Section V

Delivery of Dental Services

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Table of Contents

> Introduction
>
> Assessing and Meeting the Needs and Expectations of Customers
>
> Access to Care
>
> IHS Schedule of Dental Services
>
> Consultation and Referral
>
> Dental Facility Considerations
>
> Emergency Procedures in the Dental Office
>
> Pharmaceuticals (Including Prophylactic Antibiotic\
> Coverage for Prevention of Bacterial Endocarditis)
>
> Guidelines for Pharmacosedation
>
> IHS Dental Data System
>
> Use of a Fiscal Intermediary to Manage Contract Care Funds
>
> Inter-Agency Agreement Between the Indian Health Service and\
> the Administration on Children, Youth, and Families

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Introduction

The IHS dental care delivery system is based on a public health
approach. Winslow, who is known as the father of public health, defined
public health as "the science and art of preventing disease, prolonging
life, and promoting physical health and efficiency through organized
community efforts."

The definition of *dental* public health which has been developed by the
American Board of Dental Public Health and accepted by the American
Dental Association, the American Association of Public Health Dentists,
and the Dental Health Section of the American Public Health Association,
is as follows:

> *Dental public health is the science and art of preventing and
> controlling dental diseases and promoting dental health through
> organized community efforts. It is that form of dental practice which
> serves the community as a patient rather than the individual. It is
> concerned with the dental education of the public, with applied dental
> research, and with the administration of group dental care programs as
> well as the prevention and control of dental diseases on a community
> basis.*

Public health is "people's health," a consideration of the health of a
population group. It goes beyond the prevention of disease, promotion of
health, and prolongation of life *on an individual basis* by focusing on
the *collective health status* of a group of people. This concern for a
population group requires a broadened concept of patient and procedures
among dental staff practicing in the IHS. Following are some of the
concepts that dental public health emphasizes:

• Group oral health education

• Community-wide fluoride programs (systemic and topical)

• Organization of services to be provided based upon the disease
occurrence in the total population, rather than ideal treatment for the
patient currently being attended

• Consideration of the demand for service by the total population

An excellent reference for dental staff involved in a public health
practice is *Dentistry, Dental Practice, & the Community,* by Brian Burt
and Stephen Eklund, 4th edition, W.B. Saunders Co., 1992. This text
provides an excellent comparison between dentistry for the individual
and dentistry for the community. Following is a synopsis of that
comparison:

• Prior to treating an individual, an examination is performed. Prior to
treating a community, a survey of the needs of the population is
performed.

• A diagnosis of the patient is analogous to an analysis of the survey
data from a community.

• A treatment plan is developed for the patient, while a program plan is
formulated to address the needs of the community.

• The treatment phase for the patient is comparable to program operation
for the community.

• Remuneration by the individual patient is in the form of payment,
while the program for a community would be financed through a formulated
budget authorized by some public or private agency.

• Evaluation of the individual patient is performed during follow-up
visits and subsequent examinations, while evaluation of the efficiency,
effectiveness, and appropriateness of community programs is made by
program administrators and/or others by means of follow-up surveys,
financial analyses, and other evaluation mechanisms.

The commitment for a public health approach does not lessen the need for
efficient, high quality clinical dental care for American Indians and
Alaska Natives. The prevention and early treatment of dental caries and
periodontal disease requires both immediate clinical intervention and
long-term community interventions. The efficient delivery of clinical
dental services that can facilitate the oral health status of a
community constitutes the major activity of the IHS Dental Program.

An important component of public health dentistry is access to care for
all members of the eligible population who need and desire care. Access
to care issues in turn lead to the concept of levels of care to ensure
that the greatest number of services can be provided for the greatest
number of people with the resources that are available. This is
accomplished by directing resources first toward treating emergency
conditions, then for preventing dental disease, then for providing
routine dental care such as restorative treatment, and finally, if
resources remain, for complex rehabilitative procedures.

The "Delivery of Dental Services" section of this manual addresses the
subjects of access to care and levels of care, as well as other topics
related to clinical practice, including consultation and referral,
dental facility considerations, emergency procedures, pharmaceuticals,
guidelines for pharmacosedation, contract dental care issues, the Dental
Data System software, and the inter-agency agreement between the IHS and
the Administration on Children, Youth, and Families.

Assessing and Meeting the Needs and Expectations of Customers

Results of a survey assessing IHS patient needs and expectations, which
was initiated at the Tribal Consultation Meeting in Albuquerque, NM, in
December of 1994, were consistent with previous consumer satisfaction
studies. Patients expect the following:

1\. Short waiting time to get an appointment and short time waiting to
be seen at the appointment

2\. Quality care

3\. Access to services from providers who are caring, competent, and
respectful of the patient and the patient's traditions

In the survey patients also identified the following needs for Indian
health programs:

1\. Integration of prevention and community outreach into the health
programs

2\. Recognition of the role of traditional healing practices

3\. Training of more American Indian/Alaska Native providers from their
communities to serve their people

Perhaps the most significant finding from the 1994 consumer survey was a
patient satisfaction rate of 83 percent ("very satisfied" or "somewhat
satisfied") for all disciplines, including dental. In the 1988-1990
International Collaborative Study of Oral Health Outcomes (ICS-II), the
proportion of patients who were "satisfied" or "very satisfied" with
access was 69 percent at one IHS site and 74 percent at the other IHS
site. Satisfaction with the quality of care was 91 percent and 95
percent at the two sites. Finally, satisfaction with the
patient-provider relationship at these sites was 79 percent and 84
percent, respectively.

While these satisfaction rates are an indication that Indian health
programs are perceived by most patients as meeting their needs, there is
room for improvement in any health care system having more than 10
percent "somewhat unsatisfied" or "very unsatisfied" patients.

The findings in these surveys suggest that dental programs should
address patient needs and expectations relative to access to services,
to the patient/provider relationship, and to cultural sensitivity and
access to traditional healing. Finally, dental programs should assess
patient satisfaction on a regular basis.

Access to Services

In the 1993 publication, *Access to Health Care in America,* the
Institute of Medicine (IOM) defined "access" as "the timely use of
personal health services to achieve the best possible health outcomes."
It is important to note that two components must be present for "access"
to occur: utilization of services and desirable health outcomes. This
suggests that providers must identify and maximize access to those
health care services that can be shown to influence health status.

Managing access to care represents perhaps the most complex, demanding,
and frustrating of all processes which the IHS continually faces.
Programs are forced to ration or limit access to care because the
programs are funded well below the level of need. A similar situation
exists for other health care programs across the nation, but for most
Indian health programs the limitations on access are especially
significant, and patients either are turned away or limited to certain
services on a daily basis. In the current political environment,
increased Federal resources to address this problem are not likely. This
is the reality that Indian health programs must face.

In the attempt to provide the most good for the most people, decisions
about access to care should be addressed at the program level, with
input from Tribal or health board members, patients, and other community
members. The access policies should be made public information and
posted in clinics. Programs should strive to provide access to services
that are adequate, acceptable, efficient, and effective, which can be
defined as follows:

Adequate Access to Services:

*For the Individual:* Providing services that patients need and want,
without excessive barriers.

*For the Community:* Providing coverage of the most important health
problems in the population.

Acceptable Services:

*For the Individual:* Providing services that meet the patient's needs
in terms of the interpersonal relationship between the practitioner and
the patient.

*For the Community:* Addressing problems that the community feels are
the most important.

Efficient Services:

*For the Individual:* Providing services in a manner that treats the
patient's time as though it were of value and not wasted.

*For the Community:* Providing a large volume of services and health
benefits for the population, relative to the resources expended.

Effective Services:

*For the Individual:* Getting desirable results (health benefits) for
each patient from the services that the patient receives.

*For the Community:* Reducing a large proportion of the health problem
or problems that a program was designed to reduce.

The effectiveness of prevention programs can be celebrated more easily
at the community level than the individual level. Individuals are not
likely to take note of a condition that they never had, but the
realization that a large proportion of people in a community were saved
from a disease or condition can be motivating and empowering to the
community.

Additional information on access issues is available in the "Access to
Care" subsection of this section of the guide.

Patient/Practitioner Relationship

Patients are astute in determining the quality of their interpersonal
relationships with health care providers. The very best technical and
scientifically-based health care can be perceived by the patient as
worthless or inappropriate if they perceive the provider as rude,
insensitive, uncaring, patronizing, or arrogant. Even though the
technical quality of the treatment rendered to people is important, the
quality of the patient/provider relationship, as perceived by the
patient, can sometimes have greater effects on the patient's long-term
health status.

Because health care personnel often are from different cultures than
their patients, they may not be aware of or may not understand local
cultural norms. Following are three strategies that can help to improve
the patient/provider relationship:

1\. Recruit and train local American Indians and Alaska Natives in the
health professions so more providers are from the culture they serve.

2\. Provide a cultural orientation for health care providers who are not
familiar with the local community or traditional healing practices.

3\. Adopt the integrated perspective advocated by the IHS, wherein a
negotiated approach to serving patients is combined with specific
provider behaviors.

The guidelines which follow represent critical elements for establishing
a desirable one-on-one relationship with patients. Ideally, this
relationship will result in an atmosphere of trust, where the patient
will share openly with the practitioner about any requests, concerns, or
interests.

Patient Care Checklist:

1\. Greet and Acknowledge the Patient by Name

Begin with a respectful greeting using the patient's name, and include
"hello," "good morning," or similar expressions in the native language,
if appropriate. Local norms should determine if the first name is used
or Mr., Mrs., or some other culturally-appropriate expression.

2\. Introduce Yourself

Providers should introduce themselves at the first meeting and when it
has been a long time since they have seen each other. Provider name
badges help patients remember names, but they should not replace
introductions.

3\. Provide Support and Reassurance

Recognize the patient's nonverbal cues to pain or fear and respond to
those cues through attentiveness, nonverbal expression, and reassurance.
Culturally-acceptable norms should be followed regarding touch, eye
contact, etc.

4\. Facilitate a Dialogue

This sets the stage for developing a "negotiated relationship" between
the provider and consumer. Issues that relate to patient choices of care
or willingness to comply with recommendations should be negotiated with
the patient. Ask carefully-considered non-judgmental questions and
listen attentively to determine the patient's needs and expectations.
Specific kinds of questions to consider include the following:

• Why is the patient presenting for treatment, i.e., what is the
patient's request or problem?

• What does the patient think is wrong or needed? Does the patient have
alternative or traditional beliefs about his/her needs? Is the patient
seeking assistance from available traditional healing methods?

• What does the patient expect from treatment? What level of
responsibility is the patient assuming for his/her condition and/or
follow-up care?

5\. Respond and Teach

Based on what has been learned through the dialogue and clinical
assessment, clarify the options for treatment, being careful not to talk
down to the patient or to use jargon and unfamiliar concepts. The intent
is to respectfully respond to the patient's perspective and:

• Acknowledge and clarify the similarities and differences in his
perspective and what is clinically evident. Inform the patient as to
what you are able to provide for him or her, considering alternatives of
traditional medicine, if available and desired.

• Actively teach the patient with the intent of informing and empowering
the patient to assume appropriate responsibility for his/her health (or
his/her child's health).

• Negotiate with the patient and/or family to involve them in decisions
that are appropriate and important in the care delivered and follow-up
required.

• Tailor treatment and follow-up, as much as possible, to the
individual's or family's existing routines, and provide all important
instructions in writing.

6\. Express a Warm Goodbye

Answer any final questions and close with a gesture of goodbye.

Patient Satisfaction Assessment

Health care facilities should conduct regular patient satisfaction
surveys in order to determine that the needs of the community are being
met. A regularly-collected, reliable, and valid consumer satisfaction
assessment mechanism is not simply a matter of good public relations,
but is an essential element of good public health practice. Without a
satisfaction assessment mechanism, very few dissatisfied customers
actually complain. This unspoken discontent can be the source of
additional problems in the health care facility. Frequent patient
satisfaction surveys help the program to identify problems and make
necessary improvements quickly, in order to minimize discontent and
increase satisfaction among patients.

Access to Care

General Considerations

The 1993 Institute of Medicine's (IOM) publication *Access to Health
Care in America* defines access as "the timely use of personal health
services to achieve the best possible health outcomes." Implicit with
this definition are acceptance of the importance and interrelationship
of the use of health services and desirable health outcomes. This view
of access applied to dental care is particularly valid because, unlike
many illnesses addressed in the medical clinic, the vast majority of
disease treated by a dental program is not self-limiting. Dentistry
treats primarily dental caries, periodontal disease, oral trauma, and
the prevention of these conditions. In most cases, unmanaged dental
conditions get worse, requiring a greater expenditure of resources,
time, and effort when treatment is provided. The IOM report suggests
that, by accepting this definition, we are compelled to identify and
maximize access to those health care services that can be shown to
influence health status, and then determine if the differences in health
status across populations can be explained in terms of problems or
barriers to access.

When viewed from this perspective, managing access to care represents
perhaps the most complex, demanding, and frustrating of all processes
with which IHS, Tribal, and Urban Indian (I/T/U) programs are
continually faced. But as several American Indian/Alaska Native (AI/AN)
patient/consumer surveys have shown, it is probably the most important
process. As providers and policy makers, we try to find less offensive
ways to describe this process, such as "managed care," but the reality
is that we are continually forced to ration or limit access to care
because we are funded well below the level of need. This situation is
not unique to Indian health settings. A great majority of health care
programs ration care, in that they do not provide their patients every
service they want, anytime they want it. But the reality of most I/T/U
programs is that limitations on access are significant; every day
patients are either turned away or limited to certain services. Based on
the current political environment, increased Federal resources to
address this problem are not likely. This is the painful reality facing
I/T/Us in the foreseeable future.

Managing access is much like managing chronic diseases; the problems are
never really solved. It lies at the foundation of the recognized public
health goal of "*doing the most good, for the most people, at the lowest
possible cost, and in a manner that is acceptable to those served and
those serving*." Such a demanding task should keep us from ever being
completely satisfied with how we are managing access and inspire us to
continually look for more effective strategies.

Unfortunately, access policies are sometimes the sole creation of a
clinic or program staff. Policies made in such a vacuum are not likely
to be understood by consumers, compromise self-determination and
community empowerment, and ultimately compromise program goals. Health
care resources represent community resources, thus communities must have
a major stake in determining how they are used. This is even more
critical when the resources are few and community health problems are
many. Potentially useful collaborators in developing access policies
should include Tribal and/or health board members, patients/customers,
and other community members. To support informed decision making, these
people should be provided training about public health principles, local
disease patterns, and the opportunity costs versus the benefits of
enhancing access to a particular group or condition over others. The
access policies made with such understanding should then be made public
information and posted in clinics.

Practical Considerations of Managing Access to Dental Care

Unlike other health problems, regular utilization of dental services is
strongly associated with better dental health status. Thus, the IOM's
"timely use of personal health services\..." relative to dental care, is
regular periodic care for all beneficiaries. Therefore a dental
program's ultimate goal is to provide access to basic care for all
beneficiaries. In practical terms this means maintaining access for
routine users, while encouraging "emergency or episodic" users to become
routine users. As access to dental care improves, a greater percentage
of the population can reach a maintenance level of care. Users on a
maintenance level have lower treatment needs than episodic users. New
disease in those on a maintenance level is generally easier and less
time-consuming to treat. Ultimately, as more beneficiaries become
routine users and reach maintenance level, the yearly need for services
(i.e., workload) for a given population is reduced. As preventive
technologies continue to improve, this effect is likely to be even more
pronounced.

Extending access to dental care in a program that is under-funded is
indeed a challenge, but it is possible in most situations through
effective program management. Clear adherence to public health
principles is required, along with the most efficient use of available
resources. Strategies to increase access can be broken down into the
following areas:

• Integration of Dental Program with Other Health Care Disciplines and
Resources

It is not necessary for dental staff to do everything. Health educators,
community health representatives, water system operators, public health
nurses, medical clinical staff, system administrators, volunteers, and
other agencies (state, Federal, local, institutional, educational)
should be sought out and utilized. Integration of oral health messages
with other programs is achieved, and additional dental staff time
becomes available to do those things that only trained dental staff can
do. This increases access to clinical care without compromising access
to community care.

• Efficient and Effective Use of Program Resources

An ongoing process of program evaluation should be in place to maximize
opportunities for improving access to care. This would include
scheduling of staff and patients, evaluation of adequacy of existing
staff and facility, development of accurate projections of program
needs, impact of episodic users, and use patterns of existing facility
and staff. Detailed information on these and other aspects of efficiency
and effectiveness can be found in the *Dental Clinic Efficiency and
Effectiveness Manual,* which was developed by the IHS Dental Program in
1995 and is available from your Area Dental Consultant.

• Development of Conservative Strategies of Treatment

The majority of a dental clinic's time is generally devoted to
restorative dentistry. Half the restorative dentistry provided in this
country is the replacement of existing restorations. The initial
placement of a restoration statistically dooms the tooth to a future of
repeated replacements with ever larger and more invasive restorations.
Restorative dentistry is a destructive process, in that irreplaceable
natural structure is lost to restorative materials that are poor
substitutes for the natural tooth structure. When considering doing
restorative dentistry, the risk of not doing it (the status of the
existing disease and the destruction it is causing) clearly must be
greater than the risk of placing restorations. For more information on
this subject, see the "Dental Caries Risk Assessment" guidelines, which
can be found in the Oral Health Promotion/Disease Prevention section
(Section IV) of this guide.

A more conservative and cautious approach to clinical treatment will
lead to fewer treatment needs (as identified by the dentist), thus
freeing up additional clinic and staff time. The availability of bonding
agents, glass ionomers, sealants, and a wide variety of other preventive
and restorative materials allows a dentist to more confidently take a
less aggressive view of treatment.

An appropriate level of recall for the individual patient also should be
sought, to prevent the overuse of unneeded evaluation and treatment by
some patients at the expense of under-utilization of these services by
others. All patients *do not* need to see their dentist every six
months. Patients should be recalled based on their individual oral
health care needs. Many patients are at a sufficient level of oral
health to be placed on a recall interval of one year or longer.

In summary, maximizing access to preventive and corrective dental
services remains the essence of a dental program. How access is managed
sends important messages to a community, which is another reason for
involving the community in the process. The outline which follows is
offered as a means to present some of the many factors that are
important to consider and to have ongoing dialogue with stakeholders in
designing access policies. As suggested in this discussion, resolving
all the issues listed in this outline (and others you may identify) is
clearly a "mission impossible," given the current level of dental
resources. Nevertheless, these factors should be periodically examined
in light of the unique characteristics of each community, with the goal
of maximizing access and achieving the highest possible levels of oral
health.

**Considerations for Managing Access to Health Care in Indian Health
Settings**

+-----------------------------------------------------------------------+
| **I. Equitability Considerations**                                    |
+-----------------------------------------------------------------------+
| > • Are there significant access barriers for those who work? (e.g.,  |
| > for what hours are appointments available?)                         |
+-----------------------------------------------------------------------+
| > • Are there significant access barriers for those without           |
| > telephones? (e.g., must appointments be made by phone?)             |
+-----------------------------------------------------------------------+
| > • Are there significant access barriers for those who live farther  |
| > away? (e.g., must appointments be made in person before 8:00 a.m.?) |
+-----------------------------------------------------------------------+
| > • Are there significant access barriers to families receiving care? |
| > (e.g., are appointments unavailable for more than one family        |
| > member?)                                                            |
+-----------------------------------------------------------------------+
| > • Are there significant access barriers to the elderly and          |
| > institutionalized? If so, are there potential mechanisms available  |
| > to address access barriers to these groups?                         |
+-----------------------------------------------------------------------+
| **II. Behavioral Considerations**                                     |
+-----------------------------------------------------------------------+
| • Are undesirable health behaviors being rewarded or ignored by the   |
| access policies? (e.g., no consequences for broken appointments or    |
| providing prosthetics to people with poor periodontal control)        |
+-----------------------------------------------------------------------+
| • Are desirable health behaviors being punished by the access         |
| policies? (e.g., it is much harder to obtain routine or preventive    |
| care than emergency care)                                             |
+-----------------------------------------------------------------------+
| **III. Other Considerations**                                         |
+-----------------------------------------------------------------------+
| • Individual patient factors, age, overall health status, probability |
| of compliance, the provider's ability to improve the patient's        |
| condition, role model considerations                                  |
+-----------------------------------------------------------------------+
| • Political pressures:                                                |
+-----------------------------------------------------------------------+
| -- Pressure to generate income from insurance                         |
+-----------------------------------------------------------------------+
| -- Pressure to treat political leaders, health workers, and their     |
| families                                                              |
+-----------------------------------------------------------------------+
| -- Pressure from Area Office to follow public health principles       |
+-----------------------------------------------------------------------+
| -- Pressure from the community to provide expensive specialty         |
| services                                                              |
+-----------------------------------------------------------------------+
| • Health staff morale (e.g., "burning out" staff with lack of         |
| variety, lack of challenge, or overwork)                              |
+-----------------------------------------------------------------------+
| • Maintaining professional competence (e.g., improving skills by      |
| providing more sophisticated procedures or services)                  |
+-----------------------------------------------------------------------+
| • Using community health status data to identify target groups for    |
| care                                                                  |
+-----------------------------------------------------------------------+
| • Monitoring satisfaction with access policies to determine need for  |
| changes                                                               |
+-----------------------------------------------------------------------+

IHS Schedule of Dental Services

The Schedule of Dental Services was developed by the Indian Health
Service (IHS) to assist community dental programs in managing their
resources effectively to provide access to care in a "demand care"
setting. The schedule categorizes *all* types of dental services into
*Levels of Care,* a priority-based listing which is outlined below and
described on the following pages.

Services which alleviate pain or prevent disease are given a higher
priority than those intended to contain or correct damage caused by
disease. Thus, emergency care has the highest priority (Level I), while
providing access to complex rehabilitative care (Level VI) is given the
lowest priority for expending the available resources.

**Level I Emergency Care**

**Level II Primary (Preventive) Care**

**Level III Secondary Care**

**Level IV Limited Rehabilitation**

**Level V Rehabilitation**

**Level VI Complex Rehabilitation**

**Level X Exclusions\
**

The majority of treatment needs in American Indian/Alaska Native
communities falls within the first three levels, sometimes called "basic
care," which comprise the most cost-effective services to provide on a
community-wide basis. As additional funds become available for dental
care, the schedule can be used to expand access to care beyond basic
services in an orderly, equitable, and cost-effective manner.

The schedule forms a consistent structure for program planning as well
as for the treatment planning of individual patients. However, it is
intended to be a flexible tool which can be adapted to the situation of
each community and of dental patients. Factors such as the availability
of alternate resources, community water fluoridation, patient age, and
the prognosis for success, as well as other conditions, each play a role
in determining how the schedule should be applied to individuals and
target groups. *The general principle for implementing the schedule is
always to use the available resources for providing the greatest health
benefit to the greatest number of people for the longest time possible.*

Over the past decade, the Schedule of Dental Services has proven its
value to IHS, Tribal, and Urban Indian programs in many ways. The
following list summarizes some of the common uses:

• Provides consistent structure for program/provider performance
evaluations (in-house and JCAHO).

• Provides a way to document dental program activity and adequacy of
funding during Tribal self-determination contracts and self-governance
compact negotiations.

• Provides a framework for contracting a scope of work and standards of
care with private care providers. These contracts may be administered by
local authorities or indirectly through outside agencies (Delta Dental,
Blue Cross/Blue Shield, etc.).

• Provides a basis for planning dental facility expansion and manpower
enhancements to improve access to care, using anticipated care
utilization rates and population growth estimates.

• Provides a way to demonstrate and compare the dental needs and
relative level of access to care among American Indian/Alaska Native
communities of all sizes and backgrounds (for annual budget preparations
to the U.S. Congress and other potential funding sources).

Description of the IHS Schedule of Dental Services Levels of Care
Structure

Level I --- Emergency Care

Includes those dental services which are necessary to relieve or control
acute oral conditions, such as: serious bleeding, a potentially
life-threatening difficulty, maxillo-facial fractures, and swelling and
severe pain, or other signs of infection. Other conditions which the
patient may determine to require urgent attention are also classified as
Level I care (e.g., prosthodontic repairs).

Procedures which are frequently reported in this category of care are
listed below:

• Emergency oral examination (limited to problem area)

• One or more periapical radiographs associated with the problem

• Simple tooth extractions

• Temporary or sedative restorations

• Palliative procedures

• Prescription medications for pain and infection

• Endodontic access preparations

• Draining of oral abscesses

• Denture repairs and other urgent repairs

Level II --- Primary (Preventive) Dental Care

The procedures classified as primary care are those which prevent the
onset of oral disease. Clinical services to individual patients and
community health activities are included in Level II care.

The primary care services most frequently provided are:

• Adult prophylaxis with or w/o topical fluoride

• Child prophylaxis with or w/o topical fluoride

• Sealants by tooth or quadrant

• Preventive (self-care) training

• Periodontal recall procedures

• Athletic mouthguards

• Water fluoridation activities

• Group education

• Tracking of number of children receiving supplemental fluorides per
month

Level III --- Secondary Dental Care

Level III services are those deemed necessary for routine diagnosis and
treatment to control the early stages of disease. Level III procedures
are generally not complicated in nature, and one or more of these
services can usually be completed in one appointment.

The Level III procedures commonly reported include the following:

• Initial or periodic oral exam

• Bitewing and panoramic radiographs

• Diagnostic casts

• Space maintainers

• Amalgam restorations (1,2,3-surface)

• Composite restorations (1,2,3-surface)

• Stainless steel crowns (primary teeth only)

• Therapeutic pulpotomy (primary teeth only)

• Anterior endodontics (one canal)

• Periodontal scaling/root planing

• Biopsy, excision of lesion

Level IV --- Limited Rehabilitation

Rehabilitative care is that which restores oral structures to an
improved condition and form. Limited rehabilitation is defined by the
IHS as those dental procedures which are more complex and costly to
provide than Level III care in controlling disease and restoring
function.

The following Level IV services are those most frequently utilized:

• Complex amalgams (4 or more surfaces)

• Cast onlays or crowns with or w/o porcelain

• Post and core restoration

• Crown buildups

• Acid etch (Maryland) bridge

• Bicuspid endodontics (two canals)

• Apicoectomy/retrograde filling

• Gingivoplasty

• Limited/interceptive orthodontics

Level V --- Rehabilitation

The dental services classified into this level are rehabilitative
procedures which require more clinical chairtime, additional knowledge
and skill of the care provider, and usually greater expense than the
limited rehabilitative services listed under Level IV care. Level V
services usually require multiple appointments to complete, are usually
associated with a rehabilitative plan for the entire mouth, and
generally require a substantial patient copayment to cover professional
fees in dental insurance and other third party programs.

The Level V services most frequently provided are:

• Molar endodontics (3 or more canals)

• Periodontal surgery (mucogingival and osseous)

• Complete and partial dentures

• Denture rebase (laboratory)

• Fixed bridgework (retainers and pontics)

• Surgical extractions (impactions)

• Analgesia (e.g., nitrous oxide)

Level VI --- Complex Rehabilitation

Level VI includes those services which usually require more time, skill,
and cost than the rehabilitative procedures classified under Levels IV
and V. A substantial portion of patients may require referral to
specialists for complex rehabilitative treatment; however, referrals
must be justified by special circumstances which warrant the associated
higher costs. Level VI services may not predictably improve the overall
prognosis of many patients. Thus, careful patient selection is a
critical factor in the provision of Level VI care.

Complex rehabilitation includes the following procedures:

• Cephalometric or TMJ radiographs

• Occlusal adjustment (complete)

• Periodontal surgery

-- osseous or soft tissue grafts

-- repositioned flaps

• Overdentures

• Consultation for speciality services

• Precision attachment prosthetics

• Comprehensive orthodontics (Class I, II, or III)

-- case analysis & work-up

-- fixed appliances (usually full-banding)

-- orthodontic care follow-up visits

-- post-treatment stabilization

• Surgical extractions (bony impactions) and unusual or complex oral
surgery

• Maxillo-facial prosthetics

• Intravenous (IV) sedation, general anesthesia

Level X --- Exclusions

Level X comprises those services which are not classified as billable
procedures in programs serving American Indians/Alaska Natives.

Excluded services have one or more of the following characteristics, as
determined by the Indian Health Service:

• A highly variable rate of success

• Difficult to monitor in terms of appropriateness or effectiveness

• Not universally defined or accepted for reporting purposes

• Included as part of other reportable services (thus they need not be
reported separately)

• Involve the use of materials or techniques which are obsolete or which
may not be the most cost-beneficial

• Codes used only for management purposes on an optional basis (e.g.
broken appointments, non-clinical administrative activity)

The following procedures are examples of exclusions which are frequently
reported:

• Caries susceptibility tests

• Oral hygiene instruction (included in prophylaxis)

• Removable unilateral space maintainers

• Silicate restorations

• Gold foil restorations

• Cast inlay (2-surface)

• Porcelain inlays or crowns

• Full resin or resin/metal crowns

• Direct pulp caps

• Endodontic implants, hemisection

• Gingival curettage

• Coronal splinting

• Unilateral cast partials

• Chairside denture relines

• Alveolar/mandibular implants

• Prosthetic stress breakers

• Tooth implant/transplant

• Myo-functional therapy

• Pulpotomy in permanent tooth

• Odontoplasty

• Behavior management

• Broken appointments

Limitations

Provisions have been added to the IHS Schedule of Dental Services to
limit the frequency of utilization of certain procedures by individual
patients. The limitations are similar to those accepted in contracts
managed by most third party payers and therefore should be acceptable to
most practicing dentists. The limitations are to be used in conjunction
with applicable modifiers for specific services to assure that care is
provided with optimal effectiveness.

The following table lists dental services which are subject to the
specific limitations given:

  ----------------------------------- -----------------------------------
  **Procedure**                       **Limitation**

  Initial oral exam                   Once per patient

  Periodic oral exam                  Once per 6-month period

  Full mouth radiographs              Once during 3-year period

  Supplemental bitewings              Once per 6-month period

  Prophylaxis                         Once per 6 months, includes
                                      education

  Topical fluoride                    Selected patients with high caries
                                      activity

  Sealants                            On children receiving benefits of
                                      fluoride

                                      On molars only, in contract
                                      programs

  Crowns                              Only when a less complex
                                      restoration is not possible
                                      (supported by x-rays)

  Class II posterior composites       By report only

  Periodontics                        Limitations on type and frequency
                                      of services vary with disease
                                      severity

  Prosthodontics                      No replacement within 5 years

                                      Chrome/acrylic material of choice
  ----------------------------------- -----------------------------------

Treatment Modifiers

To further enhance the appropriateness and effectiveness of oral health
care for Native Americans, the Schedule of Dental Services contains
modifiers which practitioners must consider before planning treatment.
These modifiers are based upon differences between the needs and
circumstances of individual patients. Factors such as the patient's age,
their health behavior or motivation, existing medical conditions, as
well as other factors, may dictate the priority and extent of dental
care which can be provided.

Following is a list of modifiers which may affect the provision of
higher levels of care:

• Age of patient

• Arch integrity

-- strategic importance of teeth involved in treatment

• Patient's health behavior or motivation

-- compliance

-- willingness to receive treatment

-- dependability (history of keeping or breaking appointments)

• Oral hygiene and periodontal status

-- activity of destructive disease

• Caries activity

-- recurrent caries

-- smooth-surface lesions

-- root-surface lesions

-- pit and fissure lesions

• Medical conditions

-- diabetes

-- other systemic conditions which may affect the patient's ability to
receive or respond to dental therapy

• Access to care

-- distance from clinic

-- availability of skilled provider

-- backlog of demand for lower levels of care

Consultation and Referral

Consultation with IHS Dental Specialists

The *IHS Dental Program Resource Directory,* also known as the "dental
roster," contains a list of the IHS dental specialists. All of the
dental specialties recognized by the American Dental Association are
included, except for oral pathology. General practitioners who desire
consultation on a specialty case are encouraged to contact one of the
specialists on the list.

If the IHS Area in which the general practitioner works has a consultant
for the specialty in question, usually that specialty consultant will be
the contact of choice. If the Area specialty consultant is unavailable,
or if the Area has no consultant for that specialty, then the general
practitioner should contact one of the others on the list.

Ideally, a request for specialty consultation is made in writing, with
accompanying radiographs and study casts, as needed. It is a good idea
to call the specialist before mailing the request to determine what
specific items to include in the consultation request. **Form
HRSA-199-1, "Patient Referral Notice," is commonly used for the written
request.**

If a general practitioner has an urgent question, such as during the
treatment of a patient, he or she should not hesitate to contact the
consultant by phone. An example is a surgical procedure that has proven
to be more difficult than anticipated. In some cases the specialist can
provide sufficient guidance over the phone to help the general
practitioner to complete the procedure.

In some cases, depending on the patient's proximity to the IHS
specialist and the work load of the specialist, it may be possible to
refer a patient to the specialist for treatment that is beyond the
training and experience of the general practitioner.

Consultations/Referrals between Dental Clinic and Medical Clinic

Form HRSA-199-1 also can be used for consultations and referrals between
the dentist and the medical clinic. A typical example of a medical
consultation is requesting a physician to determine whether a patient's
history of heart murmur will require the use of prophylactic antibiotics
for dental treatment. An example of a medical referral is sending a
young dental patient with severe periodontal disease to the medical
clinic to determine whether the patient is diabetic. Similar referrals
can be made from the medical clinic to the dental clinic, such as the
referral of a known diabetic patient to the dental clinic for
periodontal treatment.

Pathology Services

Biopsy specimens from the dental clinic can be sent to the same
laboratory service as specimens from the facility's medical clinic. Some
dentists prefer an oral pathology service for oral biopsies. If this is
the case, it may be possible to make arrangements with one of the
schools of dentistry to have biopsy specimens sent there.

IHS programs (and possibly Tribal and Urban programs) can also access
the oral pathology services available from the U.S. Navy laboratories at
Bethesda, Maryland and San Diego, California. Naval Oral Pathology
Services require an appropriately-completed standard form (SF 515) and a
special biopsy bottle, mailing container, and label, which are provided
by the Navy lab.

Requests for information on the availability of Naval Oral Pathology
Services for your program, as well as requests for bottles, containers,
and labels, should be made by calling (301) 295-0404. This phone number
applies to both the Bethesda and San Diego labs.

Dental Facility Considerations

The construction of a new dental clinic requires careful planning to
ensure that the resulting facility is functional and a pleasant place in
which to work. Without proper planning, a myriad of major and minor
problems can occur during the construction phase.

Dental clinics built by the IHS undergo an extensive planning process
using standardized designs to provide uniformity. Dental clinics built
by Tribal and Urban Indian programs, on the other hand, display a wide
variety of designs, because these programs have more flexibility when
choosing clinic designs. Not being bound by standard designs provides
some obvious advantages, but in some cases architects hired by Tribes or
Urban programs have little or no experience in designing dental clinics.
Whether new clinics are being constructed by the IHS, Tribes, or Urban
Indian programs, the planning phase should include input from sources
that are well-versed in the building of dental facilities.

The purpose of this subsection is to provide some general
recommendations regarding dental clinic design and dental equipment
selection which should be helpful to programs that are planning new
dental clinics.

General Recommendations

• Whether the clinic is being built by the IHS, by a Tribe, or by an
Urban Indian program, it is a good idea to consult the dental section of
the *IHS Health Facilities Planning Manual,* which is scheduled for
completion in 1997. This manual will be available from the IHS Dental
Branch in Rockville, Maryland at (301) 443-1106.

Following are some of the types of information provided by the
facilities planning manual:

-- Dental clinic designs for facilities of various sizes

-- Equipment lists, by room, for real property (furnished when a
building is built and usually consisting of large items which are bolted
to the wall or floor) and for major unattached equipment such as dental
chairs, autoclaves, film processors, and handpieces. Disposable items
and hand instruments are not included in these master lists.

-- Air exchange recommendations

-- Ambient light recommendations

-- Safety codes

• Visit other IHS, Tribal, and Urban dental clinics. Don't rule out any
possibilities, including military installations and veterans hospitals,
if they are available nearby.

• Contact people in other IHS, Tribal, or Urban Indian dental clinics
who have experience in building new facilities, especially those who
have recently planned construction of a new clinic.

• Talk with Area Office staff, including the Area Dental Consultant and
the Area Facilities Planning Officer.

• Meet with representatives from dental supply houses. They can provide
useful information about clinic design, even though their primary job is
to sell equipment.

• Use the toll-free number of equipment manufacturers to get advice
regarding facility requirements for the equipment that you intend to
place in the new clinic.

• Obtain and use government price lists for equipment. Having the
catalogs on hand will facilitate the ordering of equipment by allowing
for comparison of prices and features.

• Get actively involved in the project. Most construction projects have
a better result if the dentists and other dental staff at the facility
have direct input at the design stage. If an architect or company
representative has made an obvious error, such as forgetting to include
a sink in the lab, dental staff members should be able to detect the
error.

• Use manufacturer's templates and size guidelines. If a certain amount
of floor space is required, avoid the temptation to get by with less.
Follow the manufacturer's instructions!

• Make every operatory identical, with the exception of doors for quiet
rooms. This will help to eliminate the problem of providers using
"favorite rooms" the majority of the time, which can have a negative
effect on dental clinic efficiency.

• If possible, have windows in the operatories to facilitate the
selection of tooth shades and to provide a pleasant atmosphere for
patients and staff. North-facing windows are best, and east-facing are
second-best.

• Plan for proper air exchange in each operatory. It should be driven
with its own special system. Consult the IHS *Facilities Planning
Manual* for details.

• Provide adequate overhead light in the operatories to prevent
eyestrain.

• Provide vacuum and air systems with their own exhaust/intake lines.
The trap for the vacuum system should be easily accessible for cleaning.
The discharge point for the exhaust should not be near a fresh air inlet
or open windows, and it should not discharge into a supply room or other
occupied place.

• Provide each operatory with two sinks.

• Provide each operatory with its own x-ray machine.

• Provide plenty of electrical power for each operatory for future
expansion. Also provide each operatory with telephone and data jacks.

• Provide a staff changing area, with lockers, within the dental clinic
area. This will facilitate the separation of clothing used to treat
patients from clothing that is worn outside of the clinic, which is
important for infection control.

Square Footage Recommendations

The *IHS Health Facilities Planning Manual* will contain detailed charts
of size recommendations for various types of space in the dental clinic.
Following are recommendations for some of the most common clinic
configurations:

*Note:* It is anticipated that the areas in the planning manual will be
expressed in square meters, in order to meet government requirements. In
this guide the areas will be expressed in square feet.

**Conversion Factor= 10.76 ft2 per m2**

Fixed Operatories = 110 square feet (sq. ft.) per operatory (usually
10\' X 11\')

Panoramic x-ray= 30 sq. ft.

Clean-up Alcove (2 to 3 operatory clinic) = 90 sq. ft.

Clean-up Alcove (4 to 8 operatory clinic) = 100 sq. ft.

Clean-up Alcove (9 to 12 operatory clinic) = 150 sq. ft.

Laboratory (2 to 3 operatory clinic) = 40 sq. ft.

Laboratory (4 to 8 operatory clinic) = 80 sq. ft.

Laboratory (9 to 12 operatory clinic) = 120 sq. ft.

Darkroom (2 to 8 operatory clinic)= 60 sq. ft. (one automatic\
developer)

Darkroom (9 to 16 operatory clinic)= 90 sq. ft. (two automatic
developers)

Unit Supply Area (2 to 3 operatory clinic) = 40 sq. ft.

Unit Supply Area (4 to 8 operatory clinic) = 80 sq. ft.

Unit Supply Area (9 to 12 operatory clinic) = 120 sq. ft.

Reception Area (2 to 4 operatory clinic) = 100 sq. ft.

Reception Area (5 to 8 operatory clinic) = 120 sq. ft.

Reception Area (9 to 16 operatory clinic) = 240 sq. ft. (two reception
areas)

Dental Supervisor's Office= 120 sq. ft.

Dental Manager's Office or DA Supervisor's Office= 100 sq. ft.

Non-supervisory Dentist's Office= 80 sq. ft.\
(add 40 sq. ft. for each additional dentist)

Toilet (8 to 12 operatory clinic)= 50 sq. ft.

Waiting Area (8 to 13 operatory clinic)= 240 sq. ft.

Janitor's Closet= 40 sq. ft.

Cephalometric X-ray (for clinics with full-time orthodontic services)=
100 sq. ft.

*Note:* Space is also needed for staff lockers, staff toilets, and
employee lounge, but is not listed here.

Delivery Systems

The dental delivery system traditionally used by the IHS is the
rear-delivery system. While it has proven to be an economical,
functional system, the rear-delivery method does have some shortcomings.
As a result, many Tribal and Urban programs and some IHS programs
recently have chosen alternative delivery systems. Following is a
comparison of the commonly-used delivery systems, showing the advantages
and disadvantages of each:

Over-the-Patient Delivery

***Advantages:***

• The most ergonomically-sound system for the dentist

• Easily converts to left-handed or right-handed

• System moves up or down with the chair to maintain a constant
relationship

• Provides the most practical use of space

• Allows dentist and assistant to handle instruments and switches

• Allows the dentist to let go of the handpiece without looking up

***Disadvantages:***

• The most visible system to patients

• Is confining for patients, and patients may bump into unit if they
rise up suddenly

• Expensive

Rear Delivery

***Advantages:***

• The least expensive system and easily combinable with an assistant
cart for little additional expense

• Easily converts to left-handed or right-handed

• The least-visible system for patients

• Easy patient access to dental chair

• Allows handpieces to be transferred and burs to be changed by the
assistant

• Easy to connect to in-wall utilities

***Disadvantages:***

• Ergonomically less sound for the dentist, who must twist to reach
handpieces or instruments

• Places the dentist at increased risk for sharps injuries from dental
burs, due to the location of the handpiece holder near the dentist's
forearms

• Cords can become tangled and difficult to position for dentist use

• Requires two entries to operatory --- one for the dentist, and one for
the assistant

• Makes working alone or standing up difficult for the dentist

Side Delivery

***Advantages:***

• Provides easy patient access to chair

• Less confining to patients

• Easy to connect to in-wall utilities

***Disadvantages:***

• Most do not convert to left-handed and right-handed

• Handpieces inaccessible to assistant, so dentist must change burs

• Ergonomically less sound for the dentist, who must twist to reach for
handpieces or instruments

Because of the lack of convertibility for right-handed and left-handed
dentists and the difficulties the system presents for performing
four-handed dentistry, the side delivery system is generally not
recommended for dental programs serving American Indians and Alaska
Natives.

Equipment Considerations

In addition to information provided in the *IHS Health Facilities
Planning Manual,* general and specific recommendations for the selection
of patient chairs, dental units, operators' chairs, assistants' chairs,
and other equipment items can be found in various dental periodicals. An
example of a useful article is the June 1994 issue of *The Dental
Advisor---The Quarterly for the Dental Profession* (Volume 11, Number
2).

The Dental Advisor

P.O. Box 1583

Ann Arbor, MI 48106

\(313\) 665-2020

The article provides a list of features that a buyer should seek when
purchasing dental equipment items and also offers recommendations,
including brand names. It breaks down the features into primary
features, which meet efficiency and infection control needs, and
optional features, which depend on the personal needs and preferences of
the operator. For details on the selection of equipment, one should read
the article, but following is a synopsis of the primary features:

Patient Chairs

• Stable base and lift mechanism (hydraulic type lift mechanism is
quieter than screw drive type)

• Seamless and removable upholstery for easy cleaning/repair (all-vinyl
is recommended, because it can withstand disinfection procedures)

• Adjustable headrest for patient comfort and operator visibility

• Ergonomic contoured design

• Good lumbar support for patient comfort

• Movable armrests for easy patient access

• Auto preset positioning and auto return with safety stop

• Right/left convertibility

Dental Units

• At least one fiber optic high-speed outlet (two is ideal, to prevent
down time in the event of malfunction)

• One fiber optic low-speed outlet

• Smooth snap-on/off handpiece connectors for efficient operation and
sterilization of handpieces

• Handpiece flush system for infection control

• Non-ribbed tubing for easy cleaning/disinfection

• Anti-retraction valves for infection control

• Quick connect/disconnect, sterilizable high- and low-volume evacuators
and 3-way syringes for efficient operation and sterilization

• Self-contained water purification system for infection control

• Right/left convertibility

Operator and Assistant Stools

• Metal frame with 5-legged base for stability

• Double wheel castors (need tile castors, not carpet castors, for hard
floors)

• Gas cylinder for height adjustment

• Easily reached height adjustment lever or paddle

• Seat pan tilt adjustment

• Multi-density padding for comfort

• Seamless upholstery for easy cleaning

Another source of information for large equipment items such as dental
units and chairs, as well as for small equipment items such as
ultrasonic scalers, visible light curing units, and handpieces, is the
*CRA Newsletter.* Clinical Research Associates also publishes a list of
all major manufacturers and suppliers in the U.S., which is very useful
when building a new clinic. These items can be purchased by contacting:

Clinical Research Associates

3707 North Canyon Road, Suite 6

Provo, UT 84604

\(801\) 226-2121

Sample Dental Clinic Equipment List

Following is a sample of an equipment list that was used by one Tribal
program which was building a new dental clinic. It is not necessarily an
all-inclusive list, but it may be helpful to other programs
contemplating new construction or remodeling.

Operatory

Dental Chair

Handpiece Control Unit (either chair- or cart-mounted)

Assistant Cart

Dental Light (wall-, chair-, or ceiling-mounted)

Two Handwashing Sinks/Paper Towel, Cup, and Soap Dispensers per
Operatory

Faucets (either pedal or electric)

Intraoral X-Ray Unit

X-Ray Viewer

Lead Apron/Hanger

Dentist and Assistant Stools

Glove/Mask Dispensers

Amalgamator

Fiberoptic Curing Light

Coat Hook

Wastebaskets

Sharps Container

Clock/Intercom/Timer

Computer Terminal

Soiled Clean-up Area

Ultrasonic Cleaner (small)

Ultrasonic Cleaner for Multiple Cassettes (or washing station)

Deep Double Sink/Paper Towel and Soap Dispensers

Wastebasket

Dishwasher

Handpiece Lubricating Station

Autoclave Tape Dispenser

Compressed Air Outlet

Eyewash Station

Clean Room

Large Autoclave (for multiple cassettes --- 15)

Small, Fast-Turnover Autoclaves

Handpiece Autoclave (e.g., Kavoklave)

Water Distiller

Dry Heat Sterilizer

Shelving To Hold All Clean Items (cassettes, etc.)

Refrigerator

Label Gun (for expiration dates)

Biological Incubator

Laboratory

Articulators

Heat Sealer

Whip-Mix

Surveyor

Plaster Trap

Water Bath

Plaster Bin

Bunsen Burner

Lab Handpiece

Omnivac

Ventilation System

Model Trimmer

Wastebasket

Gas Jet/Compressed Air

Lathe

Microetcher

Vibrator

Darkroom

Automatic Processor

Developer and Fixer Recovery Unit

Deep Sink (to clean rollers)

Wastebasket

Viewbox

Water Temperature Regulator

Safe Light

Panoramic Area

Panoramic Unit (pan/ceph)

Lead Apron/Hanger

Mechanical Room

Dental Suction Unit (e.g., Ramvac)

Air Compressor

Office, Chief/Dentist

Chair/Desk

Bookshelves

Computer System

Storage

Shelving Units

Supply Desk/Chair/Filing Cabinets

Papoose Board

Washer/Dryer

Education

Sinks for Toothbrushing

TV/VCR

Models/Posters/Pamphlets/Educational Aids

Reception/Appointing

Magazine Rack

Chairs/End Tables/Lamps

Computer Terminals

Printer

Photocopier

Intercom System

Typewriter

Filing Systems

Other Items

Instrument Cassette System

Hand Instruments

Rubber Dam Setups

Slow-Speed Fiberoptic Handpieces

High-Speed Fiberoptic Handpieces

Surgical Handpieces

Ultrasonic Scaler

Blood Pressure Recording Device

Nitrous Oxide Delivery System

Surgical Instruments

Prosthodontic Supplies (trays, etc.)

Curing Radiometer (Curing Light Tester)

Pulp Tester

Electronic Thermometer

Clothing Hamper

Tubs/Trays/Racks

Electrosurgery Unit

Ultrasonic Endodontic Unit

Employee Lockers

XCP X-Ray Holders

Educational Videos

Emergency Procedures in the Dental Office

Dental officers in the Indian Health Service should be aware that urgent
or emergent medical and dental situations may arise in their clinics. It
is their responsibility to ensure that they themselves and their dental
staffs are well-prepared to cope efficiently, quickly, and appropriately
on such occasions. Preparation and training must take place well in
advance so that when action is needed in potentially life-threatening
situations appropriate action will be taken.

Equipment for providing supplemental oxygen to hypoxic patients should
be available in all IHS, Tribal, and Urban Indian dental clinics. This
equipment should provide capabilities for forced respiration through the
use of a rubber reservoir bag and a face mask that can produce an
air-tight seal around the patient's nose and mouth. An ambu-bag is ideal
for such purposes. Portable oxygen machines or nitrous oxide/oxygen
machines can also be easily adapted to provide such capabilities.

All dental staff should be trained in cardiopulmonary resuscitation and
maintain current certification. Courses may be obtained through local
American Red Cross units to assist in meeting certification
requirements.

Emergency Care Equipment and Drugs Recommended for IHS/Tribal/Urban
Indian Dental Clinics

Each dental clinic should have a plainly marked and readily available
emergency drug kit containing the following basic diagnostic and
treatment equipment and drugs for emergency use, as recommended by the
IHS Oral Surgery Consultant:

Basic Equipment and Drugs:

• Ambu-bag (or oxygen machine with mask and bag attached for assisting
in ventilation procedures for the patients)

• Sphygmomanometer (blood pressure cuff)

• Stethoscope

• Molt or McKesson mouth props (or taped stack of 8 to 10 wooden tongue
depressors for use as a mouth prop)

• 13-gauge sterile needles (2) (to use in providing emergency airway at
cricothyroid space)

• Adult-sized and child-sized oropharyngeal airways (1 each)

• 1/2\" or 3/4\" wide tape (adhesive, autoclave, paper, or "Scotch")

• Tubex syringes (2) or Luer lock syringes with 22-gauge needles

• Alcohol sponges (in foil wrappers to keep them moist)

• Band-aids (6)

• Sterile 2\" x 2\" gauze packets (12)

• Sterile 5cc. disposable syringes (3)

• Epinephrine or IV fluids (aqueous) 1:1000 in 1 ml. Tubex syringe
cartridges with sterile protected needle attached (6) or 1:1000 in 1 ml.
ampules

• Benadryl (25 or 50 mg.) ampule (3)

• Nitroglycerine tablets (1/150 grain) for angina pectoris

• Alupent inhaler for treatment of acute asthma (asthma patients should
have their own inhalers in their possession when receiving dental
treatment)

• Ammonia inhalant (4)

• Atropine (1 mg. ampule) for bradycardia

• Glucagon (1 mg. IM) for hypoglycemia

The rationale behind the preceding list of critical items is that the
emergency kit should contain only those items that the dentist knows how
to use. In a real emergency, the IV is not the number one tool for
treating the emergency. The dentist should focus on doing those things
that will increase the patient's chance for a good outcome once the
emergency room staff arrives, and should let them start the IV and give
the drugs, if possible.

**If a crash cart and medical staff are not available in the facility
(such as in stand-alone dental clinics without a medical clinic nearby),
or if intravenous sedation is being performed in the dental clinic,
additional equipment and drugs should be present.** A dentist working in
such a clinic should plan ahead very carefully for the possibility of a
medical emergency, such as considering the likely response time for a
911 call. Advanced training in the treatment of medical emergencies is
also strongly recommended, so that he/she will be able to use the
following drugs and equipment if necessary:

Additional Items for Clinics Without a Crash Cart :

• Rubber tourniquets (2)

• Sterile 25-gauge x 5/8\" length, and 22-gauge x 1 5/8\" length needles
(3)

• Intravenous infusion set

• IV tubing (2)

• 1000 cc. of Normal Saline for hypotension

• 500 cc. of 5% Dextrose and water for piggyback meds or IV fluids

• Meperidine (Demerol) in 50 mg. Tubex cartridges with sterile protected
needle attached (3) or Talwin 50 mg. ampule

• Ephedrine Sulfate 50 mg. ampule for use as a vasopressor to treat
hypotension

• Solu-Cortef (100 mg. vial) for use as an anti-inflammatory agent

• Narcan (1 ml. ampule) to counteract narcotic depression

• Amyl nitrite inhalant (3) for coronary artery dilatation

• Valium (10 mg. vial) IV/IM for convulsions

• Glucose 50% (25 mg. in 55 cc vial) for hypoglycemia

• Aminophyllin (500 mg. vial) mix 500 cc D5W for acute asthma

Emergencies in the Dental Office

Syncope (Mild Neurogenic Shock)

*Symptoms:* Ashen gray; cold perspiration; lightheadedness;
restlessness; depressed medullary function; unconsciousness; low blood
pressure; rapid, thready, or slow, weak pulse; shallow, slow
respirations.

*Prevention:* Adequate emotional evaluation; barbiturate or tranquilizer
premedication; aspiration when giving injection.

*Treatment:* Supine position; spirits of ammonia; oxygen; cold packs to
forehead; if syncope persists, watch vital signs.

Hyperventilation Syndrome (Neurogenic)

*Symptoms:* Hyperventilation; apnea; lightheadedness; paresthesia of
hands and feet; sometimes carpopedal spasm; syncope may develop.

*Prevention:* Adequate evaluation; premedication; "vocal anesthesia."

*Treatment:* Breathing expired CO2 from a paper bag; quiet reassurance;
instruct patient to take *slow*, deep breaths.

Allergic Reaction

*Symptoms:* Rash; hives; itching; rhinitis; swellings; asthma;
bronchospasm; angioneurotic edema; shock; cardiovascular collapse.

*Prevention:* Adequate medical history; sensitivity test.

Toxic Reaction

*Symptoms:* CNS stimulation --- CNS depression

*Stimulation:* vital signs elevated; apprehensive, excitation,
convulsions.

*Depression:* vital signs depressed; lethargy, unconsciousness.

*Prevention:* Adequate medical history; aspiration when injecting; do
not approach toxic limit.

*Treatment:* Mild --- no treatment; IV Valium 5-10 mg. for convulsions;
oxygen; supportive therapy for depression; ephedrine sulfate 10-25 mg IM
or IV.

Idiosyncrasy

*Symptoms:* Same as toxic reaction.

*Prevention:* Same as toxic reaction.

*Types:* 1) Local anesthetics --- most stimulate, then depress;
lidocaine, carbocaine, and monocaine depress; 2) Barbiturates --- CNS
stimulation; 3) Epinephrine --- tremor, stimulation.

Coronary Insufficiency (Angina Pectoris)

*Symptoms:* Severe precordial or substernal pain which may radiate to
left arm; pain described as tight or choking; may have headache;
duration of pain only a few minutes.

*Prevention:* Adequate history; premedication; prophylactic
nitroglycerine.

*Treatment:* 0.4 mg. nitroglycerine sublingually, x 3 if needed; oxygen;
keep patient quiet and in a semi-reclined position.

Anaphylactic Shock

*Symptoms:* Sudden circulatory and respiratory collapse; cyanosis;
bronchospasm; weak pulse; spasms; dyspnea; vomiting; headache; coughing.

*Treatment:* Activate EMS. Epinephrine (0.5-1.0 ml 1:1000) IV or SC;
oxygen therapy; CPR as necessary.

Adrenal Crisis

*Symptoms:* Sudden circulatory collapse; pallor; sweating; respiratory
collapse; weak pulse; nervousness early, then apathy and
unconsciousness; may terminate in death if not treated.

*Treatment:* Activate EMS; Solu-Cortef 100 mg. IV; oxygen therapy.

Asthma

*Symptoms:* Wheezing; cough; difficult respiration; cyanosis; agitation.

*Treatment:* Alupent inhaler 1-2 puffs (use patient's supply).
Epinephrine (0.5 ml 1:1000) SC; oxygen therapy. Unless attack is severe
give only oxygen. Activate EMS if epinephrine is given (a general rule).

Cerebrovascular Accident

*Symptoms:* Sudden onset; mild dizziness to unconsciousness; varying
degree of paralysis; headache; aphagia; nausea; numbness; diplopia;
blindness.

*Treatment:* Maintain airway; give oxygen; obtain medical help.

Insulin Shock

*Symptoms:* Sweating; nervousness; headache; mental confusion;
dizziness; transient unconsciousness; convulsions; coma.

*Treatment:* Give glucose orally if able; or IV dextrose (50 ml 50%
sol.) or glucagon 1 mg. IV or IM.

Diabetic Coma

*Symptoms:* Gradual loss of consciousness; face flushed; dry mouth;
breath has fruity odor; headache; weakness; apathy; abdominal pain;
nausea.

*Treatment:* Recognize early course and obtain medical help; give
glucose or dextrose to distinguish from insulin shock.

Airway Obstruction

*Symptoms:* Nervousness; difficult respiration or complete blockage;
paradoxical respiration; cyanosis; laryngeal stridor (harsh grating or
creaking sound).

*Treatment:* Clear airway and insert oral airway; oxygen therapy; CPR;
Heimlich abdominal thrust; if above fails, do a cricothyrotomy and give
oxygen.

Laryngospasm

*Symptoms:* Inspiratory and expiratory stridor; complete or partial
blockage of airway; paradoxical respiration; cyanosis; initially rapid
pulse followed by a slowing pulse rate; terminates in cardiac arrest.

*Treatment:* 100% oxygen administered under gentle, positive pressure
will sometimes break spasm; activate EMS; Succinylcholine (1/2 cc) given
IV and 100% oxygen; if above is unsuccessful, give succinylcholine (3-4
cc) IV and insert endotracheal tube; administer 100% oxygen; alternate
method --- cricothyrotomy.

Cardiopulmonary Emergency

*Treatment:*

1\. If unconscious: Check respirations; clear airway; insert oral or
nasal airway. Activate EMS.

2\. If breathing: Give oxygen; suction airway if necessary; give
aromatic spirit of ammonia. Check pulse and blood pressure.

3\. If not breathing: Establish patient airway; administer oxygen or air
via mechanical device or mouth-to-mouth, mouth-to-nose, or
mouth-to-airway artificial respiration. Activate EMS. Check pulse.

4\. If carotid pulse is present: Continue 12 lung inflations per minute.
Check blood pressure. Activate EMS.

5\. If apparent cardiac arrest with absence of carotid pulse and dilated
pupils: Activate EMS and start CPR.

References

Emergencies in the Dental Office. Needham, MA: Hoyt Laboratories.

Peterson LJ, et al. Contemporary Oral and Maxillofacial Surgery. St.
Louis: The C.V. Mosby Co; 1988; pp 41-70.

Pharmaceuticals (Including Prophylactic Antibiotic Coverage for
Prevention of Bacterial Endocarditis)

Prescription of pharmaceuticals is a form of communication that involves
the dentist, the patient, the pharmacist, and the patient's physician.
Clear communication between all parties is essential.

When the patient's medical record is available to the attending dentist,
prescribed or administered drug information must be recorded on the
clinical record for outpatients and on the doctor's orders for
inpatients. When no medical record is available, the prescribed
medication should be recorded on the patient's dental record.

When prescribing drugs, the dentist should know the properties of the
medication being prescribed, including the adverse effects. All
prescribed drugs should be consistent with the health needs of the
patient.

In hospitals and most health centers, there is ordinarily a pharmacy,
with a pharmacist to dispense drugs. In very small facilities, such as
health stations or dental trailers, dentists may be required to dispense
drugs. In these small facilities, it is important that the following
requirements are met:

• The pharmaceutical storage area or drug cabinet must be kept locked
when not in use.

• Records should be kept of all drugs dispensed, and the expiration
dates should be checked to ensure that outdated drugs are not dispensed.
**The Drug Enforcement Agency (DEA) *requires* record keeping for all
scheduled drugs, including narcotics, chloral hydrate, etc.**

• Only small amounts of narcotics should be kept on hand.

• When narcotics are dispensed, a record of the patient receiving them
and the amount dispensed must be maintained and provided monthly to the
pharmacy issuing the narcotics.

• When a trailer is being transported or stored, narcotic drugs should
be removed and locked up in the main clinic or returned to the pharmacy.

General Recommendations for Narcotic Drugs

• The use of strong narcotics for chronic pain syndromes should be
avoided; the addictive capability of all narcotic compounds is serious.

• No narcotic should be administered or prescribed if a less potent
analgesic will suffice.

• Narcotics should not be used primarily to relieve apprehension;
barbiturates and tranquilizers are better suited for this purpose.

Guidelines for Prophylactic Antibiotic Coverage for the Prevention of
Bacterial Endocarditis

The American Heart Association recommends prophylactic antibiotics for
patients at risk for endocarditis whenever they undergo procedures
likely to cause a bacteremia with organisms that commonly cause
endocarditis.

Some cardiac conditions are more predisposed to endocarditis than
others, and some dental procedures are more likely to initiate an
endocarditis-causing bacteremia. The recommendations provided here are
based on the 1990 revision of the American Heart Association
recommendations, which were published in the February 1991 issue of the
*Journal of the American Dental Association.*

Cardiac Conditions Requiring Endocarditis Prophylaxis

• Prosthetic cardiac valves, including bioprosthetic and homograft
valves

• Previous bacterial endocarditis, even in the absence of heart disease

• Most congenital cardiac malformations

• Rheumatic and other acquired valvular dysfunction, even after valve
surgery

• Hypertrophic cardiomyopathy

• Mitral valve prolapse with valvular regurgitation

Cardiac Conditions Not Requiring Endocarditis Prophylaxis

• Isolated secundum atrial septal defect

• Surgical repair of the following conditions, without residual problems
for at least six months:

-- Secundum atrial septal defect

-- Ventricular septal defect

-- Patent ductus arteriosus

• Previous coronary artery bypass graft surgery

• Mitral valve prolapse without valvular regurgitation

• Physiologic, functional, or innocent heart murmurs

• Previous Kawasaki disease without valvular dysfunction

• Previous rheumatic fever without valvular dysfunction

• Cardiac pacemakers and implanted defibrillators

Dental or Oral Surgical Procedures Requiring Endocarditis Prophylaxis

• Dental procedures likely to induce gingival or mucosal bleeding,
including professional cleaning (prophylaxis)

• Surgical procedures involving respiratory mucosa (including maxillary
sinus)

• Incision and drainage of infected tissue

• Intraligamentary injections

Dental or Oral Surgical Procedures Not Requiring Endocarditis
Prophylaxis

• Dental procedures not likely to induce gingival or mucosal bleeding,
such as simple adjustment of orthodontic appliances or restorations
above the gingival margin

• Injection of local intraoral anesthetic (except intraligamentary
injections)

• Shedding of primary teeth

• New denture insertion

Recommended Standard Prophylactic Regimens for Dental, Oral, or Upper
Respiratory Tract Procedures in **Adult** Patients:

For Patients Able to Take Amoxicillin/Penicillin

• Amoxicillin 3.0 grams orally 1 hour before procedure, then 1.5 grams 6
hours after initial dose

For Patients Allergic to Amoxicillin/Penicillin

• Erythromycin ethylsuccinate 800 milligrams orally 2 hours before
procedure, then 400 milligrams 6 hours after initial dose

Or:

• Erythromycin stearate 1.0 gram orally 2 hours before procedure, then
0.5 grams (500 milligrams) 6 hours after initial dose

Or:

• Clindamycin 300 milligram orally 1 hour before procedure, then 150
milligrams 6 hours after initial dose

Recommended Standard Prophylactic Regimens for Dental, Oral, or Upper
Respiratory Tract Procedures in **Pediatric** Patients:

For Patients Able to Take Amoxicillin/Penicillin

• Amoxicillin 50 milligrams per kilogram orally 1 hour before procedure,
then 25 mg/kg 6 hours after initial dose

For Patients Allergic to Amoxicillin/Penicillin

• Erythromycin ethylsuccinate 20 mg/kg orally 2 hours before procedure,
then 10 mg/kg 6 hours after initial dose

Or:

• Erythromycin stearate 20 mg/kg orally 2 hours before procedure, then
10 mg/kg) 6 hours after initial dose

Or:

• Clindamycin 10 mg/kg orally 1 hour before procedure, then 5 mg/kg 6
hours after initial dose

***Note:* The following weight ranges may be used for the initial
pediatric dose of amoxicillin:**

**Less than 15 kg (\<33 lbs)= 750 mg**

**15 to 30 kg (33-66 lbs)= 1500 mg**

**\>30 kg (\>66 lbs)= 3,000 mg (full adult dose)**

Guidelines for Pharmacosedation

The goals for the management of pharmacosedation in the ambulatory
patient are:

• Patient welfare

• Control of patient behavior

• Production of positive psychological response to treatment

• Return to pretreatment level of consciousness by time of discharge

Definition of Terms

For the purpose of this document the following definitions shall apply:

• *Anxiolysis:* A dissolution or reduction of anxiety through the use of
the hypnotic dose of a sedative agent, i.e., light sedation.

• *Nitrous Oxide-Oxygen Analgesia:* The relative reduction of fear,
anxiety, and pain response through the controlled delivery of nitrous
oxide and oxygen through a dental inhalation sedation delivery system.

• *Conscious Sedation:* A controlled, pharmacologically-induced,
minimally depressed level of consciousness that retains the patient's
ability to maintain a patent airway independently and continuously, and
respond appropriately to physical stimulus.

• *Deep Sedation:* A controlled, pharmacologically-induced state of
depressed consciousness from which the patient is not easily aroused and
which may be accompanied by a partial loss of protective reflexes,
including loss of the ability to maintain a patent airway independently
and/or respond purposefully to physical stimulation or verbal command.

• *General Anesthesia:* The elimination of all sensation, accompanied by
a loss of consciousness, by the use of inhalation or parenteral agents.

General Considerations

• *Applicability:* These guidelines should be considered as minimum
guidelines and may be superseded by more stringent local policies and
procedures.

• *Privileging:* Each dental program should use a Dental Privileges
Request Form. Dentists requesting privileges for Pharmacologic
Management must specify each technique for which privileges are
requested. Full or limited privileges will be granted or denied on the
basis of the requesting dentist's documented training and experience.
Documentation of training and experience in the form of an appropriate
training certificate or a letter specifying past experience from the
requesting dentist's current or immediate past dental supervisor must
accompany the Dental Privileges Request Form.

• *Local Anesthesia:* All local anesthetic agents can become cardiac and
central nervous system (CNS) depressants when administered in excessive
doses. There is a potential interaction between local anesthetic and
sedatives used in pediatric dentistry which can result in enhanced
sedative effects and/or untoward events; therefore, particular attention
should be paid to doses used in children. To avoid excessive doses, a
maximum recommended dose in mg/kg or mg/lb should be calculated for each
patient and recorded prior to administration for all sedatives and local
anesthetics used. (Table 1)

• *Candidates:* Patients who are ASA (American Society of
Anesthesiologists) Class I or II may be considered candidates for
conscious sedation or deep sedation. Patients in ASA Class III or IV
present special problems and require individual consideration and should
be treated in a hospital setting. General anesthesia requires
consultation with an anesthesiologist.

• *Responsible Adult:* The pediatric patient should be accompanied to
and from the treatment facility by a parent, legal guardian, or other
responsible adult who should be required to remain at the treatment
facility for the entire treatment period. Adult patients should be
accompanied by a responsible adult.

**Table 1**

**Local Anesthetic Dosages**

  ---------------- --------------- -------------- ------------- -----------
  Generic\         **Brand\        **Conc.\       **Max. Rec.   **Mg per
  Name             Name**          (%)**          Dose          Carpule**
                                                  (Mg/Kg)**     

  Lidocaine        Xylocaine       2              4.4           36

  Mepivacaine      Carbocaine      2              6.6           36

  Mepivacaine      Carocaine       3              6.6           54

  Prilocaine       Citanest        4              7.9           72

  Bupivacaine      Marcaine        0.5            2.0           9
  ---------------- --------------- -------------- ------------- -----------

Facilities

• *Medical support:* The Dental Supervisor and the Clinical Director may
limit the use and type of dental sedation performed based upon the
availability of medical support. Utilization of some sedation
techniques, e.g., IV sedation techniques, may require the prior
notification of a physician present in the facility to assure that
adequate medical support is available.

• *Staffing:* The dentist must have a dental assistant present during
the sedation procedure to provide for proper monitoring and support. The
assistant must be certified in basic life support. Deep sedation may
require additional staff.

• *Armamentarium:* Basic emergency diagnostic and treatment equipment
and an emergency drug kit must be readily available. This should
include: sphygmomanometer, stethoscope, oxygen source, positive pressure
ventilator, adequate suction apparatus with tonsillar suction tip, oral
and nasal airways, and IV kits. The equipment and supplies should be
appropriate for both pediatric and adult patients. If narcotic drugs are
administered, Narcan must be available in the emergency drug kit.

• *Nitrous Oxide:* When nitrous oxide is used, the facility should be
compliant with the guidelines in the Environmental Health and Safety
section (Section VI) of this guide. A flowmeter capable of delivering
100% O2 should be used. Normal operation should be restricted to 50% or
less N2O.

Emergency Services

Back-up emergency services should be identified. A protocol outlining
necessary procedures for their immediate employment should be developed
and operational for each facility. For non-hospital facilities, an
emergency assist system should be established with the nearest hospital
emergency facility, and ready access to ambulance service must be
assured.

Documentation Prior to Treatment

The practitioner must document each sedation procedure in the patient's
record. Documentation should include the following:

• *Informed consent:* Each patient, parent, or other responsible
individual is entitled to be informed regarding benefits, risks, and
alternatives to sedation and to give consent. The patient record should
document that appropriate informed consent was obtained according to the
procedures of the facility.

• *Instructions to parents or responsible individual:* The practitioner
should provide verbal and written instructions to the parents or
responsible individual. Instructions should be explicit and include an
explanation of pre- and post-sedation dietary precautions, potential or
anticipated postoperative behavior, and limitation of activities.

• *Dietary precautions:* The administration of sedative drugs should be
preceded by an evaluation of the patient's food and fluid intake. Intake
of food and liquids should be as follows: (a) no milk or solids after
midnight prior to scheduled procedure; (b) clear liquids up to 4 hr.
before procedure for children ages 6 months to 3 years; (c) clear
liquids up to 6 hr. before procedure for children ages 3 to 6 years; and
(d) clear liquids up to 8 hr. before procedure for children aged 7 years
or greater. No restrictions are necessary for anxiolysis or nitrous
oxide-oxygen sedation.

• *Preoperative health evaluation:* Prior to the administration of
sedatives, the practitioner should obtain and document information about
the patient's current health status.

For nitrous oxide-oxygen and anxiolytic sedation only a review of the
medical history form is required.

For conscious sedation, deep sedation, and general anesthesia the
evaluation should include:

-- Health history

-- Review of systems

-- Vital signs, including heart rate, respiratory rate, and blood
pressure.

-- Risk assessment (ASA guidelines)

-- Evaluation of airway patency

• *Patient immobilization:* If patient immobilization will be required
as part of the procedure, specific informed consent, including planned
device and duration, should be obtained.

• *Prescriptions:* When prescriptions are used for prescribing drugs,
such as minor tranquilizers to be administered enterally by a
responsible adult preprocedurally outside the treatment facility, a copy
or a note describing the content of the prescription should be
documented in the patient's record, along with a description of the
instructions given to the responsible individual.

Monitoring

• *Vital signs:* The patient's record should contain documentation of
intermittent quantitative monitoring and recording of oxygen saturation
(pulse oximetry), heart and respiratory rates, and blood pressure, as
recommended for specific sedation techniques. Responsiveness of the
patient should be monitored at specific intervals before and during the
procedure and until the patient is discharged.

• *Drugs*: The patient's record should document the name, dose and
route, site, and time of administration of all drugs administered. The
maximum recommended dose per kilogram or pound should be calculated and
the actual dose given shall be documented in milligrams. The
concentrations, flow rate, and duration of administration of oxygen and
nitrous oxide should be documented.

• *Patient immobilization:* Patient immobilization devices used and
duration should be documented.

The condition of the patient and the time of discharge from the
treatment facility should be documented in the record. Documentation
should include that appropriate discharge criteria have been met. The
record should also identify the responsible adult to whose care the
patient was discharged. (Table 2)

**Table 2**

**Recommended Discharge Criteria**

1\. Cardiovascular function is satisfactory and stable.

2\. Airway patency is uncompromised and satisfactory.

3\. Patient is easily arousable and protective reflexes are intact.

4\. State of hydration is adequate.

5\. Patient can talk, if applicable.

6\. Patient can sit unaided, if applicable.

7\. Patient can ambulate with minimal assistance, if applicable.

8\. For the very young child or disabled person who is incapable of the
usually expected responses, the presedation level of responsiveness or
the level as close as possible for that person has been achieved.

9\. Responsible individual is available.

Training

• For anxiolysis and nitrous oxide-oxygen inhalation sedation:

For most candidates, documentation of nitrous oxide training and
pharmacology in the form of dental school transcripts or a letter
attesting to training from the institution. Where nitrous oxide was not
taught, training should be at least 16 hours in duration and include
supervised administration of nitrous oxide oxygen anesthesia in no less
than five cases.

• For sedation techniques (conscious sedation, deep sedation, or general
anesthesia):

-- Training of at least forty hours duration, including treatment cases
performed under supervision for each technique.

The provision of these sedation procedures may take place following
didactic instruction at the training facility or at the dentist's duty
station, if supervision is available by a health professional adequately
trained in the conscious sedation technique being taught. Senior
clinicians who are currently practicing sedation techniques should
demonstrate sufficient experience by providing documentation that they
have properly performed the procedure a minimum of ten times during the
past year or that they have attended a refresher course in the past
year.

-- Satisfactory completion of a graduate training program or residency
in a recognized dental specialty or ADA-approved General Practice
Residency which provides training and experience in the use of sedation,
including airway management, risk assessment, physical evaluation, and
medical emergency management.

-- Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life
Support (PALS) are encouraged.

Reporting

Any incidents of mortality or incidents of temporary or permanent
physical or mental injury requiring the hospitalization of the patient
as a result of the utilization of sedation must be reported to the
Chief, IHS Dental Program. The report should include the following
information:

• Description of dental procedures performed

• Description of the preoperative physical condition of the patient

• List of the drugs and dosage administered

• Detailed description of techniques utilized to administer the drugs

• Names of personnel in attendance

• Description of adverse occurrences, as follows:

1\. Detailed description of the nature of any complications to include,
but not limited to, onset and type of symptoms of the patient

2\. Treatment interventions

3\. Response of the patient to the treatment

4\. Description of the patient's condition upon termination of any
interventive procedures

A copy of the Occurrence Report Form can be used for such reporting.
Failure to comply with reporting may be grounds for disciplinary action.

Conscious Sedation

Personnel

The practitioner responsible for the treatment of the patient and/or the
administration of drugs for conscious sedation must be appropriately
trained in the use of such drugs and techniques, must provide for
appropriate monitoring, and must be capable of managing any reasonably
foreseeable complications.

In addition to the operating practitioner, an individual trained to
monitor appropriate physiologic parameters and to assist in any
supportive or resuscitation measures required should be present. Both
individuals must have training in basic life support, should have
specific assignments, and should have current knowledge of the emergency
cart (kit) inventory.

The practitioner and all treatment facility personnel should participate
in periodic reviews of the office's emergency protocol, including
simulated exercises to assure proper equipment function and staff
interaction.

Operating Facility and Equipment

The operating facility used for the administration of conscious sedation
should have available all facilities and equipment previously
recommended. With the exception of light sedation with minor
tranquilizers administered enterally and/or nitrous oxide and oxygen
inhalation sedation at 50% nitrous oxide concentration or less, minimum
monitoring equipment for sedation shall be a pulse oximeter. A
precordial/pretracheal stethoscope is highly desirable.

Operative Monitoring Procedures

Whenever drugs for conscious sedation are administered, the patient
should be monitored continuously for responsiveness and airway patency.
With the possible exception of light sedation with minor tranquilizers
administered enterally and/or nitrous oxide and oxygen inhalation
sedation at 50% nitrous oxide concentration or less, there should be
continuous monitoring of oxygen saturation by oximetry and heart and
respiratory rates. Oxygen saturation and heart and respiratory rates
should be recorded intermittently on a time-based record throughout the
procedure and until the patient is discharged. A precordial/pretracheal
stethoscope also may be used for obtaining additional information on
heart and respiratory rates and for monitoring airway patency.
Restraining devices should be checked periodically to prevent airway
obstruction or chest restriction. The patient's head position should be
checked frequently to ensure airway patency. A sedated patient must be
constantly observed by a trained individual.

Postoperative Monitoring Procedures

After completion of the treatment procedures, vital signs should be
recorded at specific intervals. The practitioner shall assess the
patient's responsiveness and discharge the patient only when the
appropriate discharge criteria have been met.

Deep Sedation

Personnel

The techniques for deep sedation require the following individuals: 1)
the treating practitioner who may direct the sedation; 2) a qualified
individual to assist with observation and monitoring of the patient and
who may administer drugs if appropriately licensed; and 3) other
personnel to assist the operator as necessary. The operator and at least
one other individual must be currently certified in basic life support.

Operating Facilities and Equipment

In addition to the facilities and equipment previously recommended for
conscious sedation, in the operating facility used for the
administration of deep sedation, the capability for ECG monitoring, and
the availability of a capnograph and a defibrillator are desirable.

Intravenous Access

Patient receiving deep sedation should have an intravenous line in place
or have immediately available an individual skilled in establishing
vascular access in pediatric and adult patients.

Operative Monitoring Procedures

The sedated patient should be continuously monitored by an
appropriately-trained individual. There should be continuous monitoring
of oxygen saturation by oximetry, heart and respiratory rates, and blood
pressure. Oxygen saturation, heart and respiratory rates, and blood
pressure should be recorded intermittently on a time-based record. A
pulse oximeter, precordial/pretracheal stethoscope, and blood pressure
cuff are minimum monitoring devices; ECG, capnography, and temperature
monitoring are desirable. The patient's head position should be checked
frequently to ensure airway patency. A sedated patient must be
constantly observed by an appropriately-trained individual.

Postoperative Monitoring Procedures

After treatment has been completed, the patient must be observed in a
suitably-equipped recovery facility. This facility must have functioning
suction apparatus and suction catheters of appropriate size, as well as
the capacity to delivery greater than 90% oxygen and provide positive
pressure ventilation. An individual experienced in recovery care must be
in attendance at all times in order to asses and record vital signs,
observe the patient, and ensure airway patency. The patient must remain
in the recovery facility until cardiovascular and respiratory stability
are ensured and appropriate discharge criteria have been met.

General Anesthesia

Policies and procedures for the provision of general anesthesia are the
prerogative of the Medical Staff Committee or Anesthesia Department of
the facility. The dental practitioner should make himself/herself aware
of all applicable provisions.

IHS Dental Data System

The IHS Dental Data System provides information that is essential at all
levels of program management. Local program managers need data on the
extent of access to care of the service population, the breakdown of
services by level of care and age group, and the level of clinical
production of various providers and the dental program as a whole in
order to manage their programs effectively. Area Dental Consultants need
the same type of data for all programs under their purview to enable
them to establish Area guidelines and to serve as one basis for
evaluating programs in the Area. IHS Headquarters needs data for the IHS
as a whole in order to manage the overall IHS Dental Program and to
advocate on a National level for the oral health needs of American
Indians and Alaska Natives.

The Resource and Patient Management System (RPMS) is an automated data
system that provides data for all disciplines in IHS, Tribal, and Urban
Indian health programs. The Dental Data System (DDS) software is the
dental component of the RPMS and has been designed to meet common data
processing needs of facility-based dental program operations, as well as
those of central management. The DDS captures the minimum data
requirements for direct care and contract care programs and includes
data extraction and transmission routines for central processing.
Various additional data entry/edit and retrieval options are available
which may be tailored to the needs of the local site.

If the DDS is operating as part of the IHS Patient Care Component (PCC)
software, the dental visit data entered into the DDS options
automatically generate a patient encounter in the PCC. This is important
for third-party billing and administrative reasons, but it also
generates information in the Patient Health Summary of the PCC which is
of value to any type of care provider. The PCC Health Summaries, Disease
Problem Registers, and Surveillance functions each can be of significant
value to dental and other care providers for patient treatment and
tracking of individuals or target groups. For example, registers can be
created for people with diabetes, disabilities, high risk pregnancies,
unmet needs, and any other health problems (including dental) which
clinicians wish to track for treatment, follow-up, or evaluation
purposes. The PCC health surveillance module enables providers to
receive computer-generated reminders for primary care procedures.

The DDS software contains numerous reports which meet common information
needs. The software also provides tools to generate customized reports
for special local information requirements. On a quarterly basis the
Basic Measures Report (BMR) automatically provides a set of clinic
workload data summaries for all programs using the RPMS/DDS software.
The BMR creates permanent retrospective reports for observing local
program trends over time. Also, the Client-Server Database at
Headquarters West in Albuquerque, New Mexico, provides Area Dental
Consultants and Headquarters staff with summary data for multiple dental
programs. These data can be sorted in various ways by means of Excel
spreadsheets to meet individual needs.

A complete description of the installation, use, and features of the IHS
Dental Software is available in the printed *IHS Dental Software User
Manual.* Additionally, the software itself contains extensive on-line
help.

Community-Based Data

In addition to the collection of data for clinic-based dental services
the RPMS/DDS software provides for the collection of community-based
data by means of the following three modules:

• Water Fluoridation Module

Allows for the entry and retrieval of water fluoridation data, including
baseline fluoride levels, sampling frequency, compliance, and percent of
population served by compliant water systems.

• Community-Based Activity Reporting System (CBARS)

Allows for the entry and retrieval of data on health promotion/disease
prevention activities (including time spent on these activities) and
descriptive data on the recipient population.

• P.L. 94-437 Oral Health Objectives Monitoring Module

Allows for the entry and retrieval of data that enable local dental
programs to monitor trends in specific measures of oral health status
among dental patients.

Additional information on these modules, including user guides, can be
obtained by contacting:

IHS Oral Health Promotion/Disease Prevention Consultant

Dental Field Support and Program Development

5300 Homestead Road N.E.

Albuquerque, NM 87110

\(505\) 248-4175

Use of a Fiscal Intermediary to Manage Contract Care Funds

In the mid-1970s, the Indian Health Service Dental Branch became the
first branch of the IHS to develop arrangements with a fiscal
intermediary (FI) to administer the use of contract health care funds in
Tribally-managed as well as Federally-managed programs. At that time
several Area programs set up agreements with Delta Dental Service
corporations to handle the authorization of care (based upon IHS
guidelines) and payments to private dentists. The arrangements also
called for post-treatment reviews to detect fraud, abuse, and quality of
care problems.

In addition to providing hard copy reports to IHS program management
each month, Delta also was responsible for submitting the computerized
records of all dental claims paid to the IHS central database for
processing with all other dental workload data. Each Area program
obligated its entire contract dental care budget to Delta at the
beginning of each fiscal year. By doing so, Delta could offer a lower
administration fee per treatment claim they processed. Claims were paid
during the year from the contract care dollars available, as private
providers submitted them to Delta, in a manner very similar to other
dental insurance plans carried by Delta organizations.

A careful evaluation of these FI arrangements with Delta organizations
revealed numerous benefits to dental programs, including the following:

• Dental care could be authorized throughout a fiscal year by expending
funds in an equitable manner among all Service Unit programs.

• Cost savings were realized by having Delta bill other payers for care
(e.g., state Medicaid programs) when possible.

• Private dentists understood and responded better to the Delta Dental
process than the Federal contracting and payment system, which seemed
complex, slow, and inconsistent.

These fiduciary arrangements were most beneficial to the very small and
the very large Service Unit Dental Programs. Small Tribally-managed
programs, which often had limited dental contracting expertise, or which
had no clinic to provide care, could devote their entire dental budget
to contract care via Dental Dental. Large dental programs that
authorized a large volume of contract care with multiple private
providers each year also benefited substantially from such agreements
with Delta, because of the extensive paperwork involved in large CHS
programs.

In 1988 the IHS consolidated medical and dental contract health care
funds under one comprehensive national FI arrangement with Blue Cross
and Blue Shield of New Mexico (BCBS/NM). This action has forced the
eventual phasing out of operations with Delta Dental organizations.
Although similar in intent, the fiscal intermediary arrangement with
BCBS/NM is substantially different from the structure and process which
was possible under the Area contracts with Delta Dental organizations.
For example, conducting FI operations at a National, rather than
Area/state level, limits the flexibility and affordability of
implementing features such as post-treatment reviews, provider fee
reviews, and other special fiduciary services which have become a dental
industry standard.

The FI arrangement for handling contract dental care through BCBS/NM is
an administrative services only (ASO) contract which focuses on the
prompt payment of care providers and the provision of intensive support
services to all levels of IHS program management. The emphasis on these
two aspects of contract care management go hand in hand. The process
required for obligating and transferring IHS funds, unlike the Delta
arrangements, can be tedious and must be continually and carefully
managed from Service Unit to Area to Headquarters and to the FI
throughout the year.

*BCBS/NM is required to provide a high level of support for the IHS
staff and care providers who interact with the FI.* This special effort
is intended to eliminate chronic material deficiencies in the management
of contract health funds which have been pointed out by the Federal
Office of Management and Budget (OMB). Thus, more information and
support is available to local dental programs with the National FI than
was provided through regional arrangements with Delta Dental
organizations. However, the national FI, which must handle both medical
and dental activity, is not able to offer the range of dental-specific
services which Delta organizations are designed to provide.

The BCBS/NM continually offers training and orientation to those who
seek it. With the high level of clerical and clinical staff turnover
that occurs in many Service Units, these training and day-to-day support
activities are substantial, including newsletters for providers and
administrators and detailed FI reference manuals, which are updated
periodically and distributed to the Areas and Service Units. The BCBS/NM
also maintains a toll-free Customer Service number (**800-225-0241**)
and strives to hire Native Americans to help process claims and to
provide customer support. Considerable effort is made to remove all
barriers in getting help from the FI when questions or problems arise.

BCBS/NM also provides support data to IHS program managers on a
quarterly and annual basis in hard copy and via transmissions to the
central IHS database in Albuquerque. Various reports are available to
facilitate contract cost management, including the distribution of
dental fees charged by procedure code and by provider. Special ad hoc
reports can be requested from the BCBS/NM, but considerable lead time is
needed to produce such special information.

Beginning in FY1997 or later, all contract dental and outpatient medical
care authorizations will be executed using a universal Purchase Delivery
Order (PDO) form (T-843). In other words, the use of unique dental and
medical authorization forms by the IHS will end. Contract care providers
are instructed to attach a copy of the universal PDO form (with required
signatures) to the dental claims they submit (e.g., ADA standard form)
before sending the claims to the FI for payment. Despite this change,
dental care authorizations will be based upon the same type of coded
system which was created specifically for processing claims through a
National fiscal intermediary. These codes and/or associated language
must appear on all dental PDOs handled by the BCBS/NM. They are
automatically printed on authorization forms generated by the RPMS
Contract Health Services software used in most Service Units.

Dental Contract Referral Codes

The dental contract "referral" codes and their uses are listed following
this paragraph. The code system is designed to simplify contract care
authorizations, while allowing considerable flexibility in the provision
of care. The codes are intended to cover the normal scope of contract
dental care activity which can be handled through the FI. *These
referral types are a "boilerplate" template which can be modified as
necessary by local dental programs.* Thus, the FI can relate to each
Service Unit as a unique client, if necessary. For example, the dollar
obligation thresholds can be raised by the local IHS authorizing
officials, or higher levels of services can be authorized on individual
PDOs or for specified groups of patients. *The key to this flexibility
lies in making sure that signatures authorizing specific changes are
included on each PDO. If exceptions to the referral type coding system
will be routine, the FI should be instructed in writing by the
authorizing dentist or other local official. Then it will be unnecessary
to sign each PDO, and future claims submitted to the FI will not pend
needlessly.* Note that when providers are paid using the "I" (invoice)
authorization code, no documentation of the specific services provided
to each patient is required to receive payment.

  ---------- ----------------- ---------------------------------------------
  **Code**   **Type of         **Description of Authorized Care**
             Referral**        

  G          GENERAL           Before providing services other than
                               examination, radiographs, or emergency
                               services, the claim must be returned to the
                               IHS for predetermination. (Used for open
                               market procurements, when the dentist has no
                               contract agreement with the IHS.)

  E          EMERGENCY         Emergency examination and treatment not to
                               exceed the stated estimate of the dollar
                               amount stated on the authorization form.
                               (Services are limited to levels I--III of the
                               IHS Schedule of Dental Services.)

  B          BASIC             Examination and treatment limited to Levels
                               I--III of the IHS Schedule of Dental
                               Services. Treatment plans exceeding a
                               threshold amount (e.g., \$500) must be
                               returned for predetermination. (Often used
                               for school children.)

  S          SPECIALTY         Treatment must be limited to specific
                               services stated on the authorization form and
                               not to exceed the dollar amount obligated on
                               the form. (Often used for specialty care.)

  L          Laboratory        Payment for specific dental laboratory
                               services is authorized to support treatment
                               performed in direct care facilities.

  I          Invoice           The provider is authorized to provide care in
                               Federal or Tribal facilities on a
                               per-clinic-day basis. Treatment is limited to
                               a negotiated scope of work for the period of
                               performance specified in a formal contract
                               agreement with the provider (e.g., a
                               part-time dentist or hygienist, or locum
                               tenens provider). An invoice for the number
                               of days worked is submitted in lieu of
                               individual patient claims.
  ---------- ----------------- ---------------------------------------------

Inter-Agency Agreement Between the Indian Health Service and the
Administration on Children, Youth, and Families

The American Indian Programs Branch (AIPB) of the Administration on
Children, Youth, and Families' (ACYF) Head Start Bureau has entered into
an inter-agency agreement with the Indian Health Service (IHS) to
provide technical assistance (TA) to AIPB grantees. This TA is
accomplished by arranging and conducting follow-up visits and supplying
other technical services to support the Head Start Bureau's health
component.

The Head Start program emphasizes the importance of early detection of
health problems. The IHS will assist the AIPB to ensure that every child
enrolled at an AIPB-funded Head Start site is involved in a
comprehensive health program, which includes medical, dental, mental
health, and nutritional services.

The funds for carrying out the TA of the inter-agency agreement are
distributed to each Area Dental Consultant, who is responsible for
meeting the requirements of the agreement in his/her Area, unless he/she
elects not to participate in this agreement. The funds are distributed
based on the number of Head Start grantees and children enrolled.

The IHS Dental Program has agreed to provide the following services:

• Assist the AIPB grantees in accessing dental health services.

• Provide technical assistance to Head Start programs that are having
problems complying with the dental health performance standards.

• Assist the AIPB grantees and Tribal governments with the development
and implementation of oral health education programs for Head Start
children, parents, and staff.

• Provide technical assistance to the AIPB grantees in the development
and maintenance of dental health records.

• Provide up to 25 percent of the AIPB grantees with dental health
assessments.

The identification, scheduling, and delivery of these IHS services for
specific grantees will be determined by the AIPB. The IHS will provide
intensive, direct, on-site technical assistance to grantees which have
recently been monitored and to those grantees that have special problems
or needs.

The IHS should work with the AIPB Coordinator and the Technical
Assistance Support Center (TASC) contractor in planning on-site
technical assistance prior to the delivery of such assistance. Reports
must be submitted on a quarterly basis to:

Dental Field Support and Program Development Section

IHS Headquarters West

5300 Homestead Road NE

Albuquerque, NM 87110

Phone: (505) 248-4175