpretations by which conclusions are drawn.
All conclusion should be clear, accurate, and relevant to the key question at issue.
Conclusions drawn should not go beyond what the data imply.
Conclusions should be consistent and reconcile discrepancies in the data.
Conclusions should explain how the key questions at issue have been settled.
5) All clinical research is conducted from some POINT OF VIEW or frame of reference.
All points of view in the research should be identified
Objections from competing points of view should be identified and fairly addressed.
6) All clinical research is based on ASSUMPTIONS.
Clearly identify and assess major assumption in the research.
Explain how the assumptions shape the research point of view.
7) All clinical research is expressed through, and shaped by, CONCEPTS and ideas.
Assess for clarity the key concepts in the research.
Assess the significance of the key concepts in the research.
8) All clinical research leads somewhere (i.e., have IMPLICATIONS and consequences).
Trace the implications and consequences that follow from the research.
Search for negative as well as positive implication.
Consider all significant implications and consequences.

Fig. 1.6 Analyzing and assessing clinical research (Hawkins et al. 2010)

1.10  he Importance of Universal Intellectual Standards

T
in Evidence-Based Dentistry

Once the eight parts have been analyzed, then a critical assessment of the article,
lecture, event, etc. can be accomplished. For this, we must understand, internalize,
and adhere to universal intellectual standards on a daily basis. Essential intellectual
18 M. T. Goupil and L. Elder

standards include clarity, accuracy, precision, relevance, significance, depth,

breadth, logic, and fairness (Fig. 1.7). From a practical standpoint, certain parts of
the analysis and assessment can be accomplished at the same time. Using only a few
of the analysis and assessment items, a quick determination as to the potential value
of a given piece of research can often be accomplished.

Universal Intellectual Standards

Essential to Sound Clinical Reasoning
Universal intellectual standards are standards which must be applied to thinking
Whenever one is evaluating the quality of reasoning about a problem, issue, or
situation. To think cirtically one must have a command of these standards. While
there are a number of universal standards, we focus here on some of the most
significant:
Clarity
Could you elaborate further on that point? Could you express that point in another
way? Could you give me an illustration? Could you give me an example?
Clarity is a gateway standard. if a statements is unclear, we cannot determine
whether it is accurate or relevant. infact. In fact, we cannot tell anything about it (except
that it is unclear) because we don’t yet know what it is saying.
Accuracy
Is that really true? How could we check that? How could we find out if that is true?
What evidence is there to support the validity of your clinical thinking?
A statement can be clear but not accurate, as in “Most creatures with a
spine weigh more than 300 pounds.”

Precision
Could you give me more details? Could you be more specific?
A statement can be both clear and accurate, but not precise, as in “The solution
in the beaker is hot.” (We don’t know how hot it is.)
Relevance
How is that connected to the question? How dose that bear on the issue?
A statement can be clear, accurate, and precise, but not relevant to the
question at issue. If a person who believed in astrology defended his/her view by
saying “Many intelligent people believe in astrology.” their defense would be
clear, accurate, and sufficiently precise, but irrelevant to clinical reasoning.
Depth
How dose your answer address the complexities in the question? How are you
talking into account the problems in the question? Are you dealing with the most
significant factors?
A statement can be clear, accurate, precise, and relevant, but superficial (that
is, lacks depth). For example, the statement “Just Say No” which is often used to
discourage children and teen from using drugs, is clear, accurate, precise, and
relevant. Nevertheless, it lacks depth because it treats an extremely complex
issue, the pervasive problem of drug use among young people, superficially. It fails
to deal with the complexities of the issue.

Fig. 1.7 Analyzing and assessing clinical research (Hawkins et al. 2010)
1 Evidence Based Dentistry: What, Why, How 19

Breadth
Do we need to consider another point of view? Is there another way to look at this
question? What would this look like from the point of view of a conflicting
theory, hypothesis or conceptual scheme?
A line of reasoning may be clear, accurate, precise, relevant and deep, but lack
breadth (as in a well-reasoned argument from either of two conflicting theories which
ignores insights into the conflicting theory).

Logic
Does this really make sense? Is this consistent with what we know about this issue
or problem?
When we think, we bring a variety of thoughts together into some order.
When the combination of thoughts is mutually supporting and makes sense
in combination, the thinking is “logical.” When the combination is not mutually
supporting, is contradictory in some sense, or does not “make sense” the
combination is “not logical.” In clinical reasoning, new conceptual schemes
become working hypotheses when we deduce from them logical consequences
which can be tested by experiment. If many of such consequences are shown to
be true, the theory (hypothesis) which implied them may itself be accepted as true.
Significance
Is the most important problem to consider? Is this the central idea to focus
on? Which of these facts are most important?
When dealing with a complex issue it is essential to consider relevant variables
but some are more significant than others. The most significant variables should be
considered first. Secondary relevant variables come next in order of importance.

Fairness
Do we nhave a vested interest in this issue? Am I represnting the viewpoints of
others in a way that is fair and balanced?
We naturally think from our own perspective, from a point of view which tends
to privilege our position. Fairness implies the treating of all relevant viewpoints
alike without reference to one’s own feelings or interests. Because we tent to
be biased in favor of our own viewpoint, it is important to keep the standard of
fairness at the forefront of our thinking. This is especially important when the
situation may call on us to see things we don’t want to see, or give something up
that we want to hold onto.

Fig. 1.7 (continued)

In assessing the quality of this chapter, using essential intellectual standards, the
reader should find the following to be true:
Clarity—Hopefully the reader has found this chapter relatively straightforward
and easy to read. Diagrams and charts were included to illustrate the material to help
the reader better understand the text. The chapter itself has been used to provide an
example on how to use the Paul-Elder Framework for Critical Thinking™ in EBD.
Accuracy and Precision—Terms were defined, and figures were taken from
published materials. Appropriate literature was cited.
Depth and Breadth—The depth of the chapter is appropriate for the stated pur-
pose (see above). Should the reader desire more depth, there are numerous articles
20 M. T. Goupil and L. Elder

and texts devoted to the topic of evidence-based practice available through the
sources indicated in this chapter. Similarly the breadth of the chapter was limited to
only one literature review technique—the Paul-Elder Approach to Thinking™. This
is also in keeping with the stated purpose.
Relevance—The concept of evidence-based practice is now an established part
of contemporary dental practice. The Paul-Elder Critical Thinking Model provides
a structured method for analyzing and assessing the scientific literature.
Significance—EBD is essential for reasonable dental practice in today’s com-
plex information society.
Logic—The chapter starts with defining EBD and flows from why to how. EBD
is logically connected with the richer concept of critical thinking.
Fairness—Evidence and ideas in this chapter have been presented objectively
and without bias.

1.11 Conclusion

To sum up this chapter, we may return to our question: What is evidence-based

dentistry? First and foremost, it does not entail simply “doing an intervention” just
because some given piece of research may offer “correct” course of action. Rather,
evidence-based dentistry involves a critical appraisal of appropriate research and
other information that addresses a patient’s specific circumstances, as well as her or
his value system, interpreted through the clinician’s knowledge, experience, and
expertise.
Why do it? Because it takes into account the worldview of the dental patient as
well as the best knowledge available at a given time, in the field of dentistry.
How can EBD be reasonably accomplished?

1. Listen to patients to determine what they want.

2. Make an honest assessment of the dental situation in context.
3. Critically review the literature most relevant to the specific situation.
4. Then using personal experience, determine the best options to address the spe-
cific situation. There is usually more than one way to reach a satisfactory result.
Conduct a cost-benefit, risk-benefit discussion with the patient. This is the
informed consent process; make sure it is documented.

This chapter encourages the use of Paul-Elder’s Framework for Critical

Thinking™. It is one of the many ways to select and critically assess the literature.
But it has been chosen for inclusion here because it provides an excellent method
for reasoning through specific decisions, using the richest tools of criticality extant.
And we have recommended that the reader apply this approach to all aspects of life.
In starting this critical thinking process, consider beginning with assumptions. What
assumptions have you or others made about others that resulted in a course of action
detrimental or not in the best interest of your client?
1 Evidence Based Dentistry: What, Why, How 21

The tools of critical thinking can be easily documented in the best thinking in
dental practice. But dentists have yet to embrace, as a profession, a robust conception
of fair-minded critical thinking. This will be required if the best evidence-based
dental practices are to be achieved.

References
ADA. State CE Statutes and regulations dentist continuing education. n.d. http://www.ada.org/~/
media/ADA/Advocacy/Files/continuing_ed.pdf.
Elder L, Paul R. The thinker’s guide to analytical thinking. 2nd ed. Tomales, CA: Foundation for
Critical Thinking; 2010.
Hawkins D, Elder L, Paul R. The thinker’s guide to clinical reasoning. 1st ed. Tomales, CA:
Foundation for Critical Thinking; 2010.
Paul R, Elder L. The miniature guide to critical thinking. 7th ed. Tomales, CA: Foundation for
critical thinking; 2015.
Sakaguchi R. Evidence-based dentistry: achieving a balance. J Am Dent Assoc. 2010;141:496–7.
Sandhu A. The evidence base for oral and maxillofacial surgery: 10-year analysis of two journals.
Br J Oral Maxillofac Surg. 2012;50:45–8.
Sillet A, Katsahian S, Range H, Czernichow S. The Eigenfactor™ score in highly specific medical
fields: the dental model. J Dent Res. 2012;9(4):329–33.
Smyth RMD, Kirkham JJ, Jacoby A, Altman DG, Gamble C, Williamson PR. Frequency and reasons
or outcome reporting bias I clinical trials: interviews with trialists. BMJ. 2011;342(7789):155.
Office Environment
2
Melissa E. Ing and Peter Arsenault

“I fear that if the matter is beyond humanity it is certainly

beyond me.”
—The Adventure of the Devil’s Foot

Abstract
The dental profession is predisposed to various occupational hazards including
blood-borne pathogens, chemical agents, and particulate projectiles which can
cause skin and eye safety issues and musculoskeletal disorders. Oral surgery
procedures can cultivate these occupational hazards. This chapter discusses these
problems, their implications, and subsequent approaches to create a safe and
functional work environment. In addition, this chapter focuses on how to incor-
porate proper ergonomics to prevent musculoskeletal disorders, thereby helping
dentists maintain a healthy, long-term career.

2.1 Office Environment/Office Design

A dental office environment with thoughtful attention to details allows for patient
comfort as well as employer and employee satisfaction. The practice should look
professional and organized, with up-to-date technology, as superior office design
can be an excellent marketing tool. The workplace is an expression of the dentist’s
personality and should make a positive impression on the patient. Particular atten-
tion should be given to make the waiting area appealing and reassuring to anxious
patients. Furthermore, treatment areas should have soundproof walls to drown out
loud noises such as those from turbine-driven handpieces.
Dentists will always have their personal vision of what the office space should
consist of. However, an office’s clinical function will dictate its layout and ergo-
nomic considerations.

M. E. Ing (*) · P. Arsenault

Division of Operative Dentistry, Department of Comprehensive Care, Tufts University School
of Dental Medicine, Boston, MA, USA
e-mail: [email protected]; [email protected]

© Springer International Publishing AG, part of Springer Nature 2019 23

E. M. Ferneini, M. T. Goupil (eds.), Evidence-Based Oral Surgery,
https://doi.org/10.1007/978-3-319-91361-2_2
24 M. E. Ing and P. Arsenault

The floor plan should have good traffic flow. There should be areas that are
accessible to patients and private areas designated only for the staff.
Dental professionals can be exposed to numerous occupational hazards includ-
ing exposure to blood-borne pathogens, chemical agents, and musculoskeletal dis-
orders due to ergonomic setups. The office environment should provide protective
mechanisms and a systematic approach to safe practices.

2.2 Blood-Borne Pathogens

Dental offices must vigilantly follow the Centers for Disease Control and Prevention
(CDC) and the Occupational Safety and Health Administration (OSHA) guidelines
for proper infection control and safe work practices. While the CDC is a govern-
ment agency within the US Public Health Service, it is not a regulatory authority
(Cuny and Collins 2013). However, creating infection control recommendations
according to evidence-based research is one of the CDC’s many tasks. OSHA is part
of the US Department of Labor, and their duty is to protect the health and safety of
workers within the USA. OSHA creates regulations such as the Bloodborne
Pathogens standard to reduce the risk of occupational exposure to blood-borne
pathogens (Cuny and Collins 2013).
The blood-borne pathogens that are of concern to dental health-care personnel
(DHCP) are hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency
virus (HIV). HBV vaccinations became routine in 1982 and universal precautions
have been recommended since 1987.
Due to hepatitis B vaccinations and universal precaution recommendations,
transmission of blood-borne pathogens in the dental setting has rarely been reported
during the last decade. In the 1990s, there was one case where a dentist with
autoimmune deficiency disease (AIDS) was found to have transmitted HIV to five
of his patients after invasive procedures (Ciesielski and Marianos 1992). At this
time, there are no known patient to patient reports of HIV transmission.
Yet, a 2016 review of the literature cites three reports of blood-borne pathogen
transmissions of hepatitis B and hepatitis C from 2003 through 2015 (Cleveland
2016). The article described an incident from 2002 as a single HBV transmission
from one patient to another patient that occurred in an oral surgery office. The
article described a 2009 occurrence as the first documented patient to patient HBV
transmission which occurred in a large portable free dental clinic setting. The third
reported incident occurred in 2013 at an oral surgery office and is considered the
first documented case of patient to patient transmission of HCV in an American
dental setting. In the 2002 case, investigators speculated that there was a breach in
cleaning the environmental surfaces that resulted in cross contamination of blood
with the source patient who had chronic HBV with a high viral load at the time of
the surgery (Cleveland 2016). In the 2009 documented case, five HBV transmissions
occurred from a portable free dental clinic that was held in a gymnasium. Multiple
failures in infection control were cited retrospectively as the cause of the transmission
of HBV to three other patients as well as to two DHCP. It was reported that the
2 Office Environment 25

utilized handpieces were not heat sterilized; unwrapped sterilized instruments were
utilized, and patients were allowed to transport partially used anesthetic cartridges
in metal syringes to another station for later reuse (Cleveland 2016). Investigators
speculate that the 2013 patient to patient transmission of HCV occurred due to the
failure to administer IV sedation by licensed, trained dental personnel, due to the
use of improperly sterilized equipment, and due to the reusing of contaminated
medication vials, needles, and syringes (Cleveland 2016).
Lesson gleaned from the above reporting is that even though blood-borne patho-
gen transmissions are infrequent, they can happen from routine restorative and oral
surgery procedures. There are several potential routes for the spread of infection in
the dental clinic. These include (1) direct contact with bodily fluids of an infective
patient, (2) contact with contaminated instruments or environmental surfaces, and
(3) contact with infectious airborne particles from an infective patient (Harrel and
Molinari 2004).
HBV and HCV can survive on blood-contaminated environmental surfaces for
long periods of time. Bond et al. demonstrated that the HBV virus can survive in
dried blood at room temperature on environmental surfaces for at least 1 week
(Bond et al. 1981). Furthermore, Paintsil et al. demonstrated that HCV infectivity
can remain on dry surfaces for up to 6 weeks (Paintsil et al. 2014). HIV can survive
in dried blood at room temperature for 5–6 days if placed in an ideal pH level. For
long-term survival, HIV cannot have a pH below 7 nor a pH above 8 (Tjotta 1991).
In 2003 the CDC published the Guidelines for Infection Control in Dental Health
Care Settings. To this day, this remains the standard for offices and institutions to
follow (CDC 2003). More recently, the CDC also published the Summary of
Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care.
This includes a handy infection prevention checklist that DHCP can use to evaluate
infection control compliance (CDC n.d.-a). Offices should designate an infection
control officer to be in charge of assessing annual safe practice policies and updating
a written manual. Dental offices should ensure each DHCP hire and current
employees have yearly OSHA training.
Clinicians should always keep in mind that all patients could be carriers of an
infectious disease. Therefore, universal precautions should always be followed.
Since oral surgical procedures can increase the risks of local or systemic infection,
it would be prudent to have an extra vigilant infection prevention routine in place.

2.3 Spatter and Aerosols

In the dental operatory, a visible spray is created each time high-speed rotary hand-
pieces, ultrasonic scalers, or air-water syringes are utilized. Water is often used as
coolant with handpieces and ultrasonics to prevent overheating of tooth structure.
Studies show that when high-speed rotary handpieces are used, the air can be
contaminated for a period of time until the particles settle (Harrel and Molinari
2004). In oral surgery, Hall drills, Stryker drills, and high-speed and low-speed
drills are often used to section teeth for easier extraction and for implant placement.
26 M. E. Ing and P. Arsenault

The water spray alone that is generated from the rotary equipment may not be
harmful, but once mixed with the patient’s oral fluids such as saliva, blood, bone
fragments, human tissue, bacteria, and debris, it can turn into a potential health
hazard.
This visible spray contains larger and smaller particles. The larger particles, in
the size of 50 μm or more, are called “spatter” (Harrel and Molinari 2004; Micik
et al. 1969). Since spatter particles are large and heavy, they traverse short distances,
landing fairly quickly on operatory surfaces, equipment, the clinician, and the
patient.
In contrast, aerosols are defined as a collection of solid or liquid particles
which are less than 50 μm in size (Harrel and Molinari 2004; Micik et al. 1969).
Since aerosols are much smaller particles, they remain suspended in air much
longer than spatter before finally contacting surfaces (Harrel and Molinari 2004).
In fact, aerosols can stay suspended in the operatory air for up to 30 min (Harrel
and Molinari 2004). Some of the smaller aerosols that range in size from 0.5 to
10 μm can potentially travel to and penetrate into the pulmonary passages (Harrel
and Molinari 2004). Harrel and Molinari noted that if DHCP remove face shields
upon completing the procedure to talk with the patient, there is potential contact
with aerosol contaminants which are floating in the environment (Harrel and
Molinari 2004).
Studies have demonstrated that the ultrasonic scaler produces the greatest amount
of airborne contamination followed by the high-speed handpiece. The air-water
syringe also produces a great deal of aerosols (Harrel and Molinari 2004).
Investigators have demonstrated that during scaling and root planing, blood is
always present in the ultrasonic scaler aerosols (Harrel and Molinari 2004). Harrel
and Molinari deduced that blood is most likely present in aerosols where any rotary
instrumentation was used within an operating field containing blood. This would
include any subgingival, periodontal, and oral surgery procedures (Harrel and
Molinari 2004).

2.4 Infection Control Measures

The most logical and first precautionary measure to reduce spatter and aerosols is to
ensure that DHCP wear OSHA-approved personal protection equipment (PPE)
while treating patients as well as when preparing and breaking down the operatory.
PPE consists of and should be donned in the following sequence: (1) fluid resis-
tant clinic gowns, (2) face masks, (3) safety eyewear, and (4) gloves.
Clinic gowns should have high necks and long sleeves, with ribbed cuffs at the
neck and at the wrists. The gowns should at least cover the operator’s knees when
seated. Rutala et al. studied the cost differences between disposable and reusable
gowns and found that reusable gowns did not always save money due to the fact that
the gowns would be damaged during the handling and laundering process thus
rendering them useless (Rutala et al. 2001). Rutala also demonstrated that some
2 Office Environment 27

reusable gown materials proved more superior than others. Gowns with a laminated
coating of polypropylene provided the most superior resistance to blood and other
liquids seeping through. A single-layered non-woven fabric was found to be the
next best performing reusable gown fabric. 50 cotton/50 polyester was not very
effective in preventing blood strike through, and 100% cotton offered the least
amount of protection (Rutala et al. 2001).
If masks become soiled or wet during the procedure, they should be replaced.
Clinicians should always avoid touching masks during the course of treatment to
prevent cross contamination. All dental mask styles provide protection of covered
facial areas (nose, mouth, and portions of the cheeks) against splash and projectiles.
Dental masks are available in a variety of designs and profiles. Pleated-type den-
tal masks are preferred by dental practitioners since they are easy to wear and have
low resistance to breathing. Most pleated masks contain an inner layer of melt-­
blown filtration material (Arsenault and Tayebi 2016). However, since there is no
effective seal between the perimeter of the mask and the wearer’s face, air leakage
occurs through the perimeter of the mask, and hence, the mask fails to provide
effective respiratory system protection. The National Institute for Occupational
Safety and Health (NIOSH), which is part of the CDC, utilizes research to promote
safer recommendations for workers. In comparison to NIOSH-approved respirators,
most pleated masks lack the seal between their perimeter and the wearer’s face and
hence would not meet NIOSH approval requirements (Arsenault and Tayebi 2016).
Masks that are fitted with a full-face transparent shield such as an up visor or a full
down visor may be particularly desirable when an oral surgery procedure generates
excessive blood splashes, fluids, or particulates.
The CDC recommends that prior to oral surgical procedures, a fast-acting anti-
microbial soap with a broad spectrum of bactericidal activity is utilized for hand-
washing. For oral surgery procedures in the operating room, sterile gloves should be
used. If gloves become wet and torn or are deemed defective, they should be
promptly replaced. Scrupulous handwashing after the procedure is completed must
take place.
In 2006, Rautemaa et al. studied how far aerosols travel from a patient after the
use of high-speed rotary instrumentation is utilized in the operatory. Investigators
placed agar plates in distances varying from 0.5 to 2 m from the patient. The agar
plates were samples before and after dental procedures. At the same time, they
also sampled the facial masks of the DHCP before and after the procedure. The
most commonly found bacteria in the agar plates were Viridans streptococci and
staphylococci. Significant contamination was found from agar plates at all dis-
tances. Face masks were found to be equally contaminated when high-speed
rotary instruments were used. Rautemaa’s study substantiates how aerosols spread
beyond the area and equipment used for the procedure (Rautemaa et al. 2006).
Thus, all PPE needs to be removed as soon as the DHCP leave the operating area
to prevent cross contamination. This study also substantiates the need to wear PPE
when cleaning, preparing, and breaking down operatory surfaces and equipment
(Rautemaa et al. 2006).
28 M. E. Ing and P. Arsenault

In addition, Rautemaa’s work demonstrates that all environmental surfaces, even

if not used for the procedure, must be thoroughly disinfected at the beginning of the
workday, in between each patient, and at the end of the workday. Rautemaa’s study
also suggests that only necessary equipment items needed for the procedure at hand
be placed within the operatory work surfaces to minimize contamination and that all
other items be placed within a closed cupboard (Rautemaa et al. 2006). Furthermore,
Rautemaa et al. (2006) suggest protection of the exposed skin and hair to prevent
bacterial spread.
As a second precautionary measure, having patients use an antiseptic preopera-
tive rinse such as 0.01% chlorhexidine for 1 min prior to the procedure can lower
overall bacterial counts in the operating environment (Harrel and Molinari 2004).
A third essential method in reducing airborne aerosols is to use an efficient high-­
volume evacuator (HVE) to prevent aerosols and bacteria from escaping the imme-
diate operating site. An HVE suction system is defined as one that removes a large
volume of air within a short period of time. Most HVE used in dentistry are attached
to an evacuation system and will have an 8 mm or greater opening and are able to
remove up to 100 cubic feet of air per minute. Since a saliva ejector has a very small
opening, it cannot remove enough volume of air to be classified as an HVE. Studies
demonstrated that an HVE with a good suction system can reduce up to 90% of
operatory area contamination (Harrel and Molinari 2004; Micik et al. 1969). A
study done by Noro et al. in Japan demonstrated that the use of a high-­speed vacuum
aspirator effectively reduced the spread of streptococci bacteria (Micik et al. 1969;
Noro et al. 1995).
It is important that each dental unit suction hose be flushed twice daily with dis-
infecting agent and routinely cleaned according to manufacturer’s instructions. The
water in each unit should be flushed for any utilized handpieces, ultrasonic scalers,
and air-water syringes for 30 s after each patient.
Whenever possible, single-use devices such as aspirator tips and drill burs should
be used. Disposable instruments and equipment eliminate the risk of patient to
patient contamination once it is discarded after one-time use. Items such as patient
bib clip chains are sources of cross contamination. The University of North Carolina
cultured bib chains in a study and found strains of Pseudomonas, E. coli, and
Staphylococcus aureus. These bacteria can put immunocompromised populations at
even greater risk for respiratory disease transmission. Disinfecting the napkin
holders does not eradicate the bacteria completely, so disposable holders should be
considered instead (Molinari 2010). The CDC recommends that one-time-use
gauze, irrigating syringes, syringe needles, and scalpel blades used for oral surgery
procedures be sterile (CDC n.d.-b).
At the end of the appointment, the CDC recommends the following sequential
order for instrument processing (Cuny and Collins 2013; CDC 2003). Sharps,
including syringe needles, burs, and scalpel blades, need to be carefully discarded
into specially marked puncture-resistant sharps containers. Next, single-use
disposable materials and waste should be discarded. Biohazard waste must be
disposed of in specially marked biohazard containers in accordance with state
2 Office Environment 29

regulations. The equipment and instrument cassettes should be transported to a

centrally located cleaning and sterilization area that fosters one-directional work
flow which will prevent cross contamination (Cuny and Collins 2013). There should
be separate areas for receiving dirty instruments and cassettes as well as areas for
decontamination, packaging for sterilization, and sterilization. There should be a
separate storage area to place sterile packaged instruments until ready for the next
procedures.
The CDC has made three categories of criteria to determine how instruments
should be sterilized. These categories are (1) critical, (2) semi-critical, and (3) non-
critical. Critical instruments are those that penetrate soft tissue, contact the bone, or
have entered the bloodstream. Critical instruments used in oral surgery procedures
would include dental burs, elevators, forceps, and scalpel blades. Semi-­critical
instruments are those that contact mucous membranes but have not penetrated soft
tissue or bone and have not entered the bloodstream. These instruments would
include dental mouth mirrors and dental handpieces. Noncritical instruments are
those that contact intact skin, and this equipment would include blood pressure
cuffs, pulse oximeters, and radiographic tube heads. The CDC stipulates that all
critical instruments be heat sterilized as well as all dental handpieces even though
they are considered semi-critical (Cuny and Collins 2013; CDC 2003).
Utilized handpieces should be lubricated after use to prolong the life of the
equipment prior to sterilization. Hand instruments should be cleaned thoroughly
with either a washing disinfecting machine or an ultrasonic soak. The pre-cleaning
helps to remove blood or debris that could potentially harm the DHCP that is
packaging the cassettes for sterilization. Used handpieces and hand instruments
must be inspected thoroughly for any left on particles of blood, tooth, and bone
debris. Debris must be removed so as not to compromise the sterilization process. A
metal cleaning brush can be used to clean off caked on debris. Equipment should
then always be prepared for sterilization by wrapping and sealing in special pouches
or bound in sterilization appropriate sheeting that are labeled to show the date of
sterilization, which sterilizer was used, and the load or cycle.
Quality assurance of the instrument sterilization process must be upheld for
patient safety. It is crucial that sterilization machines are not improperly loaded.
Overloading is a common reason for sterilization failure. Utilizing a combination of
biological and chemical indicator methods ensures that adequate sterilization condi-
tions have been achieved (Cuny and Collins 2013).
The biological indicator method is also commonly referred to as “spore testing.”
Spore testing is recommended at least once a week for private practice offices and
institutions. Spore testing is the most widely accepted method of testing sterilization
efficacy since it can kill highly resistant microorganisms such as Geobacillus and
Bacillus (Cuny and Collins 2013; CDC 2003).
Since spore testing might only be done once a week and takes some time to
obtain the results, it is prudent to also utilize a chemical indicator method. Chemical
indicators can provide more timely indications if sterilization equipment malfunc-
tion were to occur (Cuny and Collins 2013; CDC 2003).
30 M. E. Ing and P. Arsenault

Peel and seal sterilization pouches specially marked with sensitive chemical
indicators will change color if the contents have been sterilized to correct temperature
and time. It is also possible to place chemical indicating tape over wrapped
instruments. If a color change does not occur after the sterilization process, this
indicates that the sterilization process has been compromised, so the instruments
should be repackaged and sent through sterilization again (Cuny and Collins 2013;
CDC 2003).
Furthermore, chemical indicating devices, called “multiparameter integrators,”
are highly suggested to be placed within the instrument pouches to determine
optimal sterilization conditions. The integrators verify that the sterilization process
has penetrated the instruments within the packaging (Cuny and Collins 2013; CDC
2003). Multiparameter integrators indicate if the contents of the peel and seal pouch
have been exposed to the correct time, temperature, and pressure during autoclaving
procedures (see Photo 2.1).

Photo 2.1 Example of a

chemical multiparameter
integrator (courtesy of
Vapor Line)
2 Office Environment 31

2.5 Eyewear Safety Considerations

OSHA Standard 1910.133(a) (1) states:

“The employer shall ensure that each affected employee uses appropriate eye or face
protection when exposed to eye or face hazards from flying particles, molten metal, liquid
chemicals, acids or caustic liquids, chemical gases or vapors, or potentially injurious light
radiation.”

By their nature, dental procedures involving drilling at very high speeds

(180,000–500,000 rpm) generate debris that can travel at speeds of up to 50 mph
(Arsenault and Tayebi 2016). Such debris could include pieces of amalgam, tooth
enamel, calculus, pumice, and broken dental burs. In the absence of a protective
means, such debris may find its way to the eyes of the practitioner, the staff, or the
patient.
CDC and OSHA mandate that dentists wear protective eyewear (either glasses or
loupes, prescription or nonprescription) while performing dental procedures. Most
often, dental assistants wear either prescription or nonprescription safety eyewear.
Masks with full-face shield or a mask and visor combination provide the most
effective facial and eye protection to date against projectile and spatter hazards (see
Photos 2.2 and 2.3). However, their use by dental practitioners is limited due to their
higher cost, reflective glare, fogging, and optical distortion caused by the unavoid-
able curvature of the face shield when the mask is worn and hotness of the air in the
zone between the face shield and the wearer’s face. This results in discomfort and
inconvenience.
There are three possible routes dental debris may follow in order to reach the eye
of a practitioner not wearing a full-face shield mask or mask and visor
combination.

(a) Frontal entry route by debris traveling perpendicular to the dental professional’s
face. Glasses provide the necessary protection against such debris. Not only do
the glasses need to meet OSHA Standard 1910.133(a) (1), but they also must
meet ANSI Standard (Z87.1) (Arsenault and Tayebi 2016). ANSI is the
American National Standards Institute which supervises the development of
safety standards from products, systems, and services in the USA. By choosing
eyewear that meets both OSHA and ANSI, fewer eye injuries are caused by
flying debris.
(b) Sideway (right to left or left to right) entry routes by debris traveling tangential
to the face. Side shields provide effective protection against such debris and are
specifically required by OSHA Standard 1910.133(a) (2), which states:

“The employer shall ensure that each affected employee uses eye protection that provides
side protection when there is a hazard from flying objects. Detachable side protectors (e.g.
clip-on or slide-on side shields) meeting the pertinent requirements of this section are
acceptable.”
32 M. E. Ing and P. Arsenault

Photos 2.2 and 2.3

Up visor and down visor
prevent bottom gap space
breach

(c) Bottom gap entry routes (see Photo 2.4) by debris traveling vertically and tangen-
tial to the face. Such debris may reach a practitioner’s eye through the open gaps
(bottom gaps) between the lower rims of the lenses of the protective eyewear and
the upper edge of the mask worn by the practitioner (Arsenault and Tayebi 2016).

Since frontal entry route and sideway entry routes are effectively blocked by the
use of OSHA-required protective eyewear (OSHA Standard 1910.133(a) (1)) and
side shields (OSHA Standard 1910.133(a) (2)), the bottom gap entry routes are the
most frequent, yet unaddressed, routes of eye-injury-causing debris.
2 Office Environment 33

Photo 2.4 Bottom gaps

Arsenault and Tayebi demonstrated in their studies that there is a major inade-
quacy and breach in protecting the dental care provider’s eyes using the present den-
tal mask and standard/typical eyewear combination. Closing the bottom gaps is
essential and should be considered “appropriate” when defining adequate or appro-
priate personal protective equipment standards as noted by OSHA (Arsenault and
Tayebi 2016).
It is inherent and unavoidable in the process of wearing a non-full-face shield
dental mask or mask/visor combination and deforming the mask’s nose clip to fit
over the wearer’s nose that bottom gaps are generated; therefore, the currently used
combination of protective eyewear and standard dental mask does not provide the
“appropriate” eye protection required by OSHA. Also, the unavoidable generation
of the bottom gaps renders the combination of regular protective eyewear and stan-
dard mask combination to be a potentially dangerous combination since it is reason-
ably foreseeable that dental debris may reach the eyes of the dental practitioner or
dental personnel through such open bottom gaps.
It is also important to consider protection for the patients’ eyes. Instruments
can be sharp and heavy and could inadvertently fall into the patient’s face or
eyes so it is imperative to provide appropriate safety eyewear with side shield
protection for all patients. It would be prudent to pass instruments either around
the back of the patient’s head or below their chin areas instead of over their
faces.
At the end of the procedure, all protective eyewear should be wiped down with a
hospital-approved disinfectant, then rinsed off, and allowed to air-dry.

2.6 Extracted Teeth

The CDC guidelines state that extracted teeth can be returned to patients upon
request (CDC n.d.-c). If a tooth is returned to a patient, then OSHA regulations do
not apply since OSHA regulations are set forth to protect the employees. If the tooth
34 M. E. Ing and P. Arsenault

is given to the patient, OSHA does not consider it a risk to DHCP since they do not
need to transport, clean, or dispose of human tissue. However, if extracted teeth are
to be discarded in the dental office, then OSHA compliance must be followed as the
teeth would be considered potentially infectious waste. Extracted teeth must be dis-
posed of in specially marked medical waste containers (CDC n.d.-c).
Teeth containing amalgam must not be disposed of in the same medical waste
containers that use an incineration process. Clinicians should be familiar with their
state laws regarding amalgam disposal.
Often, dental offices will be approached by dental students who wish to collect
teeth to be used in educational and research settings. The CDC suggests that
collected teeth be stored in 1:10 bleach to water in a sealed container upon leaving
the dental office. Per CDC recommendations, the students should autoclave the
teeth prior to using for the teaching exercises or research purposes (CDC n.d.-c).

2.7 Handling and Shipping of Biopsy Specimens

Often tissue is biopsied at the dental office and sent to a laboratory facility for
pathology evaluation. Any time materials are handled in the dental laboratory,
OSHA-approved PPE should be worn. The preservatives used to store the tissues
are considered potentially hazardous materials by the US Federal Department of
Transportation (DOT) or the International Air Transport Association (IATA), so
great care must be given to packaging and shipping.
Most clinicians use 10% formalin as a tissue preservative. 10% formalin is pre-
pared by diluting a 37% formaldehyde solution. A 10% formalin solution contains
3.7% formaldehyde. It is considered within regulatory limits to store a specimen in
a solution that contains 10% or less of formaldehyde.
The shipper is responsible for any spills while in transit. Should the package
break open and require an emergency cleanup, the DOT or the Federal Aviation
Administration will fine the shipper. Dental offices should triple package the
specimens using leakproof containers with watertight lids. The specimen must be
placed in a primary leakproof container, affixed with a biohazard label, which
goes into a secondary leakproof container. In between the primary and secondary
containers, there should be enough absorbent materials and bubble wrap to absorb
all the liquids in case anything breaks. This should all be placed inside a rigid box
that is concisely marked with the number of items contained within. In addition,
the outside of the box needs to be labeled with the following specific words for
biopsy specimens: “Exempt Human Specimens” along with the addressed “To”
and “From.” In addition, there should be arrows indicating the orientation of the
test tubes or containers upright position. Once packaging is completed, the box
should be able to sustain a drop of several feet without the container boxes break-
ing apart. It is important that the outside packaging not be contaminated.
Consideration should be given to the shipping personnel that will be handling the
package and not wearing PPE once the package leaves the office premises (see
Fig. 2.1).
2 Office Environment 35

Wrap absorbent material

around biohazard labeled
specimen container (with snap
on/secure lid) before being
placed in the secondary leak-
proof container. Wrap securely
in enough absorbent materials

Secondary
Leak proof
Container
Wrap leak-proof secondary container
in enough absorbent materials and in
bubble wrap securely in case container
breaks. Place inside rigid specially
marked box.

Exempt Human
Specimens

Up

Fig. 2.1 Triple packaging of biopsy specimens. Drawn by Melissa E. Ing, D.M.D., and Ms.
Patricia DiAngelis

The shipper should use their best practices professional judgment and always
follow the triple packaging principles.

2.8 Musculoskeletal Disorders and the Dental Surgeon

Musculoskeletal disorders (MSDs) are injuries or disorders of the soft tissues that
can include the muscles, tendons, ligaments, joints, cartilage, and nerves. DHCP are
prone to work-related MSDs, which are MSDs that are made worse when exposed
to certain work conditions and risk factors. Dentists commonly report MSDs in the
areas of the neck, shoulders, back, and arms (Valachi and Valachi 2003a). While
treating patients, dental surgeons tend to work in static seating or standing postures,
often bending over to peer into the patient’s oral cavity. In addition, dentists are
36 M. E. Ing and P. Arsenault

prone to tightly grasp small hand instruments and use vibrating handpieces for pro-
longed periods. Repeatedly straining to visualize with little movement of joints and
muscles while working in a very confined oral cavity spaces predisposes dentists to
MSDs.
MSDs can result in reduced productivity and lost wages due to healing time.
Michalak-Turcotte estimated that American dental professionals report an annual
income loss of approximately 41 million dollars due to MSDs (Michalak-Turcotte
et al. 2000).
MSDs have long been described by dental clinicians. In 1946, at a time when all
dentistry was done in an upright standing position, F.E. Biller reported that 65% of
dentists reported back pain (Biller 1946). Decades later, the advent of four-handed
dentistry has decreased operator stress and increased office efficiency. Dental equip-
ment has ergonomically evolved as well, yet, there is no less reporting of MSDs
(Valachi and Valachi 2003a; Shaik et al. 2011; Ayatollani et al. 2012). Studies con-
ducted from 1987 until 2000 showed that up to 81% of dental professionals report
pain in the back, neck, shoulders, or arms (Shaik et al. 2011). Most clinicians favor
a standing rather than sitting position without back support when performing pres-
ent-day oral surgical procedures such as extractions. Anecdotally, when oral sur-
geons are asked why they choose standing over sitting, they most often will answer:
“It’s tradition.” Most general dentists prefer a seated position when performing
restorative procedures. Valachi and Valachi (2003a) compared pain statistics of the
1946 standing dentists to the present-day seated clinicians and found that the seated
position made little difference in how frequently MSDs were reported. Instead, the
investigators found that pain reporting fluctuates to different areas of the body
depending on whether clinicians chose a seated or standing position. Clinicians that
favored a seated position reported pain in the back, neck, shoulders, and arms.
Clinicians that favored a standing position reported lower back pain, varicose veins,
and flat foot (Valachi and Valachi 2003a).
Pejcic et al. demonstrated that it is best to alter sitting and standing positions
while performing dentistry (Pejcic et al. 2016). Different sets of muscles are used
when standing versus sitting, so alternating the positioning will give one set of
muscles the chance to rest while the workload is turned over to another set of
muscles (Biller 1946). Furthermore, Catovic et al. (1991) found that a seated
position is preferred when visually intensive or precise work is being done, while a
standing position may be more ideal for maximizing gripping forces.
In addition, the University of California at Los Angeles Ergonomics Group dem-
onstrates that alternating standing and sitting during a workday of tasks is a better
way to prevent MSDs of the back and may help to maintain a neutral spine position.
Neutral spine is also referred to as a healthy spine or good posture. When viewed
from the side of the body, there are three natural curves in maintaining a healthy
spine. These consist of the neck or cervical spine area which gently curves inward,
the mid-back or thoracic area which curves outward, and the lower back or lumbar
area which curves inward (see Photo 2.5).
The dental professional spends much of their day in a forward leaning posi-
tion. While trying to get closer to the patient for better access and vision, the
2 Office Environment 37

Photo 2.5 Operator chair

with five castor wheels and
proper lumbar support
allowing neutral spine.
Operator thighs at approxi-
mately 110° waterfall

Neutral
spine

tendency is to slouch. Due to the forward flexion slouching assumed during most
of the workday, many DHCP report back pain. It is important to work on building
strong core muscles which can help stabilize and protect the spine (Valachi and
Valachi 2003b).
Arm, wrist, and hand ailments are commonly reported by dental professionals.
Common complaints to hand surgeons include carpal tunnel discomfort, trigger
finger, and wrist tendonitis.
The median nerve and several tendons loop through a small passageway in the
wrist called the carpal tunnel. The median nerve controls movement and sensitivity
in the thumb and the first three fingers. Prolonged wrist flexure positioning and grip-
ping instruments too tightly can cause carpal tunnel syndrome (CTS). CTS can
cause pressure and swelling of the median nerve. Symptoms can include numbness,
tingling, weakness of the thumb area, and pain that can run from the hand, up the
wrist, and to the elbow. It is reportedly mostly in the dominant hand but can also be
bilateral (Ashworth 2016).
In addition, exceedingly firm and awkward ergonomic grips on instruments can
cause a stenosing tenosynovitis of the digits, which is also called “trigger finger.”
Trigger finger is characterized by pain on the palm side of the hand involving the
metacarpal heads of the digits. A true trigger finger can cause the fingers to lock up
so that movement is staggered and painful. Furthermore, there is wrist tendonitis.
The most common is De Quervain’s tendonitis which consists of inflammation of
the first dorsal compartment tendons located behind the thumb area. Prolonged
deviation and repetitive activity increase the risk of ulnar neuropathy. Other tendon-
itis ailments affecting dentists involve the radial, ulnar, and dorsal regions of the
wrist (Shehab and Mirabelli 2013; Tallia and Cardone 2003).
Other documents randomly have
different content
name="" eleven="" hayward="" nine="" itichards.="" but="" few=""
graves="" without="" stones.="" stones="" face="" south.=""
ground="" not="" worked="" upon="" leveled="" off="" so=""
obliterate="" resting="" places="" those="" no="" head="" deed=""
ancient="" manuscript="" these="" premises="" any="" thereof=""
known="" exist.="" ebenezer="" copeland="" sr.="" present=""
james="" bridgewater="" lost="" seveu="" his="" family="" jan.=""
march="" wife="" typhoid="" fever="" wit:="" d.="" ruth="" feb.=""
abby="" godfrey="" molly="" rachel="" betsey="" mch.="" g=""
.aged="" mehitable="" eben="" jr.="" they="" were="" opposite=""
burial-ground.="" father="" copelaiul="" tliat="" iu="" built=""
tomb="" had="" bodies="" put="" into="" that="" tomb.=""
another="" deacon="" joseph="" kingman="" brother="" shortly=""
third="" spot="" ilezekiah="" copeland.="" tombs="" removed=""
pine="" hill="" cemetery="" taken="" away="" then="" widened.=""
owned="" where="" located="" formerly="" brett="" nathan=""
road.="" probably="" grandson="" settlers="" greatest=""
landholder="" gave="" original="" lot="" burial.="" tradition=""
more="" sandy="" nearly="" elihu="" leonard="" which=""
stands="" site="" very="" cellar="" occupied="" successively=""
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some="" appearance="" an="" grave="" found="" if="" w:ls=""
ever="" much="" burial="" would="" discovered="" evidence=""
its="" purpose.="" clerk.="" nathaniel="" sarah="" buried.=""
she="" he="" late="" gamaliel="" stone="" capen="" houses=""
stand="" called="" second="" n.="" fourth="" clerk="" death=""
grave.="" indicated="" natural="" rough="" foot="" inscriptions.=""
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HISTORY OF WEST BRIDGEWATER. 913 birth or age. The

first wife died 1771, and their son, Uriah, died 1708, aged 28. Tlie
old Powder-House stood in tills yard, near the southwest corner.
El'ITAl'II.S IN THE I'OWDER-IIOUSE GKAVEYAUD. 1. Lt. Jonathan
Packard, died May 27, 1805, in i his 73'' year. 2. Mrs. Martha, wife of
Lt. Jonathan Packard, died March 11, 1810, in her 82" year. .5. Ill
memory of Miss Silence Hayward, who died Dec. lli, 1823, in the 73''
year of lier age. 4. In memory of Mis. Silence, wife of Mr. Elijah
Hayward ; she died Oct. 22", 1803, aged 75. Iltiiuy uugeld guurd
tUiu lovely cluy Till couiutf tile grcut dL-ciaive duy WliuQ itUa Hliall
wiiku fur tu put on Tlio lobe wliicli Cliridt prep^rtMl :ui loii(;. 5. iu
memory of Mr. Elijah Hayward, who died July ;U, 1800, his aj,'e 78.
Sly cliildreii de.ir, this plaru draw iieur, A fiitbur'ei giiivu to HUB ; Nut
Iwiig tigu I wuD with yuu, And soon yuu will be with me. 6. In
memory oi'Mrs. Betty Hayward, wife of Mr. Luther Huywurd, who
died Nov. 9, 1703, in the 2S^^ year of her age. My Irii'iiili dniw ut-ur
unti drup n tear, In tltid duik grave I lie; 0 tbiuk of nie wben this yuu
^ee, And be prepared to die. 7. Erected in memory of Mr. Luther
Hayward, who died Nov. 12, 1S32, aged 74 years. 8. In memory of
Mr. Daniel W. Lewis, who died Aug. 17, 1815, ill the 28 year of liis
age. FriendH nnr phyHiciau cuuld oot ttave My niortul body fruui the
gruve; Nor cuti the gruvu cuuline uie bete When Ciirbt dhull cull uiu
tu iippeur. 9. Erected iu memory of Caleb K. Reed, who died Oct. 2,
A.D. 1837, aged 38 years. Ueuth, like 11(1 over>Iluwiiig atix-uni,
SuuD beara aa to the tomb; but luioiortality and life Didpel the
darkwjuie gtuuoi. 10. Erected in memory of Mrs. Hauuah Reed,
widow of the late Timothy Reed, Ese; Shall munut triuniplmnt to
thettkieo; Wheu bi ight thla love, the gniije divine, Thiis mortal shall
in glory eliine. 14. In memory of Mr. Joseph Edson, who died Aug.
27, 1791, y* 3G year of his age. 16. Rebecca, wife of Ezekiel Reed,
died Jan. 3, 1845, aged 74 years, 6 mo., 27 days. In her was
manifested that wbdoni which is from aliove, is first pure, then
peaceable, gentle, and easy to be entreated, full of mercy uud gooti
Iruit, without purliality aud witbuut hypocrisy. IG. .Jesse, son of Mr.
Jesse Edson, dieil Aug. 12, 1708, in y" 4"' year his age. 17. Iu
memory of Mr. Jesse Edson, who died Nov. 18, 1787, in the 60"' year
of his age. 18. Here lies buried Mrs. Lydia Edson, wife of Jlr. Jesse
Edson, who died Jan. 23, 1702, in y" ZG"' year of Iter age. 19. Here
lies buried Mrs. Lydia Edson, y' wife of Dea. Joseph Edson, who died
January 24, 1762, in y" 80"" year of her age. 20. Here lies buried
Dea. Joseph Edson, who died Aug. 26, 1768, in y'' 90"' year of his
age. 21. In memory of Luther, son of Mr. John Richards and Kezia,
his wife, who was born Dec. 20, 1764, and died Nov. 5, 1776. 22. In
memory of Daniel, son of Mr. John Richards and Kezia, his wife, who
was born February 4, 1757, and died June 28, 1776. 23. In memory
of Rhoda, dau. of Mr. John Richards aud Kezia, his wife, who was
born Dec. 11, 1760, and died March 27, 1775. 24. Iu memory of
Mrs. Kezia, wife of Mr. John Richards, who died June 9, 1807, in her
73 year. 25. In memory of Mr. John Richards, who died Dec. 26,
1812, in the 90'" yesir of his age. 26. In memory of Ruhamah,
daughter of Ca|>t. Josiah Snell and Mrs. Ruhamah, his wife; she
died March y° 15, 1786, in y" 17'" year of her age. Uubamali bid a
long farewell To all below, where she did dwell ; She trod the dark,
the gluotny ruad, Tn dwell forever with her Qod. 27. In memory of
Mr. Barnabas Snell, whu died Jan>. y* 28, 1783, in the 27"' year of
his age. My time is spent, my days ikre pat^I ; Eternity must count
the rest; My glass Is out, my ruce is run ; Tbe holy will of Ood is
done. 28. In memory of Mrs. Ruhamah ynull, wife of Capt. Josiah
Snell, who died Jan". 25, 1792, in y' 61" year of her age. 29. In
memory of Capt. Josiah Snell, who died Feb. 17, 1803, his age 73.
30. Here lies buried Mrs. Rebecca Urett, y" wife of Deac. Nathaniel
Brett, who was born Feb. 25, 1700, and died May 12, 1771. (Deacon
N. Brett wiis fourth town clerk, 1730 to 1779.) 31. Here lies buried
the body of Mr. Uriah Brett, only son of Mr. Nathaniel and Rebecca
Brett, who
The text on this page is estimated to be only 23.07%
accurate

9U HISTORY OF PLYMOUTH COUNTY. was born Feb. 25,

1740, died March 28, ITGS. (Tliis Nathaniel Brett was a deacon, and
fourth town clerk, 1736 to 1779.) 32. In memory of Miss Martha,
dau. of Lt. Jona- | than Packard and Mrs. Martha, his wife, wlio
departed j this life Jan? y^' 19, 17S4, in tlio 19tli, year of lier age. j
Hail! liuppy yuiitli, (f'liie, tliou liiidt tuuk Iby lli;4lit, TbruU{;b Cliiist, lu
dwell in rculiiiH uf ^lori^ud l>glit; Tliy Diuy Wiis nliort uii tiiicli, vut
tiiuilo to Unuw, Thu puius of pailUiQ wilti lliy frieuiis Uuluw. 33. In
memory of Mr. Caleb Packard, wlio departed tliis life May y'-' 27,
17S3, in the 24'" year of liis age. See tiere'd the youth whose
ciieerful bloom Prouiideil u tniiii uf ye;ii"i» to coliiu; WliOBO eoft
udilieMd liud giiueful air Uuil ubtuiiieiJ the yeublin;; fiiir. When fute
diviiie.i, thro' uxplodi-il joy, Aud ull lild Hatteriii^ boi)es dL-aticy. 34.
In memory of Jonathan Packard, y° son of Mr. Jonatiian Packard and
Martha, his wife, lie died Jan. 2, 17t)2, aged 0 years, 10 mo., 12
days. 35. In memory of Mrs. Susanna, daugh' of Lieut. Jonathan
Packard and Mrs. Martha, his wife, who departed this life Aug'' y-'
5"', 1785, and y"^ 24"* year of licr age. A life UKrcL'uble, Ulid de:itli
triiiiii|diant through H Saviour. 36. In memory of Mrs. Abigail,
daugliter of Lieut. Jonathan Packard and Mrs. Martha, his wife, who
departed this life Nov. y" 20, 1786, in y" 17"* year of her age. Fulber
I give my spirit up, Aud truat it in tliy buud; Ti\y dying tleab abiill
reat iu hope, Aud rise ut thy coiuOiuiid. 37. Mrs. Aletha Packard, died
Dec. 30, 1805, in her 52'' year. 38. Mrs. Sarah Snell, wife of Mr.
Caleb Suell ; she died Aug. 27, 1807, in her 27'" year. Over lliy uow
departed ft if nd The te.ilrt of aynipatby duaceud ; The ground wlieie
thou alt beduw, Aud Liing thy fuuturea plain to view. 39. Catherine,
daughter of Caleb Snell, died Aug. 31, 1807, aged 9 mos. 40. In
memory of Mrs. Anna, wife of Dea. Elijah Snell, who died April 20'",
1800, iu her 50'" year. 41. In memory of Mrs. Susanna Suell, wifeof
Deac. Elijah Suell, who died June 19, 1795, aged 53 years, 1 mo., 14
days. 42. In meinory of Anna, wife of Mr. Etlmuml Hayward, who
died May 14, 1776, in y'' 45"' year of her age. 43. In memory of Mr.
Edmund Hayward, who died February the 12'^, 1781, iu the 01"'
year of his age. 41. Ill memory of Abigail .Snell, daughter of Mr.
Josiah Snell, Juu., and Abigail, his wife, who was born May 30'",
1739, deceased May y' 13'", 1747. 45. In memory of Macey Snell,
daughter of Mr. Josiah Snell, Jr., and Abigail, his wife, who was born
Sept y' 30", 1736, deceased May y'' 27'", 1747. 46. In memory of
.Mrs. Abigail, wife of Capt. Josiah Suell; she died Dec. y" 2, 1784, iu
y 76 year of her age. Reinember me as you piias by, For art you ale
ho once w.ib I ; Aa I am uow ao you must be ; Prepare for death,
and follow lue. 47. In memoryof Capt. Josiah Snell, be died Aug. y
20'", 1785, in y^' 85'" year of his age. Here, in this gloomy iiuraery
of the dead, A neiglibor good, a faitiiful fliend la l.ild; JuBl, peaceful,
careful, pnnctu.tl, and aiucere, A father kind, u tender liuaband dear.
48. Here lies buried Mr. Josiah Snell, who dec'' April y' 4'", 1753, in y'
79"' year of his age. 49. In memory of Luther, son of Mr. Natlian
Snell and Betty, his wife; he died Nov. y"^ 12'", 17S7, in his 5'" year.
50. Sacred to the memory of Mrs. Betty Snell, wife of Mr. Nulhan
Suell, who died Jan. 5, 1830, a; SO. 51. Ill meinory of Mr. Nathan
Snell, who died June 20, 1802; his age 54. 52. Linthea Snell, died
April 5, 1859, aged 64 years, 6 mo. and 4 days. 53. In memory of
Mrs. Betsey, wife of Mr. Cyrus Snell; she died Dec. 14, 1805, in her
28'" year. Think on the parents, uiolhera, tliiiik how great ; How
favureil with yourciiiblren iu yi.ur view; W bile you enjoy your beallii,
your wealth and atate. Prepare to follow me; teach theui to follow
you. 54. In memory of ilr. Cyrus Snell, who died Oct. 29, 1805, aa 27
years. Death is a soleniu acene you all muat pass, When y.-u draw
near. Oh I .Morl.il-. tbiiik bow auun, Jly blooming hopes and yi-ara
are lied in liaale, So may your Dioniiug aun go down at noon. 55. In
memory of Mrs. Maty Brett, wile of Dea. Nathaniel Brett, dec"', who
departed this lii'e, Jan. y* 21"', 1780. 56. Erected in memory of
Caleb Kingman PlcciI, son of Mr. Timothy Reed and .Mrs. Hannah,
his wife, who was born .July 20, A.D. 1789, and deptirted this life
Oct. 10, 17'J6, which made his residence in this world 7 years, 2
mos. 20 days. God, my redeemer lives. And olten I'lulu the skies,
Louks down and watches all my du^t Till heaball bid it liae. 57. In
memory of Mr. Caleb Kiiiginaii, born Sept. 25, 1744, died Sept. 16,
1807, le 63. All husbands kind and gooil, a parent dear. To all
ubiiging and to all aiaceie. Title to his otlapring, fiieud and guide, lie
lived beloved, aud lamuuted dit.d. 58. In memory of Freelove
Kingman; she died Jan. y' 3", 1815, aged 69 years.
The text on this page is estimated to be only 27.50%
accurate

HISTORY OF WEST BRIDGEWATER. 915 Id prHine IMI

spend my latrHt brenib, Tlien yield it tu tlie cmII ur dfutli, In liuiH^
timt tbuu my tteNJi will ruise To cultrbrute tliy deulblend praidu. 59.
Mrs. Sarah, wile of Mr. Steaven Vinall, she died Nov. 4, 1785, in llie
75"' year of her aa, his wife, who died Oct. 17, 1824, aged 4 years, 6
mo. 66. In memory of Mr. James Ingalls, who died Sept. 11, 1816, in
the 54"" year of his age. Art tliuu a nmu of liunest mould, Wiib
fervent benrt sincere? A biisbiiiid, Tullier, Irieiid bebuld, Tby brother
slumbers here. 67. In memory of Samuel, son of Mr. Samuel Willis
and Susanna, his wife, who died April y' 10"', 1780, in his 20"- year.
Depart my friends, Wipe otf your tears ; liere I must lie Till Christ
appears. 68. In memory of Mrs. Susanna, wife of Mr. Samuel Willis,
who died Dec. y^ 10, 1783, in y' 58 year of her age. Stop, kind
render, and drop a tear; Tliliik on tlie dust tlmt fllnmbers here; And
while you read the late tif Die Think uu tbe t;lass that runs fur thee.
69. In memory of Mr. Samuel Willis, who died Nov. y-- JO"-, 1778, in
y" 54"' year of liis age. Dehuhl and see aa you pass by, For as yuu
are sii uuce wits 1 ; And as [ iiui IHIW so yull must be ; Prepare for
death, aud follow me. 70. In memory of Miss Martha Snell ; who
died Sept 2^ 1817, U3 64. Could (fratefnl love recall the fleeting
breath. Or fond iiffection sooth relenlb-HS deiith ; Then had tliis
stoii** ne'er chtinied a social tear. Or reail to IhoiiKhtless man a
leaoou here. 71. Here lies Mrs. Sarah Snell, she died Nov. 17, 1800,
in her 39"' year. 72. In memory of Mrs. Martha, wife of Mr. Jonathan
Snell, she died Nov. 16, 1781, in y" 54"" year of her ajce. 73. In
memory of Mr. Jonathan Snell, who died Nov. 22, 1800, in his 83"
year. My time is spent, my days are past ; Klernity must couut tbe
rest ; Uy glass is out, my race is run ; Tlie holy will of God is done.
74. In memory of Mr. Jonathan Snell, Jr., son ot Mr. Jonathan Snell
and Martha, his wife ; he died March 9'^ 1782, in the 30"" year of
his age. 75. In memor)' of Edward, son of Mr. Jonathan Snell and
Martha, his wife, he died Dec. 22, 1782, iu y 18"" year of his age.
76. In memory of Mr. Israel Packard Jr., who died April 20"", 1752,
aged 35 years and 14 days. 77. Rhoda, daugh" of Mr. Robert Packard
and Lydia, his wife, born Oct. 4, 1749, died April 4, 1750. 78.
Erected in memory of Mrs. Anne, wife of Mr. Ephraim Snell, who died
June y' 9"', 1790, in y'^ 34"" year of her age. 79. In memory of
Capt. Ephraim Snell, who died Sept. 30, 1805, in his 50"" year. My
cbildreD dear this place draw uear, A father's grave to see ; Not long
ago I whs with you, Aud BouD you'll be with me. 80. Mrs. Hannah,
widow of Caleb Snell, formerly widow of Josiah Williams and Capt.
Ephraim Snell, died July 5, 1846, in the 83" year of her age. 81.
Erected to the memory of Ephraim, son of Mr. Ephraim Snell, and
Mrs. Anne, his wife, who died July y' 10"*, 1790, aged 7 weeks and
1 day. 82. In memory of Miss Bathsheba Snell, who died Oct. 7,
1734, aged 47. 83. Florette, daughter of Levi P. and Melora A. Bailey,
died Sept. 1, 1846, aged 7 months and 6 days. Early fled life, care
and sorrow, Lowly in the grave to rest ; She shall on a glorious
morrow ; Bise to mingle with the blest. 84. Edward Snell, born Aug.
2, 1804, died Juue 8, 1858. Gooe Home, 85. la memory of Mary W.,
wife of Edward Snell, who died May 29, 1844, in her 31"' year. 86. In
Memory of Mrs. Hannah T., wife of Mr. Edward Snell, who died Nov.
3, 1840, in her 30 year. Also their infant dau., died Oct. 29, 1840,
aged 3 weeks. 87. In memory of Emraeline S., wife of Edward Snell,
who died April 7, 1838, in the 30'" year of her age. 88. Samuel, son
of Calvin aud Sally Jackson, died Dec. 15, 1810, a; 11 days. 89. In
memory of Mrs. Lydia Richards, widow of Mr. Benjamin Richards,
who died April y" 23, 1788, in y'^ 93" year of her age. Worn and
with age we did receive Our death by Ailam and by Eve ; But life and
pardon that is shown To us by Christ, God's ouly son.
The text on this page is estimated to be only 25.90%
accurate

yiG HISTORY OK PLYMOUTH COUNTY'. yo. In memory of

Mr. Ezra Richards, who died Sept. >■■-■ 2G"", 178U, iu y" 59"' year
of \i\a agu. 91. In niLMiiory of Deac. Ju.siah Richards, who died April
6, 1815, aged 90 years. 92. Mrs. Anne, wife of Dea. Josiah Richards,
died Aug. 12, 182S, 03 81. 93. In memory of Marcus, son of Mr.
Daniel Hartwell and Mehetabel, his wife, he died May y"' 9, ISSl,
aged 9 mos. 8 days. Depult my friemla. Wipi) uil" your teiirb; Here I
uiuht lie Till Cliridt ;ippt,';irs. 94. In Mieniory of David, .son of Mr.
Daniel llartwuU and Mahetabel, his wife; he died Oct. y 24''', 1782,
aged G mo., 13 days. 95. Betty, daughter of Mr. Johu Coiieland, Jr.,
and Mehetabel, his wife, born Feb. 27'", 1770, and died May 19,
1775. 9lj. In memory of Ambrose, sou to Mr. Benjamin and Mrs.
Mary Marsliall ; he died Dec"' y" 5"', 1784. aged G mos., 23 Jays. 97.
John, son of Mr. Eleazer Churchell and Lucy, his wife; he died Oct.
2", 1801, in infancy. 98. Deborali, daugliter of Mr. Eleazer Cliurchell
and Lucy, his wile; she died Sept. 17'", 1804, in her 9'" year. 99. In
memory of Mrs. Hannah O. Douglas, wife of George Douglas, who
died Nov. 25, 183G, aged 30 years. 100. Hugh Carr. (No inscri|)tion.)
(101, 102, 103, 104, and other graves near this place, are colored
people, witliout stones, such as Thomas Sutten, Peter and Parmeuas
Pierce, Levi, John, and Jacob, Jr., Tarbut or Talbut, and wife of Jacob,
Jr., and two wives of Jacob, Sr., Sally Carden, Frank Sutten, and
others.) Jerusalem Graveyard. — The Jerusalem Graveyard is on the
west side of the road leading from the almshouse to Jerusalem, and
was established as early as 1749; contains thirty-three square rods;
is oue hundred and fifty feet on said road, running north and south,
and extending back sixty-four feet ea-st and west; has thirty-six
lettered grave-stones and some half a dozen graves unmarked,
except by native fiat stone, without inscription ; graves head east,
foot west, and all stones facing east. The Rev. John Burr, aged sixty-
one, and ]>r. Abiel Howard, aged seventy-two, were buried here in
1777. The first two persons buried here were Mary Hayward, a child,
died June 15, 1749, and .John Howard, a child, died 1753; and the
last two persons buried here were Jonathan Hayward, died April 30,
1824, aged eighty-eight, and Charity Howard, died Dec. 4, 1829,
aged eighty-two. Twelve of the thirty-six persons having gravestones
died during ten years succeeding 17U0, and half of the thirty-six
died between 1770 and 1800, and only three, besides the two above
named, have died since 1800 — one in 1803, one in 1811, and oue
in 1813. I This ground was virtually abandoned and wlioUy '
neglected for many years. A good growth of wood and timber had
grown up, and was standing thereon ; a few years ago, when the
town of West Bridgewater extinguished the outstanding title, took
possession of the premises, caused the wood and timber to he cut
and removed, and inclosed the ground with a wooden post and rail
fence on three sides thereof, and a stone wall on the back side.
There are in this yard thirteen Ilaywards, five Burrs, ami four each of
the Bretts and llartwelU. We are unable to find any ancient recjrd
relating to this graveyard, and only one deed of land i.s known to
exist, and that recently taken from .Jane S. T. Ilervey, daughter of
Zeba Howard, and wife of L. D. Ilervey, conveying the premises to
the town of Went Briilgewater. EPITAPHS IN THE JEIIUSAI.E.M
(iUAVEYARD. 1. In memory of Hannah, daughter of Mr. Philip
Reynolds and Hannah, hi.s wife, wlni died Dec. y' 23, 1774, in y 0'"
year of her age. 2. In memory of Mr. Philip Reynolils, who died Jan.
4, 1775, in y' 35'" year of his age. 3. In memory of Freelove Brett,
d.uigli. ot .Mr. John Brett aud Alice, his wife, who died Jan^ 12,
1779, in the 33'' year of her age. 4. In memory of Hannah Brett,
dangh. of Mr. John Brett and Alice, his wife, who died Oct. 20'",
1779, in the 26"" year of her age. 5. Here lies Mr. John Brett, who
died Aug. 28'", 1793, in the 88*" year of his age. G. In memory of
Alice, widow of Mr. Jnhii Brett, who died Dec. P', 1794, in her 81-'
year. 7. In memory of Mrs. Anna Williams, wite of Mr. George
Williams, wlni died Sept. 4, 1775, in y' 23'' year of her age. 8. In
memory of Mrs. Sarah Kingman, wife <>[' Mr. Alexander Kingman,
who died Nov. l(i, 17.S'.i, age
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HISTORY OF WEST BRIDGEWATER. 917 12. In memory of

Mr. Joshua Howard, who diecl March y' 31", 17S0, in y ^'J'" year of
his a^'e. 13. In memory of Miss Charity Howard, who died Dec. 4,
lti->9, ;l- S2 years. 14. Here lies Mr. Jonathan Burr ; he died January
24"', in the 66"' year of liis aj,'e. Deulli, iiiexorulile, hath hijd iu the
duttt The mail who wim fuitliful. piuua, aiu) jUHt; Fn>ni toruitjiitd
extreaie, liovt happy the Ilight From luibery lu joy — from (lurkiiesii
to light. 15. In memory of Mrs. Martha, wife of Mr. Jonathan Burr,
who died Dec. y" 12'", 1791, in y* 55"' year of her age. Our loving
rriciid in goue, No uiure to cheer bel flieuild iiiiU childreu Ueur, O
L'crtuiti t'ute, we view thi^ teuchliig etoQe .\iid moiirii thy death to
uiedilate our own. 10. In memory of Mrs. Mary Hayward, the wife of
Mr. Abiier Hayward, wlio died Dec. 4, m 1783, in the 65"' year of her
age. Our life Id ever on the wiog. And death m ever oigh ; The
uiouieiitd when our lived tegia AVe all begin to die. Death is a debt
to iiiiture due \V liich 1 have paid, and h\i must you. 17. In memory
of Mrs. Susanna Hayward, who died March 25, 1800, iu the 48'" year
of her age. Here let yuu redt iu peaceful duet Till God to glory raise
the duut. 18. In memory of Rev. John Burr, who died March tlie 16"',
1777, in y" 02'' year of his age. In memory of Mrs. Silence Burr, wife
of Deac. John Burr, who died May 6, 1773, in y" 68 year of her age.
(Deacon John Burr liere means the Rev. John Burr above.) 19. In
memory of Ruth, daugli. of Mr. Jonathan Burr and Martha, his wife;
.she died Oct. 15, 1776, in the 2"* year of her age. 20. John, son of
Mr. Theophilus Howard and Susanna, his wife, born Sept. 30, 1750,
died Mch. 1, 1752-3. 21. Kezia, wife of 5Ir. Tliaddcus Howard, died
May 20, 1811, in lier 50 year. 22. In memory of Jcrahmul, son of
Jonathan Hayward and Mary, his wife; he died Aug. 28, 1774, in y* 3
year of his age. 23. In memory of Mr. Jonathan Hayward, who died
April 30, 1824, in the 89"' year of liis age. stop, kind friends, and
take a view ; The uUruud and grave do wait for yuu ; When uu niy
grave you east an eye, Thiuk OD cold death ; you soon must die. 24.
Miss Mary Hayward wife of Mr. Jonathan Hayward, died Oct. 6, 1813,
ce 61. Let this vuiu world engage DO more, Dehuhl the gaping touib
; It bids us seize the present hour, To-uiorrow death may come. 25.
In memory of Mrs. Betty Hartwell, the wife of Mr. Nathan Hartwell,
who died Feb. 28, 1762, aged 26 years and 0 mos. 26. In memory of
Silence Burr, daughter of Mr. Seth Burr and Charity, his wife, who
died March y' 20, A. D. 1780, in the 26th year of her age. Ton,
reader, stop And lend a tear; ThIuk on the dust That slumbers here.
27. Orin Hayward, son of Mr. Solomon HaywMrd and Mrs. Martha his
wife, died Feb. 15, 1707, aged 6 mos. 28. Sally B. Hayward,
daughter of Mr. Solomon Hayward and Mrs. Martha, his wife, died
Feb. 6, 1803, iu the 4 year of her age. 29. Royal Hayward, son of Mr.
Solomon Hayward and Mrs. Martha, his wife, died Feb. 7, 1797, aged
2 years, 9 months. 30. In memory of Mrs. Abigail Hayward, wife of
Mr. Peter Hayward, who died Oct. 9, 1776, in y' 67"year of her age.
(She was one of five daughters of Jonathan Williams, of Taunton, a
large landholder. Her sister, Mary, married Seth Dean, of Raynliam,
and her daughter, Rebecca Dean, married Woodward Latham.) 31.
In memory of Mr. Peter Hayward, who died July the 14, 1765, in y"
56"' year of his age. (He was son of Deacon Joseph.) 32. Abigail,
daughter of Mr. Peter Hayward and Abigail, his wife, died April y"
21"', 1760, in y' IS"year of her age. 33. Peter, son of Mr. Peter
Hayward and Abigail, his wife, died January y" 13"', 1753, in the 2"
year of his age. 34. Here lies buried Mr. Samuel Hartwell, who dec'
December y'^ 25, 1760, in the 67'" year of his age. Here lies buried
Mr. Jonathan Hartwell, who died Feb. 8"', 1761, in the 40'" year of
his age. And Hannah, his daughter, dec" Jaii^ y' 30"', 1761, in y* 3"
year of her age. (These persons died with smallpox.) 35. Mary,
daugh. of Mr. Benjamin Hayward and Sar.ih, his wife, died June 15,
1749, aged 6 years and 6 mos. 36. In memory of Thomas, son of Mr.
David Wade and Mary, his wife; he died March y' 14"', 1768, iu y"
4"" year of his age. The Alger Graveyard and Tomb.— This yard
contains sixteen to twenty square rods of land on Wolf Trap Hill,
west side of Flaggy Meadow Biook, south side of the road, nearly
opposite the dwellinghouse of John Otis Alger, in West Bridgcwater.
There is a common balance- wall on the we.it .lide, and a bank wall
on the north side, next to the road, and otherwise it is uninclosed.
There are four graves with gravestones having the following
inscription thereon, to wit : 1. James Keith, son of Mr. Calvin Keith,
died of an epilepsy, March 13, 1801, in his 17'" year.
 918 HISTORY OF PLYMOUTH COUNTY. i. Erected in
memory of Lieut. James Alger, wiio died May 20, 1810, in hia 82''
year. 3. Erected in meniory uf Mrs. Martha Alger, wife of Lieut. James
Alger; she died 23* Aug., 1S13, in her 81" year. 4. Hannah, daugliter
of Kingman and Sarah Cook, died Jan. 29, 1822, 2 years, 10 mos.
And tliere are five graves in this yard witliout monumeut or
inscription, to wit: 1. A daughter of Abiezer Alger, Jr., stillborn, June
21, 1813. 2. Rachel Keith, born July 22, 1744, died about 1815, 71
years of age. (She was a daughter of Ebenezer Keith, and half-sister
of the first Abiezer Alger's w i fe. ) 3. Abiezer Alger, 3'' son of Abiezer
Alger, Jr., born Nov. 20, 1820, died Feb. 14, 1822, 1 year 2 months,
25 days. 4. A son of Abiezer Alger, Jr., stillborn, Jan. 10, 1823. 5.
Dilly Green, colored, buried about 1824. She was probably over GO
years of age, and w.is one of the four wives of Robert Prince, belter
known by the name of Robert Green, who was a large, strong man,
jet black, born in Virginia, lived on the Alger farm for many years ; is
said to have served in the old French war, and was a body-servant of
Gen. Green, in the Revolutionary war; died in the poor-house in
West Bridgewater, in January, 1827, lOG years of age. And tliere is
also one large tomb upon these premises, built by the late Abiezer
Alger, Jr., in the early part of the year of 1828, containing the
remains of fourteen persons deposited there in the order of their
deaths, to wit : 1. Cornelia Alger, born Aug. 24, 1800, died Oct. 26,
1824. (Put into Zephaniah Lathrop's tomb and removed June 7,
1828). 2. A son of Abiezer and Annie C. Alger, stillborn, June o,
1828. 3. Abiezer Alger, Sr., born July 25, 1757, died July 31, 1830. 4.
Hepsibah Alger, wife of Abiezer -Vlger, born in Scotland, Dec. 20,
17C0, died Feb. 25, 1841. 5. Vienna Keith, born in Scotland, Aug. 1,
1764, died July 21, 1847 (a daughter of Ebenezer Keith, and sister of
said Uepsibah.) 6. Annie Dean Alger, dau. of James and Caroline B.
Alger, born Feb. 185(>, died, aged 10 days. 7. Anne Cushing Alger,
wife of the second Abiezer Alger, born in Pembroke now Hanson,
Oct. 15, 1786, died Sept. 24, 1857. 8. Abiezer Alger, born May 21,
1787, died March 1, 1863. 0. Martha Kingman Alger, born May 16,
1848, died May 17, 1866. 10. Hepsey Alger, born Oct, 24, 17'J2, died
June 14, 1866. 11. Caroline Belinda Alger, born in Raynham, Mar. 2,
1825, died April 2, 186U. I 12. Caroline Richmond Alger, born July
16, 1845, died July 4, 1869. I 13. James Alger, born Aug. 29, 1816,
died Jan. : 26, 1878. (Son of Abiezer, Jr.) j 14. Henry Williams Alger,
born April IS, 1854, ' died Feb. 26, 1878. The Pleasant Hill Cemetery
Association, at ; Cocliesett, was organized April 1, 1872. The Pine
Hill Cemetery was orgunizetl May 16, ! 1870. This cemetery is
located in the Centre Village. CHAPTER IV. MISCELLANEOUS. I
Ilowurd Collegiate lostitute — Tlio Press — West Eridgewater Times
— West Bridgewuter News — Pbysiuians — Furmera' Club —
Manufat'turers — Civil History — Incorpuration uf Town — Clerks —
Treasurers — Selectuien — Ucpi-esentatives — War of tbe Hebelliun
— Action of tbe Town — A'arious \'otcs — Auiount of Money
Expended for War Purposes — The Town Quotas — List of Soldiers
— Soldiers' Monument, Its Inception, Cooipletion, and Dedication.
Howard Collegiate Institute. — This institution was established by
the munificeucc of the late Benjamin B. Howard (see biography of
JMr. Howard elsewhere in this work). The building is a handsome
and commodious brick structure, beautifully located, in the midst of
a wealthy and beautiful agricultural region. The institution is for girls
and young women, and was opened Oct. 2, 1883. The principal is
Miss Helen Magill, Ph.D. (Boston University, and more recently from
Cambridge Uuiveisity, England), who is assisted by an able corps of
instructor.s. The present faculty of inatruclion and government is as
follows: Helen ftlagill, Ph.D., principal and instructor in Ancient
Languages and in History; Rev. William Brown, instructor in I\lental
and Moral Philosophy; Eudora Magill, A.B., instructor in Mathematics;
Gertrude B. Magill, A.B., instructor in Modern Languages, English
Literature, and Elocution ; Lydia S. Ferguson, instructor iu Physical
Science and English branches; Drawing and Painting, vacant; Sarah
Washburn Ames, instructor in Music; Matron, Mrs. Eliza A. Kingsbury.
The present trustees are Dr. J. C. Swan, West Bridgewater, Mass. ;
Oliver Ames, North Eastou, Mass. ; Charles W. Copeland, West
Bridgewater, Mass. ; James Copeland, West Bridgewater, Mass. ;
Nahum Leonard, Bridgewater, Mass. ; Benjamin Howard, West
Bridgewater, ^lass. ; Beujaiuiu B. Howard, West Bridgewater, Mass. ;
Francis E.
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HISTORY OF WEST BRIDGEWATER. 919 Howard, West

Bridgewater, Mass. ; Wallace C. Keith, West Bridgewater, Mass. ;
Edward Tisdale, West Bridgewater, Mass. The officers for 188i^— 84
are as follows: President, Beojamiu Howard ; Secretary, Benjamio B.
Howard ; Treasurer, Francis E. Howard. Board of visitors: Mrs. Julia
Ward Howe, Boston ; Mrs. Emily Talbot, Boston ; Mrs. Kate Gannett
Wells, Bcston ; Miss Lucia M. Peabody, Boston; Miss Katherine P.
Loring, Beverly Farms, Mass. ; I Rev. Edward E. Hale, D.D., Roxbury.
M;iss. ; Rev. Joseph Osgood, Cohasset, Mass. ; Hon. Juho D. Long,
Hiogham, Mass.; Rev. Russell N. Bellows, New York City ; Arthur
Oilman, Cambridge, Mass. ; Dr. William L. Richardson, Boston;
George Herbert Palmer, Cambridge, Mass. ; Arnold B. Chace,
Providence, R. I. The institute, as at present organized, offers a
seven years' course of study. This course is so arranged as to give a
good general education, and at the same time a thorough
preliminary training for those who may wish to pursue their studies
further at- such institutions as offer University work to women. The
curriculum includes the work usually done in the first two years of
the best college courses, with more work in some departments,
especially history and English literature, than is required for entrance
to college or in tliis part of the college curriculum. The residence is
arranged on the cottage .system, one cottage having been already
built, accommoduting a small number of students, each with a single
room. This plan is considered most favorable to individual training,
and will be adhered to in future building. The aim is to retain as
much of the character of home-life as may be in an institution. The
institution is under able management, and is destined to take front
rank among similar institutions in this country. Town Statistics. —
Valuation, as assessed May 1, 1883: Viiluo of re^l estate
$739,878,110 " |ier8uiiul proporty i:f3,'J48.00 Total $87.'i,82U.OO
ASSKSSMKSTJ. State ta.\ County tax Town grant Overlaying on
taxed.. $340.00 001. CO 0,;i50.U0 2-18.31 Total tax $li,:i3y.ai Kate
of tax, $12 per $1000. Poll tax, $2. Number of polls 427 " dwelling.
housed ta.xed 35U " acres of land 9816 " horses 2S»9 " cows 4H7 "
sheep 81 AprnoPKiATiONS. For support of schools $3000.00 '*
repairs on school property liOO.OO " repairs oD higliways 260i>.00 "
new roads iud.uo " support of poor 13UU.00 " town officers 700.00 "
incidentals 600.00 " public lectures 1011.00 " old cemeteries 50.00
Total $0350.00 Town Puoi-ERTr. Value of town farm $4,100.00 "
personal property..'. 2,057.21 " nine school-houses .. 11,700.00 "
town library ;;,000.00 Public Library. — The Public Library was
organized Oct. 4, 1879, and is located in the Howard Institute. There
were added to the library for the year ending Feb. 1, 1884, four
hundred and twentynine volumes by purchase, many of which were
standard works of permanent value, consisting of choice selections,
and embracing most all subjects. There were donations also from Mr.
John S. Martin and from Mr. C. W. Copelaod amounting to thirty-
eight volumes, making the total number of books in the library Feb.
1, 1884, two thousand one hundred and sixty-two. The books in all
the departments have been selected with much care and criticism,
and they constitute a comprehensive and valuable library for a small
town. By the librarian's memoranda, it appears that the total number
of books taken from the library during the year was six thousand
four hundred and seventynine, or a weekly distribution of about one
hundred and twenty-five volumes, divided among the various classes
of subject-matter in the following ratio, viz. : fiction, about fifty-one
per cent. ; juvenile, about twenty per cent. ; travels, about four and
one-half per cent. ; history and humorous, about two and one-half
per cent, each ; science and general literature, about two per cent,
each ; biography, about three percent. ; poetry, about one and one-
half per cent. ; magazines, periodicals, about ten per cent. School
committee's financial report for the year ending Feb. 1, 1884:
ExFKNOITURIiS. Paid for teachers $29(1('>.00 Fuel 3U7.S4 Balance
due Eaflt Bridgewater 115.83 Care of houses and incidentals 110.00
Total $3439.07 RCCKIITS. Town grant $3000.00 Massachusetts
school fund 233.41 Overdrawn from treasury 200.26 ToUl $3439.67
Repaius. Expendituroa $489.41 ReceipU 600.00 Balance in treasury
$110.59
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\)-20 HISTORY OF PLYMOUTH COUNTY. It was

recommended that the town raise the sum of ihree thousauJ dollars
for tlie support of schools for the ensuing year and four hundred
dollars for repairs. The Press. — A sheet called the West BiiJ(ji:water
Times was issued here in 18G7, and lived about two years. It was
printed in Middleboro', and the corre.spundeut iu this town was Rev.
J. G. Forman. The latest Venture iu this field was the West
BiiJjewater News, which was issued here iu 1882, by William Fay. It
was short-lived. Post-Offices. — There are two post-offices in the
town, — one at Central Square, Charles R. Packard, postmaster, and
one at Cochesett, Edward Tisdale, postmaster. Physicians. — The
present physicians are J. C. Swan and Wallace C. Keith. West
Bridgewater Farmers' Club was established in December, 1871, with
James Howard as president. The present officers are Davis
Copeland, picsident; James Howard, vice-president; J. A. Shores,
secretary ; J. E. Ryder, treasurer. This was the first farmers' club
established in the county, and is in a progressive condition. Copeland
& Hartwell's Shoe Manufactory. — This establishment is one of the
oldest iu Plymouth County, having been established in 1845 by Caleb
Copeland and Josiah Quiney Hartwcll, and the oriijinal firm has been
continued without change to the present lime. This factory has been
enlarged several limes, and is now one hundred and thirty feet long
by twenty-five feet wide. They employ fifty hands, and the value of
the annual product amounts to i'rom seventy-five thousand to one
hundred thousand dollars. Edward Tisdale Shoe Manufactory. —
(See biography.) Among the other manufaclurcrs may be noted M. A.
Ripley, flouring-mlll ; George W. Bent, iron foundry ; Milvin C. Edson,
Joseph Ring, T. P. Ripley, shoe manufacturing; 0. Ames & Sou, saw-
and shingle-mills, and Jonathan Howard, vinegar manufacturer.
Incorporation of Town and Civil List. — It is a somewhat singular fact
that West Bridgewater as a parish was never incorporated by an act
of the Legislature. The parish was incorporated as a town Feb. 10,
1822. The following is a list of the clerk.s, treasurers, selectmen, and
rcpresentalives from the incorporation of the town to the present
time : CLERKS. John E. HowurU, 1S22, '2:1, '24. Oeorge W. IVrtins,
1825, '26. Notth Whitmiin, 1827, '28, '29, '?,», '31, '32, 'US, -ii, '35,
'36, '37, '38, '39, 'JO, '41, '42, '43, '44, '45, '16, '47, '48, '4'.i, '50, '51,
'52, '53. Juliii E. Howurd, 1354. Martin V. Pratt, 1855. Jiiuies Ilowuril,
1856, '57, '58, '59, '60, '76, '77, '73, '79, 'SO, 'SI, '82, '83. George A.
Colainore, 1861. John W. Ilowiura, 1S62, '63, '64. Austin Packard,
1S65, '66, '67, '08, '69, '70, '71, '72, '7:!, '71, 75. licnjamiii li.
Howard, 1884. TRKASUIlEnS. John E. Howard, 1822, '23, '24. Fisko
Ames, 1825, '2fi. Abiol Packard, 1827, '2.S, '29, '3U, '31, '32, '33, '.U,
'35, ':.(,; :;7. John II. Packard, 1838. Howard, 1839. Nahuui
Leonard, 1840, '41, '42. Thomai Pratt, 1843, '44,' 45, "46, '47, '48,
'49, '50, '51, '52, '53, '54, '56, '57, '58, '59, '60. Josiah Q. Uartwell,
1S55. George M. Pratt, 1861, '62, '63, '04, '65, '66, "07, '08, '09, '70,
'71, '72, '73, '74, '75, '76, '77, '78, '79, 'SO, '81, '82. James Howard,
1883. Charlea E. Tisdale, 1884. SELECTMEX. 1822. — David Howard,
A. Algier, .^^aiiiuel Dunbar. 1823-24. — Josiab Richards, David
Howard, .Samuel Dunbar. 1825-26. — David Howard, Josinli
Ricbards, Ca|pt. S[jcncer Lathrop. 1827. — Josiab Richards, Spencer
Lathrop, Zepaniab Howard. 1828. — N. Edson, Josiab Richards,
Jonas Hartwell. 1829-31. — N. Edaon, Jonaa Hartwell, Josepb
Kinguian. 1832. — Abiol Packard, Jonaa Hartwell, Xahuui Leonard.
1833. — Nahuui Leonard, Abiel Packard, Caleb Howar.l. is;i4. —
Nabum Leonard, Caleb Howard, Jobn Ricbanls. 1S35. — Caleb
Howard, John Richard.-!, Daiuon Uingman. 1836. — Caleb Howard,
Daruon ICinguwn, Nahuui .Siiill. 1S37. — Nahuui Snoll, Seth Leach,
'rhuiua.s Aiiie:<. jonathan="" copeland="" james="" i="">. Cianc.
1811-42. — Jonathan Copeland, Austin Packard, Libljiiis Packard,
1843. — Austin Packard, Libbeus Packard, Alh.i Howard. 1844. — A.
Packard, L. Packard, Nabuin .Siidl. 1845-47.— A. Packard, L. Paekar.l,
Job H.irllett. 1348.— A. Packard, Job liartlett, i^aiiiuul Rj.lc-r. 1847-
52. — A. Packard, James Copeland, Ward I'.icliards. 1853-54. — A.
Packard, James Copclniid, Jona> Hartwell. 1855-56.— T. B. Caldwell,
Elaiu Howard, Austin P;iekard. 1357-58.— T. D. Caldwell, A. Packard,
James Copelan.l. 1859-62. — James Howard, A. Copeland, Jr.,
Gcoigc Li. Ryder. 1863. — James Howard, Albert Copeland, I'rancis
E. llow.iid. 1S64-56.— James Howard, Francis E. Howard, C.ilcb
Copeland, Jr. 1867. — Jainea Howard, Caleb Copeland, Jr., Shepard
L. Pralt. 1868. — Francis E. Howard, Nahuui Leonaid, Jr., J. C. Keith.
1869. — Nahuiu Leonard, Jr., F. E. Howard, Charles Perkins. 1870.—
James Howard, George D. Ryder, S. H. Howard. 1671.' — James
Howard, S. 11. Howard, Davis Copeland. 1872-73. — James Howard,
S. N. Howard, Davi,- Copeland. 1874. — James Howard, Davis
Copeland, Henry ^V. Leach. 1375. — James Howard, Henry W .
Leach, Caleb Copelau.l, Jr. 1876-78. — James Howard, Henry W.
Leach, Henry Copeland. 1379-80. — Henry Copeland, Jo»iah Q.
Hartwell. S. H. Ilonard. 1831-84. — Henry Copolaud, .S. H. Howard,
M. \. Ilipley.
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HISTORY OF WEST BRIDOEWATER. 1)-J1 Representatives.

— West Bridfiewater, witli Brockton, cunstitutcs a representative
district. From tlie incoiporation of tlie town to 1827 it voted to scud
uo reprt'Miutative. Tlic following is a list of representatives : 1S27.
Julin i;. HowiuJ. 1S2S-2'J. S:iuiuel Dunbar. 1530. W'illiuni liajlics,
E^q. 1531. Siiuiucl Dunbar. 1S32-35. Ellis .\iiies, Esq. 1S36-;','.I.
J.ibn E. Iluward. 184U. Nullum Siiell. 1841. J..bn K. Howuia. 1842.
Juliii Itichai'ds. 1543. Jonas Hurtnell. 1544. C;ilcb Uowftrd. 1S4J.
Dwclley Fobes. 1346. Juoiitlutn CupelanJ. 1847. Aujtiu PftckarJ.
1848. Elij;.h .Siuitb. i 1849-52. No choice. 1S53. Albert Copulund. I
1854. I'aul Townsend. [ 1865, Voted to send none. I 1850. James
Copeland. I 1853. Jarvis D. Euirell. ISo'J. Caleb Copeland, Jr. 1864.
Georyo D. Uydcr. lSr>6. Edward Tisdalo. 1868. Nabum Leonard, Jr.
1873, Benjamin Howard. 1S76. Curtis Eddy. 1878. Henry Copeland.
1881. Francis E. Howard. War of the Rebellion. — Tlie first town-
meeting relating to the war was held April 27, 1861, vfheti it was
voted to pay each volunteer belonging to the town while in the
service eight dollars per month, and $1.25 per day spent in drilling,
and money sufficient for the comfortable maintenance of his family.
It was also voted to furni.sh arms and equipments to the military
conijiany then forming, and the selectmen were authorized to
expend two thousand dollars for that purpose. July 18, 1862, voted
to pay a bounty of one hundred and twenty-five dollars for recruits
for three years, to the " number of twenty-three." A committee of
one from each school district was appointed to act with the
selectmen in procuring volunteers, each to be paid two dollars per
day while engaged. August ISth, the bounty was increased one
hundred dollars. August 22d, the bounty to volunteers for nine
months was fixed at one hundred and twentyfive dollars. It was also
recommended that the recruits of West and KasL Bridgewater unite
and furm a company for nine months' service, also " that the whole
town attend the meeting on Wednesday evening next, at Agricultural
Hall, Bridgewater, to encourage recruiting." Another meeting for a
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