**Chapter 1, Management of Oral Health Programs**

**Table of Contents**

A. Introduction

B. Historical and Legislative Highlights

C. Mission, Goal, and Foundation of the IHS

D. Diversity of Programs

E. Title I and Title III Legislation Compared

(Self-Determination and Self-Governance)

F. Program Management and Planning

G. Legal Aspects of Medical/Dental Care

H. Resource Requirement Methodology and HSP

I. Guide for Preparing a Request for Contract (RFC)

J. Oral Health Surveys

K. Scientific Inquiry (Research)

L. Government Performance and Results Act (GPRA)

M. Emergency Medical Treatment and Labor Act (EMTALA)

N. Health Insurance Portability and Accountability Act (HIPAA)

O. Service Unit Dental Budget Management

Service Unit Dental Budget management Excel Spreadsheet

P. Dental Program Policies and Procedures

Q. Billing, Collecting, and coding

R. Incident Reporting

Appendix I, Sample Policies and Procedures

**Introduction**

The administration and the management of health programs for American
Indians and Alaska Natives have changed progressively since their
inception. The "Management of Oral Health Programs" section provides a
historical and legislative overview, followed by current information on
the administration and management of health care programs for Native
Americans. Included are the mission and goal of the Indian Health
Service (IHS), a description of the diversity of health programs within
the IHS infrastructure, a comparison of Title I and Title III
legislation, references to various planning documents and management
models that are applicable to health programs, a description of various
legal issues relevant to the practice of dentistry, an overview of the
Resource Requirement Methodology, a guide to completing a Request for
Contract, information on oral health surveys, and a description of
research activities in the IHS Dental Program, including a list of
publications related to the oral health of American Indians/Alaska
Natives.

*Note: For simplicity, the term "management" in this section refers to
both the administrative and management aspects of programs.*

In general, health care for American Indians and Alaska Natives can be
considered as a prepaid insurance plan. There are several mechanisms for
carrying out this plan, including traditional IHS programs, Title I
Tribal contract programs, Title III Tribal self-governance compacts, and
Title V Urban Indian programs. Legislation during the last 20 years
clearly shows the intent of Congress to achieve the maximum
participation of Indian people in the administration and management of
Indian health care programs. In the case of Tribal and Urban programs,
the role of the IHS is becoming primarily consultative in nature. This
chapter emphasizes that consultative role.

Additional information can be found on the IHS fact sheet at:
<http://info.ihs.gov/Files/IHSFacts-June2006.pdf>.

**Historical and Legislative Highlights**

Article I of the Constitution of the United States reserves to the
Federal Government the authority "\...to regulate Commerce with foreign
nations, and among the several states, and with Indian Tribes."

In the early history of this country, the only Federal health services
available to Indian people were those provided by military physicians
relative to the prevention of the spread of smallpox and other
contagious diseases --- diseases which were virtually unknown to Indian
people before their contact with non-Indians. In 1849, Indian health
policy shifted from military to civilian administration with the
transfer of the Bureau of Indian Affairs (BIA) from the War Department
to the newly-created Department of the Interior. Although some limited
progress occurred under this new administrative arrangement, by 1875
there were only about half as many physicians as there were Indian
agencies, and by 1900 the physicians serving Indians numbered only 83.

During this time, Indian health services were financed from
miscellaneous funds appropriated to the BIA. Appropriations earmarked
specifically for health services to Indians first occurred in 1911, in
the amount of \$40,000. Dental services for Native Americans began in
1913, when the BIA assigned five dentists to travel among the
reservations and Indian schools providing dental care. Since there were
few roads, travel was often on horseback. A treadle handpiece, forceps,
and the shade of a tree sometimes served as a clinic, and a bedroll as a
home.

The Snyder Act of November 2, 1921, (25 USC 13), provided the formal
legislative authorization for Federal health care for Indian people. It
authorized the Secretary of the Interior to expend funds for the "relief
of distress and conservation of the health of Indians." This short
phrase of the Snyder Act continues to be the basic legislative statement
of the Federal Government's obligation to provide health services to
Indian people.

In the mid-1920's, a more serious commitment was made to address the
health needs of Indian communities. Civil service health professionals
were aided by the assignment of commissioned officers of the United
States Public Health Service (USPHS) to the Bureau of Indian Affairs.
While the increased number of professionals helped to some degree, the
program was continually plagued with outdated facilities, severe
understaffing, and inadequate appropriations. The Merian Report of 1928
described conditions and recommended additional Federal assistance to
help the Indian people to once again become self-sufficient.

By 1934 there were 12 full-time dentists attempting to serve some
260,000 Indian people. Clinics were held in hospital rooms, school
rooms, small adobe houses, or anywhere that space was available. There
were still no fixed dental facilities, but in 1934 two dental trailers
were purchased to serve as mobile clinics.

The number of professional staff serving Indian people declined during
World War II. Several studies evaluated the BIA health program,
including the 1948 Bureau of the Budget study, the 1949 report by the
Hoover Commission, and a 1949 study by the American Medical Association,
which identified the need for a new approach to Indian health programs
through the USPHS.

In 1955, Public Law 83-568 (42 USC 2001), the Transfer Act, transferred
responsibility for the health care of American Indians from the BIA to
the Public Health Service with the establishment of the Indian Health
Service (IHS). This act described the scope of the Federal health
program for Indian people in more detail than the Snyder Act. The
Transfer Act made specific reference to the maintenance and operation of
hospitals and health facilities.

By 1955 the Dental Program had 46 dentists and 22 auxiliary dental
staff. The development of fixed clinics, the concept of preventive care,
and the use of assistants to help dentists work more efficiently all had
been incorporated into the program by the time the IHS came into
existence.

In 1957, Public Law 85-151 (42 USC 2005) authorized Federal assistance
in the construction of community hospitals, thus making needed hospital
facilities available to Indians. In 1959, Public Law 86-121 (42 USC
2004a) gave legislative form to IHS responsibilities for sanitation
facilities and services. It provided specific legislative authority for
domestic and community water systems, drainage, and sewage and waste
disposal systems. Other laws, court decisions, and policies continued to
clarify, increase flexibility, and add responsibilities to the IHS
throughout the next two decades.

The Indian Self-Determination and Education Assistance Act, P.L. 93-638
(25 USC 450), was signed into law on January 4, 1975. Like the Transfer
Act of 1955, the Self-Determination Act addressed questions of who would
be the administrators of the Indian Health Program, rather than
questions on the nature and extent of the program. The Act directed the
IHS to turn over administrative and operational responsibility for all
or parts of the IHS program to the Tribe(s) served by that program, upon
the request of the Tribe(s), using the mechanisms of grants and
contracts. The act authorized the IHS to make grants to Tribes for the
planning, development, and facility construction of health programs.

With the passage of the Indian Health Care Improvement Act, P.L. 94-437
(USC 1601), on September 30, 1976, the Congress defined the scope of the
Indian Health Program by describing two major goals:

1.  To ensure that the health status of Indian people is brought to the
    highest possible level.

2.  To achieve the maximum participation of Indian people in Indian
    health programs.

This act was structured to address the backlog of unmet health care
needs of Indian people in both reservation and urban settings, and to
maintain a system for providing high-quality health services to these
two groups. P.L. 93-638 provided the mechanism for utilizing resources
provided by P.L. 94-437 and other authorities to fund the development of
Indian self-determination.

Not only did P.L. 94-437 enumerate the nation's goals for Indian health,
but it also explained in legislative language many of the programs and
services already provided by the IHS. The law also established a number
of new programs such as those that deal with Indian health manpower,
alcohol abuse, the eligibility of IHS facilities for Medicare and
Medicaid reimbursements, and services for Urban Indians. This provided
the IHS with a broad legal base supporting the comprehensive health
programs necessary to effectively advance toward the goals defined in
P.L. 94-437.

More information on this Act can be found at
[http://info.ihs.gov/Files/IHCIA_ReauthorizationAct-Jan%202006.pdf](http://info.ihs.gov/Files/IHCIA_ReauthorizationAct-Jan 2006.pdf).

In 1988 the Indian Self-Determination Act underwent a major revision,
and the Self-Governance Demonstration Project (SGDP) was established.
The SGDP gave a limited number of Tribes the ability to enter into
compacts with the Federal Government which increased the scope of each
participating Tribe's administrative control over its health programs
(See "Title I and Title III Legislation Compared" subsection of Section
I).

In 1994 the Indian Self-Determination Contract Reform Act was enacted,
which enabled Title I Tribes (Tribes operating under Indian
Self-Determination contracts) to have access to many of the same
benefits as Title III Tribes (Tribes operating under Self-Governance
compacts). Under both systems Tribes now have access to "Tribal shares,"
which represent the proportion of funds, attributable to each Tribe,
that are used to support IHS Headquarters and Area Office activities.

The 1994 legislation was a major step in achieving the goal of maximum
participation of American Indians and Alaska Natives in Indian health
programs. The Indian Health Service continues to move steadily from a
management role to a consultative role, helping Tribes and Urban Indian
programs to successfully manage their own health programs, including
dental programs.

Additional information on the legal basis for the provision of Indian
Health Services can be found on the IHS fact sheet at
<http://info.ihs.gov/Files/BasisForServices_Jan2006.pdf>.

**Mission, Goal, and Foundation of the IHS**

The Indian Health Service (IHS), an agency within the Department of
Health and Human Services, is responsible for providing federal health
services to American Indians and Alaska Natives. The provision of health
services to members of federally-recognized tribes grew out of the
special government-to-government relationship between the federal
government and Indian tribes. This relationship, established in 1787, is
based on Article I, Section 8 of the Constitution, and has been given
form and substance by numerous treaties, laws, Supreme Court decisions,
and Executive Orders. The IHS is the principal federal health care
provider and health advocate for Indian people, and its goal is to raise
their health status to the highest possible level. The IHS currently
provides health services to approximately 1.5 million American Indians
and Alaska Natives who belong to more than 557 federally recognized
tribes in 35 states.

**MISSION**

*The mission of the IHS, in partnership with AI/AN people,*

*is to raise the physical, mental, social, and spiritual health*

*of American Indians and Alaska Natives to the highest level*.

**GOAL**

*To assure that comprehensive, culturally acceptable personal*

*and public health services are available and accessible to*

*American Indian and Alaska Native people.*

**FOUNDATION**

*To uphold the Federal Government\'s obligation to promote healthy*

*American Indian and Alaska Native people, communities, and cultures*

*and to honor and protect the inherent sovereign rights of Tribes.*

In order to carry out its mission, attain its goal, and uphold its
foundation, the IHS:

-   Assists Tribes in developing their health programs through
    activities such as health management training, technical assistance,
    and human resource development;

-   Assists Tribes in coordinating health planning, in obtaining and
    using health resources available through Federal, State, and local
    programs, and in operating comprehensive health care services and
    health programs.

-   Provides comprehensive health care services, including hospital and
    ambulatory medical care, preventive and rehabilitative services, and
    development of community sanitation facilities.

-   Serves as the principal Federal advocate in the health field for
    Indians to ensure comprehensive health services for Indian people.

Additional information can be found at:
<http://www.ihs.gov/PublicInfo/PublicAffairs/Welcome_Info/ThisFacts.asp>.

**Diversity of Programs**

**IHS Programs**

Between 1955 and 1975 virtually all health programs that provided dental
care for Native Americans were managed by the Indian Health Service.
With few exceptions the dentists were commissioned officers of the U.S.
Public Health Service, and the dental auxiliary staff were Federal civil
service employees. Many of these "traditional" IHS programs are still in
operation, but now they are only one of four different types of programs
which provide health services for Indian people.

**Tribal 638 Contracts**

Since the advent in 1975 of Public Law 93-638, the Indian
Self-Determination and Education Assistance Act, many Tribes have
elected to manage their own health programs, including the dental
components. Funds that would have been used to operate an IHS program
are transferred to the Tribe through a Title I "638 contract," and the
Tribe operates the program. Typically the dental staff are hired
directly by the Tribe (Tribal-hires), but Tribes have the option of
hiring PHS commissioned officer dentists through a Memorandum of
Agreement (MOA) with the IHS. Civil service employees also can be
detailed to Tribal programs for a limited tour through an
Intergovernmental Personnel Agreement (IPA).

The 1994 Indian Self-Determination Contract Reform Act gave Tribes the
right to gain access not only to funds used for the provision of direct
services but also to non-residual funds (funds for services that are
contractible by Tribes) which are used to support the IHS Area Offices
and IHS Headquarters. These are known as "Tribal shares." Using the
Dental Program as an example, Tribes now have the right to determine
whether they would like to continue to receive the dental support they
have received from the Area and/or from Headquarters. If they decide to
continue to receive support from the Area Dental Program, then that
Tribe's portion of those funds is left in the Area budget. This is known
as "retained Tribal shares." If the Tribe decides to take its share of
the Area dental funds, then the Tribe will provide administrative
support to its own Dental Program, either internally, through the hiring
of outside consultants, or via some other mechanism. A similar decision
must be made by the Tribe regarding support from the IHS Headquarters
Dental Program.

A detailed description of this process is included in the "Title I and
Title III Legislation Compared" subsection, which follows this
subsection.

**Self-Governance Compacts**

The Self-Governance Demonstration Project was initiated in the Bureau of
Indian Affairs in 1988 and applied to the IHS in 1992. It gave 30 Tribes
(plus 30 additional Tribes each year) the right to assume administrative
responsibilities beyond those provided by the original Indian
Self-Determination Act. This was accomplished through compacts with the
Federal Government that enabled Tribes to manage not only the operation
of their health programs, but also to assume control over the
administrative support provided by IHS Headquarters and Area Offices.

This demonstration project was the precursor of the 1994 Indian
Self-Determination Contract Reform Act, which contains many of the same
provisions. See the "Title I and Title III Legislation Compared"
subsection for details.

**Urban Indian Programs**

The legislative basis that supports health programs for Urban Indian
people lies in two pieces of legislation: the Snyder Act of 1921 and
Title V (Health Services for Urban Indians) of the Indian Health Care
Improvement Act of 1988 (P.L. 100-713). Although the arrangement is
similar to the Tribal 638 contracting mechanism, there are differences.
Urban programs exist through a contract or grant with a nonprofit Urban
Indian organization. The eligible Indian population for Urban programs
has been expanded to include American Indians who are from
State-recognized Tribes and members of Tribes terminated by the Federal
Government in the 1950's.

Approximately one-third of Urban Indian programs provide only
information and referral (usually for behavioral health services such as
substance abuse and mental health), one-third provide limited primary
care, and the remaining one-third provide comprehensive primary care,
including medical and dental services. The level of direct care
available is related to the capability of the Urban programs to gain
access to alternate resources from Federal, State, and local sources to
supplement the Title V funding.

As in Tribal programs, staff are usually hired directly by the Urban
Indian program, but Federal employees such as USPHS commissioned
officers can be detailed to Urban programs. Staff from Urban Indian
programs also are eligible for scholarship payback and the Loan
Repayment Program, if funds are available.

Unlike Tribal programs, Urban Indian programs are not eligible to assume
Tribal shares for services that they receive from Area or Headquarters,
nor are they eligible to enter into self-governance compacts.

**Additional Resources**

Tribal Programs:
<http://www.ihs.gov/NonMedicalPrograms/Tribal/Tribal_index.asp>

Urban Programs:
<http://www.ihs.gov/NonMedicalPrograms/Urban/Urban_index.asp>

Tribal Self Governance:
<http://www.ihs.gov/NonMedicalPrograms/SelfGovernance/>

**Program Management and Planning**

The management and planning of dental programs above all must address
the needs of the customers (i.e., patients) who will receive the dental
care. This includes stated needs that individual patients demand, such
as having convenient access to emergency dental care, and unstated
needs, such as a high prevalence of untreated oral diseases in the
population being served by the program.

Ideally, services to be provided should be based upon the rates and
types of disease among the total population, appropriateness of services
for the total population, and demand of the total population, rather
than upon ideal treatment for the individual patient. This is the public
health principle of "doing the most good for the most people."

When the issue of limited resources is added to the concept, this
principle becomes, "doing the most good for the most people, at the
lowest possible cost." This implies the existence of community and
clinical prevention programs, since in most cases it costs less to
prevent dental disease than to treat it.

Finally, when the issues of patient satisfaction and provider
satisfaction are added to the equation, the principle can be expanded to
read, "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." This implies that customer expectations be assessed and
addressed, and that working conditions, pay, and benefits meet the needs
of the staff providing the services.

For these things to occur, the Dental Program must respond to community
needs, the community must respond to the needs of the Dental Program,
and decisions that affect the Dental Program must be made jointly.
Rather than dental professionals making all the program decisions and
doing things "to" and "for" people, as was often done in the past,
program decisions now should be made in partnership with Tribal or Urban
Indian boards and with the community as a whole.

Following are some specific concerns dental health providers should
address when applying the public health approach to practice management:

1.  *Assuring access to oral health services for all American
    Indian/Alaska Native people for which the program is responsible.*

> Some questions to ask are: What is the oral health status of the
> community? What does the community perceive its oral health to be? Are
> the providers aware of and sensitive to oral disease rates and unique
> risk factors in the community? Does the practice respond to the actual
> treatment needs of the community or to those dictated by the Tribe,
> Service Unit, Area, or Headquarters?

2.  *Assessing the demand for care.*

> What are the barriers? What are the facilitators? Where is the
> community in terms of socio-economic, cultural, ethnic, and
> educational achievement elements that relate to demand? What are the
> professional and personal health attitudes and values that control
> demand?

3.  *Determining the resources that are available to the community.*

> What number and types of manpower are there? What is their productive
> capacity and potential? Has every fiscal source been examined? Can the
> Tribe help? Are there concerned individuals and groups within the
> community that could be used as dental resources? Are volunteers
> available? Are there organizations (such as dental, dental hygiene, or
> dental assisting schools) or individuals outside the community that
> could be used as resources?

If these and similar issues are considered, the management of the
program will better meet the oral health needs of the community, but
first they need to be incorporated into a plan. The program planning
mechanism most commonly used in the IHS Dental Program is Denniston's
POARE model:

P = Problem Statement

O = Objectives

A = Activities

R = Resources

E = Evaluation

The first step is the development of a problem statement, which
identifies a situation or condition of people or the environment that is
considered undesirable by the program staff and the community. The
problem statement identifies the gap between what exists and what the
program and community would like to see exist.

The second step is the development of one or more objectives which
address the problem. Each objective is a situation or condition that is
desirable and which the program will attempt to attain or maintain. An
objective should describe *what* condition will be addressed, *who* has
the condition, *where* the condition exists, the amount or *extent* of
the condition that is intended will exist, and *when* this is will be
accomplished.

The third step is the development of activities, which are procedures
that are carried out in order to accomplish the program objectives.
Specification of activities should include *what* will be done, *when*,
by *whom*, *where*, and *how*.

The fourth step is the identification of resources, which include the
persons, money, equipment, facilities, technology, talent, and time
involved in the performance of the activity or set of activities.

The fifth step in the planning process is identification of an
evaluation process to determine the outcome of the activities and the
effectiveness, efficiency, and acceptability of the outcomes.

Finally, the steps in the POARE model should be viewed as a circle,
representing a continual process, because the results of the evaluation
should be used in the development of future problem statements.

Additional information on POARE and the planning process can be found in
Chapter 4 of this manual in the section titled "HP/DP Program Planning
-- POARE."

Following is an excellent reference for information on the public health
approach to dentistry:

Burt, Brian A. and Eklund, Stephen A. *Dentistry, Dental Practice, and
the Community,* 6th edition, W.B. Saunders Co., 2005.

**Legal Aspects of Medical/Dental Practice:**

**Overview And Selected Issues**

*Disclaimer: All legal claims are unique, with their own circumstances
and nuances. While the study of trends can yield useful information,
legal counsel is suggested when addressing any individual legal claim.*

*The following introduction to dental malpractice issues was written by
an HHS representative who at the time of writing serves as an HHS dental
representative to the Medical Claims Review Panel (MCRP). In the course
of these duties approximately 1,000 medical and dental malpractice
claims have been reviewed over the course of seven years. Trends and
comments in this introduction are based on personal observation. This
overview was not written by an attorney, and is not to be construed as
legal advice.*

It is human nature to avoid detailed consideration of potentially
disturbing issues. The thought of being involved in a malpractice claim,
or of being named to the National Practitioner Data Bank (NPDB), is
unsettling. Yet a basic knowledge of the system in which Federal claims
are handled in IHS, Health and Human Services (HHS), and the Department
of Justice (DoJ), along with strategies to minimize the probability of a
successful claim, are of obvious value.

The set of topics related to malpractice claims in IHS, such as the
Federal Tort Claims Act (FTCA), the NPDB, informed consent, standard of
care, scope of work, and so on is reviewed in detail in "Risk Management
and Medical Liability, A Manual for IHS and Tribal Health Care
Professionals" by Dr. Steve Heath. This document is available on the IHS
website at
<http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/RM2_a.pdf>. All
dentists and hygienists are encouraged to review the pertinent detailed
information in Dr. Heath's document. If questions remain after review of
the pertinent information, the reader should feel free to contact Dr.
Patrick Blahut, or the current dental representative of HHS on the MCRP.

This introduction will address the questions most commonly asked by
dentists and dental hygienists. These are:

-   Who is at risk when a claim is filed, and exactly what specific
    risks are involved?

-   How can I avoid being named in a malpractice claim?

-   What dental procedures are most closely associated with successful
    dental malpractice claims?

There is a fourth set of questions that are not commonly asked, but
should be:

-   What is informed consent?

-   Who can legally give consent?

-   Do I need to obtain informed consent in order to treat minors when
    parents are not readily available?

**Who is at risk? What are the specific risks?**

When a dental patient files a malpractice claim, the issues of "who is
at risk?" and "what specific risks are involved?" can be very confusing.
In order to shed light on these two seemingly simple questions, the
reader must first have a rudimentary understanding of the Federal Tort
Claims Act and the National Practitioner Data Bank.

Before 1946, the federal government could not be held liable for the
actions of its employees because of the doctrine of sovereign immunity.
The recourse of individuals injured by federal employees was limited to
suing the employee and petitioning Congress. In 1946 Congress passed the
FTCA, which provides that the United States may be liable for the
negligent acts of its employees (and of certain contractors). It is
under the FTCA that claims alleging negligent dental or medical care are
made against the federal government.

The FTCA provides a limited waiver for the sovereign immunity of the
federal government when a federal employee or employees are negligent
within the scope of their employment or their scope of work. Strictly
speaking, it is the government and not the health care provider that is
sued. Patients alleging under the FTCA can ask only for money; and since
the request is directed at the government, it would seem that the answer
to "who is at risk?" is "only the federal government." This would be the
case if it were not for the NPDB.

One common misconception is that the government provides malpractice
insurance for its employees. Coverage under the FTCA is fundamentally
different from private sector malpractice insurance. This distinction
has important ramifications, both positive and negative, for the
providers involved in malpractice claims. The primary positive attribute
of the FTCA: it is free to all federal health care providers. The
primary negative attribute: while the federal government is the
defendant in any suit, the health care provider is at risk to being
named to the NPDB. Since the government and not the provider is being
sued, the provider's opportunity for representation may be limited.

The NPDB is a clearinghouse or data warehouse that collects and releases
information about payments made on behalf of physicians, dentists,
dental hygienists, and other licensed health care providers as a result
of malpractice actions and claims. The NPDB was created by Congress in
1986, in response to a number of perceived problems with our health care
system:

-   The number of malpractice claims against health care providers, and
    especially against physicians, was increasing rapidly.

-   There were disturbing instances of physicians named in multiple
    malpractice claims moving from state to state to "start anew" and
    avoid detection. One specific practitioner with a string of serious
    malpractice claims, profiled in influential New York and Washington
    D.C. newspapers, provided Congress with the motivation to act.

-   There was growing concern about the general quality of health care
    and the accountability of providers in the United States.

Health care providers are named to the NPDB for two general reasons:

(1) If a hospital or clinic restricts or curtails privileges for 30
    consecutive days or more based on conduct or competence, this action
    must be reported under law to the NPDB.

(2) If any payment is made, including settlements or court judgments, as
    a result of a malpractice claim, the provider must be named to the
    NPDB.

The answer to "who is at risk?" is both the federal government and the
individual health care provider. The specific risk to the government is
financial; the risk to the provider is that of being named to the NPDB.

A number of misconceptions surround the FTCA and the NPDB. The following
points are accurate, but often misconstrued:

-   The FTCA covers some, but not all contractors. Independent
    contractors are covered only if it can be shown that the government
    had authority to control the detailed performance of the contractor,
    and exercised substantial supervision over the contractor's day to
    day activities.

-   The HHS cannot name to the NPDB individuals who are not covered by
    the FTCA. Nor can unlicensed individuals be named to the NPDB. Thus,
    if a dental assistant or unlicensed student injures a patient, it is
    the supervising federal employee who is at risk to being named to
    the NPDB.

-   The respective roles of the Office of General Counsel (OGC), the
    DoJ, and the MCRP are understandably confusing to IHS health care
    providers. The OGC and DoJ defend the federal government, and are
    not involved in determination of who, if anyone, is named to the
    NPDB. The MCRP is the sole entity charged with the responsibility
    for identifying practitioners to be named to the NPDB.

-   The significance of being named to the NPDB is unclear. Almost all
    state licensing boards ask about malpractice settlements during the
    process of license renewal. Dentists and hygienists seeking license
    in a new state will likely be asked to document any entries in the
    NPDB. Hospitals and HMO's regularly query or check the NPDB during
    the credentialing process. The entry in the NPDB, accompanied by a
    brief narrative outlining the details of the case, is appropriately
    viewed as a "red flag" suggesting the need for further
    investigation. The practical significance of the entry in the NPDB,
    and the ramifications of the entry, rest in the perspectives of the
    investigating body. A provider seeking to change his state of
    practice or enter into an HMO may have some explaining to do. On the
    other hand, a practitioner in private practice and remaining in the
    same state may find an entry in the NPDB to be of little practical
    significance.

**How can I avoid being named in a malpractice claim?**

Strictly speaking, there is no way to absolutely avoid being named in a
malpractice claim. Good clinical skills and judgment, a pleasing
chair-side manner, and attention given to receiving and documenting
informed consent are all important factors that can minimize but not
eliminate the risk of being named in a malpractice claim.

Since anyone can choose to file a lawsuit, a more practical question is
"how can I avoid being named in a [successful]{.underline} malpractice
suit?" Specific suggestions include:

-   Maintain your clinical competency. Be careful of getting into
    complicated procedures, especially if your local or immediate
    "back-up system" of expert clinical support is minimal.

-   Document all professional communications, including telephone
    conversations.

-   Make clear, legible, and complete record-keeping a high priority,
    identified as part of the clinical care process rather than as a
    necessary additional chore separate from the provision of care.

-   Pay particular attention to clear communication with your patients.
    Foster realistic expectations, obtain and document informed consent
    in writing.

-   Pay particular attention to the dental procedures listed immediately
    below that are associated with malpractice claims.

**What dental procedures and treatment decisions are most closely
associated with successful dental malpractice claims?**

While the total number of medical and dental malpractice claims in HHS
is increasing, and the number of IHS dental claims has increased
gradually in recent years, the total number of IHS dental claims remains
relatively small. Because of the small number of claims, any apparent
trends are obscured by the general variability of claims from one year
to the next. Also, a small number of similar claims in the coming years
could alter the trends discussed herein. Nevertheless, approximately 12
years of HHS dental data yield the following associations:

-   Oral surgery procedures are closely associated with successful
    malpractice claims. In this regard, two issues stand out:

    -   Extraction of the wrong tooth. This specific claim is seen by
        the MCRP as somewhat analogous to a physician who operates on
        the wrong body part. All such claims received over the past
        decade, when substantiated, have been settled rather than
        defended. While the total number of claims over the years has
        been low, this is nevertheless the one most common specific
        clinical misadventure associated with successful dental
        malpractice claims.

    -   Extractions that result in temporary or permanent nerve damage.
        Note that unlike the extraction of the wrong tooth, the
        infliction of nerve damage can sometimes be successfully
        defended. Less than ideal results from surgery are not
        necessarily grounds for a successful malpractice claim. The
        outcome of each individual case depends on the circumstances,
        general documentation, diagnostic records, and specific
        documentation with regard to informed consent.

> These two oral surgery problems account for approximately one-half of
> all successful dental malpractice claims.

-   Poorly documented informed consent, or lack of documentation in this
    regard, are both associated with successful malpractice claims.
    While lack of informed consent in lieu of any injury may constitute
    grounds for assault but is unlikely to result in a successful
    malpractice claim, any perceived injury whatsoever that triggers a
    claim is difficult to defend without carefully documented informed
    consent.

This last piece of advice leads into the final series of related
questions concerning informed consent.

**What is informed consent?**

The concept goes back to the early years of the twentieth century, and
gained widespread acceptance immediately after World War II. The
underlying premise is that all competent adults have the right to
determine what is done to their bodies. Informed consent includes
discussion of diagnosis, proposed treatment, risks of proposed
treatment, and alternatives, including the prognosis associated with no
treatment whatsoever. Informed consent requires communication and
information transfer; it is not a piece of paper with signature.

**Who can legally give consent?**

The authority to consent to treatment lies solely with the patient,
assuming he or she is a competent adult.

**Do I need to obtain informed consent in order to treat minors if
parents are not available?**

This is a particularly relevant issue in many locations in Indian
Country. Many providers, support staff, and parents remember a time not
long ago when informed consent was not consistently documented, and when
complex treatment plans requiring multiple appointments were completed
on youngsters without ever consulting with parents or guardians.

Documented informed consent is now considered mandatory prior to
treating minors. The convoluted situations IHS provider encounter with
regard to unavailable parents, expectations of Head Start programs,
children cared for by relatives, and so on are beyond the scope of this
introduction. Suffice it to say that with the exception of true
emergencies, treatment should not be rendered to minors (defined in most
states as individuals under the age of 18) without documented informed
consent from the parent(s) or legal guardian(s).

Each malpractice claim is unique, in that the details and circumstances
are always at least slightly different. Because of this, attorneys
rarely speak in generalities, and prefer to focus on the particulars of
individual cases. However, DoJ attorneys were recently asked the
following questions:

-   "What factors commonly result in settlement rather than defense of a
    malpractice claim?" and

-   "What do providers commonly do that results in losing a potentially
    defensible case?"

They offered three responses:

-   Poor documentation of professional communications and poorly
    documented records in general. If something is stated in the
    patient's record, it is presumed to have occurred. Conversely, if it
    is not stated in the record, it cannot be assumed to have happened.

-   Lack of documentation of informed consent, or poorly documented
    informed consent.

-   Alteration or falsification of medical records. Such an act can be
    construed almost as a personal affront to the integrity of the
    Federal District Court system.

Additional general information about Malpractice and Informed Consent
can be found on the Safety Net Dental Clinic Manual Website at:

<http://www.dentalclinicmanual.com/chapt4/section_03/topic_01/images/malpractice.doc>

and at

<http://www.dentalclinicmanual.com/> Chapter 4 (Clinic Operations)
Sections IV j, IV k, IV l, IV m, and IV n.

**Resource Requirement Methodology**

The Resource Requirement Methodology (RRM) is a systematic process for
determining the resource requirements, including personnel and contract
dollars, which are necessary to provide effective, efficient, and
acceptable dental services for eligible American Indians and Alaska
Natives. The RRM provides a mechanism for all programs, Service Units,
Tribes, or Areas to be compared on the same relative scale with regard
to resource requirements. The RRM also provides important supportive
data for Congressional appropriation hearings.

The current RRM formula is based on oral health status and treatment
needs data provided by the 1991-1992 IHS Oral Health Survey. While there
are newer data from the 1999 IHS Oral Health Survey, it was decided that
it would not be cost-effective to re-do the RRM formulas with the new
data. The survey data and official IHS population data are used as
variables in a formula to calculate an RRM profile. Following are some
of the assumptions used in the RRM calculation:

1.  Approximately 70 percent of eligible Native Americans would seek
    dental treatment in a given year if relatively free access were
    available. This estimate is based on studies of utilization of
    dental care under various dental insurance coverage rates.

2.  The backlog of treatment needs for a given population will not be
    reduced all at once, but over a period of eight years.

The calculation of annual workload per capita is accomplished by
multiplying the eligible Indian population by the 70 percent utilization
rate, and then multiplying the result by per capita annual treatment
needs for incidence. A similar calculation is performed using a prorated
portion (12.5 %) of the per capita backlog needs. Then these two numbers
are added together to provide an annual workload total. Finally, this
total is adjusted by other factors, such as the proportion of services
typically referred to specialists or other contract dentists.

Because this calculation is cumbersome, a simplified method has been
adopted which assumes that 95 service minutes are required per capita
for all programs serving American Indians and Alaska Natives. Simply
multiplying the official Indian population by 95 service minutes will
provide an estimate of annual per capita treatment needs for a given
population.

The RRM was originally calculated using service minutes as the workload
measure. The IHS now uses Relative Value Units (RVUs) rather than
service minutes as the workload measure, and there is no direct
conversion factor between the two. Therefore, to eliminate the need to
devise a new RRM based on RVUs, the RRM was converted to measure
resource needs based on service population. An estimate of the resource
needs of a dental program based on the size of the population it serves
(dentists, auxiliaries, and operatories) can be found in Table 1.

**TABLE 1**

**Resource Requirements Methodology**

**Dental Staff and Facility Recommendations for Selected Ranges of
Service Population**

  ------------------ -------------- ----------------- -------------- -----------------
  **Population       **Dentists**   **Auxiliaries**   **Total        **Operatories**
  Range**                                             Staff**        

  0 - 700            0              0                 0              0

  700 - 906          1              2                 3              3

  907 - 1284         1              3                 4              4

  1285 - 1789        1.5            5                 6.5            5

  1790 - 2421        2              7                 9              6

  2422 - 2673        2              8                 10             7

  2674 - 2926        2              9                 11             8

  2927 - 3431        3              10                13             9

  3432 - 4042        3              12                15             10

  4043 - 4547        4              13                17             11

  4548 - 5052        4              15                19             12

  5053 - 5557        4              17                21             13

  5558 - 6063        5              18                23             14

  6064 - 6315        5              19                24             15

  6313 - 6821        6              20                26             16

  6822 - 7073        6              21                27             17

  7074 - 7578        7              22                29             18

  7579 - 7831        7              23                30             19

  7832 - 8336        8              24                32             20

  8337 - 9094        8              27                35             21

  9095 - 9600        9              28                37             22

  9601 - 10,105      9              30                39             23

  10,106 - 10,610    9              32                41             24

  10,610 and over    Revert to the                                   
                     beginning of                                    
                     the chart to                                    
                     identify                                        
                     additional                                      
                     resources                                       
                     required to                                     
                     meet need in                                    
                     excess of                                       
                     10,610                                          
                     population                                      
  ------------------ -------------- ----------------- -------------- -----------------

It is recommended that no dental clinic be over 24 operatories. Larger
clinics are inefficient. They also present access problems for dispersed
populations.

Note: Auxiliaries include dental assistants, dental hygienists, and
clerks.

The IHS webpage for the dental RRM is located at:
<http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ac-dental.asp>

**Health Systems Planning Process Overview**

The Indian Health Service (IHS), in meeting its mission of providing
health care to the Native American population of the United States, is
involved in the design and construction of a wide range of health care
facilities. IHS involvement in these health care facilities construction
projects may be either planning, design and construction or if the
project is to be managed by a tribe, funding and consultation with the
tribal or Alaska Native organization. The IHS uses the Health System
Planning (HSP) Process to establish the IHS supportable project
services, size, and design criteria for health care facility
construction. The process uses specifically designed software to project
space needs and layouts for the different components of a health care
facility. The staffing projections from the Resource Requirements
Methodology (RRM) for the proposed facility are entered into the HSP
system and in turn the HSP projects the space needs.

The goals of the HSP process are to provide the IHS with a better,
faster and more cost effective way of developing Program Justification
Documents (PJD), Program of Requirements (POR), and facility design.

**Guide for Preparing a Request for Contract (RFC)**

Dental program personnel may find that their program is in need of goods
or services (i.e., equipment or contract dental services from a
specialist or general dentist) not readily available from Federal
Government sources. When this occurs, an acquisition from the private
sector may be necessary. Large purchases of goods or services require a
contract between the Government and the supplier of those goods or
services. This includes obtaining bids from three different vendors
([www.gsa.gov](http://www.gsa.gov/)). If only one source is available,
then a Justification for Other than Full and Open Competition (JOFOC
)has to be completed and submitted citing FAR 6.302-2- Unusual and
Compelling need ([http://www.arnet.gov](http://www.arnet.gov/)) The role
of project officer for the acquisition is usually filled by the program
personnel. The project officer is responsible for coordinating with
acquisition officials on projects for which contract support is being
considered, as well as for technical monitoring and evaluation of the
contractor's performance after the contract has been awarded. Providers
need daily supervision if they sign a personal services contract but do
not if they sign a non-personal services contract. Non-personal services
contracts are preferred over personal services contracts by most
facilities. On the other hand, because of the required level of
supervision, personal services contracts provide the contractor coverage
under the Federal Tort Claims Act whereas non-personal services
contracts do not. Many providers therefore prefer the personal services
contract because they are not responsible for personal malpractice
coverage, which is required under non-personal services contracts. This
guide has been written to assist program personnel in the role of
project officer.

**Definition of a Contract**

A contract is a mutually-binding legal relationship obligating the
seller to furnish the supplies or services (including construction) and
the buyer to pay for them. It includes all types of commitments that
obligate the Government to an expenditure of appropriated funds and
that, except as otherwise authorized, are in writing. In addition to
bilateral instruments, contracts include (but are not limited to) awards
and notices of awards; job contracts; orders, such as purchase orders,
under which the contract becomes effective by written acceptances or
performance; and bilateral contract modifications.

**The Contracting Process**

It is a requirement that anyone serving as a project officer must
complete Basic Project Officer's Training. This is a five-day training
course presented by the Department of Health and Human Services. The
Area Office Division of Acquisition Management can be contacted for
enrollment information, availability, and scheduling.

When the need for a contract has been identified and the program staff
have basic knowledge of the types of contracts available, they are ready
to begin the contracting process. It is at this point that they are
strongly encouraged to contact the Division of Acquisition Management.
The contracting officer will assign a contract specialist to lead and
assist them through the contracting process successfully.

The negotiated contracting process has three phases: preparation for
solicitation, solicitation and award, and post-award administration.

I.  **Preparing for the Solicitation**

> The first phase of the contracting process, preparing for the
> solicitation, is designed to produce two major documents: the
> Acquisition Planning Document (APD) and the Request for Contract
> (RFC).

**A. Advance Planning**

> Planning for an acquisition is the best way to ensure that the product
> or service will be acquired in the most efficient manner. Advance
> planning is critical to assuring that the contract award takes place
> in time to receive the goods or services when they are needed. Advance
> planning is comprised of three phases, which are briefly described
> below.

1.  **Developing the Concept**

> In this phase the agency realizes the need for an acquisition and
> defines, in broad terms, what effort will be required. Concept
> development serves to determine interest, scientific approaches,
> technical capabilities, and the relevant state of the art. It may
> include the assessment of prior contract results, literature searches,
> and discussions with technical and scientific personnel.
>
> Once the concept has been formulated, it must be reviewed for program
> relevance, need, merit, priority, and timeliness. It is beneficial to
> tie the concept development to the budget process, since the budget is
> the primary method of identifying, defining, and approving
> acquisitions.

2.  **The Acquisition Planning Document (APD)**

> The Acquisition Planning Document(APD) is an administrative tool
> designed to enable the project officer and the contracting officer to
> accomplish the tasks required to acquire goods or services within a
> specified time schedule. This document is developed before the
> preparation and submission of the Request for Contract (RFQ). It
> outlines a schedule of the steps necessary to accomplish the
> acquisition, serves to avoid and resolve problems early in the
> acquisition cycle, and therefore avoids delay of the award.
>
> The project officer usually assumes a lead role in developing an APD,
> while coordinating such development with the contracting officer.
> Project officer responsibilities also include finalizing the Statement
> of Work (SOW); preliminary development of the RFC, including required
> cost-estimates and delivery requirements; requesting the necessary
> funds; suggesting vendor sources; determining criteria for evaluation;
> obtaining required clearances; and submitting the completed RFC to the
> contract officer.
>
> **a. Statement of Work (SOW)**
>
> The Statement of Work is a critical document in the acquisition
> process. The SOW does the following:
>
> 1\. Describes the work to be performed or the services to be provided
>
> 2\. Defines the responsibilities of the IHS and the contractor
>
> 3\. Provides an objective measure so that both the IHS and the
> contractor will know when the work is complete and payment is
> justified.
>
> Ambiguous work statements can result in unsatisfactory performance,
> delays, disputes, and higher costs. It is highly recommended to meet
> with the contract specialist for assistance in writing the statement
> of work . Many service units have templates available for the
> preparation of SOWs (as well as JOFOCs).

b.  **Government Cost Estimates**

> The project officer must also prepare a detailed independent
> Government cost estimate for all requisitions. Unit-pricing, pricing
> by lot, or total pricing may be used when price is controlled by
> competition for specific off-the-shelf type items or services. This
> involves contacting vendors or contractors for their fee schedules.
> For a negotiated acquisition the estimate should include the following
> cost factors: labor hours by category, travel, per diem, malpractice
> insurance, aterials, consultants, subcontracting, overhead, general
> and administrative costs, and fees. At the Service Unit, Contract
> Health Services (CHS) funds are used to pay for contractor services
>
> Government cost estimates are privileged information and may not be
> disclosed to persons outside the Government or to any person who does
> not have a compelling reason to know. The exception is a solicitation
> for construction, which includes an estimated price range in the
> solicitation.
>
> The Division of Acquisition Management has a standard format and set
> of instructions for completing the Acquisition Planning Document
> (APD). It is imperative that program personnel contact the contracting
> officer before attempting to prepare this document.

3.  **Special Approvals and Clearances**

> In addition to the standard approvals required on an APD, some types
> require particular approvals or clearances. Program personnel should
> consult with the contracting officer to determine if any of these
> special approvals and clearances are required on the APD. On thing
> that is required, the APD must be completed and approved by personnel
> in Acquisitions Management before proceeding to work on the RFC

B.  **The Request for Contract (RFC)**

> The RFC is a request from the project officer that is needed to begin
> the process necessary to award a contract. It is vital to the quality
> of the acquisition and the timely placement of a contract that the RFC
> be transmitted to the contracting office as early as possible. As with
> the APD, the Division of Acquisition Management has a standard format
> and set of instructions for preparing the RFC. It is important that
> the project officer work closely with the contracting officer in
> preparing the request for contract, in order to ensure its accuracy,
> completeness, appropriateness, and applicability.

**II. Solicitation and Award**

The request for contract reflects the results of acquisition planning.
It gives contracting personnel the information they need to make
necessary determinations about how the acquisition will be conducted and
how a contract will be awarded. It enables them to prepare and issue a
solicitation document which tells prospective offerors what the
Government needs, what terms will govern the anticipated contract, and
how to submit proposals or bids. Advertisement is required in Fed Biz
Ops for a period of 30 days ([www.fbo.gov](http://www.fbo.gov/)).

The bids, or technical and cost proposals submitted by offerors, are
evaluated separately by personnel working under the direction and
supervision of the contracting officer. Usually a group called the
Technical Evaluation Panel is assembled to evaluate the technical
proposals. The criteria for evaluation developed in the APD are used at
this point. The contracting officer retains the cost/price proposals and
assesses them with assistance, as needed, from contracting, legal, and
audit personnel. The contracting officer is responsible for the
selection of the offeror to be awarded the contract. The contracting
officer's decision should take into consideration the recommendations of
the program official, Technical Evaluation Panel, or other personnel
directly involved in the evaluation process. Of prime importance in
making the selection is the solicitation language concerning the
evaluation criteria and basis for award.

All contractors are subject to character investigations in accordance
with P.L. 101-630 "Indian Child Protection and Family Violence Act of
1990."

**III. Post-Award Administration**

Administration of a contract begins after negotiations have been
successfully concluded and the contract has been signed; it ends at the
closeout of the contract when performance has been completed and the
contractor has received its final payment. The project officer must
monitor a contractor's progress closely and make known to the
contracting officer potential problems that threaten performance so that
remedial measures may be taken. Contract administration includes all the
functions and duties relating to such tasks as:

-   

-   Monitoring the contractor's technical progress This includes
    overseeing the contractor's time and daily attendance for a period
    of two weeks written on a self-certification form

-   

-   Approving invoices for payment in accordance with contractual terms
    and signing and submitting invoices to Acquisitions Management (AM)
    citing "certifying to the best of my knowledge that supplies and/or
    services have been received and are acceptable in accordance with
    the terms of the contract... (signature)............Project
    Officer........Date. "Invoices need to be printed on the letterhead
    of the vendor's r contractor's stationary or they may not be
    processed by AM for payment. Electronic Funds Transfer shall be the
    utilized method of payment.

-   

-   Controlling government property. Contractors shall wear visible
    Government-provide identification at all times while on the premises
    of the I..S aclity.

-   

-   Monitoring subcontractors

-   

-   Reviewing purchase orders for accuracy and completeness

-   

-   Overseeing contract modifications and terminations where authorized.

-   Performing other administrative tasks required by the contract.
    Contractor shall provide worker's compensation, income tax
    withholding, social security payments, health insurance.

Contracts can be written for up to a five year period.

Problems:

If this process is not followed and an invoice is received from a
contractor or vendor for goods and services already received, then a
***[ratification]{.underline}*** will need to be done by the project
officer. However, a ratification also includes parties that have signed
for the project officer but were not given signature uthority for this
individual. If the ratification is not approved by local administrative
personnel, the project officer is responsible for payment of services
out of pocket. ***It is imperative to avoid a ratification because it is
a very time consuming process, puts the officer at financial risk, and
could result in administrative action.***

Be aware that submissions of APD's and FQ's can tae several months to
process.

**References**

*Indian Health Service Manual,* Section 5

*Basic Project Officer Student Manual*

*Advanced Project Officer Student Manual*

The above references can be obtained from the Division of Acquisition
Management in the Area Offices.

**Oral Health Surveys**

Periodically the Indian Health Service Dental Program conducts oral
health surveys in order to determine oral health status, trends, and
treatment patterns among American Indians/Alaska Natives (AI/AN). Data
provided by these surveys are valuable for estimating the resources
required to treat the oral health problems of Native Americans and for
evaluating the effectiveness of interventions that have been initiated
to reduce the prevalence of oral diseases in this population.

Until the late 1970's, periodic surveys were not considered a high
priority, because epidemiological data were collected on all patients
via the dental examination forms and analyzed at Headquarters. This type
of data collection was discontinued because the data did not vary
significantly from year to year. It also required valuable dental
resources to collect the data on every patient who received a dental
exam.

Since the termination of routine data collection on all patients, three
major oral health status surveys have been conducted to determine
progress in reducing the prevalence of oral diseases among American
Indians and Alaska Natives:

1.  The 1983-1984 IHS Oral Health Survey was a nationwide dental
    patient-based survey which was instrumental in calling attention to
    the extensive oral health problems and needs of Native Americans.
    One of the findings of the survey was that the caries prevalence
    among AI/AN schoolchildren was approximately twice that of
    schoolchildren in the general U.S. population.

2.  In 1988-1990 the IHS participated in the International Collaborative
    Study of Oral Health Outcomes (ICS-II). Two IHS Areas and a total of
    four Service Units were included in the survey. A combined site made
    up of the Chinle and Shiprock Service Units represented the Navajo
    Area. In the Aberdeen Area, the Pine Ridge and Rosebud Service Units
    participated. Survey participants were drawn from a random sample of
    people registered at the local Indian hospital in each Service Unit.
    The ICS-II was designed to provide new information on the relative
    contributions of socioenvironmental, delivery system, and personal
    lifestyle factors to oral health status and the cost of care.

> Compared to other ICS-II sites, findings from the Native American
> sites showed more caries, more periodontal disease (and higher
> severity of perio disease), more untreated oral disease, more missing
> teeth, more edentulism, and more compromises to quality of life of the
> people as a consequence of their oral conditions. Also, the Native
> American groups tended to utilize fewer dental services, practiced
> less oral self-care, perceived their dental health to be worse,
> disliked the way their teeth looked, and perceived the acceptability
> of dental care available to them less favorably than people from other
> sites.
>
> One of the important aspects of the ICS-II was that it enabled the IHS
> to compare survey results drawn from a random sample with past and
> future dental patient-based survey results, as well as with other U.S.
> sites and other countries. Additional information on the ICS-II can be
> found in "The World Health Organization International Collaborative
> Study of Oral Health Outcomes (ICS-II): Preliminary Results from
> Indian Communities," which is referenced in the bibliography at the
> end of Section I.

3.  The 1991 IHS Oral Health Survey was a dental patient-based survey
    similar to the 1984 survey, except that the protocol had been
    updated considerably. Almost 25,000 dental patients of all ages were
    examined at over 100 IHS, Tribal, and Urban Indian clinics
    throughout the country. Items such as fluorosis, anterior tooth
    trauma, access to fluoridated water, medical conditions, oral
    lesions, and patient access issues were included in the survey. The
    results of the 1991 IHS survey are summarized in a monograph
    entitled, "Oral Health of Native Americans: A Chartbook of Recent
    Findings, Trends, and Regional Differences."

> The findings of the ICS-II survey and the 1991 IHS survey were quite
> similar, suggesting that the dental patient-based surveys typically
> used by the IHS are probably adequate for determining the health
> status of communities. Although using a community-based random sample
> is still the ideal method, a dental patient-based survey is
> logistically much easier to accomplish.

4.  The 1999 IHS Oral Health Survey was also a dental patient-based
    survey similar to the 1984 and 1991 surveys. For the 1999 Oral
    Health Survey, the IHS collected data from 12,881 dental patients
    ranging from 2 to 96 years. In some cases, the findings point to
    conditions that are continuing to improve, such as children's access
    to preventive dental sealants. But more often, the data reveal
    stable or even worsening oral health trends for thousands of AI/AN
    families. A copy of this survey can be found at:
    <http://www.ihs.gov/MedicalPrograms/Dental/downloads/Oral_Health_1999_IHS_Survey.pdf>.

**Pathfinder Surveys**

For local programs or IHS Areas wishing to conduct their own surveys, a
pathfinder survey is suggested. The pathfinder methodology is a
practical, economic survey sampling technique. The surveyor is able to
use a smaller-than-normal sample by focusing on index ages such as 12,
15, 35-44, and 65-74, which allows the survey to be completed with less
resources than a larger survey would require. Contact your Area Dental
Officer or IHS Division of Oral Health for more information, or obtain a
copy of the publication "*Oral Health Surveys - Basic Methods,* World
Health Organization, 4th ed, Geneva, 1997.

**Scientific Inquiry (Research)**

Continual observation and the formulation of opinions based upon these
observations are activities in which virtually all dental professionals
are involved. Formal scientific inquiry, or research, on the other hand,
is conducted by relatively few dentists, either in private practice or
in IHS, Tribal, or Urban Dental Programs. Nonetheless, formal research
does have a place in the IHS Dental Program because of the benefits that
it can provide for American Indians and Alaska Natives.

IHS-supported Dental Programs benefit from new knowledge in research
areas being investigated by the National Institute of Dental Research,
dental schools, state dental directors, schools of public health, and a
variety of other dental and public health professionals. Therefore,
relatively little emphasis should be directed toward scientific inquiry
into basic research in anatomy, physiology, microbiology, chemistry,
pharmacology, systemic and topical fluoride compounds, or basic
education and behavioral science research.

When formal scientific inquiry is conducted in Dental Programs which
serve American Indians and Alaska Natives, it should be directed toward
those areas having the greatest potential impact on the oral health of
the Indian people. Such research should emphasize methods of application
of proven or promising oral disease prevention and control measures or
techniques for the delivery of oral health services. For example, the
1993-1995 "Pima Periodontal Disease and Diabetes Clinical Trials" have
provided the Indian Health Service with a new clinical regimen that has
been shown to be effective in the treatment of periodontal disease.

Chapter 7 of Part 1 of the *Indian Health Service Manual* provides
detailed information on "Research Activities in the Indian Health
Service." Anyone in IHS, Tribal, or Urban Dental Programs who is
planning to attempt a research project should review this information
before proceeding. The manual is available at IHS Headquarters in
Rockville, MD, and can be accessed online from the IHS homepage. Part 1,
Chapter 7 is available at
<http://www.ihs.gov/PublicInfo/Publications/IHSManual/part1/pt1chapter7/pt1chpt7.htm>.

Especially important is the approval process that is necessary before
research can be conducted by Indian health programs. This includes the
following:

-   Local Approval

    -   Tribal government

    -   Service Unit or Tribal health program

-   Area Approval

    -   Area Research and Publication Committee (RPC)

    -   Area Institutional Review Board

-   National Approval

    -   National Institutional Review Board

Research involving survey questionnaires must also be approved by the
Office of Management and Budget (a time-consuming process), unless the
survey is part of clinical care. Detailed information on the approval
process can be found in the *IHS Research Manual.*

**EMTALA**

In 1986, Congress enacted the Emergency Medical Treatment & Labor Act
(EMTALA) to ensure public access to emergency services regardless of
ability to pay. Section 1867 of the Social Security Act imposes specific
obligations on Medicare-participating hospitals that offer emergency
services to provide a medical screening examination (MSE) when a request
is made for examination or treatment for an emergency medical condition
(EMC), including active labor, regardless of an individual\'s ability to
pay. Hospitals are then required to provide stabilizing treatment for
patients with EMCs. If a hospital is unable to stabilize a patient
within its capability, or if the patient requests, an appropriate
transfer should be implemented.

<http://www.cms.hhs.gov/manuals/Downloads/som107ap_v_emerg.pdf>

Special responsibilities of Medicare hospitals in emergency cases

<http://a257.g.akamaitech.net/7/257/2422/09nov20051500/edocket.access.gpo.gov/cfr_2005/octqtr/pdf/42cfr489.24.pdf>

The *IHS Provider* published an update of EMTALA in Indian Country in
2004. This overview can be found at:
<http://www.ihs.gov/publicinfo/publications/healthprovider/issues/prov0804.pdf>

**Health Insurance Portability and Accountability Act (HIPAA)**

The Health Insurance Portability and Accountability Act (HIPAA) is also
known as the Kennedy-Kassebaum bill. It was first proposed with the
simple objective to assure health insurance coverage after leaving a
job. Congress added an Administrative Simplification section to the
bill.

The goal of the Administrative Simplification section of the bill was to
save money. It was requested and supported by the health care industry
because it standardized electronic transactions and required standard
record formats, code sets, and identifiers.

The impact of Electronic Standardization, however, was that it increased
risk to security and privacy of individually identifiable health
information. Because Congress did not provide legislation defining the
privacy and security requirements of HIPAA, the Department of Health and
Human Services (DHHS) was required to provide them.

There are currently four proposed or final rules from DHHS for HIPAA:

1.  Transaction and Code Set standards

2.  Privacy standard

3.  Security standard

4.  Identifier standards

**HIPAA Project Team**

The strategic plan developed by the headquarters HIPAA team calls for
them to interpret the regulations and develop national policies needed
to comply with them. The team will cooperate with regional and national
I/T/U programs and provide them with related information and materials
as they are developed for HIPAA compliance.

It is expected that the IHS Area Offices will develop Area HIPAA
compliance plans that will include policy development needed to achieve
HIPAA compliance at the Area level. Also, the Area Offices will work
with the local I/T/U programs in helping them become HIPAA compliant.

**Additional Information**

The IHS has developed multiple resources to aid in the implementation of
the various HIPAA requirements. The homepage for IHS HIPAA resources can
be found at <http://www.ihs.gov/AdminMngrResources/HIPAA/index.cfm>.

By following the various links in the HIPAA home page, the reader can
access IHS Forms and Policies and Procedures; FAQs; Privacy, Security,
and Identifier Standards; HIPAA training resources and other pertinent
information.

More information about HIPAA can be found by clicking on the following
links:

[[Department of Health and Human Services Questions and
Answers]{.underline}](http://answers.hhs.gov/cgi-bin/hhs.cfg/php/enduser/std_alp.php)
(click on question 15, "Generally, what does the HIPAA Privacy Rule
require the average provider or health plan to do?")

[[http://www.hipaa.org/]{.underline}](http://www.hipaa.org/)

[[http://www.ada.org/prof/resources/topics/hipaa/index.asp]{.underline}](http://www.ada.org/prof/resources/topics/hipaa/index.asp)

**SERVICE UNIT DENTAL PROGRAM BUDGET MANAGEMENT**

**Introduction**

Over the past several years, the IHS Dental Program budget has been
decentralized in most areas from the Area Offices to the Service Unit
level. This change has made it necessary for each Service Unit Dental
Program Chief to become familiar with IHS dental budget allocation,
tracking, and management. While there are many ways to keep track of the
local dental budget, the method listed below has proven to be useful in
simplifying the process and making budget information readily available.
The process described below consists of filling in local program numbers
into an Excel spreadsheet in which the formulas needed to do various
budget calculations have been embedded. A file containing this
spreadsheet and a file with a sample spreadsheet with sample numbers
already filled in are included in this chapter of the OHPG.

**Budget Spreadsheet Background**

The service unit budget worksheet is an Excel spreadsheet, which can be
used to plan your fiscal year budget. By planning a fiscal year budget,
you will have the information necessary to make decisions regarding
personnel, supplies, equipment, and so forth. All too often, service
unit leadership will come to the dental chief late in the fiscal year
because the dental program is either out of money, or there is an excess
that needs to be spent in a short period of time. Prior planning can
assist the dental chief by identifying a budget surplus or shortfall
early in the fiscal year when there is time to react in a calm and well
thought out manner.

The budget worksheet can be used while meeting with finance or the
clinical director. When a shortfall is projected, the dental chief can
decide which spending areas can be reduced. Or, the chief can approach
the leadership for additional funds from third party collections.
Without documentation such as the worksheet, it is often difficult to
persuade leadership. When a surplus is projected, the dental program can
review its equipment needs, or perhaps fund a new program.

The initial set-up of the worksheet will take about three hours. It
could be delegated to a responsible clerk, once all of the information
has been gathered. Subsequent years can then be set-up within one hour
or so.

**Information Needed to Fill in the Spreadsheet**

The information necessary to complete the worksheet is as follows. It
should all be gathered prior to setting up the worksheet.

1.  ***Advice of Allowance***: This one-page document is available from
    your finance department. It documents the number of dollars which
    the dental line item budget will receive at your service unit. This
    memo is important, as it identifies the money to which the dental
    program is entitled.

2.  ***List of employees***. This list is available from either finance
    or human resources. It should include the Position Control Number
    (PCN), Job Title, Employee Name, Personnel System (Commissioned
    Officer (CO) or Civil Service (CS)), Grade and Step for Civil
    Service and/or rank and number of creditable years for Commissioned
    Corps, Series number (680 for dentists, 681 for assistants), Status
    (full or part time) and CAN number. Some service units will apply a
    different CAN number for dental employees who work at satellite
    clinics.

3.  ***Service Unit Flowback Sheet***. This sensitive form is protected
    by the Privacy Act. But, the dental chief has a right to receive it,
    as they are responsible for the dental budget. This information
    should be entered into the worksheet by the chief only. It is
    inappropriate for a clerk to have access to this data. The flow back
    sheet contains, by civil service employee, the gross pay by pay
    period, the FICA amounts, Federal Employee Health Benefits (FEHB or
    the dental program's portion of health insurance to be paid),
    Retirement (CSRS or FERS), and Federal Employees Group Life
    Insurance (FEGLI) which will come from the dental budget. CS
    salaries may also be found at
    <http://www.opm.gov/oca/06tables/indexGS.asp>

4.  ***Cost of Living Allowance*** (COLA). This is the increase in pay
    that employees get each January. There are usually different amounts
    for CS and CO staff.

5.  The amount of dollars for ***Continuing Dental Education*** (CDE)
    which is determined by either the chief or service unit leadership.

6.  ***Title 38 Bonus Pay*** for any CS dentists. This is available from
    the human resources office.

7.  ***Recruitment/Retention/Relocation Allowance*** (3R bonus) for any
    CS dentist who may receive it. Again, this is available from the
    human resources office.

8.  ***Commissioned Officer Basic Pay*** and ***Subsistence*** rates can
    be found at <http://dcp.psc.gov/PDF_docs/2006_paychart.pdf>

9.  ***Dental Special Pay Rates*** are available at
    <http://dcp.psc.gov/DSP_fact_sheet.htm>

10. ***Basic Allowance for Quarters*** ***(BAQ)*** can be found at:
    <http://www.military.com/benefits/military-pay/basic-allowance-for-housing-rates>

**Instructions For Setting Up The Work Sheet**

1.  Open the Excel spreadsheet. Notice the tabs at the bottom, "budget"
    and "salary". Click on these tabs to go back and forth.

2.  Click on Salary tab. Fill in the following:

    a.  PCN#,

    b.  category (full or part time),

    c.  title,

    d.  name,

    e.  grade and step,

    f.  series and CAN \#

> for each civil service employee within the top table. PCN numbers are
> important to track as they are your allowable positions. It may be
> allowed by your service unit to change, for example, a dental
> assistant position into a dentist position. PCNs are also helpful in
> tracking vacancies, and in determining which position you will
> recruit. The grade and step are important in order to define an
> employee's base pay per the pay chart. The series number is used to
> determine continuing education dollars.

3.  The spreadsheet is set up for pay period information. Therefore, if
    you enter the annual pay rate under CS Base Pay, you will need to
    divide by 26.2 pay periods. Use the formula: (=annual pay from pay
    chart)/26.2, without the parentheses (e.g. if the annual pay rate
    from the pay chart is \$26,311, the formula would be =26311/26.2).
    Enter the base pay for each CS employee.

> (For those not familiar with Excel, the "equals" sign (=) placed
> immediately before a number or symbol indicates that what follows is a
> mathematical formula: e.g., =A/B would mean A divided by B)

4.  Enter Title 38 bonus pay and 3R bonus in their respective columns
    for each employee who receives them.

5.  For the column titled, "Pay Periods Filled", enter 26.2 if the
    position will be filled for the entire year. If you have a vacancy
    or expect a vacancy, reduce the 26.2 pay periods by an amount you
    figure that the position will go vacant. The dollars that go unused
    when a position is vacant are often referred to as lapsed salary
    dollars. These dollars can be used to balance a budget with a
    shortfall, or to purchase additional equipment. It is important to
    know of and to track this information.

6.  Enter info for FICA, FEHBA, CSRS/FERS, and FEGLI from the flowback
    sheets. Again, these benefits are paid for through the dental line
    item budget.

The spreadsheet will then calculate the following:

-   total salary,

-   total benefits,

-   grand total (salary plus benefits), and

-   percent benefits for each employee and

-   will give a total.

Percent benefits may be of benefit to the chief. It is IHS policy to
determine an employee's benefits at a fixed percent (around 25%).
However, if the employees choose to not partake of the health or life
insurance benefits, then the program will see a total percent of less
than 25%. It is important to know that this extra money exists, and it
can be used for special projects.

The small table below the Civil Service section calculates additional
dollars that are required for:

-   COLA,

-   any Within Grade Increase that may occur (a figure of 1.8% is the
    rule of thumb),

-   cash awards (figured at 2% of total salaries). The cash awards
    figure can be adjusted down in order to balance a budget, but gives
    the chief a figure to use when planning the awards program.

For the Commissioned Officer table:

1.  Fill in all information for:

    a.  PCN #,

    b.  CAT,

    c.  Title,

    d.  Incumbent name,

    e.  Rank/years,

    f.  Series and

    g.  CAN

2.  CO Base Pay tables are set up on a monthly basis, as is the
    worksheet. Place the proper base pay amount for each employee, and
    place the Subsistence amount in Cell N59. There is a formula to
    place this amount in each employee's row.

3.  Enter the number of months during which the position will be filled.
    Again, this can be used to determine lapsed salary dollars which may
    become available.

4.  Total CO Salary is figured by formula.

5.  Enter ASP and any Accession bonuses into their respective columns.

6.  Enter any estimated change of station costs (including moving of
    household goods, travel, and dislocation allowance) for an officer
    who will move into or out of the service unit. The service unit is
    responsible for moving any CO into the area and for moving any
    officer away who separates. Travel costs for officers who transfer
    out are paid-by the receiving clinic.

7.  FICA is figured by formula.

8.  Enter Variable Special Pay (VSP), Basic Allowance for Housing (BAH),
    and any Multi-Year Retention Bonus (MRB).

9.  CO Subsistence will enter automatically.

10. The remaining columns are filled by formula.

The small table below the CO section calculates additional dollars
similar to that below the Civil Service Section.

Now, click on the "Budget" tab. You will notice several cells already
filled in from data calculated from the "Salary" tab. There are a few
cells that you will have to fill in manually.

1.  Sub-object 21.21, TDY is used for travel that is not CDE related. It
    should include travel for chiefs meetings, National Oral Health
    Conference representative's travel, and/or program reviews. You
    might use historical data by averaging those amounts actually used
    over a three year period.

2.  21.61 and 21.63, Permanent Change of Station can be figured on
    vacancy rates. Your service unit travel clerk can provide an
    estimate for you.

3.  22.21 GSA vehicles. You can project this by historical data or by
    going to the GSA website at
    <http://apps.fss.gsa.gov/vehicles/leasing/2006/>

4.  23.80 Communication is used for cell phones or for beepers. Use
    current contract/ARMS document figures.

5.  24.00 Printing is used for superbills, med history forms, pamphlets
    and so on. Use historical data.

6.  25.00 Services. This is for lab services, copy/fax machine
    maintenance agreements, or dentist personal service contracts. Use
    current projections from ARMS documents.

7.  26.00 Supplies. Use last year's historical data from ARMS and add an
    amount for inflation.

8.  31.00 Equipment. Enter the amount from your equipment wish list.

Some of the amounts in 1-8 above may need to be adjusted up or down in
order to balance your Total to the Advice of Allowance.

**Policies and Procedures**

The Joint Commission on Accreditation of Healthcare Organizations
defines Policies and Procedures as the \"formal, approved description of
how a governance, management, or clinical care process is defined,
organized, and carried out.\"

A Policies and Procedures (P&P) manual is, therefore, a series of
documents that describe how the dental clinic functions. The manual
provides instructions for all of the program\'s functions, including
procurement, health records, recruitment and retention of staff,
position descriptions, hours of operation, scope of services,
evaluation, etc.

Staff members of any healthcare organization come from diverse
educational backgrounds and points of view. Without guidance from an
established set of P&Ps, each person would develop individual strategies
to accomplish job responsibilities, which may be disjointed and lead to
inefficient and possibly ineffective clinic operations. The P&P manual
ties all functions together; it is the instruction manual that helps to
ensure smooth and efficient operations. It should be used to help orient
new staff to their jobs and to update current staff whenever policies or
procedures are changed. Summaries of various P&Ps can be made available
to the clinic\'s user population to explain why the clinic provides
services the way it does.

Establish a uniform or standard format for all Policies and Procedures
(P&Ps) used throughout the facility. A common format includes:

-   purpose of the policy

-   policy statement

-   a step-by-step description of the procedures required to implement
    the policy.

Most IHS facilities will already have an approved format for P&Ps that
the dental program should follow in developing its manual.

All P&Ps should be marked as either \"new\" or \"revised\", and should
be signed and dated by the person having authority to approve and
implement them. Policies should be reviewed at least annually and
revised as necessary.

**Sample Table of Contents**

The following section provides a sample table of contents for a dental
program P&P manual. The topics are only suggestions, as local service
unit policies may stipulate other topics that should or should not be
included in the manual. Many of the policies suggested in the Table of
Contents can be service unit policies and may not need to be developed
specifically for the dental program

**[SAMPLE POLICY AND PROCEDURE MANUAL]{.underline}**

**[TABLE OF CONTENTS]{.underline}**

Introduction

Facility or Service Unit Goals and Objectives

Facility or Service Unit Organizational Chart and Lines of Authority

Dental Program Goals and Objectives

I.  Facility Dental Program

-   Facility Dental Program Description

    -   Policy

    -   Purpose

    -   Dental Scope of Services/Functional Statement

    -   Description of Dental Facility

-   Organization

    -   Organization Chart

    -   Qualifications of Staff

-   Daily Program Operations and Priorities of Care

    -   Clinic Hours

    -   After Hours Procedures

> II\. Patients\' Rights and Responsibilities

-   Bill of Rights and Responsibilities

-   Confidentiality/HIPAA

-   Grievance Procedures

-   Release of Information

-   Informed Consent

-   Patient Education

-   Language Interpretation

-   Handling of alleged or suspected child abuse cases

> III\. Referrals

-   Emergency Patient (DDS unavailable)

-   Medical Consultation and Follow-up

-   Dental Specialist Consultation

> IV\. Emergency procedures

-   Medical Emergency (Code Blue)

-   Fire Evacuation Plan

-   Disaster Plan

V. Dental Program

-   Continuous Quality Improvement/Performance Improvement Plan

-   Technical Quality of Care Evaluations

-   Program Reviews

-   Prevention Programs

-   Levels of Care

-   Patient Management

    -   Eligibility

    -   Fee Schedule/Sliding Fee Schedule (if appropriate)

    -   Outpatients

        -   Emergency Patient

        -   New Patient

        -   Recall Patient

        -   Checking Blood Pressures, Blood sugars, etc.

        -   After-hours Emergency Coverage

        -   Prescriptions

        -   Narcotic Prescriptions

    -   Inpatients

        -   Admissions (Hospital and Emergency Room)

        -   Consults

        -   Inpatient seen in dental clinic

        -   Inpatient seen in a hospital room

        -   Inpatient prescriptions

        -   Property of patient

    -   Clinical Charts

        -   Charting Symbols and Procedures

        -   Approved Abbreviations

        -   Retention of medical records

        -   Retirement of inactive records

    -   Appointments / How to access the appointment system

    -   Broken and Cancelled Appointment Policy

    -   Recall Policy

    -   Deferred Services

    -   Referral Policy

    -   Use of Standing Orders

    -   Policy for Utilization of Dental Laboratories

    -   Adverse Drug Reaction Policy

    -   Drug Sample Policy

    -   Storage of Medications in the Dental Clinic

    -   Antibiotic Prophylaxis Policies

-   Operational Procedures

    -   Environmental Concerns

    -   Safety Policies

    -   Security Plan

    -   Equipment Maintenance Schedules and Repair Policies

    -   Inventory/Procurement Procedures

    -   Infection Control Protocols

        -   Needle Recapping

        -   Autoclave use and Monitoring

        -   Handwashing

        -   Surface Disinfection

        -   Exposure Control Plan and Bloodborne Pathogens

    -   Mercury Safety

    -   Biopsy Monitoring

    -   Response to medical device recalls and hazard notices

    -   Hazard Communications

VI\. Human Resources

-   Billets/Job Descriptions

-   Standards of Performance

-   Career Plans with Educational Requirements

-   Knowledge, Skills, and Abilities per Position

-   Staff Training

-   Volunteer Process

-   Student Requirements

-   Volunteer Process

-   Temporary/Intermittent Employees

-   Credentialing Process

-   Privileging

-   Orientation

-   Provision for Employee Health Services and Screening

-   Continuing Education Policy

-   Staff Grievance Procedures

-   Peer Review

> VII\. Short and Long-Term Plans

VIII\. Listing of Standard Forms

> IX\. Dental Reference Documents

**Additional Resources**

Appendix I of this chapter contains samples of Policies and Procedures
that have been used in IHS dental programs in the past. These samples do
not represent IHS policies or guidelines. Rather, they are examples that
should be used as templates to help dental clinics develop policies and
procedures for local circumstances.

The following links provide examples of Policies and Procedures manuals
and other clinic protocols currently in use by community dental clinics
around the country:

[[Tennessee Department of
Health]{.underline}](http://www2.state.tn.us/health/oralhealth/pdf/Contents.PDF)

[[Plan de Salud del Valle (Salud Family Health Centers, Fort Lupton,
CO]{.underline}](http://www.astdd.org/docs/policies.pdf)

[[Dental Program
Procedures]{.underline}](http://www.dentalclinicmanual.com/chapt4/section_01/topic_04/images/Dental Program Procedures.doc)

**Incident Reporting**

In 2003, the IHS launched a new web-based incident reporting system,
named *WebCident*. The new computer application, which meets all Federal
reporting requirements, was developed by IHS Environmental Health
Officers to replace the old, paper-based system. *WebCident* was created
by the IHS to document employee, patient, and visitor injuries and
illnesses, as well as hazardous conditions and certain property and
security incidents, all of which must be reported. This new system will
greatly improve the incident reporting process, which previously was
impeded by difficulties in proper form completion and routing. Also,
with the addition of computer support, the information can be better
analyzed to identify incident rates and trends. Incident information
will be made immediately available to supervisors and safety officers
for follow-up and corrective actions that will help prevent future
incidents.

*WebCident* has many features that make it superior to the paper-based
incident reporting system, and it is designed to be readily accessible
by any IHS employee with access to the IHS intranet. Among its many
features is that it will automatically generate reports required by OSHA
and other agencies, it does not require installation of a computer
program because it is web-based, and it will provide a set of data that
captures incidents nationwide. Personal information, such as employee
names is kept confidential; however, safety officers or researchers may
use the data set to identify injury and incident rates locally,
regionally, or nationally.

WebCident can be accessed on the IHS intranet at:
<http://webcident.ihs.gov/> or by clicking on the WebCident link on the
Institutional Environmental Health website at
<http://www.ihs.gov/NonMedicalPrograms/IEH/index.cfm>.

**APPENDIX I**

**SAMPLE POLICIES AND PROCEDURES**

+--------------------------------------------------------+-------------+
| Policy                                                 | Page Number |
+--------------------------------------------------------+-------------+
| 1.  Inspection and Review of Emergency Kit             | 2           |
+--------------------------------------------------------+-------------+
| 2.  Treatment of Minors                                | 3           |
+--------------------------------------------------------+-------------+
| 3.  Maintenance and repair of Dental Equipment         | 4           |
+--------------------------------------------------------+-------------+
| 4.  Broken and Cancelled Appointments                  | 5           |
+--------------------------------------------------------+-------------+
| 5.  Use, Storage, and Testing of Lead Aprons           | 6           |
+--------------------------------------------------------+-------------+
| 6.  Indications For Sedation                           | 7           |
+--------------------------------------------------------+-------------+
| 7.  Endodontic Policy                                  | 8           |
+--------------------------------------------------------+-------------+
| 8.  Dental Clinic Schedule and Hours of Operation      | 10          |
+--------------------------------------------------------+-------------+
| 9.  Safety policy                                      | 11          |
+--------------------------------------------------------+-------------+
| 10. Recall Policy                                      | 14          |
+--------------------------------------------------------+-------------+
| 11. Prosthodontics Policy                              | 16          |
+--------------------------------------------------------+-------------+
| 12. Granting of Dental Privileges                      | 18          |
+--------------------------------------------------------+-------------+
| 13. Eligibility for Care                               | 19          |
+--------------------------------------------------------+-------------+
| 14. Conscious Sedation                                 | 20          |
+--------------------------------------------------------+-------------+
| 15. Standing Orders for Dental Assistants and          | 23          |
|     Receptionist                                       |             |
+--------------------------------------------------------+-------------+
| 16. Succession to Authority in the Dental Clinic       | 24          |
+--------------------------------------------------------+-------------+
| 17. Treatment of Dental Emergencies in the Walk-in     | 25          |
|     Clinic                                             |             |
+--------------------------------------------------------+-------------+
| 18. Common Dental Abbreviations                        | 27          |
+--------------------------------------------------------+-------------+
| 19. Treatment of Intoxicated Patients                  | 32          |
+--------------------------------------------------------+-------------+
| 20. Drug Storage Review                                | 33          |
+--------------------------------------------------------+-------------+
| 21. Deferred Services                                  | 34          |
+--------------------------------------------------------+-------------+
| 22. Broken and Cancelled Appointments                  | 36          |
+--------------------------------------------------------+-------------+
| 23. Biopsies                                           | 37          |
+--------------------------------------------------------+-------------+
| 24. Procedure and Tray Setups                          | 38          |
+--------------------------------------------------------+-------------+
| 25. Management of Appointed Patients                   | 44          |
+--------------------------------------------------------+-------------+
| 26. Access to Medical Records in the Dental Clinic     | 45          |
+--------------------------------------------------------+-------------+
| 27. CHS Referral Policy                                | 46          |
+--------------------------------------------------------+-------------+
| 28. Disposal of Extracted Teeth and Oral Tissues       | 52          |
+--------------------------------------------------------+-------------+
| 29. Clinical Education Affiliation Agreement           | 54          |
+--------------------------------------------------------+-------------+

\_\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: INSPECTION AND REVIEW OF EMERGENCY KIT

Effective Date: Revision Date: Supersedes:

Distribution: DENTAL STAFF, SAFETY COMMITTEE

PURPOSE: To insure that the Dental Clinic\'s emergency kit is kept fully
stocked at all times, and to insure that all drugs in the emergency kit
have not exceeded their respective expiration dates.

POLICY: A check list of all items in the Dental Clinic\'s Emergency Kit
will be kept in the cabinet in which the kit is stored. On a monthly
basis and any time that the kit is used, the contents of the kit will be
checked against the list, and any missing or outdated items will be
replaced by the person checking the kit. The responsibility for the
monthly checking of the kit will be shared by all dentists on the staff.
The Deputy Chief of the Dental Program will develop a monthly schedule
for these reviews.

\_\_\_\_\_\_\_\_\_\_ DENTAL CLINIC

POLICY/PROCEDURE

Subject: TREATMENT OF MINORS

Effective Date: Revision Date: Supersedes:

Distribution:

PURPOSE: To provide for obtaining legal informed consent for treatment
of persons under the age of 18 years.

POLICY: Patients under the age of 18 must be accompanied by a parent or
guardian to provide informed consent before any dental treatment will be
rendered. This policy will be waived only under the following
circumstances:

1\. The minor patient is suffering from an acute dental emergency and
the patient\'s health and well-being might be adversely affected if
treatment is delayed.

2\. The minor patient has suffered a traumatically avulsed or fractured
tooth while at school and is accompanied by a school nurse or school
official.

3\. Once a treatment plan has been established, presented to the parent
or guardian, and agreed to by the parent or guardian, then follow-up
restorative work may be done without the presence of the parent or
guardian. However, the parent or guardian must still accompany the minor
patient if any extractions are to be performed.

PROCEDURE: When a patient under the age of 18 presents to the dental
clinic unaccompanied by a parent or guardian for exam or walk-in care,
and is not suffering from an acute emergency condition, the patient will
be asked to return to the clinic when he/she can be accompanied by a
parent or guardian. A copy of this policy will be presented to the
patient to give to the parent or guardian. Older brothers, sisters,
aunts, uncles, and grandparents are not to be considered as the guardian
of the minor unless the minor is in their legal custody.

Legally emancipated minors will be treated as adults.

­­­­­­­­\_\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: MAINTENANCE AND REPAIR OF DENTAL EQUIPMENT

Effective Date: Revision Date: Supersedes:

Distribution: DENTAL AND BIO-MED DEPTS.

PURPOSE: To insure that all dental equipment is maintained in safe and
effective working condition so as to minimize risks to patients and
staff and minimize down time due to equipment failures.

POLICY: Preventive maintenance of dental equipment will be the
responsibility of the Area Bio-Medical Engineering Department, and will
be conducted on a semi-annual basis according to their policies,
procedures, and schedules. Unscheduled repairs of dental equipment will
be the responsibility of the Bio-Medical Engineering Department and will
be conducted according to the policies and procedures of that
department. Preventive maintenance and repair logs are maintained by the
Bio-Med department.

PROCEDURES: 1. The Area Bio-Medical Engineering department will be
responsible for scheduling and conducting preventive maintenance in the
\_\_\_\_\_\_\_\_ Dental Clinic.

> 2\. For unscheduled repairs, Dental personnel will contact the
> \_\_\_\_\_\_\_\_ Bio-Med Department by phone, whenever possible, to
> apprise them of the needed repairs. Then, a Bio-Med work order will be
> completed by the Dental staff member and forwarded to the Bio-Med
> Department, with the back, yellow copy kept in the Maintenance and
> Bio-Med Log in the Dental office.

DENTAL CLINIC

POLICY/PROCEDURE

  ----------------------- ----------------------- -----------------------
  Subject: Broken And                             
  Cancelled Appointments                          

  Effective Date:         Revision Date:          Supersedes:

  Distribution:                                   
  ----------------------- ----------------------- -----------------------

PURPOSE:

Due to the large number of people who make appointments but fail to show
up for them or fail to give adequate advance notice when canceling them,
it has become necessary to have a policy on appointment responsibility.
Broken and cancelled appointments waste the clinic's very limited time
and hinder the dental program's efforts to improve the oral health
status of the people that we serve.

POLICY:

The Dental Program will allow only 2 broken appointments per six month
period. An appointment is considered to have been broken if any of the
following occur:

1)  the patient fails to show up for the appointment,

2)  the patient appears more than 15 minutes late for a scheduled
    appointment, or

3)  the patient calls to cancel an appointment with too little advance
    notice to allow that appointment time to be rescheduled with another
    patient ( 24 hours will be considered to be the minimum time
    necessary to avoid a broken appointment ).

Patients who wish to cancel dental appointments must do so a minimum of
24 hours in advance of their scheduled appointment. If less notice is
given without a valid excuse, the appointment will be considered to have
been broken.

PROCEDURE:

When a patient accumulates 2 broken appointments in a 6 month period,
that person will not be allowed to schedule any further routine
appointments for a period of 6 months following the second broken
appointment.

\_\_\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: USE, STORAGE, AND TESTING OF LEAD APRONS

Effective Date: Revision Date: Supersedes:

Distribution: DENTAL STAFF, X-RAY DEPT.

PURPOSE: To provide guidelines for the use, storage, and testing of
protective lead aprons in dental radiography.

> POLICY:

1.  Lead aprons shall be used for [all]{.underline} dental x-rays.

2.  Dual lead aprons shall be used whenever the patient is pregnant.

3.  Lead aprons shall be stored by hanging them on wall-mounted hooks in
    such a manner as to prevent them from being folded or crimped, which
    could violate the integrity of the lead barrier.

4.  In order to insure the integrity of each lead apron in use in the
    dental clinic, all aprons shall be tested by being exposed to x-rays
    over flat plane films in the Radiology department on an annual
    basis. The films obtained in this manner shall be reviewed by the
    Chief, Dept. of Radiology for the purpose of certifying the
    integrity of the aprons.

5.  Aprons not passing this test shall be removed from service by the
    Chief or Deputy Chief of the dental program.

INDICATIONS FOR SEDATION IN THE DENTAL CLINIC

1\. The pre-cooperative and the fearful, anxious or uncooperative child
whose disruptive behavior precludes the safe delivery of quality dental
care and whose developing psyche should not be exposed to the potential
emotional/psychological liabilities of treatment under duress.

2\. A patient who has had prior sensitization to, or exhibits an acute
anxiety reaction to the professional environment and has resisted
reasonable behavior modification techniques.

3\. A co-existing medical complication presenting either a relative or
absolute contraindication to treatment outside a sedation modality (i.e.
poorly controlled seizure disorder, severe cerebral palsy, etc.).

4\. Patients who are physically, mentally, or sensorially compromised
and whose disabilities present management problems in a fully conscious
state.

5\. Patients with severe orofacial trauma or requiring extensive oral
surgical treatment.

6\. The patient with extensive treatment needs who lives in a remote
area and has a verifiable transportation constraint.

SHIPROCK SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: ENDODONTICS POLICY

Effective Date: Revision Date: Supersedes:

Distribution:

PURPOSE: To establish a policy for the provision of endodontic services
in the \_\_\_\_\_\_\_\_\_\_\_\_ Dental Program.

BACKGROUND: Endodontic services fall within the higher levels of the IHS
Dental levels of care document. The majority of endodontic services are
relatively time consuming, requiring from two to three hours of chair
time per tooth from start to final restoration. In addition, most
endodontic services, excepting those necessitated as the result of
traumatic injuries to the teeth, are required because of previous long
term neglect on the part of the patient.

POLICY: 1. Endodontic services in the \_\_\_\_\_\_\_\_ Hospital Dental
Program will be offered to those patients who exhibit an adequate level
of oral health and hygiene to make the long-term success of the
procedure predictable. It shall be the sole responsibility of the
treating dentist to make this determination. Patients whose past dental
histories indicate long term neglect, frequent broken appointments,
and/or high levels of caries and/or periodontal disease will be
considered to be poor candidates for endodontics and will not be offered
the option of endodontics unless the treating dentist feels that there
are extenuating circumstances that justify the provision of endodontics.

2\. Anterior and bicuspid endo will be routinely offered to those
patients who meet the above criteria. However, due to the extreme amount
of time required for molar endodontics, molar endodontics will not
routinely be done. Molar endodontics may be offered to a few selected
patients based on age, oral health and hygiene, and the strategic
importance of the molar in the dental arch. Molar endodontics, when
provided, will be limited to first molars, unless a second or third
molar occupies the space of a first molar due to the previous loss of
the first molar, or the second molar is to be used as the distal
abutment for a dental prosthesis. The treating dentist, in consultation
with the Chief or Deputy Chief, Complex Dental Unit, will make these
determinations.

3\. All posterior endos will be restored with cusp-protecting
restorations. This will include both cast crowns and onlays when levels
of care allow for the provision of these services, and cusp protecting
amalgams.

4\. The dental program will make every effort to complete every
endodontic procedure that is started by the program, except for those
molar root canals that the patient(s) agreed to have completed at their
own expense at a private dentist.

> 5\. In general, endodontics will be treatment planned after other
> level I through III services have been provided.

PROCEDURES: 1. Endo patients who have root canals started in the walk-in
clinic will be instructed that they must schedule an appointment for a
routine examination before the root canal can be completed. If the
patient fails to follow-up, and the tooth again becomes symptomatic, the
patient will then be offered only extraction of the tooth, regardless of
whether the tooth is an anterior or posterior tooth. An information
sheet explaining these requirements will be given to all patients who
have endos started, and this will be recorded in the progress notes.

2\. Patients who have endodontics treatment planned as part of a routine
exam will, in general, have all other routine preventive and restorative
services treatment planned ahead of the endo. Exceptions to this would
include the tooth that is symptomatic and requires endodontic treatment
to stop the pain or active infection.

3\. Patients with rampant caries or numerous teeth which are pulpally
involved will be offered endodontics only for strategically important
teeth; the others will be extracted.

4\. Patients who have exceeded the clinic\'s broken appointment limit
will not be offered endodontics if they appear for treatment in the
walk-in clinic; rather, they will be offered only extractions.

\_\_\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: DENTAL CLINIC SCHEDULE AND HOURS OF OPERATION

Effective Date: Revision Date: Supersedes:

Distribution: DENTAL STAFF, CLINICAL DIRECTOR, DON

The dental clinic will be open to see patients from 8:00 AM until 12:30
PM Monday through Friday, and from 1:00 PM until 4:30 PM Monday,
Tuesday, Thursday, and Friday. The clinic will be closed from 12:30 PM
until 1:00 PM each day so that the staff can take a lunch break. The
clinic will also be closed to patients every Wednesday from 1:00 PM
until 4:30 PM to allow the staff to attend service unit committee
meetings, to order and re-stock supplies, to participate in staff
meetings and in-services, and other related non-clinical duties.

The dental clinic will be closed on all Government Holidays.

CLINIC SCHEDULE

A walk-in clinic will be scheduled every day that the clinic is open to
see patients with urgent or emergent dental problems. The hours of the
walk-in clinic will be the same hours that the clinic is open to see
patients. Patients may sign in for the walk-in clinic each morning from
8:00 AM until 11:30 AM and on Monday, Tuesday, Thursday, and Friday
afternoons from 1:00 PM until 3:00 PM. Patients will continue to be seen
until closing time each clinic day. The walk-in clinic will be staffed
by 1 dentist and 3 dental assistants, and 3 dental operatories will be
used to see the walk-in patients.

In addition to the walk-in clinic, the dental clinic will also have
appointment and expanded functions clinics, to be held during the same
hours of operation. All exam, prophy, perio, restorative, endodontic,
prosthetic, and most surgical appointments will be scheduled for these
clinics. Staffing of the appointment clinics will depend on the numbers
of dentists and dental assistants available, and will usually consist of
3 chairs of expanded functions and 1 or more chairs of general clinic
(where more specialized and time-consuming procedures are performed).

\_\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: SAFETY POLICY

Effective Date: Revision Date: Supersedes:

Distribution: SAFETY OFFICER, DENTAL STAFF

POLICY: The dental clinic will be a safe place to work with any unsafe
conditions corrected as soon as possible. All dental employees are
required to adhere to the set policy as written.

PURPOSE: To minimize the possibility of injury while employees are on
the job.

PROCEDURE: The following topics will be covered: responsibility,
electrical and storage safety, smoking, eye and hand safety, dental lab,
patient treatment areas, and environmental hazards.

RESPONSIBILITY

> As detailed by Presidential directive and subsequent organizational
> directives, supervisors have the responsibility to instruct all
> employees to see that any discrepancies from the policy are dealt
> with, and to have any unsafe conditions corrected as soon as possible.
> Employees have the responsibility to report any existing problem and
> to conduct themselves in a manner so as to eliminate any possibility
> of injury to themselves or to others. All employees have the
> responsibility to report any accidents. All employees should be
> familiar with hospital fire, safety, and disaster (F.S.D.) plans.
> Supervisors must keep copies of these procedures readily available in
> the clinic. The F.S.D. plans should be reviewed by each employee at
> least annually.

ELECTRICAL AND STORAGE SAFETY

> Inadequacies must be presented in writing to the service unit Safety
> Committee. Corridors and working areas should be kept free of
> obstacles, debris, or clutter which could cause falling accidents. Any
> new appliances or electrical equipment must be safety tested prior to
> being placed into use following service unit policies.

OXYGEN AND COMPRESSED GASES

> Emergency oxygen cylinders in the dental clinic will be stored on
> mobile carts. The pressure in emergency oxygen cylinders will be
> monitored and recorded by the dentists on a daily basis. Nitrous oxide
> cylinders will be kept on the Nitrous Oxide-Oxygen sedation unit, as
> will the oxygen cylinders used for this purpose. The pressure in these
> cylinders will be checked by the dentist prior to the initiation of a
> Nitrous Oxide-Oxygen sedation procedure, and changed whenever the
> pressure is too low to allow the safe completion of the procedure.
> Oxygen and Nitrous carts will be stored in readily accessible
> locations, but out of normal traffic patterns.

FLAMMABLE LIQUIDS

> All flammable liquids will be stored according to service unit
> policies, as determined by the Safety and Infection Control Committee.

HAZARD COMMUNICATIONS

> All dental employees shall be required to undergo the annual training
> on Hazardous Materials and Hazard Communications as provided by the
> service unit and as mandated by service unit policies and procedures
> as implemented by the Safety and Infection Control Committee. Material
> Safety Data Sheets will be maintained, in a notebook kept in the
> dental office, for all potentially hazardous materials in use in the
> dental clinic, as per service unit policies. This register will be
> maintained by the Staff Dental Officer. All materials in use in the
> dental clinic will be labeled according to the criteria set out in the
> Hazard Communications Standard and service unit safety policies.

ON THE JOB INJURIES

> All on the job injuries, needle sticks, etc. will be reported to the
> safety officer according to service unit safety policies using the
> standard incident report form.

DENTAL RADIOLOGY

> Lead aprons are to be placed on [ALL]{.underline} patients receiving
> x-rays. All permanent dental staff will wear monitoring badges. All
> x-rays will be taken from behind the protective shields.

MEDICAL EMERGENCIES FOR DENTAL PATIENTS

> 1\. [CPR]{.underline}: Dental staff will be trained to render CPR and
> receive refresher courses annually.
>
> 2\. [Emergency Life Support]{.underline}: The dental staff shall know
> where the emergency drugs are kept. The dental staff shall know where
> the emergency equipment is kept and how to operate it. The dental
> staff shall request medical staff support immediately at the onset of
> life threatening emergencies.

MERCURY HYGIENE

> The dental staff will abide by the Mercury Hygiene guidelines as
> adopted by the American Dental Association.

NITROUS OXIDE

1\. Nitrous Oxide equipment shall be of the fail safe variety.

2\. No Nitrous flows unless there is adequate pressure.

3\. Nitrous will not exceed 50% of the gaseous volume.

> 4\. All nitrous oxide equipment will be used with scavenging masks.
> All scavenging equipment will be vented to the outside.
>
> 5\. Until supplementary ventilation can be installed in the dental
> clinic, the use of nitrous oxide will be limited to those cases where
> sedation is necessary and CHS dollars are not available to refer the
> patient.

\_\_\_\_\_\_\_\_\_\_\_ DENTAL CLINIC

POLICY/PROCEDURE

  ----------------------- ----------------------- -----------------------
  Subject: RECALL POLICY                          

  Effective Date:         Revision Date:          Supersedes:

  Distribution:                                   
  ----------------------- ----------------------- -----------------------

PURPOSE: The presence of a recall program allows the dental department
to follow-up on all patients who enter the recall system and thereby
insure the quality and longevity of the services that have been
provided, and to maintain a state of dental health once it has been
achieved. In addition, the presence of a recall system helps to
reinforce to the patients the need for routine dental examinations and
routine care to protect their dental health.

POLICY: At the completion of all planned treatment, each patient will be
offered the opportunity to be placed on recall status. The recall period
for those patients who choose to enter the recall system will be
established by the treating dentist and will be individualized to the
patient\'s needs based on previous disease rate, presence of space
maintainers, presence of prostheses, oral hygiene, etc.

PROCEDURE: 1. Upon completion of all planned treatment, each patient
will be offered the opportunity to enter the recall system.

2\. Patients choosing to enter the recall system will be asked to
self-address a postcard or franked envelope.

3\. The dental receptionist will mark in the lower left-hand corner of
the card or envelope the month and year that the dentist has selected as
the recall period for the patient.

4\. The card or envelope will then be placed in the recall file in the
month that the recall is to occur.

5\. Once each month, the receptionist will remove all of the cards and
envelopes in the file for that month, attach a recall notice, and mail
the cards and envelopes to the patients.

6\. Recall notices will serve as a reminder only to the patients,
appointment slips will not be mailed with the notices. It will remain
the responsibility of the individual patients to schedule the recall
exam according to normal appointment procedures (see appointment
policy). The dental staff is too small to provide services to everyone
in the service population, so to provide open access to exam
appointments to those people in the recall system would in the long run
end up denying access to exam appointments to new patients who wish to
avail themselves of the services of the dental clinic. Therefore, the
recall system will serve as a reminder only.

\_\_\_\_\_\_\_\_\_\_\_ DENTAL CLINIC

POLICY/PROCEDURE

  ----------------------- ----------------------- ------------------------
  SUBJECT: Prosthodontics                         

  EFFECTIVE DATE:         REVISION DATE:          SUPERCEDES:

  DISTRIBUTION:                                   
  ----------------------- ----------------------- ------------------------

Purpose:

Prosthetics are very expensive both in terms of dollars and clinical
time. It is therefore necessary to insure that all prosthodontic
services provided in the \_\_\_\_\_\_\_\_ Dental Clinic go to only those
patients who have demonstrated the oral health practices necessary to
maintain the prosthetic device after it has been completed.

Policy:

In keeping with the public health concept of providing emergency,
preventive, and routine restorative procedures before more complex
rehabilitative services, all patients receiving prosthetics must first
receive all basic levels of care (i.e., periodontal, preventive,
restorative care) before prosthetic services are offered, without
exceeding the clinic's broken appointment limit.

Patients treatment planned for prosthetics must prove that they can
maintain an adequate level of oral hygiene to ensure the long term
success of the prosthesis.

All periodontal services needed to bring the teeth involved in the
prosthesis, both as abutments and as opposing occlusion, to PSR level I
or better must be provided prior to the prosthesis. Teeth not meeting
PSR level I criteria are not eligible for prostheses.

Stainless steel crowns are not acceptable as permanent restorations on
permanent teeth. They should be treatment planned for replacement with a
cast or porcelain crown.

If clinic scheduling should become overly backlogged, with scheduling
extending significantly more than three weeks in advance, prosthetic
services may be eliminated from the schedule of direct care services
being provided.

Because of the lengthiness of prosthetic appointments, broken
appointments will not be allowed. If a patient breaks a prosthetic
appointment, his/her treatment will be halted at that point.

Procedure:

Patients may be required to undergo an oral hygiene program to reduce
plaque indices to acceptable levels prior to receiving prosthetic
services.

Prosthetic services needed as a result of traumatic tooth fractures or
avulsions are to be prioritized higher than services needed as a result
of caries or periodontal neglect. In general, the prognosis for long
term success is greater in these cases.

Once prosthetic treatment has started, no broken appointments will be
allowed. If a patient breaks an appointment after prosthetic work has
started, the treatment will be terminated at that point and any unused
portions of their lab fees will be requested from the lab and returned
to the patient.

An information sheet detailing the requirements for prosthetics will be
provided to all patients entering that portion of their treatment plan.

\_\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: GRANTING OF DENTAL PRIVILEGES

Effective Date: Revision Date: Supersedes:

Distribution: ALL NEW DENTISTS, CLINICAL DIRECTOR

PURPOSE: To establish guidelines by which initial clinical privileges
will be granted to Dentists coming on duty in the \_\_\_\_\_\_\_ Service
Unit.

POLICY: Full clinical privileges will be granted for all level I, II,
and III services (from the IHS dental Schedule of Services). In general,
level IV and V services not pertaining to complex oral, periodontal, or
endodontic surgery, conscious sedation, reduction and fixation of
fractures of the jaws, and comprehensive orthodontics will also be
granted as full privileges. In general, privileges for the services
contained in the above list of exceptions (see attached copy of the
Dental Privileges Form for the specific procedures) will be granted as
limited until proof of additional training, experience, and competence,
as indicated by records of CDE, quality assurance activities, peer
recommendations, and peer review are available.

PROCEDURE: 1. Initial privileges are granted using the standard Navajo
Area Dental Privileges form, copy attached.

2\. Dentists wishing to increase their privileges must do so by applying
to the Medical-Executive Committee, through the Chief, Complex Dental
Unit, in writing for the increased privileges, and including
documentation of their training, competence, and experience to justify
the requested increase.

\_\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: ELIGIBILITY FOR DENTAL CARE

Effective Date: Revision Date: Supersedes:

Distribution: DENTAL STAFF, MEDICAL RECORDS, ALL COMMISSIONED OFFICERS

PURPOSE: To establish a policy that insures that all eligible patients
have access (at minimum) to services falling within level I of the
Indian Health Service Dental Schedule of Services at the
\_\_\_\_\_\_\_\_\_ Service Unit.

POLICY: Eligibility for care in the \_\_\_\_\_\_\_SU will be determined
by the Patient Registration Office and/or Medical Records. In general,
Native Americans and their descendants, and Commissioned Officers of the
Public Health Service and their dependents are eligible for care.

PROCEDURE Due to the extreme backlog of services needed by the local
Native American population, services for the dependents of Commissioned
Officers may be provided on a \"Space Available\" basis only (i.e. no
appointments may be given, dependents must wait for broken appointments
and other unscheduled openings in the appointment system in order to be
seen). Care for Commissioned Officers may be provided by appointment
(see Appointment Policy) but is limited to the same levels of care that
are provided to the Native American population. Dental care for all
non-beneficiaries, including dental emergency care, must be approved in
advance by the Service Unit administration and all necessary
non-beneficiary forms and arrangements for payment must be completed
before services will be rendered.

\_\_\_\_\_\_\_\_\_\_ DENTAL CLINIC

POLICY/PROCEDURE

  ----------------------- ----------------------- -----------------------
  Subject: Conscious                              
  Sedation                                        

  Effective Date:         Revision Date:          Supersedes:

  Distribution:                                   
  ----------------------- ----------------------- -----------------------

PURPOSE: To insure the safety of the patients and staff of the
\_\_\_\_\_\_\_\_\_ Dental Clinic.

POLICY: A. *Anyone seeking to perform conscious sedation must meet all
of the following qualifications and must be granted specific clinical
privileges for the use of the techniques:*

1\. Must have graduated from a school accredited by the American Dental
Association, American Medical Association or the American Osteopathic
Association. If an individual is a graduate of a foreign school, the
requirements mandated by each of the above named associations for
foreign graduates must be met.

2\. Must have received formal training via residency or internship in
the use of conscious sedation techniques ; or must have received formal
training in the administration of conscious sedation from an ADA or AGD
certified continuing education course. The training should include a
hospital anesthesia rotation with emphasis on airway management,
management of emergencies, pharmacology of sedative drugs, physical
evaluation of patients, and risk assessment.

3\. Formal training must include the use of equipment, the recognition
of medical problems which may exist, indications and contraindications
to conscious sedation, limitations of sedation, signs and symptoms of
adequate and inadequate sedation, complications that may arise, and the
treatment of these complications.

4\. Must maintain annual certification in CPR.

5\. Must demonstrate continued clinical competence in the use of
conscious sedation.

B. *Documentation and Limitations*

1.  All sedation techniques used will be maintained at levels defined as
    conscious sedation.

2.  At the termination of a sedation procedure, the dentist will record
    in the patient\'s chart all pertinent events that took place during
    the course of sedation, including the dose of all drugs used, vital
    signs obtained pre-op, post-op, and at a minimum of 15 minute
    intervals intraoperatively, adequacy of the depth of sedation
    obtained, and the patient\'s condition upon discharge from the
    dental clinic.

3.  A log of all sedation procedures, including date, patient\'s name,
    and chart number will be kept.

C. *The appropriate equipment and personnel must be present for the use
of conscious sedation.*

1.  Stethoscope and appropriately sized sphygmomanometer must be
    present.

2.  For all sedation techniques except anxiolytic sedation a pulse
    oximeter must be used throughout the duration of the procedure.

3.  For all sedation techniques except anxiolytic sedation, monitoring
    of the vital signs must be done by an appropriately trained member
    of the operating team other than the dentist or chairside assistant.

D. *Procedural Controls for all Sedations*

1.  Conscious sedation will be used only on those patients on whom other
    forms of behavior modification are either contraindicated or
    ineffective (i.e. indications for its use must exist and be stated
    in the patient\'s records).

2.  A complete and current medical history, including appropriate
    medical consultations, current weight of the patient, and indication
    for using the sedation must be documented in the chart.

3.  Conscious sedation in the dental clinic will be limited to ASA class
    I and II patients.

4.  Use of any restraints, including the papoose board, must be
    documented.

5.  After any conscious sedation procedure, the patient will not be
    discharged until fully recovered or until the patient is oriented to
    time, place and person and is accompanied by a responsible adult.

6.  All patients receiving conscious sedation must be NpO for at least 4
    to 6 hours prior to the sedation procedure, and have this documented
    in the dental record.

7.  All patients scheduled to receive conscious sedation will receive
    both verbal and written instructions concerning the sedation
    procedure prior to the appointment, and the provision of such
    instructions will be documented in the dental chart. In addition,
    written consent must be obtained prior to the procedure.

E. *Nitrous Oxide-Oxygen Sedation*

1.  All gauges and flow meters will be in full view while in use.

2.  All rubber goods will be inspected prior to each use.

3.  Ambient atmospheric levels of waste gases will be measured twice a
    year.

4.  Leak testing will be performed quarterly.

5.  Hoses and breather bags will be replaced when visual inspection
    reveals deterioration or whenever leaks are found during testing.

6.  Equipment will be inspected for leaks and operational status prior
    to each use.

7.  Procedural Controls for Nitrous Oxide

    a.  N~2~O will be used only in operatories that have proper plumbing
        and ventilation for the scavenging and elimination of waste
        gases

    b.  Patient speech should be minimized and rubber dam should be used
        whenever possible.

    c.  The proper sized mask should be used to insure a tight seal.

    d.  N~2~O will not be used if any dental staff member is pregnant or
        is suspected of being pregnant unless that person can be
        isolated from waste gasses until ambient levels have returned to
        zero.

\_\_\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: STANDING ORDERS FOR DENTAL ASSISTANTS AND RECEPTIONIST

Effective Date: Revision Date: Supersedes:

Distribution: DENTAL STAFF

> Staff members will assemble and properly fill out forms 42-1, Patient
> Service Record, and 42-2, Patient Progress Notes. The assistant will
> verbally review the patient\'s Health History, check with the patient
> for any changes in health status, and date and initial the health
> status section of the 42-1 form.
>
> Dental auxiliaries trained and certified in dental radiography shall
> take bitewing x-rays for each exam patient according to FDA guidelines
> on frequency of radiographs, copy attached. A panoramic x-ray shall be
> taken on all new patients 8 years and older every 5 years. Emergency
> patients shall have a periapical x-ray taken of the area of the chief
> complaint. The dental officer shall be consulted in the case of
> \"loose\", exfoliating primary teeth prior to taking a periapical
> radiograph. Pregnant patients shall not have any x-rays taken without
> the order of a dentist.

\_\_\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: SUCCESSION TO AUTHORITY IN THE DENTAL CLINIC

Effective Date: Revision Date: Supersedes:

Distribution: DENTAL STAFF, CEO, CLINICAL DIRECTOR, CHS DIRECTOR

PURPOSE: To allow for the orderly transfer of administrative authority
in the dental program whenever the Chief and/or Deputy Chief of the
Dental program are away from the Service Unit.

POLICY: 1. In the absence of the Chief of the Dental Program, the Deputy
Chief will assume all of the duties and responsibilities of the Chief.

> 2\. In the absence of the Deputy Chief of the Dental Program, the
> Chief of the program will assume all of the duties and
> responsibilities of the Deputy Chief.
>
> 3\. In the absence of both the Chief and Deputy Chief of the Dental
> Program, the Staff Dental Officer, Advanced billet will assume the
> duties and responsibilities of both the Chief and Deputy Chief of the
> program.
>
> 4\. In the unlikely event that the Chief, Deputy, and Advanced Staff
> Dentist are all absent from the Service Unit at the same time, the
> Chief (or acting Chief) will designate by memo one of the remaining
> Staff Dental Officers to assume the role of Acting Chief until the
> return of one of the higher ranking members of the staff.

\_\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: TREATMENT OF DENTAL EMERGENCIES IN THE WALK-IN CLINIC

Effective Date: Revision Date: Supersedes:

Distribution:

PURPOSE:

> To establish a policy for the appropriate use of the dental walk-in
> clinic.

POLICY:

1.  The dental clinic will operate a walk-in clinic for the treatment of
    urgent and emergent dental problems during all hours that the clinic
    is open to see patients. Urgent and emergent dental problems
    include, but are not limited to pain, infection or swelling, broken
    fillings, loose teeth, broken prostheses, loose or broken space
    maintainers, and similar complaints.

2.  The minimum staffing for the walk-in clinic will be one dentist and
    two assistants, utilizing 3 chairs.

3.  Care provided in the walk-in clinic will be directed towards the
    relief of the patients\' chief complaints. If other dental problems
    are noted during the emergency oral exam, the patient will be
    apprised of the problem but will be required to use the normal
    appointment system if further care is desired (see appointment
    policy).

4.  The walk-in clinic will not be used to by-pass the normal
    appointment system or to receive routine care.

PROCEDURE:

1.  Patients who wish to be seen in the walk-in clinic must first sign
    in at Medical Records to have their chart sent to the Dental Clinic,
    and then proceed to the Dental reception desk where they must sign
    in to be seen.

2.  Patients will be seen first-come, first-served in the walk-in
    clinic. Exceptions to this rule can be made by the OD to allow for
    the immediate treatment of patients with true emergencies such as
    fractured or avulsed teeth, fractured jaws, rapidly progressing
    odontogenic infections with facial swelling and/or cellulitis, etc.
    In cases such as this, the dental assistant working in the walk-in
    clinic should inform the OD that such a patient is present in the
    waiting room and allow the OD to triage.

3.  The walk-in clinic may also be used to schedule such procedures as
    suture removals, follow-up visits, simple orthodontic extractions,
    etc. as time and experience permit. The dental receptionist will
    routinely schedule visits such as these at times when the walk-in
    clinic is usually less busy so as to not prolong the time that
    walk-in patients must wait to be seen.

PHS INDIAN HOSPITAL

ABBREVIATIONS COMMONLY USED IN THE DENTAL CLINIC

A assessment (as in SOAP)

AAA Acute Apical Abscess

ABU amalgam build-up

amal amalgam

AAP Acute Apical Periodontitis

AF apical file

ant anterior

ANUG Acute Necrotizing Ulcerative Gingivitis

appt appointment

B buccal

BA broken appointment

BBTD baby bottle tooth decay

BP blood pressure

BW bitewing x-ray

c with

CA cancelled appointment

calc calculus

CaOH Calcium hydroxide

Carbo Carbocaine

CB cement base

C&B crown and bridge

CD complete denture

CMCP Camphorated parachlorophenol

Cl cavity liner, copalite

cop copalite

Comp composite restorative material

CPA cusp protected alloy

CPITN Community periodontal index of treatment needs

Crn crown

D distal

d deciduous

DF defective filling ( restoration )

Dx diagnosis

Dent dental

Dy dycal

Ed D diabetes education

Ed P Perio Education

Ed C caries education

Ed F fluoride education

Ed MCH Maternal Child Health Education

Ed BBTD Baby bottle tooth decay education

Ed ST smokeless tobacco education

EF expanded function dentistry

Emer emergency

endo endodontics

epi epinephrine

ept electric pulp tester

ER emergency

eval evaluate

ext extraction

F facial

F/U full upper denture or follow-up

F/L full lower denture

FF final file

FGC full gold crown

Fl fluoride

FM full mouth

FMX full mouth extractions

FC, FMC formocresol

F/P full over partial denture

Fx fracture

form formocresol

GG gates glidden

ging gingival

GI glass ionomer cement

GP gutta percha

I incisal

I&D incision and drainage

Imp impacted

imp impression

inf inferior, informed

IRM intermediate restorative material

IV intravenous

IM intramuscular

L lower, lingual, left

LA local anesthetic

lab laboratory

LLQ lower left quadrant

LRQ lower right quadrant

lat lateral

LT length of tooth

LKP 1 leukoplakia I

LKP 2 leukoplakia II

LKP 3 leukoplakia III

LMP last menstrual period

M mesial, missing

mand mandibular

max maxillary

MB Maryland bridge

med(s) medication

MI mechanical instrumentation of the root canal

Md mandible

MH medical history

Mx maxilla

N2O-O2 nitrous oxide / oxygen

NTI no treatment ( indicated )

NV non-vital

O2 oxygen

0 occlusal or objective (as in SOAP)

occ occlusal, occlusion

OH oral hygiene, or overhang

OHI oral hygiene instruction

op operative ( procedures )

ortho orthodontic (s)

OS oral surgery

OD officer of the day

ops operative dentistry

P plan (as in SOAP)

P/ partial denture (s)

PA periapical x-ray

Pal palatal

Pan panoramic x-ray

PAP periapical pathology

PE partially erupted

pedo pedodontic (s)

perc percussion

perio periodontic/periodontal

PI partially impacted, patient informed

PMH past medical history

PO post operative, by mouth

POI post operative instructions

POIG post operative instructions given

Post posterior

PPC personal plaque control

PPD periodontal pocket debridement

prep preparation

prn as needed

prophy prophylaxis

prosth prosthodontics

Pt patient

PTC planned treatment completed

PTF prophy and fluoride treatment

pulp pulpotomy

q quadrant

quad quadrant

R right

RCT root canal therapy

R/O rule out

RPD removable partial denture

RT root tip

RTC return to clinic

Rx prescription, or therapy

ref reference point

S sealant, or subjective (as in SOAP)

SA silver amalgam

SBE subacute bacterial endocarditis

SC space closed

SI sealant intact

SM space maintainer or study model

SOAP subjective, objective, assessment, plan

STWNL soft tissue within normal limits

SR suture removal

SSC stainless steel crown

Sp Maint space maintenance

TA toothache

Temp temporary restoration

TMJ temporomandibular joint

TX treatment

TBP tooth brush prophy

TB tooth brush

U upper

UE unerupted

URG upper right quadrant

ULQ upper left quadrant

Wl working length

WNL within normal limits

w/o with out

x times

XC extraction due to caries

XO extraction for orthodontic reasons

XP extraction due to periodontal disease

XX extraction for other reasons

Xylo xylocaine 2% with epinephrine 1:100,000

ZOE zinc oxide and eugenol

ZnPO zinc phosphate cement

\_\_\_\_\_\_\_\_\_\_\_\_\_ DENTAL CLINIC

POLICY/PROCEDURE

  ----------------------- ----------------------- -----------------------
  SUBJECT: TREATMENT OF                           
  INTOXICATED PATIENTS                            

  EFFECTIVE DATE          REVISION DATE:          SUPERCEDES:

  DISTRIBUTION:                                   
  ----------------------- ----------------------- -----------------------

PURPOSE: To provide a protocol for the treatment of intoxicated persons
who present themselves to the dental clinic requesting care.

POLICY: Intoxicated individuals will not be treated in the dental
clinic.

PROCEDURE: If a patient, in the judgment of the treating dentist, is
under the influence of alcohol or other intoxicating substances, he/she
will be asked to leave the clinic and return when sober for care.
Security will be called to remove the intoxicated patient if he should
become belligerent or abusive. This policy is necessary for the
following reasons:

1\. Intoxicated patients are often unable to remember or to follow
post-operative instructions.

2\. Intoxicated patients are more likely to become nauseated during or
after dental treatment.

3\. Intoxicated patients cannot give adequate medical histories.

4\. Intoxicated patients cannot be given appropriate pain medications
due to the possible interactions between the pain medication and the
intoxicating substance.

5\. Intoxicated patients have in the past become abusive, unmanageable
and violent while receiving treatment.

\_\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: DRUG STORAGE REVIEW IN THE DENTAL CLINIC

Effective Date: Revision Date: Supersedes:

Distribution: CHIEF, PHARMACY, AND P&T COMMITTEE

POLICY: The members of the Dental Staff shall make quarterly reviews of
all Pharmaceutical items stored in the dental clinic.

PURPOSE: To insure that all Pharmaceutical items used in the dental
clinic are stored properly and safely and have not exceeded their
expiration dates.

PROCEDURE: 1. Once each quarter, a dental officer, to be designated by
the Dental Chief, will be responsible for surveying all dental units and
storage areas for the storage of Pharmaceutical items. The dental
officer will look specifically for expiration dates on such items, and
for the safe and appropriate storage of such items.

> 2\. Any outdated Pharmaceutical products will be immediately removed
> from the clinic and disposed of in a manner consistent with the
> policies and procedures of the Pharmacy department.
>
> 3\. Pharmaceutical items which are used internally will be stored
> separately from pharmaceutical items which are used externally.
>
> 4\. All drugs will be stored separately from other chemical products
> which are covered by the Hazard Communications policy.
>
> 5\. A report of each drug storage review will be made available to the
> Dental QA Coordinator, to the Chief of the Pharmacy Department, and to
> the P&T Committee.

\_\_\_\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: Deferred Services

Effective Date: Revision Date: Supersedes:

Distribution: \|

PURPOSE:

> Contract monies are usually available to cover services falling within
> levels I through III of the IHS Schedule of Services. In addition,
> clinical backlogs often make it impossible for the dental program to
> provide anything but level I through III care. Many of our patients
> would benefit from the provision of higher levels of care but cannot
> receive them due to the unavailability of funds to pay for the
> services or the lack of time for the clinic to provide them. This
> policy will identify a method of tracking and prioritizing these
> deferred needs.

POLICY:

> In order to become eligible to be placed on the deferred services
> list, a patient must first complete all needed services within levels
> I through III without exceeding the broken appointment limit, and
> agree to be placed on recall status. At the completion of this
> treatment, the patient will be offered the option of continuing with
> the higher level services at his/her own expense (ONLY WHEN THE CLINIC
> IS ABLE TO PROVIDE THESE SERVICES WITHIN ITS CURRENT SCHEDULE OF
> SERVICES), or having his/her name placed on the deferred services
> list. Patients choosing to have their names placed on the deferred
> services list will be listed by name, service (and level of service)
> needed, and the date their name was placed on the list.
>
> If, due to excessive backlogs in the appointment system, no level IV,
> V, and VI services are being provided, then all patients requiring
> such services will have their names placed on the deferred services
> list at the time their routine care is completed and they are placed
> on recall status. Whenever it becomes possible to provide deferred
> services, patients will be called in the order in which their names
> appear on the list, for the levels of care that are authorized.

PROCEDURE:

1.  Patients must complete treatment and be placed on recall status
    before they qualify to be placed on the deferred services list. The
    requirement to be placed on recall is to help emphasize to the
    patient the need to maintain an active participation in his/her own
    health care, and to insure that when deferred services can be
    provided, the patients who are called will still have an adequate
    level of oral health to justify the provision of the higher level of
    care. This requirement will be waived for edentulous patients who
    seek full dentures.

2.  All prosthetic services provided with deferred monies must meet all
    other requirements of the service unit prosthetics policy (i.e.
    periodontal health, broken

3.  appointments, Ante\'s rule, etc.).

4.  Patients who agree to be placed on recall status but then later fail
    to schedule a recall visit after their recall notice has been mailed
    will have their name removed

5.  from the deferred services list.

6.  Patients on the deferred services list who later exceed the broken
    appointment limit will have their names removed from the list.

\_\_\_\_\_\_\_\_\_\_\_ DENTAL CLINIC

POLICY/PROCEDURE

  ----------------------- ----------------------- -----------------------
  Subject: BROKEN AND                             
  CANCELLED APPOINTMENTS                          

  Effective Date:         Revision Date:          Supersedes:
  10/01/90                                        

  Distribution:                                   
  ----------------------- ----------------------- -----------------------

PURPOSE:

Due to the large number of people who make appointments but fail to show
up for them or fail to give adequate advance notice when canceling them,
it has become necessary to have a policy on appointment responsibility.
Broken and cancelled appointments waste the clinic\'s very limited time
and hinder the dental program\'s efforts to improve the oral health
status of the people that we serve.

POLICY:

The Dental Program will allow only 2 broken appointments per six month
period. An appointment is considered to have been broken if any of the
following occur:

1.  the patient fails to show up for the appointment,

2.  the patient appears more than 15 minutes late for a scheduled
    appointment, or

3.  the patient calls to cancel an appointment with too little advance
    notice to allow that appointment time to be rescheduled with another
    patient ( 24 hours will be considered to be the minimum time
    necessary to avoid a broken appointment ).

Patients who wish to cancel dental appointments must do so a minimum of
24 hours in advance of their scheduled appointment. If less notice is
given without a valid excuse, the appointment will be considered to have
been broken.

PROCEDURE:

When a patient accumulates 2 broken appointments in a 6 month period,
that person will not be allowed to schedule any further routine
appointments for a period of 6 months following the second broken
appointment.

\_\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: BIOPSIES

Effective Date: Revision Date: Supersedes:

Distribution: TISSUE AND BLOOD COMMITTEE

PURPOSE: To establish guidelines to aid in the determination of which
tissues removed in the course of dental treatment need to be submitted
for pathologic review, and to establish a policy for the tracking and
follow-up of all pathology reports thereby generated.

POLICY: All pathologic tissues removed from a patient in the course of
dental treatment will be submitted to the Navy Oral Pathology Service as
per the attached memo, with the following exceptions:

1.  Teeth and associated soft tissue removed in the course of routine
    and surgical extractions.

2.  Gingival tissue removed during the course of routine periodontal
    procedures such as curettage and gingivectomy.

3.  Soft and hard tissue removed during the course of routine
    alveoloplasty, other preprosthetic surgery, and operculectomy.

PROCEDURE All tissue submitted for pathologic examination will be
recorded in a log to be kept in the dental files labeled \"BIOPSIES\".

> All specimens submitted for pathologic review will be promptly
> immersed in 10% formalin.
>
> Each specimen shall be properly identified and accompanied by a
> corresponding pathologic report (SF-515, copy attached), with
> appropriate data filled in by the attending dentist or his designee.
>
> The reply from the pathologist shall be reviewed and signed by the
> attending dentist and then entered into the patient\'s medical record.
>
> Patients having tissues submitted for pathologic examination will be
> informed of the pre-op diagnosis at the time of the biopsy procedure
> and will be notified by mail or Public Health Nurse if the biopsy
> report differs from the pre-op diagnosis.

Appropriate follow-up for the patient shall be provided.

PHS INDIAN HOSPITAL

DENTAL CLINIC

POLICY AND PROCEDURES MANUAL

PROCEDURE AND TRAY SETUPS FOR DENTAL ASSISTANTS

I. ROUTINE EXAMINATION, ADULT

a)  mirror

b)  explorer

c)  CPITN probe

d)  2x2 gauze pads

II\. ROUTINE EXAMINATION, CHILD (UP TO AGE 12)

a)  mirror

b)  explorer

c)  2x2 gauze pads

III\. OPERATIVE, AMALGAM

a)  mirror

b)  explorer

c)  syringe and needle (blue for 4-13(and d), yellow for all others),
    anesthetic, needle guard

d)  spoon

e)  condensers, large and small

f)  ball burnisher

g)  amalgam carrier

h)  carvers (walls, cleoid-discoid, and JPC)

i)  rubber dam, appropriate clamp, punch, clamp forceps, scissors,
    young\'s frame

j)  330, 557, or 558 bur in high speed

k)  round bur in slow speed

l)  matrix band and retainer, with wedges, for MO, DO, MOD, etc.

m)  floss

n)  articulating paper

o)  cavity liner

p)  dycal

q)  amalgam well

r)  cotton rolls and gauze

s)  acorn burnisher

IV\. SEALANTS

a)  sealant kit

b)  etching liquid, not gel

c)  pumice or hydrogen peroxide and prophy brush

d)  cotton rolls, holders, and dry angles, or rubber dam

V. OPERATIVE, COMPOSITE

a.  mirror

b.  explorer

c.  syringe and needle (blue for upper anteriors, yellow for lowers) and
    anesthetic, needle guard

d.  rubber dam, punch, clamp and forceps if needed, young\'s frame

e.  floss ligatures

f.  330 bur in high speed

g.  round bur in slow speed

h.  plastic instrument

i.  composite

j.  bonding agent

k.  Dycal or Vitrabond when available

l.  Ketac-conditioner, when available

m.  mylar matrix and wedge(s)

n.  curing light

o.  light shield

p.  finishing burs, strips, and discs

q.  articulating paper

r.  etching [gel]{.underline} not liquid

s.  brush

t.  cotton rolls and gauze

VI\. PULPOTOMY, PRIMARY TOOTH

a)  mirror

b)  explorer

c)  syringe and needle (blue for 4d-13d, yellow for all others) and
    anesthetic, needle guard

d)  spoon

e)  round bur in slow speed

f)  cotton pellets

g)  formocresol

h)  IRM

i)  rubber dam, punch, clamp forceps, #4 clamp(usually), young\'s frame,
    scissors

j)  cotton rolls and gauze

VII\. PULPECTOMY, PRIMARY TOOTH

a)  mirror

b)  explorer

c)  syringe and needle (blue for 4d-13d, yellow for all others) and
    anesthetic, needle guard

d)  spoon

e)  round bur in slow speed

f)  cotton pellets

g)  formocresol

h)  IRM

i)  endo files, gates glidden burs

j)  endo irrigation

k)  paper points

l)  ZOE paste

m)  CR syringe and needle tube

n)  rubber dam, punch, clamp forceps, clamp (#4 usually), young\'s
    frame, scissors

o)  cotton rolls and gauze

VIII\. STAINLESS STEEL CROWN

a)  mirror

b)  explorer

c)  syringe and needle (blue for 4d-13d, yellow for all others) and
    anesthetic, needle guard

d)  spoon

e)  round bur in slow speed

f)  169 or 699 bur or diamonds in high speed

g)  Flecks or Durelon

h)  contouring and crimping pliers

i)  crown and collar scissors

j)  rubber dam, punch, clamp forceps, clamp (#4 usually), young\'s
    frame, scissors

k)  orangewood stick or band seater

l)  cotton rolls and gauze

IX\. ENDO, ALL BUT MOLARS, ONE APPOINTMENT FILE AND FILL

a)  mirror

b)  explorer

c)  syringe and needle (blue for 4-13, yellow for all others) and
    anesthetic, needle guard

d)  endo spoon

e)  round bur in slow speed

f)  endo explorer

g)  files and gates glidden burs

h)  endo irrigation

i)  paper points

j)  hemostat or film holder and x-ray film

k)  spreader

l)  plugger

m)  gutta percha

n)  sealer

o)  chloroform

p)  cavit or IRM

q)  endo ruler

r)  rubber dam, punch, clamp forceps, clamp, young\'s frame for 6-11 or
    ostby frame for all others

s)  cotton rolls and gauze

t)  scissors

X. ENDO, MOLAR, FILING APPOINTMENT

a)  mirror

b)  explorer

c)  syringe and needle (blue for 4-13, yellow for all others) and
    anesthetic, needle guard

d)  endo spoon

e)  round bur in slow speed

f)  endo explorer

g)  files and gates glidden burs

h)  endo irrigation

i)  paper points

j)  hemostat or film holder and x-ray film

k)  rubber dam, punch, clamp forceps, clamp, ostby or young\'s plastic
    frame

l)  plugger

m)  cavit or B&T

n)  endo ruler

o)  cotton rolls and gauze

XI\. ENDO, MOLAR, FILLING APPOINTMENT

a.  mirror

b.  explorer

c.  syringe and needle (blue for 4-13, yellow for all others) and
    anesthetic, needle guard (may not be needed)

d.  endo spoon

e.  round bur in slow speed

f.  endo explorer

g.  files and gates glidden burs

h.  endo irrigation

i.  paper points

j.  hemostat or film holder and x-ray film

k.  rubber dam, punch, clamp forceps, clamp, ostby frame

l.  gutta percha

m.  chloroform

n.  sealer

o.  spreader

p.  plugger

q.  cavit or IRM

r.  endo ruler

s.  cotton rolls and gauze

t.  scissors

XII\. CUSP PROTECTED AMALGAM BUILDUP (CPA or ABU)

a)  mirror

b)  explorer

c)  syringe and needle (blue for 4-13(and d), yellow for all others) and
    anesthetic, needle guard (may not be needed)

d)  spoon

e)  condensers, large and small

f)  ball burnisher

g)  amalgam carrier

h)  carvers

i)  rubber dam, appropriate clamp, punch, clamp forceps, and scissors,
    young\'s frame

j)  330, 557, or 558 bur in high speed

k)  round bur in slow speed

l)  matrix band and retainer, with wedges and extra piece of band
    material, or automatrix

m)  floss

n)  articulating paper

o)  cavity liner and cotton pellets

p)  amalgam well

XII\. SURGICAL EXTRACTION, FLAP KIT

a)  mirror

b)  syringe, yellow needle, anesthetic, needle guard

c)  Minnesota retractor

d)  periosteal elevator

e)  double ended surgical curette

f)  scalpel with 15 blade

g)  mouth prop

h)  bone bur, straight handpiece

i)  high volume suction tip

j)  surgical suction tip

k)  rongeur

l)  bone file

m)  irrigation

n)  hemostat

o)  straight elevators

p)  needle holders

q)  Dean scissors

r)  suture material

s)  gauze

t)  AM-40 or surgical handpiece, sterile

u)  Sterile suction hose and clip

v)  Surgical suction light source and tips

XIII\. FRACTURE SET-UP

a)  Panorex

b)  syringe, needle, anesthetic, needle guard

c)  mirror, 2

d)  Minnesota retractor

e)  mouth prop

f)  wire twisters, 2

g)  24 and 25 gauge wires

h)  wire cutters

i)  Erich arch bar material

j)  wire director

k)  suction tip, surgical, high volume

l)  elastics

m)  sterile suction hose and clip

\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: MANAGEMENT OF APPOINTED PATIENTS

Effective Date: Revision Date: Supersedes:

Distribution: DENTAL STAFF

PURPOSE: To define the routine scope of care for patients receiving
either an initial examination or a recall examination.

POLICY: The following services shall constitute the routine scope of
care for all examination patients.

PROCEDURE:

A. A new patient or one who has not had a dental exam in over 1 year
will receive the following services, as needed:

1.  examination

2.  bitewing radiographs (see radiology policy)

3.  review of medical history

4.  oral hygiene instructions as needed

5.  dental prophylaxis as needed

6.  fluoride treatment as per Area guidelines

7.  panorex if none is available or is over 5 years old, and the patient
    is 8-10 years of age or older

8.  treatment plan for all services falling within current levels of
    care guidelines

9.  follow-up appointments until all planned treatment is completed or
    until the broken appointment limit is exceeded

B. Recall Examination

1.  review and update of medical history

2.  examination

3.  bitewing or PA x-rays as ordered by the treating dentist to
    follow-up on the previous treatment plan

4.  updated treatment plan

5.  oral hygiene reinforcement as needed

6.  dental prophylaxis as needed

7.  follow-up appointments as needed to complete treatment

\_\_\_\_\_\_\_\_\_\_ SERVICE UNIT

POLICY/PROCEDURE

Department: Dental

Subject: ACCESS TO MEDICAL RECORDS IN THE DENTAL CLINIC

Effective Date: Revision Date: Supersedes:

Distribution: DENTAL STAFF, MEDICAL RECORDS

PURPOSE: To insure that the privacy and confidentiality of all
patients\' medical records is maintained according to Federal law and
\_\_\_\_\_\_\_\_\_\_\_ Hospital policy.

POLICY: Only those persons having a compelling professional need to see
the contents of medical records shall have access to medical records in
the Dental Clinic. This shall include all staff involved in direct
patient care (i.e. Dentists, Dental Assistants, Hygienists, and Dental
Students) as well as the clinic\'s receptionist who prepares the dental
portion of the medical record prior to the patient\'s being seen.

**\_\_\_\_\_\_\_\_ Service Unit Dental Program**

POLICY/PROCEDURE

  ------------------------ ------------------------ ----------------------
  **SUBJECT**:                                      
  \_\_\_\_\_\_\_ Service                            
  Unit Dental Program CHS                           
  Referral Policy                                   

  **EFFECTIVE DATE:**      **REVISION:**            **SUPERSEDES**:

  **DISTRIBUTION:** SU                              
  Clinical Director, SU                             
  Dental Staff, Contract                            
  Health Services                                   
  ------------------------ ------------------------ ----------------------

**PURPOSE**

To establish a policy by which patients, who require dental care which
falls within the currently approved levels of care but cannot be
properly provided in the \_\_\_\_\_ Service Unit Dental Program, can be
referred to appropriate IHS and non‑IHS clinics for the required care;
and to establish a policy for the handling of referrals made through the
\_\_\_\_\_\_\_\_ Service Unit Dental Program from other dentists, both
IHS and non IHS, and from other health care providers in the
\_\_\_\_\_\_\_\_ Service Unit.

**POLICY**

***A. Referrals made:***

Patients may be referred to other IHS facilities, to private dentists,
or to other health care providers for the following reasons:

> 1\. The patient with a toothache or other urgent/emergent dental
> condition that cannot be adequately temporized by the medical staff
> with analgesics and/or antibiotics, when [no dentist is available in
> any Service Unit facilities.]{.underline}
>
> 2\. The patient requires level I dental care which cannot be provided
> in the \_\_\_\_\_\_\_\_ Service Unit Dental Program due to lack of
> appropriate training among the dental staff, lack of appropriate
> facilities or equipment in the service unit, or medical conditions of
> the patient that may increase the risk of adverse events during the
> dental procedure. Examples would include: complex jaw fractures
> requiring open reduction and fixation, uncontrollable pediatric
> patients requiring full‑mouth rehabilitation where treatment in the OR
> would be indicated, and any patient requiring hospitalization.
>
> 3\. The patient who receives emergency care while visiting a facility
> in the \_\_\_\_\_\_\_\_ Service Unit but who permanently resides in
> the Contract Health Service Delivery Area (CHSDA) of another IHS
> facility, may be referred under alternate resources or self-pay but
> not \_\_\_\_\_\_\_\_ Service Unit CHS.
>
> 4\. Eligible Native American Head Start students being referred for
> routine care as part of the Head Start Program.
>
> 5\. Students away at school or other people living away from the
> reservation but qualifying for CHS care due to the 180 day rule (see
> CHS policy -- must have a completed student form on file every
> semester).
>
> 6\. Patients with acute dental emergencies when no dentist is
> available at the service unit (see Emergency Policy ).
>
> 7\. Dental patients with acute or chronic medical conditions which, in
> the opinion of the treating dentist, require acuity of care not
> available within the \_\_\_\_\_\_\_\_ Service Unit.
>
> 8\. Eligible Native Americans living away from the direct service
> delivery area of the \_\_\_\_\_\_\_\_ Service Unit, if within the
> 180-day rule.

***B. Referrals received:***

> The dental program will accept referrals directly into the appointment
> system for the following reason:
>
> The patient\'s dental problems are a contributing factor in the
> treatment of a medical condition. Examples of this would include the
> uncontrolled diabetic with periodontal disease or other active dental
> infections, the end‑stage renal patient being prepared for kidney
> transplant, etc. This does not include patients whose only medical
> problem is severe caries or periodontal disease because this describes
> a significant proportion of the total population being served. This
> also does not include the pregnant patient because routine dental care
> is in many cases not appropriate during the first and third trimesters
> of pregnancy.
>
> All other patients referred to the dental program will first be
> scheduled to be seen in the walk‑in clinic for evaluation and
> appropriate disposition of the problem for which they have been
> referred. The treating dentist will decide if it is appropriate to
> allow any patient so referred to enter directly into the regular
> appointment system or whether the patient should be required to go
> through normal appointment procedures along with all of the other
> regular dental patients. Because of the inability of the clinic to
> appoint all patients who need to be seen (due to staffing) and the
> demand care nature of the appointment system, referrals to the dental
> clinic cannot be allowed to have priority for the limited appointments
> except under the circumstances listed above.

C.  ***Priority I Dental Procedures***

> Specific dental procedures that may be approved through Contract
> Health Services for referral to non-IHS providers include, but are not
> limited to, the following:
>
> 1\. The extraction of third molars when all of the following
> conditions are met:
>
> a\. The tooth (teeth) is mesioangular, distoangular, or horizontally
> impacted;
>
> b\. The tooth (teeth) is causing the patient pain (subjective
> evaluation);
>
> c\. The removal of the teeth may prevent destruction of the second
> molars;
>
> d\. The extraction(s) cannot be performed safely in one of the service
> unit dental facilities.
>
> 2\. Treatment of pediatric patients (under age 12) and special needs
> patients (documented disability or mental impairment) when one of the
> following conditions is met:
>
> a\. The pediatric patient requires extensive rehabilitation -- greater
> than 6 teeth with dental caries or greater than 4 teeth with
> interproximal dental caries requiring stainless steel crowns or other
> justifiable reasons -- that would be best performed by a pediatric
> dentist.
>
> b\. The pediatric patient is unable to be treated in one of the
> service unit dental facilities due to situational anxiety, disability,
> or a large geographic distance from the patient's home to the nearest
> service unit dental facility.
>
> c\. The pediatric patient is currently receiving orthodontics and
> requires multiple extractions or other oral surgery procedures that
> cannot be performed in a service unit dental facility.
>
> d\. The pediatric patient requires space maintenance following
> premature loss of a deciduous tooth, and such procedure cannot be
> performed at the service unit dental facility.
>
> 3\. Oral surgery when one of the following conditions is met:
>
> a\. The service unit dentist cannot perform the simple or surgical
> extraction due to (1) inability to obtain sufficient anesthesia to the
> affected tooth; (2) inoperable dental equipment or due to conditions
> beyond the dentist's control (such as loss of electricity); (3)
> removal of a tooth from the maxillary sinus or inferior alveolar
> canal; (4) sustained infection (abscess or cellulitis) that cannot be
> reduced after repeated tries;
>
> b\. Multiple extractions are necessary but the patient has either
> experienced past difficulties by the providing dentist or is medically
> compromised;
>
> c\. The patient desires an immediate denture and multiple extractions
> (greater than 10 at one time) are required.
>
> 4\. Periodontal surgery when all of the following conditions are met:
>
> a\. The patient has received comprehensive Phase I (non-surgical)
> therapy in one of the service unit dental facilities;
>
> b\. The patient is diagnosed with refractory or rapidly progressive
> adult periodontitis, localized or general juvenile periodontitis,
> prepubertal periodontitis, or another severe periodontal condition and
> treatment for the condition cannot be adequately performed by the
> dental provider (hygienist and/or dentist);
>
> c\. The patient has been given the treatment alternative of extracting
> the affected teeth and desires a periodontal referral to potentially
> save the teeth;
>
> d\. The patient is in compliance to directions from the dental
> provider, including the respective dental clinic's broken appointment
> policy, adequate oral hygiene as determined by the provider, etc.
>
> 5\. Pathology referral for patients with suspected oral pathology, if
> a biopsy or more thorough evaluation cannot be completed by the dental
> provider.
>
> 6\. Temporo-mandibular joint dysfunction (TMJD) evaluation only, when
> such evaluation cannot be completed by the dental provider.
>
> 7\. Emergency dental treatment, including access/instrumentation of
> abscessed teeth (but not obturation or the permanent restoration),
> pending approval of the service unit dental chief.

***D. Dental Procedures Outside CHS Priority I Requirements***

Currently, the \_\_\_\_\_\_\_\_ Service Unit operates under Priority I
("life or limb") CHS requirements. As such, there are numerous
procedures that should not, except under extenuating circumstances, be
approved for referral to a non-IHS entity under CHS. These include:

1.  Endodontic treatment (root canal therapy), except under the
    following condition -- re-treatment of a previously treated tooth
    when two of the three criteria below (must include c.) are met:

    a.  The tooth is vital to the patient's occlusion or esthetics
        (would not include second or third molars)

    b.  The tooth serves as an abutment to a bridge

    c.  The patient has, or agrees to purchase, appropriate coronal
        coverage following the root canal therapy (crown or bridge
        abutment)

2.  Orthodontic treatment, except under condition C.2.c. above.

3.  Fixed and removable prosthodontics, including surgical implants and
    implant prostheses.

4.  Routine restorative, preventive, surgical, endodontic, and
    periodontal services.

5.  Temporo-mandibular joint dysfunction treatment.

6.  Cosmetic bleaching, veneers, etc.

**PROCEDURE**

> 1\. The referring dentist or medical provider (in the absence of the
> dentist) will determine the need for an appropriate referral to a
> dental or medical specialist (oral surgeon, periodontist, pediatric
> dentist, ENT, pathology, etc.)
>
> 2\. The referring dentist will then prepare a Referral Form (IHS
> 199-1) in triplicate, and submit all but one copy for his/her records.
> One copy should be retained by the dental department. The Referral
> Form should include the following:
>
> a\. Item 1 -- specialty of provider (even if name is unknown, the type
> of specialist should be written or typed in this box)
>
> b\. Priority Box -- Priority I should be marked only if the referral
> meets the criteria as set forth above in Section C above. Otherwise,
> the appropriate priority should be listed (if unsure, the dental
> provider can consult his/her CHS clerk).
>
> c\. Items 2-4 -- the demographic information should be entered (CHS
> clerks will complete 5-9).
>
> d\. Item 10 -- the dental provider should write down the exact reason
> for the referral **[and reference the exact criteria that supports
> such a referral (from section C above), if the service unit CHS
> funding is anticipated for the referral.]{.underline}** A few examples
> are given below:
>
> *"39 year-old male with mesioangular impacted teeth #17 and #32,
> causing pain for 3 weeks. Referral to an oral and maxillofacial
> surgeon, under local anesthesia, to extract teeth #17 and #32
> (Reference C1)"*
>
> *"3 year-old female with nine carious lesions - #a,b,c,d,e,f,g,h,I --
> needing comprehensive rehabilitation by a pediatric dentist under IV
> sedation or OR care, and unable to treat in a general dentistry
> setting (Reference C2a)"*
>
> It is the dental provider's responsibility to write this section of
> the referral, including the referral reference code.

e\. Item 11 -- the dental provider should be more specific and write
down the diagnosis and recommended treatment for the patient. A few
examples are given below:

*"Panoramic radiograph shows mesioangular impactions #17 and #32.
Clinical evaluation shows pericornitis. Prognosis for the teeth is
poor."*

*"Caries #a-OL, #b-DO; #c-F, etc. Recommend stainless steel crowns #a,
#b, and possible pulpotomy #a"*

f\. Item 12 -- the dental provider should not complete this section, but
instead allow the CHS clerk at the respective facility to complete it.

g\. Signature -- the dental provider must sign and date the referral.

> 3\. Again, one copy of the dental referral should be kept in the
> dental department of the referring facility. The patient should not be
> given a copy of the referral until it has been approved, if the
> service unit CHS funding is anticipated. Otherwise (if the patient
> will self-pay for the referral or if there are non-IHS alternate
> resources), the patient or parent/guardian should receive a copy of
> the referral form with "self-pay" clearly marked on the IHS-199 form.
> In any case, the dental provider should provide the CHS clerk/office
> with the referral form regardless if CHS funding is being sought
> (i.e., every referral goes to the CHS clerk).
>
> 4\. If copies of dental records or x‑rays are also being sent, the
> patient will be required to complete a Release of Information form
> prior to releasing the documents or x‑rays.
>
> 5\. If the patient is being referred for treatment with anticipated
> service unit CHS funding, all aspects of this Dental CHS policy and
> Levels of Care guidelines will be adhered to. This includes emergency
> patients, students, Head Start students, etc. (see CHS policy).
>
> 6\. Dental patients who are found to have medical problems that
> require follow‑up or treatment (such as untreated hypertension,
> uncontrolled diabetes, etc.) will be referred to the medical clinic by
> preparing an IHS-199 and sending the patient with a copy of the
> referral form to the medical appointment desk for a medical
> appointment. If the problem is thought by the treating dentist to be
> urgent, the dentist will contact a physician and refer the patient
> directly to the walk‑in clinic.
>
> 7\. Once a referral is complete, the CHS clerk should enter an
> electronic (RPMS Mailman and/or RCIS) message to the service unit
> dental chief, writing in everything entered by the dental provider in
> Item 10, including the CHS dental criteria reference number (see
> section C above).
>
> 8\. The \_\_\_\_\_\_\_\_ Service Unit Dental Chief will make the final
> determination as to whether the referral fits the criteria as outlined
> in Section C or if there are extenuating circumstances that warrant
> the referral, and shall timely (within 7 days) inform the appropriate
> CHS clerk of the decision. The service unit dental chief may request
> additional documentation or explanations from the referring dental
> provider prior to any decision.
>
> 9\. For CHS referrals that are denied by the service unit dental
> chief, the dental providers and/or facilities should keep a list of
> denials under a Deferred Services List. This list is critical to
> further amending the service unit dental CHS policy in the future, as
> well as if unexpected funding occurs during the fiscal year.
>
> 10\. Patients referred from other IHS clinics (non- \_\_\_\_\_\_\_\_
> Service Unit) or private dentists for follow‑up on emergency care that
> was begun at the other clinic will first be seen as a walk-in in one
> of the service unit dental clinics to determine the nature of any
> follow‑up needs. Appointments may be given to complete treatment of
> the emergency procedure (if doing so falls within local Levels of Care
> guidelines). Once the emergency follow‑up is completed, the patient
> will be required to go through normal appointment procedures for any
> further care.
>
> 11\. Patients referred from other IHS clinics or private dentists for
> routine dental care when there is no underlying medical priority for
> the treatment will be informed of the appointment system and will be
> required to follow normal appointment procedures.
>
> 12\. The service unit dental program dentists should not refrain from
> an appropriate referral solely on the basis of whether the referral
> qualifies under Section C above. [If a patient's condition warrants a
> referral, the dentist is ethically and legally bound to refer the
> patient to an appropriate dental or medical specialist.]{.underline}
> The dentist should mark "Priority I" if the referral meets, or may
> meet, the CHS dental criteria listed in Section C, and any other
> priority if the referral definitely does not meet the CHS dental
> criteria.
>
> Review of the \_\_\_\_\_\_\_\_ Service Unit Dental Referral Policy and
> Procedure shall be done annually.

**\_\_\_\_\_\_\_\_ Service Unit Dental Program**

**POLICY & PROCEDURES**

**SUBJECT** Disposal of extracted teeth and oral tissues

**EFFECTIVE DATE**

**DISTRIBUTION** \_\_\_\_\_\_\_\_ SUDP Policy Manual, Service Unit
Director, Clinical Director, Dental Staff, Health Directors

**I. POLICY**

Disposal of extracted teeth and oral tissues

**II. PURPOSE**

> To establish a policy for the disposal of teeth and soft tissue
> following dental treatment.

**III. PROCEDURE**

> A. INTRODUCTION. All patients will be offered the opportunity to keep
> their extracted teeth or oral tissue removed during a dental surgery.
> If a patient wishes to save an extracted tooth it will be cleaned and
> surface-disinfected with an EPA-registered hospital disinfectant with
> intermediate-level activity and placed in a water-resistant bag or
> other suitable container.

B. All oral hard and soft tissues shall be disposed of according to
guidelines established by the Centers for Disease Control and
prevention, and comply with regulations set forth by OSHA and the
Environmental Protection Agency.

C.  Disposal -Extracted teeth that are being discarded are subject to
    the containerization and labeling provisions outlined by OSHA\'s
    bloodborne pathogens standard. OSHA considers extracted teeth to be
    potentially infectious material that should be disposed in medical
    waste containers. Extracted teeth sent to a dental laboratory for
    shade or size comparisons should be cleaned, surface-disinfected
    with an EPA-registered hospital disinfectant with intermediate-level
    activity (i.e., tuberculocidal claim), and transported in a manner
    consistent with OSHA regulations. However, extracted teeth can be
    returned to patients on request, at which time provisions of the
    standard no longer apply. Extracted teeth containing dental amalgam
    should not be placed in a medical waste container that uses
    incineration for final disposal.

# D. Teeth saved for educational purposes - Extracted teeth are occasionally collected for use in pre-clinical educational training. Written consent from the patient shall be obtained for teeth collected for use in training or research. These teeth should be cleaned of visible blood and gross debris and maintained in a hydrated state in a well-constructed closed container during transport. The container should be labeled with the biohazard symbol. Because these teeth will be autoclaved before clinical exercises or study, use of the most economical storage solution (e.g., water or saline) is practical. Liquid chemical germicides can also be used but do not reliably disinfect both external surface and interior pulp tissue. Before being used in an educational setting, the teeth should be heat-sterilized to allow safe handling. Microbial growth can be eliminated by using an autoclave cycle for 40 minutes. 

> **[Clinical Education Affiliation Agreement]{.underline}**

**Education Affiliation Agreement for Placement of**

**Institution Students in a Clinical Experience at a Hospital/Facility
or Other Facility**

This Agreement is made between the Board of Regents of the \_\_\_\_\_\_
System of Higher Education, on behalf of **\_\_\_\_\_\_\_\_ Community
College** located at \_\_\_\_\_\_\_*,* hereinafter referred to as
"Institution," and **the \_\_\_\_\_\_\_\_\_\_\_\_ Health Clinic,**
hereinafter referred to as "Facility."

**RECITALS**

A. Facility is the operator of health care facilities, including an
IHS-supported health care facility; and,

B. Facility has the capability to provide a site for Dental Hygiene
training experience; and,

C. Facility has agreed to assist in the educational experience of Dental
Hygiene students by providing a Dental Hygiene Clinical facility; and,

D. Institution is currently conducting a Dental Hygiene program for
which it desires to obtain the assistance of Facility to further the
training and experience Institution's students can receive toward their
educational objectives; and,

E. Institution employs faculty interested in supervising at Facility
while retaining their status as employees of Institution.

**TERMS**

In consideration of the mutual promises and conditions contained in this
Agreement, Institution and Facility agree as follows:

1.0 [Purpose, Term, and General Policy of the Affiliation]{.underline}.

> 1.1 Institution and Facility agree to affiliate and cooperate for
> their mutual benefit in order to provide a high standard of health and
> dental hygiene services to the public.
>
> 1.2 This Agreement is for a term of four years beginning on 1
> September, 2005, and reserves the right to periodically review to
> determine if the continuation or the cancellation of the agreement is
> in order. Either party may notify the other of its intentions not to
> renew the agreement in writing at least thirty (30) days prior to the
> effective day.
>
> 1.3 Facility seeks to achieve the following goals with this Agreement:
>
> 1.3.1 To improve the quality of care while providing an environment
> conducive to education;
>
> 1.3.2 To improve its recruitment ability;
>
> 1.3.3 To establish an affiliate clinical program consistent with the
> values and needs of Facility.
>
> 1.4 Institution seeks to achieve the following goals with this
> Agreement:
>
> 1.4.1 To provide its students with the necessary clinical experience
> to prepare them for Dental Hygiene careers that include public health
> service;
>
> 1.4.2 To enhance and maintain strong ties to local Facility.
>
> 1.5 Neither party intends for this Agreement to alter in any way their
> respective legal rights or their legal obligations to one another, the
> students and Faculty assigned to Facility, or to any third party.
>
> 1.6 Facility retains final responsibility for all aspects of patient
> care and assumes the responsibility to perform procedures that a
> student has not performed if the faculty cannot assume the
> responsibility.
>
> 1.6.1 Facility may permit Institution faculty members to provide such
> patient services at Facility as deemed necessary by Facility for
> teaching purposes.
>
> 1.7 Both parties and their employees shall conduct themselves in
> compliance with all applicable federal, state, and local laws, rules,
> and regulations and in compliance with the standards, rulings, and
> regulations of the Joint Commission on Accreditation of Health Care
> Organizations, the Department of Health and Human Services, and the
> ADA Commission on Dental Accreditation, as well as their own
> respective institutional rules and regulations.

2.0 [Annual Operating Plan]{.underline}.

> 2.1 The parties agree that each year they shall set forth a written
> operating plan which shall include:
>
> 2.1.1 The clinical education programs to be provided and the starting
> and ending dates for each program;
>
> 2.1.2 The number, names, clinical assignment opportunities, and
> clinical assignment schedule for the students;
>
> 2.1.3 The name of the individual for each party who shall have
> authority to act for and on behalf of each party in all matters
> relevant to this Affiliation Agreement.

3.0 [Curriculum]{.underline}.

> 3.1 It shall be Institution's responsibility to:
>
> 3.1.1 Establish and maintain for this clinical placement, curriculum
> standards and educational policies that meet Institution standards and
> ADA Commission on Dental Accreditation requirements;
>
> 3.1.2 Administer, organize, and operate the overall clinical placement
> educational program;
>
> 3.1.3 Inform students that they will be responsible for private health
> insurance during clinical experience. It is agreed that any student
> injury or exposure occurring during the clinical experience remains
> the full responsibility of the student, including related treatment,
> testing or immunization.
>
> 3.2 It shall be Facility's responsibility to:
>
> 3.2.1 Cooperate with faculty and students to select and arrange
> Facility learning experiences that meet clinical objectives;
>
> 3.2.2 Orient Facility staff to the curriculum and encourage an
> atmosphere conducive to learning;

4.0 [Program Coordination]{.underline}.

> 4.1 Institution and Facility agree to work together to establish and
> maintain a quality clinical training program.
>
> 4.2 Institution shall provide a faculty member who will serve as
> liaison with Facility personnel.
>
> 4.3 Institution and Facility agree to provide representatives to serve
> as Liaison to meet each semester to fashion, discuss, evaluate, and
> make recommendations to revise the Clinical Program experience at
> Facility.
>
> 4.3.1 Institution representatives serving as Liaison shall be:
> Director of Dental Hygiene, or his/her designee.
>
> 4.3.2 Facility's representatives serving as Liaison shall be: Dental
> Services Director or his/her designee.
>
> 4.4 Institution and Facility agree to cooperate in planning hours of
> practice and selecting areas of clinical services so that all programs
> can benefit.
>
> 4.5 Neither party, nor any joint committee, shall have the power to
> obligate Institution or Facility resources, or commit either to any
> particular action.

5.0 [Clinical Faculty and Staff]{.underline}.

> 5.1 It shall be the responsibility of Institution to:
>
> 5.1.1 Employ and assign to this clinical training program only those
> employees who are State-licensed;
>
> 5.1.2 Employ for this clinical training program only administrative
> and instructional staff who meets the applicable qualifications;
>
> 5.1.3 Discipline, terminate, reassign, and reinstate such Institution
> personnel in its reasonable discretion;
>
> 5.1.4 Assign to the clinical training program only faculty who agree
> to follow Facility rules and regulations even though they are not
> Facility employees;
>
> 5.1.5 Provide evidence, as requested, of appropriate credentials for
> each of its provided faculty members.

5.2 It shall be the responsibility of Facility to:

> Employ medical, administrative, and direct patient care staff who are
> qualified either through experience and/or academically to uphold and
> demonstrate standards of medical care as established by Facility;

6.0 [Student Records and Student Participation in the Facility Clinical
Program]{.underline}.

> 6.1 Institution shall provide and maintain the following records and
> reports required by the Facility for conducting the clinical training
> program:
>
> 6.1.1 All faculty and student records for compliance with
> confidentiality, privacy of patients and other documents required by
> federal, state, JCAHO, OSHA, or any other regulatory agencies. These
> documents shall be current and available to Facility upon request;
>
> 6.1.2 All infection control, immunization, and OSHA requirements upon
> request.
>
> 6.2 Subject to the understanding below, Facility agrees to complete
> the following evaluations and student records developed by Institution
> concerning student participation and performance in the clinical
> training program:
>
> 6.2.1 Facility shall only have the obligation to make reports to the
> Institution regarding the students participating in the Program.
>
> 6.2.2 It is understood that Institution alone has the responsibility
> and authority to make a final evaluation of student performance and to
> determine the appropriate recognition (grades, credits, etc.) for such
> performance.
>
> 6.3 The parties acknowledge that many student educational records are
> protected by the Family Educational Rights and Privacy Act ("FERPA"),
> and that student permission must be obtained before releasing specific
> student data to anyone other than Institution. Institution agrees to
> provide guidance to Facility with respect to complying with FERPA.
>
> 6.4 It shall be Institution's responsibility to:
>
> 6.4.1 Send to Facility for clinical experience only those students who
> have met all Institution requirements and qualifications and who agree
> to follow Facility rules and regulations;
>
> 6.4.2 Notify students of their assignments with Facility;
>
> 6.4.3 Upon request, provide Facility with documentation that the
> students have successfully completed the following prerequisites,
> tests, and training deemed necessary for placement in the Clinical
> Program: including
>
> 6.4.3.1 Rubella titer or proof of MMR vaccination if born after 1957;
>
> 6.4.3.2 Current TB skin test;
>
> 6.4.3.3 Made disclosure of pregnancy or potential pregnancy;
>
> 6.4.3.4 Consent or declination to the Hepatitis B vaccine;
>
> 6.4.3.5 Health Care Provider CPR Certification
>
> 6.4.3.6 Training in the use and disclosure of patient's confidential
> medical information which they may access during their training,
> including specifically the requirements of the HIPAA Privacy Rule.
>
> *6.*5 It shall be Facility's responsibility to:
>
> 6.5.1 Advise Institution of the number of students who can be
> accommodated at Facility;
>
> 6.5.2 Maintain administrative and professional supervision of students
> insofar as their presence and program assignments affect the
> operations of the Facility and its care, direct and indirect, of
> patients.
>
> 6.6 Institution and Facility agree:
>
> 6.6.1 That any student who becomes injured or ill shall receive
> emergency treatment and attention;
>
> 6.6.2 That any Student who does not meet the health criteria
> established by Facility cannot be assigned to Facility. Facility has
> the right, at any time, to request health status reports on students;
>
> 6.6.3 That Institution will not be responsible for the ultimate
> performance of students at Facility.

7.0 [Clinical Facilities]{.underline}.

> 7.1 The Facility agrees to provide:
>
> Adequate facilities for the clinical training program.

8.0 [Relationship between the Parties]{.underline}.

> 8.1 Institution and its employees shall not be employees of Facility,
> and shall not hold themselves out as employees of Facility. Nothing in
> this Agreement is intended or shall it be construed to create a joint
> venture relationship, a lease, or a landlord/tenant relationship. It
> is expressly agreed and understood by Institution and Facility that
> the students are in attendance at Facility for educational purposes,
> and they are not to be considered employees of Facility for any
> purpose, including, but not limited to compensation for services,
> employee welfare and pension benefits, or workers compensation
> insurance.
>
> 8.2 Employees of Facility shall not be considered and shall not hold
> themselves out to be employees of Institution.
>
> 8.3 Each party shall be solely liable for its own debts, obligations,
> acts and omissions, including the payment of all required withholding,
> social security, and other taxes or benefits on behalf of its
> employees.
>
> 8.4 Neither party shall engage in direct purchasing or otherwise
> contract any liability on behalf of, or charge the credit of, the
> other.
>
> 8.5 Should the Internal Revenue Service or any other governmental
> agency question or challenge the independent contractor status of
> Institution, Facility, or its employees, both Facility and
> Institution, upon receipt by either of them of notice, shall promptly
> notify the other party and afford the other party the opportunity to
> participate in any government agency discussion or negotiations
> irrespective of whom or by whom such discussions or negotiations are
> initiated.
>
> 8.6 Facility shall retain and exercise the final authority in the
> appointments, reappointments, revocations, amendments to, and
> suspensions of practicing privileges and of membership on Facility
> staff
>
> 8.7 Institution shall retain and exercise the final authority in the
> appointments, reappointments, revocations, amendments to, and
> suspensions of its faculty/employees, in accordance with Institution
> policies and procedures.
>
> 8.8 The parties acknowledge that each participates in various
> third-party payment programs and agree to fully cooperate with the
> other by providing assistance to meet all requirements for
> participation and payment.

9.0 [Insurance]{.underline}.

> 9.1 Facility shall, at Facility's sole expense, procure, maintain, and
> keep in force for the duration of this Agreement the following
> insurance conforming to the minimum requirements specified below.
> Unless specifically noted herein or otherwise agreed to by
> Institution, the required insurance shall be in effect prior to the
> commencement of work by Facility and shall continue in force as
> appropriate until the latter of:
>
> 9.1.1 Final acceptance by Institution of the completion of this
> Agreement; or
>
> 9.1.2 Such time as the insurance is no longer required by Institution
> under the terms of this Agreement.
>
> 9.2 Any insurance or self-insurance available to Institution shall be
> excess of and non-contributing with any insurance required by
> Facility. Facility's insurance policies shall apply on a primary
> basis. Until such time as the insurance is no longer required by
> Institution, Facility shall provide Institution with renewal or
> replacement evidence of insurance no less than thirty (30) days before
> the expiration or replacement of the required insurance. If at anytime
> during the period when insurance is required by this Agreement, an
> insurer or surety shall fail to comply with the requirements of this
> Agreement, as soon as Facility has knowledge of any such failure,
> Facility shall immediately notify Institution and immediately replace
> such insurance or bond with insurance or bond meeting the Agreement's
> requirements.
>
> 9.2.1 Workers' Compensation and Employer's Liability Insurance:
> Facility shall provide proof of workers' compensation insurance as
> required by NRS 616B.627 or proof that compliance with the provisions
> of Nevada Revised Statutes, Chapters 616A-D and all other related
> chapters, is not required.
>
> 9.2.2 Commercial General Liability Insurance
>
> a\. Minimum limits required:
>
> \$1,000,000 General Aggregate
>
> \$1,000,000 Products & Completed Operations Aggregate
>
> \$1,000,000 Personal and Advertising Injury
>
> \$1,000,000 Each Occurrence
>
> b\. Coverage shall be on an occurrence basis and shall be at least as
> broad as ISO 1996 form CG 00 01 and shall cover liability arising from
> premises, operations, independent contractors, completed operations,
> personal injury, products, and liability assumed under contract.
>
> 9.2.3 Business Automobile Liability Insurance
>
> a\. Minimum limit required: \$5,000,000 combined single limit per
> Occurrence for bodily injury and property damage.
>
> b\. Coverage shall include owned, non-owned, and hired vehicles.
>
> c\. Coverage shall be written on ISO form CA 00 01 or a substitute
> providing equal or broader liability coverage.
>
> 9.2.4 Professional Liability/Errors & Omissions Insurance
>
> a\. Minimum limit required: \$1,000,000 per Claim.
>
> b\. Minimum limit required: \$3,000,000 Annual Aggregate.
>
> c\. Retroactive date: Prior to commencement of the performance of this
> Agreement.
>
> d\. Discovery period: Three (3) years after termination of Agreement.
>
> e\. A certified copy of this policy will be made available upon
> request.
>
> 9.2.5 Umbrella or Excess Liability Insurance
>
> a\. May be used to achieve the above minimum liability limits.
>
> b\. Shall be endorsed to state it is "As Broad as Primary Policies."
>
> 9.2.6 General Requirements
>
> a\. Deductibles and Self-insured Retentions: Insurance maintained by
> Facility shall apply on a first dollar basis without application of a
> deductible or self-insured retention unless otherwise specifically
> agreed to by Institution. Such approval shall not relieve Facility
> from the obligation to pay any deductible or self-insured retention.
> Any deductible or self-insured retention shall not exceed \$5,000.00
> per occurrence, unless otherwise approved by the UCCSN Risk Manager.
>
> b\. Approved Insurer: Each insurance policy shall be:
>
> i\) Insured by insurance companies authorized to do business in the
> State of Nevada or eligible surplus lines insurers acceptable to the
> State and having agents in Nevada upon whom service of process may be
> made; and
>
> ii\) Currently rated by A.M. Best as "A- IX" or better.
>
> 9.3 Institution shall maintain, at its own cost and expense,
> professional liability insurance covering Institution as an entity and
> each of its provided physicians/employees and students against
> professional liability (malpractice) claims, in the minimum amount of
> one million dollars (\$1,000,000.00) per occurrence and three million
> dollars (\$3,000,000.00) aggregate. Evidence of such insurance shall
> be provided to Facility upon request. This provision shall in no way
> be considered a waiver of Institution's right to raise the defense of
> sovereign immunity under NRS 41.0305 to NRS 41.039, which right
> Institution specifically reserves. Torts claims against
> physicians/employees are limited to \$50,000.00 per cause of action by
> the provisions of said professional liability insurance and by NRS
> 41.035.
>
> 9.4 Institution shall carry Workers' Compensation and Employer's
> Liability Insurance as required by NRS 616B.627 or provide proof that
> compliance with the provisions of \_\_\_\_\_\_\_\_\_ Revised Statutes,
> Chapters 616A-D and all other related chapters, is not required.
>
> 9.5 Institution shall maintain self insurance sufficient to cover the
> institution liability under NRS 41. Coverage shall include liability
> arising out of bodily injury, wrongful death, and property damage.

10.0 [Access]{.underline}.

Contractor agrees to provide Institution and its insurer access and
authority to investigate on site and to obtain such information from
Contractor as may be required to defend the Institution and its officers
or employees from claims or litigation arising from activities under
this Agreement.

11.0 [Indemnification]{.underline}

> 11.1 Facility shall indemnify, defend, and hold harmless Institution,
> its governing board, officers, faculty, agents, employees and from and
> against any and all liabilities, claims, losses, lawsuits, judgments,
> and/or expenses, including attorney fees, arising either directly or
> indirectly from any act or failure to act by Facility or any of its
> medical staff, employees, or the residents which may occur during or
> which arise out of the performance of this Agreement, and limited to
> the extent of the professional liability insurance limits set forth
> above.
>
> 11.2 To the extent limited in accordance with NRS 41.0305 to NRS
> 41.039, Institution shall indemnify, defend, and hold harmless
> Facility, its governing board, officers, faculty, agents, and
> employees from and against any and all liabilities, claims, losses,
> lawsuits, judgments, and/or expenses, including attorney fees, arising
> either directly or indirectly from any act or failure to act by
> Institution, its officers or employees, which may occur during or
> which may arise out of the performance of this Agreement, and limited
> to the extent of the professional liability insurance limits set forth
> in paragraph 9.3 hereinabove. In accordance with NRS Chapter 41,
> Institution will assert the defense of sovereign immunity as
> appropriate in all cases, including malpractice and indemnity actions.
> Claims against Institution, its officers, and employees are limited to
> \$50,000.00 per cause of action.
>
> 11.3 In the event each of the parties is found to be at fault, then
> each shall bear its own costs and attorneys' fees and its
> proportionate share of the judgment or settlement based on its
> percentage of fault, as determined by a procedure established by the
> parties.
>
> 11.4 This Article shall continue beyond termination or expiration of
> this Agreement.

12.0 [Termination of the Agreement]{.underline}.

> 12.1 This Agreement may be terminated without cause upon providing at
> least **30** days' written notice to the other party prior to the
> beginning of the next academic term. Such termination must not affect
> students affiliated with Facility for the academic term in which
> notice is given.
>
> 12.2 This Agreement may be terminated for cause by the non-offending
> party, as follows:
>
> 12.2.1 In the event Institution or Facility fails by omission or
> commission in any substantial manner to provide the services in
> accordance with this Agreement; or
>
> 12.2.2 In the event either party becomes insolvent or has a bankruptcy
> petition filed against it; or,
>
> 12.2.3 In the event either Institution or Facility or their staff fail
> to perform their duties hereunder causing imminent danger to patients
> or materially and adversely affecting the licensure or accreditation
> status of Facility or Institution.
>
> 12.2.4 Such termination shall be effective upon written notice to the
> other.
>
> 12.3 This Agreement may be terminated by either party if the other
> party has substantially defaulted in the performance of any other
> obligation under this Agreement.
>
> 12.4 Upon termination of this Agreement, neither party shall have any
> further obligations hereunder except for obligations accruing prior to
> the date of termination, obligations that are expressly extended
> beyond the term of this Agreement, including indemnification, and
> obligations made by Facility with respect to any student.

13.0 [Non-Discrimination and Compliance with Laws]{.underline}.

13.1 The parties agree in this clinical program to comply with all the
federal, state, local, and institutional laws, ordinances and rules
applicable to Institution, and specifically agree not to unlawfully
discriminate against any individual on the basis of race, creed, color,
sex, religion, age, disability, or national origin, and to comply with
all anti-discriminatory laws and policies which Institution promulgates
and to which Institution is subject.

14. [Withholding]{.underline}.

With respect to employee compensation for services provided in
connection with this Agreement, each party shall indemnify the other for
their own employees' withholding taxes, workers' compensation, and other
employment-related taxes.

15. [Entire Agreement Modification]{.underline}.

This Agreement contains all the terms between the parties and may be
amended only in writing signed by both parties.

16. [Severability]{.underline}.

Each paragraph of this Agreement is severable from all other paragraphs.
In the event any court of competent jurisdiction determines that any
paragraph or subparagraph of the agreement is invalid or unenforceable
for any reason, all remaining paragraphs and subparagraphs will remain
in full force and effect.

17. [Governing Law]{.underline}.

The parties agree that the laws of the State of Nevada shall govern the
validity, construction, interpretation, and effect of this agreement.
Any and all disputes arising out of or in connection with the agreement
shall be litigated only in the Second Judicial District Court in and for
the County of Washoe, State of Nevada, and Facility hereby expressly
consents to the jurisdiction of said court.

18. [Assignment]{.underline}.

Nothing in this Agreement shall be construed to permit the assignment by
Facility or Institution of any rights or obligations hereunder, and such
assignment is expressly prohibited without the prior written consent of
either Institution or Facility.

19. [Notice]{.underline}.

Any notice to either party hereunder must be in writing signed by the
party giving it and shall be deemed given when mailed postage prepaid by
U.S. Postal Service first class, certified or express mail, or other
overnight mail service, or hand delivered, when addressed as follows:

To Institution:

Copy to:

To Hospital/Facility:

or to such other addressee as may be hereafter designated by written
notice. All such notices shall be effective only when received by the
addressee.

20. [Paragraph Headings]{.underline}.

The paragraph headings in this Agreement are used only for ease of
reference and do not limit, modify, construe, or interpret any provision
of this Agreement.

20.1 [No Third Party Beneficiaries]{.underline}.

The parties have entered into this Agreement solely for their own
benefit, and expressly agree that there are no third party beneficiaries
to this Agreement; including, particularly, students or Faculty.

IN WITNESS WHEREOF, the authorized representative(s) of Facility and of
Institution execute this Agreement on this 20^th^ day of September,
2005.

Board of Regents of the \_\_\_\_\_ HOSPITAL/FACILITY

System of Higher Education, on

behalf of \_\_\_\_\_\_\_\_\_\_\_

Community College

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Governing Board President

**Chapter 2, Human Resources**

**Table of Contents**

A. Human Resources Development Philosophy

B. Recruitment

C. Orientation

D. Credentialing and Privileging

E. Continuing Dental Education

F. Advanced General Practice Residency Programs

G. EFDA Training and Utilization

H. Distance Learning

I. Personnel Systems

J. Career Development

K. Equal Employment Opportunity

L. Labor Relations

**Human Resources Development Philosophy**

The goal of the human resources component of the IHS Dental Program is
to maintain a motivated workforce of sufficient size and quality to
carry out the mission of the program. The Dental Program believes that
its most valued resource is its people and is firmly committed to human
resource development. Program excellence and success are dependent upon
individuals who are collectively committed to organizational goals, show
personal integrity, maintain high ethical standards, and demonstrate
professional expertise. Human resource development must be a continuous
process which is diverse and flexible to meet the needs of the IHS and
Tribal groups, as well as the individual. Following are the core
components of the human resources program:

1.  A recruitment process that informs potential employees of the
    expectations and realities of the Dental Program, thereby matching
    the needs and skills of the individual to those of the IHS, Tribal,
    and Urban programs.

2.  An ongoing orientation process that provides personnel with
    essential and timely information.

3.  A continuing educational process that promotes professional and
    personal growth to enhance the individual's capacity to serve
    American Indian and Alaska Native communities.

4.  A process that outlines career pathways based upon clearly-defined
    qualifications, provides counseling and monitoring of individual
    growth and development, and retains sufficient numbers of career
    employees to provide for program continuity and leadership.

To support the core components, the following principles should be
followed:

1.  Human resource development is an integral component of the
    decision-making process at all levels of the organization. It
    fosters at all times a climate of openness, honesty, mutual respect,
    teamwork, and receptivity to learning.

2.  The program will stay abreast of state-of-the-art methods for
    transferring knowledge and promoting human resource development and
    organizational development.

3.  The program is empowered at all levels to meet its identified human
    resource needs.

4.  The individual has primary control of the course of his/her career;
    however, there is a shared responsibility between the individual and
    the organization to identify the career direction which is most
    appropriate.

5.  The primary responsibility of a supervisor is successful development
    of staff, including creation of opportunities for training.

6.  Educational activities are developed consistent with adult learning
    principles. These include the recognition that individuals come into
    the program with life experiences, knowledge, and skills. Both the
    learner and instructor are active participants in the process.

7.  Educational activities are cost-effective and based upon the needs
    of the individual and the organization.

8.  One-time educational efforts are less likely to have lasting
    effects. To successfully improve performance, participants will be
    provided the opportunity to immediately apply newly-learned concepts
    and ideas. Educational activities are continually reinforced.

9.  The program makes use of available staff to train, reinforce, and
    transfer knowledge and skills at the local level.

10. The program fosters the development of community-oriented dental
    programs which focus on the oral health of the community as well as
    the individual patient.

11. Community support and participation are essential for Dental Program
    operations in the future. We need to bridge cultural barriers and
    balance legitimate consumer preferences with the practice of public
    health dentistry.

12. Management accountability for resources and the need to operate
    along consistent philosophical lines is essential for organizational
    survival.

**Human Resources Homepage**

The IHS has developed a Human Resources homepage that contains a wealth
of information about employment in the IHS. This homepage can be found
at: <http://www.ihs.gov/NonMedicalPrograms/DHR/>.

**Recruitment**

The greatest determinant of an agency's ability to achieve its goals is
the strength of its human resources. Without a dedicated, motivated, and
well-trained staff, quality health care services cannot be ensured.
These are fundamental principles of the Indian Health Service Dental
Program, its staff development component, and its recruitment effort.
Thus, whether managed by the IHS, Tribes, or Urban Indian programs,
health care facilities serving American Indians and Alaska Natives
require the recruitment of capable, conscientious, and caring health
care providers.

The IHS Dental Program has initiated multiple recruitment strategies to
increase the exposure of dental students and dentists to the IHS.
Fundamental to this recruitment effort is the recognition that potential
candidates must have a knowledgeable source of information concerning
policies, personnel requirements, pay/benefit structures, and assignment
opportunities. The recruitment project's ultimate goal is the creation
of a clearinghouse of quality dental candidates from whom to draw
potential recruits.

These strategies are coordinated by the IHS dental recruiter, who is
stationed at IHS Headquarters. The recruiter's primary duties involve
providing information for prospective candidates and referring
candidates to appropriate programs and sites for possible placement. In
response to the growing challenges resulting from demographic,
financial, and retention factors, IHS recruitment services have evolved
into a personalized, "user-friendly" program. Consultation regarding
candidates' educational needs, social interests, spousal employment
opportunities, housing costs, and other quality-of-life concerns have
taken the forefront in employment counseling sessions.

The addition of a toll-free telephone line (800-447-3368) (800-IHS-DENT)
has greatly enhanced communications. Candidates are now able to contact
the IHS conveniently and at no cost. Dental recruitment outreach also is
enhanced through several other avenues, including the following:

-   Use of the Internet web pages and E-mail services
    (<http://www.ihs.gov/MedicalPrograms/Dental/index.cfm> )

-   Formal and informal student externship programs

-   Frequent interactions with key dental school administrators,
    including formal affiliations

-   Recruitment of senior dental students into the IHS General Practice
    Residency Program

-   Promotion at annual dental conferences

-   Marketing among the various professional sectors, such as the
    American Student Dental Association, the American Dental
    Association, the Young Dentists of America, and the American Women
    Dentists Association

-   Publication of classified and display advertisements

-   Coordinated site visits of IHS, Tribal, and Urban Indian program
    dentists to dental schools, including their alma maters

-   Preparation and distribution of professional-quality recruitment
    materials to schools, students, and practicing dentists

Further information is available from:

> IHS Dental Recruiter
>
> IHS Division of Oral Health
>
> 801 Thompson Avenue, Suite 335
>
> Rockville, MD 20852-1627

Toll-free recruitment number: (800) 447-3368 (800-IHS-DENT).

**Orientation**

The IHS Dental Orientation Manual, last revised in 2001, contains a
wealth of information about the IHS in general and the IHS Oral Health
Program in particular. Every dentist and hygienist should be encouraged
to download and review this manual to increase their knowledge of the
system for which they work. The Table of Contents of the Orientation
Manual is reprinted below to illustrate the scope of information
available in the manual:

**Chapter I - Indian Health Service Dental Program**

Facts About The Indian Health Service

Types of Dental Programs

Personnel Systems

Comparison Between Commissioned Corps and Civil Service

Additional Information about HIS Employment

Loan Repayment Program

Summary

**Chapter II -- Initial Orientation Packet**

Mission Statement

Mentoring Program

Formal Orientation

The Way to Use This Manual

Important Documents

Supplemental Documents 8

Did You Remember To...?

Additional For Commissioned Officers

Selected Topics

Structure/Organization

Administrative Policies

Roles of Dental Staff Members

Appointments

Clinical Protocol

Commissioned Corps Matters

Equipment

Familiarization

Items of Business

Record Keeping

Acronyms

**Chapter III -- Three Month Packet**

Cultural Orientation

Dental Data

Goals and Objectives

Professional Support

Safety

Becoming Involved

Certifications

Contract Health Services

Familiarization

Evaluation

Prevention

Purchasing

Quality

Performance Improvement

Special Populations

Suggested Reading

**Chapter IV -- One Year**

Budget

Career Development

Important Legislation

PHS/HIS Committees

Commissioned Corps Promotions

Research

**Chapter V -- Government Forms**

Notice of Arrival

Direct Deposit Sign Up

Employees Withholding Allowance Certificate

Basic Allowance for Housing

Uniform Services ID Card/Deers Enrollment

Commissioned Officers' Leave Request Form

Civil Service Leave Request Form

Travel Order

Travel Voucher

Training Nomination and Authorization

Purchase/Service/Stock Requisition

Performance Appraisal System

Request for Personnel Action, Commissioned Officer

Request for Personnel Action

**Appendices**

Websites of Interest

Uniform Allowance Sample Memo

PATIENT RECORD FORMS

> Examination Record
>
> Medical History
>
> Consent Form
>
> Outpatient Sedation Record
>
> Periodontal Examination Record
>
> Progress Notes

ADMINISTRATIVE FORMS

> Notice of Arrival (PHS 287)
>
> Direct Deposit Sign Up (SF1199A)
>
> Employee\'s Withholding Allowance Certificate (W-4)
>
> Request for Basic Allowance for Housing
>
> Application for Uniformed Services I.D./DEERS Enrollment
>
> Leave Slip (CO) (PHS 1345)
>
> Leave Slip (CS) (SF 71)
>
> Travel Order (HHS 1)
>
> Travel Voucher (SF 1012)
>
> Training Nomination and Authorization (HHS 350)
>
> Purchase/Service/Stock Requisition (HHS 393)
>
> Purchase Order (OF 347)
>
> Request for Personnel Action (PHS 1662 A & B)
>
> Request for Personnel Action (SF 52)
>
> COER (PHS 838)

Links to the manual can be found on the IHS website by clicking on the
following link and scrolling to the bottom of the web page:
<http://www.ihs.gov/MedicalPrograms/Dental/download.cfm>.

**Credentialing and Privileging**

Prior to providing clinical services at any health care facility,
licensed providers (physicians, dentists, physician assistants, nurse
midwives, dental hygienists, optometrists, psychologists, etc.) are
required to be credentialed and privileged. This process assures that
providers are qualified to perform the services they offer and that the
facility is equipped to deliver and support those services.

**Credentialing**

Credentialing consists of verifying the provider's graduation from an
accredited program, post-graduate specialty training, past history of
practice (through letters of recommendation and inquiry to the National
Practitioner Data Bank), and current licensure. Credentialing may be
done by a central organization that includes multiple facilities, or it
may be done at each individual facility, depending on the organization's
policy. A specific individual at the facility should be trained to do
all of the credentialing for the facility, if it is to be done locally,
to ensure that it is done consistently and thoroughly.

In 1965, the landmark legal decision *Darling v. Charleston Community
Hospital* helped to establish the principle of corporate liability in
the healthcare industry. Simply stated, this means that the clinic can
be held legally liable for the actions of those it employs (including
contractors and volunteers). Proper credentialing helps to ensure that
only fully qualified practitioners work in the clinic and that they do
not practice outside the limits of their training and expertise, or
beyond the capabilities of the clinic to support the services being
provided (e.g., sedation and general anesthesia).

Most, if not all, accrediting organizations require that the
credentialing process include primary source verification of the
professional diploma, specialty certificate(s) and state license(s).
Primary source verification means that direct contact is made with the
professional school, residency program, and state licensing board,
preferably in writing, to verify the credentials. If the primary source
verification is done by phone, then detailed notes of the phone call
must be kept, including the date of the contact, the names and titles of
the person making the call and the person providing the information,
etc. Direct contact by phone or letter should also be made with all
professional references as a means to determine current levels of
competence.

**Privileging**

Privileging is accomplished at each individual facility. It is the
process by which the provider's scope of services at that facility is
defined. The granting of privileges is based on the provider's training
and experience, practice history, and the ability of the facility to
provide and support the services for which he/she is privileged.

Privileging in the IHS is usually done by developing a list of all of
the dental services that the Governing Board and/or CEO feel are
appropriate to be provided at the clinic. The provider then completes an
application for medical staff membership and privileges and requests
which of the privileges on the list he/she wishes to have by selecting
either full privileges (i.e., with no restrictions), limited privileges
(i.e., with some restrictions, such as under the observation of a more
senior staff member), or no privileges to provide each service. The
chief dentist then compares the requested privileges with the provider's
credentials to make sure that there is evidence of adequate training and
experience for each of the requested privileges before recommending
granting or denying them.

A committee of health care providers and peers (usually, but not always,
the medical staff committee) then reviews the recommendations of the
chief dentist, makes any changes they feel are appropriate, and passes
the application for privileges on to the Governing Board for final
approval.

A provider should not attempt to provide services without being both
credentialed and privileged at the facility where services are to be
provided. Likewise, an organization (facility) should not allow
providers to deliver services unless they are credentialed and
privileged. Being credentialed by an organization and privileged at one
of its facilities does not imply privileging at any other of the
organization's facilities, unless such privileges are specified.

Credentialing and privileging are individual processes unique to each
provider. While training, degrees, and licensure (credentialing) may
imply the ability to provide certain services, these services should not
be provided without specific privileging. Providers should not assume
that their training and experience create a right to provide services
for which they are not privileged. A few states allow independent
practice by dental hygienists (i.e., without the direct supervision of a
dentist). If your clinic employs a hygienist licensed in one of these
states, then the dental hygienist can also be assigned independent
privileges, if the medical staff committee and Governing Board so
approve.

Credentialing generally is a condition of employment and/or membership
on the medical staff of the facility. Privileges must be formally
requested and granted in writing from the privileging body.

Credentialing should be reviewed at a frequency defined by the
organization's policies and by-laws, usually every 2 years. Privileging
should be reviewed at least at the same frequency as credentialing.
Privileging may change at any time, based on the provider's additional
training, a change in the facility's ability to provide or support
services, or by actions of the privileging body.

Renewal of privileges should be based on peer review and ongoing quality
assurance programs. If a provider wishes to add services to his/her list
of privileges (e.g., as a result of receiving new training or changes in
facility staff or resources supporting those services), formal
application for a change in privileges must be made to the privileging
body and new privileges granted. Privileges for specific services may
also be withdrawn at either the request of the provider or the
privileging body. Withdrawal of privileges by the privileging body may
be based on either changes in the scope of services the facility
provides and supports or as an adverse action from the quality assurance
process and peer review. Reduction of privileges based on the latter
must be reported to the National Practitioner Data Bank. Such reductions
should not be taken lightly and must be well-documented. The privileging
body must have appeals procedures defined in its by-laws.

Samples of credentialing/privileging packages may be obtained from most
IHS hospitals, training centers, or Area Offices.

Whoever is given the responsibility to perform the credentialing and
privileging activities should keep either a written or computerized
"tickler file" that lists all of the credentialed employees and the
dates of their significant credentials:

-   Date of appointment to the staff, and date for renewal of
    appointment and staff privileges

-   Date for renewal of license(s)

-   Date for renewal of malpractice insurance(for contractors)

-   Date for renewal of specialty certification

-   Date for renewal of CPR, ACLS and other such certifications

The credentials coordinator should check this file monthly and ensure
that all credentials and staff appointments and privileges are kept up
to date. Notices for renewal of privileges should be sent out to
employees two to three months in advance of the expiration of the
privileges to allow time to gather and submit necessary documentation.

**Continuing Dental Education**

The IHS Division of Oral Health (DOH) recognizes that a strong
commitment to continuing dental education (CDE) is essential to
improving the oral health of American Indian and Alaska Native people
and is fundamental to professional growth. Many other benefits of CDE
accrue in terms of improved staff morale, retention of employees, higher
quality of care, upward mobility, and the introduction of new ideas and
technologies.

An essential component of CDE is to assess the educational needs of
dental staff in relation to the many competencies required in IHS,
Tribal, and Urban Indian (I/T/U) dental programs, and to create
opportunities to meet those needs. One available assessment tool is the
Individual Development Plan (IDP) which can be found on the IHS CDE
website. The IDP helps to recognize training needs that would be most
appropriate for an employee. Using the IDP is an excellent way to open
communication between a supervisor and an employee. Completing the IDP
offers an opportunity to discuss and identify short and long-term
training goals that are in alignment with dental program objectives

The IHS Division of Oral Health has developed an array of CDE training
courses (3-5 days each) designed to meet I/T/U dental staff needs. Many
of these courses are hands-on clinical courses that are rarely available
from other sources, and, if available from other sources, are very
expensive. IHS CDE courses may be added, modified, or dropped each year,
based upon assessed needs and suggestions from field personnel and
others.

Recently, the DOH developed a website where I/T/U staff can locate and
register for IHS CDE training courses. Go to
[www.ihs.gov/medicalprograms/dentalcde](http://www.ihs.gov/medicalprograms/dentalcde)
to read descriptions of IHS CDE courses available during a fiscal year.
It is possible to download and print the current IHS CDE catalog by
clicking on the *Print Catalog* button. Online IHS CDE courses are also
available through the IHS CDE website.

IHS CDE courses are open to all IHS, Tribal, Urban, and Contract dental
personnel. Instructions about how to register for courses can be found
on the IHS CDE website. During the month of October, supervisors are
able to select and prioritize three IHS CDE courses for each of their
employees. On November 1, a lottery is run and staff are notified by
email and through the IHS CDE website which courses they are registered
or waitlisted for. Staff are then required to indicate if they plan to
attend a course or not. If someone decides not to attend a course, staff
on the waitlist are then contacted to assure all IHS CDE courses are
filled.

Tuition is not charged for dental personnel who work at IHS federal
facilities. However, tuition is charged for dental personnel working for
Tribal dental programs that have taken Headquarters Dental Shares.

IHS sponsored courses should not be viewed as the only source of CDE
available. Individuals are encouraged to seek CDE which may be planned
by their Area, Service Unit, Tribal, or Urban program. In addition, CDE
is available through the military, the state, and local dental
professional groups. Routine educational involvement with other health
professionals, including private dentists, physicians, and others, can
be stimulating and educationally rewarding. Organizing a study club may
be particularly productive at locations where regular contact with other
dental professionals is limited. Providing training during regularly
scheduled staff meetings helps staff to learn together, to understand
policies and procedures, and to implement changes in a dental program.
By using a combination of methods, it should be possible to engage in a
variety of excellent CDE experiences.

**General Practice Residency and Advanced General Practice Residency
Programs**

The Indian Health Service (IHS) offers post-graduate educational
programs for general dentists. A two year advanced general practice
residency (AGPR) is offered at the Hastings Indian Medical Center (HIMC)
in Tahlequah, Oklahoma and the Alaska Native Medical Center (ANMC) in
Anchorage, Alaska. The type of residency offered at each training center
may change from time to time, depending on the availability of
resources. The AGPR is designed primarily for early to mid-career
officers.

The residencies are accredited by the American Dental Association's
Commission on Dental Accreditation, a specialized accrediting body
recognized by the Council on Postsecondary Accreditation and by the
United States Department of Education. On successful completion of the
residency, the graduate is awarded a certificate. The graduate of the
AGPR is eligible to challenge the American Board of General Dentistry
(ABGD). Although the AGPR does not teach to the board, several Indian
Health Service AGPR graduates have successfully completed the board,
and, as a result, are eligible to receive specialty pay.

The advanced general practice residency program prepares the general
dentist for hospital dental practice, with special emphasis on care for
the medically compromised patient. Training includes medical risk
assessment and rotations in anesthesia, emergency medicine, and medical
services. Clinical training in the dental specialties is provided by
staff specialists and specialty consultants. The program helps the
graduate to better diagnose oral and maxillofacial diseases, provide
dental care in the context of each patient's total health care,
communicate and function effectively with other health care
professionals in the IHS, and understand the role of these professionals
within the organization. The graduate is expected to plan and provide
both routine and complex dental care for a wide variety of patients by
applying advanced knowledge, clinical and public health skills. The AGPR
programs use the second year to provide training in management, public
health, research, and educational techniques, and to provide additional
clinical experience.

AGPR graduates should seek an assignment at the O-5 or higher level. At
some point after completion of the AGPR the graduate is expected to
effectively manage a multi-dental officer Service Unit Dental Program
and to provide consultation services. Billets at the O-5 level are
Chief, General Service Unit and Deputy Chief, Complex Service Unit. A
minimum two-year tour of duty is expected of the dentist in the
post-residency assignment.

Residents are selected in a competitive process that begins with the
solicitation of applicants in the fall preceding the year the residency
begins. Applicants submit their curriculum vitae, letters of reference,
transcripts from dental school, and other items directly to the
residency programs in which they are interested. Each residency site has
its own selection process through which applicants are evaluated.
Applicants are notified of the results of the selection process, and
personnel actions are initiated at the residency sites.

Dentists who are interested in post-graduate education in general
dentistry in the Indian Health Service and would like further
information about the residency programs may contact the directors of
the individual programs or the dental staff development officer.
Applications for July of the following year are available in the late
fall on the Indian Health Service list server.

Chief, Dental Staff Development Officer

Indian Health Service

Division of Oral Health

801 Thompson Avenue, Suite 300

Rockville, Maryland 20852\
(301) 443-0029

Dental AGPR Director

Hastings Indian Medical Center

100 South Bliss Avenue

Tahlequah, OK 74464\
(918) 458-3150

Dental AGPR Director

Alaska Native Medical Center

255 Gambell St.

Anchorage, AK 99501\
(907) 257-1317 or 1215

**Personnel Systems**

Individuals who are employed by IHS-funded dental programs generally
fall into one of the following four employment systems:

-   Civil Service System

-   Commissioned Corps of the United States Public Health Service

-   Tribal employment systems (Tribal-hire)

-   Urban Indian program employment systems (Urban-hire)

Many dentists and dental hygienists also have been hired by the IHS,
Tribes, and Urban Indian programs to provide health services as private
contractors. Technically, they are not employees, because they are
usually self-employed.

The Civil Service System and USPHS Commissioned Corps are Federal
employment systems, i.e., the employee is employed directly by the U.S.
Government. Tribally-managed programs have the option of hiring their
own staff or hiring Commissioned Corps employees through a Memorandum of
Agreement (MOA) with the IHS. Tribal programs also can hire Civil
Service employees for a maximum of four years, through an
Intergovernmental Personnel Agreement (IPA). Finally, Urban Indian
programs can also hire Federal employees through a similar arrangement.

Both the PHS Commissioned Corps and the Civil Service System are subject
to Indian Preference, a Federal mandate which states that qualified
Indian candidates for vacant positions must be selected before
non-Indian candidates. This is consistent with the IHS philosophy that
encourages Indian self-determination.

Following is a comparison which shows some of the differences between
the two Federal systems:

**Civil Service System**

-   Is the basic mode of employment used by the U.S. Government.

-   Employs a wide range of professional, technical, administrative,
    clerical, and labor personnel.

-   Uses competitive procedures to fill virtually all positions, with
    employment and advancement based strictly on merit.

-   Requires establishment of eligibility through U.S. Office of
    Personnel Management competitive application procedures, which
    usually includes filing an Application for Federal Employment
    (SF-171) and may require passing an exam.

-   Provides pay/grade based on the position, i.e., the employee holds
    the grade of the position occupied.

-   Normally does not require the employee to relocate involuntarily.

-   Provides pay that is set by Executive Order and based on
    comparability with the private sector. All pay is taxable.

-   Provides annual leave that is determined by the years of service: 13
    days per year for first three years, 20 days per year during years
    four through 14, and 26 days per year for 15 years or more of
    service.

-   Provides 13 days of sick leave each year, with unlimited carryover.

-   Has two contributory retirement systems, the Civil Service
    Retirement System (CSRS) and the Federal Employees Retirement System
    (FERS). Any new employee since 1984 falls under the FERS.

-   Provides retirement age which ranges from 55 to 62, depending on
    number of years of service and whether the employee is on CSRS or
    FERS.

**USPHS Commissioned Corps**

-   Is a personnel system composed entirely of officers who are health
    professionals (no enlisted personnel).

-   Is one of the seven uniformed services of the United States, along
    with the Army, Navy, Air Force, Marine Corps, Coast Guard, and the
    Commissioned Corps of the National Oceanic and Atmospheric
    Administration.

-   Provides for appointment of candidates under the age of 44 who meet
    the required educational and degree standards for their category and
    who pass a physical exam.

-   Provides pay/grade/rank based on the officer and his/her
    professional training and experience, rather than on the position
    held; rank is retained throughout a variety of assignments.

-   Requires officers to serve in whatever assignment or location
    needed.

-   Provides pay and benefits that are generally equivalent to those of
    the other uniformed services. A portion of the pay is non-taxable.

-   Provides 30 days of annual leave per year for all officers,
    regardless of number of years of service.

-   Provides sick leave as needed, with no accumulation of sick leave.

-   Has a non-contributory retirement system based on the military
    retirement system.

-   Does not require a minimum retirement age, as long as officer has
    received credit for a minimum of 20 years and a maximum of 30 years
    of active service. Officers also can retire at age 64, regardless of
    number of years of service.

Following is a list and brief description of commonly-used Federal
personnel forms that employees are likely to encounter:

-   *Form SF-52: Request for Personnel Action* --- The form used to
    initiate action to recruit for a vacant Civil Service position.

-   *Form SF-171: Application for Federal Employment (Civil Service)
    ---* The form used to apply for civilian Federal employment.

-   *Form SF-71: Application for Leave ---* The form used to request and
    report leave for a Civil Service employee.

-   *Form PHS-50: Application for Appointment as a Commissioned Officer
    in the United States Public Health Service ---* The form used by
    dentists or dental hygienists to apply for initial appointment to
    the Commissioned Corps.

-   *Form PHS-1662: Request for Personnel Action --- Commissioned
    Officers ---* The form that initiates a personnel action for the
    initial hiring or transfer of a commissioned officer.

-   *Form PHS-1373: Separation of Commissioned Officer ---* The form
    submitted by a commissioned officer to initiate retirement or
    separation from the Commissioned Corps.

-   *Form PHS-1345: Request for and Authority for Leave of Absence ---*
    The form used to request and report leave for a commissioned
    officer.

-   *Form PHS-31: Officers Leave Record ---* The form used by the leave
    clerk to track commissioned officer leave. (It is recommended that
    commissioned officers keep a copy of this record, since officers are
    responsible for the accuracy of their own leave records.)

-   *BIA Form 5-4432: Verification of Indian Preference for Employment
    in* Bureau of Indian Affairs *and* Indian Health Service *Only ---*
    The form with which documented American Indians/Alaska Natives
    request Indian Preference when applying for a position.

Following are some of the sources available for additional information
on the Federal employment systems:

-   *Commissioned Corps Handbook*

-   IHS *Dental Orientation Manual*

-   Any Federal Government Personnel Office

-   Supervisor

-   Area Dental Consultant

-   Division of Commissioned Personnel, USPHS

**Tribal and Urban Employment Systems**

Tribal-hire and Urban Indian program-hire employees are those who are
hired directly by Tribes or Urban Indian programs through their own
personnel systems. Because each Tribe's and each Urban Indian program's
personnel system is different from the others, any attempt to provide a
detailed description in this document would not be very meaningful. Many
Tribal and Urban Indian personnel systems are similar to the Federal
Civil Service System, but pay scales and benefits may vary considerably.
For example, some Tribes offer comprehensive retirement programs, but
other Tribes offer minimal retirement programs or none at all.

Regarding licensure, Civil Service and Commissioned Corps dentists and
dental hygienists must be licensed in at least one state, but not
necessarily the state in which they are providing services. Commissioned
officer dentists have a one-year grace period following graduation from
dental school, or following completion of a dental residency, during
which to obtain a license. Civil servants and commissioned officer
dental hygienists must be licensed before they start working as Federal
employees. Although the issue of Tribal sovereignty has not been fully
resolved with regard to dental licensure, Tribal-hire and Urban-hire
dentists and dental hygienists generally must be licensed by the state
in which they are providing services.

Each personnel system has its own advantages and disadvantages. The
Commissioned Corps offers good retirement benefits, but the initial pay
level may be lower than that offered by the other systems. Also,
commissioned officers are expected to make periodic geographic moves to
advance their careers and to fulfill the needs of the USPHS. Tribal and
Urban programs may offer more pay initially, but late-career pay levels
and retirement benefits may not be able to match those of the
Commissioned Corps. However, each Tribe's personnel system is different,
and prospective Tribal employees should request specific information on
employment benefits on a Tribe-by-Tribe basis. It is important for
prospective employees to find a personnel system that will best meet
their own and their families' short-term and long-term needs.

**Career Development**

IHS, Tribal, and Urban Indian (I/T/U) programs all can benefit from
staff whose careers have provided a broad background with a variety of
assignments and experiences. Staff who have had experience in applying
public health principles to the day-to-day operation of dental programs
serving American Indians and Alaska Natives are especially valuable. The
development of professionals into employees who have these and other
desirable attributes is a shared responsibility between each individual
professional and the organization which employs the professional. The
employee, however, should have primary control over the course of
his/her career, and it is important for an individual to identify career
goals early. This will facilitate the seeking of positions that will
enhance the attainment of these goals.

The process of and support for career development will vary, depending
on the personnel system under which the professional is working. PHS
Commissioned Corps dentists and dental hygienists have standard career
tracks with substantial guidance in career development. Federal Civil
Service employees also have many resources available to them to further
their careers. The amount and type of guidance provided for Tribal-hire
and Urban-hire employees varies considerably, depending on the
individual program.

**Tribal-Hire and Urban-Hire Employees**

Because of the variability among Tribal and Urban Indian programs in the
career development support provided for employees, it is important for
employees of these programs to monitor their own careers carefully and
to seek positions that will help them to meet their personal and
professional goals. In the past, IHS staff, including Area Dental
Consultants and staff development specialists from Headquarters, have
been available to assist Tribal and Urban employees in making career
decisions. In the future the availability of assistance from these
sources for Tribal employees will be affected by whether individual
Tribes choose to take their Tribal shares of Headquarters and Area
Office support funds. The number of Area and Headquarters dental staff
who are available will depend on the number of Tribes which choose to
request support services from the IHS.

It may be helpful for Tribal-hire and Urban-hire dentists to review the
Commissioned Corps career development paths described in this section.
Even though they are not commissioned officers, they may wish to seek
career paths that are similar in direction and sequence.

PHS Commissioned Corps Dentists and Dental Hygienists

The philosophy of the PHS Commissioned Corps maintains that individuals
should be incrementally challenged to become capable of accepting
greater responsibility through advanced training and experience.
Commissioned Corps personnel in the IHS Dental Program are initially
challenged to become proficient in all phases of clinical dentistry.
They are next challenged to accept community health (non-clinical) and
management responsibilities and then to assume this combination of
responsibilities for programs of increasing size. Moreover, the
experience and training obtained during the early years of a career
enable mid-career and senior officers not only to pursue Service Unit
objectives but to provide guidance to enhance the careers of less
experienced officers. The system, therefore, provides for continuing
professional growth, building toward the more complex positions, which
are rated at higher grade levels by the Commissioned Corps. By the time
officers reach a senior level, they should have progressed in a career
track which provides them with significant personal and professional
responsibilities and rewards.

It is *essential* that IHS commissioned officers realize that they are
part of two systems. Although employed by a Federal agency, the Indian
Health Service, officers are members of the Commissioned Corps of the
U.S. Public Health Service (PHS). Through this personnel system, they
have opportunities to serve in other programs of the PHS. Because the
IHS is the largest clinical program in the PHS, it is possible that an
officer may spend an entire PHS career with the IHS program. However,
the officer is still expected to gain broad experience that increases
his/her value to the PHS and warrants promotion within the
rank-in-officer system.

In selecting a career track an officer should avail him/herself of
career counseling by the Service Unit Dental Chief, the Area Dental
Consultant, the Director of Dental Staff Development at Headquarters
West, and/or the Dental Staffing Officer from the Division of
Commissioned Personnel.

IHS Dental Program Career Tracks (Commissioned Corps)

In the IHS, dentists can pursue three basic career tracks (General
Practice, Public Health Administration, and Clinical Specialty), with
each requiring somewhat different training and experience. All include
management functions appropriate to the track and billet. A discussion
of each track follows.

**General Practice Track**

The General Practice career track in the IHS is an exciting and
challenging one, which combines essential elements of public health,
education, social/behavioral, management, and clinical practice
knowledge and skill areas. These billets form the "heart and soul" of
the IHS Dental Program and comprise a large number of senior leadership
billets. Both clinical and management skills are required to perform
well in the higher billets within this track. Most IHS Dental Officers
pursue this career path.

These billets start with entry level responsibilities and progress
through comprehensive program management, as reflected by the grade
rating assigned to each. The standard billets which comprise this track
are:

Billet \# Title Grade

02HGO60 Staff Dental Officer/Basic O-3

02HGO61 Staff Dental Officer/Advanced O-4

02HGO62 Chief, Basic Dental Unit - Satellite O-4

02HGO63 Chief, Basic Dental Unit - Solo O-4

02HGO64 Chief, General Dental Unit O-5

02HGO65 Deputy Chief, Complex Dental Unit O-5

02HGO66 Chief, Complex Dental Unit O-6

02HGO33-36 GPR and Advanced GPR O-3 to O-6

02HGO74 Dep. Chief/Clinical Program Director, O-6

Complex Dental Unit

**Experience and Education Required**

Dentists who have limited experience in clinical dentistry (recent
graduates) generally begin service with the IHS in the Staff Dental
Officer/Basic (SDO/B) billet. This position allows the officer to gain
clinical experience rapidly under the direction of more experienced
clinicians, without having responsibility for the day-to-day management
of the clinic.

Some recent graduates or dentists with limited practice experience or
General Practice Residency (GPR) training may be assigned initially to
Staff Dental Officer-Advanced (SDO/A); Chief, Basic Dental
Unit-Satellite (C,BDU-Sat) or Chief, Basic Dental Unit-Solo (C,BDU-Solo)
billets. Although still in entry level billets, these individuals assume
responsibility for community-wide activities, supervision of employees,
prevention programs, and other related responsibilities. These
comprehensive duties are a real challenge for new professionals. This
situation is seen as a compromise by the Dental Program; ideally, the
program manager (dentist) would have experience in a Staff Dental
Officer/Basic billet before assuming these more advanced duties. Stellar
performance in these 0-4 billets early in a career may, however, enable
an officer to accelerate the process of career progression.

Dentists who are selected for advanced billets (O-5 and O-6) should have
a broad base of program experience. Both the community and clinical
components of these positions are substantial. Additional educational
qualification in the form of a General Practice Residency, or ten years
of professional experience, is required for the following billets:

-   Deputy Chief, Complex Dental Unit

-   Chief, Complex Dental Unit

-   Deputy Chief/Clinical Program Director, Complex Dental Unit

**Public Health Administration Track**

The practice of public health dentistry is the responsibility of *every*
dentist in the IHS. The allocation of resources and application of
programs among populations is based on public health principles.
Therefore, the ability to progress through the Public Health
Administration track hinges on one's ability to understand and practice
public health dentistry at the Service Unit level. Consideration for
administrative billets within the IHS Dental Program is contingent upon
demonstrated Service Unit-level management ability.

The billets which comprise the Public Health Administration track
consist of positions in the General Practice Track, *plus* the
following:

Billet \# Title Grade

02HGO4530 Area Dental Prevention Officer O-5

02HGO3793 Assistant Chief, Area Dental Services O-5

02HGO5382 Prevention Officer Supervisor O-6

02HGO3794 Deputy Chief, Area Dental Services O-6

02HGO69 Area/Regional Dental Consultant O-6

02HGO3797 Assistant Chief, Dental Services Branch O-6

02HGO71 Deputy Chief, Dental Program O-6

02HGO72 Chief, Dental Program O-7

02HGOO4-OO6 Out-Of-Service Student-MPH (training) O-4 to O-6

02HGO33-36 Dental Public Health Resident (training) O-4 to O-6

**Experience and Education Required**

These positions require a sound base of IHS general practice experience,
plus additional experience and/or formal training in Dental Public
Health. In some cases a Masters in Public Health (MPH) is required, and
in others Dental Public Health specialty training (MPH plus a Dental
Public Health Residency) is necessary. This career track leads to
management positions in Area and Headquarters Offices. The incumbents
coordinate the development of overall program goals and objectives,
provide technical assistance, and evaluate outcomes. Broad
responsibility for program structure, process, and outcome is shouldered
by individuals in these billets.

**Clinical Specialty Track**

The successful practice of a dental clinical specialty in the IHS is
another track which is dependent upon achieving a sound base in the
general practice setting. Clinical specialists serve Service Units,
Areas, and the IHS in staff development, consultation, policy
development, and the provision of clinical specialty care.

The standard billets in this track consist of positions in the General
Practice Track *plus* the following:

Billet \# Title Grade

02HGO67 Staff Dental Clinical Specialist O-5

02HGO68 Area/Regional Clinical Specialist O-6

02HGO70 National Dental Clinical Specialty Consultant O-6

02HGO23-26 Out-Of-Service Student (Training) O-4 to O-6

**Experience and Education Required**

A certificate or masters degree in the clinical specialty is the
necessary additional training required. Some dentists enter the IHS
having accomplished clinical specialty training prior to employment. The
IHS also sponsors limited numbers of career IHS dentists in specialty
training. In order to practice a clinical specialty most effectively in
the IHS, the specialist must clearly understand Service Unit care
delivery, including the use of general public health principles. This
understanding can be gained by practicing as a general dentist in the
IHS either prior to or after training as a specialist.

IHS-sponsored trainees obviously have general practice experience prior
to training. Clinical specialists, with or without previous IHS
experience, are expected to be able to provide general dental services
as the need may arise. The amount of general practice required of a
specialist will vary with the size of the Service Unit, the number of
staff, and the demand for specialty services. Clinical specialists with
many years of PHS service and a firm understanding of IHS goals and
objectives will be considered periodically for appointment as IHS-wide
specialty consultants. These billets incorporate an IHS-wide leadership
role in the particular specialty with all the responsibilities inherent
in the Clinical Specialty Track.

**Equal Employment Opportunity (EEO)**

The Indian Health Service (IHS) is fully committed to Equal Employment
Opportunity (EEO) without regard to race, color, religion, gender,
national origin, age disability, or sexual orientation. This involves
providing all employees with a work environment free of discrimination
and with the opportunities, tools, training, and support systems they
need to develop to their fullest potential. This may be facilitated by
assisting employees in balancing their work and family needs, and
evidenced by providing appropriate accommodations and support systems
for individuals with disabilities.

All IHS employees need to be knowledgeable about EEO, its laws,
policies, processes, local and Area counselors. The IHS requires that
all employees attend a yearly EEO training session. The training for
supervisors is more intense and rigorous, since supervisors must enforce
the EEO regulations, within their departments

There are differences in the mechanism of action between Civil Service
and Commissioned Corps employees. It is important that you become
familiar with the mechanism under which you as an employee fall.

If you have not had the opportunity to participate in the EEO training,
you can access all the needed information through the IHS EEO website
at:

<http://www.ihs.gov/AdminMngrResources/eeo/index.asp>. This website also
contains information on all aspects of the IHS EEO program.

**Labor Relations**

Dealing with Union matters is part of daily operations in most Indian
Health Service facilities. This section of the OHPG will discuss a few
of the more-important concepts of Labor Relations (LR) in general terms.
It is not intended to be a substitute for formal training in LR at the
local level, but rather to provide a foundation of knowledge for the
dental program supervisor. Dental Supervisors should be familiar with
the terms of the Collective Bargaining Agreement at their local
facility, and should always consult with local or Area human resources
personnel when dealing with union matters.

Official IHS documents and regulations concerning Employee
Relations/Labor Relations can be found at the following website:
<http://www.ihs.gov/NonMedicalPrograms/DHR/index.cfm?module=ERLR>

**Important key items that need to be understood:**

**Bargaining unit** - A bargaining unit is a group of employees found
appropriate for representation by Federal Labor Relations Authority
(FLRA) and voted upon by employees who are represented by a labor union
in their dealings with agency management. Bargaining unit status
pertains solely to the positions employees hold within the agency.
Employees are either in a bargaining unit (bargaining unit members) or
are excluded based on the unit definition or statutory exclusion.

**Collective bargaining** - The process of negotiating a union contract
or settling grievances under the grievance procedure provided in an
existing contract.

**Collective bargaining agreement** - The agreement reached between an
employer and the union representing the employees that embodies the
terms and conditions of employment agreed upon in collective bargaining.
Ordinarily, the agreement is written and is effective for a defined
period.

**Exclusive Representative:** An employee organization that has the
right to solely represent the bargaining unit for purposes of collective
bargaining. Many, if not all Collective Bargaining Agreements in the IHS
grant this right.

**Free Riders:** A term used by unions to designate non-members within
the bargaining unit who obtain, without cost, the benefits of a
contract/MOU gained through the efforts of the dues\--paying members.

**Grievance:** A formal complaint usually lodged by an employee or the
union alleging a misinterpretation or improper application of one or
more terms in a collective bargaining agreement. The method for dealing
with grievances is through a grievance procedure negotiated in the union
contract. If a grievance cannot be settled at the supervisory level, it
can be appealed to higher levels of management.

**Investigatory interview**: An investigatory interview occurs whenever
a supervisor questions an employee to obtain information which could be
used as a basis for discipline. The employee must have a \"*reasonable
belief*\" that disciplinary action may result from what he or she says
at the interview. Any employee who is involved in an investigatory
interview and is a member of the bargaining unit has a right to union
representation. Supervisors should always refer to their collective
bargaining agreement to determine their rights and responsibilities when
conducting an investigatory interview.

Investigatory interviews relate to such subjects as:

-   absenteeism,

-   accidents,

-   compliance with work rules

-   damage to company property

-   drinking

-   drugs

-   falsification of records

-   lateness, poor attitude

-   poor work performance

-   sabotage

-   slowdowns

-   theft

-   violations of safety rules

Please visit the following website for more information on
investigations:
<http://www.ihs.gov/NonMedicalPrograms/DHR/Documents/superman/investigation.pdf>

**Negotiation requirements**: The Agency / IHS facility is required to
provide the union "Notification" when the employer intends to change the
conditions of employment or working conditions of employees in the
bargaining unit (e.g., work schedules, leave policies, etc.).

**Formal Discussions**:

Management has an obligation to invite the union to attend any formal
discussion between one or more representatives of the agency and one or
more employees in the unit or their representatives concerning any
grievance or any personnel policy or practices or other general
condition of employment.

There are two key characteristics in determining whether a discussion is
a \"formal discussion\" thus requiring the union to be invited or some
other type of discussion supervisors may have with their employees:

-   who will be at the meeting; and

-   the subject of the discussions.

*Attendance:* For a meeting to be considered a formal discussion, it
must include:

-   one or more representatives of the agency (e.g., supervisor(s)),

-   management official(s),

-   personnelist(s), or

-   attorney(s)); and

-   one or more employees in the [bargaining
    unit](http://cpol.army.mil/library/permiss/411.html) or their
    representative(s).

*Subject of the meeting*: A meeting does not become a formal discussion
unless the subject concerns [an individual\'s
grievance](http://cpol.army.mil/library/permiss/416.html) or general
conditions of employment. Normal shop talk is not a formal discussion.
Nor are employees are entitled to union representation if the employer
is simply informing the employee of some discipline which has already
been decided. Performance Reviews and Performance Improvement Plans,
which relate to performance rather than conduct, also do not fall under
the guidelines for formal discussions.

The Federal Labor Relations Authority has indicated certain factors that
determine whether a meeting was a formal discussion:

-   whether the individual who held the discussion is a first-level
    supervisor or is higher in the management hierarchy (the higher the
    level, the more a formal discussion is indicated);

-   whether any other management representatives attended;

-   where the individual meeting took place (i.e., in the supervisor\'s
    office, at each employee\'s desk, or elsewhere);

-   how long the meeting lasted;

-   how the meeting was called (i.e. with formal advance written notice
    or more spontaneously and informally);

-   whether a formal agenda was established for the meeting;

-   whether each employee\'s attendance was mandatory; and

-   the manner in which the meeting was conducted (i.e., whether the
    employee\'s identity and comments were noted or transcribed.)

The above list provides indicators of a formal discussion, they need not
all be present for the Authority to find a meeting was a formal
discussion. The Authority looks to the totality of the meeting and not
just any single factor.

If the meeting meets the definition of a formal discussion, the
supervisor **must** invite the union to attend. Having a shop steward,
who works in the clinic, at the meeting in his or her role as an
employee does not meet this obligation. Rather, the supervisor must
invite the union to the meeting with the union being free to designate
whom it wants to act as its representative.

Finally, the union is allowed to participate in these formal discussions
by raising questions/comments/concerns, but it cannot disrupt the
meetings.

**Union Representative**: represents the Union and members of the
bargaining unit and those who do not pay dues.

**Weingarten Rights**

A situation where the union is entitled to represent bargaining unit
employees involves meetings with employees in connection with an
investigatory interview. This provision is often referred to as
employees\' \"Weingarten\" rights, based on a Supreme Court decision.
The Federal Service Labor-Management Relations Statute establishes three
conditions that must be met for a meeting to be considered a
\"Weingarten\" meeting:

-   One or more agency representatives are examining (questioning) a
    [bargaining unit](http://cpol.army.mil/library/permiss/411.html)
    employee in connection with an investigation;

-   The employee reasonably believes that the examination may result in
    [disciplinary action](http://cpol.army.mil/library/permiss/5a1.html)
    against the employee; and

-   The employee requests union representation.

\"Weingarten\" rights are not applicable when management issues a
disciplinary action since management is not asking any questions.
Additionally, the \"Weingarten\" right does not come into play when
engaging in performance counseling as this does not concern disciplinary
matters but, rather, performance issues.

It is imperative that each supervisor obtain a copy of the Local Union /
Bargaining Agreement and the Federal Labor Relation manual,
([www.FLRA.gov](http://www.flra.gov/)). Also available is "the
Supervisors Guide to Federal Labor Relation, 6^th^ Edition"; contact
your Area Labor Relation Office for a copy or contact:

FPMI Solutions Inc.

4901 University Square Suite 3

Huntsville, AL 35816

256-539-1850

256-539-0911 fax

[www.fpmisolutions.com](http://www.fpmisolutions.com/)

**Chapter 3, Program Resources**

**Table of Contents**

A. Introduction

B. The Budget Process, National

C. Oral Health Resource Guide

D. HP/DP Awards Program

E. Sources of Grants

F. Tips for Obtaining Grants

G. Listserv

H. IHS Website

I. Area Supports Centers

**Introduction**

The achievement of Dental Program goals depends in large part upon
cooperation among IHS, Tribal, and Urban Dental Program staff, Tribal
officials and organizations, and Indian communities. Information
exchange among these entities is mutually beneficial and is essential if
we are to raise the oral health status of American Indians/Alaska
Natives to the level of our healthiest Americans. Information can be
obtained from the Indian Health Service Dental Program through personal
contact with program personnel; through IHS publications such as this
guide, from the IHS website ([www.ihs.gov](http://www.ihs.gov/)), from
the IHS listserv, from the IHS dental newsletter (available at
<http://www.ihs.gov/MedicalPrograms/Dental/download.cfm> ), and other
sources.

In addition to these internal resources, external resources also are
available that can help dental programs, Tribes, and individuals to
achieve program goals. These include local, state, national, and
international organizations, as well as the Congress itself, which is
the ultimate funding source for most of the monies that support dental
programs for Native Americans.

Governmental agencies outside of the Indian Health Service are one
external source of information. The IHS has always worked closely with
the PHS Chief Dental Officer and with other Public Health Service
agencies, such as the Centers for Disease Control and Prevention (CDC,
<http://www.cdc.gov/oralhealth/>), the Food and Drug Administration
(FDA, [www.fda.gov](http://www.fda.gov/)), and the National Institute of
Dental and Craniofacial Research (NIDCR, <http://www.nidcr.nih.gov/>).
Valuable information is available with a simple phone call to these
agencies or a quick scan of their websites. The IHS Dental Program also
has worked closely with non-PHS agencies, such as the Administration for
Children, Youth, and Families (ACYF) and the Bureau of Indian Affairs
(BIA) on projects and issues of mutual concern.

The American Dental Association, American Dental Hygienists'
Association, American Dental Assistants' Association, and their state
and local components are other examples of external sources of
information that are widely used by dental staff. These affiliations not
only provide dental staff with information, materials, and continuing
education courses, but the needs of Indian dental programs can be
relayed to the organizations, which in turn can support Indian programs
at the state and national level.

**The Budget Process**

Federal responsibility for health care for Indian people had its genesis
in treaties between the United States and Indian nations. This
responsibility has since been reconfirmed and defined by many actions of
the Federal Legislative, Judicial, and Executive branches. The Snyder
Act provides the earliest legislative basis for health care for Native
Americans in stating that the Government will "\...direct, supervise,
and expend such moneys and assistance as Congress may from time to time
appropriate, for the benefit, care, and assistance of the Indians
throughout the United States\...for relief of distress and conservation
of health\..."

The language used in the Snyder Act authorizes the provision of health
services within the limits of Congressionally-appropriated funds.
Therefore, the Federal budgeting arena provides opportunities for the
many stakeholders in Indian health to inform and influence the
Legislative and Executive branches as the budget is negotiated each
year. Some understanding of the budgeting process is often useful for
those who wish to promote Indian health issues in the budget arena.

The Federal budget process is a three-year cycle which begins two years
before the year in which funds will be expended.

The annual budget request of the Indian Health Service (IHS), an agency
in the Department of Health and Human Services (HHS), is the result of a
budget formulation and consultation process that involves IHS and Tribal
Indian health program representatives and providers from the local to
the national level. This process ensures that the budget is relevant to
the health priorities of Indian country.

The IHS budget request is improved and strengthened with the
participation of health providers and Tribal and Indian health
representatives in its development. The process begins at the local
level, where budget priorities are established based on the health
priorities of the local community. The IHS and Tribal Indian leadership
and health program and budget staff of the 12 IHS regions develop and
submit budget recommendations for an agency budget request to HHS. In
addition, the IHS budget formulation process contributes to the tribally
developed national budget priorities. These priorities are presented to
HHS by representatives of the Tribal budget workgroup. The Tribal
priorities are instrumental in informing senior officials of other HHS
agencies of the health needs of Indian country so that they have the
opportunity to include those priorities in their individual budget
requests to HHS. The IHS presents the formal IHS budget request to HHS.

The IHS and Tribes evaluate the budget formulation process to ensure it
remains relevant and effective. As a result, the process is steadily
improving and is responsive to changes in Tribal leadership and IHS and
Tribal emerging and shifting health priorities. The IHS and Tribes have
identified two items for focused attention:

1.  The Tribal partners in the development of the budget request are not
    directly involved in the budget process once the request is
    submitted to HHS and the Office of Management and Budget. Because of
    the government-to-government relationship with Tribes and the
    established consultation policies of the IHS and HHS, it would be a
    reasonable business practice to have Tribal leadership involved
    throughout the budget formulation decision-making process.

2.  The Tribal leadership is requesting an exemption from rescissions.
    Between FY 2003 and FY 2006 the IHS appropriation has been subject
    to rescissions amounting to \$143 million. Given the unique mission
    of the IHS as a direct service provider in comparison to other HHS
    agencies, a funding rescission to IHS translates into a reduction of
    health care services for American Indians and Alaska Natives.
    Medicare and Medicaid were not subject to such rescissions.

Details about IHS budget formulation can be found on the IHS Budget
Formulation Website at:
<http://www.ihs.gov/NonMedicalPrograms/BudgetFormulation/>.

**IHS Dental Listserv**

The IHS Dental Listserv is a forum for sharing information with and
asking questions of the IHS dental program as a whole. Any email sent to
the listserv is routed to everyone who has subscribed to the listserv.
Obviously, the value of the listserv increases as the number of dental
personnel subscribed to it increases. The manner by which you can
subscribe depends on the computer from which the subscription is sent.
If the computer is behind the government firewall, the first set of
instructions is used, and all communication to and from the listserv
will be from the government email address. It is also possible to
subscribe to the listserv using a non-government computer with a private
or commercial email address. To do so, follow the second set of
instructions, below.

Please share this information with your dental colleagues. There is much
useful information shared on the listserv and it is in everyone\'s best
interest to subscribe to the IHS Dental Listserv.

**Subscribing From a Government Computer/IHS Email Account**

Access the following URL:
[[http://listserv.ihs.gov/archives/ihsdental.html]{.underline}](http://listserv.ihs.gov/archives/ihsdental.html)

1.  Click on \"Join or leave the list (or change settings)\".

2.  Fill in the information (email address and your name). You can
    select the other settings you want to use, but it is recommended to
    stay with the default settings.

3.  Click on the applicable box of either \"Join IHSDENTAL\", or \"Leave
    IHSDENTAL\".

4.  You should shortly receive an email message titled \"Command
    confirmation request\". Follow the directions on that email message
    to confirm your intent to subscribe (or unsubscribe).

5.  A message will then be sent to the listserv owners, who will then
    have the ability to request that your subscription is made active.

6.  Once the listserv owners request that your subscription is made
    active, you should then receive a message confirming your
    subscription. This message will include information on how you may
    post messages to the IHS Dental Listserv.

**Subscribing From a Non-Government Computer with a computer-based Email
Client such as Outlook Express**

1.  From your non-government computer with your default email account,
    open your browser and go to [www.ihs.gov](http://www.ihs.gov/)

2.  click on IHS Listserv under "Key IHS Links" in the left column

3.  click on "Available Lists" in the left column

4.  from the list of available lists, click on "IHS Dental"

5.  near the bottom of the page, find "subscribe" under "List Functions"
    and click on it

6.  enter your name between the \< \> symbols and send the email

7.  you will receive confirmation of your subscription

**If you are using a web-based email account (such as Hotmail, Gmail,
Yahoo Mail, etc.) rather than a computer-based email client, you will
need to modify the above instructions.**

1.  Open and sign in to your personal email account

2.  Compose a new email message as follows:

    a.  In the "To:" line, place the following email address
        <listserv@listserv.ihs.gov>

    b.  In the body of the email message (**not the subject line**),
        place the following message: "subscribe ihsdental \<your name
        here\>", without the quotation marks and substituting your name
        for "your name here" between the \< \> symbols.

    c.  Send the email message.

You will receive an email confirmation that your subscription has been
accepted.

**Sending a Message to the IHS Dental Listserv**

Once you are subscribed to the dental listserv, communicating with all
other subscribers is as easy as sending a single email. Address all such
communications to: <ihsdental@listserv.ihs.gov>. Only use the
<listserv@listserv.ihs.gov> address to subscribe to or unsubscribe from
the dental listserv.

**Area Dental Support Centers**

**Albuquerque Area Dental Support Center**

The Albuquerque Area Dental Support Center was established in 2000 to
provide clinical and preventive support to Indian Health Service (IHS),
Tribal, and Urban dental programs in New Mexico, Southern Colorado, and
Texas. Its primary goals are directed towards supporting and enhancing
the I/T/U dental infrastructure in order to effectively address both
Government Performance Results Act (GPRA) and Healthy People 2010
objectives relating to oral health. Three goals have been established
for this program:

> 1\. Provide assistance and support in oral health promotion and
> disease prevention, particularly in the area of primary prevention;
>
> 2\. Continue the established efforts of the Albuquerque Area Dental
> Support Center as a centralized resource for training and technical
> assistance; and,
>
> 3\. Provide technical assistance and resources to national IHS
> preventive and clinical initiatives.

The Support Center provides essential services to the Area Dental
Programs by acting as a centralized resource and communication center
for Area dental leadership and staff; acting as liaison in Area wide
partnerships (WIC Head Start, Environmental Health; Area Prevention
Council, etc.); providing support and resources in Area and local health
promotion and disease prevention initiatives

The Support Center engages in many strategies to enhance the efforts of
local oral health programs including: acting as a resource for
designing, implementing, and evaluating effective oral health programs;
providing continuing education opportunities for Dentists, Hygienists
and Dental Assistants; serving as liaison to other agencies,
organizations and coalitions; developing both community specific and
Area wide oral health promotion programs; coordinating and assisting
with clinical site reviews; and seeking out funding opportunities on
behalf of IHS and Tribal Dental programs.

One of the main strengths of the Support Center is its expertise in
health promotion and health communications. Evidence based best
practices from the broader health promotion arena have been used to
develop not only dental health educational materials, but also
prevention interventions that target health behaviors.

By building on the strengths of the Indian Health Service Dental clinics
and promoting public awareness of the benefits of good oral health, the
Support Center is having a positive impact on not only quality of dental
care and access to that high quality care, but on attitudes regarding
oral health as well. This multifaceted approach ultimately results in
positive health outcomes for children and families.

[]{.mark}

P.O. Box 67830

Albuquerque, NM 87193

\(505\) 922-4264

Fax: (505) 346-2311

**Northwest Tribal Dental Support Center**

The Northwest Tribal Dental Support Center (NTDSC), originally funded in
Fall 2000 and currently in its second grant cycle, provides services to
all 33 IHS and tribal dental programs in Idaho, Oregon, and Washington.
The overall goal of the NTDSC is to improve the oral health of American
Indian and Alaska Native (AI/AN) people in the Pacific Northwest.
Services provided include preventive and clinical on-site dental program
reviews, planning and evaluating HP/DP initiatives, and Area-wide
training.

The objectives of the NTDSC include the provision of technical
assistance through site visits and other modes of communication,
increased access (overall and for targeted groups such as infants and
patients with diabetes), increased use of sealants, increased
application of topical fluoride treatments, and technical assistance in
the evaluation of HP/DP programs and grant writing. Furthermore, the
objectives include the identification and provision of Area-wide
trainings and collaboration with IHS Headquarters and other Dental
Support Centers towards meeting national HP/DP objectives. All of the
activities of the dental support center are supported through ongoing
communication with local dental programs via site visits, email groups,
telephone consultation, and an annual Prevention Coordinators' meeting.

The NTDSC has produced a Prevention Manual outlining the policies and
procedures for both clinical and community-based HP/DP activities. The
consultants have also developed various clinical and prevention
assessment tools used during program reviews. Many HP/DP pamphlets and
other educational tools have been designed by the NTDSC, some in
conjunction with other dental support centers. Most of the products of
the NTDSC can be viewed through the online version of the IHS Oral
Health Education Resource Guide.

The accomplishments of the NTDSC in meeting our HP/DP objectives can be
attributed to the fierce commitment of those dental providers in the
Northwest who have worked both independently and collaboratively to
achieve these objectives, adopting them as their own, and putting in the
time and effort required to improve the oral health of the people they
serve.

Contact: Joe Finkbonner, Director

Ticey Casey: Administrative Assistant

Northwest Portland Area Indian Health Board

527 SW Hall, Suite 300\
Portland, Oregon 97201\
(503) 228-4185

Consultants: Bonnie Bruerd, DrPH; Jeff Hagen, DDS, MPA; Kathy Phipps,
DrPH

**Oklahoma City Area Dental Clinical And Preventive Support Center**

The Oklahoma City Area (OCA) Dental Support Center (DSC) provides
services through a contract between the OCA Indian Health Service (IHS)
dental program and the Oklahoma City Area Inter-Tribal Health Board
(OCAITHB). It began operations in 2001 after receiving a five year
competitive award.

The OCA encompasses a three state area (Oklahoma, Texas and Kansas) and
provides services to 39 federally recognized tribes making the OCA the
largest IHS service population in the United States extending health
care to over 306,000 American Indians and Alaskan Natives (AI/AN).
Within the OCA, there are 34 Indian Health Service, Tribal and Urban
(I/T/U) dental clinics as well as 81 tribally run Head Start and Early
Start centers to which the DSC provides services and products. The areas
included in the OCA/DSC scope of work include:

-   Oral Health Promotion/ Disease Prevention (OHP/DP) and Head Start

-   Recruiting (Hygienist and Dental Assistants)

-   Continuing Dental Education

-   Data Collection and Information Management

-   Oral Health Survey Analysis

-   Staff Orientation

Services and products currently provided by the OCA/DSC include the
following:

**Oral Health Promotion/ Disease Prevention (OHP/DP) and Head Start**

-   Grant writing assistance provided to clinics

-   Award annual mini-grants for OHP/DP community based initiatives

-   Award clinics with head start specific mini-grants

-   Secure partnership funding for head start educational program

-   Provide on-going educational program in-service to head start
    children, staff and parents

-   Create oral health educational brochures and distribute throughout
    OCA bi-annually

-   Supply over 12,000 toothbrushes annually to head start programs

-   Offer and award Annual Outstanding OHP/DP Individual

-   Produced standardized form used in all area wide school sealant
    programs

-   Facilitate Annual Head Start Staff Conference

-   Facilitate Annual OHP/DP coordinators meeting

-   Provide T/TA to clinics developing or refining their OHP/DP programs

-   Maintain OCA OHP/DP video and audio library

-   Coordinate area wide prevention project (changes annually)

-   Provide on-going TA to head start programs

-   Serve as OCA OHP/DP representative for the national level

**Recruiting**

-   Participate in various career fairs with professionally lighted
    display board

-   Informational recruiting flyers designed for dental assistants and
    dental hygienist

-   Recruiting presentations given yearly at 4 universities

-   Contact maintained with 14 dental assistant training programs

-   Assist in the placement process of dental assistant interns

-   Database created and maintained tracking interested job candidates

-   Prepare, update and disseminate bi-annually area dental roster

-   On-going TA provided to interested applicants for I/T/U and USPHS

-   Work with local and national IHS dental recruiters for placement of
    applicants

**Continuing Dental Education**

-   Coordinate the OCA Annual Dental meeting for over 175 attendees and
    vendors

```{=html}
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-   Offer BLS to dental staff providers

-   Coordinate 3 CDE courses each year

-   Coordinate hands-on CDE course annually

-   Established and maintain 2 MOUs with University of Oklahoma CDE
    dept.

-   Serve as OCA National Training Coordinator

-   Offer web-site training/technical assistant for IHS CDE website

-   Survey and track training needs for OCA dental staff

**Data Collection and Information Management**

-   Collect annual dental data through RPMS systems

-   Convert data from tribal dental programs that do not use the DDS
    system

-   Assist IHS dental program with annual dental clinical efficiency and
    effectiveness report

-   Collect data for school based sealant programs

**Staff Orientation and Development**

-   Develop and provide new staff orientation kits

-   Provide on-site staff orientation to new dental staff members

-   Provide orientation to newly commissioned officers

-   Provide OHP/DP T/TA to new prevention clinic coordinators

-   Offer staff development trainings; team building, customer
    relations, etc.

**Other**

-   Assisted in the coordination of the State of Oklahoma Children's
    Oral Health Forum

-   Member of the State of Oklahoma Children's Oral Health Coalition

-   Member of the State of Oklahoma Mobile Unit Taskforce

-   Produce quarterly informational newsletter and distribute

# **Contact Information:** Oklahoma City Area Inter-Tribal Health Board (OCAITHB)

Dental Support Center

> Amy Holder, RDH, Director
>
> P.O. Box 57377
>
> Oklahoma City, OK 73157-7377
>
> Phone: (405) 951-3940 ext. 101
>
> Fax: (405) 951-3902
>
> Email: <amy.holder@ihs.gov>

Website: [http://www.ocaithb.org](http://www.ocaithb.org/)

**Inter Tribal Council of Arizona, Inc.**

**Dental Clinical and Prevention Support Center**

Mission: To assist Tribal, urban American Indian, and IHS dental
programs in the Phoenix and Tucson Service Areas in supporting clinical
services, effective program management, and prevention activities.

**Services that can be provided**:

-   Community presentations on all aspects of oral health for children,
    adults and elders

-   Community oral health surveys

-   Conduct unmet dental needs assessments

-   Chlorhexidine mouth rinse programs for elders

-   School brushing programs

-   Denture cleaning supplies

-   Dental prevention supplies

-   Develop and distribute oral health brochures and fact sheets (10
    currently available, including a Diabetes and Oral Health booklet)

-   Water testing for fluoride levels

-   Fluoride supplement programs

-   Xylitol chewing gum programs

-   Saliva testing to determine bacterial levels

-   Fluoride varnish programs for infants, children and elders

-   Train Tribal members to deliver dental prevention services in their
    community

-   Dental consulting

-   Oral Care Training Program for caretakers of Elders and Special
    Needs Patients

-   School sealant programs

-   Train Tribal dental health educators

**Current Major Emphasis**

-   Fluoride varnish programs for preschool and school children

-   School sealant program for grades K-6

-   Training tribal dental health educators

For additional information please call 602-307-1576

**Chapter 4, Oral Health Promotion and Disease Prevention**

**Table of Contents**

A. How to Use the OHP/DP Section

B. The Community-Oriented Primary Care Model

C. HP/DP Program Planning and Implementation, POARE

D. Community Oral Health Education and Promotion

E. Caries Diagnosis, Risk Assessment, and Management

F. Use of Fluorides in a Public Health Program

G. Community Water Fluoridation

H. Dietary Fluoride Supplements

I. Topical Fluorides and Fluoride Varnish

J. Pit and Fissure Sealants

K. Running a School-based Sealant Program

L. Nutrition and Dental Caries

M. Xylitol

N. Early Childhood Caries

O. Risk-Based Approach to Periodontal Disease Prevention and Treatment

P. Periodontal Disease Treatment Protocol for Individuals with
Non-Insulin- dependent Diabetes Mellitus

Q. Oral and Oropharyngeal Cancer and Tobacco Cessation

R. Traumatic Injury/Accident Prevention

S. Head Start

T. School HP/DP Programs

U. Child Abuse and the Mandated Reporter

V. Evaluation of Oral Health Promotion/Disease Prevention Programs

**How to Use the OHP/DP Section**

As oral diseases continue to be a significant health problem in the
American Indian/Alaska Native (AI/AN) population, health
promotion/disease prevention must play a key role in improving the oral
health of this population. This section of the *IHS Oral Health Program
Guide* is intended for use by all oral health care providers, not just
dentists and hygienists. New information about the prevention of dental
diseases becomes available almost daily. In order to keep this chapter
as up-to-date as possible, hyperlinks to additional sources of HP/DP
information are provided throughout the chapter.

This chapter is divided into several topics. The first topic discusses
community development. The IHS Dental Program has adopted a philosophy
of Community-Oriented Primary Care (COPC) to assess the health status
and needs of a defined population in a community in order to better
manage resources based upon the situation in each community. Also
included is information on how to develop a community prevention plan
and examples based upon the POARE format.

The second topic describes the prevention methods for lowering disease
rates for dental caries, periodontal disease, and oral cancer and for
decreasing the use of tobacco. A section on caries diagnosis, risk
assessment, and management of dental caries is included. Treating the
caries process as an infectious disease and applying a medical model to
eliminate or reduce the bacteria are program strategies described in
this section. Proven effective preventive strategies for caries control
include use of dental sealants and systemic and topical fluorides.
Information on some practical suggestions related to nutrition and
dental caries that dental staff can share with patients, caregivers of
young patients, and with other health professionals is also included.
The strategies include encouraging patients to follow the Food Guide
Pyramid. Baby Bottle Tooth Decay/Early Childhood Caries is a common
problem at IHS facilities. Strategies for preventing this condition are
presented for both clinical and community settings.

Recent oral health surveys conducted by the IHS have indicated a high
prevalence of periodontal diseases throughout AI/AN populations. Much of
this disease can be contributed to the high rates of non-insulin
dependent diabetes mellitus (NIDDM) in the population. The latest
techniques in controlling and treating periodontal disease with
chemotherapeutic measures is included in the section. By identifying and
providing treatment to those patients at high risk, resources can be
used most effectively. Specific treatment protocols for patients with
NIDDM are also presented in this section.

Although oral cancer rates are generally low in Indian populations, with
the exception of Alaska Natives, the use of commercial tobacco products
is extraordinarily high---particularly in Northern Plains Indians and
Alaska Natives. Use of tobacco (and alcohol) place these populations at
high risk for oral and oropharyngeal cancers. Strategies on early
detection and education are presented.

The third topic is oral health education programs. Examples of oral
health education programs in Head Start and school-based settings are
included.

The fourth topic is program evaluation. Evaluation is a critical aspect
of the HP/DP program and ensures that resources are used wisely.
Examples of quality assessment methods for clinic- and community-based
programs and activities are provided. Documentation techniques
individual preventive services and community-based programs are
included, as is a brief description of the POARE planning model.

Overall, the goal of improving the oral health of AI/AN people depends
on changing behaviors, increasing access to care, and embracing the
latest technologies for health promotion/disease prevention in both
clinic and community settings.

**The Community-Oriented Primary Care Model**

The World Health Organization defines Primary Health Care this way:
"Primary health care is essential health care based on *practical,
scientifically sound, and socially acceptable* methods and technology,
made *universally accessible* to individuals and families in the
community through their *full participation* and at the *cost that the
community and country can afford* to maintain at every stage of their
development in the *spirit of self-reliance and self-determination*."
The Indian Health Service (IHS) utilizes the World Health Organization's
definition of Primary Health Care in their Community-Oriented Primary
Care (COPC) Programs. In addition, COPC is a health delivery concept
which *integrates all health disciplines and community resources* in
order to address the health problems identified within the community.
This concept thus extends primary care outside the clinic and
acknowledges that to achieve improved health in a community, both
technical expertise of the health practitioners and cultural and social
experts from the community must be involved.

There are three essential elements of COPC. First, there must be a
definable community. If the people of a town, region, or locale cannot
be identified and have no characteristics that join them together as a
community, a COPC program cannot be accomplished. Second, an integrated
health care delivery program within the community must be present.
Third, a management process by which the health care program identifies
and addresses the major health problems of the community must be
available. In addition, the management process must function with the
participation of the community.

In IHS, Tribal, and Urban Indian (I/T/U) programs, defined communities
and integrated health care delivery programs generally exist and have
been present for many years. In so much as that is true, the focus here
is on the third essential element of COPC, the management process. The
management process of COPC consists for four functional steps, the first
two of which are covered in this section, and the last two of which are
covered in the following section on the POARE model:

-   Define the community.

-   Identify the health problems of the community.

-   Develop a health care program to address the identified health
    problems.

-   Monitor the efficiency and effectiveness of health care program
    modifications.

1\. Define the Community

In I/T/U programs the definition of community is usually a Tribe or
collection of Tribes within the confines of a reservation or service
delivery area. The community can also be extended to a geographic
region, such as an IHS Area, and can include Urban settings. Further,
definition of the community also includes its characterization by
demography, socioeconomic status (SES), and the way the community makes
decisions based on these factors. Definition of the community includes
identification of community opinion leaders, accepted community programs
such as Head Start, and an understanding of how the community makes
decisions that affect its members.

2\. Identify the Health Problems of the Community

Identification of the health problems of the community requires input
from the health care provider, epidemiological surveys of the community,
and the perception of the community. There are a number of community
groups and individuals that can and should be involved in this process.
Some of them are listed here:

-   Tribal Council

-   Tribal or Urban Indian Health Board

-   Local Opinion Leaders (usually elders)

-   Head Start

-   Local Schools

-   Women, Infant, and Children (WIC) program

-   Community Health Representatives

-   Public Health Educators

-   Maternal and Child Health

-   Social Workers

-   Other Outreach Workers

Only when the entities agree on the health problems to be addressed and
support is developed at the local level can a program of intervention be
successful. This approach requires flexibility on the part of I/T/U
programs and willingness of the dental team to respond to the priorities
set by the community.

**Needs Assessment**

The identification and description of a community's health problems
requires a needs assessment. The first step is to accurately determine
the problem to be addressed, the segment of the population who has the
problem, and the extent of the problem. Needs assessments can be done on
different levels, using a variety of techniques, including: dental
records review, health risk appraisals, focus groups, key informant
interviews, and community surveys of oral health status and perceived
health needs.

Assisting the community to examine and quantify its own oral health
status is an essential first step for appropriate planning, targeting,
monitoring, and evaluation of the COPC program. Once the health problems
of the community have been identified and prioritized, a health care
program can be tailored for that community and specific program
objectives can be developed. The Association of State and Territorial
Dental Directors (ASTDD) has developed a comprehensive manual entitled,
*Assessing Oral Health Needs: ASTDD Seven-Step* *Model*. It is available
online at: <http://www.astdd.org/index.php?template=seven_steps.html>.

**HP/DP Program Planning -- POARE**

The Indian Health Service advocates the use of the POARE model in
planning, implementing and evaluating health promotion/disease
prevention activities. By following this model, the dental staff will
able to clearly identify a problem of importance to the community they
serve, make plans for the best use of resources, and plan a thorough
evaluation of the program. Below are the components of the POARE model.

**Problem**: Decide which health problems are of the greatest concern in
your community. You will also want to take into account the major health
problems among adults in your community. For instance, if diabetes is a
major health problem in you community, then you might want to focus on
limiting pop and other sweetened beverages. Also take into consideration
the health problems that parents are most concerned with.

**Objectives**: Write one or more objectives that address what you can
realistically achieve. Try to make each objective measurable. Ask
yourself how you will I know if you have achieved this objective?

**Activities:** What actions or activities will you implement to reach
your objectives. This could include educating parents, making an
appointment to talk to the dentist, purchasing educational materials,
etc.

**Resources:** How much money and other resources will you need to
achieve your plan? Items might include personnel, outside services,
materials, funding and approvals. Start out by thinking big. You can
make reductions later if you have to. The people who get their budget
increased have positive attitudes about money. You have to think big and
play to win. Don't be afraid of money and don't be afraid to use it.

**Evaluation:** Put simply, how will you know if you have met your
objectives? Keep your evaluation plan simple and measurable.

**P - PROBLEM IDENTIFICATION**

**Find the root of the problem (the real problem)**. Often, the problem
isn't as simple as it seems. For example:

> *"Our clinic doesn't have a school sealant program, so we want to
> start one. We have the support of the school and the tribal
> administration. If we start the school sealant program, we'll see more
> school-age children and meet IHS GPRA indicators for sealants."*

In the above case, what is the problem?

-   Is the problem access to care?

-   Is the problem dental caries?

-   Is it both?

Another way to identify a problem from the example above is:

> *"Our clinic has a dental caries rate of 65% in school-age children.
> Access to care is limited because of the unavailability of many
> after-school appointments."*

Below is another example of a sample write-up for an HP/DP program that
fails to clearly identify a problem:

> *"Our clinic wants to start a free denture program for our elders,
> since many of our elders cannot afford dentures. We have approached
> the Tribe and asked for the funds, and they have agreed. We are really
> looking forward to starting a denture program."*

But again, what is the true problem? The above problem could be written
another way that explains the problem better:

> *"Over half of our elders (60 and over) are completely or partially
> edentulous. Because of this, many of them are unable to have a
> nutritious diet. In fact, the medical department at our clinic has
> conducted a survey and found that elders without dentures weigh an
> average of 10 pounds less than those with teeth (either natural or
> dentures)."*

***Keys to problem identification-Questions to ask***

-   "Is it a problem worth solving?"

-   "How big of a problem is it?"

-   "Can it be solved?"

-   "Do we have the manpower to address it?"

-   "Do we have the \$\$\$ to support it?"

-   "Do we have the ability to sustain it?"

-   "Do we have proof of the problem?"

***Keys to problem identification - "The Don'ts"***

-   Don't assume that because you have the funds or support, it is a
    worthwhile project

-   Don't rush into the project without clearly identifying the problem
    and solution

-   Don't use only anecdotal evidence to determine a problem

-   Don't assume that because it was once a problem, or it was once a
    program, it is still is a problem

***Keys to problem identification - "The Do's"***

-   Do get the facts first

    -   RPMS (QA, SCOM, annual reports)

    -   Chart reviews

-   Do identify how it is a problem

    -   How does it match up with national data?

    -   How does it compare to other clinics or your own clinic years
        ago?

-   Do keep the focus on the problem

    -   Keep everything else -- objective, activities, resources, and
        evaluation -- centered on the problem

***One suggested format for Problem Identification***

-   The problem statement should be the most important part of any grant
    or plan

-   Suggested format:

    -   Identify clinic, location, unique qualities

    -   Identify the problem -- backed up by numbers

    -   Identify how the problem compares with other data from other
        sources (national, Area, etc.)

    -   Identify how the problem has been addressed in the past
        (successes and failures)

**O -- SETTING OBJECTIVES**

The key way to understanding if you have planned and implemented a
successful program is through the setting of clear objectives at the
onset of the program and then evaluating those objectives at the end of
the program.

Most dental programs have very limited time to implement a Health
Promotion/Disease Prevention Program, so if you do begin one, you'll
want to make the best of your available resources and time to conduct a
successful program, a program that is not only successful by dental
standards but one that is meaningful to both the Tribe and the
community. In addition, sometimes dentists delegate HP/DP programs to
dental hygienists or dental assistants or non-dental staff. In order to
clearly delineate responsibilities and expected outcomes, it is
important for the dental team to clearly plan the program to include
measurable objectives.

The Indian Health Service Division of Oral Health advocates the "SMART"
acronym in setting up HP/DP objectives.

-   **S -- Specific** -- the objective must be specific to the problem
    identified. For example, an objective for a caries problem might be
    to "reduce the caries prevalence", but an objective of "we'll go to
    the school" isn't quite specific enough to address the problem.
    Remember, the objectives are not only for your use, but they help
    explain your program and expected outcomes to all of those support
    staff, including non-dental staff.

-   **M -- Measurable** -- the objective must be measurable by available
    data sources such as RPMS. For example, you wouldn't want to state
    that the objective is to make patients "happy" or "satisfied" unless
    you are prepared to survey the patients before and after the
    program.

-   **A -- Attainable** -- the objective must be attainable. One of the
    biggest disappointments in a dental HP/DP plan is to conduct the
    program and then not have the results that the dental staff was
    expecting. Keep it simple and easily attainable. Remember that
    things may happen over the course of the program beyond your
    control, such as losing key funding or key staff.

-   **R -- Relevant** -- the objective must be relevant to the community
    and based on evidence. For example, as caries prevalence usually
    does not dramatically decrease in a short period of time, an
    objective to reduce caries prevalence by 10% in a one-year period
    would not be realistic. Instead, reducing prevalence by 2% in a
    two-year span might be more appropriate, or reducing incidence (new
    cases) by 10% in a two-year period might be possible. However,
    remember that RPMS is best at tracking prevalence proportions, if
    IHS data is entered by the dental staff.

-   **T -- Timely** -- the objective should have a definitive timetable,
    such as reducing caries prevalence by x% in a specific period of
    time.

**CHECKLIST TO EVALUATE OBJECTIVES**

**S=Specific**

The statement is clear and concise. Vague terms or words should be
avoided.

> [Vague Action Words]{.underline} [Specific Action Words]{.underline}
>
> Know the material List 4 reasons...
>
> Help the community Decrease dental caries...
>
> Talk to the doctors Give a presentation
>
> Set up a program Establish a school-based program at Grant
>
> Elementary School
>
> Do more sealants Increase sealant application by 25%

**M=Measurable**

Objectives need to be worded so the desired result can be clearly
measured or observed.

**A-Attainable**

The objective should be challenging but realistic.

**R=Relevant**

The objective should be science-based and relevant to your community.

**T=Time-based**

The objective needs to have a time frame in which the desired result is
expected to be achieved.

**A -- PLANNING ACTIVITIES**

Many dental staff make the mistake of first planning activities. The
problem with this approach is that it may not be based on a sound
problem statement or clearly defined objectives. An example might be
planning a school sealant program without understanding what the caries
prevalence is in the program group and without having clear objectives
to carry out such a program. Plan activities only AFTER:

-   You have clearly defined the problem

-   You have clearly defined objectives using the SMART principle (the
    objective(s) should be significant (S), measurable (M), attainable
    (A), realistic (R), and timely (T)-i.e., they must have a set start
    and end date.

***Considerations***

Before planning your program, you must ask yourself some key questions:

-   What is the best evidenced-based approach at tackling the problem?

-   What are the alternative approaches?

-   How much manpower, out-of-clinic time is going to be needed?

-   How much will it cost?

***Example***

Suppose you have identified a problem on your reservation being a dental
caries prevalence in 6-8 year old children. You have established an
objective of reducing this caries prevalence by 5% in the next two
years. Answer the following questions.

-   Activities:

    -   Who will be the target group?

    -   What are some evidence-based approaches?

    -   How much will it cost in terms of money and manpower?

***Sound HP/DP Programs that might work for you***

-   **To address access to care:**

    -   School screenings

    -   Head Start screenings

    -   Health fairs

    -   Open access policies for target groups

    -   Training others to perform screenings

    -   Promoting the clinic through newsletters, parent/patient
        letters, etc.

    -   What else can you think of?

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-   Dental Sealants

    -   School sealant program

        -   Expensive, though, so are there alternatives?

        -   But can you reach more this way?

    -   Universal sealants in the clinic by assistants or dentists or
        hygienists

        -   Just a change in practice can make a difference

    -   Other

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```
-   Fluoride

    -   Start a fluoridation program

    -   School fluoride varnish program

    -   Head Start fluoride varnish program

    -   Train others (medical providers, Head Start) to apply fluoride
        varnish

    -   Health fair

    -   Other

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```
-   Xylitol gum program

    -   Expensive, so make sure it's worth it

-   Parent education classes

    -   A lot of recruiting and follow-up is required

-   Pre-natal education

    -   Need the support of the OB-GYN

-   "Stop the Pop" or similar program

-   Athletic mouthguard program

-   Periodontal program

    -   Tertiary prevention for diabetics

-   Other

***Keys to planning***

-   Be as detailed as possible

-   Set up contingency plans

-   Make sure the activities make common sense to you

-   Be prepared to hold the activity/program together yourself

-   Line up support for the program!

-   Don't get discouraged from failures

**R and E --RESOURCES and EVALUATION**

Resource identification and evaluation are components of plans that are
often ignored or given too little consideration, but they are both
important components of successful programs. It is essential that the
cost of programs be estimated as accurately as possible over the time
specified in the objective, so that the program can be maintained
throughout its duration. The resources needed include staff time,
supplies, community volunteers' time, and funds available. *It is
important for the health care providers and the community to have a full
understanding of the commitment in time and money that is being made in
order to meet the objective.*

The evaluation component should be delineated during the planning of the
program and should include assessment of the specific activities
involved in the program, as well as assessment of the desired health
outcome (the health outcome is usually the objective that was identified
earlier in the POARE process).

**Activity Evaluation**

The activities that have been identified and completed in the activities
component of the POARE format should be evaluated separately from the
evaluation of the objective that was identified in the POARE format.
Only then can it be determined if the health outcome was achieved
because the activity was successful. For example, you may have a very
successful sealant program that was done well in every way, but the 6 to
8 year-old children targeted in the objective still have a high rate of
decay because smooth-surface caries made up the majority of lesions. Or
pit and fissure lesions may be the most prevalent, but your sealant
program was not effective because the response was poor (e.g., only half
of the children returned their permission slips for sealants), the
timing was bad (e.g., the children in the second grade that were
targeted already had decay), or the technique was poor (e.g., half of
the sealants fell off shortly after placement). Only after ensuring that
the activities have met pre-specified quality parameters can the
determination be made that the activities had a positive impact on the
objective. The documentation and assessment of specific activities
should also include careful recording of the time and resources invested
in all phases of performing the activity, such as planning, materials,
travel, set up, and implementation.

**Health Outcome Evaluation**

Measurement of the health objective should be consistent with the method
used to determine the baseline. For example, if calibrated examiners
used tongue blades and fiberoptic lights in the classroom setting to
determine how many 6 to 8 year-olds were caries-free five years ago, the
same calibration standards, equipment, and location should be used to
measure whether the objective was met five years later. The evaluation
method should be easily understood and accepted by health care providers
and the community.

Measuring the impact of a specific activity on a health outcome can be
quite complex and may involve techniques beyond the scope of the
program. Most health outcomes are influenced by multiple factors, many
of which are out of the Dental Program's control. In addition, when
several activities are targeted toward the same outcome, it is difficult
to determine which activity or activities were effective. Most programs
will need to settle for an **assumption** that the activities
implemented had an impact on the health outcome listed in their
objective. The extent of the impact often must be assessed through
comparisons to the literature and other programs which are similar and
do not implement the same activities. The simplest strategy is to
implement one activity at a time for a specific health objective. When
the impact of that activity is clear, another activity can be
implemented. Determining the impact of one activity is much easier than
determining which of ten activities (if any) is making the difference.

**Monitor the Efficiency and Effectiveness of Health Care Program
Modifications**

Monitoring the efficiency and effectiveness of the health care program
is done through the resource and evaluation components of the POARE
format. The community and health care professionals should be informed
of the results of the evaluation phase of the program and the amount of
resources expended. During discussions about these two components
decisions can be made about changes in the program that will increase
efficiency and effectiveness and continue to improve health status of
the community.

If the quality of a program cannot be assured, the program should be
discontinued. Also, programs that are cost- and time-intensive and that
demonstrate little effect on health outcome should be dropped,
redesigned, or scaled back. For example, health fairs build good public
relations in the community; however, it may be difficult to evaluate
changes in health behavior or health status based on attending a health
fair. Programs that demonstrate a strong positive effect should be
retained, as long as resources are available to implement them.
Discussions with the community about these issues should be undertaken
before the project is implemented, so that there is a clear
understanding as to why some activities may need to be dropped or
enhanced later in the program.

**Community Oral Health Education and Promotion**

**An inherent responsibility of all IHS dental staff is to help prevent
and control dental diseases.**

Health education and health promotion are necessary to achieve both
individual and community oral health. The ultimate responsibility for
oral health must be shared by individuals, families, health
professionals, and the program as a whole. Health education can help
increase knowledge and reinforce desired behavior patterns, but to be
successful, it must be integrated with other influences on
health---economic, social, and environmental---all of which affect
access and acceptance of preventive programs.

**Definitions (From 1990 Joint Committee on Health Education
Technology)**

> ***Health Promotion and Disease Prevention(HP/DP)**:* Aggregate of all
> purposeful activities designed to improve personal and public health
> through a combination of strategies, including the competent
> implementation of behavioral change strategies, health education,
> health protection measures, risk factor detection, health enhancement
> and health maintenance.
>
> ***Health Literacy**:* The capacity to obtain, interpret and
> understand basic health information and services and the competence to
> use such information and services in ways which are health enhancing.
>
> ***Health Education Program**:* A planned combination of activities
> developed with the involvement of specific populations and based on a
> needs assessment, sound principles of education and periodic
> evaluation using a clear set of goals and objectives.

Frazier defines health education in dental public health programs as:

> *A process of organizing and involving groups of decision-makers and
> opinion leaders in active decision-making with regard to the selection
> and implementation of organized community dental programs which: a)
> are designed to prevent or control oral diseases; b) have been shown
> to be effective and practical at the community level; and c) operate
> independently of individual performance or habit* (1).

Frazier states that community education efforts should be focused on
adult decision-makers and opinion leaders in the community, versus
individual motivational efforts, since these broader methods are more
cost-effective (2).

Others have suggested that the number of people who are susceptible to
prevention messages is a small fraction of those who need them and that
oral health depends on a style of living which is not easily influenced
by the dentist. People may not be susceptible to the prevention message
because of physical and psychological conditions which do not provide a
receptive and supportive environment. Community education prepares or
enhances the conditions to provide a more receptive and supportive
environment.

The underlying principle in applying the skills and methods of health
promotion and health education at any public level is the attempt to
modify or change behavior. Education alone is usually insufficient to
achieve optimum oral health. Knowledge is seldom sufficient to produce
behavioral changes. Patients' perceptions, attitudes, and values must
also be considered. Appropriately-directed behavior will then result in
the prevention or reduction of disease and an elevation of health status
of an individual or community.

Integral components of these prevention efforts are patient and
community education. It is not enough to tell people what to do; we need
to work toward establishing positive health values. Health professionals
should always be assessing whether a patient's/community's noncompliance
is due to a lack of technical skills or knowledge, failure to recognize
the importance of self-care, or a lack of motivation. Education must
permeate every aspect of the prevention program and focus on changing
specific health behaviors.

Health behavior can be divided crudely into two general types:

-   compliance behavior and

-   innovations.

Compliance behaviors are behaviors which are generally known and
recognized by both the learner and the community to be important to
health. Indeed, one of our biggest challenges in reducing the burden of
chronic disease is to improve compliance by our clients with prescribed
behaviors. In contrast, innovations are novel behaviors, ideas, or
attitudes. What we as health professionals may perceive as a compliance
behavior issue, may be viewed by the client (or community) as something
novel --- an innovation. Our concern is how to decrease the length of
time it takes for adoption of the innovation and to increase the number
of people who adopt it.

The stages of adoption which the client and the community must pass
through are awareness, interest, trial, decision, and adoption (3).
These stages are part of a process and not an end point. Different parts
of the community will be at different stages of adoption. People or
communities must go from one stage to the next. The challenge is to
target the education to the stage that the person or community is at,
i.e., match the stage and educational effort.

In acting as change agents, we are more likely to be credible if our
programs:

1\. Fit the clients' cultural beliefs and values.

2\. Involve clients in planning the change.

3\. Increase the client's ability to evaluate innovations.

4\. Use opinion leaders to spread the program (4).

Four methods for approaching change are as follows:

-   persuasive communication,

-   empirical-rational education,

-   normative re-education, and

-   community organization (5).

These all overlap to some extent and are often used in combination to
tailor an approach toward a specific community problem. Persuasive
communication is trying to convince and motivate people to take a
specific action, often using mass media. Empirical-rational education
conveys a body to knowledge and skills that people rationally want to do
because it serves their self-interest. This is the standard "classroom"
approach to education used in schools. Knowledge, however, does not
necessarily lead to behavior change.

Normative re-education involves the learner as an active participant who
must unlearn old behaviors in order to learn new ones. It recognizes
that learning is influenced by social norms and values and by
institutional biases. The way the client sees himself and his problem
must be brought into a dialogue with the way in which he and his problem
are seen by the change agent. The problem may not be one of knowledge,
but of attitudes, values, norms, or social relationships. *The client
should be collaboratively involved in defining and solving the problem.*
Acceptance or modification is not a random process but depends on how
the new item or idea is perceived by the potential recipients, how it
accords with their values and assumptions, and whether it is consistent
with their system of social relationships. It also depends on the social
status of the innovator and the implications of that status for the
various segments of the community (6). An outcome of this approach is
that social norms are redefined.

It is clear that public funds should not be expended in activities that
have not been demonstrated to be effective. Certainly the most
cost-effective methods for preventing disease should be used first.
Activities directed only toward the dissemination of information, but
that do not focus efforts on changing behavior, fall short of inclusion
as health education activities.

All community efforts should be evaluated on adequacy, efficiency,
effectiveness, appropriateness, and side effects. Evaluation of
community education efforts can be accomplished through surveys on
knowledge, skills, and attitudes. Baseline information can be gathered
before and after intervention strategies are implemented.

Oral health education and health promotion are components of each
prevention strategy recommended in this manual. Although the effects of
oral health education are subtle and have not always proven to be
effective in reducing disease rates, educational presentations are often
useful for raising the public's interest or getting people to
support/adopt a program. These presentations might include the
following:

1\. Health fairs

2\. Oral health in the clinics or community

3\. Media messages through radio, TV, newspapers, and posters

4\. Presentations to specific targeted groups

5\. Tribal presentations

6\. Speeches at special events

7\. Parades

Providing a consistent oral health message over time may increase
behavior compliance when integrated with other community-based
strategies.

Here are some tips for making more effective group presentations:

1.  Use attention getters/visual aids.

2.  Tell stories or use examples to teach the facts. (Present good local
    data when available.)

3.  Use appropriate and effective audiovisual aids.

4.  Call for action. Let your audience know what they can do to prevent
    dental disease. What do you want them to do differently tomorrow as
    a result of your presentation?

5.  Above all, don't forget to KISS --- Keep It Short and Simple! No one
    likes a boring technical discussion. Education is the most effective
    when it is given in small steps and in language the audience can
    understand.

**References**

1.  Malvitz DM. Education for oral health. Chapter 15 in Striffler,
    Young, & Burt, Dentistry, dental practice, & the community,\
    p. 469.

2.  Frazier, P Jean. The effectiveness and practically of current dental
    health education programs from a public health perspective; a
    conceptual appraisal. Presented as a part of symposium, Methods for
    the Prevention of Dental Disease: Effectiveness and Practicality, an
    annual meeting of the Dental Health Section, American Public Health
    Association, Miami Beach, Florida, Oct. 20, 1976. 28p duplicated.

3.  Rogers EM. Diffusion of Innovations, 3rd Ed. New York: The Free
    Press, 1983.

4.  Bennis WG, Benne KD, Chin R. The Planning of Change, 4th Ed. New
    York, New York: CBS College Publishing, 1985.

5.  Greene, WH, Simons-Morton, BG. Introduction to Health Education. New
    York, New York: Macmillan Publishing Company, 1984.

6.  Paul, BD. Health culture and community: case studies of public
    health reactions to health problems. New York, Russell Sage
    Foundation, 1955.

**Caries Diagnosis, Risk Assessment, and Management**

**Introduction**

For many years the scientific literature has suggested that a risk-based
assessment of an individual patient's dental caries history and oral
health status is an important prerequisite for appropriate preventive
and/or treatment actions (1-7, 55). In the Indian Health Service (IHS),
program managers and clinicians also support this risk-based approach. A
practical guide entitled "Caries Diagnosis, Risk Assessment and
Management" was developed by a work group of senior clinicians, general
practice and pediatric specialists, epidemiologists, and public health
consultants. A risk classification table with preventive regimens and
suggested recall interval appropriate to risk category was also
developed (54). The information provided in this section is a summary of
this IHS practical guide.

This risk-based model provides a framework for decision-making to
determine a patient's risk of dental decay and appropriate preventive
and treatment strategies. It considers the clinician's judgment as well
as available resources. In a public health program, clinicians should
also assess resources and activities such as community water
fluoridation and school-based programs, including sealant screening and
placement, and fluoride mouthrinse programs. The overall objective is to
work with patients and communities to improve the oral health of
American Indian/Alaska Native people in the most effective and efficient
manner possible.

The underlying principle of a caries risk protocol is to approach dental
caries as an infectious disease (8-12, 56). Most resources in our dental
clinics are invested in the diagnosis, treatment, and prevention of this
infection. These resources are maximized by appropriately addressing the
diagnosis, prevention, and treatment of dental caries. Studies have
shown that flexible recall systems and targeted care are cost-effective
and time-effective, providing the greatest health benefits to defined
populations (4, 13-15). Each patient's individual risk for caries
impacts on that patient's treatment plan. Since most restorative
treatments result in irreversible changes in those teeth involved,
establishing a treatment plan involves weighing the risk of dental
disease progression against the risk of receiving irreversible dental
intervention. The guidelines in this subsection can assist you in
exercising your clinical judgment by organizing caries diagnosis, risk
assessment, prevention, and treatment strategies. Information provided
in this program guide is derived from the IHS "Caries Diagnosis, Risk
Assessment and Management: A Practical Guide" and can be referred to for
more in depth discussion of this topic.

**Diagnosis**

Dental caries must first be correctly diagnosed before appropriate
interventions can be considered. Dental diagnosis is best accomplished
longitudinally, comparing available examination and radiographic data
over time. Single "snapshots" often do not supply information about
disease progression/regression, especially when lesions are in the early
stages of development. Exams are best completed in a dry field with
bright illumination. The explorer is [not]{.underline} the instrument of
choice for diagnosing caries. A sharp explorer has been shown to cause
cavitation of otherwise reversible active lesions, gives false
information when diagnosing by "stick" and does not improve the validity
of diagnosis (16-18). On rare occasions when the use of an explorer is
indicated, the explorer should be dull and light pressure should be
used. Radiographs are ordered to confirm, not establish, the diagnosis
of caries. They should be used in longitudinal sequence to assess lesion
activity whenever they are available from previous exams. Stained
grooves and rough restoration margins are not of themselves indications
of active caries or of caries potential (17-22). Only carious lesions
which are active, frank, and cavitated require the irreversible surgical
intervention of operative dentistry. Carious lesions that are not
active, frank, and cavitated, such as "white spot lesions" and/or
incipient lesions, are best addressed using a medical model, or
non-surgical approach (12, 21). The clinician may rely on
pharmacotherapeutic interventions such as professionally-applied (foam,
varnish, and gels) and home-use topical fluoride products (toothpaste,
rinses) as well as chlorhexidine to control the infection.

**Caries Risk Assessment**

There is evidence in the scientific literature that dental caries
history or experience (usually expressed as DMFT/DMFS, deft/defs scores)
is not evenly distributed in the general population (23-26). In the IHS,
it has also been documented that dental caries experience is not evenly
distributed (27-29). In contrast to the U.S. population, most of our IHS
subpopulations have a small proportion of people who have either low or
high dental caries experience and a relatively large proportion who have
moderate dental caries experience. One goal of the Dental Program is to
increase the proportion of low-risk patients and decrease the proportion
of high-risk patients in a given community. Targeting resources for
high-risk patients and "moving" patients from high-risk to moderate-risk
and from moderate-risk to low-risk categories can maximize the impact of
limited program dollars. The more patients in the low-risk category, the
more opportunity to increase access to those in the moderate- and
high-risk categories and increase their opportunity for achieving better
oral health. Since there is generally less disease if patients have
better access to routine and preventive services, an effective public
health approach to Oral Health Promotion/Disease Prevention (OHP/DP)
includes improving access as a preventive strategy.

The American Dental Association (ADA) published a 1995 Journal
Supplement outlining caries risk classifications and appropriate
preventive regimens to complement them (12). The IHS used the ADA
document as a framework to tailor a product (54) for our populations,
which have, in general, higher levels of decay. The IHS Table relies
heavily on the clinician's judgment to use modifying factors (see below)
in assigning risk categories. The IHS Table also redefines age groups
from the ADA's child/adolescent and adult groupings to ages 0-4 and 5+.
In addition, the IHS Table adds a "very high risk" category to address
that proportion of AI/AN populations with significantly high levels of
dental caries and bolsters treatment regimens for those individuals.

Sound clinical judgment is necessary to establish dental caries risk and
prescribe appropriate interventions. Gathering information from and
about patients is critical in determining this risk. In this model, the
key decision, which drives caries risk assessment, is the presence of
active cavitated lesions at the time of the examination. Many studies
indicate that previous caries experience is one of the best predictors
of future caries experience (1,2,4-7,30-34).

Other factors, or modifiers, that may predispose an individual to dental
decay include the following (57, 58):

-   Age,

-   family's dental experience,

-   diet,

-   white spot lesions,

-   tooth morphology,

-   fluoride exposure (both too much and not enough),

-   rate of caries progression,

-   oral hygiene,

-   socioeconomic status,

-   frequency of dental visits,

-   medical conditions and medications being taken,

-   salivary flow,

-   root exposure,

-   mutans streptococci levels,

-   special assistance requirements,

-   orthodontics, and

-   removable appliances.

The type and nature of modifiers applicable to an individual may
indicate that he/she should be moved into a different risk category. No
attempt was made to regulate the number of modifiers, which would move a
person into a different risk category; this decision has been left up to
the **clinician's judgment**. However, patients should be reassessed and
reclassified at subsequent recall visits for the appropriate risk
category. A patient initially classified as "high-risk" or
"moderate-risk" may fall into a "low-risk" category at recall if no new
lesions are found and modifying factors such as fluoride exposure and
oral hygiene have changed. "Low-risk" patients may also move into other
categories if oral conditions change. Risk categories and classification
are fluid.

The IHS "Caries Diagnosis, Risk Assessment and Management" manual
defines the following risk categories and provides guidelines for
preventive regimens as well as recall intervals for assessing caries
risk status (54):

**Patients 0-4 years:**

**Low Risk:** No active carious lesions of any type (cavitated or white
spot) at exam.

> **High Risk:** Any cavitated or white spot lesions at exam. Continued
> bottle feeding after 12 months or a family history of caries.

**Patients 5 years and older:**

**Low Risk:** No active cavitated or non-cavitated lesions at exam.

> **Moderate Risk:** One active cavitated smooth surface lesion or any
> pit and fissure lesions at exam.
>
> **High-Risk:** 2-5 active cavitated smooth surface lesions at exam or
> two new lesions of any type with a history of smooth surface lesions
> in permanent teeth. Former "very high risk" patients may also be
> placed in this group.

**Very High Risk:** 6 or more active cavitated smooth surface lesions at
exam.

**\*\*To reiterate, modifying factors could place a patient in a higher
or lower risk category.\*\***

**Management**

Treatment planning and management of active carious lesions involves
three steps:

1.  Arresting the infectious disease process and preventing disease
    using a medical model (Preventive Regimen).

2.  Completing restorations and/or extractions (Surgical Treatment).

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3.  Evaluating the outcome of the chosen preventive regimen and surgical
    treatment (Recall).

It is imperative that the **prevention strategies** based on risk
assessment are initiated prior to completing restorations or
extractions. The prevention regimen should be based on the patient's
risk category. If there is a high demand for services and few resources,
preventive regimens should be focused on strategies proven to be
effective like fluoride and sealants (35-39). Proven strategies that are
cost effective for most IHS populations are identified with as asterisk
on the IHS Risk Classification table. All preventive services should be
specifically described as part of the overall treatment plan. The
patient's risk status can be indicated on the line for target group on
the exam form, e.g., "high risk caries".

Restorative treatment and extractions are **surgical processes** that
are destructive. They are justified only if the risk of destruction
caused by an irreversible, frank, active carious lesion is greater than
that of the surgical procedure itself. In low and moderate risk
patients, more concern should arise from a false positive diagnosis of
dental caries leading to unnecessary surgical tooth destruction than
from a false negative caries diagnosis (53). Carious lesions in
permanent teeth usually progress slowly, and may be arrested or
reversed. Therefore, conservative treatment options such as sealants,
preventive resin restorations, avoiding "extension for prevention," and
appropriate recall based on risk are preferred. The goals of this
conservative approach are twofold: first, to avoid unnecessarily placing
the first restoration, which likely commits the patient and the dental
program to a series of future replacement restorations of increasing
size at the expense of natural tooth structure; and second, to minimize
the unnecessary replacement of restorations. High and very high risk
patients, however, require more aggressive preventive and restorative
treatment. Their lesions, even in permanent teeth, are often rapidly
progressive. Treating too conservatively may result in adverse outcomes
such as pulpal involvement and tooth loss. Although it is easy for most
dentist for focus solely on restorative needs of high and very high risk
patients, necessary preventive regimens should not be ignored. The need
for restorative treatment should not overshadow the provision of
preventive services, and in these patients they should be provided
concurrently. Remember, the decision to do one thing is often a decision
to not do something else, even if this decision is not consciously made.
In our programs, decisions to provide extensive treatment frequently
translate to the provision of services to one patient at the expense of
access to care for another.

[]{.mark}

Individual treatment plans will be impacted by the patient's oral and
systemic conditions, dental program resources and priorities, and the
dental staff's capabilities and interests. The ability of a dental
program to provide access is influenced by the choices each dentist
makes about when to treat each individual patient and when to have each
patient return to the clinic for follow-up and recall care. Of course,
the patient's responsibility and commitment to oral health are critical
to any intervention. Patients should be informed that their commitment
to their oral health is critical to any intervention. Recall is an
important component for evaluating a patient's specific needs.
Appropriate recall allows for longitudinal assessment of carious
lesions, patient modifiers and the efficacy of interventions to date. A
patient's willingness or ability to comply with recall appointments is a
modifier in judging their risk classification. A clinical program
without an active recall system is typically limited to "snapshots" of
patient status and has fewer opportunities for consistent intervention
to successfully control their patient's caries infections.

The success of a caries risk management program can be observed both
programmatically and individually. Programmatically, a properly
functioning program will increase clinic utilization by patients who are
in the greatest need of care. Treatment choices using this philosophy
will result in preservation of tooth structure by increased use of
sealants and preservative dentistry. With this early intervention, you
can expect to see fewer destructive restorations even though the disease
is not totally eliminated from the patient population. Individually,
patients in higher risk categories will move into lower risk categories
and/or require longer recall intervals upon return. Success can be
defined when moderate and high risk patients return with no new lesions
or exhibit healing of incipient lesions upon recall exam.

[]{.mark}

**Summary**

This subsection is not a cookbook; clinical judgment is required. The
information presented here is to serve your caries diagnosis, risk
assessment, and treatment planning process regarding your patient's
actual risk, relative to the infectious disease of dental caries. With
limited resources and high dental disease rates, it is critically
important that clinicians manage the infectious disease process rather
than focus only on surgical restorative treatment. Assessing the
patient's risk, applying appropriate preventive regimens, and evaluating
compliance with these regimens before providing invasive restorative
procedures are essential. Following these guidelines should assure wise
expenditure of limited resources and increased access to the health care
delivery system.

# Additional Resources/Articles of Interest

[]{.mark}

IHS "Caries Diagnosis, Risk Assessment and Management: A Practical
Guide" (24 hours of continuing dental education offered) (54)

University of Michigan's caries risk website:
<http://oralhealth.dent.umich.edu/CDRAM/CariesHome.htm>

NIH Consensus Development Program website:
<http://consensus.nih.gov/2001/2001DentalCaries115html.htm>

March 2003 Journal of the California Dental Association

<http://www.cdafoundation.org/journal/jour0303/consensus.htm>

University of Iowa Caries Risk Factors and Activity Assessment

<http://www.uiowa.edu/~op2l/caries98.html>

2000 Australian Dental Journal

[http://www.ada.org.au/media/documents/Products_Publications/Journal%20Archives/2000%20Archive/March/0003Brea.pdf#search=\'caries%20risk%20assessment](http://www.ada.org.au/media/documents/Products_Publications/Journal Archives/2000 Archive/March/0003Brea.pdf#search='caries risk assessment)

1999 International Dental Journal

[http://www.fdiworldental.org/assets/pdf/commission/95_4.pdf#search=\'caries%20risk%20assessment](http://www.fdiworldental.org/assets/pdf/commission/95_4.pdf#search='caries risk assessment)'

American Academy of Pediatric Dentistry Oral Health Policy

<http://www.aapd.org/media/Policies_Guidelines/P_CariesRiskAssess.pdf>

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WC. Factors influencing the caries experience of a group of children at
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epidemiological study. J Dent. 1990;18(1):37-48.

2\. Newbrun D, Leverett D. Risk assessment of dental caries working
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Chapel Hill: University of North Carolina Dental Ecology, 1990.

3\. Koch G. Importance of early determination of caries risk. Int Dent
J. 1988;38:203-10.

4\. DeLiefde B. Identification and preventive care of high caries-risk
children: a longitudinal study. New Zealand Dent J. 1989;85:112-116.

5\. Leverett DH, Featherstone JD, Proskin HM, Adair SM, Eisenberg AD,
Mundorff-Shrestha SA, Shields CP, Shaffer CL, Billings RJ. Caries risk
assessment by a cross-sectional discrimination model. J Dent Res.
1993;72(2):529-37.

6\. Beck JD, Weintraub JA, Disney JA, Graves RC, Stamm JW, Kaste LM,
Bohannan HM. The University of North Carolina Caries Risk Assessment
Study: comparisons of high risk prediction, any risk prediction, and any
risk etiologic models. Community Dent Oral Epid. 1992;20(6):313-21.

7\. Disney JA, Graves RC, Stamm JW, Bohannan HM, Abernathy JR, Zack DD.
The University of North Carolina Caries Risk Assessment Study: further
developments in caries risk prediction. Community Dent Oral Epidemiol.
1992;20(2):64-75.

8\. Keys PH. The infectious and transmissible nature of experimental
dental caries. Findings and implications. Arch Oral Biol.
1960;1:304-320.

9\. Milnes AR, Bowden GHW. The microflora associated with the developing
lesions of nursing caries. Caries Res. 1985;19:289-97.

10\. Kohler B, Bratthall D, Krasse B. Preventive measures in mothers
influence the establishment of the bacterium Streptococcus mutans in
their infants. Arch Oral Biol. 1983;28:225-31.

11\. Rogers AH. The source of infection in the intra-familial transfer
of Streptococcus mutans. Caries Res. 1981;15:26-31.

12\. Treating caries as an infectious disease. J Am Dent Assoc. Special
Supplement 1996;126:2S-3S.

13\. Wang N, Marstrander P, Holst D, Ovrum L, Dahle T. Extending recall
intervals --- effect on resource consumption and dental health. Comm
Dent and Oral Epid. 1992;20:122-4.

14\. Wang NJ, Holst D. Individualizing recall intervals in child dental
care. Comm Dent and Oral Epid. 1995;23:1-7.

15\. Wang NJ, Riordan PJ. Recall intervals, dental hygienists and
quality in child dental care. Comm Dent and Oral Epid. 1995;23:8-14.

16\. Ekstrand K, Qvist A, Thylstrup A. Light microscope study of the
effect of probing in occlusal surfaces. Caries Res. 1987;21:368-374.

17\. Lussi A. Validity of diagnostic and treatment decisions of fissure
caries. Caries Res. 1991;25:296-303.

18\. Pitts NB. Current methods and criteria for caries diagnosis in
Europe. J Dent Educ. 1993;57(6):409-414.

19\. Brantley CF, Bader JD, Shugars DA, Nesbit SP. Does the cycle of
rerestoration lead to larger restorations? J Amer Dent Assoc.
1995;126:1407-1413.

20\. Anderson MH. Repairing the ditched amalgam. IDA-Journal 1993:19-21.

21\. Anderson MH, Bales DJ, Omnell K. Modern management of dental
caries: the cutting edge is not the dental bur. J Amer Dent Assoc.
1993;124:37-44.

22\. Kidd EA, Joyston-Bechal S, Beighton D. Marginal ditching and
staining as a predictor of secondary caries around amalgam restorations:
a clinical and microbiological study. J Dent Res. 1995;74(5):1206-11.

23\. Brunelle JA. Dental caries in US children 1986-1987. NIH
Publication No. 89-2247, Bethesda, MD: Sept 1989.

24\. Hicks MJ, Flaitz CM. Epidemiology of dental caries in the pediatric
and adolescent population: a review of past and current trends. J Clin
Pediatr Dent. 1993;18(1):43-9.

25\. Caplan DJ, Weintraub JA. The oral health burden in the United
States: a summary of recent epidemiological studies. J Dent Educ.
1993;57(12):853-62.

26\. Disney JA, Graves RC, Stamm JW, Bohannan HM, Abernathy JR. The
University of North Carolina Caries Risk Assessment Study. II. Baseline
caries prevalence. J Public Health Dent. 1990;50(3):178-85.

27\. Niendorff W, Collins R. Oral health status of Native Americans,
selected findings from a survey of dental patients conducted in FY
1983-84 by the Indian Health Service. Paper presented at the annual
meeting of the American Public Health Association, Las Vegas, NM. Oct.
1, 1986.

28\. Niendorff W. The Oral Health of Native Americans. A Chart Book of
Recent Findings, Trends, and Regional Differences. DHHS, USPHS, Indian
Health Service. 1994.

29\. O'Sullivan DM, Douglass JM, Champany R, Eberling S, Tetrev S,
Tinanoff N. Dental caries prevalence and treatment among Navajo
preschool children. J Public Health Dent. 1994;54(3):139-44.

30\. Seppa L, Hausen H, Pollanen L, Helasharju K, Karkkainen S. Past
caries recordings made in Public Dental Clinics as predictors of caries
experience in early adolescence. Community Dent Oral Epidemiol.
1989;17:277-81.

31\. Bruszt P. Relationship of caries incidence in deciduous and
permanent dentitions. J Dent Res. 1959;38:416-9.

32\. Hill IN, Blayney JR, Zimmerman SO. Deciduous teeth and future
caries experience. J Am Dent Assoc. 1967;74:430-4.

33\. Greenwell AL, Johnsen D, DiSantis TA, Gerstenmaier J, Limbert N.
Longitudinal evaluation of caries patterns from the primary to the mixed
dentition. Pediatric Dent. 1990;12(5):278-282.

34\. Kaste LM, Marianos D, Chang R, Phipps KR. The assessment of nursing
caries and its relationship to high caries in the permanent dentition. J
Public Health Dent. 1992;52(2):54-8.

35\. Heller KE, Reed SG, Bruner FW, Eklund SA, Burt BA. Longitudinal
evaluation of sealing molars with and without incipient dental caries in
a public health program. J Pub Health Dent.1995;55(3):148-53.

36\. Rippa LW. Sealants revisited: an update of the effectiveness of
pit-and-fissure sealants. Caries Res. 1993;27(Suppl 1):77-82.

37\. Leverett DH, Handelman SL, Brenner CM, Iker HP. Use of sealants in
the prevention and early treatment of carious lesions: cost analysis. J
Amer Dent Assoc. 1983;106:39-42.

38\. Weintraub JA, Burt BA. Prevention of dental caries by the use of
pit-and-fissure sealants. J Public Health Policy 1987;8:542-60.

39\. Ripa LW. An evaluation of the use of professional (operator
applied) topical fluoride. J Dent Res. 1990;69(spec Issue):786-96.

40\. Holm, AK. Effect of a fluoride varnish (Duraphat) in preschool
children. Community Dent Oral Epidemiol. 1979;7:241-245.

41\. Petersson LG. Fluoride mouthrinses and fluoride varnishes. Caries
Res. 1993;27(Supplement 1)35-42.

42\. Mandel ID. Fluoride varnishes --- a welcome addition (Editorial). J
Public Health Dent 1994;54(2):67.

43\. Emilson CG. Potential efficacy of chlorhexidine against mutans
streptococci and human dental caries. J Dent Res 1994;73(3):682-91.

44\. Zickert I, Emilson CG, Krasse B. Effect of caries preventive
measures in children highly infected with the bacterium Streptococcus
mutans. Archs Oral Biol. 1982;27:861-868.

45\. Brown AT, Largent BA, Ferretti GA, Lillich TT. Chemical control of
plaque-dependent oral diseases: the use of chlorhexidine. Compend Contin
Educ Dent. 1986;7(10):719-724.

46\. Rask PI, Emilson CG, Krasse B. Effect of preventive measures in
50-60 year-olds with a high risk of dental caries. Scand J Dent Res.
1988; 96:500-504.

47\. Marsh PD, Keevil CW, McDermid AS, Williamson MI, Ellwood DC.
Inhibition by the antimicrobial agent chlorhexidine of acid production
and sugar transport in oral streptococcal bacteria. Arch Oral Biol.
1983;28(3):233-239.

48\. Yanover L, Banting D, Grainger R. Effect of a daily 0.2%
chlorhexidine rinse on the oral health of an institutionalized elderly
population. Scien J. 1988;54(8):595-597.

49\. Makinen KK, Soderling E, Isokangas P, Tenovuo J, Tiekso J. Oral
biochemical status and depression of Streptococcus mutans in children
during 24- to 36-month use of xylitol chewing gum. Caries Res
1989;23:261-267.

50\. Milnes AR, Bowden GHW. The micro flora associated with the
developing lesions of nursing caries. Caries Res. 1985;19:289-97.

51\. Kohler B, Bratthall D, Krasse B. Preventive measures in mothers
influence the establishment of the bacterium Streptococcus mutans in
their infants. Arch Oral Biol. 1983;28:225-31.

52\. Rogers AH. The source of infection in the intra familial transfer
of Streptococcus mutans. Caries Res. 1981;15:26-31.

53\. Bader JD, Brown JP. Dilemmas in caries diagnosis. J Am Dent Assoc.
1993;124:48-50.

54\. Tucker J, Eberling S, Kinney MB, Lala R, Swanberg-Austin, B. Caries
Diagnosis, Risk Assessment and Management: A Practical Guide. January
2003.

55\. Li Y, Wang W. Predicting caries in permanent teeth from caries in
primary teeth: An eight-year cohort study. J Dent Res. 2002
Aug;81(8):561-6.

56\. Marsh PD. Microbiologic aspects of dental plaque and dental caries.
Cariology. 1999 Oct;43(4):599-614.

57\. Kidd EA. Caries Management. Cariology Vol 43, Number 4, Oct 1999
Division of Conservative Dentistry Dental School of Guy's and King's and
St. Thomas' Hospital London England.

58\. Kidd EA. Assessment of caries risk. Dent Update. 1998
Nov;25(9):385-90.

**Use Of Fluorides In Dental Public Health**

Since 1945, when Grand Rapids, Michigan, first fluoridated its city
water supply, fluoridation has been considered the most cost-effective
public health measure to reduce dental caries. Other sources of fluoride
use have also increased tremendously. School fluoridation is considered
an alternative is some communities where fluoridation of the public
water supply is not feasible. Dietary fluoride supplements, with or
without vitamins, are available by prescriptions as alternative sources
of systemic (and topical) fluoride for areas without fluoridated
drinking water, as are several agents designed for professional
application by dental personnel. Fluoride-containing toothpastes have
been marketed in the U.S. since the 1950's and comprise about 95 percent
of the toothpaste market. Fluoride mouthrinses are used in school-based
programs and several brands of mouthrinses with dilute concentrations of
fluorides are sold as non-prescription items. Each of these topics is
covered in greater detail in the following pages.

This widespread availability of fluoride has resulted in a decline in
the prevalence of dental caries among U.S. schoolchildren in general, as
well as American Indian/Alaska Native (AI/AN) schoolchildren
specifically.

Caries prevention programs for individual children or groups should be
implemented based upon a risk assessment. The American Dental
Association has recently published a special supplement on caries
diagnosis and risk assessment. (1) The IHS Dental Disease Prevention
Program endorses these guidelines and recommends that dental clinics
develop preventive plans based on these strategies. It is important to
evaluate these preventive regimens based on local resources and develop
a method to monitor caries attack patterns and rates of disease.

Once the oral health status has been determined, administrators must
decide the goal of their programs---how much disease can be reduced with
fluoride, given the resources available? One must also consider the
various sources of fluoride already available for the patient/community.
Water fluoridation and fluoridated toothpaste must be the cornerstone
upon which dental disease prevention programs are built.

Use of fluoride mouthrinses, gels, and varnishes for individual patients
should be predicated upon the caries activity or risk. Use of these
methods in public health programs is a matter of cost-effectiveness,
which must be weighed against the caries prevalence of the target
population. (2)

Documentation in the literature has shown an increased prevalence of
fluorosis, most probably related to ingestion of fluoridated toothpaste.
Adult supervision of brushing is recommended, with only a pea-sized
portion of toothpaste to be used. Inappropriate prescriptions for
dietary fluoride supplements may also be a factor in the increased
prevalence of fluorosis. According to the IHS oral health survey of
dental patients conducted in 1991, mild fluorosis was found in about 16
percent of the children ages 12-13 years. (3)

The use of fluoride in its various modalities has been a sometimes
controversial but well researched area of science. The latest
controversy arose during 1990 over release of the results of a study by
the National Toxicology Program (NTP). The NTP study reported equivocal
or "uncertain" results concerning the possibility of a carcinogenic
effect of fluoride in male rats, while no effect was seen in mice or
female rats. These results prompted a thorough review by the U.S. Public
Health Service of existing scientific research into the risks and
benefits of fluoride. The resulting report, *Review of Fluoride Benefits
and Risks,* reaffirms the safety and effectiveness of the use of
fluoride in preventing dental caries. No evidence establishing an
association between fluoride and cancer was found. Concerning water
fluoridation, the report acknowledged that although the degree of
measurable benefits has been reduced recently as other fluoride sources
have become available in non-fluoridated areas, the benefits of water
fluoridation are still clearly evident. (4)

**References**

1\. Caries Diagnosis and Risk Assessment: A Review of Preventive
Strategies and Management. Special Supplement of The Journal of the
American Dental Association, Vol. 126, June 1995.

2\. Ripa, LW. A critique of topical fluoride methods (dentifrices,
mouthrinses, operator, and self-applied gels) in an era of decreased
caries and increased fluorosis prevalence. J Public Health Dent. Vol.
51, No. 1. 1991. 23-41.

3\. The Oral Health of Native Americans. Unpublished findings of a 1991
survey conducted for dental patients by the IHS Dental Program.

4\. U.S. Department of Health and Human Services, Public Health Service
*Review of Fluoride Benefits and Risks*. A Report of the Ad Hoc
Subcommittee on Fluoride of the Committee to Coordinate Environmental
Health and Related Programs. February 1991.

**Additional Reading**

1\. Ripa, LW. A half-century of community water fluoridation in the
United States: review and commentary. J Pub Health Dent
1993;53(1):17-44.

2\. Symposium of appropriate uses of fluoride in the 1990's. J Pub
Health Dent 1991;51(1).

**Community Water Fluoridation**

Community water fluoridation is the deliberate adjustment of the natural
trace element fluoride to promote the public's health through the
prevention of dental caries. Fluoride is found naturally in all soils
and existing water supplies. It is also present in animal and plant food
consumed by people.

Hailed as one of the ten greatest achievements in public health in the
20^th^ century by former Surgeon General David Satcher, water
fluoridation continues to be one of the safest, most cost effective
prevention programs. It has the potential to benefit all age groups and
all socioeconomic strata, including the lowest, which has the highest
caries prevalence and is least able to afford preventive and restorative
services. (1) Community water fluoridation is also the most
cost-effective of all community-based caries preventive methods. An
effective community water fluoridation program should be the cornerstone
of all public oral health programs. The efficiency of drinking water
fluoridation in reducing dental caries has been demonstrated in surveys
conducted in the United States as well as several other countries for
the past fifty years. Early water fluoridation studies reported caries
reductions of approximately 40 to 60 percent for the permanent dentition
and slightly lower reductions for deciduous teeth. Recent studies have
found a smaller difference in the caries prevalence between optimally
fluoridated and fluoride-deficient communities. (1) In American
Indian/Alaska Native populations the expected reductions in disease may
be even greater, given the high caries rates.

***History of community water fluoridation***

-   1908 -- Dr. Frederick McKay, Colorado Springs, CO discovered "brown
    stain"

-   1931 -- Alcoa Company chemist identifies fluoride in samples

-   1931 -- Trendley Dean starts at NIH as lone dentist, to investigate
    mottled enamel cases

-   Mid-30's -- Dean reported inverse relationship between fluorosis and
    caries

-   21 Cities Study -- IL, CO, OH, IN - established 1.0 ppm F threshold

-   1945 -- Grand Rapids -- fluoridation first began

***How does fluoride work?***

-   It reduces the solubility of enamel in acid -- fluorapatite

-   It reduces ability of plaque organisms to produce acid

-   It promotes remineralization or repair of enamel

***Fluoridation facts***

-   ALL water sources contain some fluoride

-   Optimal water fluoridation is 0.7 to 1.2 ppm (CDC WFRS 0.9-1.2)

-   No difference in effectiveness between naturally occurring and
    "artificially added" fluoride

-   Fluoridation studies have shown a 44-60% reduction in caries
    prevalence in fluoridated communities

-   Fluoride not only protects children from caries, but also adults
    (including root caries)

-   Cost effective

    -   Costs about 50 cents per person per year to fluoridate

    -   Cost savings -- for every \$1 spent, \$38 saved

        -   "Nearly all tooth decay can be prevented when fluoridation
            is combined with dental sealants and other fluoride
            products, such as toothpaste" (from CDC).

***Fluoridation Controversies***

-   "The overwhelming weight of scientific evidence indicates that
    fluoridation...is both safe and effective (ADA).

    -   No association between F and bone cancer

    -   Fluoride does not affect human enzyme activity

    -   No confirmed reports of fluoride allergies

    -   No relationship between cancer rates and F

    -   No evidence linking fluoride exposure to AIDS

    -   Fluoridated drinking water is not a genetic hazard

    -   No relationship between F and Down's Syndrome

    -   No association between F and neurological problems

    -   No link between F and Alzheimer's disease

    -   Fluoridated water does not cause or worsen kidney disease

    -   Drinking fluoridated water is not a risk factor for heart
        disease

    -   Optimal fluoridation does not affect drinking water quality

***Things you can do...***

-   Educate your community about the benefits of water fluoridation

-   Learn more about fluoridation -- get the facts, so you can dispel
    the myths about fluoridation

***Additional Resources***

<http://www.ada.org/prof/resources/topics/topics_fluoridation_resources.pdf>

<http://www.ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf>

<http://www.ada.org/prof/resources/topics/fluoride.asp#statements>

**History of Water Fluoridation in the IHS**

In 1959, Public Law 86-121, the Indian Sanitation Facilities Act was
passed. This piece of legislation was probably one of the most important
documents for Indian people. The law provided for the installation of
water systems for Native American communities upon Tribal request.
Sanitary water facilities became a reality through this legislation.

In 1981, the IHS established a surveillance system to monitor 325
systems which had fluoridation equipment. There was a two percent
compliance rate at that time.

In 1985, Area and Service Unit Fluoridation Teams were established.
These teams consisted of representatives from a variety of disciplines
including: dental, environmental health and engineering, health
education, pediatrics, public health nursing, pharmacy, and, of course,
the water operator or water utility. A policy for the implementation and
operation of the water fluoridation program was also developed at this
time.

In May 1992, a fluoride overfeed occurred at the predominantly Native
Alaskan village of Hooper Bay. An estimated 296 people became ill and
one person died. (4) This incident had a profound effect on fluoridation
throughout Indian Country. Many tribally-owned and operated water
systems discontinued fluoridation.

In 1995, the Centers for Disease Control and Prevention (CDC), with
input from IHS, developed a manual entitled, "Engineering and
Administrative Recommendations for Water Fluoridation (EARWF)" (6). The
EARWF is an excellent resource that emphasizes fluoridation safety and
the recommendations can easily be adapted for use by tribal water
utilities**.**

The current IHS fluoridation policy is Indian Health Service Circular
No. 99-01, [Water Fluoridation Policy Issuance]{.underline} and is
available through the Area or Headquarters Dental or Office of
Environmental Health and Engineering (OEH & E) programs. It should be
read by all dental care providers. (5)

**Recommendations for Fluoridated Community Water Systems**

*Administration*

The community or water system owner, with professional training and
technical assistance, is primarily responsible for assuring the ongoing
operation of fluoridation equipment and maintaining surveillance and
records of operation. A reliable, frequent monitoring and surveillance
process must be in place to maximize the benefit of water fluoridation.
Training of water operators is also a critical element in assuring AI/AN
communities the dental benefits of community water fluoridation.

Fluoridation teams should be established at each Service Unit or Tribal
program and at the Area and Headquarters levels. Each team should
include water plant operators, Tribal representatives, dental
professionals, engineers, sanitarians and other community health workers
involved in water fluoridation. Regular meetings of the fluoridation
teams provide a good means of identifying problems in the fluoridation
program and developing strategies to solve these problems.

Following is a list of activities in which the fluoridation team should
be involved:

1\. Review current water fluoridation system practices and identify any
problem areas.

2\. Work to improve fluoridation at problematic systems and delegate
responsibilities to each team member.

3\. Encourage and support training to increase both technical and public
relations skills.

4\. Educate the community and market the benefits of water fluoridation
through:

> a\. Group presentations (Tribal health groups, PTA, Head Start, WIC).
>
> b\. Media (TV, radio, newspapers).
>
> c\. Posting the water fluoridation levels in public places (assuming
> the water utility approves).
>
> d\. Educating the medical staff.

5.  Maintain communication with the state dental and state drinking
    water programs regarding aspects of water fluoridation.

**Fluoride Testing Requirements/Recommendations**:

Most tribally-owned and operated public water systems (PWS) are
regulated by the U.S. Environmental Protection Agency (EPA). The EPA
does not require routine (i.e. daily) monitoring for fluoride.
State-regulated PWSs have specific requirements for fluoride monitoring
and many AI/AN people are served by state-regulated PWSs. IHS has no
regulatory function but strongly recommends fluoridation practices that
closely follow the EARWF guidelines. Those recommendations include:

1.  Daily monitoring of the fluoride level from a representative
    sampling location in the distribution system.

2.  Monthly split samples with a certified laboratory.

3.  Performance of dosage calculations.

4.  Annual raw water (i.e., water that has not been treated) sampling
    and testing for fluoride content. The analysis should be done by a
    certified lab.

IHS generally considers a water system optimally fluoridated if the
following criteria are met:

a.  The fluoride concentration is monitored daily.

b.  The monthly average fluoride concentration falls within the control
    range.

c.  At least 75% of daily water samples fall within the control range.

d.  Split samples are submitted to a certified lab at least monthly.

e.  At least 75% of monthly split samples taken by the PWS during the
    calendar year shall agree with the Lab results within the split
    sample tolerance of +/- 0.2 ppm.

The criteria for optimal fluoridation may differ across the IHS Areas,
and even within some Areas. Optimal fluoridation criteria should be
developed in consultation with tribes and their tribal water utilities.

IHS personnel should encourage tribal water utilities to participate in
the CDC Water Fluoridation Reporting System (WFRS). State-by-State
statistics from WFRS can be found at
<http://apps.nccd.cdc.gov/MWF/Index.asp>.

**Colorimeter (SPADNS Method)**

1.  The colorimetric method (SPADNS) of fluoride analysis is based on a
    reaction in which a deep color (from zirconium in dye) turns lighter
    in the presence of fluoride (fluoride removes zirconium). The
    colorimetric method can be used where no interference occurs or
    where the interferences are consistent (e.g., from iron, chloride,
    phosphate, sulfate or color). Consistent interferences can be
    accounted for by collecting a split sample and comparing the
    colorimetric results with results provided for by Lab personnel.
    State laboratory personnel,, and the water plant operator can then
    make the appropriate adjustment.

2.  The colorimetric method (SPADNS) of fluoride analysis is applicable
    for daily testing of fluoride levels in the range 0.1 to 2.0 ppm.
    Beyond this range, dilutions must be made using deionized water to
    obtain accurate measures of the fluoride concentration.

3.  Colorimeters are easily transported and ideal for use in the field.

**Specific Ion Meter (Electrode Method)**

The electrode method is capable of measuring fluoride concentrations
from 0.1 to 10 ppm and is not subject to the interferences associated
with the colorimetric method. Specific ion meters are more difficult to
use in a field setting than a colorimeter.

The fluoride level in water systems should be maintained as close to the
recommended concentrations as possible. These values are based on annual
average temperatures. (Table 1.)

Table 1

**Recommended Optimal Fluoride Levels for Community Public Water Supply
Systems** (5)

  --------------------- --------------------- ----------------------------
  Annual Average of     Recommended Fluoride  Recommended Control Range of
  Maximum Daily         Conc. (ppm)           Fluoride Conc. (ppm)
  Temperatures F                              

  40.0 -- 53.7          1.2                   1.1 -- 1.7

  53.8 -- 58.3          1.1                   1.0 -- 1.6

  58.4 -- 63.8          1.0                   0.9 -- 1.5

  63.9 -- 70.6          0.9                   0.8 -- 1.4

  70.7 -- 79.2          0.8                   0.7 -- 1.3

  79.3 -- 90.5          0.7                   0.6 -- 1.2
  --------------------- --------------------- ----------------------------

*Technical Assistance and Training*

The IHS OEH&E Program provides technical assistance where surveillance
reveals a problem and/or when it is requested by a tribe or the
community. On-going training for the operators is also provided. The CDC
also provides training for water system operators and others involved in
the fluoridation programs. The CDC has developed manuals for operators
as well as engineers and technicians. (7)

*Safety of Community Water Fluoridation*

Community water fluoridation is a safe and cost-effective method to
ensure the oral health of all people. Technical requirements are
outlined in the EARWF and they should be followed by all
tribally-managed fluoridated water systems. These guidelines also
establish recommended emergency procedures for fluoride overfeeds.
Specific actions should be taken when equipment malfunctions or an
adverse event occurs in a community public water supply system that
causes a fluoride chemical overfeed. (See Table 2.)

TABLE 2

Recommended Fluoride Overfeed Actions for Community Water Systems (4)

+-----------------------------------+-----------------------------------+
| **Fluoride Level**                | **Actions Recommended**           |
+-----------------------------------+-----------------------------------+
| 0.1 mg/L above control range to\  | 1.  Leave the fluoridation system |
| 2.0 mg/L                          |     on.                           |
|                                   |                                   |
|                                   | 2.  Determine malfunction and     |
|                                   |     repair.                       |
+-----------------------------------+-----------------------------------+
| 2.1 mg/L to 4.0 mg/L              | 1.  Leave the fluoridation system |
|                                   |     on.                           |
|                                   |                                   |
|                                   | 2.  Determine malfunction and     |
|                                   |     repair.                       |
|                                   |                                   |
|                                   | 3.  Notify the water plant        |
|                                   |     operator supervisor and       |
|                                   |     report the incident to the    |
|                                   |     appropriate regulatory        |
|                                   |     agency.                       |
+-----------------------------------+-----------------------------------+
| 4.1 mg/L to 10.0 mg/L             | 1.  Determine malfunction and     |
|                                   |     immediately attempt repair.   |
|                                   |                                   |
|                                   | 2.  If the problem is not found   |
|                                   |     and corrected quickly, turn   |
|                                   |     off the fluoridated system.   |
|                                   |                                   |
|                                   | 3.  Notify the water plant        |
|                                   |     operator supervisor and       |
|                                   |     report the incident to the    |
|                                   |     appropriate regulatory        |
|                                   |     agency.                       |
|                                   |                                   |
|                                   | 4.  Take water samples at several |
|                                   |     points in the distribution    |
|                                   |     system and test the fluoride  |
|                                   |     content. Retest if results    |
|                                   |     are still high.               |
|                                   |                                   |
|                                   | 5.  Determine malfunction and     |
|                                   |     repair. Then, with            |
|                                   |     supervisor's permission,      |
|                                   |     restart the fluoridation      |
|                                   |     system.                       |
+-----------------------------------+-----------------------------------+
| 10.1 mg/L or greater              | 1.  Turn off the fluoridation     |
|                                   |     system immediately.           |
|                                   |                                   |
|                                   | 2.  Notify the water plant        |
|                                   |     operator supervisor and       |
|                                   |     report the incident           |
|                                   |     immediately to the            |
|                                   |     appropriate regulatory agency |
|                                   |     and follow their              |
|                                   |     instructions.                 |
|                                   |                                   |
|                                   | 3.  Take water samples at several |
|                                   |     points in the distribution    |
|                                   |     system and test the fluoride  |
|                                   |     content. Retest if results    |
|                                   |     are still high. Save part of  |
|                                   |     each sample for the state     |
|                                   |     laboratory to test.           |
|                                   |                                   |
|                                   | 4.  Determine malfunction and     |
|                                   |     repair. Then, with            |
|                                   |     supervisor's and the state's  |
|                                   |     permission, restart the       |
|                                   |     fluoridation system.          |
+-----------------------------------+-----------------------------------+

Most overfeeds do not pose an immediate health risk; however, some
fluoride levels can be high enough to cause immediate health problems.
All overfeeds should be corrected immediately because some have the
potential to cause serious long-term health effects. (4)

When a fluoride test result is at or near the top end of the analyzer
scale, the water sample must be diluted and retested to ensure that high
fluoride levels are accurately measured.

CDC has also published recommendations for treatment if a person ingests
dry fluoride chemicals (NaF and Na2SiF6). (See Table 3.)

TABLE 3

Recommended Emergency Treatment for Persons Who Ingest Dry Fluoride
Chemicals NaF and Na2SiF6 (4)

+----------------------------------+----------------------------------+---+
| **Milligrams Fluoride Ion (mg)   | **Treatment**                    |   |
| Ingested Per Body Weight         |                                  |   |
| (kg)\***                         |                                  |   |
+----------------------------------+----------------------------------+---+
| \<5.0 mg of fluoride ion/kg      | 1.  Give calcium (milk) orally   |   |
|                                  |     to relieve gastrointestinal  |   |
|                                  |     symptoms. Observe for 2--4   |   |
|                                  |     hours. (A can of evaporated  |   |
|                                  |     milk should be available at  |   |
|                                  |     all times to use for         |   |
|                                  |     emergency treatment.)        |   |
|                                  |                                  |   |
|                                  | 2.  Induced vomiting is not      |   |
|                                  |     necessary.                   |   |
+----------------------------------+----------------------------------+---+
| \>5.0 mg of fluoride ion/kg      | 1.  Move the person away from    |   |
|                                  |     any contact with fluoride    |   |
|                                  |     and keep him or her warm.    |   |
|                                  |                                  |   |
|                                  | 2.  Call the Poison Control      |   |
|                                  |     Center.                      |   |
|                                  |                                  |   |
|                                  | 3.  If the person is conscious,  |   |
|                                  |     induce vomiting by rubbing   |   |
|                                  |     the back of the person's     |   |
|                                  |     throat with either a spoon   |   |
|                                  |     or your finger or giving the |   |
|                                  |     person syrup of ipecac. To   |   |
|                                  |     prevent aspiration of        |   |
|                                  |     vomitus, the person should   |   |
|                                  |     be placed face down with the |   |
|                                  |     head lower than the body.    |   |
|                                  |                                  |   |
|                                  | 4.  Give the person a glass of   |   |
|                                  |     milk or any source of        |   |
|                                  |     soluble calcium (i.e., 5%    |   |
|                                  |     calcium gluconate or calcium |   |
|                                  |     lactate solution).           |   |
|                                  |                                  |   |
|                                  | 5.  Take the person to the       |   |
|                                  |     hospital as quickly as       |   |
|                                  |     possible.                    |   |
+----------------------------------+----------------------------------+---+
| \*Average age/weight: 0--2       |                                  |   |
| years/0--15 kg; 3--5             |                                  |   |
| years/15--20 kg;\                |                                  |   |
| 6--8 years/20--23 kg; 9--15      |                                  |   |
| years/23--45 kg; 15--21 years    |                                  |   |
| and higher/45--70 kg.            |                                  |   |
+----------------------------------+----------------------------------+---+

TABLE 4.

Recommended emergency treatment for persons who ingest fluorosilicic
acid (H2SiF6) (60)

+----------------------------------+-----------------------------------+
| Milligrams fluoride ion (mg)     | Treatment                         |
| ingested per body weight (kg) \* |                                   |
+----------------------------------+-----------------------------------+
| \<5.0 mg fluoride/kg +           | 1.  Give calcium (milk) orally to |
|                                  |     relieve gastrointestinal      |
|                                  |     symptoms. Observe for 2-4     |
|                                  |     hours. (A can of evaporated   |
|                                  |     milk should be available at   |
|                                  |     all times to use for          |
|                                  |     emergency treatment.)         |
|                                  |                                   |
|                                  | 2.  Induced vomiting is not       |
|                                  |     necessary                     |
+----------------------------------+-----------------------------------+
| \>=5.0 mg fluoride/kg            | 1.  Move the person away from any |
|                                  |     contact with fluoride and     |
|                                  |     keep him or her warm.         |
|                                  |                                   |
|                                  | 2.  Call the Poison Control       |
|                                  |     Center.                       |
|                                  |                                   |
|                                  | 3.  If advised by the Poison      |
|                                  |     Control Center and if the     |
|                                  |     person is conscious, induce   |
|                                  |     vomiting by rubbing the back  |
|                                  |     of the person\'s throat with  |
|                                  |     a spoon or your finger or use |
|                                  |     syrup of ipecac. To prevent   |
|                                  |     aspiration of vomitus, the    |
|                                  |     person should be placed face  |
|                                  |     down with the head lower than |
|                                  |     the body.                     |
|                                  |                                   |
|                                  | 4.  Give the person a glass of    |
|                                  |     milk or any source of soluble |
|                                  |     calcium (i.e., 5% calcium     |
|                                  |     gluconate or calcium lactate  |
|                                  |     solution).                    |
|                                  |                                   |
|                                  | 5.  Take the person to the        |
|                                  |     hospital as quickly as        |
|                                  |     possible. It is important     |
|                                  |     that whoever takes the person |
|                                  |     to the hospital notify        |
|                                  |     physicians that the person is |
|                                  |     at risk for pulmonary edema   |
|                                  |     as late as 48 hours           |
|                                  |     afterward.                    |
+----------------------------------+-----------------------------------+

\* Average weight/age: 0-15 kg/0-2 years; 15-20 kg/3-5 years; 20-23
kg/6-8 years; 23-45 kg/9-15 years; 45-70 kg and higher/15-21 years and
older.

\+ 5 mg of fluoride (F) equals 27 mg of 23% fluorosilicic acid.
Ingesting 5 mg F/kg is equivalent to a l54-lb (70 kg) person consuming 2
grams of fluorosilicic acid.

References

1.  Ripa LW. A half century of community water fluoridation in the
    united states review and commentary. J Pub Health Dent 1993;
    53(1):17-44.

2.  The Oral Health of Native Americans. A Chart Book of Recent
    Findings, Trends and Regional Differences. 1994. (unpublished)

3.  The 1999 Oral Health Survey Of American Indian And Alaska Native
    Dental Patients: *Findings, Regional Differences And National
    Comparisons*

4.  Gessner, B.D., Beller M., Middaugh J.P., Whitford G.M., Acute
    Fluoride Poisoning from a Public Water System. New England Journal
    of Medicine, Vol. 330: 95-99, Jan. 13, 1994

5.  Indian Health Service Circular No. 94-1, Water Fluoridation Policy
    Issuance, 1994.

6.  Engineering and Administrative Recommendations for Water
    Fluoridation, 1995. Centers for Disease Control and Prevention. MMWR
    September 29, 1995/Vol. 4/No. RR -13.
    <http://www.cdc.gov/mmwr/preview/mmwrhtml/00039178.htm>

7.  Water Fluoridation A Manual for Engineers and Technicians. US
    Department of Health and Human Services, Public Health Service,
    Centers for Disease Control and
    Prevention.<http://www.cdc.gov/fluoridation/engineering.htm>

8.  CDC Water Fluoridation Website:
    <http://www.cdc.gov/OralHealth/topics/fluoridation.htm>

**FLUORIDATION SYSTEM DESIGN:**

(from the CDC's EARWF)

**Engineering Guidelines**

1.  The fluoride feed system must be installed so that it cannot operate
    unless raw water pumps are operating (interlocked). To assure this,
    the metering pump must be wired electrically in series with the main
    well pump or the service pump. If a gravity flow situation exists, a
    flow switch or pressure device should be installed.

2.  When the fluoridation system is connected electrically to the well
    pump, the fluoride-metering pump cannot be plugged into any
    continuously active ("hot") electrical outlet. The fluoride metering
    pump must only be plugged into the circuit that contains the
    interlock protection (the interlock may not be necessary when water
    systems have an on-site water operator 24 hours a day.) One method
    of ensuring interlock protection is to install a special clearly
    labeled plug on the metering pump that is compatible with a special
    outlet on the appropriate electrical circuit. Another method of
    providing interlock protection is to wire the metering pump directly
    into the electrical circuit that is tied electrically to the well
    pump or service pump.

3.  A secondary flow-based control device (e.g., a flow switch or a
    pressure switch) should be installed for back-up protection in water
    systems that serve populations of \<500 persons.

4.  The fluoride injection point should be located where all the water
    to be treated passes; however, fluoride should not be injected at
    sites where substantial losses of fluoride can occur (e.g., the
    rapid-mix chemical basin).

5.  The fluoride injection point in a water line should be located in
    the lower one-third of the pipe, and the end of the injection line
    should extend into the pipe approximately one third of the pipe's
    diameter.

6.  A corporation stop valve should be used in the line at the fluoride
    injection point when injecting fluoride under pressure. A safety
    chain must always be installed in the assembly at the fluoride
    injection point to protect the water plant operator if a corporation
    stop valve assembly is used.

7.  Operation of a fluoridation system without a functional anti-siphon
    device can lead to overfeed that exceeds 4 mg/L. Two diaphragm-type,
    anti-siphon devices must be installed in the fluoride feed line when
    a metering pump is used. The anti-siphon device should have a
    diaphragm that is spring-loaded in the closed position. These
    devices should be located at the fluoride injection point and at the
    metering pump head on the discharge side. The anti-siphon device on
    the head of the metering pump should be selected so that it will
    provide the necessary back pressure required by the manufacturer of
    the metering pump. Oversized metering pumps should not be used
    because serious overfeeds (i.e., overfeed that exceeds 4 mg/L) can
    occur if they are set too high. Conversely, undersized metering
    pumps can cause erratic fluoride levels.4

8.  The fluoride metering pump should be located on a shelf not more
    than 4 feet (1.2 m) higher than the lowest normal level of liquid in
    the carboy, day tank, or solution container. A flooded suction line
    is not recommended in water fluoridation.

9.  For greatest accuracy, metering pumps should be sized to feed
    fluoride near the midpoint of their range. Pumps should always
    operate between 30%--70% of capacity. Metering pumps that do not
    meet design specifications should not be installed.

10. The priming switch on the metering pump should be spring-loaded to
    prevent the pump from being started erroneously with the switch in
    the priming position.

11. In a surface-water treatment plant, the ideal location for injecting
    fluoride is the rapid sand filter effluent line going into the clear
    well.

12. Vacuum testing for all anti-siphon devices should be done
    semiannually. All anti-siphon devices must be dismantled and
    visually inspected at least once a year. Schedules of repairs or
    replacements should be based on the manufacturer's recommendations.

13. An in-line mixer or a small mixing tank should be installed in the
    finished water line exiting from the water plant if the first
    customer is less than or equal to 100 feet (30.5 m) from the
    fluoride injection point and if there is no storage tank located in
    the line before the water reaches the customer. The minimum distance
    is 100 feet, assuming there are typical valves and bends in the
    water line that allow for adequate mixing.

14. Flow meter-paced systems should not be installed unless the rate of
    water flow past the point of fluoride injection varies by more than
    20%.

15. A master meter on the main water service line must be provided so
    that calculations can be made to confirm that the proper amounts of
    fluoride solution are being fed.

16. The fluoride feed line(s) should be either color coded, when
    practical, or clearly identified by some other means. Color coding
    helps prevent possible errors when taking samples or performing
    maintenance. The pipes for all fluoride feed lines should be painted
    light blue with red bands. The word "fluoride" and the direction of
    the flow should be printed on the pipe.

17. Fluoride feed equipment, controls, safety equipment, accessory
    equipment, and other appurtenances must be inspected annually.

18. All hose connections within reach of the fluoride feed equipment
    should be provided with a hose bibb vacuum breaker.

19. All fluoride chemicals must conform to the appropriate American
    Water Works Association (AWWA) standards (B-701, B-702, and B-703)
    to ensure that the drinking water will be safe and potable.

20. Storage should be provided for at least a three-month supply of
    fluoride chemical to minimize the effect of a possible fluoride
    chemical shortage. Shortages have occurred sporadically in the past
    (CDC, unpublished report, 1986).

21. Cross-connection controls that conform to state regulations must be
    provided.

**Sodium Fluoride Saturator System Requirements**

1.  The minimum depth of sodium fluoride in a saturator should be 12
    inches (30.5 cm). This depth should be marked on the outside of the
    saturator tank. The saturator should never be filled so high that
    the undissolved chemical is drawn into the pump suction line.

2.  Only granular sodium fluoride should be used in saturators, because
    both powdered and very fine sodium fluorides tend to cause plugging
    in the saturator.

3.  The water used for sodium fluoride saturators should be softened
    whenever the hardness exceeds 50 parts per million (ppm). Only the
    water used for solution preparation (i.e., the make-up water) needs
    to be softened.

4.  A flow restrictor with a maximum flow of two gallons (7.6 L) per
    minute should be installed on all up-flow saturators.

5.  In the event of a plant shutdown, the make-up water solenoid valve
    should be physically disconnected from the electrical service.

6.  For systems that use \< 10 gallons (\< 38 L) of saturator solution
    per day, operators should consider using an up-flow saturator that
    is manually filled with water.

7.  In an up-flow saturator, either an atmospheric vacuum breaker must
    be installed or a backflow prevention device must be provided in
    accordance with state or local requirements. The vacuum breaker must
    be installed according to the manufacturer's recommendations.

8.  A sediment filter (20 mesh) should be installed in the water make-up
    line going to the sodium fluoride saturators. The filter should be
    placed between the softener and the water meter.

9.  A water meter must be provided on the make-up water line for the
    saturator so that calculations can be made to confirm that the
    proper amounts of fluoride solution are being fed. This meter and
    the master meter should be read daily and the results recorded.

10. Unsaturated (batch-mixed) sodium fluoride solution should not be
    used in water fluoridation.

**Fluorosilicic Acid System Requirements**

1.  To reduce the hazard to the water plant operator, fluorosilicic acid
    (hydrofluosilicic acid) must not be diluted. Small metering pumps
    are available that will permit the use of fluorosilicic acid for
    water plants of any size.

2.  No more than a seven-day supply of fluorosilicic acid should be
    connected at any time to the suction side of the chemical feed pump.
    All bulk storage tanks with more than a seven-day supply must have a
    day tank. A day tank should only contain a small amount of acid,
    usually a one- or two-day supply.

3.  Day tanks or direct acid-feed carboys/drums should be located on
    scales; daily weights should be measured and recorded. Volumetric
    measurements, such as marking the side of the day tank, are not
    adequate for monitoring acid feed systems.

4.  Carboys, day tanks, or inside bulk storage tanks containing
    fluorosilicic acid must be completely sealed and vented to the
    outside.

5.  Fluorosilicic acid should be stored in bulk, if economically
    feasible.

6.  Bulk storage tanks must be provided with secondary containment
    (i.e., berms) in accordance with state/local codes or ordinances.

**Fluoride Dry Feed System Requirements**

1.  A solution tank that has a dry feeder (both volumetric and
    gravimetric) must be provided.

2.  Solution tanks should be sized according to CDC guidelines.

3.  A mechanical mixer should be used in every solution tank of a dry
    feeder when sodium fluorosilicate (i.e., silicofluoride) is used.

4.  Scales must be provided for weighing the amount of chemicals used in
    the dry feeder.

**SAFETY AND REPORTING**

**Water Operator Safety**

1.  The water supply industry has a high incidence of unintentional
    injuries as compared with other industries in the United States;
    with proper safety procedures injuries can be avoided.

2.  Water operator should follow proper safety procedures to avoid
    injuries and overexposure to chemicals. Water plant personnel should
    regularly receive safety training on all chemicals, including
    fluoride. Exposure hazards and first aid should be reviewed and
    emergency spill procedures should be established and explained to
    workers.

**Protective Equipment**

1.  The use of personal protective equipment (PPE) is required when
    handling fluoride chemicals or when maintenance on fluoridation
    equipment is performed.

2.  Required PPE for handling sodium fluoride or sodium fluorosilicate
    includes:

    a.  NIOSH approved high efficiency dust respirator (chemical mask)
        with soft rubber face-to-mask seal and replaceable cartridges.

    b.  Gauntlet neoprene gloves (12" glove minimum length)

    c.  Heavy duty neoprene aprons.

3.  Required PPE for handling fluorosilicic acid includes:

    a.  Gauntlet neoprene gloves (12" glove minimum length)

    b.  Heavy duty neoprene aprons.

    c.  Full 8" face shield or acid type safety goggles

    d.  Safety shower/eye washer in easily accessible location (or
        pint-size bottle of eyewash solution).

**Chemical Storage**

1.  Do not allow unauthorized personnel, especially small children, in
    areas where fluoride chemicals are fed or stored. Do not eat or keep
    food in areas where fluoride is stored.

2.  Store dry fluoride on pallets, in stacks preferably not more than
    six bags high. If fiber drums are used, keep the tops closed to
    prevent moisture contamination.

3.  Vapors from fluorosilicic acid are corrosive; containers should be
    kept tightly closed, vented to the outdoors, and stored away from
    hot temperature areas. Bulk storage tanks can be made of fiberglass
    polyethylene or rubber-lined steel.

**Glossary of Technical Terms**

**Adjusted fluoridated water system:** A community public water system
that adjusts the fluoride concentration in the drinking water to the
optimal level for consumption (or within the recommended control range).

**Calculated dosage:** The calculated amount of fluoride (mg/L) that has
been added to an adjusted fluoridated water system. The calculation is
based on the total amount of fluoride (weight)

that was added to the water system and the total amount of water
(volume) that was produced.

**Centers for Disease Control and Prevention (CDC**): An agency of the
U.S. Department of Health and Human Services charged with promoting
health and quality of life by preventing and

controlling disease, injury, and disability.

**Census designated place:** A populated place, not within the limits of
an incorporated place, that has been delimited for census purposes by
the U.S. Bureau of the Census.

**Certified Waterworks Operator:** A water operator who meets the
minimal criteria set by the State Department of Health Division of Water
Supply for certification as evident by

passing a written examination.

**Check sample:** A distribution water sample forwarded to either the
state laboratory or to a state-approved laboratory for analysis.

**Community:** A geographical entity that includes all incorporated
places as well as all census-designated places as defined by the U.S.
Bureau of the Census.

**Community water system (CWS):** Any water system serving piped water
for human consumption to 15 or more individual service connections used
year-round by consumers or regularly serving 25 or more individual
consumers year-round, including, but not limited to, any collection,
pretreatment, treatment, storage and/or distribution facilities or
equipment used primarily as part of, or in connection with such system,
regardless of whether or not such components are under the ownership or
control of the operator of such system.

**Connection:** Generally speaking, water service into an individual
housing unit or dwelling.

**Consecutive water system:** A public water system that buys water from
another public water system. For purposes of water fluoridation record
keeping, the consecutive water system should

purchase at least 80% of its water from a fluoridated water system.

**Distribution sample:** A water sample taken from the distribution
lines of the public water system that is representative of the water
quality in the water system.

**Dry Fluoride Feed System:** A fluoridation system that uses a dry
chemical compound (usually sodium fluorosilicate) as the means to
fluoridate a PWS.

**Fluorosilicic Acid System:** A fluoridation system that uses
fluorosilicic acid as the means to fluoridate a PWS.

**Fluorosis:** A clinical condition of the teeth where whitish to
brownish staining occurs due to excessively high levels of fluoride
exposure during tooth development.

**Incorporated place:** A populated place possessing legally defined
boundaries and legally constituted government functions.

**MG/L:** Milligrams per liter; also, ppm.

**Monitoring, fluoride:** The regular analysis and recording by water
system personnel of the fluoride ion content in the drinking water.

**Must:** See Shall.

**Natural fluoride level:** The concentration of fluoride (mg/L) that is
present in the water source from naturally occurring fluoride sources.

**Naturally fluoridated water system:** A public water system that
supplies water which contains naturally occurring fluoride at levels
that is beneficial to dental health.

**Operator:** The certified waterworks operator who directly supervises
and is personally responsible for the daily operation and maintenance of
a community or non-transient non-community public water system.

**Optimal Control Range:** A range within which adjusted fluoridated
water systems shall operate to maintain optimal fluoride levels. the
range is 0.7-1.3 parts per million.

**Optimal Fluoride Level:** The fluoride concentration (mg/L, which is
the same as ppm) based on the annual average of the maximum daily air
temperature in the geographical area of the

fluoridated water system.

**Optimally Fluoridated Water System:** A public water system that has
consistent optimal levels of fluoride for oral health from either
naturally occurring sources, or by adjusting the fluoride

level to optimal concentrations.

**Overfeed, fluoride:** Any fluoride analytical result above the
recommended control range of the water system. Different levels of
response are expected from the operator depending on the

extent of the overfeed.

**PPM:** parts per million. See also, mg/L.

**Public water supply/system (PWS):**

**Required Water Samples:** Required samples include a minimum of three
(3) routine fluoride samples which shall be taken on different days each
week and submitted monthly, and submission of a monthly split water
sample to the Lab for testing.

**Shall:** Indicates that which is mandatory; a requirement.

**Sodium Fluoride Saturator System:** A fluoridation system that uses a
saturated solution of sodium fluoride as the means to fluoridate a PWS.

**Split sample:** A distribution water sample taken by the water plant
operator, who analyzes a portion of the sample and records the results
on the monthly operating report to the state. The operator then forwards
the remainder of the sample to the Lab for analysis.

**Split sample tolerance:** The amount of variance allowed between the
portion of the split sample tested by the water system operator and the
Lab. the split sample tolerance is 0.2 ppm.

**State fluoridation administrator:** The employee who is responsible
for the administration of the fluoridation program.

**Surveillance, fluoride:** The regular review of monitored data and
split sample or check sample results to ensure that fluoride levels are
maintained by the community water systems in a

specific geographic area.

**Uniform flow:** When the rate of flow of the water past a point varies
by less than 20%.

**Upstream:** In a water line, a point closer to the source of water.

**Water, make-up:** Water that is used to replace the saturated solution
from a sodium fluoride saturator; this saturated solution is pumped into
the distribution lines.

**Water fluoridation:** The act of adjusting the fluoride concentration
in the drinking water of a water system to the optimal level.

**Dietary Fluoride Supplements**

There have been few well-conducted surveys to demonstrate the
effectiveness of fluoride supplements. One study in school-age children
showed a 29% reduction in caries. A potential cause for fluorosis can
exist if physicians or dentists do not know if the community where the
child resides is fluoridated. Therefore, it is important to include the
pediatricians, public health nurses (PHN), pharmacists, and other
providers in the discussion on fluoride supplements for AI/AN children.

A few suggestions are listed below:

1\. Work with the Office of Environmental Health and Engineering (OEH&E)
personnel to obtain or generate a list of water supplies and their
fluoride content. You might use a map and mark each water supply by its
fluoride content. You should include those water supplies with natural
fluoride levels too.

2\. Establish a quality assurance system for water system testing. The
ion electrode method is required. Some questions to answer include a)
How will water be collected? b) Who will do the testing? c) How will
results get returned to the person prescribing? Be sure to enter water
fluoride levels in the patient's chart. You may also want to keep a log
of each address and the level of fluoride in the water for future
reference.

3\. Identify an interested health professional(s) to be responsible to
assist with the infant supplement program. Screen the infant's water
supply at *one* pre-established encounter: a) prenatal visit, b) at the
hospital after childbirth, c) first clinic visit, d) home visit, e)
first WIC visit, etc. The program will be more effective if only a few
people are responsible and all infants are screened at one
pre-determined encounter.

4\. Develop a written protocol by Area and/or Service Unit/Tribe.
Standing orders for the prescription may be used. Dosage should be in
accordance with the ADA/CDC Schedule found in Table 1.

5\. Establish a mechanism to track compliance and to remind patients of
the importance of the fluoride supplementation.

6\. Reinforce health professionals outside the dental clinic who are
screening patients for appropriateness.

**Table 1**

**Recommended Daily Fluoride Supplement (1)**

+-----------------+----------------+----------------+----------------+
| **Fluoride      |                |                |                |
| Dose**          |                |                |                |
+-----------------+----------------+----------------+----------------+
| Age             | \<0.3 ppm      | 0.3 to 0.6 ppm | \>0.6 ppm      |
+-----------------+----------------+----------------+----------------+
| 0 to 6 months   | 0              | 0              | 0              |
+-----------------+----------------+----------------+----------------+
| 6 months to     | 0.25 mg        | 0              | 0              |
|                 |                |                |                |
| 3 years         |                |                |                |
+-----------------+----------------+----------------+----------------+
| 3 to 6 years    | 0.5 mg         | 0.25 mg        | 0              |
+-----------------+----------------+----------------+----------------+
| 6 to 16 years   | 1 mg           | 0.5 mg         | 0              |
+-----------------+----------------+----------------+----------------+

Samples of Systemic Fluoride Prescriptions

Age: 6 mo. Rx Sodium Fluoride Drops

Sig. 0.25 mg fluoride

Place drops inside cheek once a day.

Refills 1 time per year.

Age: 5 yrs. Rx Sodium Fluoride Tablets

2.2 mg. (1 mg. elemental fluoride) Dis. 120

> Sig. One tablet should be chewed and swished (for one minute), then
> swallowed.

Use at bedtime after brushing.

Refills 3 times in 1 year.

**Table 2**

**Recommended total dietary fluoride intake**

  ------------ ------------- ---------- ----------------- ----------------------
  **Age**      **Reference              **Adequate        **Tolerable Upper
               Weight\***               Intake\*\***      Intake\*\*\***

               **kg**        **lb**     **mg/day**        **mg/day**

  0-6 months   7             16         0.01              0.7

  6-12 months  9             20         0.5               0.9

  1-3 years    13            29         0.7               1.3

  4-8 years    22            48         1.1               2.2

  ≥9 years     40-76         88-166     2.0-3.8           10.0
  ------------ ------------- ---------- ----------------- ----------------------

*\* Values based on data collected during 1988-1994 as part of the third
National Health*

*and Nutrition Examination Study*

*\*\* Intake that maximally reduces occurrence of caries without causing
unwanted side*

*effects, including moderate enamel fluorosis*

*\*\*\*Highest level of nutrient intake that is likely to pose no risks
for adverse health effects*

*in almost all persons*

***Source**: Adapted from the Institute of Medicine. Fluoride. In:
Dietary reference intakes for calcium, phosphorus, magnesium, and
fluoride. Washington, DC: National academy Press, 1997:288-313*

**Procedures for Prescribing Systemic Fluoride Supplements**

The following guidelines are for prescribing systemic fluoride
supplements for those children who are not receiving optimal systemic
fluoride:

1\. Test the water supply using the ion electrode method and make a note
in the chart for the entire family. Add the fluoride results to the
preventive assessment section on the dental exam form. Testing can be
avoided if the water supply's fluoride content is already known. This
information can often be obtained from the State Health Department, OEH
& E professionals, or the CDC water fluoridation website
(<http://apps.nccd.cdc.gov/MWF/Index.asp>).

2\. Write the appropriate prescription and instruct the parent that the
tablets should be chewed and swished before swallowing when possible.
Drops may be used instead of tablets for infants. Be sure to inquire as
to whether there are other young children in the home and use this
opportunity to prescribe the appropriate dose for each child.

3\. Counsel the parents on the importance of systemic supplementation.
The parents are much more likely to comply if they thoroughly understand
the significance of the prescription. It will also increase compliance
to help the parent arrange the best time to fit this new habit into
their daily routine.

4\. On return visits, check for compliance and further counsel the
parent(s) if there is noncompliance. Document each counseling session in
the chart.

When prescribing fluorides, you have an excellent opportunity to educate
the patients and parents of the importance of water fluoridation.
Example: "Since your water is not fluoridated, you need to supplement
your diet with a fluoride tablet."

**Action**

The action of a fluoride supplement is both topical when chewed and
systemic when swallowed. The topical benefits are greatly increased if
the child chews the tablet and swishes for one minute before swallowing.
There is some evidence that a fluoride tablet consumed one time a day
has a different efficiency as compared to low doses throughout the day,
e.g., drinking fluoridated water. Fluoride drops are recommended for
infants.

*Note: Children who are totally breast-fed, even in a fluoridated
community, should receive a fluoride supplement because of the low
fluoride content in breast milk.*

Fluoride combined with vitamins may be used. Although combining use of
fluorides with vitamins may improve motivation of some parents, the
parent or guardian should be educated to the continued need for fluoride
if use of the vitamins are discontinued.

Fluoride supplements may be provided on an individual or family basis at
home or in schools. The advantage of a home-based program is that there
are no interruptions during school vacations, and supplementation may
begin from birth. Compliance, however, is a problem. A school-based
program may ensure that all children have access to fluoride supplements
despite lack of family compliance. School-based programs generally have
a higher compliance, although some schools question the legalities of
dispensing a prescribed item.

**Prenatal Fluoride Supplementation**

Prenatal fluoride supplementation is not recommended at this time
because of inadequate clinical documentation of effectiveness.

**Safety**

The dental professional must be aware of the potential for acute or
chronic toxicity problems when using supplements or combinations of
fluoride delivery methods. When prescribing dietary fluoride
supplements, the dentist must take into consideration the patient's age
as well as the fluoride ion concentration available in the primary water
source in order to recommend the correct daily dose. Recent evidence
indicates that ingestion of fluoride supplements can be a risk factor
for fluorosis. The most critical period for fluorosis development in the
aesthetically important central and lateral incisors is in the second to
third years of life, rather than early infancy.

As a safety precaution, the ADA makes the following recommendations:

1\. Do not store large quantities of sodium fluoride in the home.

2\. When prescribing fluoride supplements, no more than 264 mg of sodium
fluoride (120 mg fluoride) should be dispensed at one time. In order to
comply with this recommendation, commercial fluoride preparations
available for home use are generally dispensed in bottles of 100 to 120
tablets. Fluoride rinses and gels recommended for home use are also
prescribed in these recommended amounts.

3\. In addition to the use of the child-proof container, each package
dispensed should be also bear the statement: Caution: Store Out of Reach
of Children.

4\. If it is determined that a young child is swallowing rather than
expectorating a topical fluoride agent (such as toothpaste) on a regular
basis, the therapy should be modified, closely supervised, or
discontinued until age five.

5\. For dental clinics or institutions that store systemic or topical
fluoride preparations in amounts that may be harmful if consumed at one
time, it is essential that these supplies be kept in a locked storage
area. A current inventory should be maintained in order to readily
determine any missing supplies. (1)

If an individual is known or suspected to have taken a potentially toxic
amount of fluoride, first aid consists of inducing vomiting as quickly
as possible or ingesting a material to bind fluoride - milk is usually
the most readily available. Identify the source of fluoride and amount
consumed, if known. Observe the patient and refer to a medical facility,
if necessary.

**Recommendations**

1\. Follow the new dosage schedule to prescribe F supplements when
needed.

2\. Prescribe F supplements for children who are at moderate or high
risk for caries.

3\. Compliance is necessary for supplementation to be effective, so the
importance of giving the child a tablet every day should be emphasized.

4\. The water source must be tested before prescribing F supplements.

5\. Follow safety precautions in dispensing and storage of F
supplements.

**Reference**

1\. American Dental Association, Council on Dental Therapeutics.
Accepted Dental Therapeutics. Chicago, The Association, 1994.

**Additional Readings**

1\. Journal of Public Health Dentistry. Volume 49, Number 5, Special
Issue 1989. Proceedings for the Workshop: Cost Effectiveness of Caries
Prevention in Dental Public Health. Ann Arbor, MI May 17-19, 1989, Ed.
B.A. Burt.

2\. A Guide to the use of Fluoride for the Prevention of Dental Caries.
Journal of the American Dental Association, 1986.

**Additional Resources**

CDC Guidelines on fluoride use;
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm>

ADA Internet Resources on Fluoride & Fluoridation:
<http://www.ada.org/public/topics/fluoride/fluoride_links.asp>

ADA Interim Guidance on Fluoride Intake for Infants and Young Children

<http://www.ada.org/prof/resources/positions/statements/fluoride_infants.asp>

**Topical Fluorides and Fluoride Varnishes**

Use of topical fluorides for individual patients should be predicated
upon the caries activity or risk. Use of these methods in public health
programs is a matter of cost-effectiveness, which must be weighed
against the caries prevalence of the target population.

Documentation in the literature has shown an increased prevalence of
fluorosis, most probably related to ingestion of fluoridated toothpaste.
Adult supervision of brushing is recommended, with only a pea-sized
portion of toothpaste to be used. Inappropriate prescriptions for
dietary fluoride supplements may also be a factor in the increased
prevalence of fluorosis. According to the IHS oral health survey of
dental patients conducted in 1991, mild fluorosis was found in about 16
percent of the children ages 12-13 years.

**How does fluoride work?**

-   Pre-Eruptive

    -   Reduction in enamel solubility by incorporation of fluoride in
        hydroxyapatite crystal

-   Post-Eruptive

    -   Promotion of remineralization and inhibition of early lesions

    -   Inhibition of glycolysis, the process by which cariogenic
        bacteria metabolize fermentable carbohydrates

**Fluoride Dentifrices**

Used regularly, a fluoride dentifrice has the potential of reducing the
incidence of dental caries by 15 to 30 percent. The recent decline in
the prevalence of dental caries can be mainly attributed to the use of
fluoridated toothpaste. Approximately 95% of all toothpastes on the
market contain fluoride. The majority of the fluoride-containing
dentifrices marketed in the United States contain approximately 0.1
percent fluoride (1000 ppm). A one-gram ribbon or pea-sized amount of
the dentifrice on a toothbrush contains approximately 1 mg fluoride.
*Aim* toothpaste has 1800 ppm. Colgate's *PreviDent* contains 5000 ppm
fluoride and *Gel Kam* contains 968 ppm fluoride (the latter two are
available by prescription only).

Children under the age of five years have a tendency to swallow
one-third or more of the dentifrice used. In fluoridated communities,
parents should be cautioned to use very small amounts of the fluoridated
dentifrices and to teach their children to spit out, not swallow the
toothpaste. Frequent or continued swallowing of the fluoridated
dentifrice will result in fluorosis on the permanent incisors.

Various toothpastes are promoted as "anti-cavity, anti-gingivitis, and
anti-sensitivity." The product choice depends on the needs of the
patient. For adults with high caries rates, recommend one with more
fluoride. Stress the importance of brushing 2-3 times per day with the
fluoride dentifrice, especially at bedtime.

**Fluoride Toothpaste Use For Young Children**

The use of a dentifrice should begin as soon as the deciduous teeth
begin to erupt into the mouth of the infant. Initially, the parent
should be advised to gently swab the teeth with a cotton-tipped
applicator or a gauze or washcloth dipped in a very small amount
(pea-sized) of the dentifrice. As soon as the infant will tolerate
brushing, the parent should begin using a small, soft-bristled
toothbrush with a small amount of dentifrice. Parents can serve as role
models for the child by brushing themselves.

Studies have shown that the use of fluoride toothpaste from an early age
is associated with higher levels of very mild fluorosis. Because
toothpaste tastes so good, children tend to swallow it. Very young
children are also not capable of spitting out excess toothpaste.
Swallowing toothpaste is the biggest risk for fluorosis. According to
the 1991 IHS Oral Health Survey, only a small percentage of children had
mild fluorosis.

The cost of toothpaste may be a significant expense and/or a low
priority for some families. The dental clinic or community-based program
may want to consider providing toothpaste for families whose members are
at high risk for caries.

**School Toothbrushing Programs**

School brush-ins can also be encouraged (especially in boarding schools)
in order to help children form the habit of daily brushing. Daily
brushing and plaque removal are essential for the control of periodontal
disease.

Approximately 28,000 AI/AN children participate in school-based
toothbrush programs. School-based toothbrush programs should be
implemented for all Indian schools. In those schools in which more than
25 percent of the students are AI/AN, consider implementing a program.
For those schools with less than 25 percent AI/AN children, try to
develop linkages with the local or state dental health department in
order to make these programs available to more children.

The Dental Program should identify the schools within the service area
and determine where programs could be implemented. Proper planning for
these programs includes obtaining necessary approvals from the
principals and school board members and parents. Placing consent forms
in the school registration packets is an efficient method for obtaining
parental permission and can increase participation in these programs.

**General Dentifrice Recommendations**

1\. Use a pea-sized portion for children under age 6 years. Parental
supervision for brushing should continue until the child is 6-7 years
old. Encourage parents to use a small brush or finger cloth as soon as
teeth erupt. For children under age 6 years, do not recommend a
toothpaste with more than 1000 ppm of fluoride.

2\. Use *Extra-Strength* or a prescription fluoride toothpaste (to be
used at bedtime) for those children over age 6 years and adults at high
risk for caries (rampant caries).

3\. Encourage daily use of fluoridated toothpaste as part of oral
hygiene instructions. Daily use of fluoride toothpaste is an effective
preventive regimen for caries control.

4\. Consider providing small tubes of F toothpaste for moderate-risk to
high-risk patients in the clinic. This is a marketing tool that is also
used in private practice settings.

5\. Implement brushing programs in schools. It is a cost-effective
regimen to provide fluoride for children. See CDC guidelines on proper
handling of brushes at school. (Head Start performance standards require
that children brush at school after meals.)

**Fluoride Mouthrinses**

The idea of preventing caries by mouthrinsing with dilute F solutions
has been promoted for many years. Sodium fluoride has been tested
extensively and is the most commonly used rinse in public health
programs. NaF has been tested as a weekly rinse at 0.2% F, and at 0.05%
for daily rinsing. The caries reductions are very similar with both
solutions. For school-based programs, the cost and practicality of a
weekly program is preferred.

For individual use at home, a daily rinse is recommended for children
and adults who are at moderate or high risk for dental caries. Other
high-risk patients might include those children with orthodontic
appliances and adults undergoing radiation therapy. For AI/AN adults who
are sensitive to alcohol, recommend *Act* (for children), as it contains
no alcohol.

Three examples of over-the-counter fluoride rinses approved by the ADA.
There are:

*Act* for children, contains no alcohol (0.05% NaF)\
*Fluorigard* (0.05% NaF)\
*Stancare* (0.1% SnF2)

> *Note: Mouthrinses are not recommended for children under age 6
> years.*

By the age of six years, most children can master the rinsing technique
and minimal solution will be swallowed. At this age the permanent
incisors should have completed the mineralization process such that the
accidental ingestion of some of the rinse solution would have little
effect on the appearance of the child's teeth as a result of fluorosis.

**School Fluoride Mouthrinse Programs**

School fluoride mouthrinse (FMR) programs can be an effective measure to
control dental caries. Studies in schools using NaF and APF rinses have
shown a reduction in caries from 20-35 percent over periods of 2-3
years. Benefits can be retained for 2-3 years after completing a school
FMR program. In the IHS, there are approximately 74,000 children
participating in school fluoride mouthrinse programs. The average annual
cost is about \$1.00--1.50 per child.

Recent studies of fluoride mouthrinse programs have questioned their
effectiveness, particularly in communities with fluoridated water. While
cognizant of these studies, the IHS Dental Program believes that the
high caries rate seen in AI/AN children warrants the use of fluoride
mouthrinse programs.

However, before implementing a FMR program, the following criteria
should be considered:

-   Caries rates in the community, especially smooth-surface caries
    (determine through low-level monitoring or survey results).

-   Prevalence of use of fluoride toothpaste (determine through
    assessment method --- ask patients if they use it or consider market
    consumption through local stores).

-   Status of community or school water supply for at least five years
    (determine through OEH or State records).

-   Willingness of school administrators to allow student participation.

-   Availability of resources for program.

-   Whether schools consist of at least 25-50 percent AI/AN children.
    Joint collaboration between state/local health department and
    IHS/Tribal program should be investigated.

The following steps should be taken when implementing a school-based
fluoride mouthrinse program:

-   Contact school administrators once program is identified as needed.
    Estimate start-up and annual costs as well as teacher and class
    time.

-   Educate administrators/school officials and community members.

-   Train person(s) who will administer fluoride mouthrinse program.

-   Order supplies: jugs, packets, cups, napkins.

-   Obtain consent from parents or guardians.

-   Monitor program by keeping track of number of students
    participating, and the amount of supplies used.

-   Provide incentives or rewards to classrooms and children.

-   Recognize efforts of teachers, community health aides, community
    health representatives (CHRs) or parent volunteers who are doing a
    good job.

**Safety Issues**

Schools and other institutions that provide a FMR program must be
careful to keep the fluoride in a locked storage area that is isolated
from children or patients. Adequate administrative controls and
record-keeping are also required. The amount of fluoride in a one liter
container of 0.2 percent NaF solution or in a two or three gram NaF
pre-measured packet is potentially lethal if consumed at one time.

When dispensing fluoride products for a mouthrinse application, one
teaspoonful (5 ml) of a 0.05 percent solution contains approximately 1
mg F, which is equivalent to the amount of fluoride in one 2.2 mg NaF
tablet. Thus, ingestion of this amount of fluoride will cause no
untoward effects. Two teaspoonsful (10 ml) of a 0.2 percent NaF solution
contain 9 mg F, the equivalent of nine NaF tablets. If all 10 ml are
swallowed, the patient may become nauseous.

For patients with handicapped conditions in which it is known that some
or all of the mouthrinse will be swallowed, they should be placed on a
daily 0.05 percent NaF regimen.

The FMR program should be evaluated periodically to assess
effectiveness. Several process and outcome methods may be used, such as:

-   Patient/community/staff satisfaction survey

-   Number of students participating and the quantity of supplies used
    during the year

-   Improvement in oral health from baseline to present (after minimum
    of three years

**Conclusions/Recommendations**

-   Fluoride mouthrinses should not be used for children under 6 years
    of age. Fluoride mouthrinses are *not* recommended for children in
    Head Start programs.

-   For patients at moderate to high risk for caries, daily use of
    fluoride mouthrinses is recommended.

-   For most Indian communities, school-based fluoride mouthrinse
    programs are recommended, even in fluoridated communities. Adoption
    of FMR programs in Urban communities should be based upon cost and
    caries status of schoolchildren. Local, county, and state health
    departments can become partners in providing fluoride benefits to
    all children. Fluoride mouthrinse programs, although most easily
    implemented in elementary schools, are of greater benefit to junior
    and senior high school students. That is when the permanent teeth
    have fully erupted and are at greater risk for smooth-surface
    caries.

**Professionally-Applied Topical fluorides**

The professional topical application of fluoride is an accepted
caries-preventive procedure that is appropriate for children,
adolescents, and adults. Topical fluorides are also useful when applied
to exposed root surfaces. This is especially beneficial for older
patients, who are vulnerable to root caries and root sensitivity as a
result of the loss of periodontal attachment and/or xerostomia (dry
mouth).

As a public health measure, targeting those at higher risk for caries is
a cost-effective procedure. Criteria for moderate-risk to high-risk
children, adolescents, and adults might include the following: those
patients who have more than one active smooth-surface carious lesion;
white spot lesions; poor oral hygiene; and/or past history of caries.

Three agents are currently available for use in operator-applied topical
fluoride programs: sodium fluoride (NaF); stannous fluoride (SnF2); and
acidulated phosphate fluoride (APF). When used properly, all seem to be
equally effective and are capable of inhibiting dental caries up to 30
percent.

APF gels are the most popular, due to their ease of use as well as taste
preference. APF contains 1.2 percent F ion, has a pH of between 3.0 and
4.0 and is available in either an aqueous solution or a gel. Thixotropic
gel formulations are easier to use and more likely to reach
caries-susceptible interproximal areas.

For young children, fluoride foam applications are also available.
Neutral sodium F foam is obtainable through multiple vendors. These
products do not use a thixotropic gel and contain less fluoride mass,
although the concentration is similar. Therefore, the risk for
swallowing the product is reduced. These neutral sodium fluoride topical
regimens are also safe to use on patients with porcelain or composite
restorations. While one minute applications of these products are
popular, the vast majority of studies showing their effectiveness were
conducted using a four minute application.

**Guidelines for Topical Fluoride Application**

-   Clean teeth with a toothbrush to remove debris. A toothbrush prophy
    can remove any debris and also provide an instructional time for the
    patient. *Note: It is* not *necessary to do a rubber cup prophy on
    patients before providing the topical fluoride treatment. However,
    any calculus should be removed and the patient allowed to rinse his
    or her mouth with water before applying the fluoride.*

-   Apply gel in disposable tray for both maxillary and mandibular
    teeth. Limit the amount of gel in the tray to 1/4 to 1/2 full.

-   Sit patient upright in chair. Dry teeth with air. Insert trays in
    mouth.

-   Have patient bite down on trays for 4 minutes. A saliva ejector
    should be used to control moisture. The patient should not be left
    unattended.

> *Note: It has been clinically demonstrated that up to 90% of fluoride
> uptake occurs in the first minute. Therefore, if the patient is
> uncooperative, a shorter time than 4 minutes could be used, depending
> on the provider's judgment. One-minute gel applications are being
> considered for ADA's seal of approval.*

-   Remove trays and instruct patient to spit out excess gel.

-   Instruct patient to refrain from eating or drinking for 30 minutes.

> *Note: Fluoride may also be painted on teeth using cotton rolls and
> isolation technique for young child, or if the child is uncooperative
> or gags easily.*

**Patient Selection for Topical Fluoride Application**

The IHS Dental Program recommends targeting this procedure to
moderate-risk and high-risk patients, due to its high cost compared to
alternative forms of fluoride delivery. Those patients with one or more
smooth-surface carious lesions, white spot lesions, past history of
decay, and/or poor oral hygiene should receive gel applications every 6
months or more frequently, depending on the severity of the caries rate
and local resources. The use of fluoridated toothpaste and other
self-applied fluorides should be stressed between recalls.

**Safety**

Operator-applied topical fluorides are highly concentrated formulations
of fluoride and are not meant to be swallowed. No more than five ml of
aqueous solution or gel should be used for a professional application of
topical fluoride. Depending on the formulation, five ml contains from 45
to 100 mg of fluoride. Although this concentration is not lethal if
swallowed, even for a small child, the concentration is high enough to
make the patient nauseous.

If accidental swallowing occurs, administer milk or an antacid, which
will bind the fluoride, and seek medical assistance.

**What is the best fluoride?**

-   Fluoride varnish

    -   30-44% reduction

    -   Cariostatic

-   Fluoride rinses

    -   20-30% reduction

    -   Most cost-effective?

-   Self-applied fluorides

    -   Depends on patient

    -   Cost-prohibitive for PH

-   Toothpastes

    -   15-30% reduction (3 years)

    -   Depends on patient

-   Community Water Fluoridation

    -   44-60% reduction

    -   Depends on political climate

-   Multiple exposure

    -   "Clearly beneficial to patients who are especially susceptible
        to caries"

See the ADA's Evidence Based Recommendations for the use of Topical
Fluorides at:
<http://www.ada.org/prof/resources/pubs/jada/reports/report_fluoride.pdf>
and at

<http://www.ada.org/prof/resources/pubs/jada/reports/report_fluoride_exec.pdf>

The AAPD's guideline on the use of fluorides can be found at:

<http://www.aapd.org/media/Policies_Guidelines/G_FluorideTherapy.pdf>

**Fluoride Varnishes** (Revised from the US Air Force Dental Evaluation
and Consultation Service, used with permission)

Topically applied fluoride varnishes usually consist of sodium fluoride
in a resin carrier and are used primarily as a caries prevention therapy
for pediatric and high-risk caries patients. Only relatively recently
have they become available for use in the United States. However,
fluoride varnishes have been widely used in Western Europe, Canada, and
the Scandinavian countries since the 1980s as a caries prevention
therapy. In fact, by the 1990s, over 90% of the topically applied
fluoride in Scandinavia was in the form of varnish. In 1991, Duraflor
became the first fluoride varnish available in the United States after
it was approved by the Food and Drug Administration (FDA) as a cavity
liner; later in the decade, Duraphat, Fluor Protector C, and Cavity
Shield became available. VarnishAmerica 5% sodium fluoride varnish also
became available in 2005. A large number of studies, most done outside
the United States, have shown that fluoride varnishes are safe and
efficacious in preventing or reducing caries. Sodium fluoride-based
varnishes can have the side effect, however, of causing a temporary
color change in teeth and restorative materials. Interestingly, fluoride
varnishes are approved by the FDA for use only as cavity liners and for
treating hypersensitive tooth structure. The use of a drug or other
agent off-label means that it is being used for a purpose not described
in the information provided with the product and for which FDA approval
is lacking. This does not mean that using fluoride varnish as a
preventive agent is illegal or unethical. The Federal Food, Drug and
Cosmetic Act does not limit the manner in which physicians or dentists
may use approved drugs.

Instructions for applying cavity varnish for caries reduction vary among
the brands of products, but typically the procedure begins by cleaning
the involved tooth surfaces. One study has found that toothbrushing
appears sufficient and that a prophylaxis is not required. Prior to
application of the varnish, the teeth should be dried with gauze or a
cotton roll to remove moisture, but they do not need to be thoroughly
dried, because the varnish sets in contact with moisture. The varnish is
then applied, usually in about a 0.5-mm-thick layer using a suitable
applicator. Some manufacturers recommend that the treated teeth remain
isolated for a minute or so, while others do not call for a period of
isolation following application. The patient is usually advised not to
eat or drink anything for a period of time following treatment
(typically from 45 minutes to 2 hours) and are told to forgo brushing
that evening. Patients should be advised prior to treatment that some
varnishes (usually the sodium-based ones which are yellow) can impart a
slight discoloration to the teeth. The discoloration is temporary,
however, and is removed by brushing. Some perceptible but clinically
acceptable color change may also occur in certain restorative materials.
Biannual applications of fluoride varnishes are usually recommended,
however some clinicians advise treatment every 3 months. Fluoride
varnishes are believed to be efficacious because their stickiness helps
to keep them in contact with tooth structure for a longer time than
topically-applied fluoride gels and liquids.

***The effects of fluoride varnish***

-   44% reduction in caries incidence in 3-yr. olds

    -   Holm AK. Effect of fluoride varnish (Duraflor) in preschool
        children. *Community Dentistry & Oral Epidemiology* 1979
        October; 7(5):241-5.

-   Other studies have also shown that the use of fluoride varnish
    greatly reduces caries in children

    -   Clark DC. Results of the Sherbrook-Lac Megantic fluoride varnish
        study after 20 months. *Community Dentistry & Oral Epidemiology*
        1985 April; 13(2): 61-4.

    -   Koch G et al. Caries preventive effect of a fluoride-containing
        varnish after 1 year's study. *Community Dentistry & Oral
        Epidemiology* 1975 November; 3(6):262-6.

    -   Helfenstein U. A note concerning the caries preventive effect of
        Duraphat. *Community Dentistry & Oral Epidemiology* 1994
        February; 22(1):6-7.

***Advantages of fluoride varnish***

-   Does not require special dental equipment

-   Does not require a professional dental cleaning prior to application

-   Is easy to apply

-   Dries immediately upon contact with saliva

-   Is safe and well tolerated by infants, young children, and
    individuals with special needs

-   Is inexpensive (best "bang for the buck" among topical fluorides)

-   Requires minimal training

-   Some state Medicaid programs will reimburse physicians, nurses, and
    nurse practitioners up to \$16 per application

***Indications***

-   A child at moderate to high risk of developing caries

    -   Has had cavities in the past or has white spot lesions

    -   Continues to use the bottle past 1 year, or sleeps with a bottle

    -   Breastfeeds on demand at night

    -   Has a developmental disability

    -   Has family members with a history of caries

    -   Chronically uses high-sugar oral medicines

    -   Engages in prolonged use of a bottle or sippy cup containing
        liquids other than water throughout the day

***Contraindications***

-   Low risk of developing caries

-   Children who routinely receive optimally fluoridated water (0.8 --
    1.5 ppm) -- however, varnish + fluoridated water is OK

-   Children who regularly receive other fluoride treatments through a
    dental office

**Application technique for infants and very young children**

***Before you begin....***

-   Have the right supplies -- gloves, paper towel or bib, 2 X 2 gauze
    sponges, fluoride varnish, and disposable applicator brush (comes
    with some unit-dose products)

-   Inform the parent/legal guardian of the procedure (use information
    sheet)

-   Remind the parent ahead of time to give the child something to eat
    and drink before applying the varnish (no eating or drinking for 1
    hour after)

-   Advise the parent that the teeth may become temporarily discolored
    (but can be brushed off the next day)

***Applying the varnish***

-   Position the child (knee-to-knee or whatever works best)

-   Using gentle finger pressure, open the child's mouth

-   Remove excess saliva from the teeth with a gauze sponge

-   Apply a thin layer of varnish to all tooth surfaces -- the varnish
    will harden immediately once it comes in contact with saliva

-   Apply 2-4 times per year

***Post-application instructions***

-   The child should eat a soft, non-abrasive diet for the rest of the
    day

-   Do not brush or floss the child's teeth until the next morning

-   The dull yellow color is normal

-   Give parent information sheet

***Billing for fluoride varnish***

-   ICD-9 Code (Medical)

    -   V07.31 "Prophylactic Fluoride Administration"

-   CPT Code (Dental)

    -   1203 "Topical Application of Fluoride (Prophylaxis not
        included)"

**Go to the following links for instruction manuals on the use of
fluoride varnishes:**

<http://health2k.state.nv.us/oral/FVManual.pdf>

<http://www.doh.wa.gov/cfh/OralHealth/manuals/Sealants/2002_sealant_varnish_manual.pdf>

The fluoride varnishes currently available in the United States are
listed below along with ordering information.

+-----------+---------+------------------------------+--------+-------+
| Product   | Main    | Manufacturer                 | Retail | G     |
|           | Ingr    |                              | Price  | ov\'t |
|           | edients |                              |        | Price |
+-----------+---------+------------------------------+--------+-------+
| [[Du      | 5%      | Colgate-Palmolive Co.\       | \$     | \$1   |
| raphat]{. | sodium  | 300 Park Avenue\             | 25.95\ | 9.95\ |
| underline | f       | New York, NY 10022\          | (ie,   | (ie,  |
| }](https: | luoride | (800) 226-5428\              | \$2.   | \$2.0 |
| //decs.nh | in an   | [[www.colgate.com]{.underlin | 60/mL) | 0/mL) |
| gl.med.na | al      | e}](http://www.colgate.com/) |        |       |
| vy.mil/HO | coholic |                              | for    | for   |
| T/fluorid | s       |                              | one    | one   |
| eqa1.jpg) | olution |                              | 10-mL  | 10-mL |
|           | of      |                              | tube   | tube  |
| (item no. | natural |                              |        |       |
| F0400954) | resins  |                              |        |       |
+-----------+---------+------------------------------+--------+-------+
| [[Du      | 5%      | A.R. Medicom\                | \$1    | \$7   |
| raflor]{. | sodium  | 9404 Cote de Liesse\         | 25.00\ | 5.00\ |
| underline | f       | Montreal, Canada H8T 1A1\    | (ie,   | (ie,  |
| }](https: | luoride | (514) 636-6262\              | \$3.   | \$1.8 |
| //decs.nh | in an   | (514) 636-6266 FAX\          | 13/mL) | 8/mL) |
| gl.med.na | al      | [[www.medicom.ca/#]{.underli |        |       |
| vy.mil/HO | coholic | ne}](http://www.medicom.ca/) | for 5  | for 5 |
| T/fluorid | s       |                              | boxes; | b     |
| eqa2.gif) | olution |                              | each   | oxes; |
|           | of      |                              | box    | each  |
| (item no. | natural |                              | has 16 | box   |
| 1011)     | resins  |                              | 0.5-mL | has   |
|           |         |                              | unit   | 16    |
|           |         |                              | -doses | 0     |
|           |         |                              |        | .5-mL |
|           |         |                              |        | unit- |
|           |         |                              |        | doses |
+-----------+---------+------------------------------+--------+-------+
| [Fluor    | 0.9%    | Ivoclar Vivadent, Inc.\      | \$     | \$3   |
| Protector | difluor | 175 Pineview Drive\          | 88.15\ | 2.00\ |
| C]{.u     | osilane | Amherst, NY 14228\           | (ie,   | (ie,  |
| nderline} | in a    | (800) 533-6825\              | \$11.  | \$4.0 |
|           | poly    | (716) 691-0010\              | 02/mL) | 0/mL) |
| (item no. | urethan | (716) 691-2285 FAX\          |        |       |
| 550578)   | e-based | [[www.ivoclarvivadent.       | for 20 | for   |
|           | varnish | us.com]{.underline}](http:// | 0.4-mL | 20    |
|           |         | www.ivoclarvivadent.us.com/) | singl  | 0     |
|           |         |                              | e-dose | .4-mL |
|           |         |                              | b      | s     |
|           |         |                              | ottles | ingle |
|           |         |                              |        | -dose |
|           |         |                              |        | bo    |
|           |         |                              |        | ttles |
+-----------+---------+------------------------------+--------+-------+
| [Cavity   | 5%      | Omnii Oral Pharmaceuticals\  | \$     | \$2   |
| S         | sodium  | 1500 T-N. Florida Mango Rd.\ | 33.50\ | 7.90\ |
| hield]{.u | f       | West Palm Beach, FL 33409\   | (ie,   | (ie,  |
| nderline} | luoride | (800) 445-3386\              | \$2.   | \$2.1 |
|           | in an   | (561) 689-1159\              | 62/mL) | 8/mL) |
| (when     | al      | (479) 787-6507\              |        |       |
| ordering, | coholic | [[www.om                     | for 32 | for   |
| ask for   | s       | niipharma.com]{.underline}]( | 0      | 32    |
| Trial     | olution | http://www.omniipharma.com/) | .40-mL | 0.    |
| Size,     | of      |                              | unit   | 40-mL |
| 0.40-mL   | natural |                              | doses  | unit  |
| version)  | resins  |                              |        | doses |
+-----------+---------+------------------------------+--------+-------+
| [         | 5%      | Medical Products             | 200    | 200-  |
| VarnishAm | sodium  | Laboratories, Inc.           | -count | count |
| erica]{.u | f       |                              | boxes  | boxes |
| nderline} | luoride | 9990 Global Rd.              | -\$11  | -     |
| item      | in an   |                              | 0.00 - | \$110 |
| #070030/1 | al      | Phila., PA 19115-1803        | in the | .00 - |
| and       | coholic |                              | 0.25   | in    |
| #070020/1 | s       | \(800\) 523-0191, (215)      | mL and | the   |
|           | olution | 677-2700,                    | \$     | 0.25  |
|           | of      |                              | 130.00 | mL    |
|           | natural | \(215\) 677-7736 FAX, or     | in     | and   |
|           | resins  | [http                        | 0.40mL | \$1   |
|           |         | ://www.medicalproductslabora |        | 30.00 |
|           |         | tories.com](http://www.medic |        | in    |
|           |         | alproductslaboratories.com/) |        | 0     |
|           |         |                              |        | .40mL |
+-----------+---------+------------------------------+--------+-------+

**Pit And Fissure Sealants**

The term pit and fissure sealant is used to describe a material that is
introduced into the occlusal pits and fissures of caries-susceptible
teeth, thus forming a bonded, protective layer denying access of
caries-producing bacteria from their source of nutrient (1). New methods
of caries prevention focus on pit and fissure caries because tooth
surfaces with pits and fissures have always been the earliest and most
prevalent of carious areas. The disproportion of caries on fissured
surfaces continues to this day, with these surfaces accounting for over
80% of all caries in young permanent teeth (2).

Sealants are an important dental caries prevention technology, ideally
used in combination with patient education, effective personal oral
hygiene, fluorides and regular dental visits. Key guidelines on sealant
use include:

-   Caries risk assessment of the individual and the tooth are important
    as determinants of sealant need.

-   Caries risk on surfaces with pits and fissures may continue into
    adulthood; therefore, post-eruptive age alone should no longer be
    used as a major criterion for sealant decision.

-   Sealants should be used to prevent caries in at-risk teeth
    (preventive sealants).

-   Sealants should be used to treat teeth with questionable caries or
    caries confined to the enamel pits and fissures.

-   Sealed teeth need to be evaluated periodically for sealant integrity
    and retention.(2)

**Sealants on Primary Teeth and on Teeth Other Than Molars**

Individual differences among patients and among teeth are the basis for
risk analysis and decision making in sealant care that is now recognized
as necessary for the best benefit ratio in sealant therapy. Therefore,
many primary teeth may be judged to be at risk due to fissure anatomy
and/or patient caries risk factors. This is also true for permanent
teeth other than molars such as incisors with deep lingual pits or
premolars with incipient caries in deep occlusal grooves. Any teeth
judged to be at risk can certainly benefit from sealant application. (2)

**Caries Risk Assessment**

Assessing risk for disease development is an important component of any
disease prevention. Risk susceptibility can be determined on a variety
of levels. Assessment of a person's risk for dental caries relies on a
number of factors. These factors could include, but are not limited to
the following:

-   caries history,

-   poor preventive practices,

-   unhealthy nutritional habits,

-   deep grooves of tooth morphology, and

-   medical conditions.

Based on the clinical evaluation and information derived from a
patient's medical and dental history, the patient can be classified as
being at low risk (no new or incipient carious lesions in the past
year), medium risk (one new carious lesion in the past year or one or
more of the factors listed above), or high risk (two or more carious
lesions in the past year or two of the above factors). Since dental
caries is a bacteria-dependent disease, preventive measures such as
sealants can be implemented once those at risk are identified. (3)

**Sealant Placement Immediately After Fluoride**

For years there existed an opinion that a recent fluoride exposure, such
as in-office fluoride treatment, would interfere with the etching
pattern and, therefore, the retention of sealants. Studies have now
shown this opinion is not correct. Therefore, sealant application can be
planned to follow fluoride treatment during the same office appointment
if desired.

**Indications:**

-   Caries risk, regardless of the age of the patient, should be a major
    criterion for selecting teeth for sealant application.

-   Patients who are at moderate or high risk for developing caries
    should receive preventive sealants.

-   Patients having incipient caries (limited to enamel) of pits and
    fissures are candidates for therapeutic sealants.

**Advantages:**

-   Sealants are minimally invasive and require no patient compliance
    after they have been applied other than good oral hygiene.

-   Sealants can be applied by auxiliary personnel.

-   Long-term sealant retention rates are high;

-   Fully retained sealants are 100 percent effective and have been
    proven to halt the caries process.

**Limitations:**

-   Adequate isolation and correct application technique are essential
    for sealant retention. Always follow the manufacture's instructions
    when using their products. (4)

**RECOMMENDATIONS**

The dental literature supports:

-   Bonded resin sealants, placed by appropriately trained dental
    personnel, are safe, effective and underused in preventing pit and
    fissure caries on at-risk surfaces. Effectiveness is increased with
    good technique and appropriate follow up and resealing as necessary.

-   Sealant benefit is increased by placement on surfaces judged to be
    at high risk or surfaces that already exhibit incipient carious
    lesions.

-   Glass ionomer materials have been shown to be ineffective as pit and
    fissure sealants, but could be used as transitional sealants on
    teeth that are not yet fully enough erupted for placement of a resin
    sealant.

-   Caries risk, and therefore potential sealant benefit, may exist in
    any tooth with a pit or fissure, at any age, including primary teeth
    of children and permanent teeth of children and adults. (1, 2)

**CLINICAL PROCEDURES INVOLVED IN SUCCESSFUL SEALANT APPLICATION**

-   The tooth must be isolated so that adequate access is established to
    observe the field and to reach tooth surfaces with the appropriate
    instruments. This isolation must also insure that saliva
    contamination of the surfaces to be sealed can be prevented at
    critical points in the procedure.

-   The surfaces should be cleaned with a prophylaxis brush or rubber
    cup and a cleansing agent that contains no oil or other substance
    that cannot be completely and quickly washed from the surfaces with
    water. The cleansing agent should be carefully washed from the
    surfaces using a water syringe and aspiration or high speed
    evacuation.

-   When the teeth are effectively isolated from saliva contamination,
    the surfaces are dried and etched by application of a 30-50 percent
    phosphoric acid solution for 15 to 30 seconds (always follow the
    manufacturer's instructions for the sealant being used). The
    solution is gently agitated during the application. It should cover
    all of the areas to be sealed.

-   The acid should be washed away with water and aspiration or high
    speed evacuation. The surfaces are carefully dried and inspected to
    ensure that the frosty-appearing etch covers the area intended. The
    absolute avoidance of contamination with saliva or air-line moisture
    or oil is critical from the time of acid removal and drying until
    the sealant is cured. If contamination is suspected, re-etching of
    the surface for twenty seconds is indicated.

-   The sealant should be applied according to the manufacturers'
    instructions. Care should be taken to avoid entrapment of air
    bubbles, to extend the sealant into all the grooves and pits, and to
    avoid extension of the sealant onto unetched smooth surfaces or soft
    tissues. The sealant must remain uncontaminated and undisturbed
    until it is cured to hardness.

-   The sealant should be examined to ensure that underextension,
    overextension, undercuring, or voids have not occurred. A reasonable
    attempt should be made to remove the sealant to determine if
    adequate bond strength has been established. (5)

**SEALING INCIPIENT CARIES**

Heller et al. (1995) evaluated the effect of sealants placed as part of
a school-based program on permanent first molar teeth after 5 years.
Sealants were applied to both sound teeth and those with incipient
carious lesions (where the fissure is stained but not yet cavitated).
For the initially incipient carious surfaces, the 5-year decay rate was
10.8 percent for sealed surfaces and 51.8 percent for unsealed surfaces.
Initially sound surfaces had a decay rate of 8.1 percent for sealed
surfaces and 12.5 percent for unsealed surfaces. The study showed
potential efficiencies in targeting teeth with incipient caries for
sealants.

**EFFICACY**

Initial clinical trials using a random half-mouth design and first or
second generation sealant materials established the efficacy of
sealants. Llorda et al. (1993) used a systemic process to select and
review studies of one time sealant placement on permanent teeth in
subjects unexposed to other preventive measures. Pooled results from 17
studies found that second generation sealants reduced caries over 70
percent.

A sealant is virtually 100 percent effective if it is fully retained on
the tooth (NIH 1984). Mertz-Fairhurst (1984) reported 92 to 96 percent
retention rates in second generation sealants after 1 year, with 67 to
82 percent retention after 5 years. A review of studies of long term
retention of second generation sealants showed 41 to 57 percent intact
after 10 years (Ripa 1993). Retention results for third generation
sealants are similar to those for second generation systems (Ripa 1993).
(6)

**References:**

1\. Simonsen, Richard J., DDS, MS. Pit and Fissure Sealant: Review of
the Literature. Pediatric Dentistry 2002;24:393-414.

2\. Feigal, Robert J., DDS, PhD. The Use of Pit and Fissure Sealants.
Pediatric Dentistry 2002;24:415-422.

3\. Rethman, Jill, RDH, BA. Trends in Preventive Care: Caries Risk
Assessment and Indications for Sealants. JADA, Vol. 131, June 2000.

4\. Intervention: Pit and Fissure Sealants. JADA, Vol. 126, June 1995;
17-S. (Adapted from previous Oral Health Program Guide).

5\. NIH Consensus Development Program. National Institutes of Health
Consensus

Development Conference Statement December 5-7, 1983. Dental Sealants in
the

Prevention of Tooth Decay.

6\. Oral Health in America: A Report of the Surgeon General. Community
and

Other Approaches to Promote Oral Health and Prevent Oral Disease. Part
4,

Chapter 7. July 2000.

**Running a School-based Pit and Fissure Sealant Program**

**When Should The Program Start?**

The amount of time needed for a school-based sealant program will be
determined by the number of schools that will be served and the number
of students who will be treated. Larger programs will obviously need
more time and should plan on starting in September, within a few weeks
after the beginning of the school year.

**Which age groups should be targeted?**

Many sealant programs target children in the first, second, sixth, and
seventh grades. This coincides with the eruption patterns of the first
and second molars. Incisors and pre-molars are sealed if they have deep
grooves. Each school-based program should keep records of the number of
children seen by grade level and the percent of target teeth that are
fully-enough erupted to be sealed in each grade level. This will allow
the local program to alter its target age groups if need be to capture
the greatest possible number of target teeth.

**Scheduling**

A schedule should be generated in the month of August showing which
schools are scheduled for sealants. A school calendar should be
requested from each school district participating in the program to
allow the sealant program to mesh with the school schedule with the
least possible interruption of school activities. The following criteria
are taken into consideration when planning the schedule:

-   how the scheduling of schools went the previous school year,

-   parent-teacher conferences,

-   early release,

-   testing,

-   field trips, and

-   assemblies

-   other

Once the schedule is completed, it is sent out to the schools along with
a memo, a school information sheet, and a copy of the consent forms. The
memo should ask the schools to look over the schedule and to contact the
dental program immediately if conflicts exist. The school information
sheet requests that each school include their address, the name of the
principle, the name of the contact person in charge of the prevention
programs.

Some programs have found it helpful to get the information packets and
consent forms to the schools before the start of the school year. This
allows the schools to distribute the consent forms with any registration
materials and other information that is usually distributed at the start
of classes. This in turn often guarantees a higher return rate for
completed consent forms.

**Training For Staff**

A departmental in-service for all dental staff participating in the
sealant program should be performed a week or so before the sealant
program starts seeing patients. The in-service should cover the
following topics:

-   proper use and maintenance of sealant equipment,

-   patient care,

-   proper sealant technique,

-   all of the forms used,

-   prevention of back injury - how to properly lift objects, and

-   teamwork.

**Sealant Program Coordinator**

Each dental program conducting a sealant program should appoint one
individual to coordinate the program. This individual can be a dentist,
hygienist, dental assistant or clerk. The sealant program coordinator
should be responsible for the following tasks:

-   obtaining school schedules and setting up the sealant program
    schedule

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-   notifying schools a week to two week in advance of arrival dates and
    times,

-   notifying dental staff of possible delays in the schedule,

-   checking on consent form returns,

-   working closely with school nurses and health aids to keep the
    program flowing efficiently.

-   Ensuring that appropriate dental staff are scheduled for the sealant
    program each day.

**Which Schools Should Be Included In The Sealant Program?**

The Dental Program should contact all BIA schools and public schools on
the Reservation, as well as selected off-reservation schools. To
determine which off-reservation schools should be included, the sealant
coordinator needs to determine which schools have the highest number of
Native American students in their student body. Once those schools are
identified, an invitation letter should be sent to the school nurse or
health aid along with a description of the program, how it works, what
role the school plays, and how the program will benefit their students.
The letter should be followed by a phone call. The school also needs to
be informed of the facilities that the sealant program will need in
order to set up equipment and provide services.

**Day Of Arrival**

On the day of arrival to a school the first contact should be with the
school nurse/health assistant. The following information should be
obtained:

-   a list of all students eligible for the program,

-   consent forms,

-   a map of the school,

-   a schedule of when classes switch,

-   lunch, and

-   when school lets out.

After this information is collected the sealant coordinator or other
designated team member needs to begin filling out the screening forms
and note-home forms with the students' information. The school
nurse/health aid can also be asked to send new copies of the consent
form home with any students who have not yet returned the form.

**Getting Students To The Sealant Program**

Once the sealant equipment has been properly set up, a designated member
of the sealant team needs to begin bringing students from the classroom
four or five at a time. Each student should be given a toothbrush and
instructed to dry-brush their teeth while they are waiting their turn.
After the students are screened and sealed, they should be given a
"Take-Home Note." This note informs parents/guardians of the following:

-   that sealants were placed (or not placed and why),

-   if the student is in need of further dental care, and

-   if the student was cooperative or not.

If students are found with abscessed teeth or other urgent dental needs,
these needs should be noted on the take-home note and on a list kept by
the dental program. Parents should be instructed to seek care for the
urgent needs through the appointment and walk-in policies of the dental
program. A copy of the Urgent Treatment List can be given to the school
nurse/health aid who should be encouraged to follow up on the students
placed on that list. Some programs give expedited entry to their
appointment systems to patients with urgent needs identified in the
sealant program.

**Day to Day Operations**

At the end of the day a supply list should be generated for the
following day to insure that instruments and supplies do not run short
during any day.

Once a school is completed the following things take place:

-   the Urgent Treatment List is given to the nurse,

-   a school inventory sheet is generated, which records the following

    -   how many Native American students are enrolled at the school,

    -   how many students returned consent forms,

    -   how many students were actually treated,

    -   how many students were absent,

    -   how many students were placed on the Urgent Treatment. List, and

    -   how many days were spent at that school

This information is helpful in scheduling the following year.

**Supply List**

The following lists of supplies and instruments should be adequate to
run any sealant program. Additions to and deletions from the list can be
done by any program to meet local needs.

**Supplies**

-   dri-angles small and large;

-   cotton rolls;

-   sealant material, either auto-cure or light cure;

-   kwick tips;

-   hi-volume evacuators

-   saliva ejectors;

-   cotton pellets;

-   patient napkins;

-   disposable air-water tips,

-   mixing wells, and mirrors;

-   masks;

-   gloves;

-   adult and child toothbrushes

-   alcohol based hand cleaner;

-   antibacterial soap;

-   bottled distilled water for closed dental units;

-   sandwich bags to cover lights

-   surface disinfectant

-   ultrasonic solution

-   towels for sterilization area

-   cleaners

-   trash bags

**Instruments/Equipment**

-   mirror,

-   cotton pliers,

-   cotton roll holders, adult and child

-   explorers

-   curing light(s) if light-cured sealant is used

-   sealant applicator (brush, dycal applicator, applicator that comes
    with the sealant kit);

-   safety glasses;

-   broom/dust pan;

-   ultra-sonic unit (if instruments are sterilized on-site);

-   autoclave (if instruments are sterilized on-site)

-   a soaking/storage basin (if instruments are transported back to the
    dental clinic for sterilization)

**Forms**

-   Consents forms,

-   supply lists,

-   take-home notes,

-   urgent treatment lists,

-   school inventory sheet,

-   screening exam form (carbon copy)

**Sealant Equipment**

Each dental program conducting a school-based sealant program will have
to decide whether to use portable equipment or a mobile dental unit.
Portable equipment can work fine for small and medium sized programs,
but large programs serving many different schools might want to consider
the use of a mobile dental unit.

**Portable Equipment**

Portable units that work well for sealant programs are available from
several vendors, including:

-   ADEC Corporation

-   Aseptico

-   DNTLWorks

Depending on the size of the program and the number of students to be
treated, the dental program will need either one or two complete units

-   patient chairs,

-   Dental light(s)

-   two operator chairs per unit,

-   dental unit(s),

-   one compressor (can drive 2 units) unless using units with
    self-contained compressors such as the DNTLWorks,

-   storage boxes for supplies,

-   a mini-van for transporting equipment and supplies from school to
    school.

Facilities needed for a portable unit include the following:

-   Need to be close to outlets and

-   water source.

Advantages:

-   less expensive,

-   low maintenance costs,

Disadvantages:

-   loading and unloading heavy equipment and supplies,

-   more likely to become damaged,

-   sometimes a burden for schools to find room with adequate outlets
    and water source,

**Mobile Dental Unit**

Mobile dental units are available from several vendors, including, but
not limited to the following:

-   LifeLine <http://www.lifelinemobile.com/>

-   <http://www.startracksmedical.com/fordf5504x4.html>

-   <http://www.medcoach.com/products/index.html>

-   <http://www.internationalmobilehealthassociation.org/corporate.html>

-   <http://dentalvan.com/dental_van.html> 

-   <http://www.medcoach.com/products/dental/>

-   <http://www.usv1.com/Mobile-Clinics.html>

-   A mobile dental unit can also be designed and sourced through GSA

Advantages:

-   self-contained electric and water/waste source,

-   no loading and unloading of heavy dental equipment/supplies

Disadvantages:

-   Much higher initial cost

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-   high maintenance costs,

-   larger vehicle,

-   more responsibility,

The Association of State and Territorial Dental Directors (ASTDD) has
developed a website
[http://www.mobile-portablemanual.com](http://www.mobile-portablemanual.com/)
that will be launched in late 2006 or early 2007 that has five chapters:
Intro and Planning, Mobile Vehicles, Portable Equipment, Mobile-Portable
Hybrids, and Evaluating Effectiveness and Outcomes. It will provide
information to help plan for mobile vs. portable and is a companion
manual to
[www.dentalclinicmanual.com](http://www.dentalclinicmanual.com/) which
also has information comparing fixed, portable and mobile dental units.

**Billing**

Medicaid will pay for sealants for their beneficiaries. A member of the
sealant team needs to be assigned the task of properly completing all
necessary paperwork to insure that billing and collections for the
sealants take place.

**Additional Sources of Information on School-Based Sealant Programs**

Many State, County, and local Public Health departments operate
school-based dental prevention programs. Additional information can be
found on the following websites. The Washington State manual gives
detailed descriptions of equipment needs and specifications, supplies
lists, etc.

-   <http://www.astdd.org/bestpractices/pdf/DES38002OHsealantprogram.pdf>

-   (The Seal America protocols) <http://www.mchoralhealth.org/seal/>

-   Wisconsin Seal-A-Smile program
    <http://www.chawisconsin.org/oralHealthSealASmileProgram.htm>

-   Washington State sealant and fluoride varnish guidelines:
    <http://www.doh.wa.gov/cfh/OralHealth/manuals/Sealants/2002_sealant_varnish_manual.pdf>

**Nutrition and Dental Caries**

This section addresses two questions:

1.  What is currently known about nutrition and dental caries?

2.  What are some practical suggestions related to nutrition and dental
    caries that dental staff can share with patients, with caregivers of
    young patients, and with other health-care professionals?

Several definitions may prove helpful in understanding this section:

> **Dental caries** = tooth decay
>
> **Cariogenic foods** = foods (including beverages) capable of causing
> dental caries because they are converted to acid by microorganisms in
> the mouth
>
> **Fermentable carbohydrates** = carbohydrates like sugar and starch
> that bacteria can convert to acid; fermentable carbohydrates are
> cariogenic
>
> **Cariostatic foods** = foods that cannot be converted to acid by
> microorganisms in the mouth

**1. What is Known About Nutrition and Dental Caries?**

Dental caries can develop when the following conditions are present:

-   cariogenic bacteria are present in the mouth,

-   fermentable carbohydrates are present in the mouth,

-   caries-susceptible tooth surfaces are present, and

-   time is sufficient for caries to develop.

The bacteria use the fermentable carbohydrate as food, and in doing so,
the bacteria produce acid. The strength of the acid increases the *more
often* fermentable carbohydrates are eaten and the *longer* they stay in
the mouth.

**Fermentable Carbohydrates**

*Sugars* are fermentable carbohydrates, so they are cariogenic. Sugars
include white and brown sugar, honey, fructose, and syrup. The sugar in
fresh and dried fruit and in fruit juice is also a fermentable
carbohydrate. Sweet drinks such as soda pop and other foods like candy,
which are made from sugar, contain a lot of fermentable carbohydrate. In
fact, soda pop is the source of large amounts of sugar in the diets of
many Americans, including American Indians and Alaska Natives: Each
12-ounce can of regular soda pop has approximately 10 teaspoons of sugar
--- that works out to 55 teaspoons per two-liter bottle!

*Starch* is a fermentable carbohydrate. Flour has a lot of starch, so
flour and foods made with flour such as bread, cereal, crackers,
tortillas, and pretzels contain fermentable carbohydrates. Foods like
potato chips and taco chips also have fermentable carbohydrate because
they are made from a starchy vegetable.

Foods made with sugar *and* starch can be cariogenic. Cookies, cake,
pie, and doughnuts and other such foods contain a lot of fermentable
carbohydrates. These foods also tend to stick to the teeth and stay in
the mouth much longer.

Non-Cariogenic sweeteners include artificial sweeteners such as
aspartame and saccharin (brand name products like Equal and Sweet'N Low)
and naturally occurring sugar substitutes such as sugar alcohols like
mannitol, sorbitol, and xylitol.

**Overall Diet**

Although much research has examined sugar and starch in the decay
process, most of this work has focused on specific foods eaten
separately, not on the varying patterns of different foods that people
eat over a period of time. *For this reason, specialists in nutrition
and oral health recommend that patients* first *eat a healthy diet
overall, and then look at their sugar and starch intake, especially as
snacks.*

*Eating habits*. Frequent eating of snacks with fermentable carbohydrate
increases the risk of dental caries.

*Water.* Drinking water after meals and snacks can help prevent caries
by decreasing the amount of food that sticks to the teeth.

*Saliva Production*. Some foods stimulate saliva production, which can
help prevent caries in two ways: First, saliva buffers the acid in the
mouth. Second, increased saliva makes a person swallow more often. This
means that foods (and any acid) are in the mouth a shorter time, so they
are less likely to cause caries. Foods with fiber --- vegetables,
fruits, and whole grains --- stimulate saliva production.

*Oral hygiene habits*. Brushing with a fluoridated toothpaste after
eating meals and snacks can greatly reduce the risk of caries. When
brushing isn't possible, rinsing the mouth with water and chewing
sugarless gum are helpful alternatives.

*Fluoride*. Fluoride in drinking water and toothpaste can help prevent
dental caries. Some fluoride enters the tooth directly through the tooth
surface (topical), and some enters the tooth internally from the
bloodstream (systemic). The degree to which fluoride's positive effects
can be overcome by a poor diet is unknown.

**2. What Are Some Practical Suggestions Related to Nutrition and Dental
Health that Dental Staff Can Share with Patients, with Caregivers of
Young Patients, and with Other Health-Care Professionals?**

Following is a list of suggestions for adults and caregivers of young
patients:

**Food and Tooth Decay: What Can YOU Do to Prevent Cavities?**

Nutrition-Related Suggestions for Adult Patients

-   *Eat a healthy diet* by following MyPyramid.

-   *Avoid soda pop*

    -   Drink water to quench thirst.

    -   Choose healthier alternatives to soda pop, for example, fruit
        juice mixed with club soda,

    -   Native teas, or mineral water.

    -   Be a healthy role model for children in your family and
        community: Drink less soda pop!

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-   *Snacks*

    -   When you snack, choose healthy snacks like those listed in the
        box on the second page following.

    -   Limit snacks like candy and raisins that have a lot of sugar and
        stick to teeth.

    -   Drink water with snacks.

    -   After you snack, brush your teeth, rinse your mouth out with
        water, or chew some sugarless gum.

-   *Artificial sweeteners and preferences for sweet foods*

    -   If you chew gum, chew sugarless gum.

    -   Try to develop preferences for less sweet foods. To do so, limit
        your intake of artificially sweetened foods. Also, try to eat
        foods with less added sugar, for example, eat more fruit for
        dessert.

**Nutrition-Related Suggestions for Caregivers of Young Patients**

-   *Encourage children to eat a healthy diet*

-   *Avoid* *soda pop*

    -   Serve children water to quench their thirst.

    -   Serve children low-fat regular or chocolate milk instead of soda
        pop.

    -   If children don't drink soda pop, don't start them on it!

    -   If children drink soda pop, limit the amount and frequency.

-   *Other sweets*

    -   Limit the amount of candy, regular gum, and other sweets (like
        cookies, cake, and doughnuts) that children are offered.

    -   When children eat candy and other sweets, try to include these
        with a meal rather than as snacks.

-   *Snacks*

    -   Serve children healthy snacks like those listed in the box on
        the next page.

    -   Limit snacks like candy and raisins that have a lot of sugar and
        stick to teeth.

    -   Try to limit snack times to no more than three per day.

    -   After children snack, encourage them to brush their teeth, rinse
        their mouth out with water, or --- if they are old enough --- to
        chew some sugarless gum.

-   *Artificial sweeteners and preferences for sweet foods*

    -   If children chew gum, provide them with sugarless gum.

    -   Help children develop preferences for less sweet foods. To do
        so, serve children artificially sweetened foods only
        occasionally. Also, offer foods with less added sugar, for
        example, serve fruit more often for dessert.

**Suggestions for Other Health-Care Providers**

-   Encourage patients and caregivers of young patients to develop
    positive dental health habits by following the suggestions listed in
    this section.

-   Support local initiatives to fluoridate the community water supply,
    and to improve the nutritional quality of the local food supply. For
    example, encourage vendors to supply healthy alternatives in vending
    machines, encourage schools to provide healthy meals, encourage
    local grocery stores to offer high-quality fruits and vegetables,
    etc.

-   Encourage routine, periodic visits to the dentist. These visits can
    help to prevent decay as well as allow for early detection and
    treatment when decay occurs. These visits also give dental staff the
    opportunity to involve patients in health education and decay
    prevention activities.

**Food Pyramid**

The US Department of Agriculture released the MyPyramid food guidance
system ([www.mypyramid.gov](http://www.mypyramid.gov/)) in 2005 as a
replacement for the Food Guide Pyramid. MyPyramid is based on the 2005
USDA Dietary Guidelines for Americans
(<http://www.healthierus.gov/dietaryguidelines/index.html>). Along with
the new MyPyramid symbol, the system provides many options to help
Americans make healthy food choices and to be active every day.

MyPyramid is broken into the following guidelines:

-   Grains,

-   Vegetables,

-   Fruits,

-   Oils,

-   Milk,

-   Meat and Beans, and

-   Physical Activity.

General recommendations for each topic include the following:

Grains:

-   Make half of all grains consumed whole-grains

-   Eat at least 3 ounces of whole grain products every day

-   Look for "whole" before the grain name on lists of ingredients

Vegetables:

-   Eat more dark green vegetables

-   Eat more orange vegetables

-   Eat more dry beans and peas

Fruits:

-   Eat a variety of fruit

-   Choose fresh, frozen, canned or dried fruit

-   Go easy on fruit juices

Oils:

-   Make most of your fat sources from fish, nuts and vegetable oils

-   Limit solid fats like butter, stick margarine, lard, and shortening

Milk:

-   Go low fat or fat-free

-   If you can't consume milk, choose lactose-free products or other
    sources of calcium

Meat and Beans:

-   Choose low-fat or lean meats and poultry

-   Bake, broil or grill (don't fry)

-   Vary your choices with more fish, beans, nuts, peas, and seeds

Physical Activity

-   Find a balance between food and physical activity

-   Be physically active at least 30 minutes most days of the week

-   Children and teenagers should be physically active at least 60
    minutes every day, or most days

Additional details on the recommendations are available on the website.
The site also contains links and educational materials for both
consumers and professionals
(<http://www.mypyramid.gov/professionals/index.html>). It is recommended
that the reader explore these websites and download the various posters,
PowerPoint presentations, and other resources to aid in your nutritional
counseling for the dental patient.

**Additional Resources**

ADA's position on soft drinks and oral health
<http://www.ada.org/prof/resources/topics/topics_softdrinks.pdf>

ADA's information for the professional on diet and oral health:
<http://www.ada.org/prof/resources/topics/diet.asp>

ADA's consumer information on diet and oral health:
<http://www.ada.org/public/topics/diet.asp>

AAPD brochure on diet and snacking:
<http://www.aapd.org/publications/brochures/snacking.asp>

AAPD's Policy on Dietary Recommendations for Infants, Children, and
Adolescents**:**
<http://www.aapd.org/media/Policies_Guidelines/P_DietaryRec.pdf>

Dentalresource.org: <http://dentalresource.org/topic44nutrition.htm>

**References**

DePaola DP, Faine MP, Vogel RI. Nutrition in relation to dental
medicine. In: Modern Nutrition in Health and Disease, 8th ed. Shils ME,
Olson JA, Shike M, eds. Philadelphia: Lea & Febiger; 1994: 1007-1028.

Lucas B. Nutrition and the school-age child. In: Nutrition in Infancy
and Childhood, 5th ed. Pipes PL, Trahms CM, eds. St. Louis: Mosby; 1993:
142-164.

Touger-Decker R, Mobley C. Position of The American Dietetic
Association: Oral health and nutrition. J Am Dietetic Assoc 1996;96:
184-189.

Rugg-Gunn HA. Nutrition and Dental Health. Oxford: Oxford University
Press; 1993.

**XYLITOL**

Xylitol is a natural sugar alcohol that sweetens without causing decay.
It actually inhibits caries formation. Below are some facts about
xylitol.

-   Xylitol is a naturally-occurring 5-carbon sweetener found in
    berries, fruits, vegetables, and mushrooms, etc., and is even
    produced in the human body. It is also known as pentose, pentitol,
    polyalcohol, and polyol.

-   The xylitol used in most products is produced from birch trees

-   Its taste is indistinguishable from sucrose and it is 40% less
    caloric

-   Slow absorption evokes low glycemic response

-   Mutans streptococci are unable to metabolize Xylitol. This prevents
    the bacteria from forming acids that cause caries.

-   Xylitol enhances remineralization

-   Xylitol is unique among the polyols because it inhibits the growth
    of mutans streptococci, thereby reducing caries susceptibility.
    Continued use of xylitol will help to reduce the number of bacteria
    in plaque

-   Xylitol is significantly more effective than other sugar substitutes
    in reducing the weight of plaque in the oral cavity. It also reduces
    the proportion of insoluble polysaccharides and increases the
    proportion of soluble polysaccharides present in plaque which
    results in plaque that is less adhesive.

-   Regular use (5 to 10 grams per day) has been shown to reduce caries
    by 30 to 85%

-   Works well in conjunction with fluorides

-   Lowers the rate of otitis media in children (gum by 40%, syrup by
    30%)

-   Xylitol is safe and approved by the FDA for use as a food additive
    in "sugar-free" products since 1993

-   It is safe to use for diabetics since it does not raise blood sugar
    levels

-   Xylitol comes in a crystal form which gives a strong, pleasant
    cooling sensation when dissolved in the mouth

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-   Xylitol gum is being used in Head Start programs as a preventive
    measure to help reduce caries formation

-   The US Army has found the evidence supporting Xylitol so compelling
    that it has added xylitol-containing chewing gum to all MREs and all
    base exchanges

-   Xylitol gum is effective when 3- 5 pieces (each containing 1.6 grams
    or more of xylitol) are chewed daily for 5 to 15 minutes

-   Xylitol gum can be purchased online and at health food stores such
    as Wild Oats, and Whole Foods

-   Xylitol causes GI laxative effects at very high doses (over 50 to 70
    grams per day)

The most fundamental difference between xylitol and other sweeteners is
that xylitol reduces the amount of plaque and the virulence of mutans
streptococci in plaque. Xylitol functions as a modulator of the oral
flora. Oral bacteria will not adapt to metabolize xylitol regardless of
the duration of its use, so its benefits continue while it's being
consumed and after Xylitol is no longer a part of daily use. This effect
has been shown to persist for at least five years.

A study published in the Journal of Dental Research (March 2000)
demonstrated significant reductions in the transmission of mutans
streptococci (MS) from mother to child as a direct result of the
consumption of chewing xylitol-containing chewing gum by their mothers.

Soderling E. et al; J Dent Res 2000 Mar; 79(3)882-7

-   169 mother-child pairs, 2 year study

-   All mothers had high S. mutans during pregnancy

-   Study group chewed 2-3 sticks of xylitol gum per day starting 3
    months after delivery

-   2 control groups, 1 treated with chlorhexidine and 1 treated with
    fluoride varnishes at 6, 12, and 18 months post delivery

-   At 2 years of age, 9.7% of the children of mothers in the xylitol
    group had detectable S. mutans levels compared with 28.6% in the
    chlorhexidine group and 48.5% in the varnish group

-   Appears to work by selecting for S. mutans with impaired adhesion
    properties

A follow-up study published in the Journal of Dental Research looked at
whether maternal consumption of sugar free chewing gum sweetened with
xylitol could reduce the risk of dental caries in their children.
Earlier published studies have demonstrated that prevention of
colonization by these bacteria in early childhood can lead to reduction
of dental decay and that mothers are the primary source of infection
with mutans streptococci. These bacteria are passed from mother to child
through everyday contacts such as kissing and tasting of food.

Isokangas P et al; J Dent Res 2000 Nov;79(11):1885-9

-   Follow-up of the same children in the previous study

-   Examined annually out to 5 years by double blinded examiner

-   dmf of xylitol group at 5 years was 70% of that in the fluoride or
    chlorhexidine group

In study in which xylitol was placed in a reservoir in the pacifiers of
one year old children (Aaltonen et al. Acta Odontol Scand. 2000 Dec;
58(6):285-92.), xylitol was shown to produce the following results:

-   Reduced mutans strep infection by 16%

-   Reduced caries to zero in test group (p\<0.001)

-   Reduced otitis media by 19% - 38%

IHS dental staff can easily implement a xylitol gum program by providing
the gum to post-natal mothers as an indirect preventive method (to
decrease the transmission of S. Mutans from mother to child) or by
providing the gum to a fixed group of children, such as Head Start,
working in collaboration with the Head Start teachers.

Additional information about Xylitol and its use in caries-prevention
programs can be found at the following links:

<http://www.aapd.org/media/Policies_Guidelines/P_Xylitol.pdf>

<http://www.xylitol.org/>

<http://jada.ada.org/cgi/reprint/137/2/190> (you will need to be an ADA
member to access this article)

**Xylitol Abbreviated Bibliography**

*To date, nearly 1,000 articles have been written on Xylitol. The
following are some directed to caries prevention research.*

Alanen P, et al. (2000). Sealants and xylitol chewing gum are equal in
caries prevention. Acta Odontol Scand. 58(6):279-84.

Alanen P, et al. (2000). Xylitol candies in caries prevention: results
of a field study in Estonian children. Community Dent Oral Epidemiol.
28(3):218-24.

Autio JT. (2002). Effect of xylitol chewing gum on salivary
Streptococcus mutans in preschool children. ASDC J Dent Child.
69(1):81-6, 13.

Calamari SE, et al. (1997). Effects of xylitol, sorbitol and fluoride
mouthrinses on glucose clearance in adolescents. Acta Odontol
Latinoam.l0(1):25-36.

Edgar WM. (1998). Sugar substitutes, chewing gum and dental caries\--a
review. Br Dent J. 184(1):29-32.

Gales MA, Nguyen TM. (2000). Sorbitol compared with xylitol in
prevention of dental caries. Ann Pharmacother. 34(1):98-100.

Hayes C. (2001). The effect of non-cariogenic sweeteners on the
prevention of dental caries: a review of the evidence. J Dent Educ.
65(10):1106-9.

Hildebrandt GH, Sparks BS. (2000). Maintaining mutans streptococci
suppression with xylitol chewing gum. J Am Dent Assoc. 131(7):909-16.

Honkala S, et al. (1999). Use of xylitol chewing gum among Finnish
schoolchildren. Acta Odontol Scand. 57(6):306-9.

Hujoel PP, et al. (1999). The optimum time to initiate habitual xylitol
gum-chewing for obtaining long-term caries prevention. J Dent Res.
78(3):797-803.

Isokangas P, et al. (2000). Occurrence of dental decay in children after
maternal consumption of xylitol chewing gum, a follow-up from 0 to 5
years of age. J Dent Res. 79(11):1885-9.

Isogangas P, et al. (1993). Long-term effect of xylitol chewing gum in
the prevention of dental caries: a follow-up 5 years after termination
of a prevention program. Caries Res. 27(6):495-8.

Machiulskiene V, et al. (2001). Caries preventive effect of
sugar-substituted chewing gum. Community Dent Oral Epidemiol. 20
29(4):278-88.

Makinen KK, et al. (1998). Physical, chemical, and histologic changes in
dentin caries lesions of primary teeth induced by regular use of polyol
chewing gums. Acta Odontol Scand. 56(3):148-56.

Makinen KK, et al. (1998). A descriptive report of the effects of a
16-month xylitol chewing-gum programme subsequent to a 40-month sucrose
gum programme. Caries Res. .32(2):107-12.

Makinen KK, et al. (1996). Conclusion and review of the Michigan Xylitol
Programme (1986-1995) for the prevention of dental caries. Int Dent J.
46(1):22­34.

Makinen KK, et al. (1996). Polyol-combinant saliva stimulants and oral
health in Veterans Affairs patients\--an exploratory study. Spec Care
Dentist. 16(3):104-15.

Petersson LG, et al. (1991). Caries-preventive effect of dentifrices
containing various types and concentrations of fluorides and sugar
alcohols. Caries Res. 25(1):74-9.

Rekola M. (1986). Changes in buccal white spots during 2-year
consumption of dietary sucrose or xylitol. Acta Odontol Scand.
44(5):285-90.

Roberts MC, et al. (2002). How xylitol-containing products affect
cariogenic bacteria. J Am Dent Assoc. 133(4):435-41.

Scheie AA, Fejerskov OB. (1998). Xylitol in caries prevention: what is
the evidence for clinical efficacy? Oral Dis. 4(4):268-78.

Scheinin A, et al. (1993). Xylitol-induced changes of enamel
microhardness paralleled by microradiographic observations. Acta Odontol
Scand. 51(4):241-6.

Scheinin A, et al. (1985). Collaborative WHO xylitol field studies in
Hungary. VII. Two-year caries incidence in 976 institutionalized
children. Acta Odontol Scand. 43(6):381-7.

Simons D, et al. (2002). The effect of medicated chewing gums on oral
health in frail older people: a 1-year clinical trial. J Am Geriatr Soc.
50(8):1348-53.

Simons D, et al. (1999). The effect of xylitol and chlorhexidine
acetate/xylitol chewing gums on plaque accumulation and gingival
inflammation. J Clin Periodontol. 26(6):388-91.

Soderling E, et al. (2000). Influence of maternal xylitol consumption on
acquisition of mutans streptococci by infants. J Dent Res. 79(3):882-7.

Soderling E, et al. (1991). Long-term xylitol consumption and mutans
streptococci in plaque and saliva. Caries Res. 25(2):153-7.

Soderling E, Scheinin A. (1991). Perspectives on xylitol-induced oral
effects. Proc Finn Dent Soc. 87(2):217-29.

Tanzer JM. (1995). Xylitol chewing gum and dental caries. Int Dent J.
45(1 Suppl 1):65-76.

Trahan L, et al. (1996). Emergence of multiple xylitol-resistant
(fructose PTS-) mutants from human isolates of mutans streptococci
during growth on dietary sugars in the presence of xylitol. J Dent Res.
75(11):1892-900.

Yanagisawa T, Miake Y, Saeki Y, Takahashi M. (2003) Remineralization in
enamel caries and restoration of carious lesions by enhanced
remineralization induced by saliva and xylitol. Dent in Japan, vol
39:208-215.

**Early Childhood Caries**

Early Childhood Caries (ECC), formerly known as Baby Bottle Tooth Decay
(ECC ) presently affects as many as 50 percent of American Indian/Alaska
Native children under age five. ECC is defined as dental decay of
varying severity affecting at least two of the four primary maxillary
anterior teeth of children under age three years and attributable to
improper feeding practices. ECC encompasses a broader etiology with a
wider range of interventions, and includes conditions such as rampant
caries in posterior primary teeth.

ECC and its consequences are causes of major resource expenditures in
the IHS Dental Programs. New approaches for the prevention and treatment
of ECC must take into account the permissive behaviors in families. The
prevention of ECC must be integrated with other health disciplines such
as medical, mental health, and nutritional care in order to have a
significant impact, because ECC occurs before most young children reach
the dental clinic.

Virtually everyone can support initiatives to improve the health status
of young children. ECC is an important dental health issue around which
extensive, strong community-based HP/DP programs can be built.

**Primary Prevention**

Recommendations for parents and caretakers:

1.  Never put a child to bed with a bottle containing anything but
    water.

2.  Do not let a child walk around or sit with a bottle during the day.

3.  Teeth should be cleaned daily, beginning when they first erupt.

4.  Start a child drinking from a cup no later than one year of age.

5.  Encourage parents/caregivers to bring their child to the dental
    clinic by age 12-18 months for a check-up.

**Prevention Activities**

The Indian Health Service Dental Program developed educational materials
for parents and caregivers. *Stop Dental Decay Among Our Native American
Children!* contains information about caring for children's teeth from
ages one to five years, focuses on ways that parents/caregivers can take
care of their children's teeth, and includes clinical primary
intervention recommendations. CDC has also developed a manual entitled,
*Preventing BBTD : A Comprehensive Training Program for Community
Workers and Health Professionals.*

Dentists in the IHS, as well as private dentists in the community,
should encourage parents to bring their children to the clinic at about
age one year for a screening exam. This visit also provides an
opportunity to discuss oral health care with parents and caregivers.

The following steps will provide assistance in implementing an ECC
program:

1\. Establish Baseline Prevalence of ECC in the Community

This measure will provide you with a means to measure your effectiveness
and evaluate your program. It will also give you local data to generate
support for the program. A community-based sample, such as WIC clinics,
Head Start, or day care centers, is preferable to a dental clinic-based
sample, because those who receive clinical services may not be a
representative sample. On the other hand, if a large percentage of
children receive oral exams in a clinical setting, this sample would
suffice.

A visual examination is all that is required to determine if there are
any carious lesions or restorations on the four maxillary primary
anterior teeth. Most of the surveys to date have been conducted in Head
Start centers using flashlights or overhead light where adequate. Only
mirrors were generally used and there were no radiographs used.

To determine prevalence, count the total number of children screened and
divide this number into the number of children with ECC. ECC is defined
as two decayed, extracted, or restored teeth of the four maxillary
anterior teeth. The resulting figure is the prevalence of ECC in your
community. To evaluate program effectiveness, examine the same-age
children in the same setting in three to five years and compare your
findings.

2\. Select a Site Coordinator

Each potential site should select a suitable site coordinator, keeping
in mind the central role and contribution that this person can make to
the success of an ECC program. Characteristics of effective coordinators
include enthusiasm, commitment, ability to motivate other people, and
credibility among both the lay community and the health professionals.
Each site also should consider obtaining training for the site
coordinator from Indian Health Service to assure an acceptable level of
knowledge about implementation of the program and to obtain technical
assistance for the transfer of the program.

3\. Obtain Support Contracts

You will need to contact several key persons in your community to get
their support and cooperation. The best way to do this is to contact
them on an individual basis. Written agreements of support for
implementation of the ECC program from local political and health
agencies are recommended. These agreements are not legally binding, but
document a commitment within the political structure of the community.
They are often used to inform the community about the benefits of the
program.

4\. Assemble a Task Force

The task force should be composed of policy-makers, parents, health
workers, and other people who have the potential to make a substantial
contribution to the program. The role of the task force is to
"customize" the ECC program to the community, report on activities, plan
future strategies, and evaluate the program's success. The task force
meets three to four times a year (more often during the early design
stages of the program). Head Start, WIC, day care providers, and other
local groups should be encouraged to participate.

5\. Design a Program Plan

The program plan should be customized to the community and encourage the
ongoing development of strategies and education materials tailored to
the population. A budget should be developed as part of your program
plan. The development of a program plan is largely a function of the
task force.

6\. Develop an Evaluation Plan

The plan will be used primarily to monitor the success of the program
within the community. An evaluation plan should include measurement of
ECC prevalence and surveys of knowledge, attitudes, and behaviors of the
caretakers of young children.

**Additional Resources**

CDC video training program:
<http://www2.cdc.gov/phtn/catalog/bottle.asp>

AAPD Definitions, Oral Health Policies, and Clinical Guidelines:

<http://www.aapd.org/media/Policies_Guidelines/D_ECC.pdf>

<http://www.aapd.org/media/Policies_Guidelines/P_ECCClassifications.pdf>

<http://www.aapd.org/media/Policies_Guidelines/P_ECCUniqueChallenges.pdf>

ADA Statement on ECC

<http://www.ada.org/prof/resources/positions/statements/caries.asp>

ECC fact sheet: <http://www.mchoralhealth.org/PDFs/ECCFactSheet.pdf>

ASTDD best practices:
<http://www.astdd.org/bestpractices/pdf/DES51002VTbbtdprogram.pdf>

Journal of the California Dental Association. *Causes, Treatment and
Prevention of Early Childhood Caries: A Microbiologic Perspective*

<http://www.cda-adc.ca/jcda/vol-69/issue-5/304.html>

**Risk-Based Periodontal Disease Prevention and Treatment**

**Background**

The effective treatment of periodontal disease in a public health
setting has always been challenging. Recent advances in the
understanding of periodontal diseases are offering new opportunities for
prevention and treatment using a public health approach. Natural history
studies have revealed the presence of individual periodontal risk
differences within populations. Individuals with similar levels of
periodontal risk can be placed in subgroups. Subgroups with high
periodontal risk generally involve a relatively small percentage of the
total population. Moderate-risk subgroups are quite large, accounting
for the majority of any population. Factors that increase the risk of
periodontal breakdown are now well known. Individuals who smoke and
those who suffer from diabetes, immune suppression diseases, and certain
blood dyscrasias are all at high risk for periodontal disease. Some
individuals may fall into the high-risk category simply because they
inherit an immune system that is less than efficient in managing the
periodontal disease pathogens or the inflammatory processes these
bacteria produce. There is also evidence that periodontitis and its
associated systemic inflammation increases risk for several chronic
illnesses such as diabetes mellitus, cardiovascular diseases, and
certain respiratory conditions, as well as increasing risk for adverse
pregnancy outcomes.

A better understanding of the effects of so called "scaling and root
planing" (S/RP) has occurred in recent years. Many synonymous, and
perhaps confusing, terms are used today to describe the S/RP activity.
Some clinicians refer to S/RP as deep scaling, pocket debridement,
cavitroning, or ultrasonic cleaning. However, probably the best
description is root debridement. Regardless of its name, the process of
removing all soft and hard debris from the root surfaces, even if it is
done without perfection, results in greatly enhanced periodontal health.
Removing or even disturbing subgingival plaque and calculus deposits
causes a dynamic interactive process that involves bacterial
recolonization, activation of the immune system (particularly specific
circulating antibodies), and initiation of wound healing.

New chemotherapeutic agents have been developed as adjuncts to
periodontal treatment, including subgingival irrigation with
anti-infective agents such as chlorhexidine and locally delivered
resorbable antibiotics. These agents can improve the success of S/RP,
improve nonresponding sites, and prolong the period of gingival health
between cleaning sessions.

**Purpose**

The purpose of this clinic manual is to describe diagnosis and treatment
methods which combine population-based periodontal disease risk
assessments with current treatment technologies. The methods described
in this manual prioritize care delivered to a population by targeting
individuals with the highest risk for periodontal breakdown. High-risk
individuals will receive the most intensive therapy and follow-up. Care
will be provided to moderate-risk or advanced disease individuals based
on the resources available to the treating staff and facility. *Note:
The system of prioritized periodontal treatment delivery described in
this manual assumes that all dental staffs are capable of providing the
treatment needs associated with CPITN/PSR scores of 0 through 3 for all
patients receiving examinations in their clinics.*

I. Early Disease Assessment and Treatment

**A. Periodontal Disease Assessment (CPITN 0 to 3)**

At each initial examination appointment (0150) and at least annually,
the periodontal status should be assessed. The diagnosis and risk
assessment of individuals will be based on the Community Periodontal
Index of Treatment Needs (CPITN)/Periodontal Screening and
Recording(PSR). A brief outline of CPITN/PSR scores and corresponding
diagnoses is shown below:

# 

# 

# American Academy of Periodontology & CPITN

#  Classification of Periodontal Diseases and Conditions 

+------------------+---------------------------+----------------------+
| ## Class         | **Conditions**            | ### CPITN            |
| ification of Per |                           |                      |
| iodontal Disease |                           |                      |
+------------------+---------------------------+----------------------+
| #### Pe          | #### None                 | **0 - Periodontal    |
| riodontal Health |                           | Health**             |
+------------------+---------------------------+----------------------+
| ##               | No pockets, bleeding on   | **Sextant Scores of  |
| ### Gingivitis/G | probing                   | 1 & 2**              |
| ingival diseases |                           |                      |
|                  | > A. Dental               | #### *Bleeding       |
|                  | > plaque-induced gingival | on probing, and/or c |
|                  | > diseases                | alculus or restorati |
|                  | >                         | on overhang present* |
|                  | > B. Non-plaque-induced   |                      |
|                  | > gingival lesions        |                      |
+------------------+---------------------------+----------------------+
| ##### Chron      | [Age                      | **Sextant Score of 3 |
| ic Periodontitis | Distinction]{.underline}: | to 4**               |
|                  | Was described as adult    |                      |
| > A. Localized   | onset periodontitis, in   | ***CPITN- 3** = 3.5  |
| >                | people older than 35      | -- 5.5 mm probing    |
| > B. Generalized | years.                    | depth*               |
| > (\> 30% of     |                           |                      |
| > sites are      | **[Severity of            | *-4 =                |
| > involved)      | Disease]{.underline}**:   | [\>]{.underline} 6mm |
| >                |                           | probing depth*       |
| > **Example:**   | [Slight]{.underline}: 1-2 |                      |
| > Two sextants   | mm clinical attachment    | **[Severity of       |
| > of CPITN of 4  | loss (CAL \*); (3-4mm     | Dis                  |
| > could be       | pockets, \< 30% bone      | ease]{.underline}**: |
| > "localized     | loss)                     |                      |
| > chronic        |                           | > [Slight -- CPITN   |
| > periodontitis" | [Moderate]{.underline}:   | > of 3]{.underline}  |
| > and maybe      | 3-4 mm CAL; (4-6mm        | >                    |
| > three or more  | pockets, \< 50% bone      | > [Moderate -- CPITN |
| > sextants would | loss)                     | > of 3]{.underline}  |
| > be             |                           | >                    |
| > "generalized   | [Severe]{.underline}:     | >                    |
| > chronic        | [\>]{.underline}5 mm CAL: | [Severe]{.underline} |
| > periodontitis" | ( [\>]{.underline} 6mm    | > -- [CPITN of       |
|                  | pockets, \> 50% bone      | > 4]{.underline}     |
|                  | loss)                     |                      |
|                  |                           |                      |
|                  | **Written Diagnosis:**    |                      |
|                  |                           |                      |
|                  | **Use the descriptors     |                      |
|                  | localized or generalized  |                      |
|                  | depending on the          |                      |
|                  | distribution of sextant   |                      |
|                  | scores, and severity of   |                      |
|                  | disease.**                |                      |
|                  |                           |                      |
|                  | *Examples:*               |                      |
|                  |                           |                      |
|                  | -   *Generalized slight   |                      |
|                  |     chronic               |                      |
|                  |     periodontitis*        |                      |
|                  |                           |                      |
|                  | -   *Generalized slight,  |                      |
|                  |     locally severe        |                      |
|                  |     chronic               |                      |
|                  |     periodontitis*        |                      |
+------------------+---------------------------+----------------------+
| ##### Aggressi   | **[Age                    | **Sextant Score of   |
| ve Periodontitis | Di                        | -- 3 to 4**          |
|                  | stinction]{.underline}**: |                      |
| > A. Localized   | **Usually described as    | ***CPITN - 3** = 3.5 |
| >                | early onset \< 35 years   | -- 5.5 mm probing*   |
| > B. Generalized | of age or rapidly         |                      |
| > (\> 30% of     | progressing**             | > *-4 =              |
| > sites are      |                           | > [\>]{.underline}   |
| > involved)      | **[Severity of            | > 6mm probing depth* |
|                  | Disease]{.underline}**    |                      |
|                  | (same as above):          | **[Severity of       |
|                  |                           | Dis                  |
|                  | [Slight]{.underline}: 1-2 | ease]{.underline}**: |
|                  | mm CAL; (3-4mm pockets,   |                      |
|                  | \< 30% bone loss)         | > [Slight -- CPITN   |
|                  |                           | > of 3]{.underline}  |
|                  | [Moderate]{.underline}:   | >                    |
|                  | 3-4 mm CAL; 4-6mm         | > [Moderate -- CPITN |
|                  | pockets, \< 50% bone loss | > of 3]{.underline}  |
|                  |                           | >                    |
|                  | [Severe]{.underline}:     | > [Severe -- CPITN   |
|                  | [\>]{.underline}5 mm CAL: | > of 4]{.underline}  |
|                  | [\>]{.underline} 6mm      |                      |
|                  | pockets, \> 50% bone loss |                      |
|                  |                           |                      |
|                  | *In the world of oral     |                      |
|                  | epidemiology, any pocket  |                      |
|                  | depth [\>]{.underline}6mm |                      |
|                  | is considered a \"deep    |                      |
|                  | pocket\" with advanced or |                      |
|                  | severe periodontal        |                      |
|                  | disease*.                 |                      |
|                  |                           |                      |
|                  | **Written Diagnosis       |                      |
|                  | Example**:                |                      |
|                  |                           |                      |
|                  | *Localized Severe,        |                      |
|                  | Aggressive Periodontitis* |                      |
+------------------+---------------------------+----------------------+

+-------------------+---------------------------+---------------------+
| Periodontitis as  | A. Associated with        |                     |
| a Manifestation   | hematological disorders   |                     |
| of Systemic       |                           |                     |
| Diseases          | (neutropenia, leukemia)   |                     |
|                   |                           |                     |
|                   | B. Associated with        |                     |
|                   | genetic disorders         |                     |
|                   |                           |                     |
|                   | (Down's, histiocytosis)   |                     |
|                   |                           |                     |
|                   | C. Not otherwise          |                     |
|                   | specified                 |                     |
+-------------------+---------------------------+---------------------+
| **Necrotizing     | [Necrotizing Ulcerative   |                     |
| Periodontal       | Gingivitis]{.underline}   |                     |
| Diseases**        | (NUG) -- gingival         |                     |
|                   | disease\...does not       |                     |
|                   | extend into periodontal   |                     |
|                   | attachment.               |                     |
|                   |                           |                     |
|                   | [Necrotizing Ulcerative   |                     |
|                   | P                         |                     |
|                   | eriodontitis]{.underline} |                     |
|                   | (NUP) - extending into    |                     |
|                   | periodontal attachment    |                     |
+-------------------+---------------------------+---------------------+
| #                 | A. Gingival abscess       |                     |
| #### Abscesses of |                           |                     |
|  the Periodontium | B. Periodontal abscess    |                     |
|                   |                           |                     |
|                   | c\. Pericoronal abscess   |                     |
+-------------------+---------------------------+---------------------+
| **Periodontitis   | Combined                  |                     |
| Associated With   | periodontic-endodontic    |                     |
| Endodontic        | lesions                   |                     |
| Lesions**         |                           |                     |
+-------------------+---------------------------+---------------------+
| **Developmental   | A. Localized              |                     |
| or Acquired       | tooth-related factors     |                     |
| Deformities and   | that modify or predispose |                     |
| Conditions**      | to plaque-induced         |                     |
|                   | gingival                  |                     |
|                   | diseases/periodontitis    |                     |
|                   |                           |                     |
|                   | B. Mucogingival           |                     |
|                   | deformities and           |                     |
|                   | conditions around teeth   |                     |
|                   |                           |                     |
|                   | C. Mucogingival           |                     |
|                   | deformities and           |                     |
|                   | conditions on edentulous  |                     |
|                   | ridges                    |                     |
|                   |                           |                     |
|                   | D. Occlusal trauma        |                     |
+-------------------+---------------------------+---------------------+

\* Clinical Attachment Loss, obtained by adding recession from the CEJ
to probing depth (or subtracting if a pseudopocket). 

Remember, the CPITN does not recognize recession and clinical attachment
loss. A patient could have generalized severe periodontitis with 70%
bone loss and mobile teeth, but 3mm or less pocket depths due to
recession. CPITN scores could look like: [X / 2 / 2]{.underline} because
probing depths are shallow. 2 / 2 / X

For additional information on periodontal classifications, contact the
American Academy of Periodontology at
[www.aap.org](http://www.aap.org/).

In addition to clinical descriptions, the CPITN also provides standard
treatment requirements for each score of 0 through 3. Standard
treatments exist for these minimal disease scores because the treatment
needs are relatively simple. With appropriate treatment and patient home
care, CPITN scores of 1, 2, and 3 can be returned to 0 (periodontal
health). The following describes the treatment needs associated with
CPITN scores of 0 through 3:

  --------------------- -------------------------------------------------
  CPITN SCORES          Treatment needs

  0                     promote self-assessment skills

  1                     oral hygiene instructions (ohi)

  2                     OHI + ultrasonic cleaning/overhang removal

  3                     ohi + Ultrasonic cleaning
  --------------------- -------------------------------------------------

**B. Treatment (CPITN 0 to 3)**

Standardized treatment needs have been established for the minimal
periodontal disease conditions described by CPITN scores of 0 through 3.
These standardized treatments have been found to be helpful guides to
dental auxiliaries who often are assigned the task of providing the
basic periodontal care associated with low CPITN scores.

**1. Self-Assessment --- CPITN Score 0**

Self-Assessment is a method taught to patients that enables them to
determine the status of their own oral health. The self-assessment
techniques most commonly used focus on the identification of gingival
bleeding as an indicator of the presence of gingival and/or periodontal
disease.

**2. Oral Hygiene Instructions (OHI) --- CPITN Scores \>1**

Oral hygiene instructions should include individualized patient
education with emphasis on plaque and bleeding self-assessment, use of
cleaning devices (toothbrushes, proxabrushes, rubber tips, floss and
floss aids) and in some cases, the home use of chemotherapeutics and
irrigators.

The cornerstone of oral hygiene instructions is teaching the proper use
of the toothbrush. A sulcular brushing technique, the Modified Bass
Technique, is suggested as the standard for OHI.

Once toothbrushing competence has been achieved, techniques for
interproximal cleaning can then be taught. The use of rubber tips and
proxabrushes (where possible) should be emphasized. The mastery of
dental flossing is difficult. Flossing aids may be indicated to improve
compliance and effectiveness.

**3. Ultrasonic Cleaning --- CPITN Scores 2 to 3**

In recent years, research has lead to a great improvement in the
understanding of the biological effects of traditional scaling and root
planing (S/RP). Due to this greater knowledge, a revolution has occurred
in the approach, methods, and instrumentation used in non-surgical
periodontal therapy. Studies have demonstrated that root surfaces do not
need to be meticulously scraped or planed to remove "infected cementum
and dentin." *The goal of periodontal root debridement currently is to
simply remove all hard and soft debris from the roots.* This task can be
most easily accomplished through the use of ultrasonic instruments.
Dental researchers have compared traditional hand instrumentation with
sonic and ultrasonic instruments. The conclusion is that both
instruments produce similar results with regard to crown and root
debridement and improvements in the health of periodontal tissues.
However, it is generally conceded that sonic and ultrasonic instruments
are faster and easier to use than hand instruments. Further, technologic
advances have greatly reduced the size of many ultrasonic tips, which
are now capable of functioning in deep pockets and able to reach into
small defects, irregularities, and furcations that a hand instrument
cannot reach.

**II. Advanced Disease: Risk Assessment and Treatment**

**A. Risk Assessment (CPITN 4 or Deep Pockets)**

Once CPITN scores reach 4 (pocket depths [\>]{.underline}6 mm in a
sextant), it is certain that periodontal attachment loss has occurred.
Pocket depths of 6 mm or greater are generally considered to be deep
pockets. Deep pockets suggest advanced or advancing disease. For a small
percentage of any given population, deep pockets occur earlier in life
(before age 35). An assessment system was developed which includes *both
disease severity and age* to establish risk for disease. A model for
risk assessment, using CPITN and age, is presented below:

+--------------------+---------------+---------------+---------------+
| **Population       |               |               |               |
| Periodontal        |               |               |               |
| Treatment Needs    |               |               |               |
| Using CPITN**      |               |               |               |
+--------------------+---------------+---------------+---------------+
| **CPITN SCORES**   | **Treatment   |               |               |
|                    | needs**       |               |               |
+--------------------+---------------+---------------+---------------+
| **0**              | **Oral        |               |               |
|                    | hygiene       |               |               |
|                    | instructions  |               |               |
|                    | (OHI)**       |               |               |
+--------------------+---------------+---------------+---------------+
| **1**              | **OHI**       |               |               |
+--------------------+---------------+---------------+---------------+
| **2**              | **OHI and     |               |               |
|                    | prophy**      |               |               |
+--------------------+---------------+---------------+---------------+
| **3**              | **ohi and     |               |               |
|                    | prophy**      |               |               |
+--------------------+---------------+---------------+---------------+
| **[                | **AGE         |               |               |
| \>]{.underline}4** | DETERMINES    |               |               |
|                    | RISK          |               |               |
|                    | CATEGORY**    |               |               |
+--------------------+---------------+---------------+---------------+
| **Deep\            | **14 -- 35    | **36 -- 59    | **[\>]{       |
| Pockets**          | YEARS**       | YEARS**       | .underline}60 |
|                    |               |               | YEARS**       |
|                    | ***HIGH       | ***MODERATE   |               |
|                    | RISK***       | RISK***       | ***LOW        |
|                    |               |               | RISK***       |
|                    | **OHI**       | **OHI**       |               |
|                    |               |               | **OHI**       |
|                    | **High        | **Closed or   |               |
|                    | Intensity,**  | Open**        | **Closed      |
|                    |               |               | Root**        |
|                    | **N           | **Root        |               |
|                    | on-Surgical** | Debridement** | **            |
|                    |               |               | Debridement** |
|                    | **C           | **Recall as   |               |
|                    | hemotherapy** | Resources     | **Recall as   |
|                    |               | Allow**       | Resources     |
|                    | **Active      |               | Allow**       |
|                    | Recall**      |               |               |
+--------------------+---------------+---------------+---------------+

Dental managers who wish to address the advanced periodontal disease in
their treatment population can utilize this model to target high-,
moderate-, and low-risk groups for care. Patients at high-risk can be
prioritized for treatment. *Young individuals with advanced disease are
at the highest risk for tooth loss and therefore should be given the
highest priority for treatment.* Another important advantage this model
affords is that dental managers, considering their resources, i.e.,
facility and staff size, can rationally control the access of advanced
disease patients to their clinic(s).

**[1. High-Risk Patients]{.underline}**

+--------------------+---------------+---------------+---------------+
| **population       |               |               |               |
| periodontal        |               |               |               |
| treatment\         |               |               |               |
| needs using        |               |               |               |
| CPITN**            |               |               |               |
+--------------------+---------------+---------------+---------------+
| **CPITN SCORES**   | **Treatment   |               |               |
|                    | needs**       |               |               |
+--------------------+---------------+---------------+---------------+
| **0**              | **Oral        |               |               |
|                    | hygiene       |               |               |
|                    | instructions  |               |               |
|                    | (OHI)**       |               |               |
+--------------------+---------------+---------------+---------------+
| **1**              | **OHI**       |               |               |
+--------------------+---------------+---------------+---------------+
| **2**              | **OHI and     |               |               |
|                    | prophy**      |               |               |
+--------------------+---------------+---------------+---------------+
| **3**              | **ohi and     |               |               |
|                    | prophy**      |               |               |
+--------------------+---------------+---------------+---------------+
| **[                | **AGE         |               |               |
| \>]{.underline}4** | DETERMINES    |               |               |
|                    | RISK          |               |               |
|                    | CATEGORY**    |               |               |
+--------------------+---------------+---------------+---------------+
| **Deep\            | **14 -- 35    |               |               |
| Pockets**          | YEARS**       |               |               |
|                    |               |               |               |
|                    | ***HIGH       |               |               |
|                    | RISK***       |               |               |
|                    |               |               |               |
|                    | **OHI**       |               |               |
|                    |               |               |               |
|                    | **High        |               |               |
|                    | Intensity,**  |               |               |
|                    |               |               |               |
|                    | **N           |               |               |
|                    | on-Surgical** |               |               |
|                    |               |               |               |
|                    | **C           |               |               |
|                    | hemotherapy** |               |               |
|                    |               |               |               |
|                    | **Active      |               |               |
|                    | Recall**      |               |               |
+--------------------+---------------+---------------+---------------+

a\. Assessment of High-Risk Patients

Age and severity parameters for high-risk individuals were established
using available epidemiologic studies and the American Academy of
Periodontology's definition of early onset periodontal diseases, now
known as Aggressive Periodontitis. Therefore, any individual 14-35 years
of age with one or more site of CPITN scores of 4 would be determined to
be at high-risk for periodontal disease. The high-risk assessment
criterion is designed to identify attachment or bone loss on individuals
within the 14-35 age range.

*Note: It is possible that people who are older than 35 years of age can
also be categorized as high-risk. Episodic dental users with aggressive
periodontitis may not have received a dental examination until after age
35. At 36-45 years of age for example, these high-risk individuals, who
have not received routine treatment, would be expected to have
generalized advanced bone loss and perhaps some missing teeth. Likewise,
older individuals (age 36-45) who suffer rapid bone loss, such as
uncontrolled diabetics and heavy smokers, should also be included as
high risk. Untreated high-risk people will lose many of their teeth in
the third and fourth decade of life.*

b\. Oral Hygiene Instructions for High-Risk Patients

Although oral hygiene instructions are an essential element of overall
periodontal treatment, positive oral hygiene behavior changes often do
not result. However, if the intent of this risk-based periodontal
disease treatment approach is to prioritize care for those who need it
most (i.e., high-risk individuals), then it makes sense to offer the
best and most intense therapy possible. This also applies to oral
hygiene instructions. For high-risk individuals, a high-intensity oral
hygiene program should be provided.

**Patient Revisits:** An evaluation of the patient's oral home care is
essential at each dental visit. Based on this evaluation, the
high-intensity oral hygiene program may have to be repeated. However, as
the patient becomes aware of the information provided and oral hygiene
improves, many of the steps above may be skipped at the recall visit.

c\. Treatment for High-Risk Patients

Treatment should be based on a high-intensity, nonsurgical approach
using adjunctive systemic antibiotic therapy. Emphasis should be placed
on the use of ultrasonic rather than hand instruments. Frequent,
periodic root debridement should be the goal. Local anesthetics will
frequently be required for the adequate cleaning of deep pockets (CPITN
4) with ultrasonic instruments. The use of local or topical gel
anesthetics may not be required for subsequent recall cleaning visits if
root surfaces are relatively free of deposits.

**Root Debridement Procedure:** Cleaning all root surfaces is the most
important aspect of nonsurgical periodontal therapy. Removing plaque and
calculus from subgingival areas has challenged dental providers since
plaque was determined to cause gum disease, over one hundred years ago.
Dental researchers in the last four decades have repeatedly documented
the difficulty of removing soft and hard debris from root surfaces that
are irregularly shaped and cannot be visualized. The effectiveness of
instrumentation during root debridement decreases progressively with
increasing pocket depths. Maintaining sharp curettes, obtaining secure
finger rests, activating the appropriate instruments at the correct
angles, and cleaning all root surfaces are some of the major obstacles
that must be overcome in traditional hand root planing. Obviously, the
success of hand instrumentation is determined largely by the skill level
of the operator. In order to provide hand-instrumented periodontal
services to a large population, it is necessary to have many
highly-skilled providers. This requirement is not achievable for many
publicly-funded programs.

Fortunately, technology has produced and constantly improved the sonic
and ultrasonic instruments. With advances in these instruments and our
current understanding of root debridement, ultrasonic machines can
virtually replace hand instruments. Ultrasonic instruments offer many
advantages over hand instruments. Most importantly, they require less
skill to master, they require less time to effectively debride roots,
produce less hand fatigue for the operator and do not need to be
sharpened. Training in the ultrasonic method of root debridement is
definitely required, but much less practice time is needed to master the
skill.

**Technique:** *The use of ultrasonic instruments is recommended for
high-risk patients.* *Frequently, local anesthetic is required for
initial subgingival cleaning procedures.* However; subsequent recall
procedures, which do not include heavy calculus removal, can usually be
accomplished without local anesthetic. The working tip of the ultrasonic
instrument should be applied to the tooth surface in small erasing or
scribbling motions. The debridement process should begin at the coronal
aspect of the tooth, moving gradually to the most apical area of the
pocket. Care must be taken to assure that all crown and root surfaces of
each tooth are touched by the instrument. The last few millimeters of
the instrument tip must always remain in motion and in contact with the
tooth surface. Do not put the point of the tip on the root surface,
however, as it can damage the root. Very little force should be applied
to the instrument. It is also important that the instrument tip of any
sonic or ultrasonic instrument never be directed "end-on" to the tooth
surface. Following the initial use of the ultrasonic instrument during
the procedure, the operator should carefully re-examine all crowns and
roots with a periodontal probe, pig-tail explorer, or other suitable
instrument to assure that the surfaces are free of hard and soft debris.
Any remaining deposits can be removed with either the ultrasonic
instrument or hand instruments.

**Irrigation:** Irrigating or lavaging anti-infective agents into the
most apical aspects of periodontal pockets helps to eliminate resistant
anaerobic organisms. They serve as an adjunct to the cleaning process by
improving the healing response and delaying bacterial recolonization of
the periodontal pockets. These agents can be employed in conjunction
with the coolant spray of certain ultrasonic scaling units or as a
separate subgingival irrigation procedure following the ultrasonic
cleaning. It appears that the exposure time of the anti-infective agents
to the subgingival bacteria is critical for the success of the
procedure. *Studies have demonstrated a minimum of 5-10 minutes of
constant lavage or exposure is required to produce the desired effect.*
When an anti-infective agent is used with the ultrasonic instrument, the
minimum exposure time is automatically achieved. Hand irrigation,
conducted as a separate procedure, does not appear as effective. The
chemotherapeutic agent currently recommended is a prescription
mouthrinse with 0.12% chlorhexidine (CHX).

**Systemic Antibiotics:** Antibiotics should be considered for use on
high-risk periodontal patients during the initial cleaning visits. The
purpose of systemic antibiotic usage is to optimize healing and reduce
the chances of re-infection of the periodontal pocket. Systemic
antibiotics do this by eliminating periodontal pathogens that have
penetrated gingival tissues. Their use should be considered during the
initial cleaning visits on any high-risk individual 14-35 years of age
who has two or more sextants of CPITN 4 scores. If no health related
contraindications exist, antibiotics should be prescribed to high-risk
individuals for a period of 7-21 days. During this period of time the
entire mouth should be thoroughly cleaned, usually over two
appointments. Antibiotic use without full mouth root debridement is of
very little benefit*.* The antibiotic recommended for routine use is
doxycycline. Doxycycline is a long-acting tetracycline that is effective
against most periodontal pathogens (Gram negative facultative and
anaerobic rods) and also acts as an enzyme suppressant so there is less
collagen breakdown. Doxycycline, because of its long-term action,
requires the patient to take only one or two capsules each day, thus
enhancing patient compliance. Doxycycline is also relatively inexpensive
since it is a generic drug. Doxycycline should be prescribed as follows:

Rx: Doxycycline 100 mg

Disp. 42 capsules

Sig. 1 capsule twice a day until all are taken.

If Doxycycline cannot be given, or if a refractory disease condition
exists, Augmentin 500 mg can be substituted in those not allergic to
penicillin or amoxicillin. Augmentin should be taken three times per
day, and the prescription should read:

Rx: Augmentin 500 mg

Disp: 30 capsules

Sig: 1 capsule q. 8 hours until all are taken.

A third antibiotic regimen includes the use of both amoxicillin and
metronidazole, which is particularly effective in those under 20 years
of age:

Rx: Amoxicillin and Metronidazole, 250mg of each

Disp: 24 tabs of each

Sig: 1 tab each every 8 hours until all are taken.

Systemic antibiotics can be helpful in achieving maximum results from
the initial patient debridement. However the benefits of systemic
antibiotics in this usage scheme must be weighed against their
associated problems. Frequent antibiotic use can promote resistant
bacterial strains. Antibiotics often cause significant side effects such
as allergic reaction, nausea, diarrhea, upset stomach and fungal
overgrowths. It is therefore recommended that systemic antibiotics be
administered to high-risk individuals only during the initial
debridement process. Antibiotics need not be prescribed again during
recall cleanings unless a refractory condition exists. The frequency of
antibiotic use in conjunction with subsequent debridement has not been
established. Therefore, repeating the use of systemic antibiotics will
remain a professional judgment decision until studies provide sound
guidelines.

d\. Recall for High-Risk Patients

High-risk periodontal patients will require frequent individualized
recall throughout their lives. Recall appointment intervals should be
from 1 to 6 months, based on the patient's individual needs. Maintenance
appointments should emphasize OHI, subgingival cleaning, use of
anti-infective agents, follow-up pocket depth measurements, and
encouragement of home care. In addition, high risk individuals may also
be targeted for informational mailings regarding their risk for
periodontal disease and need for frequent dental visits.

*Recall or maintenance care is the key to the success of the periodontal
disease prevention and treatment program.* High-risk periodontal
patients must be identified and continuously followed. This will require
a significant effort in establishing and maintaining a high-risk patient
register.

**2. Moderate-Risk Patients**

+--------------------+---------------+---------------+---------------+
| **population       |               |               |               |
| periodontal        |               |               |               |
| treatment\         |               |               |               |
| needs using        |               |               |               |
| CPITN**            |               |               |               |
+--------------------+---------------+---------------+---------------+
| **CPITN SCORES**   | **Treatment   |               |               |
|                    | needs**       |               |               |
+--------------------+---------------+---------------+---------------+
| **0**              | **Oral        |               |               |
|                    | hygiene       |               |               |
|                    | instructions  |               |               |
|                    | (OHI)**       |               |               |
+--------------------+---------------+---------------+---------------+
| **1**              | **OHI**       |               |               |
+--------------------+---------------+---------------+---------------+
| **2**              | **OHI and     |               |               |
|                    | prophy**      |               |               |
+--------------------+---------------+---------------+---------------+
| **3**              | **ohi and     |               |               |
|                    | prophy**      |               |               |
+--------------------+---------------+---------------+---------------+
| [\>]{.underline}4  | **AGE         |               |               |
|                    | DETERMINES    |               |               |
|                    | RISK          |               |               |
|                    | CATEGORY**    |               |               |
+--------------------+---------------+---------------+---------------+
| **Deep\            | **14 -- 35    | **36 -- 59    |               |
| Pockets**          | YEARS**       | YEARS**       |               |
|                    |               |               |               |
|                    | ***HIGH       | ***MODERATE   |               |
|                    | RISK***       | RISK***       |               |
|                    |               |               |               |
|                    | **OHI**       | **OHI**       |               |
|                    |               |               |               |
|                    | **High        | **Closed or   |               |
|                    | Intensity,**  | Open**        |               |
|                    |               |               |               |
|                    | **N           | **Root        |               |
|                    | on-Surgical** | Debridement** |               |
|                    |               |               |               |
|                    | **C           | **Recall as   |               |
|                    | hemotherapy** | Resources     |               |
|                    |               | Allow**       |               |
|                    | **Active      |               |               |
|                    | Recall**      |               |               |
+--------------------+---------------+---------------+---------------+

**a. Moderate-Risk (or Advanced Disease)**

Once the needs of the high-risk group have been addressed, the dental
manager can consider the formidable task of treating individuals from
the moderate-risk category. The moderate-risk group can be expected to
make up 70-80% of any given population. Unlike high-risk people,
individuals with moderate-risk will likely retain a functional dentition
(20 or more teeth) for most of their lives. Studies have shown that
while the moderate-risk people will retain 20 or more teeth, they will
also develop deep periodontal pockets in the 4th, 5th, and 6th decades
of life. Longitudinal tooth loss studies indicate that moderate-risk
individuals will experience some tooth loss, usually maxillary and
mandibular second and first molars, followed by incisor teeth. While the
definition of a functional dentition describes a minimal masticatory
ability, it is somewhat misleading, because it fails to account for the
likely presence of advanced periodontitis. Clearly, individuals with
moderate risk for periodontal disease will present with periodontal
treatment needs in the second half of their lives.

**b. Treatment for Moderate-Risk (or Advanced Disease) Patients**

Due to the slower rate of periodontal disease progression in
moderate-risk individuals, the treatment approach can be less intense
than that provided to the high-risk patient. Under this model, less
frequent recall would be required of the moderate-risk patients.
However, the goals of treatment (root debridement and oral hygiene
maintenance), are the same for both the high-and moderate-risk groups.
For many patients, twenty-five or thirty years of poor oral hygiene,
subgingival calculus accumulation, and untreated disease have resulted
in only moderate bone loss. For these somewhat periodontal
disease-resistant patients, one or two appointments for thorough supra-
and subgingival cleanings will provide dramatic reductions in the
progression of periodontal breakdown. The benefits of the periodontal
debridement will be long-lasting due to the slow reformation of plaque
retentive features (calculus) and harmful bacteria.

*The usual approach to treatment of moderate-risk patients is closed
(non-surgical), subgingival root debridement.* Local or topical gel
anesthetic is usually indicated to assure patient comfort and allow for
thorough root debridement. An alternative to local is topical
anesthesia, such as use of a lidocaine and prilocaine gel delivered into
the sulcus (i.e. Oraqix®).

**c. Recall for Moderate-Risk Patients**

Dental research has established that periodontal health can be
maintained through continuous 3-month professional prophys. However,
this research does not account for individual periodontal risks. For
moderate-risk patients, it is reasonable for the dental provider to
consider recall intervals longer than 3 months. Six month, annual, or
even longer recall visits may be prescribed, based on the patient's
individual needs, clinic resources, and program priorities. Again, the
moderate-risk group accounts for the majority of any population.
Therefore, it is doubtful that many publicly-funded program would have
the resources necessary to provide 3-month recalls to the entire
moderate-risk group.

**3. Low-Risk Patients**

+--------------------+---------------+---------------+---------------+
| **Population       |               |               |               |
| Periodontal        |               |               |               |
| Treatment\         |               |               |               |
| Needs Using        |               |               |               |
| CPITN**            |               |               |               |
+--------------------+---------------+---------------+---------------+
| **CPITN SCORES**   | **Treatment   |               |               |
|                    | needs**       |               |               |
+--------------------+---------------+---------------+---------------+
| **0**              | **Oral        |               |               |
|                    | hygiene       |               |               |
|                    | instructions  |               |               |
|                    | (OHI)**       |               |               |
+--------------------+---------------+---------------+---------------+
| **1**              | **OHI**       |               |               |
+--------------------+---------------+---------------+---------------+
| **2**              | **OHI and     |               |               |
|                    | prophy**      |               |               |
+--------------------+---------------+---------------+---------------+
| **3**              | **ohi and     |               |               |
|                    | prophy**      |               |               |
+--------------------+---------------+---------------+---------------+
| [\>]{.underline}4  | **AGE         |               |               |
|                    | DETERMINES    |               |               |
|                    | RISK          |               |               |
|                    | CATEGORY**    |               |               |
+--------------------+---------------+---------------+---------------+
| **Deep\            | **14 -- 35    | **36 -- 59    | **[\>]{       |
| Pockets**          | YEARS**       | YEARS**       | .underline}60 |
|                    |               |               | YEARS**       |
|                    | ***HIGH       | ***MODERATE   |               |
|                    | RISK***       | RISK***       | ***LOW        |
|                    |               |               | RISK***       |
|                    | **OHI**       | **OHI**       |               |
|                    |               |               | **OHI**       |
|                    | **High        | **Closed Root |               |
|                    | Intensity,**  | Debridement** | **Closed      |
|                    |               |               | Root**        |
|                    | **N           | **Recall as   |               |
|                    | on-Surgical** | Resources     | **            |
|                    |               | Allow**       | Debridement** |
|                    | **C           |               |               |
|                    | hemotherapy** |               | **Recall as   |
|                    |               |               | Resources     |
|                    | **Active      |               | Allow**       |
|                    | Recall**      |               |               |
+--------------------+---------------+---------------+---------------+

**Low-Risk Patients:** Members of the low periodontal disease risk group
are a fortunate few. Despite 40 or more years of exposure to oral
bacteria, these individuals have either failed to develop periodontal
breakdown or their attachment and bone loss is minimal. *Indeed, true
low-risk people will probably never develop deep pockets.* This fact
essentially eliminates this group as a risk group. Therefore, the final
working periodontal risk model can be reduced to the following:

+--------------------+---------------+--------------------------------+
| **Population       |               |                                |
| Periodontal        |               |                                |
| Treatment\         |               |                                |
| Needs Using        |               |                                |
| CPITN**            |               |                                |
+--------------------+---------------+--------------------------------+
| **CPITN SCORES**   | **Treatment   |                                |
|                    | needs**       |                                |
+--------------------+---------------+--------------------------------+
| **0**              | **Oral        |                                |
|                    | hygiene       |                                |
|                    | instructions  |                                |
|                    | (OHI)**       |                                |
+--------------------+---------------+--------------------------------+
| **1**              | **OHI**       |                                |
+--------------------+---------------+--------------------------------+
| **2**              | **OHI and     |                                |
|                    | prophy**      |                                |
+--------------------+---------------+--------------------------------+
| **3**              | **ohi and     |                                |
|                    | prophy**      |                                |
+--------------------+---------------+--------------------------------+
| **\>4**            | **AGE         |                                |
|                    | DETERMINES    |                                |
|                    | RISK          |                                |
|                    | CATEGORY**    |                                |
+--------------------+---------------+--------------------------------+
| **Deep\            | **14 -- 35    | **36 YEARS and OLDER**         |
| Pockets**          | YEARS**       |                                |
|                    |               | **MODERATE RISK or**           |
|                    | **HIGH RISK** |                                |
|                    |               | **ADVANCED DISEASE**           |
|                    | **OHI**       |                                |
|                    |               | **OHI**                        |
|                    | **High        |                                |
|                    | Intensity,**  | **Closed Root**                |
|                    |               |                                |
|                    | **N           | **Debridement**                |
|                    | on-Surgical** |                                |
|                    |               | **Recall as resources allow**  |
|                    | **C           |                                |
|                    | hemotherapy** |                                |
|                    |               |                                |
|                    | **Active      |                                |
|                    | Recall**      |                                |
+--------------------+---------------+--------------------------------+

**Summary**

The intent of the Risk-Based Periodontal Disease Treatment model is to
provide the dental public health provider with a rational approach for
identifying and prioritizing periodontal treatment within a population.
This model uses CPITN/PSR scores and age for predicting periodontal
risks and treatment priorities. High-risk individuals should receive the
highest priority for care. Generally, treatment is based on root
debridement, anti-infective agents, and periodic recall. Ultrasonic
instruments are utilized due to their efficiency and ease of operation.
Chemotherapeutics, such as mouthrinses, irrigants, and local and
systemic antibiotics, are suggested for those at high risk for
periodontal disease. Special efforts should be taken to educate
high-risk patients concerning their disease risk and self-care and
treatment needs. High-risk individuals should also receive every
opportunity for frequent and continuous recall. Moderate-risk or
advanced disease patients will receive less intense treatment and
recall. The ability to treat moderate-risk or advanced-disease
individuals from a given population or community should be a priority
for local dental providers.

**Periodontal Disease Treatment Protocol for Individuals with Type 2
Diabetes Mellitus**

The following treatment protocol has been developed, based upon the
findings of the periodontal disease clinical trial conducted on Pima
Indians with type 2 diabetes mellitus (DM) and longitudinal data at the
Periodontal Disease in Diabetics Model Program sites.

**I. Dental Examination**

A thorough dental examination should be conducted on each patient.
Bite-wing and panographic radiographs should be obtained as a minimum
requirement. Additional x-rays can be taken as needed. A complete
medical history should also be taken at this time to determine health
status, including the presence of an established diagnosis of Type 2 DM.

**Periodontal evaluation**: The Community Periodontal Index of Treatment
Needs (CPITN) or the Periodontal Screening and Recording (PSR) index
should be used to determine the periodontal status during each dental
examination. The deepest pocket in each sextant should be identified and
recorded. *The treatment protocol should be implemented on all
consenting dental patients who present with both of the following
conditions:*

-   Type 2 DM

-   CPITN scores of 4 in *two or more* sextants

A determination should also be made at this time of teeth with a
hopeless periodontal prognosis. Hopeless teeth are those that are
visibly depressible and/or have bone loss to one or more root apices.
Hopeless teeth can be removed at the appropriate time during treatment,
including during the initial debridement procedure.

**II. Dental Treatment Planning**

The priority of dental treatment is an important element of the overall
treatment plan. Emergency or acute disease obviously takes precedence
over chronic conditions. However, once the acute problems have been
addressed, it is often difficult to establish a rank order of treatment
priorities. Balancing chief complaints, chronic conditions, prosthetic
needs, and clinic resources can challenge the dental provider's
treatment planning skills.

For individuals who qualify for the periodontal disease treatment
protocol, i.e. diabetics with two or more sextants of CPITN score of 4
and evidence of inflammation/infection, the following treatment planning
order of priority should be followed:

1\. Emergency Care (trauma, acute pain and infections, etc.)

2\. Control of rampant caries and Imminent Pulpal Involvement

3\. Initial Periodontal Therapy (full mouth treatment)

4\. Restorative Treatment

5\. Elective Surgical Treatment (3rd molars, perio, etc.)

6\. Prosthetics

7\. Other Higher Levels of Care

**III. Initial Periodontal Treatment**

The periodontal treatment protocol for dental patients with Type 2 DM
uses a combination of non-surgical instrumentation (ultrasonic) with a
systemic antibiotic and anti-infective agent irrigation. The protocol
calls for two half-mouth treatment sessions which are usually scheduled
one hour per session. A description of the treatment protocol follows:

**A. Piezon Master Set-up**

The EMS Piezon Master® will serve as the standard ultrasonic instrument
for this treatment protocol.

1\. Preparation of Irrigant Solution:

Chlorhexidine (CHX) solution:

> Use 0.12% chlorhexidine as the irrigant of first choice. Place the
> chlorhexidine in the plastic irrigant bottle provided with the Piezon
> Master. Fill the bottle approximately 3/4 full. *CHX should be used
> full strength and never diluted*. (The 0.12% chlorhexidine is
> FDA-approved at a minimum effective concentration.)

2\. Plug in the Piezon Master and turn on switch on the back of the
machine. Be sure the selector switch found on the right side of the
Piezon Master is in the scaling/irrigating position. Place the plastic
bottle containing the irrigating solution into the receptacle on the top
of the machine and with a gentle clockwise 1/4 turn lock the bottle into
position. Use high power settings for the Piezon Master (approximately
[\>]{.underline} 3/4 maximum settings).

**B. Initial Treatment Procedure**

1\. Oral Hygiene

> Oral hygiene instructions should be given, emphasizing the use of a
> soft bristle brush and rubber tip. A brush and rubber tip should be
> given to the patient at this time. For patients with sufficient
> interproximal space, interproximal brushes may be demonstrated and
> provided. Oral hygiene instructions should be introduced gradually so
> that the patient is not overwhelmed by too much information. Simple
> techniques of brushing and rubber tipping can be introduced initially
> while more advanced home care instructions, such as proxabrush and
> floss use, can be taught at subsequent visits.

2\. Set up the Piezon Master and have a mirror, explorer, and probe
available.

3\. Anesthetize upper and lower quadrants on the same side of the mouth.

4\. Begin from the distal of the last tooth and continue to the midline.
Use nerve blocks or regional anesthesia as appropriate. Once the
anesthetic from these injections has taken effect, inject every
interdental papilla. For routine anesthesia, use xylocaine with
1:100,000 epinephrine. Other anesthetics can be utilized, as indicated
by existing patient health conditions.

5\. Half mouth periodontal charting is provided if not already obtained
at the oral exam appointment.

6\. Initial Ultrasonic Debridement

> The Perio Regular "P" tip should be selected and placed on the Piezon
> Master handpiece for the initial debridement procedure. The "P" tip
> should be considered the universal operating tip for subgingival use.
>
> *Note: During operation, the Piezon Master moves the instrument tip in
> a linear, back-and-forth motion. For this reason, the Piezon Master
> tip is effective only when the thin, blade-like edge of the tip is
> applied to the tooth surface. This is unlike the magnetostrictive
> instruments, such as the Dentsply Cavitron®, which moves its
> instrument tip three-dimensionally, or in all directions.*
>
> Start on the distal of the most posterior tooth of the given quadrant
> and proceed around the buccal aspects and interproximals to the
> midline with the Piezon Master. In the deep, inflamed pockets place
> the tip of the instrument apically along the axis of the tooth until
> bony resistance is felt. You should feel the osseous tissue and the
> contours of the tooth as this process occurs. This aggressive, deep
> cleaning ensures more effective removal of deep subgingival calculus
> as well as infected pocket lining. Debride all surfaces carefully.
> Although the procedure emphasis is on root debridement, all
> supragingival calculus should also be removed. Repeat the ultrasonic
> debridement from the lingual. In the deep, inflamed pockets,
> granulation tissue, pocket epithelium and plaque will be removed and
> the interdental papilla may be released. In the shallow to moderate
> depth pockets, it is important to go to the depths of the pocket and
> completely (360°) around each tooth to remove all plaque and calculus
> in the lateral and apical projections of the pockets.

7\. Check all surfaces for smoothness and hardness.

8\. Final Ultrasonic Debridement

> a\. Debride with the Piezon Master Perio Slim Tip PS using irrigating
> solution, approximately 30 seconds per tooth, from the buccal and the
> lingual as in the initial debridement. Concentrate on those areas that
> feel rough upon root surface testing. The total ultrasonic debridement
> (initial and final) per 2 quadrants may require refilling of the
> irrigant bottle.
>
> b\. If the interdental papillae become detached as a result of the
> debridement procedure, simple pressure on both sides of the papilla
> (forcing the buccal and lingual papillae back into their natural
> positions) for several minutes may be all that is necessary. However,
> for severe displacement of the papillae, suture the buccal and lingual
> papilla over the interproximal bone with a single interproximal
> suture. Use 3-0 or 4-0 suture material with no periodontal dressing.
>
> c\. All overhangs should be removed at this time with the dental
> handpiece and a flame-shaped or other appropriate bur.

9\. Extract all periodontally hopeless teeth at this time.

**C. Postoperative Care**

1\. Patients should be given doxycycline 100 mg twice a day for 21 days.

> *Note: It is essential for patients to be scheduled to receive their
> second half-mouth initial treatment during the 21-day period while
> taking the systemic antibiotics. If there is a possibility of a missed
> second appointment, start the antibiotic at the second treatment
> appointment. If the patient's blood sugar is well controlled, gingival
> inflammation is mild, and there are just a few, isolated deep pockets,
> doxycycline does not have to be prescribed.*
>
> It is often helpful to make the patient two, one hour treatment
> appointments following the dental examination. The two appointments
> should be within a 21-day period of time. Anywhere from 1 to 7 days is
> ideal. This will allow both treatment sessions to occur during the
> course of antibiotic coverage.

2\. The patient should rinse 2 times per day with 30 ml of CHX solution
for two weeks after each debridement procedure.

3\. Patients should be given appropriate OTC analgesics (ibuprofen 400
mg, acetaminophen 650 mg, etc.) either before or immediately after the
debridement procedure(s). A 7-day supply of these analgesics should also
be prescribed to the patient. For patients with lower pain thresholds or
in those whom more extensive pain is anticipated, a stronger drug can be
prescribed, such as acetaminophen with hydrocodone or codeine.

4\. Post-operative emergencies

> Treat abscesses with incision and drainage and local irrigation with
> povidone iodine (10%) and H202. As an alternative, a small open-flap
> surgical procedure can often be helpful in gaining access to the
> affected tooth root as well as encouraging drainage*.* Do not use
> systemic antibiotics unless the patient is febrile.

**IV. Continuous Periodontal Therapy (Recall)**

Results of the Gila River Indian Community periodontal disease clinical
trial indicate that patients will experience periodontal improvements,
i.e., attachment gains, pocket depth reductions, reduced gingival
bleeding, etc., for up to six months following the initial debridement
procedure(s). Therefore, all patients who are receiving the
diabetes/periodontitis treatment protocol should be recalled 6 months
following their initial periodontal treatment. According to the study
results, the 6-month post-treatment period marks the beginning of
harmful bacterial recolonization of the periodontal pockets in Type 2 DM
patients. It is at this time periodontal treatment should intervene, by
again removing and/or destroying the subgingival periodontal pathogens.
*Continuous 6-month treatments should maintain the diabetic patients'
periodontal health*.

**A. 6-Month Recall and Periodontal Examination**

At the first 6-month visit, and at all subsequent 6-month recalls, a
periodontal pocket assessment must be conducted in all sextants. Using
the CPITN, the deepest pockets must be identified and recorded in each
sextant. *The extent of treatment will be based on the presence or
absence of deep pockets*. Deep pockets are defined as CPITN scores = 4
(i.e., [\>]{.underline} 6 mm in depth).

1\. Deep Pockets --- Retreatment Procedure (CPITN=4)

> The identification of deep pockets (CPITN=4) in any area of the mouth,
> 6-months following initial treatment, *or at any recall visit*, will
> require retreatment. Retreatment should be performed only in those
> specific sites where deep pockets exist. No attempt should be made to
> retreat the entire sextant or full mouth unless deep pockets are
> generalized. The retreatment procedure should follow that described in
> the initial periodontal treatment section above, with the exception
> that systemic antibiotics should not be prescribed. An option is a
> systemic enzyme suppressor such as Periostat®, particularly in those
> patients with moderate to heavy bleeding on probing and generalized
> mediocre to poor response to the initial therapy:

RX: Periostat, 20mg

DISP: 180 tabs

SIG: 1 tablet twice a day for 90 days

> Locally Delivered Antibiotics
>
> Isolated deep pockets with bleeding on probing are excellent
> candidates for treatment with locally delivered antibiotics.
> Therefore, locally delivered antibiotics can be used in conjunction
> with the retreatment procedure(s). The currently available commercial
> products are a resorbable chlorhexidine chip (Periochip®), a
> doxycycline gel (Atridox®), and a minocycline microsphere (Arestin®).

2\. No Deep Pockets --- Deplaquing Procedure (all CPITN sextant scores
[\<]{.underline} 3)

**Piezon Master set-up:**

> The instrument set-up for follow-up treatment is similar to that of
> the initial treatment(s). A Piezon Master will serve again as the
> primary instrument. Peridex will also be used as the irrigating agent.
> As an alternative, a 5% iodine solution can be used for those
> individuals sensitive to chlorhexidine. *The thinner Piezon Master
> "PS" tip is recommended for most shallow pocket recall treatment*.
> This tip is smaller and able to reach into pockets without distention
> of the soft tissue.
>
> a\. Local Anesthesia
>
> Usually, no local anesthesia will be required for recall treatment
> visits. Patient sensitivity can normally be controlled through
> adjustment of the Piezon Master power setting. For very sensitive
> patients, however, local or topical gel anesthesia may be needed.
>
> b\. Calculus Removal
>
> Heavy subgingival calculus should not be expected at the subsequent
> recall appointments. However, light, supragingival calculus may be
> encountered, particularly in mandibular anterior areas. All calculus
> should be thoroughly removed at recall visits.
>
> c\. Deplaquing
>
> The main objective of 6-month continuous periodontal treatment is the
> removal of all soft root debris and disinfection of the periodontal
> pocket. The process of removing the soft, bacterial plaque is often
> referred to as "deplaquing." The deplaquing procedure should be
> carried out with the Piezon Master Perio Slim "PS" tip, as described
> above. All supra- and subgingival tooth surfaces should be
> meticulously debrided and irrigated using the ultrasonic instrument
> and chlorhexidine irrigant.
>
> *Note: A significant difference in the debridement procedures exist
> between the initial treatment(s) and subsequent recall or continuous
> therapy visits. Debridement apically "until bony resistance is felt,"
> should be performed only during the initial treatment visits. Recall
> treatment should involve debriding root surfaces apically only to the
> level of soft tissue attachment, i.e., to the base of the periodontal
> pocket. **In order to maintain periodontal attachment gains, no
> attempt should be made to feel the osseous tissue during the
> debridement procedures at recall visits where CPITN sextant scores are
> \< 4.***
>
> d\. Systemic Antibiotics
>
> No systemic antibiotics or enzyme suppressors will be required at
> 6-month recall visits. Exceptions may occur to this general rule for
> refractory patients. However, consultation with a periodontist is
> suggested to determine specific therapy.
>
> *Note: Some patients may demonstrate periodontal abscess formation
> and/or generalized pocket suppuration prior to the 6-month return
> visit. These "refractory" patients will require more frequent and
> perhaps more specific periodontal therapy. Consultation with a
> periodontist for treatment is recommended for these individuals.*

**B. 12-Months and Beyond (Continuous 6-Month Recall)**

It is obvious that individuals with Type 2 DM and periodontal disease
will require constant monitoring and continuous periodontal therapy as
long as they have Type 2 DM and teeth. The treatment protocol described
above allows the dental provider to effectively manage Type 2 DM
patients who are at higher risk for periodontal breakdown. A continuous
6-month recall treatment for life is recommended for most protocol
patients. For individuals who practice excellent oral hygiene and whose
periodontal tissues remain healthy, recall intervals longer than 6
months can be contemplated. *Each dental provider will have to assess at
each appointment the status and progress for his or her Type 2 DM*
*periodontal patients*. However, even for periodontally stable patients,
periodic monitoring of periodontal status is essential for the
maintenance of periodontal health.

The provision of an effective treatment protocol for Type 2 DM
individuals with periodontal disease is important. However, clinic
management activities are also essential in order to carry out the
treatment program. The establishment of the following systematic
approaches to support the treatment protocol is also suggested:

1\. Type 2 DM /Periodontal Patient Register

> The establishment of a method of identifying and following Type 2 DM
> dental patients is necessary for any long-term patient success.
> Currently, computers with database software, the Electronic Dental
> Record, or the RPMS/DDS systems exist which would allow the
> development of a Type 2 DM dental patient register (database) and
> tracking system. Any number of other systems is possible, including a
> notebook and pencil! *Without an adequate system of tracking patients
> and their recall needs, the treatment protocol will not provide
> long-term health benefits.*

2\. Patient Monitoring

> In order to determine the long-term success of the treatment, clinical
> status measurements will need to be obtained for each patient at some
> regular time interval. Unfortunately, CPITN/PSR serve only as crude
> indicators of periodontal status. For a more definitive measure of
> periodontal health, a full-mouth probing and recording is recommended
> at least annually for patients on the Type 2 DM/periodontitis protocol
> register.

3\. Program Dropouts

> It is inevitable that some individuals receiving the treatment
> protocol will choose not to continue with the program. This
> non-compliance will manifest itself in many different ways. Some
> patients will return every 6 months, some once a year, and others only
> occasionally. Two important issues are faced with non-compliant
> patients:
>
> a\. Clinic Access
>
> An important question arises concerning what clinic access
> non-compliant patients should have? *For periodontal patients with
> Type 2 DM, special clinic access should be afforded despite less than
> perfect compliance.* Diabetics with periodontal disease represent a
> special "risk-group" within the population. As such, extra efforts
> should be expended in attempting to reach this group. Although
> problems will occur with broken and canceled appointments for these
> patients, continued special clinic access should be given.
> Compensation for broken appointments can be managed in several
> different ways, e.g., over-scheduling, local callback lists,
> confirming appointments, etc.
>
> b\. Back To Go
>
> At some point, the question will occur for "protocol drop-outs," who
> periodically present to the dental clinic \... Shouldn't this patient
> start all over with the treatment? The clinical conditions which would
> indicate starting the treatment protocol over are somewhat variable.
> However, here are some general rules to follow:
>
> --- Patients who did not finish the initial treatment:
>
> For patients who received only partial initial treatment and then
> dropped out (and it has been less than three years), initial treatment
> protocol can be performed on the untreated portion of the mouth using
> chlorhexidine and doxycycline as per the protocol. The previously
> treated area of the mouth can be debrided according to the 6-month
> recall instructions, i.e., the presence or absence of deep pockets*.*
> From this point on, 6-month recall visits should be scheduled.
>
> --- Patients who finished initial treatment, then dropped out:
>
> *\< 3 years since initial treatment:* Schedule patient for 6-month
> recall treatment procedures (based on CPITN scores), with 6-month
> recall.
>
> *\> 3 years since initial treatment:* Schedule patient to begin
> initial treatment protocol again, with 6-month recalls.

4\. Staff Training Needs

> Training of the dental staff in the implementation of this protocol is
> important prior to beginning the first treatment. However, after the
> initial training needs have been met, ongoing program monitoring,
> maintaining quality of care among the providers, and training new
> staff members will provide continuous training challenges for dental
> managers.

**V. Treatment Protocol Quick Reference Guide**

**Oral and Oropharyngeal Cancer**

**Prevention and Early Detection**

There are approximately 28,150 new cases of oral and oropharyngeal
cancer per year in the United States and about 8,370 deaths from these
diseases (1). Incidence is twice as high in men as in women, and 95
percent occurs in persons over the age of 40. Approximately 50 percent
of persons diagnosed with oral cancer survive less than five years after
diagnosis. Of the 13 major cancer sites, oral cancer has the fifth
lowest survival rate. Incidence of oral and oropharyngeal cancer and
survival rates, as well as stages when detected, appear to be related
more to socioeconomic factors than to ethnic differences.

Several surveys have shown that a large percentage of the American
Indian/Alaska Native (AI/AN) population engage in behaviors that place
them at high risk for oral and oropharyngeal cancers. These behaviors
include the frequent use of alcohol and tobacco products. Of particular
concern is that in some areas 30 to 50 percent of AI/AN children and
teenagers routinely use smokeless tobacco (2). The report of the
Advisory Committee to the Surgeon General on "The Health Consequences of
Using Smokeless Tobacco" in 1986 made it clear that "the oral use of
smokeless tobacco represents a significant health risk" and "can cause
cancer (3)."

A view widely shared among IHS dentists and physicians, but yet to be
proven scientifically, is that oral and oropharyngeal cancer rates in
Native Americans are low, despite the prevalence of high-risk behavior.
Nevertheless, the importance of early detection as a means of increasing
the five-year survival rate and decreasing survival morbidity of persons
with these cancers cannot be overstated (4). Over half of oral cancers
have metastasized or become invasive by the time they are diagnosed (5).
Oral cancer may be painless or otherwise asymptomatic in its early
stages. This underlines the importance of guaranteed access to care and
regular oral examinations, including a thorough soft tissue examination
for all dental patients. Of equal or greater importance is the need to
educate patients regarding the risk factors and warning signs associated
with these cancers.

**Oral cancer prevention programs should therefore include the following
activities:**

1\. Thorough soft tissue examinations of all patients, including
emergency encounters, with documentation of normal and abnormal findings
in the medical or dental chart. This should include careful examination
for cancerous lesions of the oral cavity, especially in the elderly and
in patients who use tobacco and/or excessive amounts of alcohol, as well
as in those with suspicious symptoms or self-identified lesions.

2\. Documentation of individual preventive planning for all dental
patients who present for an initial or periodic oral exam, which
includes asking adults and adolescents to describe their use of tobacco
and alcohol and offering appropriate counseling referrals for those who
smoke, use smokeless tobacco, present evidence of alcohol abuse, or have
chronic occupational exposure to sunlight. Information on tobacco use is
to be documented on the preventive assessment section of the dental exam
form and also should be included in the health history questionnaire.

3\. In-service training for medical staff (including physicians, nurses,
and physician's assistants) in oral and oropharyngeal cancer etiology,
pathogenesis, detection, and prevention. They should be encouraged to
include inspection of the oral soft tissue in routine physical
examinations, especially in geriatric patients and in patients who use
tobacco and alcohol.

4\. Individual and community education concerning the risk factors and
warning signs associated with oral and oropharyngeal cancer, including
discussion of smoking, smokeless tobacco, sun exposure, alcohol, and
local irritants.

5\. School-based education on the hazards of smoking and smokeless
tobacco use; school and community-based cessation programs.

6\. Community-based prevention and intervention strategies. Some
examples of intervention/cessation programs follow:

> a\. The National Cancer Institute (NCI) and the American Cancer
> Society have recently joined forces to mount the largest demonstration
> project for tobacco control ever conducted. The project, the America
> Stop-Smoking Intervention Study (ASSIST) (6), is designed to reach
> over one-fifth of the U.S. population and at least 15 million smokers
> through community-based tobacco control coalitions. The NCI encourages
> the involvement of dental professionals in tobacco issues and this
> project. This project is community oriented. It provides "an excellent
> opportunity for dentistry to become involved with a social concern
> that affects oral health as well as general health and public well
> being" (Dr. Mecklenburg). Further information may be obtained from the
> NCI Smoking, Tobacco and Cancer Program on the internet at
> <http://www.cancer.gov/cancertopics/tobacco>.
>
> b\. Successful tobacco use interventions include drug-based cessation
> programs using pharmacologic nicotine and combined drug and behavioral
> tobacco cessation programs. Methods that have not proven successful
> are acupuncture, hypnosis, over-the-counter medications and nostrums.
> Tobacco cessation strategies can be reinforced through psychological
> counseling, group therapy, or self-help programs.
>
> c\. Studies indicate that smokers are more likely to use a
> telephone-based cessation service than they are a face-to-face program
> (20). Quitlines also offer important advantages from a health
> education / program perspective. Quitlines function based on a
> centralized system of operation and promotion, allowing for:

-   Economies of scale, where financial and staffing resources can be
    utilized more efficiently.

-   Standardized protocols and training for all cessation/counseling
    activities.

-   Routine monitoring of counseling for quality assurance and
    continuity of services.

-   Easier collection and evaluation of data.

-   Ease of marketing and promotion, as only one campaign is necessary,
    though it may be (or need to be) large scale.

The national Quit-line number is 1-800-QUIT-NOW.

> d\. An example of a multi-method approach to tobacco cessation is the
> Stanford Stop Smoking Program. This program uses a pharmacological
> agent (nicotine gum), self-control strategies, a set of self-help
> manuals, and a personal contract setting a quit date. The program can
> be obtained from the Stanford Health Promotion Resource Center, on the
> internet at <http://hprc.stanford.edu/pages/store/itemDetail.asp?39> .
>
> Excellent self-help materials are also available through the American
> Cancer Society (1-800-227-2345 and on the web at
> [http://www.cancer.org](http://www.cancer.org/) ) and the American
> Lung Association (1-800-586-4872 and on the web at
> <http://www.lungusa.org/tobacco> ). The State of Arizona also offers
> online individual tobacco treatment certification training, approved
> by the IHS tobacco task force, at
> <http://bandura.sbs.arizona.edu./hcp/right.html>
>
> e\. "Teens and Tobacco, A Community Handbook for Developing a Youth
> Diversion/Tobacco Awareness program" is a program based on the
> Minnesota Plan for Nonsmoking and Health. This program is available on
> the internet at http://www.ansrmn.org/Youth%20Access.htm .
>
> f\. Health care professionals are in a uniquely favorable position to
> influence their patients' tobacco use behavior. Dr. Louis Sullivan,
> former Secretary for Health and Human Services, estimates that if
> every physician routinely counseled his or her patients about the
> dangers of tobacco use and encouraged them to quit smoking, at least
> one million Americans would stop smoking in one year. Dentists can be
> equally effective in promoting tobacco avoidance by showing patients
> the tangible drawbacks of tobacco use, such as staining of teeth, bad
> breath, etc. During routine oral examinations, dentists can inform
> their patients that tobacco causes oral and other types of cancer.
> They can join their medical colleagues in encouraging their patients
> who use tobacco to enter tobacco cessation programs.
>
> g\. A guide for clinical intervention, "Clinical Opportunities for
> Smoking Intervention," is available from the Public Health Service,
> National Institutes of Health. NIH Publication No. 86-2178, August
> 1986. This guide describes specific ways that dentists and physicians
> can promote tobacco cessation, including the following:

-   Act as a role model by not using tobacco and creating a tobacco-free
    environment.

-   Provide information on risks associated with tobacco and reduction
    of risk if the patient stops.

-   Encourage abstinence by direct advice and suggestions.

-   Refer the patient to a tobacco cessation program.

-   Prescribe and follow up on use of specific cessation and maintenance
    strategies.

> h\. Additional resources can be found on the CDC's Tobacco Information
> and Prevention Source website at <http://www.cdc.gov/tobacco/> or by
> calling 1-800-232-1311.

The U.S. Preventive Task Force questions the efficacy of routine
screening examinations for oral cancer by primary clinicians for all
asymptomatic persons. However, it does recommend that all patients
should be counseled to receive regular (annual) dental examinations, to
discontinue the use of all forms of tobacco, and to limit consumption of
alcohol. It also recommends that persons with increased exposure to
sunlight should be advised to take measures to protect their lips and
skin from the harmful effects of ultraviolet rays (8).

A complete oral examination must include both inspection and digital
palpation of circumoral as well as intraoral structures. Adequate
lighting, a tongue blade or depressor, a dental mirror, some strips of
gauze, and rubber gloves or finger cots are the only materials required.
The examination should be systematic and repeatable. It should include
all hard and soft tissues and underlying structures of the oral and
perioral region, with attention given to color, tissue tone, surface
texture, and radiological findings. The following sequence is
recommended:

> 1\. Obtain a thorough medical history. Question patient about alcohol
> and tobacco use and occupational sun exposure.
>
> 2\. Visually inspect the head and neck for keratoses, ulcers, unusual
> pigmentation, skin blemishes, asymmetry, and abnormal masses.
>
> 3\. Palpate the regions of the major salivary glands and the lymph
> nodes of the head and neck, noting any abnormal swelling, masses, or
> indurations.
>
> 4\. Inspect and palpate the external vermillion border and the
> commissures of the lips.
>
> 5\. Thoroughly examine the intraoral cavity, proceeding from anterior
> to posterior oral structures and pharynx. The sequence may be: lips,
> buccal mucosa, floor of the mouth, tongue, hard and soft palate,
> faucial arches and tonsils, posterior pharynx, retromolar areas, teeth
> and gingiva. To properly inspect the tongue, it should be grasped with
> gauze and pulled forward to expose the lateral borders, while the
> cheek is retracted with a tongue blade or dental mirror. Following
> careful inspection, these areas should be thoroughly palpated with
> thumb and index finger of the gloved hand to detect areas of swelling,
> roughness, induration, or asymmetry.

In 1987, the National Institute of Dental Research suggested the
following classification system of mucosal lesions associated with
smokeless tobacco use (9-11):

> **Degree 1** Slight superficial wrinkling of the mucosa. Color of the
> mucosa may range from normal to pale white or gray. Mucosa does not
> appear to be thickened.
>
> **Degree 2** Distinct whitish, grayish, or occasionally reddish color
> change. Wrinkling is obvious, but there is no thickening of the
> mucosa.
>
> **Degree 3** Mucosa is obviously thickened, with distinct whitish or
> grayish color change. Deep furrows are present within the thickened
> area.

Although self examination has been an effective form of screening for
some types of cancer, such as breast cancer, the efficacy of self
screening for oral and oropharyngeal cancer is questionable, except for
lip cancer. The time required for the dentist to teach patients self
examination techniques might be better spent in performing thorough soft
tissue examinations, counseling patients regarding high risk behaviors
and the recognition of warning signs, and teaching other health care
professionals oral soft tissue examination techniques.

**Warning Signs Of Oral And Oropharyngeal Cancers** (13)

1\. A swelling, lump, or growth in or about the mouth, with or without
pain

2\. White, scaly patches or red, velvety areas in or about the mouth

> 3\. A sore or ulceration in or about the mouth that does not heal
> within two weeks

4\. Numbness or tingling in any part of the mouth

5\. Repeated bleeding for no apparent reason

6\. Loosening of teeth with no apparent cause

7\. Excessive dryness or wetness of the mouth

> 8\. Prolonged hoarseness, sore throat, persistent cough, or the
> feeling of a "lump in the throat"

9\. Difficulty in chewing, swallowing, speaking, or opening the mouth

**High-Risk Groups**

1\. Persons who use tobacco

2\. Persons who drink alcohol

3\. Persons with a history of cancer or premalignant lesions

> 4\. Professions that are chronically exposed to the sun (e.g.,
> farmers, sailors, fishermen)

5\. Males over age 40

The use of toluidine blue (tolonium chloride) vital stain has been
advocated by some oral cancer experts as diagnostic adjunct to
subjective clinical impression in detecting oral cancer (14). While
staining of early mucosal cancers is more objective than clinical
impressions without staining, familiarity with stain interpretation is
necessary. This technique is not recommended as a routine screening tool
for IHS general practitioners. The U.S. Preventive Task Force stated
that further research is needed to evaluate the accuracy and
acceptability of this technique before routine use in the general
population can be considered (15). Exfoliative cytology, while used
extensively in the diagnosis of less visible and accessible lesions, it
is not a substitute for biopsy in the diagnosis of oral cancer, although
it can be a useful diagnostic adjunct in some cases. A problem with
exfoliative cytology is the suspected frequency of false negatives,
which can lead to a false sense of security (16). For definitive
diagnosis of oral cancer, excisional or incisional biopsy is essential
(11, 17).

(It should be noted that approximately 400,000 patients per year develop
oral complications as a result of cancer therapy. Following diagnosis of
any cancer, a pre-treatment oral examination is vital to identify
pre-existing oral problems which may have an impact on cancer therapy).

**Conclusion:** Early detection of oral and oropharyngeal cancers result
in more easily treated lesions with less post-treatment morbidity and
increased survival rates (18). An effective primary preventive program
should include public awareness of the disease, including knowledge of
warning signs and risk factors. It should also include education of
medical and paramedical personnel in the symptomatology and pathogenesis
of these cancers and training in early detection techniques. The
avoidance of tobacco products in any form, particularly in combination
with heavy alcohol consumption, is crucial to the prevention of oral and
oropharyngeal cancer (19).

**References:**

1\. Cancer Facts and Figures, 1995. American Cancer Society.

2\. Bruerd B. Smokeless use among American school children.

3\. The health consequences of using smokeless tobacco: A report of the
advisory committee to the surgeon. 1986;Preface: vii.

4\. Mashberg A, Samit A. Early detection, diagnosis, and management of
oral oropharyngeal cancer. American Cancer Society Professional
Education Publication 1989: 1. (Reprinted from Ca --- A Cancer Journal
for Clinicians 1989;39:67-68, 1989.)

5\. DiGuiseppi C, Atkins D, Woolf SH, editors. US Preventive Services
Task Force. Guide to clinical preventive services. 2nd ed. Alexandria,
VA: International Medical Publishing, 1996: 61.

6\. America Stop-Smoking Intervention Study (ASSIST). For information on
this program, contact Dr. Robert Mecklenburg, 12304 River's Edge,
Potomac, MD 20854, (301) 330-9409.

7\. Lichtenstein E, Danaher BG. What can the physician do to assist the
patient to stop smoking? COLD: Clinical Treatment and Management, St.
Louis, Mosby 1978.

8\. DiGuiseppi C, Atkins D, Woolf SH, editors. US Preventive Services
Task Force. Guide to clinical preventive services. 2nd ed. Alexandria,
VA: International Medical Publishing, 1996: 63.

9\. Axell T, et. al. International seminar on oral leukoplakia and
associated lesions related to tobacco habits. Community Dent Oral
Epidemiol 1984;12(3):145-54.

10\. Greer RO Jr., Poulson TC. Oral tissue alterations associated with
the use of smokeless tobacco by teenagers. J Oral Surg 1983;56:278-84.

11\. Axell T, et al. The relation of the clinical picture to the
histopathology of snuff dippers' lesions in a Swedish population. J Oral
Path 1976;5:229-36.

12\. World Health Organization. Guide to epidemiology and diagnosis of
oral mucosal diseases and conditions. Community Dent Oral Epidemiol
1980;8:1-26.

13\. Adapted from Bednarsh H. Oral cancer self-examination. The Journal
--- Texas Dental Hygienist's Association 17, Dng Q Nov-Dec 1979:11-12.

14\. Mashberg A, Barsa P. Screening for oral and oropharyngeal squamous
carcinomas. American Cancer Society Professional Education Publication,
1984:7-8. (Reprinted from Ca --- A Cancer Journal for Clinicians
1984;34(5).)

15\. DiGuiseppi C, Atkins D, Woolf SH, editors. US Preventive Services
Task Force. Guide to clinical preventive services. 2nd ed. Alexandria,
VA: International Medical Publishing, 1996:61.

16\. Baker HW, et al. Oral cancer. American Cancer Society Professional
Education Publication 1972, 1973:23-31. (Reprinted from Ca --- A Cancer
Journal for Clinicians 1972;22(1-5), 1973;23(1).)

17\. Ibid.: 19-22.

18\. Mashberg A, Barsa P. Screening for oral and oropharyngeal squamous
carcinomas. American Cancer Society Professional Education Publication
1984: 4. (Reprinted from Ca --- A Cancer Journal for Clinicians
1984:34(5).)

19\. Green J, Louie R, Wycoff S. Preventive dentistry II, periodontal
diseases, malocclusion, trauma, and oral cancer. JAMA 1990;263:421- 5.

20\. Zhu SH, Anderson CM. Bridging the clinical and public health
approaches to smoking cessation: California Smokers\' Helpline. In:
Jammer MS, Stokols D, eds. *Promoting Human Wellness: New Frontiers for
Research, Practice, and Policy.* Berkeley, CA: University of California
Press; 2000:378-394

**Traumatic Injury/Accident Prevention**

The incorporation of activities and education targeted at reducing the
occurrence of accidental injury to the structures of the head and
oro-facial area is essential in any community-based health promotion
program. While current legislation is in place to regulate the use of
mouth-protecting devices in many organized school sport activities,
there is little emphasis placed on injury prevention in the less
traditional, non-recognized direct-contact types of athletics.
Additionally, the prevention of oral injuries, particularly in children,
that may occur through normal everyday activity, is an often overlooked
area.

Components that should be addressed within health promotion planning
include:

-   A cooperative relationship established between the dental department
    and school officials/athletic programs to help provide properly
    fitting mouth protectors for students participating in sporting
    activities. The availability of resources must be a consideration
    when planning a mouth protector program. Coaches can be particularly
    effective in encouraging support for mouth protector programs and
    increasing compliance in use by players.

-   Fabrication of impression-made, custom-fit double-layered
    heat-and-pressure-laminated EVA type devices affords the highest
    degree of protection and comfort, although "boil and bite" types of
    protectors are also be of value in individual application. Studies
    indicate that the use of mouth protecting devices may also
    significantly reduce injury risk to the head and neck, as well as to
    the oral structures, by cushioning blows that might otherwise cause
    concussions or lead to jaw fractures.

-   The use of mouth protecting devices should be stressed, and not just
    for sports such as football, wrestling, and hockey. Injury to teeth
    and oral structures in such activities as basketball, soccer,
    volleyball, weight lifting, rodeo, cycling, etc., could be reduced
    through the use of mouth guard appliances.

-   An educational component should be included in school programs to
    heighten the awareness of students to the common causes of injury to
    the teeth and mouth:

    -   Slipping/falling on objects or slick surfaces of floors, steps,
        or sidewalks.

    -   Injury caused by pushing impact at water fountains.

    -   Playground equipment such as swings, teeter totters,
        monkey-bars, and slides.

    -   Improper use of teeth for chewing on objects such as ice, hard
        candies, popcorn hulls, pencils, etc., or use of teeth to cut or
        pry hard objects.

    -   Skateboard, roller/ice skating, tricycle/bicycle accidents.

    -   The use of safety belts and child restraint seats/devices should
        be encouraged in conjunction with community injury prevention
        programs. Many injuries to the oro-facial area could be reduced
        or prevented through the use of these methods.

-   In addition to the information that is taught on the prevention of
    trauma through good safety habits, education should also include
    first aid/emergency care for initial treatment if injury does occur.
    This is of primary importance for Head Start and other school
    teachers/personnel and should include procedures to follow for
    broken, loosened, or avulsed teeth; soft tissue injury and to stop
    bleeding; and a referral procedure to the nearest clinic or provider
    for definitive care. Posting of emergency instructions and
    procedures is recommended for all school settings.

Through the use of the ideas presented, a strong program can be
developed to help reduce the incidence of injury to the head and
oro-facial area.

**References**

Hickey JC, et al. The relation of mouth protectors to cranial pressure
and deformation. J Amer Dent Assoc 1967;74:735-40.

Ranalli DN, Lancaster DM. Attitudes of college football coaches
regarding NCAA regulations and player compliance. J Pub Health Dent
1995;55(3):139-42.

**Additional Resources**

<http://www.ada.org/public/topics/mouthguards_faq.asp>

<http://www.aapd.org/media/Policies_Guidelines/P_Sports.pdf>

The AAPD's decision tree for the treatment of an avulsed tooth can be
found at:

<http://www.aapd.org/media/Policies_Guidelines/RS_TraumaFlowSheet.pdf>

The CDC's systematic review of the effectiveness of population-based
interventions to encourage use of helmets, facemasks, and mouthguards in
contact sports can be found at:
<http://www.thecommunityguide.org/oral/oral-int-ie-sports.pdf>

**Head Start**

Since 1976, the Head Start Bureau of the Administration for Children,
Youth and Families and the Indian Health Service have had an interagency
agreement that requires the I.H.S. dental program to provide training
and technical assistance (T/TA) to the Head Start Indian Grantee
programs. In FY 90 the agreement was expanded to include mental Health,
and nutrition. Head Start's basic philosophy is built on a foundation of
family community, and cultural strengths. Head Start focuses on the
positives in every child and family. Parents are the most powerful role
models and teachers for preschool children therefore all aspects of
health promotion / disease prevention (HP/DP) will be more effective
when the family is included in the process.

Training and Technical Assistance (T/TA) is an important role for any
member of the I.H.S. dental staff. Experience suggests that open lines
of communication are an essential beginning and a simple in-service
often facilitates the communication. In an idea situation, a
multidisciplinary effort with Head Start, the I.H.S. and state and local
governments to coordinate other HP/DP initiatives should be emphasized.
Master planning with parents and representatives from Head Start and the
governmental systems would also be conducted. However, initial planning
should focus on parent involvement, health care financing and access to
care.

Suggested activities for training and technical assistance from the
dental program:

1.  Participation in the local Head Start Advisory Committee.

2.  Training of Head Start staff in the caries disease process and
    disease intervention options.

3.  Dental HP/DP for parents and children e.g. *Ready! Set! Go!*
    (I.H.S.) and *Bright Smiles/Bright Futures* (Colgate-Palmolive
    Company)

4.  Screening and prioritization of treatment needs and caries
    management.

    a.  Consider implementing A.R.T.

    b.  Consider glass ionomer sealants if the child is pre-cooperative
        for radiographs

5.  The Indian Health Service dental program is often the primary source
    for Medicaid dental services however, it is important to identify
    alternate resources. It is recognized that often it is very
    difficult to find a provider who accepts Medicaid payments for
    dental services. In spite of such reality the dental office should
    encourage eligible families to enroll in Medicaid and identify any
    state or local public health dental clinics.

6.  Establish appropriate caries intervention based on caries risk.

    a.  Knowledge of the community water fluoride level is the
        foundation of caries intervention options.

    b.  Fluoride varnish is the preferred topical fluoride modality.

    c.  As data and formulation improves Chlorhexidine gel or varnish at
        the head Start classroom should be considered for high risk
        children.

    d.  Data for a Xylitol chewing gum program (4 grams daily) has mixed
        results but should be considered at the Head Start classroom.

    e.  Fluoride mouth rinse is not recommended for Head Start aged
        children. Young children often swallow much of the fluoride
        rinse; therefore children under age six are at risk of fluorosis
        in the anterior teeth.

7.  Head Start actively pursues enrollment of children with special
    needs. Special needs children often manifest with craniofacial
    anomalies and may involve complex treatment requirements with
    challenging funding problems. Grants applications are available for
    children with special needs and craniofacial anomalies. The
    applications are simple to complete and always are accompanied with
    clear instructions.

    a.  Cleft palate Association

    b.  First Hand Foundation

    c.  Shriner's Hospital and the Crippled Children's Fund

**References**

Head Start performance standards. U.S. Department of Health and Human
Services. Administration for Children, Youth and Families. Head Start
Bureau.

Dental caries: The disease and its clinical management Blackwell
publishing 2003, Edited by Ole Fejerskov and Edwina Kidd

**School Based Oral Health Promotion/Disease Prevention Programs**

School-based preventive dentistry programs in public schools and Indian
schools have been successful in reducing the caries incidence among
children (1). These school programs usually have both clinical and
classroom components. The clinical component often includes sealants,
alternative restorative techniques, oral hygiene instruction (OHI),
professional prophylaxis, and fluorides. The classroom component often
includes self-applied fluorides, classroom education, and school water
fluoridation. The type of programs implemented should be based upon risk
for dental disease.

Sealants are the single most effective measure for preventing dental
caries in school-aged children (1). With periodic observation and
reapplication when necessary, sealants are effective in reducing the
prevalence of pit and fissure caries (2). Since pit and fissure caries
account for approximately 90 percent of the caries in children 6-13
years old, school-based prevention programs should include sealants (3).

The Alternative Restorative Technique (ART) is an effective way to
stabilize a carious lesion until the child can access more comprehensive
dental care. Glass ionomer is an ideal material because it provides
effective sealing, continued fluoride release and allows
remineralization to commence. This process is done by removing soft
demineralized areas of dentin and placing the glass ionomer material as
instructed by the manufacturer. This technique should only be done if
the lesion has not reached pulpal material, is not abscessed and is not
causing pain to the child.

Community water fluoridation is still the most effective, yet
inexpensive, means of delivering the benefits of fluoride to school-aged
children (1). In non-fluoridated communities, school water fluoridation
or school-based fluoride swish programs can provide both systemic and
topical benefits of fluoride and are particularly valuable in
communities where the caries rate is high (4). Community and school
water fluoridation or school-based fluoride swish program success
requires designating responsibility and providing training to water
operators or fluoride coordinators. Dental programs frequently provide
technical assistance and monitor fluoridation programs operated by
Tribal authorities.

Self-applied fluoride (mouthrinses and supervised toothbrushing with a
fluoride dentifrice) can provide an additional 20-40 percent reduction
in dental decay (5). The decision to implement these programs should be
carefully weighed, based on the status of water fluoridation and the
caries rate, particularly smooth surface caries rate. Institutions such
as schools are ideal settings for fluoride mouthrinse programs, as high
levels of compliance are possible and the beneficial effects are
maximized. Many state dental programs provide supplies for fluoride
mouthrinse programs.

Classroom teachers are the most effective instructors for school-based
oral health education (6, 7) and can incorporate simple, accurate
elements of oral health education into routine teaching activities.
Dental professional personnel should assist the teacher by evaluating
the oral health curriculum, suggesting supplementary material, and
providing technical assistance through in-service training (8). A
curriculum which offers regular reinforcement of oral health concepts
through the school years must be available in order to promote adequate
knowledge, skills, and attitudes (KSA) for self-care. Also, the oral
health curriculum should be an integrated component of a total health
curriculum, if possible. Evaluation of the curriculum can be conducted
through KSA surveys before and after the material is presented.

School-based oral disease prevention programs should be implemented for
all schools with 25-50 percent or more enrolled American Indian/Alaska
Native (AI/AN) students. The local Dental Program should identify the
schools within the service area and determine where school-based
prevention programs could be established. Proper planning for these
programs includes obtaining necessary approvals from the principals and
school board members and parents. Providing consent forms in school
registration packets is an efficient method for obtaining parental
permission and can increase participation in these programs.

Indian schools, including Bureau of Indian Affairs (BIA) and BIA
contract schools, are administered following Federal guidelines. A
variety of clinical and non-clinical services can be delivered at the
school site because BIA schools are not restricted by state and county
regulations. School-based prevention programs that include self-applied
fluorides, sealants, school water fluoridation, and classroom education
should be considered for all BIA schools.

Public schools must conform to state and local guidelines, consequently
the logistics and legalities of school-based prevention programs can be
complicated. However, prevention programs in schools with less than
25-50 percent AI/AN children can be established by developing linkages
with state and local education departments. The National Preventive
Dentistry Demonstration Program has shown that oral disease prevention
programs in public schools that include both clinical and classroom
elements can be successful (1).

Important elements of a school-based oral disease prevention program
are:

**1. Pit and Fissure sealants**

-   Target grades are often selected for school sealant programs.
    Children in grades 1, 2, 6, and 7 should be screened, as they are
    most likely to have newly-erupted molars that meet the criteria for
    sealant placement (9). However, in communities with high caries
    rates, it is preferable to see all grades each year to evaluate
    retention of sealants, teeth needing sealants, and referral for
    decay.

-   Portable dental equipment is effective for sealant placement and can
    be brought to the school site. If transportation is available,
    children can be bused to the clinic for sealant placement.

-   Sealants provided in a school setting are reported as Level II
    clinical services. These programs generally enhance the clinical
    dental program. It is important for programs not to view sealants as
    a one-time event for life. Sealants need to be monitored.

-   See the section on sealants for selection and placement guidelines.

**2. Self-applied fluorides**

-   School-based fluoride mouthrinse programs, fluoride tablet programs,
    and supervised toothbrushing with a fluoride dentifrice are
    effective ways of delivering the benefits of fluoride to school-aged
    children. Cost-effectiveness should be determined based upon the
    caries rates of the children in the community.

-   The safety of fluoride mouthrinse and tablet programs is an
    important consideration. All personnel mixing and dispensing
    fluoride should participate in regular training sessions to review
    proper handling procedures. Fluoride must be stored in a secure
    place and distribution of mouthrinse and tablets should be
    monitored. The National Institutes of Health (NIH) publication,
    "Preventing Tooth Decay: A Guide for Implementing Self-Applied
    Fluorides in School Settings," is a valuable resource (10).

-   The number of children participating in mouthrinse programs can be
    reported through the Dental Data System. Contact your Area Dental
    Consultant or Prevention Officer for further information.

**3. Topical Fluoride**

-   Children accessing the dental services via school sealant programs
    can be provided with topical fluoride according to the needs of the
    individual child. Target those children with new smooth-surface
    caries, a history of high caries, or handicapped conditions for APF
    topical procedures.

-   See the section on fluorides and oral prophylaxis for guidelines.

**4. Oral Health Education**

-   Determine if the health education curricula used by the schools in
    your service area have oral health components. Schools often welcome
    assistance from dental professionals when evaluating materials.
    Visits by dental providers to the classroom build good public
    relations.

-   The Service Unit Dental Program can assist in the implementation of
    oral health education programs that address topics of particular
    concern to American Indian/Alaska Native populations, such as:

    -   Prevention and cessation of smokeless tobacco use and smoking

    -   Prevention/treatment of rapidly progressing periodontal disease

    -   Prevention of Baby Bottle Tooth Decay/Early Childhood Caries
        (BBTD/ECC)

-   Classroom instruction by itself should not be expected to influence
    individuals' behavior such that a group's oral health status
    improves. However, the value of classroom instruction should not be
    discounted. It is important that people have sufficient and accurate
    information about oral disease prevention to make informed decisions
    regarding personal and community oral health promotion measures.

**References:**

1\. Brunelle JA. Oral health of United States children. The national
survey of dental caries in US schoolchildren: 1986-87 National and
regional findings. US Department of Health and Human Services 1989; NIH
publication No. 89-2247.

2\. Weintraub JA. The effectiveness of pit and fissure sealants. J Pub
Health Dent 1989;49:317-327.

3\. Bohanon HM, Disney JA, Graves RC, Bader JO, Klein SP, Bell RM.
Indications for sealant use in a community-based preventive dentistry
program. J Dent Ed 1984:45-55.

4\. Horowitz HS. Effectiveness of school water fluoridation and dietary
fluoride supplements in school-age children. J Pub Health Dent
1989;49:290-296.

5\. Leverett DH. Effectiveness of mouthrinsing with fluoride solutions
in preventing coronal and root caries. J Pub Health Dent 1989:310-315.

6\. Clarke JA, MacPherson B, Holmes DR, Jones R. Reducing adolescent
smoking: A comparison of peer-led, teacher-led, and expert
interventions. J of School Health 1986:102.

7\. Woolfolk MW, Lang PW, Faja BW. Oral health knowledge and sources of
information among elementary school children. J Pub Health Dent
1989:39-43.

8\. Woolfolk MW, Lang PW, Faja BW. Oral health knowledge and attitudes
of elementary school teachers in Michigan. J Pub Health Dent 1989:44-50.

9\. Kuthy RA, Ashton JJ. Eruption pattern of permanent molars;
implications for school teachers in Michigan. J Pub Health Dent
1989:49:7-14.

10\. Horowitz A. Preventing tooth decay: A guide for implementing
self-applied fluorides in a school setting. NIDR/NIH, NIH Publication
No. 82-1196; revised December 1981.

**Child Abuse and the Mandated Reporter**

Child abuse has been recognized as a major risk to the health and
well-being of all children, including American Indians/Alaska Natives.
Today, child abuse is reported more frequently than in previous decades.
In 1991 the U.S. Advisory Board on Child Abuse and Neglect reported that
more than 2.5 million American children suffer from child abuse.
American Indian and Alaska Native children are statistically at higher
risk for abuse than the general population. Identification of children,
adults, and elders who have experienced domestic abuse is the first step
in preventing further injury.

Most states have identified dentists and dental staff as mandated
reporters of child abuse. This means that if you know or even suspect
that a child is a victim of abuse you must, by law, report it to your
local authority.

Research indicates that 2/3 to 3/4 of patients presenting with injuries
from physical abuse will have suffered trauma to head and neck, areas in
the normal working zone of dental care providers. Therefore, dental
staff are in a perfect position to identify signs of child maltreatment.

Further education in identifying, reporting and managing patients who
are victims of abuse is available through the PANDA (Preventing Abuse
and Neglect Through Dental Awareness) coalition. An online PANDA CE
course can currently be accessed on the IHS intranet at:
<http://home.ihs.gov/> then select "medical programs", then "oral health
promotion/disease prevention", click on "programs", and then select
"PANDA course". The site is currently being revised with the hope of
making access to the course easier, and to incorporate a self
administered post test and printable certificate of completion.

**What is Child Abuse?**

**The act of inflicting injury or the failure to act so that injury
results.**

The degree of injury is not the basis for making the decision to
intervene.

**What is Physical Abuse?**

**Any act which results in non-accidental physical injury.**

This may include severe corporal punishment and can happen when an adult
shakes, strikes, or throws a child. It also includes intentional assault
such as burning, biting, twisting limbs, or cutting.

Indicators used to distinguish physical abuse from accidental injury
include: location and pattern of the injury that is not consistent with
an accidental injury, unexplained injury, an injury that is unusual for
the specific age group, injuries in different stages of healing,
evidence of multiple previous injuries, inconsistent stories given by
parent and child to explain the mechanism of injury, and delay in
seeking care for the child's injury.

**What is Physical Neglect?**

**Neglectful treatment or maltreatment of a child by a parent or
caretaker that harms or threatens harm to the child's health or
welfare.**

General neglect occurs when a parent or caretaker allows a child to be
in a situation that could result in physical injury to the child. Severe
neglect occurs when a parent or caretaker causes or permits the child to
be in a situation that damages a child's health or welfare.

The extreme or persistent presence of the following factors indicate
some degree of child neglect:

-   lack of adequate medical or dental care,

-   poor personal hygiene,

-   inadequate dress for the weather,

-   poor supervision,

-   unsanitary home conditions,

-   poor nutrition, and

-   apathetic, withdrawn, antisocial, or destructive behaviors.

**What is Dental Neglect?**

The American Academy of Pediatric Dentistry defines dental neglect as
willful failure of a parent or guardian to seek and follow through with
treatment necessary to ensure a level of oral health essential for
adequate function and freedom from pain and infection.

**What is Sexual Abuse?**

**Sexual assault on or the sexual exploitation of a minor or acts
perpetrated for the intent of arousal and/or gratification of either the
perpetrator or the child.**

Sexual abuse encompasses a wide range of behavior from touching to full
intercourse with a minor as young as an infant. It includes physical
sexual assault or molestation, lewd or lascivious conduct, activities
related to pornography depicting minors, and promoting prostitution by
minors. It is estimated that a pedophile will molest approximately 300
times in his lifetime.

Indian reservations and Indian organizations may attract molesters
because of their isolation and lack of reporting. The Federal Indian
Child Protection Act mandates fingerprinting and background checks for
individuals who will be working with Native children through federally
funded programs.

Some indicators of child sexual abuse include sexual acting out
(sometimes in public) on peers, toys, or pets. Behaviors that may occur
during the dental visit are complaints of discomfort in sitting or
walking, chronic urinary problems, a display of seductive behavior
toward you, fear of going home, fear of shots or other body invasions,
and fear of restrooms.

**What is Emotional Maltreatment?**

**Verbal assault like belittling or sarcasm, unpredictable responses,
constant family discord and double-message communication that constitute
willful cruelty or unjustifiable punishment of a child.**

Emotional abuse can lead to severe psychological disorders, handicap
development, and lead to behavioral problems including criminal
activity.

Some signs of emotional maltreatment are depression, withdrawal,
phobias, and decreased communications. Sometimes these children are
clingy, or they might whine, rock, pick at scabs, or make statements
like, "I'm bad."

**Reporting Child Abuse and Neglect**

In most states health practitioners, including dentists and dental
hygienists, must report suspected or known child abuse. In many states
it is a crime to not report. Mandated reporters may be subject to civil
and/or criminal legal action if they fail to report.

Usually state law says that suspicions or knowledge of child abuse
should be reported to the local law enforcement or child protective
service immediately or as soon as practically possible. There is a
Federal/Tribal procedure established for those Tribes large enough to
have Federal/Tribal law enforcement staff available. Check with your
clinic and local law enforcement for established child abuse reporting
protocols. There is immunity for mandated reporters who make a report in
good faith.

Proper documentation of cases of suspected or known abuse is critical,
as there is a very real possibility that the practitioner will be
required to present their records in court. Documentation should include
radiographs and photos as appropriate. Parental consent is not required
for photographs in these cases. In addition copious objective notes
should be made. Subjective notes should be limited to comments such as
"injuries appear consistent with physical abuse" or "In this provider's
opinion....." and should avoid unfounded accusations or diatribes
against the suspected perpetrator. When a mandated reporter reports
child abuse as required by law, the physician-patient privilege
(confidentiality) does not apply to information reported following
procedures defined in the law. All dental practitioners should be
familiar with the state and Tribal laws pertaining to child abuse
reporting.

The goal of child abuse reporting is to eliminate the needless suffering
many children experience daily. We, as mandated reporters, have an
obligation to help our communities interrupt the destructive cycle of
abuse in Indian communities.

**Chapter 5, Delivery of Dental Services**

**Table of Contents**

A. Introduction

B. Assessing and Meeting the Needs and Expectations of Customers

C. Access to Care

D. IHS Schedule of Dental Services

E. RVUs

F. Consultation and Referral

G. Dental Facility Considerations

H. Emergency Procedures in the Dental Office

I. Pharmaceuticals

J. Prophylactic Antibiotic Coverage for Prevention of Bacterial
Endocarditis

K. Prophylactic Antibiotic Coverage for patients with Total Joint
Replacement

L. Care of the Anticoagulated patient

M. Recommendations for Conscious Sedation

N. Evaluation and Management of the Medically Complex Patients

O. IHS Dental Data System

P. Use of a Fiscal Intermediary to Manage Contract Care Funds

**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* that 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, 6th edition, W.B. Saunders Co., 2005. 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.

**Assessing and Meeting the Needs and Expectations of Customers**

The 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. Information on how to develop
and implement a patient satisfaction survey is contained in Chapter 7 of
this manual.

**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.

**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. Information on how to develop and
administer a patient satisfaction survey is included in Chapter 7 of
this manual.

**ACCESS TO CARE**

**General Considerations**

Implicit in the IOM's definition of access is acceptance of the
importance of and interrelationship between 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 should be 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,* included in Chapter 7 of this
> manual.

-   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 Chapter 4 of this manual.
>
> 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 should be a primary goal 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 that 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 barriers to access for those who work?      |
|     (e.g., for what hours are appointments available?)                |
+-----------------------------------------------------------------------+
| -   Are there significant barriers to access for those without        |
|     telephones? (e.g., must appointments be made by phone?)           |
+-----------------------------------------------------------------------+
| -   Are there significant barriers to access for those who live       |
|     farther away? (e.g., must appointments be made in person before   |
|     8:00 a.m.?)                                                       |
+-----------------------------------------------------------------------+
| -   Are there significant barriers to access to families receiving    |
|     care? (e.g., are appointments unavailable for more than one       |
|     family member?)                                                   |
+-----------------------------------------------------------------------+
| -   Are there significant barriers to access 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                                                       |
+-----------------------------------------------------------------------+

**Schedule Of Dental Services (Levels Of Care)**

The Schedule of Dental Services was developed by the Indian Health
Service (IHS) Division of Oral Health 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 prevent or contain disease, or correct
damage caused by disease. Thus, emergency care has the highest priority
(Level I), while providing access to complex rehabilitative care (Level
V) is given the lowest priority for expending the available resources.

**Level I Emergency Oral Health Services**

**Level II Preventive Oral Health Services**

**Level III Basic Oral Health Services**

**Level IV Basic Rehabilitation Oral Health Services**

**Level V Complex Rehabilitation Oral Health Services**

**Level IX 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 dental 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 ORAL HEALTH SERVICES

Emergency dental services are those necessary for the relief of
[acute]{.underline} conditions. Emergency dental care services include
all necessary laboratory and preoperative work including examination,
radiographs, and appropriate anesthesia. Emergency dental services shall
include but not be limited to the following:

a.  Control of oral and maxillofacial bleeding in any condition when
    loss of blood will jeopardize the patient\'s well being. Treatment
    may consist of any professionally accepted procedure deemed
    necessary.

b.  Relief of life-threatening respiratory difficulty and improvement of
    the airway (respiratory system) from any oral or maxillofacial
    dental condition. Treatment may consist of any professionally
    accepted procedure deemed necessary.

c.  Relief of severe pain accompanying any oral or maxillofacial dental
    conditions affecting the nervous system, limited to immediate
    palliative treatment, but including extractions where professionally
    indicated.

d.  Immediate and palliative procedures that include but are not limited
    to: (1) fractures, subluxations and avulsions of teeth, (2)
    fractures of jaw and other facial bones (reduction and fixation
    only), (3) temporomandibular joint subluxations, (4) soft tissue
    injuries, (5) broken dentures, and (6) chipped tooth.

e.  Initial treatment for acute infections.

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: PREVENTIVE ORAL HEALTH SERVICES

The listed services are those which prevent the onset of the dental
disease process. Some of the services provided to individuals are
modified by IHS definitions, exclusions, limitations, and processing
policies. Please refer to the appropriate sections for further
descriptions of exclusions, limitations, and processing policies.

The preventive oral health 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: BASIC ORAL HEALTH SERVICES

Basic dental care includes those services provided early in the disease
process and which limit the disease from progressing further. They
include most diagnostic procedures, simple restoration of diseased
teeth, early treatment of periodontal disease, and many surgical
procedures needed to remove or treat oral pathology.

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: BASIC REHABILITATIVE ORAL HEALTH SERVICES]{.underline}

Basic rehabilitation services are those necessary to contain the disease
process after it is established or improve the form and/or restore the
function of the oral structures. The word "function" as used here
includes some psychosocial considerations as well as the mastication of
food. These services are more difficult to provide since the disease
process is well established. The investment of resources will have a
good cost-effectiveness because the procedures are directed at
containment or basic rehabilitation. They include but are not limited to
complex restorative procedures (onlays, cores, and crowns), the majority
of endodontic procedures, most advanced periodontal procedures,
prosthodontic appliances that restore function, pre-prosthetic surgery,
and most interceptive or limited orthodontic procedures.

-   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 retainers (Maryland Bridge)

-   Bicuspid endodontics (two canals)

-   Apicoectomy/retrograde filling

-   Gingivoplasty

-   Limited/interceptive orthodontics

# LEVEL V: COMPLEX REHABILITATIVE ORAL HEALTH SERVICES

The complex rehabilitation services listed in Level V are those that
require significant time, special skill or cost to provide. Certain
patients will require referral to dental care providers skilled in
providing the specific procedure and/or which have limited their
practice to that specific specialty area. Generally the patient must
present special circumstances that would warrant the added time and
transportation associated with specialty referral. Level V services may
not improve the overall prognosis for most patients so patient selection
is of critical importance when considering the provision of these
services.

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)

-   Implants

-   Surgical extractions (impactions)

-   Analgesia (e.g., nitrous oxide)

-   Cephalometric or TMJ radiographs

-   Occlusal adjustment (complete)

-   Periodontal surgery

-   Overdentures

-   Consultation for specialty services

-   Precision attachment prosthetics

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

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

-   Maxillo-facial prosthetics

-   Intravenous (IV) sedation, general anesthesia

# Level IX: EXCLUSIONS

These services have been determined to be of limited benefit in the
treatment of oral disease or maintenance or oral health. These services
have a variable rate of success, are difficult to monitor from an
appropriateness or effectiveness standpoint, are not universally defined
or accepted as the preferred method of treatment. Some of the services
listed under exclusions require heroic effort and therefore are
questionable from a cost benefit standpoint. Other services use material
which is obsolete or of disputable effectiveness. In other cases the
services are considered part of treatment and do not warrant a separate
fee or value. In certain other cases the IHS simply will not pay for the
service.

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

-   Removable unilateral space maintainers

-   Silicate restorations

-   Gold foil restorations

-   Cast inlay

-   Porcelain inlays or crowns

-   Full resin or resin/metal crowns

-   Direct pulp caps

-   Unilateral cast partials

-   Chairside denture relines

-   Pulpotomy in permanent tooth

-   Tooth transplantation

-   Removable appliance therapy

-   Behavior management

-   Broken appointments

**Limitations**

Provisions have been added to the IHS Schedule of Dental Services to
limit the frequency of certain procedures provided to 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

  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

Relative Value Unit (RVU)

Since the late 1970's the IHS has used the "Service Minute" as a measure
of productivity and workload. The service minute was a loosely defined
measure that was mostly based on the time needed to perform specific
dental procedures. By 2002 the nature of dental procedures and practice
had changed significantly and it was considered necessary to update the
unit of measure.

A contractor with experience in developing relative value tables for
public and private organizations was hired to assist in developing a
dental relative value unit table for the IHS. A survey containing 125 of
the most frequently used dental procedure codes was distributed to all
IHS, Tribal and Urban dentists. The dentists were asked to assign a
relative value unit to each procedure code using D0150, Comprehensive
Oral Evaluation as an anchor code with a value of 1.00, and the
following criteria:

1.  **Time** (How long does the procedure take?)

2.  **Skill** (What level of technical skill is required to accomplish
    the procedure successfully?)

3.  **Risk and/or Benefit to Patient** (How much risk and/or benefit is
    there to the patient receiving this procedure? For example, incision
    and drainage of an intraoral abscess may carry more risk and/or
    benefit for a patient than a prophylaxis)

4.  **Risk to Provider** (How much risk (liability) is there for the
    provider performing this procedure? For example, removal of a bony
    impaction may carry more risk for the provider than a single surface
    amalgam restoration.)

5.  **Severity of Problem** (How severe is the problem being corrected
    by the procedure? For example, pulp therapy may correct a problem
    more severe than adjusting a denture does.)

6.  **Other Resources Needed** (What level of supplies, instruments,
    equipment, etc. is necessary to perform this procedure? Some
    procedures require more sophisticated and expensive equipment or
    instrumentation than others.)

7.  **IHS Dental Program Priority** (What level of care does the
    procedure fall into? Procedures in Levels I-III are of higher
    priority in the IHS Dental Program than those in Levels IV-VI)

Based on the survey results the contractor was able to develop a
relative value unit for each ADA procedure code that was statistically
valid. That table is updated every two years when the ADA/CDT is issued.

**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. This list may be found on the IHS website at
<http://www.ihs.gov/medicalprograms/dentaldir/>. The directory can be
searched by various criteria to locate the needed specialist. Login is
required to complete anything more than superficial searches of the
database.

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 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. Areas and/or
individual specialists will have policies in place regarding referrals.
These may or may not permit direct care for referred patients,
contacting the specialist is the best way to be informed of the policy.

**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. The Navy lab recommends that all tissue removed from
patients be submitted for analysis.

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 Safety Net
    Dental Clinic Manual at
    [www.dentalclinicmanual.com](../www.dentalclinicmanual.com).

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 quiet
        rooms and/or operatories used for sedative procedures (these
        will require increased space for personnel and monitoring). 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 Safety Net
        Dental Clinic Manual at www.dentalclinicmanual.com.

    -   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.

    -   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 *Safety Net Dental Clinic Manual at
[www.dentalclinicmanual.com](http://www.dentalclinicmanual.com/)*
contains 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.

Panoramic/Cephalometric combination = 50 square feet

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) = 60 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. (1 automatic developer)

Darkroom (9 to 16 operatory clinic)= 90 sq. ft. (2 automatic developers)

Digital Processing Area = 20 sq ft per scanner/computer combination

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 Director'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. Clinics with a staff of
six or fewer members can save funds by using a unisex staff restroom.

Waiting Area (1 to 4 operatory clinic)= 120 sq. ft.

Waiting Area (5 to 7 operatory clinic)= 180 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. (if stand alone, may be added to most panoramic radiograph
machines)

*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 in terms of seeing the
    instruments

-   Is confining for patients

-   Patients may bump into unit if they rise up suddenly

-   Generally NOT recommended for treating children or patients with
    conditions that result in aggressive behavior or unpredictable
    movements

-   Patient\'s feet can get tangled in the handpiece cords

-   Expense

**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 and elbows

-   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**

When selecting dental equipment, research the manufacturer of the brand
of equipment you are considering to determine 1) the stability of the
company and 2) if they provide good customer support for their
equipment. Also ask dentists and dental equipment repair services about
the reliability and durability of the brand of equipment you are
considering.

The Clinical Research Associates Newsletter \[Clinical Research
Associates 3707 North Canyon Road, Suite 6 Provo, UT 84604
(801)-226-2121\] is 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. The publication also contains other equipment and supply
information that is very useful when building a new clinic

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
Evaluation & Consultative Service (formerly USAF Dental Investigative
Service) can also be a source of unsolicited information. This is an
independent reviewer of dental equipment and supplies located online at
[https://decs.nhgl.med.navy.mil](https://decs.nhgl.med.navy.mil/).

If using literature reviews be sure to locate articles that provide a
list of features that a buyer should seek when purchasing dental
equipment items and also offers recommendations, including brand names.
The article should break down the attributes into primary
characteristics, which meet efficiency and infection control needs, and
optional features, which depend on the personal needs and preferences of
the operator.

The following is a synopsis of the primary features of large operatory
equipment:

**Patient Chairs**

-   Stable base and lift mechanism (hydraulic type 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 and wheelchair transfers

-   Auto preset positioning and auto return with safety stop

-   Right/left convertibility

-   Foot controls or a touch pad to adjust the chair position

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

**Dental Handpieces**

-   Air-powered or electronically powered rotary instruments

-   High-speed handpieces and low-speed handpieces for general dentistry

-   Surgical handpieces are needed for invasive surgical procedures
    (these can be air driven and attached in place of the high-speed,
    Impact Air 45 is an example

    -   Specialty specific handpieces may be requested:

        -   Surgical specific handpieces are equipped with a wide range
            of attachments

        -   Endodontic rotary handpieces are required for rotary
            instrumentation (torque controlled electrically driven units
            are standard)

-   Sterilization method determines the number of handpieces needed by a
    facility (faster sterilization requires fewer handpieces)

-   As a general rule you will need 4 high-speed handpieces/operatory
    and 4 slow-speed attachments/operatory

-   **Dental handpieces are expensive so make sure enough funds are
    included in your start-up budget**

**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

-   The stools for the dentist and dental assistant are different, with
    the dental assistant stool having foot and armrest

Dental Radiography (X-rays)

-   Intra-oral Radiographs (periapical, bitewing, occlusal)

    -   Require standard radiograph machine for exposure

    -   Basic dental radiographs show several teeth at a time. These can
        be standard films developed conventionally way using chemicals
        or produced with computer if using digital radiography.

-   Panoramic Radiographs

    -   This dental radiograph shows both dental arches on a single
        x-ray film that is 5\" by 11\".

    -   The panorex machine requires its own area and may be
        conventional or digitally produced.

    -   It is recommended to be take a panoramic radiograph every five
        years per patient greater than 8, if a facility does not have
        the ability to purchase this equipment, then a referral system
        must be in place in order to obtain this type of radiograph when
        needed.

-   Cephalometric Radiograph

    -   This radiograph shows the entire head and is taken using a
        panoramic machine with special attachments and may be
        conventional or digitally produced. Oral surgeons and
        orthodontists mostly use this type of x-ray. This type of
        radiograph is nice to have but not required unless your clinic
        has an orthodontic program.

-   Conventional

    -   Exposure of photographic film to x-rays and then chemically
        develop the film in a developer in a darkroom or via a
        'day-light loader'

    -   Costs of conventional developing are cheaper in the short-run,
        but increasing due to cost of chemical handling.

    -   Films are archivable, but require physical space to store
        radiographs

-   Digital Radiography:

    -   Images are captured electronically via a charge couple device
        (CCD) or via a phosphor plate system after exposure to X-rays.

    -   These images are then uploaded, viewed and stored on a computer.

    -   Computer (CPU), monitor(s) and keyboard are needed in each
        operatory, back-up storage (server) is need for archiving
        images).

    -   Costs: Initially higher but the unlimited use of a CDD decreases
        costs decrease with each image processed. The phosphor plates do
        have a limited life, but are reusable and cost-friendly

    -   Cost and space required for darkrooms, film, processing
        chemicals, and disposal of hazardous waste are eliminated.

    -   Time, money, and paperwork can be saved by utilizing digital
        images

    -   Patient exposure is minimized using digital radiography

Dental Operating Lights

-   Can be wall mounted, ceiling mounted via a track, or chair mounted

Computers

-   Needed in the operatory if the clinic will be using digital
    radiography or electronically maintained charts.

-   Computers may be mounted on the dental chair and/or placed on a
    cabinet in the operatory

-   Specific information regarding specifications can be obtained from
    the IHS internet site, in the Electronic Dental Record area (EDR)

Communication System

-   Small (e.g., only one provider and appropriate support staff), then
    intra-office communications can be as easy as word-of-mouth.

-   Color-coded flagging systems or light systems frequently are used in
    multi-provider medical and dental offices to alert the providers
    when a patient is in a treatment area or when they have a phone call
    or message.

-   An internal paging or intercom system also may be considered.

-   Intercom systems can be installed as stand-alone system or as part
    of the clinic\'s phone system, decide which type will be used before
    a phone system is purchased and installed. Local dentists or local
    group practices may be able to help you decide which system will
    best suit your needs.

-   Phone service planning, have additional lines dedicated for fax
    machines and Internet access.

-   Computer networks

    -   Desirable, but poses risks of unauthorized access to or loss of
        data.

**Sample Dental Clinic Equipment List**

Following is a sample of an equipment list. It is not necessarily an
all-inclusive list, but it may be helpful to other programs
contemplating new construction or remodeling.

**Operatory**

-   Amalgamator

-   Air compressor, central

-   Air/water syringe(s)

-   Assistant\'s stool

-   Assistant unit

-   Cabinets with sinks

-   Camera, intraoral

-   Clock/intercom/timer

-   Coat hooks

-   Computer

-   Doctor\'s unit

-   Dental chair

-   Eye wash station

-   Fiber optic unit

-   Gloves/masks

-   Handpieces,

    -   High speed

    -   Low speed

    -   Contra angle

    -   Prophylaxis angle

    -   Straight attachment

-   Hand washing stations (2)

-   Intraoral imaging system

-   Lead Apron & hanger

-   Light curing unit

-   Nitrous oxide sedation unit

-   Operating light

-   Operating stool

-   Oral evacuator: high volume and low volume

-   Oral evacuator utilities (Suction pump, central)

-   Oxygen delivery system

-   Prophylaxis unit, ultrasonic

-   Radiograph view box (not needed if using digital radiographs)

-   Sphygmomanometer

-   Stethoscope

-   Waste receptacle, trash

-   Waste receptacle, biohazard

-   X-ray unit

**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

**Laboratory**

-   Acrylic polish

-   Acrylic tray material

-   Alcohol torch

-   Articulators:

    -   Crown & bridge

    -   Denture

-   Denture reline material

-   Denture repair acrylic

-   Bench lathe

-   Bench lathe accessories:

    -   Arbor bands and mandrels

    -   Brush wheels

    -   Chucks

    -   Felt wheels/cones

    -   Polishing wheels

    -   Spindles

    -   Stone wheels

    -   Bench light

-   Boley gauge

-   Brushes

-   Bunsen burner

-   Dust collector

-   Fire extinguisher

-   Handpiece, air driven

-   Hand towels & dispenser

-   Laboratory bench, with sink

-   Laboratory engine & handpiece

-   Lab handpiece accessories:

    -   Acrylic burs

    -   Abrasive disks/mandrels

    -   Carbide burs

    -   Gold-finishing kit

    -   Model-trimming burs

    -   Porcelain-polishing kit

    -   Rubber wheels and points

-   Magnifying loops

-   Microetcher

-   Model trimmer

-   Petrolatum

-   Plaster:

    -   Lab

    -   Model

    -   Die

-   Plaster bin

-   Plaster-mixing bowls, rubber

-   Plaster knives

-   Plaster spatula

-   Plaster trap

-   Pliers

-   Pressure-curing unit

-   Pumice

-   Rouge

-   Safety glasses

-   Saw frame & blades

-   Scissors

-   Surveyor

-   Vacuum-forming machine

-   Ventilation System

-   Vibrator

-   Water Bath

-   Waxes:

    -   Baseplate

    -   Boxing

    -   Inlay

    -   Rope sticky

    -   Utility

-   Wax carvers

-   Wax spatulas

-   Waste receptacle

-   Work pan

**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

**Radiograph Exposure/Processing**

-   Radiograph Aids

    -   Rinn Instruments

    -   Snap-a-rays

    -   Endo-ray

    -   Bite-tabs

-   Film:

    -   Bitewing

    -   Intraoral, size 0

    -   Intraoral, size 1

    -   Intraoral, size 2

    -   Intraoral, size 4

    -   Panoramic/Cephalometric

-   Film envelopes

-   Film holders/mounts

-   Lead apron w/neck collar

-   Automatic film processor

-   Deep sink for cleaning rollers

-   Developer and Fixer Recovery Unit

-   Film dispenser

-   Plastic apron

-   Safe light

-   View box

-   Waste receptacle

-   Water Temperature Regulator

**Panoramic Area**

-   Panoramic Unit (pan/ceph)

-   Lead Apron/Hanger

-   Mechanical Room

**Office, Chief/Dentist**

-   Bookcase(s)

-   Chairs/executive

-   Chair/guest

-   Computer System

-   Desk

-   File cabinets

-   Prescription blanks

-   Telephone

Reception/ Business Office

-   Announcement cards

-   Answering machine

-   Appointment book

-   Appointment cards

-   Bookkeeping

-   Clipboards

-   Collection aids

-   Computer:

    -   Hardware

    -   Printer/Scanner

    -   Software/supplies

    -   Terminals

-   Copy machine

-   Desk organizer/calendar

-   Drug envelopes

-   File cabinets/folders

-   Letterheads/envelopes

-   Office manual

-   Office signs (exit, rooms, etc)

-   Patient education literature

-   Patient records

    -   Medical/dental history forms

    -   Patient exam chars

    -   Patient file folders

    -   Periodontal charts

    -   Registration forms

    -   Stickers for folders

    -   Treatment plan/record forms

-   Payroll forms

-   Postage stamps

-   Professional cards

-   Recall system (cards, index)

-   Referral slips

-   Secretary\'s chair

-   Stamp pad

-   Standard insurance forms

-   Stapler

-   Tape dispenser

-   Telephone/Intercom System

-   Typewriter

**Storage**

-   Shelving Units

-   Supply Desk/Chair/Filing Cabinets

-   Papoose Board

-   Washer/Dryer

**Waiting Area**

-   Books

-   Chairs/End Tables/Lamps

-   Coat rack

-   Decorative items

-   End tables

-   Lamps/lighting

-   Magazine rack / magazines

-   Toys for children

-   Wall mirror

**Education**

-   Sinks for Tooth brushing

-   TV/VCR/DVD

-   Models/Posters/Pamphlets/Educational Aids

**Other Items**

-   Instrument Cassette System

-   Hand Instruments (See section: DENTAL INSTRUMENTS AND SUPPLIES FOR
    START UP)

-   Curing Radiometer (Curing Light Tester)

-   Electronic Thermometer

-   Clothing Hamper

-   Tubs/Trays/Racks

-   Employee Lockers

**DENTAL INSTRUMENTS AND SUPPLIES FOR START UP**

This is a suggested list for a one dentist, 2-3 operatory dental clinic.
The list is divided into categories of equipment and supplies. Those
items listed should be able to take care of most operative, preventive
dentistry, endodontic, prosthodontic, and oral surgical needs in a
dental clinic. It should be noted that some instruments are listed in
multiple sections. Once you and the dentist decide which services your
clinic will offer you can compile the equipment/supply list. Items can
be substituted to satisfy personal and professional needs of the
dentist(s) that will be working at your clinic. The purpose of this list
is to provide you a starting point, not to be "the list".

OPERATIVE INSTRUMENTS (6 KITS PER DENTIST)

  -------------- ------------------------------------------------------------
  **Quantity**   **Item/Description**

  6              Mouth Mirrors #5 (or #3,or 4 if dentist prefers)

  6              Mirror Handles (must fit mirror heads)

  6              23 Explorer/PSR

  6              Scissors, Iris 41/2\" Straight, Economy

  12             Cotton Pliers(s), College #317

  6              Spoon Excavator #38-39

  6              Amalgam Carrier Double Ended I

  6              Amalgam Plugger l/2 Black

  6              Cleoid-Discoid 3/6

  6              Cleoid-Discoid 89/92

  6              Hollenbach

  6              Interproximal Carver (IPC)

  6              Articulating Paper Forceps

  6              Rubber Dam Frame

  6              Rubber Dam Clamp Forceps

  6              Dycal Instrument

  6              Tofflemire(s) 2 per kit, universal
  -------------- ------------------------------------------------------------

HANDPIECES

\*If you do surgical extractions, then will need to get a surgical
handpiece.

+----------+-----------------------------------------------------------+
| #        | # Item/Description                                        |
| Quantity |                                                           |
+----------+-----------------------------------------------------------+
| 6        | High-Speed Handpiece                                      |
+----------+-----------------------------------------------------------+
| 3        | Low-Speed Handpiece                                       |
+----------+-----------------------------------------------------------+
| 6        | Ball-Bearing Contra Angle Assembly (Latch)                |
+----------+-----------------------------------------------------------+
| 6        | Prophy Contra Angle Head Assembly                         |
+----------+-----------------------------------------------------------+
| 6        | Contra Angle Sheath                                       |
+----------+-----------------------------------------------------------+
| 2        | Straight Attachment                                       |
+----------+-----------------------------------------------------------+
| 2        | Spray and Clean Handpiece Lubricant                       |
+----------+-----------------------------------------------------------+

OTHER INSTRUMENTS

+----------+-----------------------------------------------------------+
| #        | **Item/Description**                                      |
| Quantity |                                                           |
+----------+-----------------------------------------------------------+
| 6        | Dental Mirrors #5 for Exam Kits                           |
+----------+-----------------------------------------------------------+
| 6        | Mirror Handles for Exam Kits                              |
+----------+-----------------------------------------------------------+
| 6        | Explorer/PSR Periodontal Probes for Exam Kits             |
+----------+-----------------------------------------------------------+
| 2        | Cement Spatulas #24                                       |
+----------+-----------------------------------------------------------+
| 9        | Aspirating Syringe CW Type                                |
+----------+-----------------------------------------------------------+
| 2        | Composite Instruments, Set of 3                           |
+----------+-----------------------------------------------------------+
| 3        | Rubber Dam Punch                                          |
+----------+-----------------------------------------------------------+
| 3        | Rubber Dam Clamps, Starter Kit                            |
+----------+-----------------------------------------------------------+

OPERATIVE SUPPLIES

+----------+-----------------------------------------------------------+
| #        | Item/Description                                          |
| Quantity |                                                           |
+----------+-----------------------------------------------------------+
| 4        | Lidocaine 2% 1: 100,000 epi/can                           |
+----------+-----------------------------------------------------------+
| 1        | 3% Mepivicaine/can                                        |
+----------+-----------------------------------------------------------+
| 1        | 5% Marcaine 1:200,000 epi/can                             |
+----------+-----------------------------------------------------------+
| 2        | 27 gauge Long Needles/box                                 |
+----------+-----------------------------------------------------------+
| 2        | 30 gauge Short Needles/box                                |
+----------+-----------------------------------------------------------+
| 2        | Topical Anesthetic                                        |
+----------+-----------------------------------------------------------+
| 2        | Sharps Container                                          |
+----------+-----------------------------------------------------------+
| 1        | Accu Film II/box                                          |
+----------+-----------------------------------------------------------+
| 1        | Amalgam -Regular Set/can                                  |
+----------+-----------------------------------------------------------+
| 1        | Glass Ionomer Kit                                         |
+----------+-----------------------------------------------------------+
| 1        | IRM Caps 50/Pkg.                                          |
+----------+-----------------------------------------------------------+
| 1        | Clear Matrix Strips/box                                   |
+----------+-----------------------------------------------------------+
| 1        | Sof-Lex Pop-On Kit #1980                                  |
+----------+-----------------------------------------------------------+
| 1        | Finishing Strips Coarse/Medium 150/Box                    |
+----------+-----------------------------------------------------------+
| 1        | Lightening Strips Medium 12/tube                          |
+----------+-----------------------------------------------------------+
| 1        | Polishing Paste/can                                       |
+----------+-----------------------------------------------------------+
| 4        | Tofflemire Matrix Bands #1, .0015 12/Pkg.                 |
+----------+-----------------------------------------------------------+
| 4        | Toff1emire Matrix Bands #2 .0015 12/Pkg.                  |
+----------+-----------------------------------------------------------+
| 1        | Dycal Ivory Shade/tube                                    |
+----------+-----------------------------------------------------------+
| 24       | Fluoride varnish boxes                                    |
+----------+-----------------------------------------------------------+
| 1        | Vitrebond 3M/box                                          |
+----------+-----------------------------------------------------------+
| 6        | Bur Block                                                 |
+----------+-----------------------------------------------------------+
| 3        | Etch Gel Syringe, with 20 Tips                            |
+----------+-----------------------------------------------------------+
| 3        | Rubber Dam Green, Medium, 5x5/box                         |
+----------+-----------------------------------------------------------+
| 1        | Rubber Dam Green, Heavy, 6 x 6/box                        |
+----------+-----------------------------------------------------------+
| 1        | Wizard Anatomical Assorted Wedges 400/Box                 |
+----------+-----------------------------------------------------------+
| 1        | MQ Lubricant/tube                                         |
+----------+-----------------------------------------------------------+

ASSORTED BURS, DOCTORS PREFERENCE

DISPOSABLES

  ---------- ------------------------------------------------------------
  Quantity   Item/Description

  1          1 Tray Covers -Mauve l000/Box

  2          2 x 2 gauze 8 ply 200/Pkg

  2          4 x 4 gauze 8 ply 200/Pkg

  1          Dry-Guard Patient Bibs (rose) 500/Case

  4          Napkin Holder

  1          Cotton Tip Applicators 6\" non-sterile l000/Box

  1          Cotton Pellets #2 2000/Box

  1          Cotton Pellets #4 3000/Box

  1          Cotton Rolls 2000/Box

  1          Cotton Roll Dispenser

  1          Plastic Cups, 1OOO/Case

  1          Cup Holder

  1          Safe-Tips EZ 150/Pouch

  3          High Speed Evacuation Tips 5O/Bag

  3          Saliva Ejectors White Opaque 100/Bag

  1          Dappen Dishes l000/Box

  1          Oral Evacuation Cleaner

  1          Disposable Spatulas l00/Box

  2          Benda Brush 144/Box

  1          Disposable Mirrors 72/Box

  1          Disposable Traps Dental Unit 144/Box, pick size needed

  1          Disposable Traps Central Suction 8/Box, pick size needed
             Paper Towels
  ---------- ------------------------------------------------------------

**INFECTION CONTROL SUPPLIES**

  ---------- ------------------------------------------------------------
  Quantity   Item/Description

  6          Latex Exam Gloves, pick sizes

  3          Sterile Surgeons Gloves, pick size

  2          Utility Gloves, pick sizes

  6          Face Masks, 50 per box, pick type

  6          Safety Glasses (dentist, DA, patient)

  3          Disposable Cover Gowns, pick size

  3          Antiseptic Hand Soap,

  1          Cleaning Solution

  3          Disinfectant

  2          Self Seal Sterilization Pouches 31/2\" x 9\",

  2          Self Seal Sterilization Pouches 31/2\" x 51/4\",

  2          Self Seal Sterilization Pouches 51/4\" x 10\"

  2          Self Seal Sterilization Pouches 71/2 x 13\",

  3          Chair Covers 48\" x 56\"

  3          Air/Water Syringe Covers

  3          Light Handle Covers

  1          ALLRAP 1200 Sheets/Roll

  3          Mouth wash, may want to order pump

  3          Chlorhexedene oral rinse 16 oz

  1          Cure Sleeve, Steri Shield 5OO/Box

  1          Tube Sleeve 2\"

  3          X-ray sleeve 14\" W x 13\" D x 241/2\" L

  1          Biological Monitoring System

  1          Biological Indicators (25/box)
  ---------- ------------------------------------------------------------

STANDARD ORAL SURGERY KIT (2-3 Kits per Dentist)

+----------+-----------------------------------------------------------+
| #        | Item/Description                                          |
| Quantity |                                                           |
+----------+-----------------------------------------------------------+
| 1        | 1 #9 Molt Periosteal Elevator                             |
+----------+-----------------------------------------------------------+
| 1        | 1 Needle Holder, Crile-Wood 6 inch                        |
+----------+-----------------------------------------------------------+
| 1        | 1 301 Elevator                                            |
+----------+-----------------------------------------------------------+
| 1        | 1 34 Elevator                                             |
+----------+-----------------------------------------------------------+
| 1        | 1 Minnesota Retractor                                     |
+----------+-----------------------------------------------------------+
| 1        | 1 Curette                                                 |
+----------+-----------------------------------------------------------+
| 1        | 1 Kelly Hemostats, Curved 51/2\"                          |
+----------+-----------------------------------------------------------+
| 1        | 1 Mouth Mirror 1 Mouth Handle                             |
+----------+-----------------------------------------------------------+
| 1        | 1 Scissors Kelly 61/4\", Curved                           |
+----------+-----------------------------------------------------------+
| 1        | 1 Mouth Prop (adult) 2/Box                                |
+----------+-----------------------------------------------------------+
| 1        | 1 Suction Tips                                            |
+----------+-----------------------------------------------------------+

ORAL SURGERY INSTRUMENTS

+----------+-----------------------------------------------------------+
| #        | Item/Description                                          |
| Quantity |                                                           |
+----------+-----------------------------------------------------------+
| 3        | Surgical scalpel #15, disposable and retractable (10/box) |
+----------+-----------------------------------------------------------+
| 3        | 150 Forceps                                               |
+----------+-----------------------------------------------------------+
| 3        | 151 Forceps                                               |
+----------+-----------------------------------------------------------+
| 3        | 17 Forceps                                                |
+----------+-----------------------------------------------------------+
| 2        | 23 Forceps                                                |
+----------+-----------------------------------------------------------+
| 2        | 88R Forceps                                               |
+----------+-----------------------------------------------------------+
| 2        | 88L Forceps                                               |
+----------+-----------------------------------------------------------+
| 2        | #1 Forceps                                                |
+----------+-----------------------------------------------------------+
| 3        | Cryer 30                                                  |
+----------+-----------------------------------------------------------+
| 3        | Cryer 31                                                  |
+----------+-----------------------------------------------------------+
| 2        | Crane Pick                                                |
+----------+-----------------------------------------------------------+
| 2        | Periosteal Elevator #9 Molt                               |
+----------+-----------------------------------------------------------+
| 2        | Heidbrink #1 Root Tip Pick                                |
+----------+-----------------------------------------------------------+
| 2        | Heidbrink #2 Root Tip Pick                                |
+----------+-----------------------------------------------------------+
| 2        | Heidbrink #3 Root Tip Pick                                |
+----------+-----------------------------------------------------------+
| 2        | Tissue Forceps                                            |
+----------+-----------------------------------------------------------+
| 2        | Rongeurs                                                  |
+----------+-----------------------------------------------------------+
| 2        | Bone File, 12 Howard                                      |
+----------+-----------------------------------------------------------+
| 2        | Straight Hemostat, Crile 51/2\"                           |
+----------+-----------------------------------------------------------+
| 2        | Needle Holder, Crile-Wood                                 |
+----------+-----------------------------------------------------------+
| 2        | Surgical Handle                                           |
+----------+-----------------------------------------------------------+
| 3        | Dental Mirror for Post-Op Kit                             |
+----------+-----------------------------------------------------------+
| 3        | Mirror Handles for Post-Op Kit                            |
+----------+-----------------------------------------------------------+
| 3        | Iris Scissors for Post-Op Kit                             |
+----------+-----------------------------------------------------------+
| 3        | Cotton forceps for Post-Op Kit                            |
+----------+-----------------------------------------------------------+
| 1        | 3-0 Silk Sutures, 18\" Cutting, Needle C-6 12/Box         |
+----------+-----------------------------------------------------------+
| 1        | 3-0 Chromic Gut Sutures, 27\", C-6 12IBox                 |
+----------+-----------------------------------------------------------+
| 3        | Biopsy Bottles                                            |
+----------+-----------------------------------------------------------+
| 1        | Dry Socket Paste, 1 oz.                                   |
+----------+-----------------------------------------------------------+
| 1        | Iodoforn Gauze 1f4\" x 5 yd.                              |
+----------+-----------------------------------------------------------+
| 1        | Gelfoam                                                   |
+----------+-----------------------------------------------------------+

ASSORTED SURGICAL BURS, DOCTORS PREFERENCE

**STANDARD ENDODONTIC KIT (2 Kits per Dentist)**

  ---------- ------------------------------------------------------------
  Quantity   Item/Description

  1          1 Mouth Mirror, #3

  1          Mouth Mirror Handle

  1          23 Explorer/Perio Probe

  1          Scissors

  2          Cotton Pliers Self-Locking Grooved

  1          Ring Rulers, Right-Handed

  1          Endo Excavator #31

  1          DG 16 Endodontic Explorer

  1          DE condenser 1/3

  1          DE condenser 5/7

  1          DE condenser 9/11

  1          Glick #1

  1          Woodson #3

  1          Hollenbach

  1          Interproximal Carver

  1          Cement Spatula

  1          Articulating Paper Forceps

  1          Rubber Dam Frame

  1          Rubber Dam Forceps

  1          Tofflemire
  ---------- ------------------------------------------------------------

ENDODONTIC SUPPLIES

  -------------- ------------------------------------------------------------
  **Quantity**   Item/Description

  2              Endo Ice (can, refrigerant)

  1              Sealer (dentist preference)

  1              Gutta Percha (Med-fine, Med, Med-large)

  2              Gutta gauge (Maiffer)

  2              Gates Glidden Drills (#2,3,4,5,6), 4/box

  1              Touch n Heat, System B, or Endo Micro-Torch (Butane Refill)

  1              Obtura + GP bullets

  1              Paper Points, fine

  1              Paper Points, medium

  1              Paper Points, coarse

  1              RC prep, Premier

  2              Cavit, 4 tubes

  1              Monojet Syringes 3cc, 5cc 50/box (dentist preference)

  2              23 Ga. Side venting needle, 25/box

  1              Sodium hypochlorite (bleach), gallon

  1              EDTA liquid (32 oz bottle)

                 Files, FlexOfiles,Flex-R-Files, assorted, Dentist preference

                 Endo Burs, assorted (recommend: #2,4 round, endoZ or
                 Safe-end)
  -------------- ------------------------------------------------------------

**STANDARD PROPHY KIT (2-3 Kits per Dentist)**

+----------+-----------------------------------------------------------+
| #        | **Item/Description**                                      |
| Quantity |                                                           |
+----------+-----------------------------------------------------------+
| 1        | Mouth Mirror                                              |
+----------+-----------------------------------------------------------+
| 1        | 23 Explorer/PSR Probe                                     |
+----------+-----------------------------------------------------------+
| 1        | S204S Sickle                                              |
+----------+-----------------------------------------------------------+
| 1        | Sickle 23                                                 |
+----------+-----------------------------------------------------------+
| 1        | 1/2 Curette                                               |
+----------+-----------------------------------------------------------+
| 1        | 11/12 Curette                                             |
+----------+-----------------------------------------------------------+
| 1        | 13/14 Curette                                             |
+----------+-----------------------------------------------------------+
| 1        | Sharpening Stone                                          |
+----------+-----------------------------------------------------------+
| 1        | Cavitron Tip, 25K FSI-I0                                  |
+----------+-----------------------------------------------------------+

PREVENTIVE DENTISTRY SUPPLIES

  -------------- ------------------------------------------------------------
  **Quantity**   Item Description

  1              Reveal Disclosing Solution

  20             Fluoride varnish, 50 box

  2              Prophy Cups, Screw Type, 36/Pkg.

  1              Uni-Pro Prophy Paste, Coarse 200/Box

  3              Floss Waxed, 200yd/box
  -------------- ------------------------------------------------------------

RADIOLOGY SUPPLIES (conventional radiography)

  ---------- ------------------------------------------------------------
  Quantity   Item/Description

  6          XCP Kit

  1          Snap-a-Ray, Set of 3

  2          X-Ray Apron, Mauve

  2          Apron Hanger

  3          View box,

  2-3 ea     EX-58 Flexi-Soft Vinyl Pack #0,1,2 films by box
  type       

  1          Film Panorex 50/Box

  1          Occlusal Film, EO-41P 25/Box

  1          FM X-Ray mounts, clear, E-Z mounts, Box

  1          X-Ray Envelopes, 21/2\" x 41/4\", Plain 500/Box
  ---------- ------------------------------------------------------------

Note: digital radiography requires: CPU, monitors, Image capture device
(CCD or phosphor plate), scanner, sterilization materials, storage
device, etc.

**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: various sizes (or oxygen machine with bag-valve-mask
    device for assisting in ventilation procedures for the patients)

-   Sphygmomanometer: automated and manual, various sizes (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 2cc. disposable syringes (4) with 18 and 21 gauge needles

-   Drugs:

1.  Oxygen: minimum 1 (one) E cylinder for 30 minutes of 8-10L/min

2.  Epinephrine: Tubex syringe cartridges with sterile protected needle
    attached (6) or 1:1000 in unit dose vials (1 mg/ml) or IV fluids
    (aqueous) 1:1000 in 1 ml for use IM or subcutaneous

3.  Benadryl (50 mg/ml) ampule (3)

4.  Nitroglycerine tablets (0.15mg) for angina pectoris and 1 bottle of
    metered translingual spray 0.4mg/dose)

5.  Aspirin: Antiplatlet: 3-4 baby chewable aspirin (162mg)

6.  Alupent (Albuterol) inhaler for treatment of acute asthma via
    metered dose inhaler (asthma patients should have their own inhalers
    in their possession when receiving dental treatment)

7.  Ammonia inhalant (4)

8.  Antihypoglycemic: non-injectable ( fruit juice, glucostat, soda,
    granulated sugar)

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

-   Versed 5mls in 5mg/ml dosage or 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

-   Glucagon (1 mg. IM) for hypoglycemia

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

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

-   Atropine (1 mg. ampule) for bradycardia

-   Automatic External Defibrillators (AED) are becoming the standard of
    care in the private sector, and have been mandated by some states.
    All stand-alone dental clinics should consider having one on hand.

**Emergencies in the Dental Office**

**Syncope (Mild Neurogenic Shock)**

*Early Symptoms:* Ashen gray(pallor), cold perspiration, nausea,
lightheadedness, restlessness (anxiety), talkativeness, tachycardia.

*Late Symptoms:* Depressed medullary function, papillary dilation, low
blood pressure, convulsive movements, bradycardia (rapid, thready, or
slow, weak pulse), shallow, slow respirations, unconsciousness

*Prevention:* Minimize hypoglycemic risk (advise a light meal), adequate
emotional evaluation; barbiturate or tranquilizer premedication;
aspiration when giving injection.

*Treatment:*

1\. Monitor vital signs

2\. Supine position (lower head slightly, elevate legs and arms
(pregnancy - roll to side)

3\. oxygen 8-10 l minute

4\. spirits of ammonia

5\. cold packs to forehead

5\. Monitor vital signs.

6\. Reassure patient

**Hyperventilation Syndrome (Neurogenic)**

*Symptoms:* Hyperventilation (rapid & shallow breathing); apnea;
lightheadedness; paresthesia of hands and feet; sometimes carpo-pedal
spasm, tension anxiety, chest pain, dry mouth, syncope may develop.

*Prevention:* Adequate evaluation; premedication; "vocal anesthesia."
Stress reduction protocol (confidence, early and short appointments,
profound anesthesia)

*Treatment:*

1.  Terminate procedure

2.  Sit upright

3.  Quiet reassurance

4.  Instruct patient to take slow deep breaths with hands cupped over
    mouth of use B-V-M mask with patient holding the mask

**Allergic Reaction**

Mild (slow onset)

*Symptoms:* Rash; hives; itching; rhinitis;

*Prevention:* Adequate medical history; sensitivity test.

*Treatment:* Benedryl 25-50mg oral or IM follow-up with 50 mg PO every 6
hours for 2 days

Toxic (Severe) Reaction (rapid onset)

*Symptoms:* Rapid onset swelling; asthma; bronchospasm; angioneurotic
edema; shock; cardiovascular collapse. 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:*

1.  Activate (call) EMS

2.  oxygen

3.  Epinephrine 0.3 -- 0.5mg 1:1000 subcutaneously NOTE: contraindicated
    in presence of severe hypertension

4.  If ACLS trained: IV Valium 5-10 mg. for convulsions

5.  If ACLS trained ephedrine sulfate 10-25 mg IM or IV

6.  supportive therapy for depression

**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:*

1.  Place in a semi-reclined position

2.  Monitor and record Vital signs

3.  oxygen

4.  0.3 mg. nitroglycerine sublingually, x 3 if needed

5.  keep patient quiet

6.  If in doubt of Angina Pectoris: ACTIVATE EMS

**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 (hypotension/syncope); pallor;
sweating; headache; pain in abdomen and legs; respiratory collapse; weak
pulse; nervousness early, then apathy and unconsciousness; coma; may
terminate in death if not treated.

*Treatment:*

1.  If conscious: semi-reclined position, monitor vital signs

2.  oxygen therapy

3.  Unconscious: Activate EMS; supine position, BLS, oxygen, Solu-Cortef
    100 mg. IV.

**Asthma**

*Symptoms:* Wheezing; cough; difficult respiration; cyanosis; agitation,
sense of suffocation

*Treatment:*

1.  Alupent inhaler 1-2 puffs (use patient's supply)

2.  Oxygen therapy

3.  Activate EMS, Epinephrine (0.5 ml 1:1000) SC

**Cerebrovascular Accident**

*Symptoms:* Sudden onset; mild dizziness to unconsciousness; varying
degree of paralysis; headache; aphasia; nausea; numbness; diplopia;
blindness, unilateral weakness

*Treatment:*

1.  Activate EMS

2.  Position patient reclined with head slightly elevated

3.  Maintain airway and provide oxygen

4.  Monitor patients vital signs

5.  Reassure patient

6.  Obtain medical help and transport rapidly.

**Insulin Shock**

*Symptoms:* Hunger, nausea, sweating (skin cool and moist), nervousness;
headache; mental confusion (poor judgment), 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:* CPR (FBAO), oxygen therapy, Heimlich abdominal thrust, if
clear airway and insert oral airway 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.

Medical Emergencies in the Dental Office, 5^th^ ed, Malamed SF, Mosby
2000

Dental Management of the Medically Compromised Patient, 6^th^ ed, Little
JW, Falace DA, Miller CS, Nelson LR, Mosby 2002

**Additional Resources**

Journal of the Canadian Dental Association article:
<http://www.cda-adc.ca/jcda/vol-65/issue-5/284.html>

ADA Report on Office Emergencies and Emergency Kits:
[http://www.ada.org/prof/resources/pubs/jada/reports/report_emergency.pdf#search=\'medical%20emergencies%20in%20the%20dental%20office](http://www.ada.org/prof/resources/pubs/jada/reports/report_emergency.pdf#search='medical emergencies in the dental office)\'

PowerPoint Presentation, Thomas Jefferson University Hospital
<http://www.tju.edu/omfs/research/powerpoint/medical_files/frame.htm>

(297 slides, broadband recommended)

AAPD Guidelines:
<http://www.aapd.org/media/Policies_Guidelines/RS_MedEmergencies.pdf>

State of Tennessee Division of Oral Health guidelines:
<http://www2.state.tn.us/health/oralhealth/pdf/Section4.pdf>

**Pharmaceuticals**

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

-   All JCAHO or AAAHC standards covering the prescription, storage,
    dispensing of pharmaceuticals should also be followed.

**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.

**Antibiotic Prophylaxis Against Infective Endocarditis (IE)**

The American Dental Association, in conjunction with the American Heart
Association, has developed antibiotic prophylaxis guidelines for
patients with heart conditions that may predispose them to infective
bacterial endocarditis. The most recent guidelines were published in
1997, and have been periodically reviewed since then to ensure that the
recommendations are based on the most recent scientific findings.

A study that appeared in the Annals of Internal Medicine in 1998
concluded that dental treatment does not seem to be a risk factor for IE
and that a reconsideration of the usage of antibiotic prophylaxis is in
order. Following the publishing of this study, the ADA issued a
**Statement on Antibiotic Prophylaxis** reaffirming the validity of the
prophylaxis guidelines. The ADA statement can be found at:
<http://www.ada.org/prof/resources/positions/statements/endoprop.asp>.

Any questions about these guidelines may be addressed by contacting the
ADA Division of Science via e-mail (<science@ada.org>) or by calling
312-440-2878. ADA members may use the Association's toll-free number
(1-800-621-8099) and ask for extension 2878.

The most current guidelines for prophylaxis against IE can be found by
clicking on the following link:
<http://www.ada.org/prof/resources/pubs/jada/reports/report_endocarditis01.pdf>.
A review of the recommendations was published in JADA in 2000 and can be
found at: <http://jada.ada.org/cgi/reprint/131/3/366>.

The AAPD's guideline on antibiotic prophylaxis can be found at:
<http://www.aapd.org/media/Policies_Guidelines/G_AntibioticProphylaxis.pdf>

It is recommended that every dental clinic download a copy of the
recommendations and keep them in a readily accessible area of the clinic
for quick reference.

The mere presence of a heart murmur does not indicate the need for IE
prophylaxis. A study published in JADA in 1998 indicated that many
patients who gave a history of a heart murmur did not have evidence of a
pathologic heart condition at previous medical exams. A copy of the
study can be found at: <http://jada.ada.org/cgi/reprint/129/7/861>.
Additionally, dental professionals need to be aware of the ADA
**Statement on the HHS Warning to Former Phen-Fen Users**, which can be
found at
<http://www.ada.org/prof/resources/positions/statements/phen_fen.asp>.

**Infective Endocarditis, Signs and Symptoms**

> IE is a rare condition that presents with flu-like symptoms within two
> days to two weeks, rarely within four weeks, following dental
> procedures. The following symptoms can be signs of bacterial
> endocarditis even if the patient has been properly prophylaxed. Any
> patient who presents with these symptoms should be immediately
> referred for medical care.
>
> Symptoms:

-   Low grade fever

-   New cardiac murmur

-   Arthralgias

-   Splenomegaly

-   Splinter hemorrhage

-   CHF

-   Neurological changes

-   Embolic episodes

-   Osler's nodes: Tender, red , raised lesions on the hands or feet

-   Janeway's lesion: Erythematous or hemorrhagic lesions seen on the
    palm or sole

> Preventative / Precautions:

-   Good oral hygiene

-   Proper teeth cleaning, clorhexidine rinse prior to extractions to
    decreases magnitude of possible bacteremias

-   Gingivitis and periodontitis increase the frequency, intensity, and
    duration of bacteremias

-   Stress to the patient that they should take their prophylactic
    antibiotic medication within the proper timeframe, and document in
    the medical record that the medication has been properly taken

**Antibiotic Prophylaxis for Total Joint Replacement**

Approximately 450,000 total joint replacement procedures are performed
each year in the United States. Deep infections of these total joint
replacements usually result in failure of prosthesis and the need for
extensive revision. Serious concerns exist that the hematogenous spread
of oral bacteria following certain dental procedures can cause such
infections and joint failures.

In 1997, the ADA, along with the American Academy of Orthopaedic
Surgeons, released antibiotic prophylaxis guidelines for patients who
have total joint replacements and may be at risk for developing
hematogenous infections at the site of the prosthetic. These guidelines
can be found at:
<http://www.ada.org/prof/resources/pubs/jada/reports/report_prophy_statement.pdf>.
As a supplement to these recommendations, in 2003, the ADA Division of
Legal Affairs released **A Legal Perspective on Antibiotic
Prophylaxis,** which can be found at
<http://www.ada.org/prof/resources/pubs/jada/reports/report_prophy_legal.pdf>.
This legal perspective was developed in response to growing concerns
about the development of antibiotic resistance and the role that the
inappropriate use of prophylactic antibiotics may play in the
development of resistance.

As with the recommendations for the prevention of Infectious
Endocarditis, it is highly recommended that every dental clinic download
a copy of the Guidelines and keep them in a readily accessible location
in the clinic for quick reference.

**Care of the Anticoagulated Patient**

**Background**

Controversy has surrounded the correct management of patients
therapeutically anticoagulated who require dental extractions. One must
carefully consider the effect that stopping warfarin therapy for even a
few days can have on the patient. Even a moderate amount of bleeding is
a minor inconvenience compared with a paralyzing stroke or death.

A review article in the Archives of Internal Medicine in 1998 (1) looked
at patients receiving continuous anticoagulant therapy during dental
surgery. The primary outcome measure was the presence of postsurgical
hemorrhage not controlled by local measures.

Of the 774 patients studied, there were 12 who had a hemorrhage
requiring more than local treatment to control the bleeding. In five of
these cases, the patient\'s level of anticoagulation before the
procedure exceeded current recommendations. Vitamin K was given to 10
patients, fresh-frozen plasma to four, packed red blood cells to three.
No other serious morbidity was reported.

Of 493 patients who stopped anticoagulant use before having dental
surgery, five experienced severe embolic events. Complications included
cerebral thromboembolism, brachial artery embolism, and myocardial
infarction. Four of the 5 cases were fatal. These data are limited
because case reports do not establish a cause-and-effect relationship. A
similar review article published in JADA (2) revealed similar results.

A study reported in the Journal of Oral and Maxillofacial Surgery in
2003 (3) supports the contention that dental extractions can be
performed without modification of oral anticoagulant treatment. Local
hemostasis with an absorbable oxidized cellulose mesh, tranexamic acid,
and sutures was the more cost efficient of the 2 methods compared.
Autologous fibrin glue was found to have an important role in patients
unable to use a mouthwash effectively.\
\
Another review published in the Australian Dental Journal in 2003 (4)
stated that an improved understanding of the importance of fibrinolytic
mechanisms in the oral cavity has resulted in the development of various
local measures to enable these patients to be treated on an outpatient
basis. The authors concluded that patients therapeutically
anticoagulated with warfarin can be treated on an ambulatory basis,
without interruption of their warfarin regimen provided appropriate
local measures are used. Additionally, a review article in JADA
concluded that the scientific literature does not support routine
discontinuation of oral anticoagulation therapy for dental patients (5)

***Tranexamic Acid and Epsilon Aminocaproic Acid***

One of the most significant factors for the development of bleeding
after oral surgery is the activation of fibrinolysis in the oral cavity.
In 1989 a study by Sindet-Pederson *et al*. (6) demonstrated that
maintenance of oral anticoagulant therapy in conjunction with oral
surgery does not result in severe bleeding complications in patients
receiving a tranexamic acid mouthwash post-operatively.

Tranexamic acid is a competitive inhibitor of plasminogen activation,
and at much

higher concentrations, a noncompetitive inhibitor of plasmin, i.e.,
actions similar

to aminocaproic acid. Tranexamic acid is about 10 times more potent *in
vitro* than aminocaproic acid. Tranexamic acid binds more strongly than
aminocaproic acid to both the strong and weak receptor sites of the
plasminogen molecule in a ratio

corresponding to the difference in potency between the compounds.

**Dental Extractions and the Anticoagulated Patient**

The following information discusses how to evaluate and treat the
anticoagulated dental patient during extractions. **In all cases, this
treatment should be coordinated with the patient's primary care
physician**.

**Pre-op Work-up of the Patient**

1\. **Thorough Medical History**

Questions to ask include the following:

-   How long have you been on anticoagulant medication?

-   Have you had problems with previous dental appointments?

-   Why are you on anticoagulants?

-   What are your most recent laboratory results relative to your
    anticoagulation or bleeding problem status?

2\. **Consult Patient's Primary Care Physician**

-   Contact the patient's primary physician and ask how brittle the
    patient is (i.e., how great is the patient's risk of
    thromboembolism), and what options they recommend.

-   Can Warfarin therapy be discontinued for the dental procedure?

-   Can the patient be converted to a Low Molecular Weight Heparin
    (LMWH, i.e. Lovenox) or Low Density Unfractionated Heparin (LDUH)
    which is preferred in patients with poor renal function? If these
    are medications with which you have limited or no experience, ask
    the patient's physician to prescribe the medications and explain
    their use to the patient.

-   Does the patient need to be hospitalized and converted to heparin
    because he/she is too brittle?

3\. **Diagnostic Tests (Morning of the procedure, due to rapid changes,
don't rely on old values)**

-   Warfarin Therapy

    -   PT - prothrombin time (Normal range 11.5 -- 13.5 seconds)

    -   PTT - partial thromboplastin time (Normal range 25 to 35
        seconds)

    -   INR - international normalized ratios -

> [(Patient PT]{.underline})
>
> INR= (control PT)

-   recommended INR levels as prophylaxis against thromboembolic events:

> \- Atrial fibrillation 2-3 (2.5)
>
> \- Deep vein thrombosis (DVT's) 2-3
>
> \- Hx of Pulmonary embolism 3.5
>
> \- Metallic cardiac valve 3-3.5

-   Aspirin and other non-steroidal anti-inflammatory agents, and
    anti-platelet medications such as Plavix

    -   Bleeding time

-   Thrombocytopenia

    -   CBC with a differential (which will give platelet count)

    -   Bleeding time

4\. **Pre-Operative Precautions**

-   Avoid drugs that may cause drug interaction, such as erythromycin
    and ketoconazol, which inhibit warfarin metabolism. Also avoid drugs
    that can prolong bleeding, such as aspirin or other non-steroidal
    anti-inflammatories.

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-   Encourage patient to keep you informed of any drug changes and their
    use of any over-the-counter medications.

5\. **Management During Dental Treatment**:

-   No type of dental treatment should be rendered that has the
    potential for **[severe]{.underline}** bleeding (i.e. extractions,
    scale/root plane).

    -   If bleeding time greater than 10 minutes

    -   If platelet count less than 60,000

    -   If PTT greater than 45 seconds

    -   If PT greater than 22 seconds

    -   If INR greater than 3.5

-   If bleeding parameters are greater than the above, medical
    coordination is required. For example, the physician should decrease
    the anticoagulant dose or provide packed platelets or prescribe
    supplemental vitamin K until bleeding parameters are compatible with
    dental treatment.

-   During dental procedures minimize physical trauma and pack
    extraction sites that have the potential to bleed with local
    pressure and other coagulation procedures (e.g. Gelfoam). If gauze
    is changed, the new gauze needs to be wet so it will not attach to
    the clot and dislodge it.

-   Establish primary closure and/or put pressure on potential/actual
    bleeding sites.

-   Extractions can be performed safely with an INR at 2 (some say 1.5)
    or below.

-   With an INR of 2 -- 2.5 (some recommend 3.5) extractions in
    conjunction with oral antifibrinolytics such as aminocaproic acid or
    tranexamic acid can be performed. Use 10 ml of a 4.8% aqueous
    solution to irrigate the socket before suturing. This is followed by
    a mouthwash of the same solution for 2 minutes, four times a day for
    1 week. It is also helpful to use a fibrin sponge (Gelfoam). Again,
    this must be coordinated with the patient's primary care provider.

-   A full liquid diet for 24 -- 48 hrs, followed by a soft diet for
    another 5 days is recommended to prevent trauma to the surgical
    site. Hot drinks or soups should be avoided because increased
    temperatures promote clot lysis.

-   It is important that the patient not be given aspirin or NSAIDs for
    postoperative pain as this will increase bleeding. If patents are
    taking these, they should be discontinued 7 -- 10 days prior to
    extractions.

-   If LMWH is used, PTT ranges should be 1.25 -- 2.1 compared with PTT
    control. LMWH is stopped the day before and restarted the day after
    surgery. IV heparin is stopped 2 -4 hrs before the procedure and
    restarted after surgery

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-   For all patients who were taken off warfarin before surgery,
    warfarin is restarted in the postoperative period. If needed discuss
    this with the patient's primary physician. Remember -- it takes
    three days for Warfarin anticoagulation to become effective.

**Post Operative Precautions**:

-   If the patient calls from home following treatment, instruct them to
    apply pressure with gauze or cloth to bleeding site for 10-30
    minutes. If bleeding persists, have patient come into office
    immediately or to a medical emergency room.

-   In the event of a severe post-operative bleed, contact the Emergency
    Room. Fresh Frozen Plasma (FFP) is the management of choice (even
    though there is the risk of Hepatitis or other blood born diseases).
    The use of Vitamin K (10 mg subcutaneously or intravenously)
    requires 12 -- 36 hrs before its coagulation action can be seen.
    More important is the fact that patients with Vitamin K
    administration become resistant to Warfarin action. This
    re-establishes prolonged non-therapeutic INR levels and exposes the
    patient to the risk of embolism .

**References**

\(1\) Wahl MJ. Dental surgery in anticoagulated patients. Arch Intern
Med 1998; 158:1610-16

\(2\) [Wahl
MJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Wahl+MJ"%5BAuthor%5D).
Myths of dental surgery in patients receiving anticoagulant therapy. [J
Am Dent Assoc.](javascript:AL_get(this, 'jour', 'J Am Dent Assoc.');)
2000 Jan;131(1):77-81.

\(3\) Carter G, Goss A, Lloyd J, Tocchetti R. Tranexamic acid mouthwash
versus autologous fibrin glue in patients taking warfarin undergoing
dental extractions: a randomized prospective clinical study. J Oral
Maxillofac Surg. 2003 Dec;61(12):1432-5

<http://www.valvereplacement.com/forums/showthread.php?t=5662>

\(4\) G Carter, AN Goss, J Lloyd, R Tocchetti. Current concepts of the
management of dental extractions for patients taking warfarin Australian
Dental Journal 2003;48:(2):89-96

> [http://www.ada.org.au/media/documents/Products_Publications/Journal%20Archives/2003%20Archive/June/0306Cart.pdf#search=\'anticoagulant%20therapy%20and%20dental%20extractions](http://www.ada.org.au/media/documents/Products_Publications/Journal Archives/2003 Archive/June/0306Cart.pdf#search='anticoagulant therapy and dental extractions)

\(5\) [Jeske
AH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Jeske+AH"%5BAuthor%5D),
[Suchko
GD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Suchko+GD"%5BAuthor%5D)
Lack of a scientific basis for routine discontinuation of oral
anticoagulation therapy before dental treatment. J Am Dent Assoc. 2004
Jan;135(1):28.

\(6\) Sindet-Pedersen S, Ramstrom G, Bernvil S, Blomback M. Haemostatic
effect of tranexamic acid mouthwash in anticoagulant-treated patients
undergoing oral surgery. N Engl J Med 1989;320:840-843

\(7\) Additional information on this subject can be found at:
<http://www.warfarinfo.com/dentalprocedures.htm>

**Guidelines for Pharmacosedation**

**Introduction**

Pharmacosedation is a necessary adjunctive procedure for many dental
procedures, most often for behavior management and/or surgical
procedures. Specific training is required, and these guidelines are not
meant to be a substitute for that training. Sedative techniques are
subject to JCAHO review and facilities may restrict techniques for a
variety of considerations. These guidelines are based on guidelines
developed by the American Dental Association and the practitioner is
urged to review the most recent revision.

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

-   Patient welfare

-   Control of patient behavior

-   Facilitate and augment the provision of quality care.

-   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:

-   *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.

-   A*nxiolysis (minimal sedation):* A dissolution or reduction of
    anxiety through the use of the hypnotic dose of a sedative agent,
    i.e., light sedation

> Definition (ADA): Anxiolysis -- "the diminution or elimination of
> anxiety"
>
> Definition (JACHO): Minimal Sedation - "A drug-induced state during
> which patients respond normally to verbal commands. Although cognitive
> function and coordination may be impaired, ventilatory and
> cardiovascular functions are unaffected."
>
> Definition (AAPD): Mild sedation (Level 1) -- "decreased anxiety"

-   *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 and
    verbal command.

-   *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*: A controlled state of unconsciousness
    accompanied by a loss of protective reflexes, including the ability
    to maintain an airway independently and respond purposefully to
    physical stimulation or verbal command.

-   *Must or Shall:* Must or shall indicate an imperative need and/or
    duty; essential or indispensable; mandatory.

-   *Should:* Should indicates the recommended manner of achieving the
    standard; highly desirable.

-   *May or Could:* May or could indicate freedom or liberty to follow a
    suggested or reasonable alternative.

-   *American Society of Anesthesiology (ASA) Classification
    (Modified):*

> *Class I. A normally healthy patient with no organic, psychological,
> biochemical or psychiatric disturbance or disease.*

*Class II. A patient with mild to moderate systemic disturbance or
disease.*

*Class III. A patient with severe systemic disturbance or disease*.

Class IV. A patient with severe and life-threatening systemic disease or
disorder.

> Class V. A moribund patient who is unlikely to survive without the
> planned procedure.

**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*: A preoperative physical assessment should be completed
    the day of treatment by a qualified practitioner for all patients
    undergoing sedation at levels deeper than anxiolysis. A medical
    consult may be appropriate. Patients who are ASA 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, unless the person administering the general
    anesthesia has been adequately trained and privileged to assess the
    patient.

-   *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.

**Additional Points**

-   PALS and/or ACLS are strongly encouraged.

-   For IV sedation/deep sedation, providers must be able to start and
    maintain an IV line, provide positive pressure ventilation, and
    intubate a patient.

-   Providers should demonstrate current competence via provision of
    documentation that they have properly performed the procedure a
    minimum of ten (10) times during the past year or continuing
    education every two years at minimum.

-   Any patient given a sedating agent in the clinic should be
    appropriately monitored by an individual trained and competent in
    the monitoring of sedated patients. Because there have been reported
    instances of children receiving a sedating agent, returning to the
    waiting room to await the onset of sedation, and suffering
    respiratory depression due to the lack of adequate monitoring,
    administration of agents with patients returning to the waiting room
    for onset of sedation is not acceptable in the IHS. No medications
    for conscious sedation or deeper levels of sedation should be
    administered outside of the clinical setting.

-   Supplemental oxygen is recommended for all sedated patients (not
    including anxiolysis).

**Table 1**

**Local Anesthetic Dosages**

**Max. Rec.**

**Generic Brand Conc. Dose Mg per**

**Name Name (%) (Mg/Kg) Carpule**

Lidocaine Xylocaine 2 4.4 36

Mepivacaine Carbocaine 2 4.4 36

Mepivacaine Carbocaine 3 4.4 54

Prilocaine Citanest 4 6.0 72

Bupivacaine Marcaine 0.5 2.0 9

Septocaine Articaine 4 7.0 72

**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 staff required to safely conduct a sedation
    procedure will vary with the technique used.

-   *Armamentarium*: Basic emergency diagnostic and treatment equipment
    and an emergency drug kit must be readily available. This should
    include the following: sphygmomanometer, stethoscope, oxygen source
    capable of delivering bag and mask ventilation greater than 90%
    oxygen at 10 liters per minute flow for at least 60 minutes,
    adequate suction apparatus with tonsillar suction tip, oral and
    nasal airways of different sizes, and IV kits. The equipment and
    supplies should be appropriate for both pediatric and adult
    patients. If narcotic drugs are administered, Naloxone must be
    available in the emergency drug kit. If Midazolam is administered,
    flumazanil (reversal agent) must be available. Additionally, strong
    consideration should be given to having a crash cart with
    defibrillator available.

-   *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% O~2~ must be used, and only flowmeters which require
    20% minimum O~2~ flow rate are acceptable. Normal operation should
    be restricted to 50% or less N~2~O.

**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 required 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 as detailed in the
    following sections concerning the various sedation modalities.

-   *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 orally 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.

**General Requirements for the Monitoring and Documentation for Oral and
Parenteral Conscious Sedation and Deep Sedation**

The patient should be monitored from the time of drug delivery until
discharge.

-   *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
    appropriate units (e.g., fentanyl is administered in microgram
    doses, not 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.

**Sedation Techniques, Specific Criteria**

**Anxiolysis**

**Training**

> Documentation of training and pharmacology in the form of dental
> school transcripts or a letter attesting to training from the
> institution. Where anxiolysis was not taught, training should be at
> least 16 hours in duration and include supervised administration of
> anxiolytic sedation in no fewer than five cases.

**Staffing**

> No additional staff beyond those needed for the routine dental
> procedure are required

**Armamentarium**

> No additional armamentarium beyond the normal dental procedure set-up
> is required

**Pre-op evaluation**

Only a review of the dental/medical history form is required.

**Monitoring**

No additional monitoring beyond visual and verbal monitoring is required

**Documentation**

Documentation should include drug and dose used and its effectiveness.

**Nitrous Oxide-Oxygen Sedation**

> Nitrous oxide is colorless with a faint sweet smell. It is an
> effective analgesic/anxiolysis agent causing central nervous system
> (CNS) depression and euphoria, with little effect on the respiratory
> system. It causes minor depression in cardiac output while peripheral
> resistance is slightly increased, thereby maintaining blood pressure
> (advantage when treating patients with cerebrovascular system
> disorders).
>
> Nitrous oxide is absorbed rapidly, allowing for both rapid onset and
> recovery (2-3 minutes). It causes minimal impairment of any reflexes,
> thus protecting the cough and gag reflexes. To be considered
> anxiolysis, no other anxiolytic, sedative or antihistamine drug may be
> used concomitantly.
>
> Nitrous oxide has been cited extensively in the literature for more
> than 150 years as a safe and effective drug.

**Training**

> 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 sedation in no fewer than five cases. Training
> in emergency procedures is required. Only providers with appropriate
> credentials and privileges should be allowed to administer nitrous
> oxide/oxygen.
>
> Dental assistants training must include basic life support.
> Individuals involved with nitrous oxide/oxygen should participate in
> documented periodic review of emergency protocols, drug cart and
> simulated exercises to assure proper emergency management response.

**Staffing**

> During administration of nitrous oxide/oxygen, two qualified people
> must be present to monitor the patient (may be dentist and chair side
> dental assistant).

**Armamentarium**

> Only fail safe machines which deliver a minimum of 30% oxygen at all
> times will be used in the dental clinic.
>
> Equipment must have an appropriate scavenging system.
>
> Equipment must be checked and calibrated regularly according to the
> practitioners state laws and regulations (this is to include
> scavenging system).

**Pre-op evaluation**

> A review of the dental medical history form is required.
>
> Evaluation of airway patency and respiratory system

Potential contraindications include the following:

-   Upper respiratory infection, respiratory diseases, or asthma

-   Lobar emphysema

-   Possible bowel obstruction

-   Patients with severe emotional disturbances or drug-related
    dependencies

-   COPD

-   Patients with pulmonary fibrosis

-   TB

-   Pregnancy, first trimester

> Medical consultations as needed, including but not limited to:

-   severe obstructive pulmonary disease,

-   congestive heart failure,

-   recent tympanic membrane grafts and

-   eye surgery).

> **Methodology**

-   Select appropriate size nasal hood.

-   100% oxygen for 1 to 2 minutes.

-   Nitrous oxide will be titrated to achieve the appropriate effect
    based on individual patient response.

-   Concentration of nitrous oxide may be varied depending on the
    difficulty of the procedure, but should not exceed 50%.

-   Once procedure is completed patient should receive 100% oxygen for
    3-5 minutes. (avoids diffusion hypoxia).

-   Patient must return to pre-treatment responsiveness prior to
    discharge.

**Monitoring**

> Only visual and verbal monitoring of the patient for ventilation and
> level of consciousness throughout the procedure are required. The
> patients' responsiveness (verbal), color, respiratory rate and rhythm
> should be observed.
>
> The provider may utilize monitoring equipment (precordial stethoscope,
> pulse oximeter, blood pressure) as deemed necessary for the care of a
> particular patient. Pulse oximetry is recommended, but not required.
>
> Patients must be observed by dental personnel until discharged (never
> should a patient be left alone).

**Documentation**

-   Informed Consent for Nitrous Oxide

-   Indications for the use of Nitrous Oxide

-   The concentration of Nitrous Oxide used, flow rate, duration,
    effectiveness, and duration of oxygen flush

-   Patient's condition on release

**Oral Conscious Sedation**

**Training**

-   At least 40 hours of formal training, along with a proctored period
    with a specific number of cases being monitored should be a minimum
    requirement for the administration of oral conscious sedation.

-   A written and/or practical exam should also be considered. Persons
    who have received formal training in a residency or specialty
    program may not require these guidelines, but a letter from the
    residency director detailing the scope of training and competency
    should be required. The provision of the proctored 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. As stated above,
    letter from the residency director detailing the scope of training
    and competency should be required.

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

-   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.

**Staffing**

-   The dentist should have at least two properly trained dental
    personnel present for proper monitoring and support, one to assist
    in the dental procedure and one to monitor the patient. At least one
    must be certified in basic life support.

-   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.

**Armamentarium**

-   The operating facility used for the administration of conscious
    sedation should have available all facilities and equipment
    previously recommended. The minimum monitoring equipment for
    sedation shall be a pulse oximeter. A precordial/pretracheal
    stethoscope is highly desirable. ECG monitoring equipment should be
    considered but is not required.

**Pre-op evaluation**

-   Health history

-   Review of systems

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

-   Risk assessment (ASA guidelines)

-   Evaluation of airway patency

-   Evaluation of the respiratory and cardiac systems is needed

**Monitoring**

-   Whenever drugs for conscious sedation are administered, the patient
    should be monitored continuously for responsiveness and airway
    patency. There should be continuous monitoring of oxygen saturation
    by pulse oximetry and of heart and respiratory rates. Respiratory
    rate alone may not be a reliable guide to oxygenation, especially
    when the rate is hard to determine and respirations are shallow. ECG
    monitoring is once again encouraged. 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 from the
    time the sedating agent is administered until discharge from the
    facility.

**Documentation**

-   Oxygen saturation and heart and respiratory rates should be recorded
    intermittently on a time-based record (e.g., every 5 minutes)
    throughout the procedure and until the patient is discharged.

-   After completion of the treatment procedures, vital signs should be
    recorded at specific intervals. Postoperative monitoring, of blood
    pressure, heart rate, pulse oximetry , and possibly ECG is prudent.
    The practitioner shall assess the patient\'s responsiveness and
    discharge the patient only when the appropriate discharge criteria
    have been met.

**Parenteral Conscious Sedation**

**Training**

-   The training requirements for parenteral conscious sedation are the
    same as for oral conscious sedation except that a minimum of 80
    hours, rather than 40 are recommended. The potential for a conscious
    sedation technique to progress to the level of deep sedation,
    especially with the administration of intravenous drugs,
    necessitates this higher level of training.

**Staffing**

-   Staffing requirements are the same as for oral conscious sedation

**Armamentarium**

-   Same as for oral conscious sedation, with the addition of IV
    armamentarium

**Pre-op evaluation**

-   Health history

-   Review of systems

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

-   Risk assessment (ASA guidelines)

-   Evaluation of airway patency

-   Evaluation of the respiratory and cardiac systems is needed

**Monitoring**

-   Same as for oral conscious sedation. Due to the potential for a
    parenteral conscious sedation procedure to progress to deep
    sedation, the monitoring standards for deep sedation should be
    considered.

**Documentation**

-   Same as for oral conscious sedation

**Deep Sedation**

**Training**

-   The training requirements for deep sedation are the same as for
    parenteral conscious sedation

**Staffing**

-   The dentist must have at least two properly trained dental personnel
    present during any sedation procedure for proper monitoring and
    support. They should be certified in basic life support.

-   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.

**Armamentarium**

-   In addition to the facilities and equipment previously recommended
    for oral and parenteral 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.

**Pre-op evaluation**

-   Health history

-   Review of systems

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

-   Risk assessment (ASA guidelines)

-   Evaluation of airway patency

-   Evaluation of the respiratory and cardiac systems is needed

**Intravenous Access**

-   Patients receiving deep sedation should have an intravenous line in
    place prior to the start of the procedure if the patient is
    cooperative, otherwise, as soon as possible after the procedure has
    begun. The time to start an IV is before problems arise. It can be
    very difficult to start an IV on a crashing patient due to
    cardiovascular collapse and confusion in the operatory.

**Monitoring**

-   The sedated patient should be continuously monitored by an
    appropriately-trained individual. There should be continuous
    monitoring of oxygen saturation (by pulse oximetry), heart and
    respiratory rates, and blood pressure. A pulse oximeter,
    precordial/pretracheal stethoscope, and blood pressure cuff are
    minimum monitoring devices; ECG, capnography, and temperature
    monitoring are desirable, (the American Academy of Pediatric
    Dentistry considers capnography to be a standard of care for deep
    sedation). 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.

-   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
    assess 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.

**Documentation**

-   Oxygen saturation, heart and respiratory rates, Carbon Dioxide, and
    blood pressure should be recorded intermittently on a time-based
    record (e.g., every 5 minutes).

-   After completion of the treatment procedures, vital signs should be
    recorded at specific intervals. Postoperative monitoring, of blood
    pressure, heart rate, pulse oximetry , and possibly ECG is prudent.
    The practitioner shall assess the patient\'s responsiveness and
    discharge the patient only when the 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. General Anesthesia may be administered by
a qualified person on appropriate patients without medical consultation,
in an adequate facility, with provision for recovery, if local Policies
and Procedures so permit.

> **Summary Table of Characteristics, Armamentaria, And Monitoring
> Requirements**

**For Various Levels Of Sedation**

(from the AAPD's "Guideline on the Elective Use of Minimal, Moderate,
and Deep Sedation and General Anesthesia for Pediatric Dental Patients,"
used with permission)

+----------+------------+----------------+------------------+----------+
| **       |            |                |                  |          |
| Template |            |                |                  |          |
| of       |            |                |                  |          |
| Def      |            |                |                  |          |
| initions |            |                |                  |          |
| and      |            |                |                  |          |
| Charact  |            |                |                  |          |
| eristics |            |                |                  |          |
| for      |            |                |                  |          |
| Levels   |            |                |                  |          |
| of       |            |                |                  |          |
| Sedation |            |                |                  |          |
| and      |            |                |                  |          |
| General  |            |                |                  |          |
| Anes     |            |                |                  |          |
| thesia** |            |                |                  |          |
+----------+------------+----------------+------------------+----------+
|          | **Minimal  | **Moderate     | **Deep           | *        |
|          | sedation** | sedation**     | sedation**       | *General |
|          |            |                |                  | anes     |
|          |            |                |                  | thesia** |
+----------+------------+----------------+------------------+----------+
| **Goal** | Decrease   | Decrease or    | Eliminate        | E        |
|          | or         | eliminate      | anxiety; coping  | liminate |
|          | eliminate  | anxiety;       | skills           | sensory  |
|          | anxiety;   | facilitate     | unaffected and   | and      |
|          | facilitate | coping skills. | overridden.      | skeletal |
|          | coping     | Younger        | Patient uneasily | motor    |
|          | skills     | patients show  | aroused but may  | a        |
|          |            | a              | respond to       | ctivity; |
|          |            | ge-appropriate | purposeful       | a        |
|          |            | behaviors,     | stimulation      | utonomic |
|          |            | including      |                  | activity |
|          |            | crying; older  |                  | d        |
|          |            | patients       |                  | epressed |
|          |            | demonstrate    |                  |          |
|          |            | interactive    |                  |          |
|          |            | state.         |                  |          |
+----------+------------+----------------+------------------+----------+
| *        | Sub        | Subjectively,  | Subjectively,    | Unc      |
| *Patient | jectively, | the patient    | the patient may  | onscious |
| responsi | the        | may sense      | sense and/or     | and      |
| veness** | patient    | and/or express | express limited  | unre     |
|          | may sense  | less anxiety   | or no feelings   | sponsive |
|          | and/or     | about the      | of anxiety       | to       |
|          | express    | clinical       | associated with  | surgical |
|          | less       | procedure      | the clinical     | stimuli. |
|          | anxiety    | compared to    | procedure.       |          |
|          | about the  | pre-sedation   | Objectively, the |          |
|          | clinical   | periods.       | patient may      |          |
|          | procedure  |                | appear very      |          |
|          | compared   | Objectively,   | relaxed, not     |          |
|          | to         | the patient    | cognizant of and |          |
|          | pr         | may appear     | minimally or     |          |
|          | e-sedation | less tense,    | nonresponsive to |          |
|          | periods.   | cognizant of,  | clinical         |          |
|          | Ob         | but less       | stimuli. And     |          |
|          | jectively, | overtly        | noninteractive   |          |
|          | the        | responsive to, | with the         |          |
|          | patient    | clinical       | clinician at any |          |
|          | may appear | stimuli, and   | time. The        |          |
|          | calm, less | purposefully   | patient would    |          |
|          | overtly    | interactive    | not be able      |          |
|          | responsive | with the       | independently to |          |
|          | to         | clinician,     | move his/her     |          |
|          | clinical   | compared to    | head and/or      |          |
|          | stimuli,   | pre-sedation   | mandible to      |          |
|          | and        | periods. The   | maintain optimal |          |
|          | pu         | patient, if    | airway patency   |          |
|          | rposefully | behaviorally   | consistent with  |          |
|          | i          | and            | the clinical     |          |
|          | nteractive | cognitively    | situation. Under |          |
|          | with the   | cooperative    | these            |          |
|          | clinician  | should be able | circumstances,   |          |
|          | compared   | to             | the patient      |          |
|          | to         | independently  | requires         |          |
|          | pr         | move his/her   | continuous       |          |
|          | e-sedation | head and/or    | monitoring of    |          |
|          | periods    | mandible, as   | the airway and   |          |
|          |            | directed by    | continual        |          |
|          |            | the clinician  | assistance of    |          |
|          |            | and to assist  | the clinician    |          |
|          |            | in maintaining | (e.g. Head tilt, |          |
|          |            | optimal airway | chin lift        |          |
|          |            | patency        | procedure)       |          |
+----------+------------+----------------+------------------+----------+
| **Phy    | Patient    | Patient        | Patient remains  | Partial  |
| siologic | remains    | remains stable | stable and       | or       |
| c        | stable and | and within     | either minimally | complete |
| hanges** | within     | a              | or moderately    | loss of  |
|          | age-a      | ge-appropriate | below the        | pr       |
|          | ppropriate | and health     | patient's age    | otective |
|          | and health | status norms   | and health       | r        |
|          | status     | for parameters | status norms for | eflexes, |
|          | norms for  | involving      | hemodynamic,     | i        |
|          | parameters | hemodynamic,   | ventilation, and | ncluding |
|          | involving  | ventilation,   | oxygenation      | the      |
|          | he         | and            | functions.       | airway;  |
|          | modynamic, | oxygenation    | Accompanied by   | does not |
|          | ve         | functions. No  | partial or       | respond  |
|          | ntilation, | loss of        | complete loss of | purp     |
|          | and        | protective     | protective       | osefully |
|          | o          | reflexes.      | reflexes.        | to       |
|          | xygenation |                |                  | verbal   |
|          | functions. |                |                  | command  |
|          | No loss of |                |                  | or       |
|          | protective |                |                  | physical |
|          | reflexes.  |                |                  | s        |
|          |            |                |                  | timulus. |
+----------+------------+----------------+------------------+----------+
| **P      | 2          | 2              | 3                | 3        |
| ersonnel |            |                |                  |          |
| needed** |            |                |                  |          |
+----------+------------+----------------+------------------+----------+
| **Mo     | Clinical   | BPC, PO, PC or | BPC, PO, PC,     | BPC, PO, |
| nitoring | o          | capno          | capno, ECG       | PC,      |
| Equ      | bservation |                |                  | capno,   |
| ipment** | unless     |                |                  | ECG,     |
|          | patient    |                |                  | temp     |
|          | becomes    |                |                  |          |
|          | moderately |                |                  |          |
|          | sedated,   |                |                  |          |
|          | then       |                |                  |          |
|          | a          |                |                  |          |
|          | ppropriate |                |                  |          |
|          | monitoring |                |                  |          |
|          | needed.    |                |                  |          |
+----------+------------+----------------+------------------+----------+
| **Mo     | Skin       | HR, RR, BP,    | HR, RR, BP,      | HR, RR,  |
| nitoring | color,     | SaO~2~, (q 15  | SaO~2~, ETCO~2~  | BP,      |
| Inf      | r          | min)           | (q 5 min)        | SaO~2~,  |
| ormation | espiratory |                |                  | ETCO~2~  |
| and      | effort     |                |                  | temp (q  |
| fre      | (          |                |                  | 5 min)   |
| quency** | continual) |                |                  |          |
+----------+------------+----------------+------------------+----------+
| *        |            |                |                  |          |
| BP=blood |            |                |                  |          |
| pr       |            |                |                  |          |
| essure;, |            |                |                  |          |
| BPC=     |            |                |                  |          |
| blood    |            |                |                  |          |
| pressure |            |                |                  |          |
| cuff/s   |            |                |                  |          |
| phygmoma |            |                |                  |          |
| nometer; |            |                |                  |          |
| capno=   |            |                |                  |          |
| capnogr  |            |                |                  |          |
| aphy/end |            |                |                  |          |
| tidal    |            |                |                  |          |
| carbon   |            |                |                  |          |
| dioxide  |            |                |                  |          |
| monitor; |            |                |                  |          |
| EC=el    |            |                |                  |          |
| ectrical |            |                |                  |          |
| cond     |            |                |                  |          |
| uctivity |            |                |                  |          |
| as       |            |                |                  |          |
| demo     |            |                |                  |          |
| nstrated |            |                |                  |          |
| on ECG;  |            |                |                  |          |
| ECG=elec |            |                |                  |          |
| trocardi |            |                |                  |          |
| ography; |            |                |                  |          |
| ETCO~2~= |            |                |                  |          |
| end      |            |                |                  |          |
| tidal    |            |                |                  |          |
| carbon   |            |                |                  |          |
| dioxide; |            |                |                  |          |
| t        |            |                |                  |          |
| emp=temp |            |                |                  |          |
| erature; |            |                |                  |          |
| HR=heart |            |                |                  |          |
| rate;    |            |                |                  |          |
| PO=pulse |            |                |                  |          |
| o        |            |                |                  |          |
| ximetry; |            |                |                  |          |
| P        |            |                |                  |          |
| C=precor |            |                |                  |          |
| dial/pre |            |                |                  |          |
| tracheal |            |                |                  |          |
| stet     |            |                |                  |          |
| hoscope; |            |                |                  |          |
| RR=res   |            |                |                  |          |
| piratory |            |                |                  |          |
| rate;    |            |                |                  |          |
| S        |            |                |                  |          |
| aO*~2~*= |            |                |                  |          |
| oxygen   |            |                |                  |          |
| sat      |            |                |                  |          |
| uration* |            |                |                  |          |
+----------+------------+----------------+------------------+----------+

**Additional Information**

Additional information and guidelines for the use of pharmacosedation in
the dental clinic can be found at the following sites:

ADA guidelines and statements:

-   The Use of Conscious Sedation, Deep Sedation and General Anesthesia
    in Dentistry
    <http://www.ada.org/prof/resources/positions/statements/useof.asp>

-   ADA Statement On Dental Anesthesia
    [**http://www.ada.org/prof/resources/positions/statements/anes.asp**](http://www.ada.org/prof/resources/positions/statements/anes.asp)

-   Guidelines for the Use of Conscious Sedation, Deep Sedation and
    General Anesthesia for Dentists
    <http://www.ada.org/prof/resources/positions/statements/anesthesia_guidelines.pdf>

AAPD guidelines:

-   [Appropriate Use of Nitrous Oxide for Pediatric Dental
    Patients](http://www.aapd.org/media/Policies_Guidelines/G_Nitrous.pdf)
    <http://www.aapd.org/media/Policies_Guidelines/G_Nitrous.pdf>

-   [Elective Use of Minimal, Moderate, and Deep Sedation and General
    Anesthesia for Pediatric Dental
    Patients](http://www.aapd.org/media/Policies_Guidelines/G_Sedation.pdf)
    <http://www.aapd.org/media/Policies_Guidelines/G_Sedation.pdf>

ATTACHMENT 1

**SAMPLE PRIVILEGES REQUEST FORM**

**FOR SEDATION/GENERAL ANESTHESIA**

**PRIVILEGE LEVEL REQUESTED** **LEVEL APPROVED**

F L N F L N

U I O U I O

L M N L M N

L I E L I E

T T

E E

D D

Nitrous Oxide/Oxygen Sedation

Anxiolysis

Oral conscious sedation

Oral Deep Sedation

Parenteral Conscious sedation

Parenteral Deep sedation

General Anesthesia

ATTACHMENT 2

**INDICATIONS FOR SEDATION IN THE DENTAL CLINIC**

1\. The pre-cooperative and the fearful, anxious or uncooperative child
whose disruptive behavior precludes the safe delivery of quality dental
care and whose developing psyche should not be exposed to the potential
emotional/psychological liabilities of treatment under duress.

2\. A patient who has had prior sensitization to, or exhibits an acute
anxiety reaction to the professional environment and has resisted
reasonable behavior modification techniques.

3\. A co-existing medical complication presenting either a relative or
absolute contraindication to treatment outside a sedation modality
(i.e., poorly controlled seizure disorder, severe cerebral palsy, etc.).

4\. Patients who are physically, mentally, or sensorily compromised and
whose disabilities present management problems in a fully conscious
state.

5\. Patients with severe orofacial trauma or requiring extensive oral
surgical treatment.

6\. The patient with extensive treatment needs who lives in a remote
area and has a verified transportation constraint.

ATTACHMENT 3

**INSTRUCTIONS TO PARENTS FOR SEDATION OF A CHILD**

*In order to provide the best dental and emotional care for your child,
a technique involving one or more sedative drugs will be used.*

**In order to make this sedation as safe and effective as possible, we
ask that you follow the following instructions.**

1\. The child should have nothing to eat or drink for 4 to 6 hours
before the appointment time. Also, the most recent meal should be light
and easily digestible.

2\. It is important that you inform us of any recent changes in the
child\'s medical history, medications, history of illnesses,
hospitalizations, or reaction to any drugs.

3\. The child must be accompanied by a parent or guardian for all
appointments.

4\. No tight clothing should be worn by your child. Short sleeved
pajamas are a good choice.

5\. Attend to bowel and urinary needs before the appointment.

6\. If your child develops a common cold at any time before the
scheduled appointment, please inform us immediately. We may have to
postpone the appointment until the cold is over.

7\. Please be on time for the appointment. We are setting aside extra
time for your child\'s treatment needs, and this time may be wasted if
you show up too late to sedate your child or if you fail to show up.

8\. After the appointment, do not allow your child to bite his/her lip,
tongue, or cheek before the numbness wears off.

9\. After the appointment, your child should be under adult supervision
for 12 hours and not be allowed to travel unrestrained in a vehicle or
to play near streets, stairways, or other areas where injury could
occur.

10\. Encourage the child to drink clear room temperature drinks such as
ginger ale or 7-up to help reduce occasional nausea or vomiting.

11\. If the child vomits, help him bend over and turn the head to the
side to make sure that he does not inhale the vomit.

12\. Your child may remain sleepy for several hours after the
appointment, and may be irritable as the medicine wears off.

13\. If anything unusual should occur, please call us at .

**Evaluation And Management Of The Medically Complex Patient**

The safe delivery of dental services to patients with compromising
medical conditions can be problematic. As pharmaceuticals and medical
therapies improve, more patients with complex medical problems remain
healthy enough to seek dental care, yet may require special treatment
regimens to make sure dental procedures and recommendations don't
adversely affect their medical condition. The following section offers
suggestions for the evaluation and dental treatment of such patients.
Always remember, that from a medico-legal standpoint, the final decision
about the provision of dental care rests with the dentist and patient
(informed consent)

**PRE-TREATMENT EVALUATION**

The goal of the pre-treatment evaluation of the medically complex
patient is to determine the patient's ability to tolerate the planned
dental procedure(s).

The pre-treatment evaluation should help the dentist determine the
answers to the following questions:

-   Does the patient have a diagnosed or undiagnosed medical condition
    that might complicate dental care?

-   Can we proceed with dental treatment in a relatively safe manner?

-   Is a pre-treatment medical consultation indicated?

The preoperative evaluation of the patient may require the following:

-   Relatively recent History & Physical Exam

-   Laboratory Data

-   Physician consult

-   Patient anxiety evaluation

It is the responsibility of the dentist to obtain and review the
patient's Medical History and level of anxiety. However, unless the
dentist has received residency-level training in physical diagnosis, the
physical exam must be done by the patient's medical provider. Laboratory
data may be obtained and interpreted by either the dentist or medical
provider (or both) depending on the medical condition in question and
the dentist's level of training.

*Physician Consultation*

-   Review your findings and treatment plan with the physician

-   Ask for the physician's evaluation of the patient's health

-   Ask for the physician's evaluation of the patient's ability to
    tolerate your planned procedure

-   Ask for additional recommendations for the patient's care

In most cases this approach results in no change to the treatment plan;
however, the physician's advice and endorsement is obtained in the
process.

*Anxiety Evaluation*

> As with many dental patients in general, medically complex patients
> may have considerable anxiety about dental treatment and would benefit
> from an anxiety reduction protocol prior to treatment.

Suggested Anxiety Reduction Protocol

Before appointment:

-   Hypnotic agent to promote sleep the night before dental treatment

-   Sedative agent to decrease anxiety on morning of dental treatment

-   Morning appointments

-   Minimize waiting room time

During appointment:

-   Non-pharmacologic:

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-   Frequent verbal reassurances

-   Distracting conversation

-   No surprises, advise patient of all treatment

-   No unnecessary noises

-   Have instruments out of sight

-   Relaxing background music

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-   Pharmacologic

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-   Local anesthesia

-   Nitrous Oxide

-   Oral anxiolytics

> After appointment:

-   Succinct instructions of postoperative care, given both orally and
    in writing

-   Describe expected post operative sequelae

-   Effective analgesics

-   Further reassurance

-   Clinic/dentist contact information if problems occur

> **COMPLEX MEDICAL CONDITIONS**

**Diabetes Mellitus**

Diabetes Mellitus (DM) is one of the most common medical conditions that
will be encountered in the treatment of American Indian and Alaska
Native (AI/AN) populations. Approximately 5% of the American population
has DM, while the prevalence in some AI/AN populations is estimated to
approach 40%.

***Types of DM***

Insulin Dependent DM Type I

-   All forms of diabetes that requires exogenous insulin

-   Younger patients, abrupt onset, classic symptoms

-   Prone to ketoacidosis

-   Antibody to pancreatic islet beta cells often present

-   Etiology may be exposure to toxin or virus

Non-Insulin Dependent DM, Type II

-   Some endogenous insulin is present to prevent ketoacidosis

-   Middle age, gradual onset, may be asymptomatic

-   Gradual decrease in pancreatic beta cell function or resistance of
    skeletal muscle & hepatic cells to the effects of insulin

-   Less aggressive form of disease but 90% of all diabetes

***Insulin Types: Classified by onset of action**.*

-   Fast acting

    -   Regular

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-   Onset 0.5 -- 1 hr

-   Duration 6- 8 hrs

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-   Semilente

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-   Onset 1 -- 3 hrs

-   Duration 16 hrs

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-   Intermediate acting

    -   Isophane (NPH)

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-   Onset 2 -- 4 hrs

-   Duration 18 -- 26 hrs

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-   Lente

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-   Onset 2 -- 4 hrs

-   Duration 18 -- 26 hrs

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-   Long acting

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-   Protamine zinc

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-   Onset 4 -- 8 hrs

-   Duration 28 -- 36 hrs

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-   Ultralente

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-   Onset 4 -- 8 hrs

-   Duration 28 -- 36 hrs

Initial management is usually fast acting & intermediate insulin in AM &
intermediate in PM administered subcutaneously.

***DM History***

-   Age first diagnosed?

-   Type of diabetes?

-   Medication being taken?

-   If insulin is being taken, what is time interval and amount?

-   How often do you check your blood sugar?

-   Have you been hospitalized during the past year for problems related
    to your diabetes?

-   Is your diabetes well controlled or does it get out of control at
    times?

***Diagnostic Tests**:*

-   \*Fasting blood sugar (reflects current control, that day). (\> 126
    mg/dl)

-   \*Random plasma glucose \> 200mg/dl with symptoms (polyuria,
    polydipsia, unexplained weight loss)

-   \*2 hour plasma glucose \> 2100mg/dl following a 75g glucose load

-   Fructosamine test (reflects average control over last 2 -- 3 weeks)

-   Glycosylated hemoglobin (reflects average control over last 6 -- 8
    weeks). (\>7% = problem) can measure long term hyperglycemia

    -   Hemoglobin A1c is produced when a RBC is exposed to
        hyperglycemia

    -   6% - 8% is significant for prolonged hyperglycemia (normal value
        varies)

\*official diagnostic tests for diabetes

***Associated pathophysiology***

-   Hyperglycemia manifested as polyuria, polydipsia, ketoacidosis

-   Altered leukocyte function

-   Atherosclerosis, microangiopathic changes, leading to nephropathies
    and retinopathies

***Signs of Uncontrolled Diabetes***

-   Urine test - 2+ sugar or above

-   Abnormal thirst

-   Increased urine output

-   Abnormal weight loss

-   Loss of strength

-   Elevated blood glucose levels - \> 180

-   Ketoacidosis

    -   Poorly regulated-glucose levels

    -   Increased food intake

    -   Occurs with infection, vomiting, diarrhea, post-operative period

    -   Very little exercise

-   Warm, flushed, dehydrated, acetone breath

> Be alert for:

-   Periodontal problems

-   Candidiasis / Xerostomia

-   Poor response to treatment, especially periodontal therapy

-   Poor healing

-   Slow healing

> ***Dietary considerations**:*
>
> Balance must exist between caloric intake and utilization of
> circulating blood glucose. If insulin remains the same, a change in
> diet will lead to either increase or decrease in blood glucose levels.
>
> ***Management of Insulin-Dependent Diabetes Patient***

-   Early morning and short appointments

-   Anxiety-reduction protocol

-   Determine disease severity, method of control, success of control

-   Assure that diabetes is well controlled, defer treatment and consult
    physician if not

-   Pre-treatment capillary blood glucose level (finger stick sugar)

-   Eat a balanced meal (includes fat and protein as well as
    carbohydrates) within the last two hours before coming to the dental
    appointment

-   Patient should have taken their usual dose of regular insulin but
    only ½ the dose of NPH

-   Advise patients not to resume normal insulin dosage until they are
    able to return to a normal caloric intake and activity level

-   Consult physician concerning modifications of insulin regimen. It's
    always better to run a little bit sweet.

-   If appointment is going to run longer than 2 hrs, food (Power bar or
    some other balanced nutritional supplement) should be available.

-   Watch for signs of hypoglycemia

    -   Mild: hunger, nausea, dizziness, headache, lethargic, \<
        spontaneity of conversation

    -   Moderate: diaphoretic, tachycardia, anxiety, confusion

    -   Severe: hypotension, unconscious, seizures

-   Treat infections aggressively

-   Well-controlled diabetic patients do not require prophylactic
    antibiotic therapy for routine oral surgical procedures, and delayed
    wound healing should not be anticipated in the rich vascular
    environment of the oral cavity.

***Management of Non-insulin-dependent Diabetes Patients***

-   Assure diabetes is controlled, diet controlled typically required no
    modification

-   Pre-treatment capillary blood glucose level (finger stick sugar),
    watch for signs of hypoglycemia

-   Schedule early morning & short appointments, use anxiety-reduction
    protocol

-   If patient will have difficulty eating after treatment, skip
    hypoglycemics for that day. If not then take the usual dose of
    medication

-   Treat infections aggressively

-   Well-controlled diabetic patients do not require prophylactic
    antibiotic therapy for routine oral surgical procedures, and delayed
    wound healing should not be anticipated in the rich vascular
    environment of the oral cavity.

***Management of the poorly controlled DM patient (Type I or II) during
oral surgical procedures***

-   Blood sugars may be high due to chronic and/or acute dental
    infections

-   Poor DM control leads to immunosuppression as indicated above

-   Urgent treatment should focus on eliminating acute dental infections
    as atraumatically as possible

-   Antibiotic prophylaxis (AHA recommendations) may be considered for
    even simple extractions on the poorly controlled DM patient, based
    on the dentist's judgment

-   Pre-treatment antibiotics along with a 7 day post-treatment course
    may be considered even for simple extractions on the poorly
    controlled DM patient if signs of infection are present (swelling,
    lymphadenitis, fever, etc.), based on the dentist's judgment

-   Pre-treatment medical referral for an insulin dose to bring the
    blood sugar level down prior to dental care may be considered. In
    the DM patient with an active infection, however, stable control may
    be impossible until the source of the infection is removed, so high
    blood sugars should not be considered an absolute contraindication
    to oral surgical procedures (especially urgent ones).

-   Additional information about the care of patients with diabetes and
    the use of prophylactic antibiotics can be found on the following
    websites:

<http://www.aapd.org/media/Policies_Guidelines/G_AntibioticProphylaxis.pdf>

<http://dental.pacific.edu/docs/patientProtocol/Medically_Complex.pdf>

**Cardiovascular Disease**

-   Ischemic Heart Disease

-   Congestive heart failure

-   Cardiac valve abnormalities

-   Cardiac Dysrhythmias & Conduction Disturbances

-   Arterial Hypertension

***Ischemic Heart Disease: (Angina Pectoris)***

-   Characterized by impaired delivery of myocardial blood supply and
    includes coronary artery disease (CAD), angina, and previous MI.

-   Progressive narrowing and /or spasm of one or more coronary arteries

-   Myocardial blood supply cannot be increased to meet the increased
    oxygen requirements as the result of an obstruction

> Symptoms:

-   Substernal pain spreading across the chest to the left shoulder, arm
    and mandible; pressure, squeezing, or burning pain

-   Relieved by rest, last only a few minutes

-   Relieved by nitroglycerin

Stable vs. Unstable

-   Stable: Precipitated by exercise, stress, or sustained tachycardia

-   Unstable: may occur at rest & is probably precipitated by vasospasm

Laboratory examination:

-   CXR: enlarged heart indicates \< reserve

-   EKG: hypertrophy, old infarction, ST and T wave changes

Management

-   Consult physician if needed

    -   Long acting vasodilators -- nitroglycerin

    -   Beta-adrenergic blockers -- propranolol a non-specific beta
        blocker in conjunction with epinephrine in local anesthetics can
        cause severe hypotension

    -   Calcium channel blocker -- nifedipine, diltiazem

-   Use anxiety-reduction protocol

-   Have nitro tablets readily available. Use nitroglycerin
    pre-medication if indicated

-   Administer supplemental oxygen

-   Ensure profound anesthesia

-   Consider nitrous oxide sedation

-   Monitor vital signs closely

-   Limit amount of epinephrine used

    -   Exogenous (limit to 0.04mg = 2.2 carpules 1:100,000), No epi
        retraction cords

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    -   Prolonged anesthesia outweighs risk

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    -   Endogenous: Potentially a much bigger problem.

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    -   Stress -- adrenal medulla can produce 0.28mg of epi/min.

-   Avoid topical vasoconstrictors

-   Treatment of angina attack

    -   Terminated dental treatment

    -   Sublingual nitroglycerin

    -   Make patient comfortable

    -   100% oxygen

    -   Give nitroglycerin again if needed in 5 minutes

    -   Activate the Emergency Medical System (EMS)

> ***Myocardial Infarction***
>
> Pathology:

-   Ischemia leading to cellular death of myocardium, areas become focus
    for dysrhythmias

-   When chest pain last more than 30 minutes without relief by
    nitroglycerin

-   Heart failure with damage of 30% of left ventricular myocardium
    death

-   First MI, 30% die; reinfarction=70% mortality

-   Coronary artery bypass grafting

    -   treat same as post MI patient

    -   Consult physician if emergency treatment needed prior to 6 month
        waiting period

Management:

-   Consult physician to establish cardiac history and management
    requests

-   Defer treatment for 6 months after cardiac insult

    -   Less than 4 months -- 30% mortality

    -   4 to 6 months -- 15% mortality

    -   After 6 months -- 5% mortality

    -   Over 6 months -- no significant increased risk

-   Use anxiety -- reduction protocol

-   Have nitroglycerin available, use pre-treatment if physician advises

-   Administer supplemental oxygen

-   Have profound anesthesia, adequate post treatment pain management

-   Consider nitrous oxide

-   Limit epinephrine use to 0.04mg within 15 minutes in patients with
    significant disease

-   Monitor vital signs and maintain verbal contact

> ***Congestive Heart Failure***

-   Diseased myocardium caused by previous MI, ischemic heart disease,
    uncontrolled hypertension, structural aberrations of the heart, &
    cardiomyopathy

-   Increased end-diastolic pressure

-   Pulmonary edema

Symptoms

Left Sided heart failure

-   Dyspnea, orthopnea, paroxysmal nocturnal dyspnea

-   Wheezes, pulmonary congestion

-   Third heart sounds

Right Sided heart failure

-   jugular venous distension

-   peripheral edema, nocturia, ascites

> Both right and left sides

-   shortness of breath, weight gain

-   fatigue, weakness, anorexia

Usual medical management and medications

-   Low sodium diets

-   Diuretics

-   Cardiac glycosides (digoxin)

-   May be on nitrates, beta-blockers, Ca channel blockers, and
    sometimes anticoagulants

Treatment risk classification

Class I:

-   no dyspnea with normal exertion, good risk

Class II:

-   Mild dyspnea, Patient may rest after climbing a flight of stairs.
    Good risk with no contraindications for treatment.

Class III

-   dyspnea or undue fatigue with normal activity.

-   Patient comfortable at rest only.

-   Patient is a definite risk. Consultation required.

-   Short appointments.

-   Mild sedation best for management.

Class IV

-   dyspnea, orthopnea,

-   fatigue at all times.

-   Serious risk, emergency treatment only with a physician in
    attendance,

-   supplemental oxygen.

Questions to ask:

-   Do you get chest pains on exertion?

-   Can you walk up a flight of stairs without needing to rest to catch
    your breath or getting chest pains?

-   Do you take medications for your congestive heart failure? If so,
    did you take them today?

Management

-   Use anxiety-reduction protocol, N2O

    -   Avoid tachycardia and increased BP

    -   Continue present meds. Avoid atropine

-   Profound local anesthetic

-   Supplemental oxygen - lowered oxygen saturation leads to ischemia
    which can lead to MI

-   Avoid supine position

-   May have poor liver and kidney function

-   With ejection fraction \< 40%, operating room management is required

> ***Cardiac Valve Abnormalities***
>
> This includes stenosis, valvular insufficiency, prolapsed, or
> incompetent valves. With poor valve closure regurgitation occurs
> producing turbulent flow and murmurs on auscultation. The most
> important abnormalities involve the aortic and mitral valves.
>
> Murmurs are described in terms of their presence in the cardiac cycle:

-   diastolic or systolic

-   In terms of dynamics:

    -   crescendo or decrescendo

-   In terms of loudness:

    -   I : barely audible with a stethoscope

    -   II, III, IV, V

    -   VI: audible without the aid of a stethoscope

> *Aortic Stenosis*

-   Usually progressive over a lifetime

-   With progressive stenosis and insufficiency comes left ventricular
    hypertrophy

-   Cardiac output compromise results in syncope and hypotension

-   Systolic ejection murmur in the aortic region with possible S3 or S4
    or aortic ejection click

*Mitral Stenosis*

-   Could be result of rheumatic fever (symptoms 10 years post fever)

-   Increased work by left atrium, resulting in left atrial enlargement,
    pulmonary hypertension, and right ventricular hypertrophy

-   Loud S1, diastolic rumble with concomitant murmur of mitral
    regurgitation

*Aortic Regurgitation*

-   Rheumatic fever is most common etiology

-   Usually mitral involvement

-   Volume overload of left ventricle because ventricle effects atrial
    load and regurgitant volume and subsequent diminution of function
    over time

-   May produce pulmonary edema

-   Water hammer pulse, diastolic decrescendo murmur

*Mitral Valve regurgitation*

-   Most commonly with rheumatic fever

-   Back glow of blood across a closed mitral valve during systole

-   Holosystolic murmur

-   Left ventricular afterload reduction with long term impairment of
    contractility

*Mitral Valve Prolapse*

-   Very common, up to 1 in 20 individuals, more female

-   Systolic click and late systolic murmur

-   May or may not have mitral regurgitation

*Prosthetic Heart Valves*

-   Two basic designs: mechanical and bio-prosthetic

-   High risk for bacterial endocarditis

Questions to ask about murmurs:

-   When was it first diagnosed?

-   Was it termed functional or organic?

-   Did the doctor ever say you needed prophylactic antibiotics prior to
    dental treatment?

-   Did the doctor ever say you didn't need prophylactic antibiotics
    prior to dental treatment?

*Infectious Endocarditis*:

-   Pathology: Infection of sterile vegetation on abnormal heart valve

-   Turbulent flow leads to loss of endocardium exposing underlying
    collagen

-   Platelets aggregate an collagen and form sterile fibrin-platelet
    thrombus called vegetation

-   Treatment: long-term, high dose IV antibiotics

-   Initial recovery -- 100%

-   Recurrent SBE episodes -- 60%

-   Alpha hemolytic Streptococci main cause

> *Antibiotic Prophylaxis against Infectious Endocarditis*
>
> Please go the section on the American Heart Association's
> recommendations for Prophylaxis against Infectious Endocarditis for
> the most recent risk classifications and recommendations, in this
> chapter of the OHPG

***Cardiovascular Disease Dysrhythmias***

Supraventricular tachycardia:

-   Usually in patients \> 70 years

-   Ventricular rate should be under control

-   Patients on digitalis need therapeutic levels

-   Often on Coumadin

Ventricular arrhythmias:

-   Multiple unifocal PVC

-   R wave falls on T wave

-   Multifocal PVC

-   Ventricular tachycardia can rapidly degenerate to ventricular
    fibrillation

Bradycardias and conduction disturbances:

-   First degree heart block

-   Wolf --Parkinson-White Syndrome

-   Right and left bundle branch block

**Hypertension**

-   Most common condition for which patients receive prescription
    medication

-   SBP \> 140mm Hg, DBP \> 90 mm Hg

-   Nearly 1 in 3 American adults has high blood pressure

-   It can cause:

    -   Enlargement of the heart

    -   Aneurysms to form in blood vessels (e.g., aorta, brain, legs,
        intestines, and the artery leading to the spleen

    -   Narrowing of the blood vessels in the kidneys leading to kidney
        failure

    -   Acceleration in "hardening" to the arteries especially in the
        heart brain, kidneys, and legs

    -   Rupture of blood vessels in the eyes causing vision changes or
        blindness

> **Four categories based on presentation and level of aggression needed
> for treatment**

+-----------------------+-----------------------+-----------------------+
| **Blood Pressure      | **Systolic (mm Hg)**  | > **Diastolic (mm     |
| Category**            |                       | > Hg)**               |
+-----------------------+-----------------------+-----------------------+
| Normal                | less than 120 and     | less than 80          |
+-----------------------+-----------------------+-----------------------+
| Pre-hypertension      | 120 -- 139 or         | 80 -- 89              |
+-----------------------+-----------------------+-----------------------+
| High Stage I          | 140 -- 159 or         | 90 - 99               |
+-----------------------+-----------------------+-----------------------+
| High Stage II         | 160 or higher or      | 100 or higher         |
+-----------------------+-----------------------+-----------------------+

> When systolic and diastolic blood pressures fall into different
> categories, the higher category should be used to classify blood
> pressure level. For example, 160/80 mm Hg would be stage 2 high blood
> pressure.
>
> There is an exception to the above definition of high blood pressure.
> A blood pressure of 130/80 mm Hg is considered high blood pressure in
> people with diabetes and chronic kidney disease.
>
> Treatment
>
> Pharmacologic therapy (most patients will require two or more
> antihypertensive agents)

-   diuretics

-   adrenergic -- receptor blockers

-   central alpha -- 2 agonists

-   postganglionic blockers

-   calcium channel blockers

-   ACE inhibitors

-   Direct vasodilators

Lifestyle changes

-   weight reduction

-   decreased alcohol reduction

-   dynamic exercise

-   dietary modifications -- decrease in sodium and fat

Management Considerations:

> There are no professionally recognized criteria of when it is safe to
> proceed. The decision to treat is individualized based on severity of
> BP, likelihood of coexisting myocardial ischemia, ventricular
> dysfunction, cerebrovascular and renal complications, and the nature
> of the procedure.
>
> Antihypertensive drug therapy should be continued
>
> Elevation of SBP higher than 180 mm Hg or DBP higher than 110 is used
> as a cutoff by many dental professionals for treatment without medical
> consultation and referral. If BP is \> 200/110, avoid surgery and
> refer for control of hypertension.
>
> Management:

-   Identify patient (take BP on all patients). Patients with elevated
    pressure should be referred to an out patient clinic for initial
    therapy to reduce pressure prior to dental treatment.

-   Take relaxed BP (average of two)

    -   Upright position with arms at heart level for 5 mins.

    -   Proper sized cuff (cover 80% of the upper arm)

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-   Stress and anxiety reduction

    -   doctor -- patient relationship

    -   pharmacological (Benzodiazepine, Nitrous Oxide)

    -   short morning appointments

-   Avoid sudden changes in chair position, sit patient up slowly at the
    end of the procedure (orthostatic hypotension)

-   Avoid gag reflex

-   Monitor vital signs

-   Decreases exposure to epinephrine

    -   Exogenous (limit to 0.04mg = 2.2 carpules 1:100,000), No epi
        retraction cords

    -   Endogenous epi potentially a much bigger problem. Stress --
        adrenal medulla can produce 0.28 mg of epi./min.

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-   Avoid topical vasoconstrictors

**Cerebral Vascular Accident (Stroke)**

-   Often anticoagulated, on hypertensive medications

-   Defer treatment for 6 months following stroke

    -   Arthrosclerosis of carotid vessels

    -   Transient ischemic attacks

-   Use anxiety-reduction protocol

-   Supplemental oxygen

-   Monitor vital signs

-   Consider nitrous oxide

Questions to ask patient:

-   When did you have your stroke?

-   What loss of function occurred?

-   Have you recovered some function over time?

-   Have you ever had trouble with dental appointments or medical
    appointments?

-   Is there anything I need to know that will make you more comfortable
    or make it easier for you to deal with the dental appointment?

-   What medications are you taking to prevent another stoke?

> **Immunosuppressed Patients**
>
> Conditions:

-   Decreased white blood cells

-   Cyclic neutropenia

-   Agranulocytosis

-   Decreased antibody synthesis

-   Decreased chemotaxis and phagocytosis

Types of immunosuppressed patients:

-   Cancer chemotherapy patients

-   Patients on immunosuppressive drugs

-   Post-transplant, implant patients

-   HIV+/AIDS

-   Corticosteroid use to suppress severe auto-immune diseases

> Questions should be designed to evaluate the severity of the
> immunosuppression and the reason for it. Questions will vary depending
> on the reason the patient says they are immunosuppressed.

-   Why are you immunosuppressed?

-   How long have you b3een immunosuppressed?

-   Have you been hospitalized because of problems resulting from your
    immunosuppression, i.e. infections?

-   Are you taking any prophylactic medication to prevent infections
    because of your immunosuppression?

-   Has your doctor said that any special precautions should be taken
    during medical or dental treatment to prevent (prophylax against)
    possible infections?

> Diagnostic tests:

-   CBC with a differential (especially platelet count, if planning
    surgery).

-   T-suppressor cell count (HIV patients).

-   Viral load (HIV patients).

Management During Dental Treatment:

-   Depending on severity of immunosuppressants, laboratory tests,
    primarily CBC with differential, should be done immediately (within
    5 days) of major invasive procedure, i.e. extractions, scaling and
    root planning, periodontal surgery.

-   If white count below 2,000, no elective treatment until white count
    is restored.

-   If platelet count is less than 60,000, no elective treatment. If
    emergency treatment is needed with the risk of bleeding, then have a
    physician give the patient a unit of platelets prior to procedure.

-   If patient is severely immunosuppressed and infection is present,
    consider prophylactic antibiotics prior to oral surgical or
    periodontal surgical procedures.

-   Institute aggressive treatment of any dental infection, including
    antibiotics, incise and drain, and proceed with any necessary
    endodontic procedure or extraction.

-   Aggressively control any periodontal disease with proper cleaning
    and supplemental medication such as chlorhexidine rinse.

-   If there is any question about patient status of being able to deal
    with the suggested treatment, antibiotic coverage or the first sign
    of any infection, consult patients physician.

-   Prior to organ transplant or when patient is most immunocompetant,
    consider aggressive dental therapy to remove / resolve any possible
    dental problems, i.e. needed or expected endodontic procedures.
    Consider extracting teeth with compromised endodontic prognosis.

-   Good oral hygiene

-   Prophylaxis for viral and fungal infections.

Additional information on the treatment of the patient with HIV
infection can be found at the following links:

<http://www.ahrq.gov/clinic/epcsums/denthivsum.htm> (Agency for
Healthcare Research and Quality's evidence-based information)

[[UOP Protocols for the Dental Management of Patients with HIV
Disease]{.underline}](http://www.dental.uop.edu/docs/patientProtocol/HIV.pdf)

**Renal Problems: End stage Renal Disease (ESRD)**

Definitions:

***Renal insufficiency***- early stage of ESRD, asymptomatic, mild
laboratory abnormalities

***Renal failure***- decreased ability of the kidney to perform its
excretory, endocrine and metabolic functions beyond compensatory
mechanisms.

***Uremia***- syndrome caused by renal failure, retention of excretory
products and interference with endocrine and metabolic functions. GFR
\<10 -- 15ml/min.

Common causes of ESRD

-   Diabetes

-   Hypertension

-   Glomerulonephritis

-   Polycystic lupus erythematosis

-   Amyloidosis

-   Nephrolithiasis

Renal dialysis

-   Prophylactic antibiotic coverage required due to arterio-venous
    shunt.

-   Do procedures the day following dialysis

-   Assume patient has hepatitis

-   Avoid drugs that depend on renal metabolism

-   Avoid nephrotoxic drugs as NSAID

-   Use caution and alter dosage form when using drugs eliminated by the
    kidney (e.g. Penicillin is often reduced to 500mg two times per day
    versus four times per day)

-   Monitor vital signs

-   Look for signs of secondary hyperthyroidism

    -   Chronic hypocalcemia

    -   Multiple radiolucencies

    -   Loss of lamina dura

    -   "ground glass" appearing bone

    -   enamel hypoplasia

Oral Complications of Renal Failure / Uremia

-   Pallor of mucosa (anemia)

-   Decreased salivary flow

    -   Xerostomia

    -   Parotitis

-   Metallic taste

-   Ammonia odor I to saliva

-   Stomatitis

-   Oral ulceration

-   candidiasis

Renal transplant or other transplanted organs:

-   Adrenosuppressed and immunosuppressed

-   Treat infections aggressively

-   Consults required on all patients

-   Supplemental corticosteroids usually needed

-   Monitor blood pressure

-   Assume hepatitis

-   Watch for cyclosporine A induced gingival hyperplasia. Emphasize
    excellent oral hygiene.

Management During Dental Treatment:

-   Do not use drugs toxic to the kidney e.g., instead of Ibuprofen, use
    acetaminophen for pain management

-   Use caution and alter dosage form when using drugs eliminated by the
    kidney.

-   If patient is on renal dialysis, dental treatment should be done on
    the day following dialysis.

-   If patient has kidney transplant, see considerations under
    immunosuppression protocol.

Be alert for:

-   Drug toxicity because of accumulation.

-   Poor healing and oral ulcerations.

Preventative / Precautions:

-   No special dental precautions needed

-   Patient should be counseled as to potential toxicity problems from
    certain prescriptions and over-the-counter drugs, plus alcohol

> **Hepatic disorders**
>
> Suspect liver disease with:

-   Chronic alcohol or substance abuse

-   History of hepatitis

Hepatic liver function effects:

-   Vitamin K-dependent coagulation factors (II, VII, IX, X) often
    depressed

-   PT, PTT required prior to surgery

-   Thrombocytopenia often present, platelet count and Ivy bleeding time

-   Increased SGOT, LDH, alkaline phosphatase, globulins

-   Decreased total protein, albumin

Questions to Ask

-   How long have you had a liver problem?

-   What type of lever problem is it and how was it caused?

-   Do you feel unwell relative to the liver Problem?

-   Have you noticed any problems such as bleeding, difficulty in
    metabolizing / digesting food, or increased or decreased sensitivity
    to medication, form the liver problem?

-   Do you ever get jaundice (do the whites of your eyes or your skin
    turn or look tallow)?

-   Have you ever needed to be hospitalized because of your liver
    problem?

Management During Dental Treatment:

-   If bleeding problems, follow bleeding problem protocol

-   If unable to metabolize drugs, avoid using drugs metabolized in the
    liver such as erythromycin and ketoconazol. Minimize local
    anesthetics.

-   If patient having problem with drug interactions, avoid drugs with
    high potential for drug interaction used in dentistry i.e.
    erythromycin and ketoconazol.

-   Avoid drugs with potential for liver toxicity i.e. acetaminophen,
    Tylenol and any other over-the-counter / non prescription drug.

Be alert for:

-   Easy bleeding

-   Yellow tint to skin, oral mucosa, and the whites of the eye.

-   Poor healing

-   Oral ulcers

Preventative / Precautions:

Good oral hygiene to minimize oral hygiene problems

Avoidance of drugs that are toxic to the liver i.e. acetaminophen,
alcohol

*Hepatitis:*

Questions to ask:

-   What type of hepatitis do you have?

-   Are you actively infected at this time?

-   Have you had any signs or symptoms of your hepatitis?

-   Have you had any change in your liver function tests?

-   Have you taken any medication specifically to treat your hepatitis?

-   If you had hepatitis B, do you know your hepatitis antigen status?

> Since all patients are treated as though they are infectious and
> universal precautions are applied, no special precautions are
> necessary when treating a patient actively infected with the hepatitis
> virus (If patient is having liver problems secondary to hepatitis,
> then review liver protocol.

Hepatitis A -- HAV

Etiology

-   ingestion of contaminated shellfish

-   Exposure to others with HAV

-   Oral -- fecal route

Treatment:

-   Supportive

-   New vaccine

-   No dentistry in acute phase

> Hepatitis B HBV
>
> Transmission:

-   Direct percutaneous inoculation

-   Indirect percutaneous infection, cut, abrasion

-   Absorption of infected serum or plasma

-   Infected secretions

Incidence:

-   general population 5%

-   General dentists 13%

-   Oral and maxillofacial surgeons 27%

-   Others: hemodialysis patients and technicians hemophiliacs, blood

-   Bank workers, male homosexuals and bisexuals, IV drug abusers,
    institutionalize patients, friends of hepatitis patients

-   Carrier state

    -   10% of infections become carriers

    -   treat as though all are carriers

> Lab tests for hepatitis antigens and antibodies should be run. If
> patient has active hepatitis, then liver function should be run or
> request physician provide information as to liver function and
> coagulation status.
>
> Dental Management:

-   Active disease -- NO TREATMENT

-   Past history, treat as possible carrier

-   Carrier: consult with physician as to current status of disease and
    planned treatment

-   Standard Precautions

**Endocrine Disorders**

***Adrenal Insufficiency***

Inability to increase endogenous corticosteroids (Addison's disease)

*Symptoms*:

-   weakness, weight loss, fatigue,

-   hyperpigmentation, hypotension, anorexia

*Cause*:

-   Autoimmune destruction of adrenals, neoplasms, TB

-   Secondary adrenal insufficiency -- chronic steroid therapy

*Glucocorticoids (Cortisol)*

-   Controlled by adrenocorticotropin hormone (ACTH) from the pituitary

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-   Cyclic activity: High: 2am -- 8am; Low: 6pm -- 8pm

-   Increased activity with the stress response

-   Cortisol inhibits ACTH

-   Stress leads to release of ACTH

    -   Hypothalamus responds to stress

    -   Releases corticotropic releasing hormone (CRH), half life 30
        secs

    -   CRH \> ACTH release, half life 10 min.

-   ACTH stimulates release of cortisol -- half life 2-3 hours

    -   Synthesized from cholesterol

    -   80% bound to plasma proteins

    -   20 -- 30% is metabolically active

*Dental Management*

-   Use anxiety-reduction protocol

-   Monitor vital signs

-   Instruct patient to double dose of steroids the morning of surgery
    up to 200mg. If taking greater than 100mg, then give only an
    additional 100mg.

-   If on alternate day steroids, do surgery on day steroids are taken

-   If patient has had 20 mg of steroid for more than two weeks in the
    past 2 weeks, but is not currently taking steroids, then give 40mg
    hydrocortisone prior to surgery

-   Not needed for most simple extractions

Stress leads to release of ACTH. Hypothalamus responds to stress

> *Adrenal crisis*
>
> Signs and symptoms

-   Peripheral vascular collapse

-   Hypotensive, syncopal, nauseated, feverish, dehydration,
    hypoglycemia, hyperkalemia

> Management:

-   Administer IV fluids (D5NS)

-   Administer hydrocortisone 100mg IV or equivalent

-   Transport to ER

***Hyperthyroidism***:

Clinical manifestations

-   Fine hair, hyperpigmentation, excessive sweating, tachycardia,
    weight loss, palpitations, emotional lability, exophalmos,
    hyper-reflexia

-   Thyrotoxic crisis - major stress in an undiagnosed patient

    -   Mild -- restlessness, nausea, cramps

    -   Moderate -- fever, diaphoresis, tachycardia

    -   Severe -- stuporous, hypotensive, death

> Dental management:

-   Anxiety reduction protocol

-   Limit epinephrine use

-   Thyroid storm

    -   Supportive care

    -   Supplemental Oxygen, ABC's

    -   Transport to ER

> **Hematologic Problems**

-   Therapeutic anticoagulation

    -   warfarin (see information on treatment of the anticoagulated
        patient, in this chapter of the OHPG), heparin

    -   ASA, ticlopidine, clopidogrel, anagrelide, dipyradimole

    -   Prosthetic heart valves

    -   Thrombogenic cardiovascular problems

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-   myocardial infarction

-   Stoke, high risk

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-   Hemodialysis patients

-   **[Please see the section in this chapter on the treatment of the
    anticoagulated patient for details on patient
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-   Hereditary coagulopathies

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-   hemophilia A, B, C, von Willebrand's dz

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-   Platelet disorders

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-   platelet count \< 100,000 mm3

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-   Liver disease

-   Majority noted in patient's medical history

-   Consult with patients hematologist

-   Symptoms -- nose bleeds, bruising, hematuria, spontaneous bleeding

-   Factor replacement sometimes needed in Hemophilia A, B, C, or von
    Willebrand's disease

*Hereditary coagulopathies*

-   Hemophilia A -- plasma thromboplastinogen (VIII) PTT

-   Hemophilia B -- Plasma thromboplastin component (IX) PTT

-   Hemophilia C -- Plasma thromboplastin antecedent (IX) PTT

-   Von Willebrand -- deficiency of all 3 components of Factor VIII,
    bleeding time

Management of Dental Patients

-   Obtain PT, PTT, platelet count, liver panel, & hepatitis screen

-   Use sutures and well places packs

-   Monitor wound for 2 hours after any surgeries

-   Instruct patient not to dislodge clot and what to do if bleeding
    restarts

-   Amicar prevents breakdown of clot

-   Desmopressin (DDAVP) -= Factor VIII & von Willebrand Factor
    stimulant

Questions to Ask:

-   How long have you had a bleeding problem or, depending on the
    situation, how long have you been on anticoagulant medication?

-   Describe your bleeding problem.

-   Have you had problems with previous dental appointments?

-   What is the cause of your bleeding problem or why are you on
    anticoagulants?

-   Are your anticoagulants or bleeding problems due to low platelets?

-   What are your most recent laboratory results relative to your
    anticoagulation or bleeding problem status?

*Diagnostic Tests*:

General

-   PT - prothrombin time

-   PTT - Partial thromboplastin time

-   INR - international normalized ratios

Aspirin (ASA) and other non-steroidal anti-inflammatory agents

-   Bleeding time

Thrombocytopenia

-   CBC with a differential (which will give platelet count

-   Bleeding time

*Management During Dental Treatment*:

-   No type of dental treatment should be rendered that has the
    potential for severe bleeding (i.e. extractions, scale/root plane).

    -   If bleeding time is greater than 10 minutes

    -   If platelet count less than 60,000

    -   If PTT is greater than 45 seconds

    -   If PT is greater than 22 seconds

    -   If INR is greater than 3.5

    -   **See section on the management of anticoagulated patients**

Medical coordination and consultation is always a good idea with
patients on anticoagulants.

If hemophilic, have the patient's medical provider administer proper
replacement factors and run necessary test to insure patient is within
safe parameters.

During dental procedures minimize physical trauma and pack extraction
sites that have the potential to bleed with local pressures and other
coagulation procedures, i.e. Gelfoam. Obtain primary closure n any
surgical sites, if possible.

Be Alert for:

-   Easy or prolonged bleeding with minimal trauma (i.e. probing, wedge
    placed between teeth for amalgam matrix)

-   Easy bruising / multiple bruises

Preventive / Precautions:

-   Assure the patient is aware of necessary lab test that should be
    done close to the time of dental treatment (within a week, or closer
    if they have had previous problems). Some bleeding parameters can
    change quickly.

-   Avoid drugs that may cause drug interaction, such as erythromycin
    and ketoconazol, which inhibit warfarin metabolism. Also avoid drugs
    that can prolong bleeding, such as aspirin or other non-steroidal
    anti-inflammatories.

-   Encourage patient to keep you informed of any drug changes and their
    use of any other-the-counter medications.

-   If patient calls from home following treatment, instruct them to
    apply pressure with gauze or cloth to bleeding site for 10 -- 30
    minutes. If bleeding persists, have patient come into office
    immediately or to a medical emergency room.

Additional information on the management of hematologic problems can be
found at:
[http://www.dent.ohio-state.edu/postdocgd/MedComp/Medcomp09hematology.pdf#search=\'anticoagulant%20therapy%20and%20dental%20extractions](http://www.dent.ohio-state.edu/postdocgd/MedComp/Medcomp09hematology.pdf#search='anticoagulant therapy and dental extractions)\'

**Liver disease**

-   Sever cirrhosis from any cause

-   Drugs & toxins (esp. ETOH)

-   Viral hepatitis

-   Carcinomas -- primary or metastatic

-   Will have elevated PT, PTT, & decreased platelets depending on
    severity of disease

Questions to ask:

-   How long have you had a liver problem?

-   What type of lever problem is it and how was it caused?

-   Do you feel unwell relative to the liver problem?

-   Have you noticed any problems such as bleeding, difficulty in
    metabolizing / digesting food, or increased or decreased sensitivity
    to medication, from the liver problem?

-   Do you ever get jaundice (do the whites of your eyes or your skin
    turn or look yellow)?

-   Have you ever needed to be hospitalized because of your liver
    problem?

Diagnostic Tests:

-   SMAC20 (specifically SGOT, AST, ALT)

-   PT & PTT

-   INR

Management During Dental Treatment

-   If bleeding problems, follow bleeding problem protocol

-   If unable to metabolize drugs, avoid using drugs metabolized in the
    liver such as erythromycin and ketoconazol. Minimize local
    anesthetics.

-   If patient having problem with drug interactions, avoid drugs with
    high potential for drug interaction used in dentistry i.e.
    erythromycin and ketoconazol.

-   Avoid drugs with potential for liver toxicity i.e. acetaminophen,
    Tylenol and any other over-the-counter / nonprescription drug.

Be Alert for:

-   Easy bleeding

-   Yellow tint to skin, oral mucosa, and the whites of the eye.

-   Poor healing

-   Oral ulcers

Preventative / Precautions:

-   Good oral hygiene to minimize oral hygiene problems

-   Avoidance of drugs that are toxic to the liver i.e. acetaminophen,
    ETOH

**Pulmonary Problems**

Asthma (Pathophysiology)

-   Bronchoconstriction

-   Hypertrophy of mucous glands

-   Edema of the bronchial walls

-   Increased mucous production

-   Mast cells -- release mediation substances

-   Histamine -- acute bronchospasm

-   Leukotrienes SRS -- potent bronchoconstrictor

-   Prostaglandin -- PGE -- hypertrophy of glands and increase viscosity
    of secretions

Determine the severity of wheezing and dyspnea

-   What causes attacks?

-   How severe are they?

-   What medications are used?

-   How effective are the medications?

-   Have you been to the emergency room for or have you been
    hospitalized for your asthma?

Medications:

-   Beta -- agonist

    -   beta 2 aerosols

    -   epinephrine

-   Steroids

    -   aerosols

    -   oral

-   Theophylline

Dental management:

-   Defer oral surgery procedures if uncontrolled Upper Respiratory
    Infection

-   Listen with stethoscope for wheezing

-   Use anxiety- reduction protocol

-   Consider nitrous oxide

-   Inquire about steroid usage

-   Have bronchodilator handy

Chronic obstructive pulmonary disease

-   Long term exposure to irritants -- tobacco

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-   chronic bronchitis, Emphysema

-   Cystic fibrosis

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-   Loss of elastic properties of airways

-   Dyspnea with mild to moderate exercise

-   Chronic cough with large amount of secretions

Dental Management:

-   Assure that pulmonary function is adequate

-   Listen to breath sounds

-   Use anxiety-reduction protocol

-   Avoid placing patient in supine position

-   Consult physician prior to giving patient oxygen. Oxygen therapy
    almost inevitable causes CO2 retention in these patients.

-   Give steroid supplements if needed

-   Keep bronchodilator close at hand

-   Closely monitor respirations

-   Avoid sedatives and narcotics

**Seizure disorder**

Questions to Ask:

-   What type of seizure and do you have

-   What stimulates a seizure and do you have an aura prior to the
    seizure?

-   What is the cause of your seizures? (i.e. head injury, born with
    problem)

-   How frequently and when (time of day) do they usually occur?

-   What type of medications are you taking to control the seizures?

-   Does the medication work?

-   Do you take the medication regularly or do you discontinued it at
    times? If you did discontinue, was it your decision or your doctor's
    and what happened?

Management:

-   Use anxiety-reduction protocol

-   No further precautions needed if well controlled

-   If patient is unclear about types of seizure or medications, and
    seizures are poorly controlled, then medical consultation for the
    above information will be needed.

**Gastrointestinal Disease**

-   Exacerbated by stress, poor oral intake, medications and some foods

-   Defer elective surgical procedures if unstable

-   Signs and symptoms

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-   Epigastric distress

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-   Pain to epigastruim, back or shoulder

-   Anemia and occult blood in stool

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-   Ulcers

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-   Hyper-secretion of hydrochloric acid

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-   Helicobacter pylori can be found in the stomach of approximately 99%
    of patients with duodenal ulcers and 70 -- 80% of those with gastric
    ulcers.

-   Avoid Aspirin, NSAIDs

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-   Management:

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-   Diet and antacids

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-   Cimetidine or ranitidine, H2 antagonists

-   H.pylori requires Antibiotic treatment, consult a physician

**Osteonecrosis of the jaw (ONJ)**

Risk Factors

-   Radiotherapy to the head and neck

-   Periodontal disease

-   Dental procedures involving bone surgery

-   Trauma from poor fitting dentures

-   Underlying malignancy

-   Chemotherapy

-   Corticosteroids

-   Systemic or regional infections

-   Medications (i.e. Bisphosphonates)

Bisphosphonates and ONJ

-   ONJ can occur spontaneously, but is more commonly associated with
    dental procedures that traumatize bone. (i.e. extraction)

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-   Older age (over 65 years), concomitant use of estrogen or oral
    glucocorticoid use for chronic conditions, periodontitis and
    prolonged use of bisphosponates have been associated with an
    increased risk for bisphosphonate-associated osteonecrosis.

-   Although recommendations for the dental management of patients
    taking IV bisphosphonates have been developed, no specific
    guidelines exist for management of patients taking oral
    bisphosphonates.

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-   The risk of developing bisphosphonate-associated ONJ appears to be
    very low, and is estimated to occur in approximately 0.7 per 100,000
    person-years exposure to Alendronate (Fosamax) (C. Arsver, oral
    communication, March 2006). Other nitrogen containing oral
    bisphosphonates are expected to have a similar risk profile. There
    is a higher incidence of ONJ with IV bisphosphonate use.

-   Typical clinical presentation of bisphosphonate-associated ONJ
    includes pain, soft-tissue swelling and infection, loosening of
    teeth, draining, and exposed bone. Symptoms may occur spontaneously
    in the bone: or, more commonly, at the site of previous tooth
    extraction.

Management recommendations:

-   Centered on prevention

-   Patient should receive a dental examination prior to initiating
    radiotherapy or bisphosphonate therapy and, if possible, should
    complete any necessary major dental procedures (i.e., tooth
    extraction, osteointegration of implants) prior to initiating
    radiotherapy or bisphosphonate therapy

-   Patients should receive regular dental visits during radiotherapy or
    bisphosphonate therapy.

-   Patients should be encourage to practice good oral hygiene and
    minimize possible jaw trauma through use of soft linings/minimizing
    sharp edges on dentures and ensuring that prosthodontics fit and do
    not have sharp edges where possible.

-   If possible, patients should avoid dental surgery during treatment
    with bisphosphonates or after radiotherapy

The ADA's statements on ONJ can be found at:
<http://www.ada.org/prof/resources/topics/osteonecrosis.asp>

**Pregnancy**

Questions to Ask:

-   What month of pregnancy are you in?

-   Have there been any complications?

-   Have you had complications with prior pregnancies?

Management of the Pregnant Patient during dental treatment:

Pregnancy by itself is not a reason to defer routine dental care and
necessary treatment for oral health problems.

-   First trimester diagnosis and treatment, including needed dental
    x-rays, can be undertaken safely, using the FDA recommendations, to
    diagnose disease processes that need immediate treatment.

-   Needed treatment can be provided throughout pregnancy; however, the
    time period between the 14th and 20th week is ideal.

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-   First trimester of pregnancy

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-   If dental treatment rendered, use minimum medications or trauma.

-   Educate patient about the value of good oral hygiene

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-   Second trimester and first half of third trimester

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-   This is the ideal time for all dental treatment necessary or desired
    during the pregnancy

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-   Minimize drug use including OTC drug use.

-   Emphasize proper periodontal care to minimize adverse pregnancy
    outcome

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-   Last half of third trimester

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-   If dental treatment rendered, use minimum medications or trauma

-   If treatment required, be alert for supine hypotensive syndrome
    (allow the patient to turn on her side).

Be Alert for:

-   Periodontal problems. Besides the patient's own risk of bone loss,
    severe periodontal disease has been associated with low birth weight
    pre-term babies. Good periodontal health is paramount to minimizing
    this risk.

-   Pyogenic granulomas (pregnancy gingivitis)

-   Minimize drug use. Even though there is little risk with most drugs,
    spontaneous abortions can occur and concerns about drugs used during
    dental procedures should not enter into concerns about why a
    spontaneous abortion occurred.

Preventative / Precautions:

-   Good home care

-   Emphasize good nutrition. Adequate protein, folic acid supplements,
    and to eliminate alcohol, tobacco, and other drug use.

Possibly the most comprehensive discussion about the provision of oral
health care during pregnancy is contained in the New York State
*Practice Guidelines on Oral Health Care during Pregnancy and Early
Childhood.* Pages 31 through 39 of these guidelines relate specifically
to the provision of clinical dental care. The Guidelines can be found
at: <http://www.health.state.ny.us/publications/0824.pdf>. It is
recommended that all dentists review these guidelines.

Additional information about the provision of dental care during
pregnancy can be found at the following websites:

[www.nys**dental**.org/img/pdf_files/JrnlJ04Gajendra.pdf](http://www.nysdental.org/img/pdf_files/JrnlJ04Gajendra.pdf)

[www.kdheks.gov/ohi/kanellis/kanellis_part_b.pdf](http://www.kdheks.gov/ohi/kanellis/kanellis_part_b.pdf)

According to the ADA Council on Scientific affairs (JADA September 2006,
Page 1305), Dental radiographs may be prescribed for pregnant patients
with strict adherence to the FDA selection criteria guidelines:
<http://www.ada.org/prof/resources/topics/topics_radiography_examinations.pdf>.

**Herbal Medication Use**:

-   1997 -- 12% of the population used herbal medications (390% increase
    from 1990). This percentage is certainly higher.

-   70% of patients failed to disclose herbal medication used during
    routine preoperative assessment (Kaye 2000)

> Reason: - Belief that doctors are not knowledgeable

\- Doctors are prejudiced about their use

\- Fear of admitting use of unconventional therapies

\- Not considered to be dedications

\- Not considered to be part of medical care

Therefore, we must question patients carefully

-   1 in 5 patients is unable to identify the preparation they are
    taking -- bring herbal medications to appointment

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-   Can cause serious harm

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-   Reports to FDA, Jan. 1993 -- Oct. 1998

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-   2621 adverse events

-   101 deaths

***Eight Commonly Use Herbal Medications***

-   Echinacea

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-   Uses

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-   prophylaxis and treatment of viral, bacterial and fungal infections
    of the upper respiratory tract

-   internal stimulation of the immune system

-   Stimulating phagocytosis

-   increasing cellular respiratory activity

-   increasing the mobility of leukocytes

-   topical wound healing

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-   Side or toxic effects

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-   repeated daily dose ( 8 weeks) may suppress immune response

-   possible hepatotoxicity

-   allergic reactions

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-   Avoid

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-   patients requiring immunosuppression (transplant)

-   asthma

-   pre-existing liver dysfunction

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-   Ephedra (ma huang)

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-   Uses

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-   weight loss

-   increase energy

-   treat asthma and bronchitis

-   contains Ephedrine, pseudoephedrine, etc, which are noncatecholamine
    sympathomimetic agents

-   increases blood pressure

-   increases heart rate

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-   Toxic or Side effects

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-   fatal cardiac (MI) and CNS (stoke) complications

-   long-term use depletes endogenous catecholamines

-   MAO inhibitors = hyperpyrexia and HTN

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-   Avoid

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-   patients with hypertension or risk or risk of stroke

-   long-tern use

-   patients on MAO inhibitors

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-   Discontinue 24 hours before any dental treatment

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-   Garlic

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-   Uses

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-   Modify risk of developing atherosclerosis

-   Lower serum lipid and cholesterol levels

-   Reduce blood pressure and thrombus formation

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-   Actions:

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-   Inhibits platelet aggregation

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-   Side effects

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-   Prolonged bleeding

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-   Avoid

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-   use with other platelet inhibitors

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-   Discontinue 7 days prior to treatment

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-   Ginkgo biloba

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-   Uses

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-   Positive effects on cerebral blood flow, cerebral insufficiency, and
    memory, may improve cognitive performance in Alzheimer Disease

-   Flavonoids -- free radical scavengers

-   Terpenes -- inhibit platelet activating factor (Asthma and
    circulatory disorders)

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-   Side effects:

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-   prolonged bleeding

-   Headache, dizziness, heart palpitations, and GI and dermatological
    reactions

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-   Discontinue 36 hours prior to treatment

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-   Ginseng (root)

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-   Uses

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-   lower cholesterol and blood sugar

-   increased strength, endurance and mental acuity

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-   Side effects

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-   Hypoglycemia

-   Inhibit platelet aggregation

-   Decrease in warfarin anticoagulation

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-   Avoid

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-   Diabetics

-   Patients on warfarin or at risk for bleeding

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-   Discontinue 7 days prior to treatment

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-   Kava

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-   Uses

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-   Anxiolysis

-   Sedation

-   Antiepileptic

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-   Side effects

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-   Increase sedative effects of anesthetics

-   Tolerance, potential for addiction and withdrawal

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-   Discontinue 24 hours prior to treatment

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-   St. John's Wort

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-   Avoid

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-   Patients on the following medications

    -   cyclosporine

    -   alfentanil

    -   midazolam

    -   lidocaine

    -   calcium channel blockers

    -   warfarin

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-   Discontinue 5 days prior to treatment

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-   Valerian

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-   Uses

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-   Sedative, insomnia, in virtually all herbal sleep aids

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-   Actions

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-   Acts at the GABA receptor

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-   Side effects

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-   additive to sedative medication (Versed)

-   patients can become dependent

-   acute benzodiazepine withdrawal

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-   Discontinue slowly (taper) prior to treatment

> **ADDITIONAL RESOURCES**

The University of the Pacific School of Dentistry has compiled the
following guidelines for the treatment of patients with HIV and with
complex medical conditions:

[[Protocols for the Dental Management Of Medically Complex
Patients]{.underline}](http://www.dental.uop.edu/docs/patientProtocol/Medically_Complex.pdf)

[[UOP Protocols for the Dental Management of Patients with HIV
Disease]{.underline}](http://www.dental.uop.edu/docs/patientProtocol/HIV.pdf)

**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. The quarterly and annual
Basic Measures Reports (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 IHS National Data Warehouse 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.

**Chapter 6, Environmental Health and Safety**

**Table of Contents**

A. Introduction

B. Recommended Infection Control Practices for Oral Health Programs
Serving Native Americans

C. Infection Control/Exposure Control Plan Templates

D. Nitrous Oxide Safety

E. Mercury in the Dental Office

F. Radiological Safety

G. Eye Protection

H. Noise Control

I. Ventilation

J. Latex Hypersensitivity

K. Ergonomics

L. Hazard Communication Program

**Infection Control In The Dental Clinic**

Infection Control in the dental clinic is a constantly-evolving field in
which new guidelines and recommendations are published almost every
year. Because of this ever-changing "state of the art," this revision of
the OHPG will not provide specific guidelines and recommendations
because they would go out of date more quickly than the IHS could update
them. Rather, this section will provide a brief summary of the current
recommendations from the CDC and will provide links to internet websites
where the most up-to-date information should always be available. The
next section of this chapter provides samples of fill-in-the-blank
Infection Control Policies/Exposure Control Plans to aid in the
development of facility-specific policies and procedures.

In December 2003, the CDC published "Guidelines for Infection Control in
Dental Health-Care Settings \-\-- 2003" in Mortality and Morbidity
Weekly Report (MMWR). These new recommendations superseded the
recommendations previously published in 1993. A copy of the
recommendations can be downloaded from the CDC website at
<http://www.cdc.gov/oralhealth/infectioncontrol/guidelines/index.htm> in
either MS Word® or PDF format. Every dental facility should have a hard
copy of the recommendations on site for reference.

The major recommendations are copied below directly from the MMWR for
quick reference. Please refer to the complete document for more details
and the list of references used by the CDC.

An Infection Control Program Assessment tool is included in Chapter 7 of
this manual.

**Recommendations**

Each recommendation is categorized on the basis of existing scientific
data, theoretical rationale, and applicability. Rankings are based on
the system used by CDC and the Healthcare Infection Control Practices
Advisory Committee (HICPAC) to categorize recommendations:

**Category IA.** Strongly recommended for implementation and strongly
supported by well-designed experimental, clinical, or epidemiologic
studies.

**Category IB.** Strongly recommended for implementation and supported
by experimental, clinical, or epidemiologic studies and a strong
theoretical rationale.

**Category IC.** Required for implementation as mandated by federal or
state regulation or standard. When IC is used, a second rating can be
included to provide the basis of existing scientific data, theoretical
rationale, and applicability. Because of state differences, the reader
should not assume that the absence of a IC implies the absence of state
regulations.

**Category II.** Suggested for implementation and supported by
suggestive clinical or epidemiologic studies or a theoretical rationale.

**Unresolved issue.** No recommendation. Insufficient evidence or no
consensus regarding efficacy exists.

**I. Personnel Health Elements Of An Infection-Control Program**

**A. General Recommendations**

> 1\. Develop a written health program for Dental Health Care Personnel
> (DHCP) that includes policies, procedures, and guidelines for
> education and training; immunizations; exposure prevention and
> postexposure management; medical conditions, work-related illness, and
> associated work restrictions; contact dermatitis and latex
> hypersensitivity; and maintenance of records, data management, and
> confidentiality (IB).\
> 2. Establish referral arrangements with qualified health-care
> professionals to ensure prompt and appropriate provision of preventive
> services, occupationally related medical services, and postexposure
> management with medical follow-up (IB, IC).

**B. Education and Training**

> 1\. Provide DHCP 1) on initial employment, 2) when new tasks or
> procedures affect the employee\'s occupational exposure, and 3) at a
> minimum, annually, with education and training regarding occupational
> exposure to potentially infectious agents and infection-control
> procedures/protocols appropriate for and specific to their assigned
> duties (IB, IC).
>
> 2\. Provide educational information appropriate in content and
> vocabulary to the educational level, literacy, and language of DHCP
> (IB, IC).

**C. Immunization Programs**

> 1\. Develop a written comprehensive policy regarding immunizing DHCP,
> including a list of all required and recommended immunizations (IB).\
> 2. Refer DHCP to a prearranged qualified health-care professional or
> to their own health-care professional to receive all appropriate
> immunizations based on the latest recommendations as well as their
> medical history and risk for occupational exposure (IB).

**D. Exposure Prevention and Postexposure Management**

> 1\. Develop a comprehensive postexposure management and medical
> follow-up program (IB, IC).
>
> a\. Include policies and procedures for prompt reporting, evaluation,
> counseling, treatment, and medical follow-up of occupational
> exposures.\
> b. Establish mechanisms for referral to a qualified health-care
> professional for medical evaluation and follow-up.\
> c. Conduct a baseline TST, preferably by using a two-step test, for
> all DHCP who might have contact with persons with suspected or
> confirmed infectious TB, regardless of the risk classification of the
> setting (IB).

**E. Medical Conditions, Work-Related Illness, and Work Restrictions**

> 1\. Develop and have readily available to all DHCP comprehensive
> written policies regarding work restriction and exclusion that include
> a statement of authority defining who can implement such policies
> (IB).\
> 2. Develop policies for work restriction and exclusion that encourage
> DHCP to seek appropriate preventive and curative care and report their
> illnesses, medical conditions, or treatments that can render them more
> susceptible to opportunistic infection or exposures; do not penalize
> DHCP with loss of wages, benefits, or job status (IB).\
> 3. Develop policies and procedures for evaluation, diagnosis, and
> management of DHCP with suspected or known occupational contact
> dermatitis (IB).\
> 4. Seek definitive diagnosis by a qualified health-care professional
> for any DHCP with suspected latex allergy to carefully determine its
> specific etiology and appropriate treatment as well as work
> restrictions and accommodations (IB).

**F. Records Maintenance, Data Management, and Confidentiality**

> 1\. Establish and maintain confidential medical records (e.g.,
> immunization records and documentation of tests received as a result
> of occupational exposure) for all DHCP (IB, IC).\
> 2. Ensure that the practice complies with all applicable federal,
> state, and local laws regarding medical recordkeeping and
> confidentiality (IC).

**II. Preventing Transmission Of Bloodborne Pathogens**

**A. HBV Vaccination**

> 1\. Offer the HBV vaccination series to all DHCP with potential
> occupational exposure to blood or other potentially infectious
> material (IA, IC).\
> 2. Always follow U.S. Public Health Service/CDC recommendations for
> hepatitis B vaccination, serologic testing, follow-up, and booster
> dosing (IA, IC).\
> 3. Test DHCP for anti-HBs 1\--2 months after completion of the 3-dose
> vaccination series (IA, IC).\
> 4. DHCP should complete a second 3-dose vaccine series or be evaluated
> to determine if they are HBsAg-positive if no antibody response occurs
> to the primary vaccine series (IA, IC).\
> 5. Retest for anti-HBs at the completion of the second vaccine series.
> If no response to the second 3-dose series occurs, nonresponders
> should be tested for HBsAg (IC).\
> 6. Counsel nonresponders to vaccination who are HBsAg-negative
> regarding their susceptibility to HBV infection and precautions to
> take (IA, IC).\
> 7. Provide employees appropriate education regarding the risks of HBV
> transmission and the availability of the vaccine. Employees who
> decline the vaccination should sign a declination form to be kept on
> file with the employer (IC).

**B. Preventing Exposures to Blood and Other Potentially Infectious
Material (OPIM**)

1\. General recommendations

> a\. Use standard precautions (OSHA\'s bloodborne pathogen standard
> retains the term universal precautions) for all patient encounters
> (IA, IC).\
> b. Consider sharp items (e.g., needles, scalers, burs, lab knives, and
> wires) that are contaminated with patient blood and saliva as
> potentially infective and establish engineering controls and work
> practices to prevent injuries (IB, IC).\
> c. Implement a written, comprehensive program designed to minimize and
> manage DHCP exposures to blood and body fluids (IB, IC).

2\. Engineering and work-practice controls

> a\. Identify, evaluate, and select devices with engineered safety
> features at least annually and as they become available on the market
> (e.g., safer anesthetic syringes, blunt suture needle, retractable
> scalpel, or needleless IV systems) (IC).\
> b. Place used disposable syringes and needles, scalpel blades, and
> other sharp items in appropriate puncture-resistant containers located
> as close as feasible to the area in which the items are used (IA,
> IC).\
> c. Do not recap used needles by using both hands or any other
> technique that involves directing the point of a needle toward any
> part of the body. Do not bend, break, or remove needles before
> disposal (IA, IC).\
> d. Use either a one-handed scoop technique or a mechanical device
> designed for holding the needle cap when recapping needles (e.g.,
> between multiple injections and before removing from a nondisposable
> aspirating syringe) (IA, IC).

3\. Postexposure management and prophylaxis

> a\. Follow CDC recommendations after percutaneous, mucous membrane, or
> nonintact skin exposure to blood or other potentially infectious
> material (IA, IC).

**III. Hand Hygiene**

**A. General Considerations**

> 1\. Perform hand hygiene with either a nonantimicrobial or
> antimicrobial soap and water when hands are visibly dirty or
> contaminated with blood or other potentially infectious material. If
> hands are not visibly soiled, an alcohol-based hand rub can also be
> used. Follow the manufacturer\'s instructions (IA).\
> 2. Indications for hand hygiene include\
>     a. when hands are visibly soiled (IA, IC);\
>     b. after barehanded touching of inanimate objects likely to be
> contaminated by
>
> blood, saliva, or respiratory secretions (IA, IC);\
>     c. before and after treating each patient (IB);\
>     d. before donning gloves (IB); and\
>     e. immediately after removing gloves (IB, IC).
>
> 3\. For oral surgical procedures, perform surgical hand antisepsis
> before donning sterile surgeon\'s gloves. Follow the manufacturer\'s
> instructions by using either an antimicrobial soap and water, or soap
> and water followed by drying hands and application of an alcohol-based
> surgical hand-scrub product with persistent activity (IB).\
> 4. Store liquid hand-care products in either disposable closed
> containers or closed containers that can be washed and dried before
> refilling. Do not add soap or lotion to (i.e., top off) a partially
> empty dispenser (IA).

**B. Special Considerations for Hand Hygiene and Glove Use**

> 1\. Use hand lotions to prevent skin dryness associated with
> handwashing (IA).\
> 2. Consider the compatibility of lotion and antiseptic products and
> the effect of petroleum or other oil emollients on the integrity of
> gloves during product selection and glove use (IB).\
> 3. Keep fingernails short with smooth, filed edges to allow thorough
> cleaning and prevent glove tears (II).\
> 4. Do not wear artificial fingernails or extenders when having direct
> contact with patients at high risk (e.g., those in intensive care
> units or operating rooms) (IA).\
> 5. Use of artificial fingernails is usually not recommended (II).\
> 6. Do not wear hand or nail jewelry if it makes donning gloves more
> difficult or compromises the fit and integrity of the glove (II).

**IV. Personal Protective Equipment (PPE)**

**A. Masks, Protective Eyewear, and Face Shields**

> 1\. Wear a surgical mask and eye protection with solid side shields or
> a face shield to protect mucous membranes of the eyes, nose, and mouth
> during procedures likely to generate splashing or spattering of blood
> or other body fluids (IB, IC).\
> 2. Change masks between patients or during patient treatment if the
> mask becomes wet (IB).\
> 3. Clean with soap and water, or if visibly soiled, clean and
> disinfect reusable facial protective equipment (e.g., clinician and
> patient protective eyewear or face shields) between patients (II).

**B. Protective Clothing**

> 1\. Wear protective clothing (e.g., reusable or disposable gown,
> laboratory coat, or uniform) that covers personal clothing and skin
> (e.g., forearms) likely to be soiled with blood, saliva, or OPIM (IB,
> IC).\
> 2. Change protective clothing if visibly soiled; change immediately or
> as soon as feasible if penetrated by blood or other potentially
> infectious fluids (IB, IC).\
> 3. Remove barrier protection, including gloves, mask, eyewear, and
> gown before departing work area (e.g., dental patient care, instrument
> processing, or laboratory areas) (IC).

**C. Gloves**

> 1\. Wear medical gloves when a potential exists for contacting blood,
> saliva, OPIM, or mucous membranes (IB, IC).\
> 2. Wear a new pair of medical gloves for each patient, remove them
> promptly after use, and wash hands immediately to avoid transfer of
> microorganisms to other patients or environments (IB).\
> 3. Remove gloves that are torn, cut, or punctured as soon as feasible
> and wash hands before regloving (IB, IC).\
> 4. Do not wash surgeon\'s or patient examination gloves before use or
> wash, disinfect, or sterilize gloves for reuse (IB, IC).\
> 5. Ensure that appropriate gloves in the correct size are readily
> accessible (IC).\
> 6. Use appropriate gloves (e.g., puncture- and chemical-resistant
> utility gloves) when cleaning instruments and performing housekeeping
> tasks involving contact with blood or OPIM (IB, IC).\
> 7. Consult with glove manufacturers regarding the chemical
> compatibility of glove material and dental materials used (II).

**D. Sterile Surgeon\'s Gloves and Double Gloving During Oral Surgical
Procedures**

> 1\. Wear sterile surgeon\'s gloves when performing oral surgical
> procedures (IB).\
> 2. No recommendation is offered regarding the effectiveness of wearing
> two pairs of gloves to prevent disease transmission during oral
> surgical procedures. The majority of studies among HCP and DHCP have
> demonstrated a lower frequency of inner glove perforation and visible
> blood on the surgeon\'s hands when double gloves are worn; however,
> the effectiveness of wearing two pairs of gloves in preventing disease
> transmission has not been demonstrated (Unresolved issue).

**V. Contact Dermatitis And Latex Hypersensitivity**

**A. General Recommendations**

> 1\. Educate DHCP regarding the signs, symptoms, and diagnoses of skin
> reactions associated with frequent hand hygiene and glove use (IB).\
> 2. Screen all patients for latex allergy (e.g., take health history
> and refer for medical consultation when latex allergy is suspected)
> (IB).\
> 3. Ensure a latex-safe environment for patients and DHCP with latex
> allergy (IB).\
> 4. Have emergency treatment kits with latex-free products available at
> all times (II).

**VI. Sterilization And Disinfection Of Patient-Care Items**

**A. General Recommendations**

> 1\. Use only FDA-cleared medical devices for sterilization and follow
> the manufacturer\'s instructions for correct use (IB).\
> 2. Clean and heat-sterilize critical dental instruments before each
> use (IA).
>
> 3\. Clean and heat-sterilize semicritical items before each use (IB).
>
> 4\. Allow packages to dry in the sterilizer before they are handled to
> avoid contamination (IB).\
> 5. Use of heat-stable semicritical alternatives is encouraged (IB).\
> 6. Reprocess heat-sensitive critical and semi-critical instruments by
> using FDA-cleared sterilant/high-level disinfectants or an FDA-cleared
> low-temperature sterilization method (e.g., ethylene oxide). Follow
> manufacturer\'s instructions for use of chemical sterilants/high-level
> disinfectants (IB).\
> 7. Single-use disposable instruments are acceptable alternatives if
> they are used only once and disposed of correctly (IB, IC).\
> 8. Do not use liquid chemical sterilants/high-level disinfectants for
> environmental surface disinfection or as holding solutions (IB, IC).\
> 9. Ensure that noncritical patient-care items are barrier-protected or
> cleaned, or if visibly soiled, cleaned and disinfected after each use
> with an EPA-registered hospital disinfectant. If visibly contaminated
> with blood, use an EPA-registered hospital disinfectant with a
> tuberculocidal claim (i.e., intermediate level) (IB).\
> 10. Inform DHCP of all OSHA guidelines for exposure to chemical agents
> used for disinfection and sterilization. Using this report, identify
> areas and tasks that have potential for exposure (IC).

**B. Instrument Processing Area**

> 1\. Designate a central processing area. Divide the instrument
> processing area, physically or, at a minimum, spatially, into distinct
> areas for 1) receiving, cleaning, and decontamination; 2) preparation
> and packaging; 3) sterilization; and 4) storage. Do not store
> instruments in an area where contaminated instruments are held or
> cleaned (II).\
> 2. Train DHCP to employ work practices that prevent contamination of
> clean areas (II).

**C. Receiving, Cleaning, and Decontamination Work Area**

> 1\. Minimize handling of loose contaminated instruments during
> transport to the instrument processing area. Use work-practice
> controls (e.g., carry instruments in a covered container) to minimize
> exposure potential (II). Clean all visible blood and other
> contamination from dental instruments and devices before sterilization
> or disinfection procedures (IA).\
> 2. Use automated cleaning equipment (e.g., ultrasonic cleaner or
> washer-disinfector) to remove debris to improve cleaning effectiveness
> and decrease worker exposure to blood (IB).\
> 3. Use work-practice controls that minimize contact with sharp
> instruments if manual cleaning is necessary (e.g., long-handled brush)
> (IC).\
> 4. Wear puncture- and chemical-resistant/heavy-duty utility gloves for
> instrument cleaning and decontamination procedures (IB).\
> 5. Wear appropriate PPE (e.g., mask, protective eyewear, and gown)
> when splashing or spraying is anticipated during cleaning (IC).

**D. Preparation and Packaging**

> 1\. Use an internal chemical indicator in each package. If the
> internal indicator cannot be seen from outside the package, also use
> an external indicator (II).
>
> 2\. Use a container system or wrapping compatible with the type of
> sterilization process used and that has received FDA clearance (IB).
>
> 3\. Before sterilization of critical and semicritical instruments,
> inspect instruments for cleanliness, then wrap or place them in
> containers designed to maintain sterility during storage (e.g.,
> cassettes and organizing trays) (IA).

**E. Sterilization of Unwrapped Instruments**

> 1\. Clean and dry instruments before the unwrapped sterilization cycle
> (I).\
> 2. Use mechanical and chemical indicators for each unwrapped
> sterilization cycle (i.e., place an internal chemical indicator among
> the instruments or items to be sterilized) (IB).\
> 3. Allow unwrapped instruments to dry and cool in the sterilizer
> before they are handled to avoid contamination and thermal injury
> (II).\
> 4. Semicritical instruments that will be used immediately or within a
> short time can be sterilized unwrapped on a tray or in a container
> system, provided that the instruments are handled aseptically during
> removal from the sterilizer and transport to the point of use (II).\
> 5. Critical instruments intended for immediate reuse can be sterilized
> unwrapped if the instruments are maintained sterile during removal
> from the sterilizer and transport to the point of use (e.g.,
> transported in a sterile covered container) (IB).\
> 6. Do not sterilize implantable devices unwrapped (IB).\
> 7. Do not store critical instruments unwrapped (IB).

**F. Sterilization Monitoring**

> 1\. Use mechanical, chemical, and biological monitors according to the
> manufacturer\'s instructions to ensure the effectiveness of the
> sterilization process (IB).\
> 2. Monitor each load with mechanical (e.g., time, temperature, and
> pressure) and chemical indicators (II).\
> 3. Place a chemical indicator on the inside of each package. If the
> internal indicator is not visible from the outside, also place an
> exterior chemical indicator on the package (II).\
> 4. Place items/packages correctly and loosely into the sterilizer so
> as not to impede penetration of the sterilant (IB).\
> 5. Do not use instrument packs if mechanical or chemical indicators
> indicate inadequate processing (IB).\
> 6. Monitor sterilizers at least weekly by using a biological indicator
> with a matching control (i.e., biological indicator and control from
> same lot number) (IB).\
> 7. Use a biological indicator for every sterilizer load that contains
> an implantable device. Verify results before using the implantable
> device, whenever possible (IB).
>
> 8\. The following are recommended in the case of a positive spore
> test:
>
> a\. Remove the sterilizer from service and review sterilization
> procedures (e.g., work practices and use of mechanical and chemical
> indicators) to determine whether operator error could be responsible
> (II).\
> b. Retest the sterilizer by using biological, mechanical, and chemical
> indicators after correcting any identified procedural problems (II).\
> c. If the repeat spore test is negative, and mechanical and chemical
> indicators are within normal limits, put the sterilizer back in
> service (II).

9\. The following are recommended if the repeat spore test is positive:

> a\. Do not use the sterilizer until it has been inspected or repaired
> or the exact reason for the positive test has been determined (II).\
> b. Recall, to the extent possible, and reprocess all items processed
> since the last negative spore test (II).\
> c. Before placing the sterilizer back in service, rechallenge the
> sterilizer with biological indicator tests in three consecutive empty
> chamber sterilization cycles after the cause of the sterilizer failure
> has been determined and corrected (II).
>
> 10\. Maintain sterilization records (i.e., mechanical, chemical, and
> biological) in compliance with state and local regulations (IB).

**G. Storage Area for Sterilized Items and Clean Dental Supplies**

> 1\. Implement practices on the basis of date- or event-related
> shelf-life for storage of wrapped, sterilized instruments and devices
> (IB).\
> 2. Even for event-related packaging, at a minimum, place the date of
> sterilization, and if multiple sterilizers are used in the facility,
> the sterilizer used, on the outside of the packaging material to
> facilitate the retrieval of processed items in the event of a
> sterilization failure (IB).\
> 3. Examine wrapped packages of sterilized instruments before opening
> them to ensure the barrier wrap has not been compromised during
> storage (II).\
> 4. Reclean, repack, and resterilize any instrument package that has
> been compromised (II).\
> 5. Store sterile items and dental supplies in covered or closed
> cabinets, if possible (II).

**VII. Environmental Infection Control**

**A. General Recommendations**

> 1\. Follow the manufacturers\' instructions for correct use of
> cleaning and EPA-registered hospital disinfecting products (IB, IC).\
> 2. Do not use liquid chemical sterilants/high-level disinfectants for
> disinfection of environmental surfaces (clinical contact or
> housekeeping) (IB, IC).\
> 3. Use PPE, as appropriate, when cleaning and disinfecting
> environmental surfaces. Such equipment might include gloves (e.g.,
> puncture- and chemical-resistant utility), protective clothing (e.g.,
> gown, jacket, or lab coat), and protective eyewear/face shield, and
> mask (IC).

**B. Clinical Contact Surfaces**

> 1\. Use surface barriers to protect clinical contact surfaces,
> particularly those that are difficult to clean (e.g., switches on
> dental chairs) and change surface barriers between patients (II).\
> 2. Clean and disinfect clinical contact surfaces that are not
> barrier-protected, by using an EPA-registered hospital disinfectant
> with a low- (i.e., HIV and HBV label claims) to intermediate-level
> (i.e., tuberculocidal claim) activity after each patient. Use an
> intermediate-level disinfectant if visibly contaminated with blood
> (IB).

**C. Housekeeping Surfaces**

> 1\. Clean housekeeping surfaces (e.g., floors, walls, and sinks) with
> a detergent and water or an EPA-registered hospital
> disinfectant/detergent on a routine basis, depending on the nature of
> the surface and type and degree of contamination, and as appropriate,
> based on the location in the facility, and when visibly soiled (IB).\
> 2. Clean mops and cloths after use and allow to dry before reuse; or
> use single-use, disposable mop heads or cloths (II).\
> 3. Prepare fresh cleaning or EPA-registered disinfecting solutions
> daily and as instructed by the manufacturer. (II).\
> 4. Clean walls, blinds, and window curtains in patient-care areas when
> they are visibly dusty or soiled (II).

**D. Spills of Blood and Body Substances**

> 1\. Clean spills of blood or OPIM and decontaminate surface with an
> EPA-registered hospital disinfectant with low- (i.e., HBV and HIV
> label claims) to intermediate-level (i.e., tuberculocidal claim)
> activity, depending on size of spill and surface porosity (IB, IC).

**E. Carpet and Cloth Furnishings**

> 1\. Avoid using carpeting and cloth-upholstered furnishings in dental
> operatories, laboratories, and instrument processing areas (II).

**F. Regulated Medical Waste**

1\. General Recommendations

> a\. Develop a medical waste management program. Disposal of regulated
> medical waste must follow federal, state, and local regulations (IC).\
> b. Ensure that DHCP who handle and dispose of regulated medical waste
> are trained in appropriate handling and disposal methods and informed
> of the possible health and safety hazards (IC).

2\. Management of Regulated Medical Waste in Dental Health-Care
Facilities

> a\. Use a color-coded or labeled container that prevents leakage
> (e.g., biohazard bag) to contain nonsharp regulated medical waste
> (IC).\
> b. Place sharp items (e.g., needles, scalpel blades, orthodontic
> bands, broken metal instruments, and burs) in an appropriate sharps
> container (e.g., puncture resistant, color-coded, and leakproof).
> Close container immediately before removal or replacement to prevent
> spillage or protrusion of contents during handling, storage,
> transport, or shipping (IC).\
> c. Pour blood, suctioned fluids or other liquid waste carefully into a
> drain connected to a sanitary sewer system, if local sewage discharge
> requirements are met and the state has declared this an acceptable
> method of disposal. Wear appropriate PPE while performing this task
> (IC).

**VIII. Dental Unit Waterlines, Biofilm, And Water Quality**

**A. General Recommendations**

> 1\. Use water that meets EPA regulatory standards for drinking water
> (i.e., [\<]{.underline}500 CFU/mL of heterotrophic water bacteria) for
> routine dental treatment output water (IB, IC).\
> 2. Consult with the dental unit manufacturer for appropriate methods
> and equipment to maintain the recommended quality of dental water
> (II).\
> 3. Follow recommendations for monitoring water quality provided by the
> manufacturer of the unit or waterline treatment product (II).\
> 4. Discharge water and air for a minimum of 20\--30 seconds after each
> patient, from any device connected to the dental water system that
> enters the patient\'s mouth (e.g., handpieces, ultrasonic scalers, and
> air/water syringes) (II).\
> 5. Consult with the dental unit manufacturer on the need for periodic
> maintenance of antiretraction mechanisms (IB).

**B. Boil-Water Advisories**

1\. The following apply while a boil-water advisory is in effect:

> a\. Do not deliver water from the public water system to the patient
> through the dental operative unit, ultrasonic scaler, or other dental
> equipment that uses the public water system (IB, IC).\
> b. Do not use water from the public water system for dental treatment,
> patient rinsing, or handwashing (IB, IC).\
> c. For handwashing, use antimicrobial-containing products that do not
> require water for use (e.g., alcohol-based hand rubs). If hands are
> visibly contaminated, use bottled water, if available, and soap for
> handwashing or an antiseptic towelette (IB, IC).

2\. The following apply when the boil-water advisory is cancelled:

> a\. Follow guidance given by the local water utility regarding
> adequate flushing of waterlines. If no guidance is provided, flush
> dental waterlines and faucets for 1\--5 minutes before using for
> patient care (IC).\
> b. Disinfect dental waterlines as recommended by the dental unit
> manufacturer (II).

**IX. Special Considerations**

**A. Dental Handpieces and Other Devices Attached to Air and
Waterlines**

> 1\. Clean and heat-sterilize handpieces and other intraoral
> instruments that can be removed from the air and waterlines of dental
> units between patients (IB, IC).\
> 2. Follow the manufacturer\'s instructions for cleaning, lubrication,
> and sterilization of handpieces and other intraoral instruments that
> can be removed from the air and waterlines of dental units (IB).\
> 3. Do not surface-disinfect, use liquid chemical sterilants, or
> ethylene oxide on handpieces and other intraoral instruments that can
> be removed from the air and waterlines of dental units (IC).\
> 4. Do not advise patients to close their lips tightly around the tip
> of the saliva ejector to evacuate oral fluids (II).

**B. Dental Radiology**

> 1\. Wear gloves when exposing radiographs and handling contaminated
> film packets. Use other PPE (e.g., protective eyewear, mask, and gown)
> as appropriate if spattering of blood or other body fluids is likely
> (IA, IC).\
> 2. Use heat-tolerant or disposable intraoral devices whenever possible
> (e.g., film-holding and positioning devices). Clean and heat-sterilize
> heat-tolerant devices between patients. At a minimum, high-level
> disinfect semicritical heat-sensitive devices, according to
> manufacturer\'s instructions (IB).\
> 3. Transport and handle exposed radiographs in an aseptic manner to
> prevent contamination of developing equipment (II).\
> 4. The following apply for digital radiography sensors:
>
> a\. Use FDA-cleared barriers (IB).\
> b. Clean and heat-sterilize, or high-level disinfect, between
> patients, barrier-protected semicritical items. If the item cannot
> tolerate these procedures then, at a minimum, protect with an
> FDA-cleared barrier and clean and disinfect with an EPA-registered
> hospital disinfectant with intermediate-level (i.e., tuberculocidal
> claim) activity, between patients. Consult with the manufacturer for
> methods of disinfection and sterilization of digital radiology sensors
> and for protection of associated computer hardware (IB).

**C. Aseptic Technique for Parenteral Medications**

> 1\. Do not administer medication from a syringe to multiple patients,
> even if the needle on the syringe is changed (IA).
>
> 2\. Use single-dose vials for parenteral medications when possible
> (II).\
> 3. Do not combine the leftover contents of single-use vials for later
> use (IA).\
> 4. The following apply if multidose vials are used:
>
> a\. Cleanse the access diaphragm with 70% alcohol before inserting a
> device into the vial (IA).\
> b. Use a sterile device to access a multiple-dose vial and avoid
> touching the access diaphragm. Both the needle and syringe used to
> access the multidose vial should be sterile. Do not reuse a syringe
> even if the needle is changed (IA).\
> c. Keep multidose vials away from the immediate patient treatment area
> to prevent inadvertent contamination by spray or spatter (II).\
> d. Discard the multidose vial if sterility is compromised (IA).
>
> 5\. Use fluid infusion and administration sets (i.e., IV bags, tubings
> and connections) for one patient only and dispose of appropriately
> (IB).

**D. Single-Use (Disposable) Devices**

> 1\. Use single-use devices for one patient only and dispose of them
> appropriately (IC).

**E. Preprocedural Mouth Rinses**

> 1\. No recommendation is offered regarding use of preprocedural
> antimicrobial mouth rinses to prevent clinical infections among DHCP
> or patients. Although studies have demonstrated that a preprocedural
> antimicrobial rinse (e.g., chlorhexidine gluconate, essential oils, or
> povidone-iodine) can reduce the level of oral microorganisms in
> aerosols and spatter generated during routine dental procedures and
> can decrease the number of microorganisms introduced in the patient\'s
> bloodstream during invasive dental procedures, the scientific evidence
> is inconclusive that using these rinses prevents clinical infections
> among DHCP or patients (see discussion, Preprocedural Mouth Rinses)
> (Unresolved issue).

**F. Oral Surgical Procedures**

1\. The following apply when performing oral surgical procedures:

> a\. Perform surgical hand antisepsis by using an antimicrobial product
> (e.g., antimicrobial soap and water, or soap and water followed by
> alcohol-based hand scrub with persistent activity) before donning
> sterile surgeon\'s gloves (IB).
>
> b\. Use sterile surgeon\'s gloves (IB).\
> c. Use sterile saline or sterile water as a coolant/irrigatant when
> performing oral surgical procedures. Use devices specifically designed
> for delivering sterile irrigating fluids (e.g., bulb syringe,
> single-use disposable products, and sterilizable tubing) (IB).

**G. Handling of Biopsy Specimens**

> 1\. During transport, place biopsy specimens in a sturdy, leakproof
> container labeled with the biohazard symbol (IC).\
> 2. If a biopsy specimen container is visibly contaminated, clean and
> disinfect the outside of a container or place it in an impervious bag
> labeled with the biohazard symbol, (IC).

**H. Handling of Extracted Teeth**

> 1\. Dispose of extracted teeth as regulated medical waste unless
> returned to the patient (IC).\
> 2. Do not dispose of extracted teeth containing amalgam in regulated
> medical waste intended for incineration (II).\
> 3. Clean and place extracted teeth in a leakproof container, labeled
> with a biohazard symbol, and maintain hydration for transport to
> educational institutions or a dental laboratory (IC).\
> 4. Heat-sterilize teeth that do not contain amalgam before they are
> used for educational purposes (IB).

**I. Dental Laboratory**

> 1\. Use PPE when handling items received in the laboratory until they
> have been decontaminated (IA, IC).
>
> 2\. Before they are handled in the laboratory, clean, disinfect, and
> rinse all dental prostheses and prosthodontic materials (e.g.,
> impressions, bite registrations, occlusal rims, and extracted teeth)
> by using an EPA-registered hospital disinfectant having at least an
> intermediate-level (i.e., tuberculocidal claim) activity (IB).\
> 3. Consult with manufacturers regarding the stability of specific
> materials (e.g., impression materials) relative to disinfection
> procedures (II).\
> 4. Include specific information regarding disinfection techniques used
> (e.g., solution used and duration), when laboratory cases are sent
> off-site and on their return (II).\
> 5. Clean and heat-sterilize heat-tolerant items used in the mouth
> (e.g., metal impression trays and face-bow forks) (IB).\
> 6. Follow manufacturers\' instructions for cleaning and sterilizing or
> disinfecting items that become contaminated but do not normally
> contact the patient (e.g., burs, polishing points, rag wheels,
> articulators, case pans, and lathes). If manufacturer instructions are
> unavailable, clean and heat-sterilize heat-tolerant items or clean and
> disinfect with an EPA-registered hospital disinfectant with low- (HIV,
> HBV effectiveness claim) to intermediate-level (tuberculocidal claim)
> activity, depending on the degree of contamination (II).

**J. Laser/Electrosurgery Plumes/Surgical Smoke**

> 1\. No recommendation is offered regarding practices to reduce DHCP
> exposure to laser plumes/surgical smoke when using lasers in dental
> practice. Practices to reduce HCP exposure to laser plumes/surgical
> smoke have been suggested, including use of
>
> a\) standard precautions (e.g., high-filtration surgical masks and
> possibly full face shields);
>
> b\) central room suction units with in-line filters to collect
> particulate matter from minimal plumes; and
>
> c\) dedicated mechanical smoke exhaust systems with a high-efficiency
> filter to remove substantial amounts of laser-plume particles. The
> effect of the exposure (e.g., disease transmission or adverse
> respiratory effects) on DHCP from dental applications of lasers has
> not been adequately evaluated (see previous discussion,
> Laser/Electrosurgery Plumes or Surgical Smoke) (Unresolved issue).

**K. *Mycobacterium tuberculosis***

1\. General Recommendations

> a\. Educate all DHCP regarding the recognition of signs, symptoms, and
> transmission of TB (IB).\
> b. Conduct a baseline TST, preferably by using a two-step test, for
> all DHCP who might have contact with persons with suspected or
> confirmed active TB, regardless of the risk classification of the
> setting (IB).\
> c. Assess each patient for a history of TB as well as symptoms
> indicative of TB and document on the medical history form (IB).\
> d. Follow CDC recommendations for 1) developing, maintaining, and
> implementing a written TB infection-control plan; 2) managing a
> patient with suspected or active TB; 3) completing a community
> risk-assessment to guide employee TSTs and follow-up; and 4) managing
> DHCP with TB disease (IB).

2\. The following apply for patients known or suspected to have active
TB:

> a\. Evaluate the patient away from other patients and DHCP. When not
> being evaluated, the patient should wear a surgical mask or be
> instructed to cover mouth and nose when coughing or sneezing (IB).\
> b. Defer elective dental treatment until the patient is noninfectious
> (IB).\
> c. Refer patients requiring urgent dental treatment to a previously
> identified facility with TB engineering controls and a respiratory
> protection program (IB).

**L. Creutzfeldt-Jakob Disease (CJD) and Other Prion Diseases**

> 1\. No recommendation is offered regarding use of special precautions
> in addition to standard precautions when treating known CJD or vCJD
> patients. Potential infectivity of oral tissues in CJD or vCJD
> patients is an unresolved issue. Scientific data indicate the risk, if
> any, of sporadic CJD transmission during dental and oral surgical
> procedures is low to nil. Until additional information exists
> regarding the transmissibility of CJD or vCJD during dental
> procedures, special precautions in addition to standard precautions
> might be indicated when treating known CJD or vCJD patients; a list of
> such precautions is provided for consideration without recommendation
> (see Creutzfeldt-Jakob Disease and Other Prion Diseases) (Unresolved
> issue).

**M. Program Evaluation**

1\. Establish routine evaluation of the infection-control program,
including evaluation of performance indicators, at an established
frequency (II).

**Disinfectants And Sterilants**

CDC recommendations on the choice and use of disinfectants and
sterilants are excerpted below. Please refer to the CDC website at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a2.htm> or the MMWR
Appendix A for the complete text.

The choice of specific cleaning or disinfecting agents is largely a
matter of judgment, guided by product label claims and instructions and
government regulations. A single liquid chemical germicide might not
satisfy all disinfection requirements in a given dental practice or
facility. Realistic use of liquid chemical germicides depends on
consideration of multiple factors, including the degree of microbial
killing required; the nature and composition of the surface, item, or
device to be treated; and the cost, safety, and ease of use of the
available agents. Selecting one appropriate product with a higher degree
of potency to cover all situations might be more convenient.

In the United States, liquid chemical germicides (disinfectants) are
regulated by EPA and FDA. In health-care settings, EPA regulates
disinfectants that are used on environmental surfaces (housekeeping and
clinical contact surfaces), and FDA regulates liquid chemical
sterilants/high-level disinfectants (e.g., glutaraldehyde, hydrogen
peroxide, and peracetic acid) used on critical and semicritical
patient-care devices. Disinfectants intended for use on clinical contact
surfaces (e.g., light handles, radiographic-ray heads, or drawer knobs)
or housekeeping surfaces (e.g., floors, walls, or sinks) are regulated
in interstate commerce by the Antimicrobials Division, Office of
Pesticide Programs, EPA.

EPA requires manufacturers to test formulations by using accepted
methods for microbicidal activity, stability, and toxicity to animals
and humans. Manufacturers submit these data to EPA with proposed
labeling. If EPA concludes a product may be used without causing
unreasonable adverse effects, the product and its labeling are given an
EPA registration number, and the manufacturer may then sell and
distribute the product in the United States.. The following statement
appears on all EPA-registered product labels under the Directions for
Use heading: \"It is a violation of federal law to use this product
inconsistent with its labeling.\" This means that DHCP must follow the
safety precautions and use directions on the labeling of each registered
product. Not following the specified dilution, contact time, method of
application, or any other condition of use is considered misuse of the
product.

Potency against *Mycobacterium tuberculosis* has been recognized as a
substantial benchmark or potency. However, the tuberculocidal claim is
used only as a benchmark to measure germicidal potency. Tuberculosis is
not transmitted via environmental surfaces but rather by the airborne
route. Accordingly, use of such products on environmental surfaces plays
no role in preventing the spread of tuberculosis. However, because
mycobacteria have among the highest intrinsic levels of resistance among
the vegetative bacteria, viruses, and fungi, any germicide with a
tuberculocidal claim on the label is considered capable of inactivating
a broad spectrum of pathogens, including such less-resistant organisms
as bloodborne pathogens (e.g., HBV, HCV, and HIV). It is this
broad-spectrum capability, rather than the product\'s specific potency
against mycobacteria, that is the basis for protocols and regulations
dictating use of tuberculocidal chemicals for surface disinfection.

EPA also lists disinfectant products according to their labeled use
against these organisms of interest as follows:

List B. Tuberculocide products effective against *Mycobacterium*
species.

List C. Products effective against human HIV-1 virus.

List D. Products effective against human HIV-1 virus and HBV.

List E. Products effective against *Mycobacterium* species, human HIV-1
virus, and HBV.

List F. Products effective against HCV.

**Immunizations Recommended For Health Care Personnel**

The facility's Exposure Control Plan should contain a list of the
recommended immunizations for dental health care workers. Appendix B of
the MMWR contains the list of immunizations recommended by the CDC,
along with dose schedules, indications, major precautions, and special
considerations for each. This list can also be accessed at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a3.htm> .

**Methods For Sterilizing And Disinfecting Patient-Care Items And
Environmental Surfaces**

CDC recommendations for disinfection and sterilization are contained in
Appendix C of the MMWR and can also be obtained at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a4.htm> .

Due to potential health risks associated with exposure to glutaraldehyde
vapors, including:

-   Dermatitis - allergic reaction to the skin

-   Rhinitis and conjunctivitis - symptoms typical of hay fever

-   Asthma - constriction of the airways

it is recommended that disinfectants using this chemical not be used in
the dental clinic.

**Infection-Control Internet Resources**

**CDC Advisory Committee on Immunization Practices\
**<http://www.cdc.gov/nip/ACIP/default.htm>

**American Dental Association\
**[http://www.ada.org](http://www.ada.org/) (home page)

<http://www.ada.org/prof/resources/topics/icontrol/index.asp> (ADA
infection control resources)

<http://www.ada.org/prof/resources/positions/statements/lines.asp> (ADA
Statement on Dental Unit Waterlines)

**Association for Professionals in Infection Control and Epidemiology,
Inc.\
**[http://www.apic.org](http://www.apic.org/)

**CDC, Division of Healthcare Quality Promotion\
**<http://www.cdc.gov/ncidod/dhqp/index.html>

**CDC, Division of Oral Health, Infection Control\
**<http://www.cdc.gov/OralHealth/infectioncontrol/index.htm>

**CDC Slide Presentation in PowerPoint format on Infection Control for
Dental Offices**

<http://www.cdc.gov/OralHealth/infectioncontrol/guidelines/ppt.htm>

**CDC, *Morbidity and Mortality Weekly Report*\
**<http://www.cdc.gov/mmwr>

**CDC, NIOSH\
**<http://www.cdc.gov/niosh/homepage.html>

**CDC Recommends, Prevention Guidelines System\
**<http://www.phppo.cdc.gov/cdcRecommends/AdvSearchV.asp>

**EPA, Antimicrobial Chemicals\
**<http://www.epa.gov/oppad001/chemregindex.htm>

**FDA\
**[http://www.fda.gov](http://www.fda.gov/)

**Immunization Action Coalition\
**<http://www.immunize.org/acip>

**National Clinicians Post Exposure Prophylaxis Hotline**

<http://www.ucsf.edu/hivcntr/PEPline/>

This website provides the most up-to-date information on post-exposure
prophylaxis protocols and is available on the web or by toll-free phone
(1-888-448-4911) 24 hours a day.

**OSHA, Dentistry, Bloodborne Pathogens\
**<http://www.osha.gov/SLTC/dentistry/index.html>\
<http://www.osha.gov/SLTC/bloodbornepathogens/index.html>

**Organization for Safety and Asepsis Procedures\
**[http://www.osap.org](http://www.osap.org/)

**Society for Healthcare Epidemiology of America, Inc., Position Papers\
**<http://www.shea-online.org/publications/shea_position_papers.cfm>

**US Air Force Dental Evaluation and Consultation Service (DECS)**

<https://decs.nhgl.med.navy.mil/> (home page)

<https://decs.nhgl.med.navy.mil/infcontrol.htm> (Infection Control
section)

**Updated U.S. Public Health Service Guidelines for the Management of
Occupational Exposures to HIV and Recommendations for Postexposure
Prophylaxis (2005)**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm>

**Dental Infection Control Policy/Exposure Control Plan Templates**

This is a template for an Infection Control policy that may be used for
a dental clinic. It is based on the latest CDC recommendations for
dental infection control. Each section in the policy and checklist
corresponds to the CDC recommendations.

(See <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm> for the
entire recommendation)

This template CANNOT be used as presented. It MUST be adapted to your
facility. Many of the policies can be used "as is". Those sections are
in normal font. Some sections must be adapted to each facility. Those
sections are italicized. Some italicized sections may be deleted if the
topic does not apply to your setting. Some words in **bold** only need a
facility or clinic name inserted.

Included at the end of each section is a category that designates the
strength of the recommendations. The categories are listed in the first
section. These category designations help to substantiate your policies.
It is not a mandate that you follow the CDC recommendations. However
these recommendations have been well researched and are evidence based.
Therefore if you do follow them, you are within the scope of current
dental professional recommendations.

The Policy and Procedure format at the beginning of each section is a
sample only. You may substitute your own policy format and numbering
system.

Another example of a Dental Exposure Control Policy Template can be
found on the website of the US Air Force Dental Evaluation and
Consultation service (DECS) at
<https://decs.nhgl.med.navy.mil/3QTR04/incontrolfactsheet9.htm> for the
fact sheet, and at <https://decs.nhgl.med.navy.mil/3QTR04/sampleecp.doc>
for the sample exposure control plan.

If the dental clinic is part of a larger medical facility or hospital,
it will be covered under the facility's Exposure Control Plan. In such a
case, always coordinate dental clinic policies and procedures with the
Infection Control Program of the larger facility to ensure that there
are no conflicts.

Infection Control Templates

Introduction

Personnel Elements of an Infection Control Program

Preventing Transmission of Bloodborne Pathogens

Hand Hygiene

Personal Protective Equipment (PPE)

Contact Dermatitis and Latex Sensitivity

Sterilization and Disinfection of Patient-Care Items

Environmental Infection Control

Dental Waterlines, Biofilm and Water Quality

Special Considerations

Program Evaluation

Dental Department

Policy & Procedure Statement

**Subject:** Dental Infection Control **Effective Date:**

**Supercedes:**

**P&P Number:** Introduction

**Purpose:**

To establish policies and procedures to protect dental personnel from
work related exposures to infectious diseases and to protect dental
patients from exposures to infectious diseases resulting from dental
treatment.

**Authority:**

1.  Centers for Disease Control and Prevention. Guidelines for Infection
    Control in Dental Health-Care settings-2003. MMWR 2003;52 (No.
    RR-17)

> <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm>

2.  **(Handpiece manufacturer name)** recommendation for maintenance and
    sterilization of high speed and low speed handpieces

3.  Atest manufacturer's instructions

4.  **(Facility Name)** infection control policies relating to
    ambulatory patient care

5.  **(Facility Name)** safety policies relating to infection control

6.  **(Facility Name)** personnel policies relating to infection control

7.  HIPAA act of 1998

**Procedure:**

1.  Policies are numbered as IC/D (Infection Control/ Dental).

2.  All policies in the Dental Infection Control Policy Guide are
    consistent with manufacturer's recommendations, CDC, **IHS(if
    applicable),** and **(Facility Name)** recommendations and
    regulations.

3.  Authority for all policies can be located in one of the above listed
    sources

4.  Whenever possible, policies will defer to **(Facility name)** wide
    policies. Specific questions should be directed to the **(Facility
    Name**) Safety Officer, the **(Facility Name)** Infection Control
    Officer, Medical Records Chief (HIPPA regulations), or other
    appropriate authorities at **(Facility Name)**.

5.  When updating policies and procedures, current authoritative sources
    should be referenced and if possible, copied and placed in this
    guide as a reference.

6.  Guide should be updated annually or as soon as new recommendations
    become available

7.  Copies of the Dental Infection Control Policy Guide will be
    maintained at **(Facility(ies) Name(s))**

8.  Periodic quality assurance studies will be conducted to ensure
    compliance with this guide. Lack of compliance or changes in
    procedures will be discussed at dental staff meetings. The Chief-
    Dental Services will approve changes to the guide prior to
    implementation

9.  Recommendations may be classified by the following categories:

**Category IA.** Strongly recommended for implementation and strongly
supported by well-designed experimental, clinical, or epidemiologic
studies.

**Category IB.** Strongly recommended for implementation and supported
by experimental, clinical, or epidemiologic studies and a strong
theoretical rationale.

**Category IC.** Required for implementation as mandated by federal or
state regulation or standard. When IC is used, a second rating can be
included to provide the basis of existing scientific data, theoretical
rationale, and applicability. Because of state differences, the reader
should not assume that the absence of a IC implies the absence of state
regulations.

**Category II.** Suggested for implementation and supported by
suggestive clinical or epidemiologic studies or a theoretical rationale.

Dental Department

Policy & Procedure Statement

**Subject:** Personnel Health Elements of **Effective Date:**

of an Infection Control Program **Supercedes:**

**P&P Number:**

**Purpose:**

To establish guidelines for education and training in infection control,
immunizations, exposure and post exposure management, medical
conditions, work related illness, contact dermatitis and latex
hypersensitivity, maintenance of records, data management, and
confidentiality

**Procedure:**

**A. General Recommendations**

> *1. Develop a written health program for DHCP that includes policies,
> procedures, and guidelines for education and training; immunizations;
> exposure prevention and postexposure management; medical conditions,
> work-related illness, and associated work restrictions; contact
> dermatitis and latex hypersensitivity; and maintenance of records,
> data management, and confidentiality (IB).\
> 2. Establish referral arrangements with qualified health-care
> professionals to ensure prompt and appropriate provision of preventive
> services, occupationally related medical services, and postexposure
> management with medical follow-up (IB, IC).*

**B. Education and Training**

> *1. Provide DHCP 1) on initial employment, 2) when new tasks or
> procedures affect the employee\'s occupational exposure, and 3) at a
> minimum, annually, with education and training regarding occupational
> exposure to potentially infectious agents and infection-control
> procedures/protocols appropriate for and specific to their assigned
> duties (IB, IC).\
> 2. Provide educational information appropriate in content and
> vocabulary to the educational level, literacy, and language of DHCP
> (IB, IC).*

**C. Immunization Programs**

> *1. Develop a written comprehensive policy regarding immunizing DHCP,
> including a list of all required and recommended immunizations (IB).*\
> 2. Refer DHCP to a prearranged qualified health-care professional or
> to their own health-care professional to receive all appropriate
> immunizations based on the latest recommendations as well as their
> medical history and risk for occupational exposure (IB).

**D. Exposure Prevention and Postexposure Management**

> *1. Develop a comprehensive postexposure management and medical
> follow-up program (IB, IC).*
>
> *a. Include policies and procedures for prompt reporting, evaluation,
> counseling, treatment, and medical follow-up of occupational
> exposures.\
> b. Establish mechanisms for referral to a qualified health-care
> professional for medical evaluation and follow-up.\
> *c. Conduct a baseline TST, preferably by using a two-step test, for
> all DHCP who might have contact with persons with suspected or
> confirmed infectious TB, regardless of the risk classification of the
> setting (IB).

**E. Medical Conditions, Work-Related Illness, and Work Restrictions**

> *1. Develop and have readily available to all DHCP comprehensive
> written policies regarding work restriction and exclusion that include
> a statement of authority defining who can implement such policies
> (IB).\
> 2. Develop policies for work restriction and exclusion that encourage
> DHCP to seek appropriate preventive and curative care and report their
> illnesses, medical conditions, or treatments that can render them more
> susceptible to opportunistic infection or exposures; do not penalize
> DHCP with loss of wages, benefits, or job status (IB).\
> 3. Develop policies and procedures for evaluation, diagnosis, and
> management of DHCP with suspected or known occupational contact
> dermatitis (IB).*\
> 4. Seek definitive diagnosis by a qualified health-care professional
> for any DHCP with suspected latex allergy to carefully determine its
> specific etiology and appropriate treatment as well as work
> restrictions and accommodations (IB).

**F. Records Maintenance, Data Management, and Confidentiality**

> 1\. Establish and maintain confidential medical records (e.g.,
> immunization records and documentation of tests received as a result
> of occupational exposure) for all DHCP (IB, IC).\
> 2. Ensure that the practice complies with all applicable federal,
> state, and local laws regarding medical recordkeeping and
> confidentiality (IC).

Dental Department

Policy & Procedure Statement

**Subject:** Preventing Transmission of **Effective Date:**

Bloodborne Pathogens **Supercedes:**

**P&P Number:**

**Purpose:**

To establish a policy to protect personnel from bloodborne pathogens and
to prevent transmission of bloodborne pathogens

**Procedure:**

**A. HBV Vaccination**

> 1\. Offer the HBV vaccination series to all DHCP with potential
> occupational exposure to blood or other potentially infectious
> material (IA, IC).\
> 2. Always follow U.S. Public Health Service/CDC recommendations for
> hepatitis B vaccination, serologic testing, follow-up, and booster
> dosing (IA, IC).\
> 3. Test DHCP for anti-HBs 1\--2 months after completion of the 3-dose
> vaccination series (IA, IC).\
> 4. DHCP should complete a second 3-dose vaccine series or be evaluated
> to determine if they are HBsAg-positive if no antibody response occurs
> to the primary vaccine series (IA, IC).\
> 5. Retest for anti-HBs at the completion of the second vaccine series.
> If no response to the second 3-dose series occurs, nonresponders
> should be tested for HBsAg (IC).\
> 6. Counsel nonresponders to vaccination who are HBsAg-negative
> regarding their susceptibility to HBV infection and precautions to
> take (IA, IC).\
> 7. Provide employees appropriate education regarding the risks of HBV
> transmission and the availability of the vaccine. Employees who
> decline the vaccination should sign a declination form to be kept on
> file with the employer (IC).

**B. Preventing Exposures to Blood and OPIM**

1\. General recommendations

> a\. Use standard precautions (OSHA\'s bloodborne pathogen standard
> retains the term universal precautions) for all patient encounters
> (IA, IC).\
> b. Consider sharp items (e.g., needles, scalers, burs, lab knives, and
> wires) that are contaminated with patient blood and saliva as
> potentially infective and establish engineering controls and work
> practices to prevent injuries (IB, IC).\
> *c. Implement a written, comprehensive program designed to minimize
> and manage DHCP exposures to blood and body fluids (IB, IC).*

2\. Engineering and work-practice controls

> a\. Identify, evaluate, and select devices with engineered safety
> features at least annually and as they become available on the market
> (e.g., safer anesthetic syringes, blunt suture needle, retractable
> scalpel, or needle less IV systems) (IC).\
> b. Place used disposable syringes and needles, scalpel blades, and
> other sharp items in appropriate puncture-resistant containers located
> as close as feasible to the area in which the items are used (IA,
> IC).\
> c. Do not recap used needles by using both hands or any other
> technique that involves directing the point of a needle toward any
> part of the body. Do not bend, break, or remove needles before
> disposal (IA, IC).\
> d. Use either a one-handed scoop technique or a mechanical device
> designed for holding the needle cap when recapping needles (e.g.,
> between multiple injections and before removing from a nondisposable
> aspirating syringe) (IA, IC).

3\. Postexposure management and prophylaxis

> a\. Follow CDC recommendations after percutaneous, mucous membrane, or
> nonintact skin exposure to blood or other potentially infectious
> material (IA, IC).

#  

Dental Department

Policy & Procedure Statement

**Subject:** Hand Hygiene **Effective Date:**

**Supercedes:**

**P&P Number:**

**Purpose:**

To establish a policy for protecting dental health workers and dental
patients through exposure to infectious materials

Procedure:

**A. General Considerations**

> 1\. Perform hand hygiene with either a nonantimicrobial or
> antimicrobial soap and water when hands are visibly dirty or
> contaminated with blood or other potentially infectious material. If
> hands are not visibly soiled, an alcohol-based hand rub can also be
> used. Follow the manufacturer\'s instructions (1A)\
> 2. Indications for hand hygiene include\
>     a. when hands are visibly soiled\
>     b. after barehanded touching of inanimate objects likely to be
> contaminated by blood, saliva, or respiratory secretions\
>     (IA, IC);\
>     c. before and after treating each patient (IB);\
>      d. before donning gloves (IB); and\
>      e. immediately after removing gloves (IB, IC)\
> 3. For oral surgical procedures, perform surgical hand antisepsis
> before donning sterile surgeon\'s gloves. Follow the manufacturer\'s
> instructions by using either an antimicrobial soap and water, or soap
> and water followed by drying hands and application of an alcohol-based
> surgical hand-scrub product with persistent activity (IB)
>
> 4\. Store liquid hand-care products in either disposable closed
> containers or closed containers that can be washed and dried before
> refilling. Do not add soap or lotion to (i.e., top off) a partially
> empty dispenser.

**B. Special Considerations for Hand Hygiene and Glove Use**

> 1\. Use hand lotions to prevent skin dryness associated with
> handwashing (IA).\
> 2. Consider the compatibility of lotion and antiseptic products and
> the effect of petroleum or other oil emollients on the integrity of
> gloves during product selection and glove use (IB)\
> 3. Keep fingernails short with smooth, filed edges to allow thorough
> cleaning and prevent glove tears (II)\
> 4. Do not wear artificial fingernails or extenders when having direct
> contact with patients at high risk (e.g., those in intensive care
> units or operating rooms) (IA)\
> 5. Use of artificial fingernails is usually not recommended (II)\
> 6. Do not wear hand or nail jewelry if it makes donning gloves more
> difficult or compromises the fit and integrity of the glove (II)

# 

Dental Department

Policy & Procedure Statement

**Subject:** Personal Protective Equipment (PPE) **Effective Date:**

**Supercedes:**

**P&P Number:**

**Purpose:**

To establish procedures for employees to obtain and use personal
protective equipment for performing assigned duties

**A. Masks, Protective Eyewear, and Face Shields**

> 1\. Wear a surgical mask and eye protection with solid side shields or
> a face shield to protect mucous membranes of the eyes, nose, and mouth
> during procedures likely to generate splashing or spattering of blood
> or other body fluids (IB, IC).\
> 2. Change masks between patients or during patient treatment if the
> mask becomes wet (IB).\
> 3. Clean with soap and water, or if visibly soiled, clean and
> disinfect reusable facial protective equipment (e.g., clinician and
> patient protective eyewear or face shields) between patients (II).

**B. Protective Clothing**

> 1\. Wear protective clothing (e.g., reusable or disposable gown,
> laboratory coat, or uniform) that covers personal clothing and skin
> (e.g., forearms) likely to be soiled with blood, saliva, or OPIM (IB,
> IC).\
> 2. Change protective clothing if visibly soiled; change immediately or
> as soon as feasible if penetrated by blood or other potentially
> infectious fluids (IB, IC).\
> 3. Remove barrier protection, including gloves, mask, eyewear, and
> gown before departing work area (e.g., dental patient care, instrument
> processing, or laboratory areas) (IC).

**C. Gloves**

> 1\. Wear medical gloves when a potential exists for contacting blood,
> saliva, OPIM, or mucous membranes (IB, IC).\
> 2. Wear a new pair of medical gloves for each patient, remove them
> promptly after use, and wash hands immediately to avoid transfer of
> microorganisms to other patients or environments (IB).\
> 3. Remove gloves that are torn, cut, or punctured as soon as feasible
> and wash hands before regloving (IB, IC).\
> 4. Do not wash surgeon\'s or patient examination gloves before use or
> wash, disinfect, or sterilize gloves for reuse (IB, IC).\
> 5. Ensure that appropriate gloves in the correct size are readily
> accessible (IC).\
> 6. Use appropriate gloves (e.g., puncture- and chemical-resistant
> utility gloves) when cleaning instruments and performing housekeeping
> tasks involving contact with blood or OPIM (IB, IC).\
> 7. Consult with glove manufacturers regarding the chemical
> compatibility of glove material and dental materials used (II).

**D. Sterile Surgeon\'s Gloves and Double Gloving During Oral Surgical
Procedures**

> 1\. Wear sterile surgeon\'s gloves when performing oral surgical
> procedures (IB).\
> *2. No recommendation is offered regarding the effectiveness of
> wearing two pairs of gloves to prevent disease transmission during
> oral surgical procedures. The majority of studies among HCP and DHCP
> have demonstrated a lower frequency of inner glove perforation and
> visible blood on the surgeon\'s hands when double gloves are worn;
> however, the effectiveness of wearing two pairs of gloves in
> preventing disease transmission has not been demonstrated (Unresolved
> issue).*

## *E. PPE Provided*

1.  **(Facility name**) will provide suitable gowns, eye protection,
    masks, gloves, hair covers, and shoe covers needed to provide dental
    treatment.

## *F. Protection for Patients*

1.  Patients will be provided safety glasses to be worn throughout
    dental treatment.

2.  When the introduction of minimal contaminants would compromise
    dental treatment, additional protection such as towel draped over
    the patient may be used.

Dental Department

Policy & Procedure Statement

**Subject:** Contact Dermatitis and Latex Sensitivity **Effective
Date:**

**Supercedes:**

**P&P Number:**

**Purpose:**

To establish procedures for detecting allergic contact dermatitis and
providing dental treatment to patients contact dermatitis

**Procedure:**

> 1\. Educate DHCP regarding the signs, symptoms, and diagnoses of skin
> reactions associated with frequent hand hygiene and glove use (IB)\
> 2. Screen all patients for latex allergy (e.g., take health history
> and refer for medical consultation when latex allergy is suspected)
> (IB)\
> 3. Ensure a latex-safe environment for patients and DHCP with latex
> allergy (IB)\
> 4. Have emergency treatment kits with latex-free products available at
> all times (II)

# 

Dental Department

Policy & Procedure Statement

**Subject:** Sterilization and Disinfection of Patient-Care Items
**Effective Date:**

**Supercedes:**

**P&P Number:**

**Purpose:**

To establish procedures of disinfection and sterilization of
patient-care items used during dental treatment.

**Definition:**

## Infection Control Categories of Patient-Care Instruments

  ----------------------- ----------------------- -----------------------
  Category                Definition              Dental Instrument or
                                                  Item

  Critical                Penetrates soft         Surgical instruments,
                          tissues, contacts bone, periodontal scalers,
                          enters into to contacts scalpel blades,
                          the blood stream or     surgical dental burs
                          other normally sterile  
                          tissue.                 

  Semicritical            Contacts mucous         Dental mouth mirror,
                          membranes or nonintact  amalgam condenser,
                          skin; will not          reusable dental
                          penetrate soft tissue,  impression trays,
                          contact bone, enter     dental handpieces
                          into or contact the     
                          bloodstream or other    
                          normally sterile        
                          tissue.                 

  Noncritical             Contacts intact skin    Radiograph head/cone,
                                                  blood pressure cuff,
                                                  facebow
  ----------------------- ----------------------- -----------------------

CDC, 2003, p. 20

## Levels of Sterilization and Disinfection

Sterilization (autoclave)- used for heat-tolerant critical and
semi-critical patient care items

High-level disinfection- liquid immersion

Intermediate-level disinfection- Liquid contact- EPA registered hospital
disinfectant with label claim of tuberculocidal activity (Chlorine
containing products - 1:100 dilution (1/4 cup of 5.25% household
chlorine bleach to 1 gallon of water)

Alternative products may be biocide or Lysol-IC for surfaces that may be
damaged by bleach products

Low level disinfection- liquid contact- EPA registered disinfectant with
no claim of tuberculocidal activity (soap and water, alcohol)

CDC, 2003, p. 66

**A. General Recommendations**

> 1\. Use only FDA-cleared medical devices for sterilization and follow
> the manufacturer\'s instructions for correct use (IB).\
> 2. Clean and heat-sterilize critical dental instruments before each
> use (IA).\
> 3. Clean and heat-sterilize semicritical items before each use (IB).\
> 4. Allow packages to dry in the sterilizer before they are handled to
> avoid contamination (IB).\
> 5. Use of heat-stable semicritical alternatives is encouraged (IB).\
> 6. Reprocess heat-sensitive critical and semi-critical instruments by
> using FDA-cleared sterilant/high-level disinfectants or an FDA-cleared
> low-temperature sterilization method (e.g., ethylene oxide). Follow
> manufacturer\'s instructions for use of chemical sterilants/high-level
> disinfectants (IB).\
> 7. Single-use disposable instruments are acceptable alternatives if
> they are used only once and disposed of correctly (IB, IC).\
> 8. Do not use liquid chemical sterilants/high-level disinfectants for
> environmental surface disinfection or as holding solutions (IB, IC).\
> 9. Ensure that if visibly contaminated with blood, use an
> EPA-registered hospital disinfectant with a tuberculocidal claim
> (i.e., intermediate level) (IB).\
> 10. Inform DHCP of all OSHA guidelines for exposure to chemical agents
> used for disinfection and sterilization. Using this report, identify
> areas and tasks that have potential for exposure (IC).

**B. Instrument Processing Area**

> 1\. Designate a central processing area. Divide the instrument
> processing area, physically or, at a minimum, spatially, into distinct
> areas for 1) receiving, cleaning, and decontamination; 2) preparation
> and packaging; 3) sterilization; and 4) storage. Do not store
> instruments in an area where contaminated instruments are held or
> cleaned (II).\
> 2. Train DHCP to employ work practices that prevent contamination of
> clean areas (II).

**C. Receiving, Cleaning, and Decontamination Work Area**

> 1\. Minimize handling of loose contaminated instruments during
> transport to the instrument processing area. Use work-practice
> controls (e.g., carry instruments in a covered container) to minimize
> exposure potential (II). Clean all visible blood and other
> contamination from dental instruments and devices before sterilization
> or disinfection procedures (IA).\
> 2. Use automated cleaning equipment (e.g., ultrasonic cleaner or
> washer-disinfector) to remove debris to improve cleaning effectiveness
> and decrease worker exposure to blood (IB).\
> 3. Use work-practice controls that minimize contact with sharp
> instruments if manual cleaning is necessary (e.g., long-handled brush)
> (IC).\
> 4. Wear puncture- and chemical-resistant/heavy-duty utility gloves for
> instrument cleaning and decontamination procedures (IB).\
> 5. Wear appropriate PPE (e.g., mask, protective eyewear, and gown)
> when splashing or spraying is anticipated during cleaning (IC).

**D. Preparation and Packaging**

> 1\. Use an internal chemical indicator in each package. If the
> internal indicator cannot be seen from outside the package, also use
> an external indicator (II) .
>
> 2\. Use a container system or wrapping compatible with the type of
> sterilization process used and that has received FDA clearance (IB).
>
> 3\. Before sterilization of critical and semicritical instruments,
> inspect instruments for cleanliness, then wrap or place them in
> containers designed to maintain sterility during storage (e.g.,
> cassettes and organizing trays) (IA).

**E. Sterilization of Unwrapped Instruments**

> 1\. Clean and dry instruments before the unwrapped sterilization cycle
> (IB).\
> 2. Use mechanical and chemical indicators for each unwrapped
> sterilization cycle (i.e., place an internal chemical indicator among
> the instruments or items to be sterilized) (IB).\
> 3. Allow unwrapped instruments to dry and cool in the sterilizer
> before they are handled to avoid contamination and thermal injury
> (II).\
> 4. Semicritical instruments that will be used immediately or within a
> short time can be sterilized unwrapped on a tray or in a container
> system, provided that the instruments are handled aseptically during
> removal from the sterilizer and transport to the point of use (II).\
> 5. Critical instruments intended for immediate reuse can be sterilized
> unwrapped if the instruments are maintained sterile during removal
> from the sterilizer and transport to the point of use (e.g.,
> transported in a sterile covered container) (IB).\
> 6. Do not sterilize implantable devices unwrapped (IB).\
> 7. Do not store critical instruments unwrapped (IB).

**F. Sterilization Monitoring**

> 1\. Use mechanical, chemical, and biological monitors according to the
> manufacturer\'s instructions to ensure the effectiveness of the
> sterilization process (IB).\
> 2. Monitor each load with mechanical (e.g., time, temperature, and
> pressure) and chemical indicators (II).\
> 3. Place a chemical indicator on the inside of each package. If the
> internal indicator is not visible from the outside, also place an
> exterior chemical indicator on the package (II).\
> 4. Place items/packages correctly and loosely into the sterilizer so
> as not to impede penetration of the sterilant (IB).\
> 5. Do not use instrument packs if mechanical or chemical indicators
> indicate inadequate processing (IB).\
> 6. Monitor sterilizers at least weekly by using a biological indicator
> with a matching control (i.e., biological indicator and control from
> same lot number) (IB).\
> 7. Use a biological indicator for every sterilizer load that contains
> an implantable device. Verify results before using the implantable
> device, whenever possible (IB).\
> 8. The following are recommended in the case of a positive spore test:
>
> a\. Remove the sterilizer from service and review sterilization
> procedures (e.g., work practices and use of mechanical and chemical
> indicators) to determine whether operator error could be responsible
> (II).\
> b. Retest the sterilizer by using biological, mechanical, and chemical
> indicators after correcting any identified procedural problems (II).\
> c. If the repeat spore test is negative, and mechanical and chemical
> indicators are within normal limits, put the sterilizer back in
> service (II).

9\. The following are recommended if the repeat spore test is positive:

> a\. Do not use the sterilizer until it has been inspected or repaired
> or the exact reason for the positive test has been determined (II).\
> b. Recall, to the extent possible, and reprocess all items processed
> since the last negative spore test (II).\
> c. Before placing the sterilizer back in service, rechallenge the
> sterilizer with biological indicator tests in three consecutive empty
> chamber sterilization cycles after the cause of the sterilizer failure
> has been determined and corrected (II) .
>
> 10\. Maintain sterilization records (i.e., mechanical, chemical, and
> biological) in compliance with state and local regulations (IB) .

**G. Storage Area for Sterilized Items and Clean Dental Supplies**

> 1\. Implement practices on the basis of date- or event-related
> shelf-life for storage of wrapped, sterilized instruments and devices
> (IB).\
> 2. Even for event-related packaging, at a minimum, place the date of
> sterilization, and if multiple sterilizers are used in the facility,
> the sterilizer used, on the outside of the packaging material to
> facilitate the retrieval of processed items in the event of a
> sterilization failure (IB).\
> 3. Examine wrapped packages of sterilized instruments before opening
> them to ensure the barrier wrap has not been compromised during
> storage (II).\
> 4. Reclean, repack, and resterilize any instrument package that has
> been compromised (II).\
> 5. Store sterile items and dental supplies in covered or closed
> cabinets, if possible (II).

# 

Dental Department

Policy & Procedure Statement

**Subject:** Environmental Infection Control **Effective Date:**

**Supercedes:**

**P&P Number:**

**Purpose:**

To establish procedures for environmental infection control consistent
with CDC recommendations.

**Procedure:**

**A. General Recommendations**

> 1\. Follow the manufacturers\' instructions for correct use of
> cleaning and EPA-registered hospital disinfecting products (IB, IC).\
> 2. Do not use liquid chemical sterilants/high-level disinfectants for
> disinfection of environmental surfaces (clinical contact or
> housekeeping) (IB, IC).\
> 3. Use PPE, as appropriate, when cleaning and disinfecting
> environmental surfaces. Such equipment might include gloves (e.g.,
> puncture- and chemical-resistant utility), protective clothing (e.g.,
> gown, jacket, or lab coat), and protective eyewear/face shield, and
> mask (IC).

**B. Clinical Contact Surfaces**

> 1\. Use surface barriers to protect clinical contact surfaces,
> particularly those that are difficult to clean (e.g., switches on
> dental chairs) and change surface barriers between patients (II).\
> 2. Clean and disinfect clinical contact surfaces that are not
> barrier-protected, by using an EPA-registered hospital disinfectant
> with a low- (i.e., HIV and HBV label claims) to intermediate-level
> (i.e., tuberculocidal claim) activity after each patient. Use an
> intermediate-level disinfectant if visibly contaminated with blood
> (IB).

**C. Housekeeping Surfaces**

> 1\. Clean housekeeping surfaces (e.g., floors, walls, and sinks) with
> a detergent and water or an EPA-registered hospital
> disinfectant/detergent on a routine basis, depending on the nature of
> the surface and type and degree of contamination, and as appropriate,
> based on the location in the facility, and when visibly soiled (IB).\
> 2. Clean mops and cloths after use and allow to dry before reuse; or
> use single-use, disposable mop heads or cloths (II).\
> 3. Prepare fresh cleaning or EPA-registered disinfecting solutions
> daily and as instructed by the manufacturer. (II).\
> 4. Clean walls, blinds, and window curtains in patient-care areas when
> they are visibly dusty or soiled (II).

**D. Spills of Blood and Body Substances**

> 1\. Clean spills of blood or OPIM and decontaminate surface with an
> EPA-registered hospital disinfectant with low- (i.e., HBV and HIV
> label claims) to intermediate-level (i.e., tuberculocidal claim)
> activity, depending on size of spill and surface porosity (IB, IC).

**E. Carpet and Cloth Furnishings**

> 1\. Avoid using carpeting and cloth-upholstered furnishings in dental
> operatories, laboratories, and instrument processing areas (II).

**F. Regulated Medical Waste**

1\. General Recommendations

> a\. Develop a medical waste management program. Disposal of regulated
> medical waste must follow federal, state, and local regulations (IC).\
> b. Ensure that DHCP who handle and dispose of regulated medical waste
> are trained in appropriate handling and disposal methods and informed
> of the possible health and safety hazards (IC).

2\. Management of Regulated Medical Waste in Dental Health-Care
Facilities

> a\. Use a color-coded or labeled container that prevents leakage
> (e.g., biohazard bag) to contain nonsharp regulated medical waste
> (IC).\
> b. Place sharp items (e.g., needles, scalpel blades, orthodontic
> bands, broken metal instruments, and burs) in an appropriate sharps
> container (e.g., puncture resistant, color-coded, and leakproof).
> Close container immediately before removal or replacement to prevent
> spillage or protrusion of contents during handling, storage,
> transport, or shipping (IC).\
> c. Pour blood, suctioned fluids or other liquid waste carefully into a
> drain connected to a sanitary sewer system, if local sewage discharge
> requirements are met and the state has declared this an acceptable
> method of disposal. Wear appropriate PPE while performing this task
> (IC).

# 

Dental Department

Policy & Procedure Statement

**Subject:** Dental Waterlines **Effective Date:**

Biofilm **Supercedes:**

Water Quality

**P&P Number:**

**Purpose:**

To establish procedures to disinfect waterlines to prevent biofilm and
protect water quality used during dental procedures

Procedure:

**A. General Recommendations**

> 1\. Use water that meets EPA regulatory standards for drinking water
> (i.e., [\<]{.underline}500 CFU/mL of heterotrophic water bacteria) for
> routine dental treatment output water (IB, IC).\
> 2*. Consult with the dental unit manufacturer for appropriate methods
> and equipment to maintain the recommended quality of dental water
> (II).*\
> *3. Follow recommendations for monitoring water quality provided by
> the manufacturer of the unit or waterline treatment product (II).\
> *4. Discharge water and air for a minimum of 20\--30 seconds after
> each patient, from any device connected to the dental water system
> that enters the patient\'s mouth (e.g., handpieces, ultrasonic
> scalers, and air/water syringes) (II).\
> *5. Consult with the dental unit manufacturer on the need for periodic
> maintenance of antiretraction mechanisms (IB).*

**B. Boil-Water Advisories**

1\. The following apply while a boil-water advisory is in effect:

> a\. Do not deliver water from the public water system to the patient
> through the dental operative unit, ultrasonic scaler, or other dental
> equipment that uses the public water system (IB, IC).\
> b. Do not use water from the public water system for dental treatment,
> patient rinsing, or handwashing (IB, IC).\
> c. For handwashing, use antimicrobial-containing products that do not
> require water for use (e.g., alcohol-based hand rubs). If hands are
> visibly contaminated, use bottled water, if available, and soap for
> handwashing or an antiseptic towelette (IB, IC).

2\. The following apply when the boil-water advisory is cancelled:

> a\. Follow guidance given by the local water utility regarding
> adequate flushing of waterlines. If no guidance is provided, flush
> dental waterlines and faucets for 1\--5 minutes before using for
> patient care (IC).\
> b. Disinfect dental waterlines as recommended by the dental unit
> manufacturer (II).

# 

Dental Department

Policy & Procedure Statement

**Subject:** Special Considerations **Effective Date:**

**Supercedes:**

**P&P Number:**

**Purpose:**

To establish aseptic procedures for other dental office procedure and
special considerations

**Procedure:**

**A. Dental Handpieces and Other Devices Attached to Air and
Waterlines**

> 1\. Clean and heat-sterilize handpieces and other intraoral
> instruments that can be removed from the air and waterlines of dental
> units between patients (IB, IC).\
> 2. Follow the manufacturer\'s instructions for cleaning, lubrication,
> and sterilization of handpieces and other intraoral instruments that
> can be removed from the air and waterlines of dental units (IB).\
> 3. Do not surface-disinfect, use liquid chemical sterilants, or
> ethylene oxide on handpieces and other intraoral instruments that can
> be removed from the air and waterlines of dental units (IC).\
> 4. Do not advise patients to close their lips tightly around the tip
> of the saliva ejector to evacuate oral fluids (II).

**B. Dental Radiology**

> 1\. Wear gloves when exposing radiographs and handling contaminated
> film packets. Use other PPE (e.g., protective eyewear, mask, and gown)
> as appropriate if spattering of blood or other body fluids is likely
> (IA, IC).\
> 2. Use heat-tolerant or disposable intraoral devices whenever possible
> (e.g., film-holding and positioning devices). Clean and heat-sterilize
> heat-tolerant devices between patients. At a minimum, high-level
> disinfect semicritical heat-sensitive devices, according to
> manufacturer\'s instructions (IB).\
> 3. Transport and handle exposed radiographs in an aseptic manner to
> prevent contamination of developing equipment (II).\
> 4. The following apply for digital radiography sensors:
>
> a\. Use FDA-cleared barriers (IB).\
> b. Clean and heat-sterilize, or high-level disinfect, between
> patients, barrier-protected semicritical items. If the item cannot
> tolerate these procedures then, at a minimum, protect with an
> FDA-cleared barrier and clean and disinfect with an EPA-registered
> hospital disinfectant with intermediate-level (i.e., tuberculocidal
> claim) activity, between patients. Consult with the manufacturer for
> methods of disinfection and sterilization of digital radiology sensors
> and for protection of associated computer hardware (IB).

**C. Aseptic Technique for Parenteral Medications**

> 1\. Do not administer medication from a syringe to multiple patients,
> even if the needle on the syringe is changed (IA). 2. Use single-dose
> vials for parenteral medications when possible (II).\
> 3. Do not combine the leftover contents of single-use vials for later
> use (IA).\
> 4. The following apply if multidose vials are used:
>
> a\. Cleanse the access diaphragm with 70% alcohol before inserting a
> device into the vial (IA).\
> b. Use a sterile device to access a multiple-dose vial and avoid
> touching the access diaphragm. Both the needle and syringe used to
> access the multidose vial should be sterile. Do not reuse a syringe
> even if the needle is changed (IA).\
> c. Keep multidose vials away from the immediate patient treatment area
> to prevent inadvertent contamination by spray or spatter (II).\
> d. Discard the multidose vial if sterility is compromised (IA).
>
> 5\. Use fluid infusion and administration sets (i.e., IV bags, tubings
> and connections) for one patient only and dispose of appropriately
> (IB).

**D. Single-Use (Disposable) Devices**

> 1\. Use single-use devices for one patient only and dispose of them
> appropriately (IC).

**E. Preprocedural Mouth Rinses**

> *1. No recommendation is offered regarding use of preprocedural
> antimicrobial mouth rinses to prevent clinical infections among DHCP
> or patients. Although studies have demonstrated that a preprocedural
> antimicrobial rinse (e.g., chlorhexidine gluconate, essential oils, or
> povidone-iodine) can reduce the level of oral microorganisms in
> aerosols and spatter generated during routine dental procedures and
> can decrease the number of microorganisms introduced in the patient\'s
> bloodstream during invasive dental procedures, the scientific evidence
> is inconclusive that using these rinses prevents clinical infections
> among DHCP or patients (see discussion, Preprocedural Mouth Rinses)
> (Unresolved issue).*

**F. Oral Surgical Procedures**

1\. The following apply when performing oral surgical procedures:

> a\. Perform surgical hand antisepsis by using an antimicrobial product
> (e.g., antimicrobial soap and water, or soap and water followed by
> alcohol-based hand scrub with persistent activity) before donning
> sterile surgeon\'s gloves (IB).
>
> b\. Use sterile surgeon\'s gloves (IB).\
> c. Use sterile saline or sterile water as a coolant/irrigatant when
> performing oral surgical procedures. Use devices specifically designed
> for delivering sterile irrigating fluids (e.g., bulb syringe,
> single-use disposable products, and sterilizable tubing) (IB).

**G. Handling of Biopsy Specimens**

> 1\. During transport, place biopsy specimens in a sturdy, leakproof
> container labeled with the biohazard symbol (IC).\
> 2. If a biopsy specimen container is visibly contaminated, clean and
> disinfect the outside of a container or place it in an impervious bag
> labeled with the biohazard symbol, (IC).

**H. Handling of Extracted Teeth**

> *1. Dispose of extracted teeth as regulated medical waste unless
> returned to the patient (IC).\
> *2. Do not dispose of extracted teeth containing amalgam in regulated
> medical waste intended for incineration (II).\
> 3. Clean and place extracted teeth in a leakproof container, labeled
> with a biohazard symbol, and maintain hydration for transport to
> educational institutions or a dental laboratory (IC).\
> 4. Heat-sterilize teeth that do not contain amalgam before they are
> used for educational purposes (IB).

**I. Dental Laboratory**

> 1\. Use PPE when handling items received in the laboratory until they
> have been decontaminated (IA, IC)
>
> 2\. Before they are handled in the laboratory, clean, disinfect, and
> rinse all dental prostheses and prosthodontic materials (e.g.,
> impressions, bite registrations, occlusal rims, and extracted teeth)
> by using an EPA-registered hospital disinfectant having at least an
> intermediate-level (i.e., tuberculocidal claim) activity (IB).\
> 3. Consult with manufacturers regarding the stability of specific
> materials (e.g., impression materials) relative to disinfection
> procedures (II).\
> 4. Include specific information regarding disinfection techniques used
> (e.g., solution used and duration), when laboratory cases are sent
> off-site and on their return (II).\
> 5. Clean and heat-sterilize heat-tolerant items used in the mouth
> (e.g., metal impression trays and face-bow forks) (IB).\
> *6. Follow manufacturers\' instructions for cleaning and sterilizing
> or disinfecting items that become contaminated but do not normally
> contact the patient (e.g., burs, polishing points, rag wheels,
> articulators, case pans, and lathes). If manufacturer instructions are
> unavailable, clean and heat-sterilize heat-tolerant items or clean and
> disinfect with an EPA-registered hospital disinfectant with low- (HIV,
> HBV effectiveness claim) to intermediate-level (tuberculocidal claim)
> activity, depending on the degree of contamination (II).*

**J. Laser/Electrosurgery Plumes/Surgical Smoke**

> *1. No recommendation is offered regarding practices to reduce DHCP
> exposure to laser plumes/surgical smoke when using lasers in dental
> practice. Practices to reduce HCP exposure to laser plumes/surgical
> smoke have been suggested, including use of a) standard precautions
> (e.g., high-filtration surgical masks and possibly full face shields)
> (437); b) central room suction units with in-line filters to collect
> particulate matter from minimal plumes; and c) dedicated mechanical
> smoke exhaust systems with a high-efficiency filter to remove
> substantial amounts of laser-plume particles. The effect of the
> exposure (e.g., disease transmission or adverse respiratory effects)
> on DHCP from dental applications of lasers has not been adequately
> evaluated (see previous discussion, Laser/Electrosurgery Plumes or
> Surgical Smoke) (Unresolved issue).*

**K. *Mycobacterium tuberculosis***

1\. General Recommendations

> a\. Educate all DHCP regarding the recognition of signs, symptoms, and
> transmission of TB (IB).\
> b. Conduct a baseline TST, preferably by using a two-step test, for
> all DHCP who might have contact with persons with suspected or
> confirmed active TB, regardless of the risk classification of the
> setting (IB).\
> c. Assess each patient for a history of TB as well as symptoms
> indicative of TB and document on the medical history form (IB).\
> d. Follow CDC recommendations for 1) developing, maintaining, and
> implementing a written TB infection-control plan; 2) managing a
> patient with suspected or active TB; 3) completing a community
> risk-assessment to guide employee TSTs and follow-up; and 4) managing
> DHCP with TB disease (IB).

2\. The following apply for patients known or suspected to have active
TB:

> a\. Evaluate the patient away from other patients and DHCP. When not
> being evaluated, the patient should wear a surgical mask or be
> instructed to cover mouth and nose when coughing or sneezing (IB).\
> b. Defer elective dental treatment until the patient is noninfectious
> (IB).\
> c. Refer patients requiring urgent dental treatment to a previously
> identified facility with TB engineering controls and a respiratory
> protection program (IB).

**L. Creutzfeldt-Jakob Disease (CJD) and Other Prion Diseases**

> *1. No recommendation is offered regarding use of special precautions
> in addition to standard precautions when treating known CJD or vCJD
> patients. Potential infectivity of oral tissues in CJD or vCJD
> patients is an unresolved issue. Scientific data indicate the risk, if
> any, of sporadic CJD transmission during dental and oral surgical
> procedures is low to nil. Until additional information exists
> regarding the transmissibility of CJD or vCJD during dental
> procedures, special precautions in addition to standard precautions
> might be indicated when treating known CJD or vCJD patients; a list of
> such precautions is provided for consideration without recommendation
> (see Creutzfeldt-Jakob Disease and Other Prion Diseases) (Unresolved
> issue).*

# 

Dental Department

Policy & Procedure Statement

**Subject:** Infection Control Program Evaluation **Effective Date:**

**Supercedes:**

**P&P Number:**

**Purpose:**

To monitor quality infection control program to ensure compliance with
service unit infection control policies

**Procedure:**

1.  Establish routine evaluation of the infection-control program,
    including evaluation of performance indicators, at an established
    frequency (II).

Monitoring Tool is Included in Chapter 7 of the OHPG

**Latex Hypersensitivity**

**Background**.

*Latex Sensitivity*

Latex sensitivity is becoming a significant problem for patients and
health care workers. In the past two decades infection control concerns
have led to a large increase in the use of latex gloves and other latex
products among healthcare workers. This has not been without some side
effects. The elevated incidence of latex hypersensitivity and dermal
problems among healthcare workers has been directly linked to an
increase to latex product usage.

*Sources of Natural Rubber Latex*

Latex products are manufactured from the milky fluid of the rubber tree,
Hevea brasiliensis. Several chemicals are added to this fluid during the
processing and manufacturing of commercial latex. Some of the proteins
in latex can cause a range of mild to severe allergic reactions. There
are no current methods to measure and consistently identify the
allergy-causing proteins (allergens). The chemicals added during
processing may also cause skin rashes associated with latex allergy.
Several types of synthetic rubber are also referred to as "latex", but
these do not release the proteins that cause the allergic reactions.

A wide variety of products contain latex: medical supplies, personal
protective equipment, and numerous household objects. Most people who
encounter latex products only through their general use in life have no
health problems from the use of these products. Healthcare workers who
repeatedly use latex products are more susceptible to developing some
kind of hypersensitivity to latex. The following are common examples of
latex containing products:

Emergency Medical Equipment:

-   blood pressure cuffs,

-   stethoscopes,

-   disposable gloves,

-   tourniquets,

-   intravenous tubing,

-   syringes, and

-   electrode pads.

Personal Protective Equipment:

-   gloves,

-   surgical masks,

-   goggles,

-   respirators, and

-   rubber aprons.

Office Supplies:

-   rubber bands and

-   erasers.

Hospital Supplies:

-   anesthetic mask,

-   catheters,

-   wound drains,

-   injection ports,

-   rubber tops of vials,

-   dental dams.

Household Objects:

-   automobile tires,

-   motorcycle and bicycle handgrips,

-   carpeting, swimming goggles,

-   shoe soles,

-   expandable fabrics (waistbands),

-   hot water bottles,

-   condoms,

-   balloons,

-   pacifiers.

*How prevalent is latex allergy?*

The prevalence of latex allergy has been studied by several methods:

-   Questionnaires to assess reaction to latex gloves.

-   Medical histories of reactions to latex containing products.

-   Skin test.

-   Test for latex antibodies in a worker's blood.

Reports about the prevalence of latex allergy vary greatly, mostly due
to the different levels of exposure and methods for measuring latex
sensitization or allergy. The scientific literature indicates that from
1% to 6% of the general population and about 8% to 12% of regularly
exposed heath care workers are sensitized to latex allergy (*Kelly et
al. 1996; Katelaris et al. 1996; Liss et al. 1997; Ownby et al. 1996;
Sussman and Beezhold 1995*).

Several reasons may exist for the large number of latex allergies
recently reported in workers (*Truscott 1995*):

-   Workers rely increasingly on latex gloves to prevent transmission of
    infectious agents.

-   Since 1992, the Occupational Safety and Health Administration (OSHA)
    has required employers to provide gloves and other protective
    measures for their employees (*29 CFR 1910.1030, Blood Borne
    Pathogens*).

-   Some manufacturers may produce more allergenic gloves because of
    changes in raw materials, processing, or manufacturing procedures to
    meet the increased demand for latex gloves (*Hunt et al. 1995*).
    Variations might be present between lots produced by same
    manufacturer.

-   Physicians are more familiar with latex allergy and have improved
    methods for diagnosing.

Workers in the healthcare industry (physicians, nurses, dentist,
technicians, etc.) are at risk of developing latex allergy because they
use latex gloves frequently.

*Levels and routes of exposure*

Studies of other allergy-causing substances provide evidence that the
higher the overall exposure in the population, the greater the
likelihood that more individuals will be come sensitized (*Venables and
Chan-Yeung 1997*). The amount of latex exposure needed to produce
sensitization or an allergic reaction is unknown; however, reductions in
exposure to latex proteins have been reported to be associated with
decreased sensitization and symptoms (*Tarlo et al. 1994; Hunt et al.
1996*).

The proteins responsible for latex allergies have been shown to fasten
to powder that is used on some latex gloves. When powdered gloves are
worn, more latex protein reaches the skin. Also, when gloves are
changed, latex protein/powder particles get into the air, where they can
be inhaled and contact other body membranes (*Heilman et al. 1994*). In
contrast, work areas using only powder-free gloves show low levels or
undetected amounts of allergens (*Tarlo 1994; Swanson et al. 1994*).

When employees wear latex gloves during episodes of hand dermatitis, the
risk that the skin exposed to the latex proteins will develop an
allergic response to latex is increased. A skin rash may be the first
sign of allergic reaction to latex; more serious reactions could occur
with each subsequent exposure to the latex protein (*Kelly et al.
1996*).

*Who else is at risk?*

Other persons at high risk of sensitization include the following broad
categories:

-   Persons with cumulatively prolonged exposure to latex. Examples
    include those who have undergone repeated surgeries, particularly
    early in life:

    -   myelomeningocele (spina bifida)

    -   urogenital abnormalities

Prevalence of latex allergy among these people may be greater than 60
percent.

-   Persons with history of atopy

-   Persons with history of food allergy, especially:

    -   banana,

    -   avocado,

    -   passion fruit,

    -   chestnut,

    -   kiwi fruit,

    -   melon,

    -   tomato and

    -   celery.

**Latex-Associated Allergies And Conditions**

*Irritant Contact Dermatitis:*

Often mistaken for an allergic response, irritant contact dermatitis is
manifested as a sharp, defined reaction confined to the area of glove
contact. Caused by insufficient hand rinsing or drying, glove powder,
exposure to disinfectants or contact with preservatives such as
formaldehyde, this condition stems from direct physical or chemical
injury to skin cells, rather than an immunologic response. Because of
the occlusal barrier, extended glove use deprives the skin of air and
leaves cells fragile and susceptible to injury. Improper handwashing
techniques coupled with the warm, moist environment that gloving
provides, allows excessive bacterial multiplication, which can cause
irritation. Glove powder, added by the manufacturer to prevent sticking
and to facilitate glove donning, can initiate or exacerbate irritant
reactions.

Refining the handwashing technique (washing, rinsing, and drying) may
resolve irritant contact dermatitis, although refraining from gloving;
and thereby refraining from direct patient care, until the condition
resolves is recommended.

*Delayed (Type IV) Hypersensitivity:*

Type IV allergy, also referred to as delayed hypersensitivity, is
triggered by contact with sensitizing chemicals, including the
accelerators and preservatives employed in the glove manufacturing
process. In hypersensitive individuals, delayed reactions develop within
four to 72 hours of exposure and peak in 24 to 48 hours. Often mistaken
for irritant contact dermatitis, this chronic, slow forming reaction
manifests as dry, cracked, pruritic skin with inflammation and
blistering in the acute phase. Frequently, it appears first on the back
of the hands and between the fingers, where the skin is thin. When
subsequent exposure to allergen(s) is avoided, the condition may resolve
within four to 30 days. If exposure continues, however, chronic,
slower-to-resolve conditions may result.

*Immediate (Type I) Hypersensitivity*:

An immunologic response triggered by the proteins in natural rubber
latex (NRL), Type I (immediate) latex allergy manifests within minutes
of dermal or mucosal contact with latex. Reactions are more acute and,
in some cases, may require emergency medical procedures. Early symptoms
include itching and tingling at the contact site, and may be followed by
hives. In other cases, respiratory symptoms such as runny nose,
sneezing, itchy eyes, scratchy throat, and asthma may result; further
systemic involvement may include facial swelling, conjunctivitis,
nausea, abdominal cramps, bronchospasm, hypotension, and tachycardia. In
extreme cases, exposure to NRL can bring anaphylaxis and death.

Although recognized as less severe than Type I allergy, both irritant
and Type IV allergic contact dermatitis compromise the integrity of the
skin. By allowing sensitizing NRL proteins access to the body via skin
breaks, the risk of progression to Type I allergy may be dramatically
increased. Therefore, either condition should be fully resolved before
glove use is resumed.

Because there are currently no means to correlate the degree of exposure
with the severity of the allergic reaction (i.e., mild versus severe),
Type I latex-allergic individuals should avoid all contact with latex.

**Recommendations**

-   The use of latex gloves and rubber dams should be discontinued

-   Identify all latex containing products in the dental clinic. Be
    aware that latex may be found in unlikely places such as the rubber
    stoppers and membranes in anesthetic carpules

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-   Contact vendors for latex product substitutes.

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-   A clean, closed operatory should be used whenever a latex-sensitive
    patient is treated to help reduce the exposure to airborne latex
    particles. All surfaces in the operatory must be wiped to minimize
    airborne latex particles. These surfaces should be covered to
    prevent further contamination.

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-   Treatment of a known latex-allergic patient should be performed
    first thing in the morning. This will allow for reduced exposure of
    the patient to airborne latex particles. It also allows the dental
    team to set-up appropriately.

-   The dental team should be ready to provide emergent treatment in the
    event of an immediate (Type I) hypersensitive reaction, including
    the management and treatment of an anaphylactic episode.

-   A complete medical history must be evaluated. Medical history forms
    should be revised to include questions about latex allergies and
    food allergies.

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-   All employees must be educated in the signs and symptoms of latex
    sensitivity.

-   All employees must immediately report signs or symptoms of allergic
    reactions to latex to their supervisor. Supervisors must in turn
    have the employee seek medical attention, per the local Employee
    Health Program, for evaluation and treatment.

-   If the incident is job related the employee must fill out the
    appropriate forms on the *WebCident* intranet website:

-   Under the Americans with Disabilities Act, if an employee is
    determined to be latex allergic, the employer, must provide for
    reasonable accommodation for the affected employee, such as
    providing a latex powder-free environment or providing for special
    assignments or retraining.

**References**

Adams, RM, MD. Job descriptions with their irritants and allergens:
Dental Personnel. Occupational Skin Disease, 3rd Ed., pp. 662-665.

Alaska Native Medical Center. Latex Policy, Circular NO. ANMC 97-165.
Alaska Native Medical Center, 4315 Diplomacy Drive, Anchorage, AK 99508.

Association of Operating Room Nurses. Standards, Recommended Practices,
and Guidelines. Copyright 2000. Editor: Deb Reno. AORN Inc., 2170 South
Parker Road, Suite 300, Denver, CO 80231-5711 (800) 755-2676.

Ciacco Palatianos, K, MD, MPH. Latex Allergy and Dentistry. Occupational
Medicine and Risk Management Consultant, Indian Health Services.

Gallup Indian Medical Center. Latex policy and Employee Health:
Prevention and Control of Latex Allergy. Gallup Indian Medical Center,
PO Box 1337, Gallup, NM 87305-1337.

Guin, JD, MD; Hamann, C, MD; Sullivan, KM. Natural and Synthetic Rubber.
Occupational Skin Disease, 3rd Ed., Ch. 29, pp. 501-551.

Hanifin, JM, MD. Atopy and atopic dermatitis. Occupational Skin Disease,
3rd Ed., Ch. 13, pp. 209-220.

Heilman, DK; Jones, RT; Swanson, MC; Yunginger, YW \[1996\]. A
prospective, controlled study showing that rubber gloves are the major
contributor to latex aeroallergen levels in the operating room. J
Allergy Clin Immunol 98(2):325-330.

Hunt, LW; Fransway, AF; Reed, CE; Miller, LK; Jones, RT; Swanson, MC; et
al. \[1995\]. An epidemic of occupational allergy to latex involving
health care workers. JOEM 37(10):1204-1209.

Hunt, LW; Boone-Orke, JL; Fransway, AF; Fremstad, CE; Jones, RT;
Swanson, MC; et al. \[1996\]. A medical-center-wide, multidisciplinary
approach to the problem of natural rubber latex allergy. JOEM
38(8):765-770.

Katelaris, CH; Widmer, RP; Lazarus, Rm. \[1996\]. Prevalence of latex
allergy in a dental school. Med J Australia 164:711-714.

Kelly, KJ; Krup, VP; Reijula, KR; Fink, JN \[1994\]. The diagnosis of
natural rubber latex allergy. J Allergy Clin Immunol 93(5):813-816.

Kelly, KJ; Sussman, G; Fink, JN. \[1996\]. Stop the sensitization. J
Allergy Clin Immunol 98(5):857-858.

Liss, GM; Sussman, GL; Deal, K; Brown, s; Cividino, M; Siu, S; et al.
\[1997\]. Latex allergy:epidemiological study of hospital workers. Occup
Environ Med 54:335-342.

Muller, BA, MD; Steelman, VM, PhD, RN; Hartley, PG, MB; Casale, TB, MD.
An approach to managing latex allergy in the health care worker.
Environmental Health. July-August 1998, pp. 8-16.

National Institute for Occupational Safety and Health. NIOSH Alert:
Preventing Allergic Reactions to Natural Rubber Latex in the workplace.
DHHS, NIOSH, Publication No. 97-135.

National Institute for Occupational Safety and Health. NIOSH Alert:
Preventing Allergic Reactions to Natural Rubber Latex in the workplace.
DHHS, NIOSH, Publication No. 98-113.

Office Safety and Asepsis Procedures. Latex-associated allergies and
conditions. Focus #4, 1998, pp. 1-9.

Ownby, DR; Ownby, HE; McCullough, J; Shafer, AW \[1996\]. The prevalence
of anti-latex IgE antibodies in 1000 volunteer blood donors. J Allergy
Clin Immunol 97(6):1188-1192.

Organization for Safety and Asepsis Procedures. Hand care and the
Healthcare worker. Focus #2, 1999, pp. 1-6.

Reddy, Sumana, MD. Latex Allergy. American Academy of Family Physicians.
January 1998. <http://www.aafp.org/afp/980101ap/reddy.html>

Sussman, GL; Beezhold, DH \[1995\]. Allergy to latex rubber. Ann Intern
Med 122:43-46.

Swanson, MC; Bubak, ME; Hunt, LW; Yunginger, JW; Warner, MA; Reed, CE
\[1994\]. Quantification of occupational latex aeroallergens in a
medical center. J Allergy Clin Immunol 94(3):445-551.

Tarlo, SM; Sussman, GL; Contala, A; Swanson, MC \[1994\]. Control of
airborne latex by use or powder-free latex gloves. J Allergy Clin
Immunol 93:985-989.

Truscott, W \[1995\]. Abstracts:new proposals for the increased evidence
of immediate type hypersensitivity to latex. J Allergy Clin Immunol
95(1, Part 2):252.

Venables, K; Chan-Yeung, M \[1997\]. Occupational asthma. The Lancet
349:1465-1469.

**ADDITIONAL RESOURCES**

Alternative Resources Catalog

1-800-618-3129

1-412-486-4476

American Academy of Endodontists

211 East Chicago Avenue, Suite 1100

Chicago, IL 60611-2691

-   Position Paper to the membership: Natural Rubber Latex Allergy

> <http://www.aae.org/NR/rdonlyres/FE9A6996-BD3F-4495-A13E-6CDDE2A836DE/0/Latexmember.pdf>

-   Natural Rubber Latex Allergy: Patient Fact Sheet

> <http://www.aae.org/NR/rdonlyres/0DD8A80E-7F3D-4A97-97A2-1B9519D335E2/0/Latexpatient.pdf>

American Latex Allergy Association: A.L.E.R.T., Inc.

P.O. Box 13930

Milwaukee, WI 53213-0930

Toll-Free: 1-888-97ALERT (972-5378)

Fax: 1-414-677-2808

<http://www.latexallergyresources.org/>

Latex Free Dental Product List

Latex Free Crash Cart List

Latex Free Hospital Product List

Allergic Cross-Reactivity of Latex and Foods

Sources for latex allergy information and non-latex gloves:

[http://www.latex-allergy.org](http://www.latex-allergy.org/)

Johnson & Johnson -- Medical

"The Rational Approach to Latex Allergy" by Terri Goodman, PhD(c), RN

Distributed by:

ProForma Order number 9906-B

501 Duncan Road

Arlington, TX 76011

800-658-5650

Latex Allergy Information Service

1-860-482-6869

Office of Occupational Safety and Health (00s1)

Department of Veteran Affairs

810 Vermont Avenue, NW

Washington, DC 20420

-   Latex Policy, VA Directive 7701, "Latex Sensitivity/Allergy"

<http://www1.va.gov/vasafety/page.cfm?pg=242>

-   Latex Allergy Prevention

> <http://www1.va.gov/vasafety/page.cfm?pg=114>

NIOSH

-   Latex Allergy Prevention

<http://www.cdc.gov/niosh/98-113.html> and

<http://www.cdc.gov/niosh/topics/latex/>

Spina Bifida American Association

4590 MacArthur Blvd., NW, Suite 250

Washington, DC 20007-3285

Toll-Free: 1-800-621-3141

Fax: 1-202-944-3295

-   <http://www.sbaa.org/>

-   <http://www.sbaa.org/site/PageServer?pagename=fs_latex>

Journal of Contemporary Dental Practice, \"Adverse Reactions to Latex
Products:  Preventive and Therapeutic Strategies\"

-   <http://www.thejcdp.com/issue025/huber/01huber.htm>

**Ergonomics Recommendations For Dental Programs**

Much of the information contained in this document has been excerpted
directly from the public domain NIOSH publication *ELEMENTS OF
ERGONOMICS PROGRAMS: A Primer on Workplace Evaluations of
Musculoskeletal Disorders* (<http://www.cdc.gov/niosh/97-117pd.html>).
This publication can be downloaded from the NIOSH website in PDF format
for more complete information. The two public domain NIOSH surveys of
musculoskeletal disorders in IHS dental personnel, HETA 98-0032-2795 and
HETA 99-0106-2838, were also excerpted in the preparation of this
document. Copies can be obtained from NIOSH.

**BACKGROUND AND DEFINITIONS**

Ergonomics is the science of fitting workplace conditions and job
demands to the capabilities of the working population. The successful
application of ergonomics assures high productivity, avoidance of
illnesses and injuries, and increased satisfaction among workers.
Unsuccessful application, on the other hand, can lead to work-related
musculoskeletal disorders (MSDs). The term work-related MSDs refers to
musculoskeletal disorders to which the work environment contributes
significantly or to musculoskeletal disorders that are made worse or
longer lasting by work conditions or workplace risk factors. Common
examples of such workplace risk factors include jobs requiring
repetitive, forceful or prolonged exertions of the hands; frequent or
heavy lifting, pushing or pulling, or carrying of heavy objects; and
prolonged awkward postures. The level of risk depends on the intensity,
frequency and duration of the exposure to these conditions.

Ergonomics are a potentially regulated health and safety issue, and
work-related MSDs are an important problem in the workplace for several
reasons:

-   According to the Bureau of Labor Statistics in 1995, work-related
    MSDs are among the most prevalent lost-time injuries and illnesses
    in almost every industry,

-   Work-related MSDs involving the back are among the most costly
    occupational problems,

-   Work-related MSDs may cause significant pain and suffering among
    afflicted workers,

-   Work-related MSDs can decrease productivity and the quality of work.

**SCIENTIFIC FINDINGS**

Numerous studies have attempted to estimate the prevalence of
work-related MSDs in dentistry. Most such studies have been
cross-sectional in design, lacking control groups. Additionally,
cross-sectional studies cannot account for the temporal pattern of
events, and cannot therefore demonstrate true cause and effect. Given
these potential shortcomings, and the fact that all of the findings have
not been consistent, however, a review of the literature suggests that
dental personnel, including dentists, dental hygienists, and dental
assistants may be prone to work-related MSDs involving the neck,
shoulder, wrist, elbow, hand, and lower back. A brief review of the
literature concerning work-related MSDs in dentistry is included in
Appendix I.

**WORK-RELATED MSDs IN INDIAN HEALTH SERVICE DENTAL PERSONNEL**

In 1998, the National Institute for Occupational Health and Safety
(NIOSH) collaborated with the Phoenix Area to conduct a Health Hazard
Evaluation (HHE) on several IHS Dental Clinics in Arizona. Their
findings were reported in HETA Report #98-0032- 2795, copies of which
can be obtained on the NIOSH website at
<http://www.cdc.gov/niosh/hhe/reports/pdfs/1998-0032-2795.pdf>.

This study included interviews with dental employees and photographs and
videotapes of workers doing their jobs.

NIOSH found that 48 percent of workers had work related (WR) neck
disorders, 42 percent had WR back disorders and 37 percent had WR
shoulder disorders. Dental assistants had a significantly greater
prevalence of WR neck disorders than dentists. These percentages fall
within the ranges reported among dentists in other studies (see
Appendix).

The most significant risk factors for dentists were static loading of
the neck and static loading and awkward positions of the hands. The
greatest risk factors for dental assistants were twisting and turning of
the back, extended reaches of the arms to access instruments, prolonged
static postures, forceful exertions using dental instruments, and
carving fillings.

Among other factors, the work-related MSDs were associated with working
in older dental clinics (with rear delivery systems) and with
malfunctioning dental equipment. In 1999, NIOSH and the IHS collaborated
to conduct another study of work-related MSDs in IHS dental personnel,
this time sending a questionnaire to all dental employees working in IHS
federally operated programs at the time of the survey. Sixty-nine
percent of the employees completed and returned the survey. The full
report of the survey can be obtained by calling NIOSH and requesting
HETA report 99-0106-2838 or by downloading the PDF at
<http://www.cdc.gov/niosh/hhe/reports/pdfs/1999-0106-2838.pdf>

For dentists, there was a statically significant incidence of neck MSDs
related to an increased frequency of indirect viewing of the patient's
mouth and to poor to fair dental chair comfort. Increased reporting of
hand work-related MSDs by dentists was related to extracting 10 or more
teeth per week and to rating the lighting as fair or poor. The risk of
back work-related MSDs for dentists was statistically related to fair or
poor dental chair comfort and to sitting in the 9 or 10 o'clock position
as opposed to the 11 or 12 o'clock position relative to the patient.
Shoulder work-related MSDs for dentists were related to not always
having a direct view of the patient's mouth and to the time spent
working at the same location, based on spending greater than 5 years at
the same location.

For dental assistants/hygienists, neck work-related MSDs were related to
not having a fiber-optic handpiece, to fair or poor dental chair
comfort, and to the years spent working at the same clinic.

The risk of neck work-related MSDs in dental assistants/hygienists
decreased with an increase in the number of patients treated per day.
For dental assistants/hygienists, hand work-related MSDs were related to
spending more years working at the same location. For dental
assistants/hygienists, increased back work-related MSDs were
statistically significantly associated with locating the handpiece
behind the patient rather than locating the handpiece in front of the
patient and to spending more years working at the same location.
Shoulder work related MSDs for dental assistants/hygienists were related
to having an instrument tray on the left side of the patient versus in
front of the patient.

**ERGONOMIC RISK FACTORS IN DENTISTRY**

**Neck and Shoulder**

A comprehensive review of published studies, conducted by the Hazard
Evaluations and Technical Assistance Branch NIOSH, found that repetitive
neck movements and continuous arm and hand movements affecting the neck
and shoulder demonstrate significant associations with neck
musculoskeletal disorders. Researchers have also found a strong
relationship between neck musculoskeletal disorders and high levels of
static contraction, prolonged static loads, and extreme working postures
involving neck and shoulder muscles.

Dental personnel are required to adopt non-neutral postures for many of
the clinical tasks they perform. These postures frequently require
prolonged static contraction of the trunk and scapulothoracic and
scapulohumeral musculature, combined with repetitive contraction of
muscles in the wrist, hand, and fingers during fine motor control work.
Dentists, for example, most commonly use a combination of a flexed and
right-side flexion position of the neck with a head-down position, often
combined with shoulder abduction or flexion. Dental personnel assume
these positions for the following reasons:

-   To coordinate the relative positions between dentist and assistant,

-   To obtain optimal view of teeth within the patient's mouth,

-   To provide a comfortable position for the patient, and

-   To maneuver complex equipment and reach for instruments.

Much dental work requires high precision, and the muscles used in
sustaining such activity are at risk of becoming fatigued and causing
discomfort. Stability maintained through static muscle loading in the
shoulder for prolonged periods could lead to fatigue and discomfort.
Prolonged contraction of the upper trapezium during upper extremity
stabilization (without armrests) can cause compression of adjacent blood
vessels and nerves making the upper extremity susceptible to temporary
ischemia.

**Wrist and Hand**

Dental work has also been associated with hand and wrist problems.
Carpal Tunnel syndrome (CTS) has been associated with both repetitive
work and forceful work. CTS is defined as symptomatic compression of the
median nerve within the carpal tunnel, which is the space between the
transverse carpal ligament on the palmar aspect of the wrist and the
carpal bones on the dorsal aspect of the wrist. Symptoms of carpal
tunnel compression can appear from any activity causing prolonged
increased (passive or active) pressure in the carpal canal. There is
evidence of an association between CTS and highly repetitive work, alone
or in combination with other factors. Evidence also indicates an
association between forceful work and CTS, but the amount and type of
repetitive movement performed during dental work has not been accurately
quantified by most studies.

**Low Back Pain**

Low-back discomfort has been associated with dental work in numerous
studies. Shugars *et al.* found that good (neutral) posture correlated
negatively with back pain; and generally, dentists who sat 80 percent to
100 percent of the day reported more frequent lower-back pain, than
those that do not sit as often.^1^ Static work in the sitting posture
requiring spinal flexion and rotation has been associated with increased
risk of low back pain. Sitting increases loads on soft-tissue structures
of the lumbar spine and discs. Additionally, extensor muscle activity in
the lumbar spine area in the unsupported sitting posture is greater than
in standing. Back discomfort experienced by dental workers was shown to
increase over the working day.

**Psychosocial Factors and Work-Related MSDs in Dentistry**

Numerous studies have looked at stress levels in dentistry. Identified
stressors include the psychological demands of doing meticulous surgery
with little or no rest or diversion and time pressures. Dentists with
work-related MSDs showed a significant tendency to be more dissatisfied
at work and to be more burdened by anxiety, experiencing poorer
psychosomatic health and feeling less confident with their futures.
Ergonomics requires understanding of both the physical and the
psychological aspects of the workplace. From the review of literature,
it is evident that ergonomics plays a significant role in the health of
dental professionals. The musculoskeletal and stress related disorders
associated with dentistry seem to be interrelated. Literature about
work-related MSDs and psychosocial disorders associated with dentistry
is plentiful. However, ergonomic solutions for dental practitioners are
under-reported in the literature. Furthermore, the few ergonomic
solutions that have been provided have not been adequately evaluated or
validated.

**Ergonomic Interventions in Dentistry: Current State of the Art**

Dentists usually work seated on a low stool, and the assistant, also
seated, provides chairside assistance; this is commonly called
four-handed dentistry. Instruments and equipment are placed within close
reach of the dentist and the assistant. The patterns of floor area
design have evolved on an empirical basis for each functional area and
for flow in occupants\' movements. The aim of ergonomic intervention
should be to achieve optimum access, visibility, comfort, and control at
all times of treatment. Many ergonomists have urged an evaluation of the
dental workspace and process to improve not only health, but also
productivity.

**WHAT SHOULD DENTAL PROGRAMS ASSESS TO HELP PREVENT WORKRELATED MSDs IN
THEIR EMPLOYEES?**

A great deal of ergonomic research has been conducted to identify
workplace factors that contribute to the development of musculoskeletal
disorders. According to the scientific literature, the following are
recognized as important risk factors for musculoskeletal disorders,
especially when occurring at high levels and in combination. In general,
knowledge of the relationships between risk factors and the level of
risk is still incomplete. Also, individuals vary in their capacity to
adjust to the same job demands. Some may be more affected than others.

**Awkward postures**

Body postures determine which joints and muscles are used in an activity
and the amount of force or stresses that are generated or tolerated. For
example, more stress is placed on the spinal discs when lifting,
lowering, or handling objects with the back bent or twisted compared
with when the back is straight. Manipulative or other tasks requiring
repeated or sustained bending or twisting of the wrists, knees, hips, or
shoulders also imposed increased stresses on these joints. Activities
requiring frequent or prolonged work over shoulder height can be
particularly stressful.

**Forceful exertions**

Tasks that require forceful exertions place higher loads on the muscles,
tendons, ligaments, and joints. Increasing force means increasing body
demands such as greater muscle exertion along with other physiological
changes necessary to sustain an increased effort. Prolonged or recurrent
experiences of this type can give rise to not only feelings of fatigue
but may also lead to musculoskeletal problems when there is inadequate
time for rest or recovery. Force requirements may increase with:

-   use of an awkward posture,

-   the speeding up of movements,

-   increased slipperiness of the objects handled (requiring increased
    grip force)

-   use of the index finger and thumb to forcefully grip an object
    (i.e., a pinch grip compared with gripping the object with your
    whole hand), and

-   use of small or narrow tool handles that lessen grip capacity.

-   

Many of these risk factors are present in the practice of dentistry.

**Repetitive motions**

If motions are repeated frequently (e.g., every few seconds) and for
prolonged periods such as an 8-hour shift, fatigue and muscle-tendon
strain can accumulate. Tendons and muscles can often recover from the
effects of stretching or forceful exertions if sufficient time is
a11owed between exertions. Effects of repetitive motions from performing
the same work activities are increased when awkward postures and
forceful exertions are involved. Repetitive actions as a risk factor can
also depend on the body area and specific act being performed.

**Duration**

Duration refers to the amount of time a person is continually exposed to
a risk factor. Job tasks that require use of the same muscles or motions
for long durations increase the likelihood of both localized and general
fatigue. In general, the longer the period of continuous work (e.g.,
tasks requiring sustained muscle contraction) the longer the recovery or
rest time required.

**Contact stresses**

Repeated or continuous contact with hard or sharp objects such as
non-rounded desk edges or unpadded, narrow tool handles may create
pressure over one area of the body (e.g., the forearm or sides of the
fingers) that can inhibit nerve function and blood flow*.*

**Vibration**

Exposure to local vibration occurs when a specific part of the body
comes in contact with a vibrating object, such as a power hand tool.
More detailed information concerning the above parameters can be found
on the State of Washington's Department of Labor and Industries
Ergonomics website at <http://www.lni.wa.gov/wisha/ergo/>

**HOW SHOULD THESE ASSESSMENTS BE MADE?**

Screening jobs for risk factors may involve the following:

-   Walk-through observational surveys of the work facilities to detect
    risk factors.

-   Interviews with workers and supervisors to obtain the above
    information and other data not apparent in walk-through observations
    such as time and work load pressures, length of rest breaks, etc.

-   Use of checklists for scoring job features against a list of risk
    factors (an example of such a checklist is available for download
    from the US Army's ergonomics website at
    <http://chppm-www.apgea.army.mil/ergopgm/publications.aspx>) .

Of the above three methods, the checklist procedure provides the most
formal and orderly procedure for screening jobs. Numerous versions of
checklists exist in ergonomics manuals. When persons familiar with the
job task gather checklist data, the quality of the data is generally
better. Checklist procedures are also typically used in more complete
job analyses.

While screening tools such as checklists have been widely and
successfully used in many ergonomics programs, most have not been
scientifically validated. Combining checklist observations with symptoms
data offers a means of overcoming uncertainty. Integrating efforts to
identify risk factors for musculoskeletal disorders with efforts to
identify common safety hazards such as slips and trips should be
considered. Jobs with risk factors for musculoskeletal disorders also
may have safety hazards (such as the risk of sharps injuries from burs
in handpieces mounted in rear delivery systems). The US Army's
Ergonomics Program website contains information on and links to
checklists and other tools. The site can be found at:

<http://chppm-www.apgea.army.mil/ergopgm/default.aspx>

**Performing Job Analyses**

Job analysis breaks a job into its various elements or actions,
describes them, measures and quantifies risk factors inherent in the
elements, and identities conditions contributing to the risk factors.
Persons with considerable experience and training in these areas usually
conduct these job analyses. While most job analyses have common
approaches, no standard protocol exists for conducting a job analysis to
assess ergonomic hazards. Most job analyses have several common steps. A
complete description of the job is obtained. Employees are often
interviewed in order to determine if the way the job is done changes
over time. During the job analysis, the job is divided into a number of
discrete tasks. Each task is then studied to determine the specific risk
factors that occur during the task. Sometimes each risk factor is
evaluated in terms of its magnitude, the number of times it occurs
during the task, and how long the risk factor lasts each time it occurs.

The tasks of most jobs can be described in terms of (1) the tools,
equipment, and materials used to perform the job, (2) the workstation
layout and physical environment, and (3) the task demands and
organizational climate in which the work is performed. Job screening as
described above, provides some of these data. More definitive procedures
for collecting information on these components can include the
following:

-   Observing the workers performing the tasks in order to furnish
    time-activity analysis and job or task cycle data; videotaping the
    workers is typically done for this purpose.

-   Still photos of work postures, workstation layouts, tools, etc., to
    illustrate the job

-   Workstation measurements (e.g., work surface height, reach
    distances)

-   Measuring tool handle sizes, weighing tools and parts, and measuring
    tool vibration and part dimensions

-   Biomechanical calculations (e.g., muscle force required to
    accomplish a task or the pressure put on a spinal disc based on the
    weight of a load lifted, pulled, or pushed)

-   Physiological measures (e.g.. oxygen consumption, heart rate)

-   Special questionnaires, interviews, and subjective rating procedures
    to determine the amount of perceived exertion and the psychological
    factors influencing work performance.

**WHAT TRAINING CAN BE PROVIDED TO DENTAL PERSONNEL, AND WHAT SHOULD THE
TRAINING INCLUDE?**

Training is recognized as an essential element for any effective safety
and health program. For ergonomics, the overall goal of training is to
enable managers, supervisors, and employees to identify aspects of job
tasks that may increase a worker\'s risk of developing work-related
MSDs, recognize the signs and symptoms of the disorders, and participate
in the development of strategies to control or prevent them. Training
employees ensures that they are well informed about the hazards so they
can actively participate in identifying and controlling exposures.
Common forms of ergonomics training are noted below, along with their
objectives. Employers may opt to have outside experts conduct these
tasks. If so, the outside instructors should first become familiar with
local operations and relevant policies and practices before starting to
train. Tailoring the instruction to address specific concerns and
interests of the worker groups can enhance learning.

**ERGONOMICS AWARENESS TRAINING**

The objectives for ergonomics awareness training are as follows:

-   Recognize workplace risk factors for musculoskeletal disorders and
    understand general methods for controlling them.

-   Identify the signs and symptoms of musculoskeletal disorders that
    may result from exposure to such risk factors, and be familiar with
    the organization's health care procedures.

-   Know the process the employer is using to address and control risk
    factors, the employee's role in the process, and ways employees can
    actively participate.

-   Know the procedures for reporting risk factor and musculoskeletal
    disorders, including the names of designated persons who should
    receive the reports

**TRAINING RESOURCES**

Materials for offering awareness training to the workforce are
available, including videotapes and pamphlets from NIOSH and others. The
American Dental Association offers one of their seminar courses on
dental clinic ergonomics. Persons or groups assigned to or expected to
play a key role in ergonomic hazard control work will require added
instruction in problem identification, job analyses, and problem-solving
techniques. Some fact sheets and other training tools are available on
the previously mentioned Washington State and US Army websites.
Additionally, the IHS has an Ergonomics workgroup that is currently
developing training programs and policy documents. The IHS ergonomics
webpage can be found at the following address:

<http://www.ihs.gov/NonMedicalPrograms/IEH/index.cfm?module=ergo>

**WHAT DIRECT MEASURES CAN MANAGERS OF INDIAN HEALTH DENTAL PROGRAMS
TAKE NOW TO PROTECT PERSONNEL FROM WORK-RELATED MSDs?**

1.  When equipment needs to be replaced, when budget allows, or whenever
    clinic renovations are made, dental programs should replace older,
    rear-delivery equipment with more modern over-the-patient equipment.
    This delivery system allows access to the 12:00 position in relation
    to the patient, and greatly lessens the amount of twisting and
    turning that dental personnel must do to gain access to instruments
    and equipment. Utilize patient chairs that are as thin as possible
    to allow personnel to sit as close to the patient as possible and
    minimize bending. All new construction should be designed with these
    changes in mind. Additionally, elimination of the rear delivery
    systems will eliminate the risk of sharps injuries from burs on
    handpieces mounted behind the dentist.

2.  Ensure that existing equipment is functioning properly and that all
    chairs can be raised and lowered within the range for which they
    were designed. Proper positioning should help to reduce the static
    physical stresses placed on dental personnel. Malfunctioning
    equipment was identified as a significant risk factor in one of the
    IHS NIOSH reports.

3.  Design operatories so that the assistant or dentist does not have to
    get up or twist to access a handpiece or suction device, or to use
    an amalgamator or curing light. There should be adequate space
    available at the head of the patient to allow access to the 12:00
    position by the dentist, assistant, or hygienist, without bumping
    elbows on units, burs, etc.

4.  Evaluate ergonomically designed instruments, particularly dental
    instruments with larger handles. Programs could start with employees
    who are having hand/wrist work-related MSDs and assess the comfort
    and performance of such instruments before introducing them to all
    dental personnel at all clinics.

5.  Encourage dental staff to take mini-breaks to decrease the amount of
    time they have to stay in one position.

6.  Provide comfortable chairs to both dentists and dental
    assistants/hygienists. These chairs should provide adequate
    adjustability to allow proper positioning for all dental personnel
    and adequate body and arm supports to eliminate or reduce the static
    loading of arm, shoulder, neck and back muscle groups.

7.  Make sure that proper lighting is available in all operatories.

8.  Train and remind staff of the importance of proper posture, and
    periodically evaluate postures.

9.  Provide a slow-setting amalgam for use when doing amalgam build-ups
    or other large, multi-surface amalgams. Faster-setting amalgams such
    as Tytin may reach a hard set before carving is completed, leading
    to increased stress on the hands and wrists. Additionally, make sure
    that all amalgam carvers are kept sharp to facilitate the carving
    process.

10. Increased use of ultrasonic and piezo-electric scalers, as opposed
    to the use of hand scalers, on patients with heavy calculus may help
    to protect the hands and wrists of hygienists and perio-certified
    expanded functions assistants.

**APPENDIX I, A REVIEW OF THE LITERATURE**

In a cross-sectional study, 1,079 dentists were screened during the
American Dental Association\'s Annual Health Screening Program in 1997
and 1998 by means of standard electrodiagnostic measures in the dominant
hand and a self-reported symptom questionnaire. The prevalence of
symptoms consistent with CTS in the dominant hand among dentists was
higher than the prevalence in the general population. However, when
electrodiagnostic confirmation was added, the prevalence of CTS was
nearly the same as that among the general population.^2^

Bramson *et al.* undertook a study to determine the presence of certain
ergonomic risk factors in typical tasks performed by dentists and dental
hygienists. They further investigated, by means of electromyography and
goniometry, the force, frequency and duration of the task. They
concluded that when a task\'s duration, force and frequency are
accounted for, scaling, polishing, flossing and probing activities do
not represent exposure to high ergonomic risk.^3^

Rundcrantz and various associates have published numerous studies
concerning dental ergonomics and work-related MSDs in the Swedish dental
literature.^4,5,6,\ 7^ One of these studies compared dentists with and
without occupational cervico-brachial disorders with regard to the
mobility of the neck and shoulders and the static endurance of the
shoulder muscles. Differences in working position and the task
performance on a stimulated case were also analyzed. Of 143 dentists
surveyed, 96 had signs of cervico-brachial disorders and discomfort
while 47 did not. The ergonomic examination showed that significantly
more dentists without symptoms of pain applied a wedge cushion under the
upper part of the back of the patient to get an optimum view. They also
found that significantly more dentists without symptoms were aware of
and utilized the naturally arising pauses in their work than dentists
with pain and discomfort. Additionally, dentists with cervico-brachial
disorders kept their head bent to the side and rotated to a greater
extent than did dentists without symptoms. In another study, they found
a high incidence of pain and discomfort in the locomotor system among
dentists that could not be explained by ergonomic risk factors such as
positioning of the patient, use of the mirror or alteration of the
dentist\'s position. Regression analysis showed that personal harmony
and age had the highest value for explaining the number of painful sites
in the musculoskeletal system of those studied. In another study, they
looked at patient positioning and use of the mouth mirror. They found
that dentists who positioned the patient to achieve a direct view had a
significantly lower frequency of headaches. They also concluded that
those dentists who did not have discomfort in the upper locomotor system
used the mirror more often than those who did suffer discomfort.

Finsen, Christensen, and Bakke looked at musculoskeletal disorders among
dentists and variation in the tasks they performed.^8^ They looked at
working postures and conducted electromyography of the shoulder/neck
during the three most common work tasks. They found prolonged neck
flexion and upper arm abduction, as well as high static muscle activity
levels in the splenius and trapezius muscles. No differences between
work tasks were found regarding postures, frequencies of movements or
muscle activity. Alterations between the three work tasks did not
produce sufficient variation to reduce musculoskeletal load on the neck
and shoulders.

Milerad and Ekenvall studied symptoms of the neck and upper extremities
in dentists by means of telephone interviews.^9^ They compared the
dentists to a reference group of pharmacists. They found 44 percent of
the dentists and 26 percent of the pharmacists to have symptoms of the
neck, 51 percent of the dentists and 23 percent of the pharmacists to
have symptoms of the shoulder, and 12 percent of the dentists versus 1
percent of the pharmacists to have musculoskeletal symptoms in the
forearm, mainly in the form of paresthesias and numbness. They concluded
that the high frequency of symptoms from the neck, shoulders, and upper
extremities of the dentists was probably related to difficult work
positions with cervical flexion and rotation, abducted arms, and
repetitive precision-demanding handgrips.

In 1995, Liss *et al.* surveyed musculoskeletal disorders among dental
hygienists in Canada.^10^ Using logistic regression models, the number
of heavy calculus patients per day, \"clock\" position around the dental
chair, and years in practice were significant predictors of CTS among
hygienists. Days worked, time with the trunk rotated, and years of
practice were significant predictors of reported shoulder trouble in the
past 12 months. The authors emphasized the need to inform hygienists
during training and continuing education about musculoskeletal problems
in general and CTS in particular. They stated that attention should be
directed to areas such as workstation design, posture, treating patients
with heavy calculus, and scheduling rest periods. A study by Osborn *et
al.* among dental hygienists in Minnesota reported similar findings.^11^

Lehto *et al.* surveyed musculoskeletal health in 131 professionally
active dentists as part of a comprehensive health examination.12 Forty
two percent of dentists had experienced pain and interference with daily
activities by neck-shoulder problems during the preceding year, with a
tendency to greater prevalence in salaried dentists than in private
practitioners. Thirty seven percent experienced lower back problems.
Symptoms of stress, perceiving dentistry as physically or mentally too
taxing and a poorer general health status rating were all associated
with a greater 1-yr prevalence of neck-shoulder and lower back pain and
disability and with poorer general physical fitness. Age, weekly work
hours, working posture, use of an assistant, or radiographic
degenerative changes in the dentist\'s skeleton were not associated with
1-yr prevalence of neck-shoulder or lower back pain and disability.

**REFERENCES**

1.  Shugars DA, Williams D, Cline SJ, Fishburne C. Musculoskeletal back
    pain among dentists. Gen Dent. 1984 Nov-Dec;32(6):481-5.

2.  Hamann C, Werner RA, Franzblau A, Rodgers PA, Siew C, Gruninger S.
    Prevalence of carpal tunnel syndrome and median mononeuropathy among
    dentists. J Am Dent Assoc. 2001 Apr;132(4):434, 436

3.  Bramson JB, Smith S, Romagnoli G. Evaluating dental office ergonomic
    risk factors and hazards. J Am Dent Assoc 1998 Feb;129(2):174-83

4.  Rundcrantz BL, Johnsson B, Moritz U. Occupational cervico-brachial
    disorders among dentists. Analysis of ergonomics and locomotor
    functions. Swed Dent J 1991;15(3):105- 15

5.  Rundcrantz BL, Johnsson B, Moritz U. Pain and discomfort in the
    musculoskeletal system among dentists. A prospective study. Swed
    Dent J 1991;15(5):219-28

6.  Rundcrantz BL. Pain and discomfort in the musculoskeletal system
    among dentists. Swed Dent J Suppl 1991;76:1-102

7.  Rundcrantz BL, Johnsson B, Moritz U. Cervical pain and discomfort
    among dentists. Epidemiological, clinical and therapeutic aspects.
    Part 1. A survey of pain and discomfort. Swed Dent J
    1990;14(2):71-80

8.  Finsen L, Christensen H, Bakke M. Musculoskeletal disorders among
    dentists and variation in dental work. Appl Ergon 1998
    Apr;29(2):119-25

9.  Milerad E, Ekenvall L. Symptoms of the neck and upper extremities in
    dentists. Scand J Work Environ Health 1990 Apr;16(2):129-34

10. Liss GM, Jesin E, Kusiak RA, White P. Musculoskeletal problems among
    Ontario dental hygienists. Am J Ind Med 1995 Oct;28(4):521-40

11. Osborn JB, Newell KJ, Rudney JD, Stoltenberg JL. Carpal tunnel
    syndrome among Minnesota dental hygienists. J Dent Hyg 1990
    Feb;64(2):79-85

12. Lehto TU, Helenius HY, Alaranta HT. Musculoskeletal symptoms of
    dentists assessed by a multidisciplinary approach. Community Dent
    Oral Epidemiol 1991 Feb;19(1):38-44

**Chapter 7, Quality Assessment and Improvement**

**Table Of Contents**

A. Introduction to Quality Assessment and Improvement

B. Evaluation of Clinical Quality

C. Peer Review

D. IHS Quality Assessment Methods and Tools

E. Accreditation Surveys

F. An in-Depth look at Quality Improvement

G. Dental Program Management QI

**APPENDICES**

I. Responsibilities and Guidelines for Implementing the Quality
Assessment System

II\. Tool for the Evaluation of the Technical Quality of Care (Direct
Observation)

III\. Tool for the Indirect Review of Clinical Quality (Chart Review)

IV\. Tool for the Evaluation of Community Involvement in Oral Health
Programs

V. Tool for Evaluation of Management of Oral Health Programs

VI\. Tool for Evaluation of Compliance with Infection Control Guidelines

VII\. Clinic Efficiency Manual

VIII\. Sample Letter

**Introduction to Quality Assessment**

The Institute Of Medicine\'s definition of quality in medicine,
developed in 1990, is widely accepted: quality is \"the degree to which
health services for individuals and populations increase the likelihood
of desired health outcomes and are consistent with current professional
knowledge." Dimensions of quality healthcare include the following:

-   patient perspective issues (e.g. Patient satisfaction),

-   safety of the care environment,

-   accessibility,

-   appropriateness,

-   continuity,

-   effectiveness,

-   efficacy,

-   efficiency and

-   timeliness of care.\" (Joint Commission on Accreditation of
    Healthcare Organizations (JCAHO), 1994).

The dental program must provide quality services to the population it
serves if it is to achieve its mission. The provision of quality
clinical services relies on having a quality professional workforce
working in an environment that both requires and supports the provision
of quality care. Unfortunately, quality assessment and peer review by
themselves cannot guarantee that standards of care are being met on a
patient-by-patient, procedure-by-procedure, or day-by-day basis; the
maintenance of professional standards of care rests with the provider.
However, even the most highly skilled and ethical providers will not be
able to provide the highest possible quality of services unless the
policies, processes, and systems under which they work support that
level of care.

This chapter will discuss how the clinic can assess, maintain, and
improve the quality of its clinical services and administrative
processes. For the remainder of this chapter, the abbreviation "QA/I"
will be used for quality assessment and improvement.

**HISTORICAL PERSPECTIVE**

Quality Assessment (QA) in the Indian Health Service dental program
began in the late 1960's with the development of criteria to assess
technical quality of dental care. These evaluations were originally
conducted by Area Dental Officers and later by senior IHS dental
clinicians specifically trained as QA evaluators.

In 1981 a major revision of the QA document was accomplished. At that
time criteria were developed to assess management and community
components of dental programs to complement the technical QA criteria.
Subsequent to 1981 additional criteria have been developed which address
the indirect evaluation of dental care via chart audit, the evaluation
of dental disease prevention activities, the evaluation of infection
control procedures, and radiologic health and safety. In 1992, the JCAHO
subsection was expanded to include examples of important aspects of
care, indicators, and a data collection grid to facilitate
implementation of the continuous quality improvement monitoring and
review process.

After over three decades of evaluation, the quality assessment process
has become increasingly complex and broad in scope. Consequently, the
original format of "in-mouth" review of patients during a "normal"
clinic day is no longer adequate to meet the quality assessment needs of
all levels of the IHS Dental Program or the accrediting bodies that
survey IHS programs.

To address these multiple areas of need, this chapter addresses several
major areas. These include:

-   direct observation of dental care (i.e., a clinical, in-the-mouth
    review),

-   dental program management,

-   community involvement,

-   indirect methods of assessing clinical quality (i.e., chart review),

-   infection control,

-   clinical efficiency,

-   accreditation surveys, and

-   Continuous Quality Improvement (CQI) / Performance Improvement (PI)

Considerable latitude exists for using a combination of the documents
and methods presented in this chapter of the *Oral Health Program Guide*
to match situational requirements. Each individual utilizing the
document should recognize the dynamic nature of its contents and be
encouraged to contribute to its improvement. Future experience in the
quality assessment arena will permit and foster continued evolution of
the program.

**Evaluation of Clinical Quality**

**Determining What Constitutes Clinical Quality**

Because of the technical aspects of dental services, many in the
profession equate high clinical quality with the physical
characteristics of finished dental services.

-   highly polished silver and gold restorations

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-   smooth margins, proper contours, proper occlusal anatomy on
    restorations

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-   good color match on esthetic restorations

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-   fit and function of removable prosthetics

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-   root canal fills within 1 mm of the root apex

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-   removal of all stains and calculus during prophy

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-   x-rays without overlap or cone cutting

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-   low post-extraction complication rate

-   other

Clinical quality can also be measured in other ways that may be more
meaningful.

-   making the correct diagnosis

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-   providing the appropriate clinical service based on the diagnosis,
    the patient's desires, and resources available

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-   providing preventive and restorative care appropriate to the
    patient's risk of developing dental disease or risk of having
    existing conditions progress

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-   following appropriate clinical guidelines and protocols

A study performed 20 years ago through the ADA and funded by the Kellogg
Foundation looked at those criteria that best correlated with quality of
dental care. The study looked at about 30 dental offices. The conclusion
was that two criteria - diagnosis and appropriateness of treatment -
were the main measures of quality. All other criteria such as quality of
the radiographs, quality of restorations, etc. did not correlate well.

In general, there are two methods to ascertain clinical quality in
dentistry:

-   Direct observation of patient care by a trained observer

-   Review of information in the dental record (chart review)

Both of these methods have advantages and drawbacks, and neither is
ideal. The advantages and disadvantages of **direct clinical
observation** include the following:

  ----------------------------------- -----------------------------------
  **Advantages**                      **Disadvantages**

  Can identify problems in technique  Time consuming -- can take one or
  that are not discernable through    more days to get a reasonable
  review of chart entries or x-rays   sample of all of the procedures
                                      performed in the clinic

                                      Requires the consent of the patient

                                      Can be very intrusive into the
                                      clinic flow

  Provider-focused, and can review    Provider-focused, and can review
  only one provider at a time         only one provider at a time

                                      Difficult to focus on a specific
                                      aspect of care unless appointments
                                      are manipulated to schedule only
                                      one type of patient

                                      Even if there is a problem with the
                                      services provided by a dentist,
                                      that provider can attempt to hide
                                      the problem by practicing with
                                      extra care during the time when
                                      he/she is being observed

                                      The process is often disliked by
                                      providers, who correctly assert
                                      that their counterparts in private
                                      practice do not have to undergo
                                      such scrutiny in their practices
                                      once they have passed a board exam
                                      and received a license to practice.
  ----------------------------------- -----------------------------------

The advantages and disadvantages of reviewing clinical quality through
the use of a **chart review** include the following:

  ----------------------------------- -----------------------------------
  **Advantages**                      **Disadvantages**

  Does not require the presence of a  Cannot identify problems in
  patient                             clinical technique that are not
                                      visible on radiographs

  Can easily be focused on one aspect 
  of care by only reviewing the       
  charts of patients who received the 
  services in question                

  Can review all aspects of the       
  clinical practice by using a random 
  sample of the charts of all clinic  
  users                               

  A large amount of data can be       
  gathered in a relatively short      
  amount of time                      

  Much data can be retrieved and      
  recorded by clerical staff on log   
  forms (e.g., presence of absence of 
  signatures, updates of medical      
  histories, etc.) or by computer     
  searches if you have an electronic  
  record                              
  ----------------------------------- -----------------------------------

Evidence exists that there is a relationship between the quality of
clinical record keeping and the quality of care provided. Therefore,
chart reviews can provide information to determine trends in the quality
of the clinical care being provided. If your clinic employs more than
one dentist, chart review data can be used in aggregate to measure the
overall quality of the clinic. Dentists are often more accepting of
clinic-wide reviews than they are of provider-focused reviews.

If ongoing monitoring reveals problems or trends in the clinic data,
then the aggregate data can be broken down by provider to see if the
trend is provider-focused or clinic wide. Problems present in the
records of multiple dentists most likely represent problems with systems
or procedures, and should be analyzed from that standpoint. Problems or
trends that point to a single provider can be related to either systems
problems or to problems with the provider's skills or competence.

**Peer Review**

In the context of this manual, the term peer review refers to the
process of assessing the quality of clinical care provided by an
employee, contractor, or volunteer. In this context, it is a process in
which the dentist must participate as a condition of employment. The
peer review can be a direct clinical evaluation, a review of dental
charts, or a combination of the two. It can be conducted on a regularly
scheduled basis as part of the QA/I program, or as a focused review in
response to a patient complaint or other adverse occurrence. When and
how the peer review is conducted should be defined clearly in the
clinic's Policy and Procedure Manual, and all employees should be
apprised of the peer review process and standards during their initial
orientation. Peer review records should be kept secure and separate from
personnel files because they are frequently protected against legal
discovery by the Federal Healthcare Quality Improvement Act of 1986 and
state statutes. They should be labeled as "Peer Review Files" and should
be kept in a locked and secure location that is physically separate from
the location of Personnel files.

Peer review, by definition, should be conducted by a professional peer;
for example, a general dentist should review general dentists, a
pediatric dentist should review other pediatric dentists, although in
the IHS this might not always be possible. Peer review by chart review
can either be performed by the Chief, Service Unit Dental Program or
his/her designee (e.g., the Area Dental Consultant (ADC), an outside
contractor, an Area Support Center, etc.) or it can be done by having
all of the providers review charts and aggregate the data. One of the
advantages of having all providers review charts is that the review
process becomes a learning experience and each provider gets to see the
strengths and weaknesses of multiple chart entries. Peer review by
direct observation review is usually done by an ADC or outside
consultant.

Regardless of whether the peer review is a clinical review or chart
review, the criteria need to be shared with professional staff at the
beginning of employment, preferably during orientation. Like any other
practice guidelines, the review criteria should be based on the best
available science and expert input.

Dentists in private practice do not undergo regularly scheduled peer
review. As long as they maintain Continuing Dental Education
requirements for license renewal, and have no complaints or malpractice
suits filed against them, they may never again have their clinical
competence evaluated after having passed a dental licensing exam.
Employee dentists may feel threatened or that their knowledge and skills
are being questioned when required to undergo routine peer review.
However, case law has firmly established that the healthcare
organization has both the right and the responsibility to ensure that
the services provided by their employees meet the standard of care. It
is therefore incumbent on the administration of the clinic to establish
a peer review system that is fair, objective, and as palatable to the
providers as possible. Failure to consider the professional feelings of
the providers can lead to job dissatisfaction and increased turnover in
staff, both of which are detrimental to the clinic.

Questions have arisen at times about the legal standing of the dentist
performing the review and whether he or she could be held legally
accountable if the peer review failed to uncover problems that later
lead to findings of negligence against the dentist being evaluated.
While it is not possible to predict with 100% certainty that this cannot
happen, it is highly unlikely. Under both state and federal laws, a
person performing peer review in good faith is well protected. According
to Southwick in *The Law of Hospital and Health Care Administration*,
(Second Edition, Health Administration Press, 1988), pages 657 -- 666,
"members of a peer review, credentials, or similar committee and those
who transmit information to a committee will at least be protected by a
qualified or conditional privilege for all statements made in good
faith, under proper circumstances, and transmitted only to persons
having a legitimate interest in the subject matter."

**Accreditation Surveys**

Accreditation is a determination by an accrediting body that an eligible
health care organization complies with applicable standards. IHS
facilities have been directed to become accredited by one of the
national accrediting organizations. The best-known of the organizations
that accredit hospitals and ambulatory healthcare facilities are the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
and the Accreditation Association for Ambulatory Health Care (AAAHC).
The Centers for Medicare and Medicaid services (CMS) also accredit
healthcare organizations. To date, the IHS has had few, if any,
facilities that have undergone CMS accreditation, so no details about
this process are included in this chapter.

All of the recognized accrediting agencies require certain levels of
quality assessment and quality improvement activities, ongoing program
evaluation, peer review, adherence to life-safety standards, and the
like. Accreditation offers many more quantitative as well as intangible
benefits to a healthcare organization than public recognition alone.
Accreditation can actually enhance the strategic management
decision-making process. According to the AAAHC, organizations that have
achieved accreditation have indicated that accreditation helps them do
the following:

-   Find new ways to improve the care and services they offer

-   Increase their efficiency and reduce costs

-   Develop better risk management programs

-   Lower liability insurance premiums

-   Motivate staff and instill pride and loyalty

-   Strengthen public relations and marketing efforts

-   Recruit and retain qualified professional staff members

-   Develop alliances with other provider groups such as hospitals and
    managed care organizations

According to the Joint Commission, several other benefits result from
accreditation.

-   Identification of strengths and weaknesses with particular attention
    to areas in which performance may be improved

-   On-site education and consultation

-   Increased staff morale and enhanced ability to recruit staff

-   Public recognition of the organization's commitment to quality

-   Eligibility for reimbursement by many third party payers

-   Immediate eligibility to participate in the Medicare program

-   Recognition, in most states, of compliance with state licensure
    requirements

Meeting the requirements of one of these organizations is a way to
ensure that your clinic provides quality services in a safe and healthy
environment.

The survey process for both organizations will include a walk-through of
the clinic and staff interviews. It is essential that all members of the
staff be aware of the policies and procedures related to day-to-day
activities such as appointments, sterilization, infection control,
emergency protocols and procedures, and the like. Their answers to
questions about such matters must be consistent with the written
policies and procedures, or deficiencies will be noted. Additionally,
dental program procedures in areas such as infection control, sterilizer
monitoring, etc. that have similar components elsewhere in the facility
must be consistent with the policies and procedures elsewhere in the
facility.

Equally important is how deficiencies are handled during the survey
process. Both organizations frequently will not deduct points if a noted
deficiency is rectified with a new or revised policy, procedure, or
protocol before the completion of the survey. Rectification, or formal
written plans for change of deficiencies that are noted in the initial
clinic "walk through", for example, can serve as an opportunity for your
facility or department to make an immediate improvement. Such actions
can leave a positive impression with some surveyors, as this type of
rapid response by the facility exemplifies the process of cooperative
learning and improvement that the accreditation organizations wish to
foster during the review process.

***JCAHO***

Many IHS facilities that have become accredited have done so through the
JCAHO, which calls their quality assessment and improvement activities
"Performance Improvement" (PI). PI is a prospective way of improving how
things work by ongoing monitoring, data collection and analysis,
planning, implementation, and re-assessment. The details of this
process, as well as some simple statistical tools for data analysis are
included later in this chapter in the section titled "An In-depth Look
at Quality Improvement."

The focus of JCAHO surveys changes almost annually. Over the past
several years some of the areas of focus have included the following:

-   Sentinel events

-   Root cause analysis

-   Failure mode analysis

-   Surgical site documentation (e.g., marking surgical sites)

-   Prescriptions and medication errors

-   Pain assessment and management

With the frequent changes in focus and standards, it is not possible for
the OHPG to keep up with the changes and provide a detailed,
step-by-step guide on how to prepare for a JCAHO survey. Rather, each
dental program needs to be part of the overall survey process within the
local hospital or ambulatory care center, and follow the guidelines in
the most recent edition of the appropriate accreditation manual. Most
facilities appoint a JCAHO coordinator when preparations for a survey
begin. The dental program needs to coordinate with this person.

*IHS Dental Program and JCAHO Accreditation*

Even though it is difficult to predict how thoroughly a dental program
will be evaluated, some historical patterns provide guidance in
preparation for future surveys. While the JCAHO has no dental-specific
standards, programmatic components that seem to have a higher
probability of review include the following:

-   policy and procedure manuals,

-   credentialing, privileging, and competencies of non-licensed
    independent practitioners

-   in‑house quality improvement (PI) programs,

-   infection control protocols (must be consistent with the rest of the
    facility),

-   facilities and biomedical maintenance,

-   safety procedures,

-   evidence of staff meetings and in-service training,

-   drug storage and utilization

-   emergency drug kits,

-   nitrous oxide or sedation protocols and maintenance of equipment,
    and

-   adequacy of documentation of the medical record for dental treatment
    procedures.

Additionally, the dental program will likely be reviewed for its
compliance with the standards governing the JCAHO's current areas of
focus, which will change from year to year. The review procedure is
becoming more process and outcome oriented, and active ongoing
interdepartmental quality improvement is being examined more critically.

***AAAHC***

An IHS or tribal program may attain accreditation through AAAHC. There
are a total of 24 standards developed by AAAHC for ambulatory care
centers, and several of these standards may apply to all or part of
dental operations in an I/T/U facility:

-   Rights of Patients (Core Standard)

-   Governance (Core Standard)

-   Administration (Core Standard)

-   Quality of Care Provided (Core Standard)

-   Quality Management and Improvement (Core Standard)

-   Clinical Records and Health Information (Core Standard)

-   Facilities and Environment (Core Standard)

-   Anesthesia Services (Adjunct Standard)

-   Dental Services (Adjunct Standard)

-   Diagnostic Imaging Services (Adjunct Standard)

-   Teaching and Publication Activities (Adjunct Standard)

-   Research Activities (Adjunct Standard)

For more detail on these and all 24 standards, visit the AAAHC website
at [www.aaahc.org](http://www.aaahc.org/).

The AAAHC Handbook for Ambulatory Health Care does contain a chapter on
Dental Services (Standard 12). This chapter was expanded considerably in
the 2006 handbook, now containing 15 specific categories, or
"characteristics" that an "accreditable organization" that includes the
provision of dental services should have:

1.  Dental services provided or made available are appropriate to the
    needs of the patients.

2.  Clinical records are maintained according to the requirements found
    in Chapter 6, Clinical Records and Health Information, of the AAAHC
    Handbook.

3.  Anesthesia provided or made available shall meet the standards
    contained in Chapter 9, Anesthesia Services, of the AAAHC Handbook.

4.  Surgical services provided or made available shall meet the
    standards contained in Chapter 10, Surgical and Related Services, of
    the Handbook.

5.  Personnel providing dental, surgical, or anesthesia services are
    prepared to evaluate, stabilize, and transfer medical emergencies
    that may occur or arise in conjunction with services provided by the
    organization.

6.  Dental services are consistent with the definition of dentistry
    according to state regulations.

7.  Dental services performed in the facilities owned and operated by
    the organization are limited to those procedures that are approved
    by the governing body.

8.  Dental procedures are performed only by dental health professionals
    who are licensed to perform such procedures within the applicable
    state or jurisdiction; and have been granted privileges to perform
    those procedures by the governing body of the organization (in
    accordance with the Handbook, Chapter 2.11).

9.  Personnel assisting in the provision of dental services are
    appropriately qualified and available in sufficient numbers for the
    dental procedures provided.

10. An appropriate history and physical is conducted and periodically
    updated, which includes an assessment of the hard and soft tissues
    of the mouth.

11. The organization develops policies and procedures related to the
    identification, treatment and management of pain.

12. The necessity or appropriateness of the proposed dental
    procedure(s), as well as alternative treatments and the order of
    care, have been discussed with the patient prior to delivery of
    services.

13. The informed consent of the patient is obtained and incorporated
    into the dental record prior to the procedure(s).

14. Imaging services provided or made available meet all the standards
    of Chapter 17 of the handbook and the organization has guidelines to
    address the type, frequency and indications for diagnostic
    radiographs.

15. The organization has a mechanism in place to evaluate and monitor
    dental products that the organization makes available for sale to
    patients to ensure such practices are done in an ethical manner.

Programmatic components that are likely to receive attention during a
AAAHC survey include the following:

-   Appointment system/procedures

-   Peer review and Privileging activities for providers

-   Nitrous oxide and sedation protocols

-   Instrument sterilization, including sterilizer monitoring,
    instrument storage

-   Ensure that the clinic is clean and that standard infection control
    practices are in place and practiced by all employees.

-   Safety protocols, including staff knowledge of facility "code"
    responses, and facility emergency response protocols for various
    safety situations.

-   Emergency protocols, including drug kits and emergency oxygen
    supplies

-   Drug storage and expiration dates, including both proper storage of
    material (i.e. temperature) as well as security of certain items
    such as anesthetic, pharmaceuticals, and anesthetic needles and
    syringes.

-   Facilities and biomedical maintenance

-   Policy and Procedure manuals (with approval at a higher level of the
    organization)

-   Medical records documentation, including protocols for insuring
    continuity of care in the event that patient dental charts are
    separate from patient medical charts, and compliance with local and
    IHS standards.

-   Informed consent -- along with a clearly defined policy and
    procedure on informed consent within your Departmental manual,
    informed consent forms should be available for review. Forms for
    oral surgery, endodontics, nitrous oxide use, and conscious sedation
    should all be considered for use within a dental department. As
    physically marking surgical sites intraorally can be impractical due
    to many factors, a patient informed consent form should be
    considered that includes a visual representation of the mouth,
    enabling patients to mark the effected area (i.e. the tooth to be
    extracted) on the form, in an effort to ensure proper treatment is
    completed.

-   Official policy/guidelines to address type, frequency and
    indications for diagnostic radiographs taken.

-   Ensure that at least one quality assurance study is ongoing in the
    dental program, and that this quality assurance study follows the
    format of:

    -   Identify/quantify a problem -- use RPMS or other database to
        obtain data to support the problem.

    -   Propose solutions/interventions that may improve the problem.

    -   Implement the interventions and re-evaluate in a specific time
        period.

    -   After re-evaluation, make recommendations for further
        improvement to the problem.

    -   Implement revised interventions and continue steps the above
        steps (see the following section for more detailed information
        on the PDCA cycle of quality improvement).

Of course, for complete preparation for an AAAHC survey, thorough review
of the AAAHC Accreditation Handbook for Ambulatory Health Care should be
completed.

**An In-Depth Look at Quality Improvement**

The preceding pages of this chapter, along with the associated
Appendices, give the reader an overview of quality assessment and
evaluation. However, all of these steps, even taken together, are not
adequate to meet the standards set by the JCAHO and the AAAHC. To do
this, the dental program needs to move beyond quality assessment and
into the realm of Continuous Quality Improvement (CQI) or Performance
Improvement (PI).

Some dental programs may have the time, expertise, desire, and resources
to apply CQI/PI principles to the entire program. At minimum, whenever a
significant change is made in a program, such as changing staffing
patterns, changing hours of operation, changing the appointment system,
etc., CQI/PI principles should be used to identify desired outcomes from
the changes and measure progress towards those outcomes.

This section of the chapter will provide background and tools to help
the dental program manager who chooses to do so take those additional
steps towards continuously improving quality.

**CQI/PI** **Details**

[Quality improvement process (PDCA cycle)]{.underline}

![](media/image1.jpeg){width="2.0833333333333335in"
height="1.4895833333333333in"}

Continuous improvement requires that the improvement process be ongoing.
Organizations plan change (**P**lan), pilot test improvements (**D**o),
analyze results of the test (**C**heck), and institutionalize the change
(**A**ct). The improvement process then continues from this new baseline
of performance. [The following internet websites give examples of the
PDCA cycle and its use:]{.mark}

<http://www.isixsigma.com/me/pdca/>

<http://www.hci.com.au/hcisite2/toolkit/pdcacycl.htm>

QI requires a balanced approach wherein planning, doing, checking and
acting are all given the attention they deserve. It is common in our
society to act without sufficient planning and to try to jump directly
from problem identification to the solution. In doing so, the potential
for success is compromised and rework or major changes may be required.
This situation can be minimized with sufficient and comprehensive
planning. This is one of the reasons why data collection and analysis
methodologies should be built into every process within the health care
system.

The QI process improvement model is one that process improvement teams
will follow to define and solve problems and improve processes. Like any
model, it will not be followed exactly the same way every time. In fact,
PDCA is but one of many ways to conduct QI activities; it is presented
here in some detail because it is the most commonly used method in
health care today. Regardless of which model is used, it is imperative
to realize that the process is a cycle that is repeated over and over to
maximize and sustain improvements. The process must be on-going and
continuous.

[Data Collection]{.underline}

Data collection methodologies should be designed into each process and
service used within the clinic to facilitate future study of that
process or service.

Collection of data on clinical services can be accomplished by:

-   chart reviews, if a paper-based patient health record is used

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-   computer if an electronic patient record is used

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-   direct observation of clinical procedures.

Extraction of clinical data will be much simpler and less consuming of
time and other resources if electronic data files of all services
delivered to patients are available.

The systems and processes through which the clinical services are
delivered have a great impact on the ultimate quality of those services.
Therefore, it is necessary to monitor and evaluate those systems and
processes on an ongoing basis to maximize quality. Data on patient
visits, broken appointments, ordering of supplies, etc., can be gathered
by the use of check sheets in an ongoing fashion or can be extracted
from computer records if your systems are designed to allow it.

[Data Analysis]{.underline}

From all the tools available to help with quality improvement
activities, there are seven basic quality tools that can help teams as
they become involved in the quality improvement effort. They are devices
useful to help clarify quality issues, analyze data, and improve
processes. The difficulty is not in learning how to use each tool (that
is fairly simple), but when to use which tool. Experience on teams
solving problems and on-going team facilitation and support will make
deciding when to use each tool less difficult.

The seven basic quality tools are the following:

-   Flow chart

-   Cause and Effect or Ishikawa or Fishbone diagram

-   Pareto Chart

-   Scatter Diagram

-   Histogram

-   Run Chart

-   Control Chart

***Flow Chart***

A flow chart is a visual representation of the flow of work within or
through a work area. A flow chart can be used to describe a process
resulting in a service or a product. It is used to identify how the work
progresses, where decisions are made in the process, and what the final
outcome is. It can also identify who is involved.

The major components of a flow chart are:

-   Beginning activity (start)

-   Activity descriptions

-   Process flow

-   Decisions

-   Ending activity (stop).

[Click on the following links for more information on flow
charts]{.mark}:

<http://deming.eng.clemson.edu/pub/tutorials/qctools/flowm.htm>

<http://www.mcli.dist.maricopa.edu/authoring/studio/guidebook/flow.html>

![](media/image2.png){width="3.504861111111111in"
height="4.481944444444444in"}

The benefits of a flow chart include the following:

-   Helps team members better understand the importance of each
    individual part of the process and how each part fits into the whole

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-   Helps team members to see more clearly the interdependence of the
    process parts

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-   Allows team members to identify opportunities for establishing
    process requirements, measurements and control

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-   Can help everyone involved in the process understand everyone
    else\'s involvement. This can improve:

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-   Communication

-   Customer supplier relationships

-   Employee support of the quality effort

A flow chart provides excellent documentation of how a process works and
can be a useful tool to help team members uncover potential sources of
trouble. Flowcharts are pictorial representations of a process. By
breaking the process down into its constituent steps, flowcharts can be
useful in identifying where errors are likely to be found in the system.

***Cause and Effect Diagram***

[Click on the following links for additional information on cause and
effect diagrams]{.mark}

<http://www.skymark.com/resources/tools/cause.asp>

<http://www.isixsigma.com/library/content/t000827.asp>

![](media/image3.png){width="5.995138888888889in"
height="3.363888888888889in"}

A cause and effect diagram is used to categorize and display causes of
quality problems and thereby help team members to identify potential
areas for improvement. This diagram, also called an Ishikawa diagram (or
fish bone diagram), is used to associate multiple possible causes with a
single effect. Thus, given a particular effect, the diagram is
constructed to identify and organize possible causes for it.

The primary branch represents the effect (the quality characteristic
that is intended to be improved and controlled) and is typically labeled
on the right side of the diagram. Each major branch of the diagram
corresponds to a major cause (or class of causes) that directly relates
to the effect. Minor branches correspond to more detailed causal
factors. This type of diagram is useful in any analysis, as it
illustrates the relationship between cause and effect in a rational
manner.

A cause and effect diagram:

-   represents the relationship between an \"effect\" and its \"causes\"

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-   specifies possible causes for an effect

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-   visually organizes the causes into categories

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-   aids in analyzing complex problems

The cause and effect diagram has a number of uses. Some are:

-   sorts and segregates the possible causes of a problem into logical
    categories

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-   identifies areas for data-gathering activity

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-   educates participants in the problem solving process

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-   serves as a guide for discussions and serves to keep meetings on
    target

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-   can be developed into a complete project management tool that
    displays actions taken and results achieved

######### Pareto Diagram

[Click on the following links for additional information on Pareto
Charts]{.mark}

<http://mot.vuse.vanderbilt.edu/mt322/Pareto.htm>

<http://www.dartmouth.edu/~ogehome/CQI/Pareto.html>

![](media/image4.png){width="5.560416666666667in"
height="3.8534722222222224in"}

The Pareto diagram is used to help team members identify the most
significant causes related to process performance and can, therefore,
help with decisions about which factor to address first.

The Pareto diagram is a bar chart with frequency or cost displayed on
the vertical axis and causes on the horizontal axis. The causes are
ordered along the horizontal axis from most to least frequent (or
costly). There is a cumulative line chart above the bars that indicates
the cumulative contribution of each cause to the total of all causes.
They are created by plotting the cumulative frequencies of the relative
frequency data (event count data), in descending order. When this is
done, the most essential factors for the analysis are graphically
apparent, and in an orderly format.

Pareto charts are extremely useful because they can be used to identify
those factors that have the greatest cumulative effect on the system,
and thus screen out the less significant factors in an analysis.
Ideally, this allows the user to focus attention on a few important
factors in a process.

A Pareto diagram can help team members

-   determine relative importance of problems

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-   recognize priority order of problems

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-   choose a starting point for problem analysis

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-   display the results of improvement projects when diagrams are
    compared in a before/after context

The Pareto diagram illustrates what is known as the 80/20 rule. The
diagram is named after Vilfredo Pareto, an Italian economist who noticed
that in any economic system, about 80% of the wealth is held by about
20% of the people. Juran extended this idea to the analysis of problems
in general. In any problem situation, about 80% of all problems come
from about 20% of the possible categories or causes. The trick is to
find those 20% and to separate them from the other problem sources.
Juran refers to this idea as the \"vital few\" and trivial many.

***Scatter Diagram***

[Click on the following link for additional information on Scatter
Diagrams]{.mark}

<http://web2.concordia.ca/Quality/tools/25scatter.pdf>

![](media/image5.png){width="4.3284722222222225in"
height="2.1222222222222222in"}

Scatter diagrams are used to determine if there is a relationship
between two variables by plotting paired data for the variables on a
vertical and horizontal axis. The scatter diagram can help team members
understand the type of relationship that exists (if any) and the
strength of that relationship.

While a scatter diagram may be used to help determine whether a cause
and effect relationship exists between two variables, it will not prove
that one variable causes the other. It will only demonstrate whether
there is (or is not) a relationship.

***Histogram***

[Click on the following link for additional information on
Histograms]{.mark}:

<http://www.skymark.com/resources/tools/histograms.asp>

![](media/image6.png){width="3.6458333333333335in"
height="4.520833333333333in"}

A histogram is a bar graph that depicts how much variation there is in a
collection of data and, therefore, in the process being studied. The
height of each bar shows the number of data points falling within that
interval. There is some variability in all processes and the histogram
can help team members understand that variability. Histograms provide a
simple, graphical view of accumulated data, including its dispersion and
central tendency. In addition to the ease with which they can be
constructed, histograms provide the easiest way to evaluate the
distribution of data.

Histograms are used:

-   to display the shape of the distribution of data

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-   to show the pattern of variation in a process

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-   to summarize and communicate variable data effectively

######### Run Chart

[Click on the following link for additional information on Run
Charts]{.mark}

<http://hcpc.uth.tmc.edu/pihome/tools/flowchart4.htm>

![](media/image7.png){width="5.052083333333333in"
height="2.8645833333333335in"}

Run charts show changes in the way a process works during a period of
time. A quality characteristic is selected, monitored, and plotted at
equal intervals for the length of the study.

A run chart is one of the simplest tools to construct. Data are plotted
in time order, so the graph aids in understanding how basic
characteristics of a process vary and, therefore, how process
performance can vary.

***Control Chart***

[Click on the following link for additional information on Control
Charts]{.mark}

<http://www.hci.com.au/hcisite2/articles/salesup.htm>

<http://deming.eng.clemson.edu/pub/tutorials/qctools/ccmain1.htm>

<http://erc.msh.org/quality/pstools/pscchrt1.cfm>

![](media/image8.png){width="5.998611111111111in"
height="2.7493055555555554in"}

The control chart is the fundamental tool of statistical process
control, as it indicates the range of variability that is built into a
system (known as common cause variation). Thus, it helps determine
whether or not a process is operating consistently or if a special cause
has occurred to change the process mean or variance.

The bounds of the control chart are marked by upper and lower control
limits that are calculated by applying statistical formulas to data from
the process. Data points that fall outside these bounds represent
variations due to special causes, which can typically be found and
eliminated. On the other hand, improvements in common cause variation
require fundamental changes in the process.

The purpose of constructing control charts is to allow the detection of
any trends or changes in processes.

A control chart differs from a run chart in that control limits are
statistically calculated for the process based on its typical
performance. The data are plotted and compared to these limits. The
control chart can help team members determine when a process is
operating within expected limits of variation or when something unusual
has occurred. It can also be used to monitor the effects of process
improvements.

The centerline of a control chart is the mean of the sampling
distribution. The upper and lower control limits, called 3-sigma limits,
are calculated as the mean plus or minus three times the standard error
of the mean.

In summary, a control chart:

-   displays the expected range of variation in a stable process.

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-   depicts relative stability of a process.

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-   assists team members with process analysis by illustrating when
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-   shows effects of process control and process improvement efforts.

[Communicating Results of QI activities?]{.underline}

The end result of effective QI activities will be the delivery of
superior services to the population you serve. While this is an
excellent end product in and of itself, you should not stop with the
knowledge that you are doing a superior job. Share the results of your
quality activities with your staff and the community you serve.

QI activities take time, and most or all of your staff will be involved
in them at some time or another. Sharing the results with staff lets
them know what has been accomplished, and allows those involved to
receive some recognition for their work. One tool used frequently in
both industry and in health care is the use of posters or storyboards.

Storyboards can be posted in public areas of the clinic or in staff-only
areas, depending on whether or not you want to share the results with
the public. Storyboards serve as a simple graphical representation of
the nature of the process being improved, the steps that were taken, and
the results that were obtained. Staff will usually be more willing to
participate in QI activities if they can see the benefits of their work.

[Click on the following links for more information on
storyboards]{.mark}:

<http://gunston.doit.gmu.edu/healthscience/708/storyindx.htm>

<http://www.hc-sc.gc.ca/ewh-semt/alt_formats/hecs-sesc/pdf/occup-travail/radiation/dosim/storyboard-maquette_e.pdf>

Great benefits can also be realized by sharing the results of
improvement projects with the public. Patients will appreciate knowing
that the clinic is making efforts to ensure the quality of the services
you provide. If your clinic provides any of its services through the use
of volunteers, the knowledge that your clinic strives for quality should
help recruitment and retention of volunteers. Include your results in
newsletters. If you become accredited, report successful accreditation
surveys to the local press and media.

> Additional Resources

-   JCAHO <http://www.jcaho.org/>

-   AAAHC <http://www.aaahc.org/>

-   National Committee for Quality Assurance (NCQA)
    <http://www.ncqa.org/>

[]{.mark}

[The following internet website provides links to numerous sources of
information about]{.mark}

[quality improvement]{.mark}: <http://www.mytapestry.com/qlinks.html>

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, an outside contractor, an usually done by aons *The Law of Hospital
and Health Care Administration*, (Second Edition, Health Administration
Press, 1988), pages 657 -- 666, "members of a peer review, credentials,
or similar committee and those who transmit information to a committee
will at least be protected by a qualified or conditional privilege for
all statements made in good faith, under proper circumstances, and
transmitted only to persons having a legitimate interest in the subject
matter."

IHS

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**Dental Program Management QI**

The systems and processes of healthcare delivery account for nearly 85%
percent of the problems that have been identified in accreditation
surveys by the JCAHO. Improving administrative functions can therefore
have a significant impact on the overall quality of the services
provided by the dental program.

In traditional QA reviews, the aspects of care that were selected for
retrospective review were those that were high volume, high risk, and/or
problem prone. These criteria can be used to determine where to best
focus limited resources to achieve the maximum gain. Administrative
functions that should be considered include, but are not limited to the
following:

-   purchasing/inventory management including expiration dates of
    supplies

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-   referrals and the continuum of care

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-   appointment system, including broken appointments

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-   patient complaints

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-   recruitment and retention of staff

-   patient satisfaction

-   GPRA

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-   other

[Purchasing/Inventory Management]{.underline}

The clinic will need to either maintain stocks of dental supplies and
materials or rely on just-in-time ordering. The former method of
inventory management requires adequate space to store supplies, and the
latter method requires an efficient inventory tracking system and
ordering system. If either method fails, clinical care can suffer due to
lack of adequate or appropriate supplies to provide scheduled services.

The quality and effectiveness of the inventory management system
therefore should be monitored. A simple way to do so is to maintain a
log of the system. Items that can be tracked on the log include, but are
not limited to the following:

-   stocked supplies that go out of date before being used

-   frequency of emergency purchases (which usually cost more than
    routine purchases)

-   just-in time orders that are not received on time (compare with the
    number that are received on time to measure the effectiveness of
    your system and your suppliers)

-   the turn-around time for receipt of orders from your various
    suppliers

-   number of times that supplies run out

[Referrals and Continuity of Care]{.underline}

Maintain a log of all biopsies performed, when where the specimens were
sent, when the results were received, final diagnosis, when the patient
was notified of the results, and any follow-up provided. Review the log
at least quarterly to insure that your biopsy protocols are being
followed.

Maintain a log of all referrals made to other medical/dental
professionals and any consultations or reports received from these
referrals. Review the log on a regular basis to insure that appropriate
follow-up is being provided on all referrals.

[Appointment System, Including Broken Appointments]{.underline}

Probably no other system within your clinic will have as much influence
on your ability to meet your mission as the appointment system. Many
dental clinics find that their ability to provide services is
overwhelmed by the demand for those services, and the appointment system
is the gateway through which most of the clinic's patients enter into
treatment. When demand is greater than the clinic's ability to provide
appointments, broken appointments not only decrease the efficiency of
the provision of services, they also limit access to those people who
are trying to get into the appointment system.

The clinic should keep a log of broken appointments and track them as a
percentage of the total appointments scheduled. This can be done by
physically counting the number of broken appointments on a daily or
weekly basis, or by doing a computer search for broken appointments if
your information systems allow you to do so.

Another easy way to track broken appointments is to graph the number per
day or week longitudinally over time. Any changes in the number of
broken appointments per unit time will be readily apparent in graphical
form. Since many clinics have found that broken appointments tend to
increase as the time interval between appointments increases over three
weeks, the broken appointment rate should be compared with how far in
advance appointments are scheduled. Other comparisons, such as with the
arrival of new staff, changes in clinic hours, etc., should also be made
to help you determine the most effective and efficient parameters for
your appointment system.

[Patient Complaints]{.underline}

Patient complaints can be a valuable source of information about how
your patients view the clinic. The clinic should maintain a log of all
verbal and written complaints received. The log should include the date
of the complaint, the nature of the complaint, who handled the
complaint, how and when it was resolved, and whether or not the patient
was satisfied with the solution. Track the log on at least a quarterly
basis to see if there are any trends in the nature of complaints being
received. If trends do occur, try to find ways to improve the process or
system that is the subject of the complaints.

[Recruitment and Retention of Staff]{.underline}

The costs of recruiting, orienting, and training staff are high, as are
the costs of downtime when staff are not available. One method to help
with staff retention is to conduct structured interviews or surveys with
all departing staff to ascertain their reasons for leaving, and then
analyze and use the information to improve your staff retention program.

[Click on the following link to read more about exit interviews]{.mark}:

<http://www.nobscot.com/about/what_is_an_exit_interview.cfm>

[Click here for examples of exit survey instrument]{.mark}s:

<http://www.rdc.noaa.gov/~hrmo/exit-sample.htm>

<http://www.psc.gov/survey/exit/exit_1.htm>

Job satisfaction is a major determinant of staff retention. Dentistry is
currently in an era where over 6000 dentists are leaving the profession
annually and only around 3000 new dentists are entering the profession
each year. If a dentist is dissatisfied with his/her job at the clinic,
there are countless opportunities for him/her elsewhere. In many areas
of the country, there are also shortages of dental hygienists and
trained dental assistants. The routine use of staff satisfaction surveys
will allow the administrator of the clinic to identify problems and
trends before they lead to loss of staff.

Staff satisfaction surveys should provide the following benefits:

-   Provide information on which to base actions directed to

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-   Improve quality of service

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-   Improve employee retention

-   Reduce employee sick leave or other absences

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-   Demonstrate management's commitment to listening to employees views

-   Fulfill commitment made to a union or other employee representative
    body

Staff satisfaction surveys should be developed, administered, analyzed,
and utilized in much the same manner that will be described for patient
satisfaction surveys in the next section. You must assure that all
responses on staff satisfaction surveys are anonymous so that staff will
not feel threatened if they provide negative answers or other criticism
of the clinic, its administrators, or its programs.

Topics frequently included in staff satisfaction surveys include the
following:

-   Management/supervision

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-   technical competence

-   management skills

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-   sense of achievement

-   training and development

-   working conditions

-   job security

-   communication

-   recognition

-   compensation

-   attitude to quality

-   attitude to customer satisfaction

-   fulfillment of personal goals

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-   identification with organization and its goals

-   career progression

-   teamwork

[Patient Satisfaction]{.underline}

In recent years, patient satisfaction has become one of the most studied
patient outcomes. A well-constructed patient satisfaction survey will
reveal much about the positive and negative aspects of your program; it
will tell you if you are meeting the perceived needs of your service
population.

One frequently-used method to begin the development of a patient
satisfaction survey is to assemble a focus group consisting of key staff
members, patients, and other community members. Through group processes
such as brainstorming, nominal group process, and multi-voting, this
focus group can arrive at a group of topics that are of concern to the
staff, administration, and clinic users. Questions for the survey can
then be developed from the list of topics that the focus group agreed
on. Once the survey instrument has been completed, the focus group can
also be used to pilot test the instrument to ensure that it is gathering
the information that the group wants to collect.

[Click on the following internet links to view descriptions and
definitions of the group processes mentioned above:]{.mark}

<http://www.jpb.com/creative/brainstorming.html> for information on
brainstorming

<http://www.rand.org/publications/MR/MR1267/mr1267.appe.pdf> for
information on the nominal group process

<http://www.aafp.org/fpm/990500fm/improving.html> for additional
information on the nominal group process

There are few scientifically validated patient satisfaction surveys
available for ambulatory health care in general or dentistry in
particular, and every clinic and service population will have unique
problems and concerns, so you will probably need to develop your own
survey instrument.

-   Consider the average educational level of the population for which
    it is intended. Questions should be understandable to the majority
    of those who will fill it out, without being condescending.

-   If your service population is bilingual or multi-lingual, translate
    the survey into the appropriate languages, without introducing
    misunderstanding or bias.

-   State all questions clearly and concisely.

-   Word questions neutrally so as to not lead the respondent to a
    desired answer or otherwise introduce bias.

-   Simple yes/no or true/false questions are easily interpreted and
    easy to analyze, yet fail to identify areas in the middle.

-   Many patient satisfaction surveys use the five point or seven point
    Likert scale to attempt to quantify the middle ground.

-   Multiple choice responses and written answers can also be used, but
    they tend to be more difficult to analyze statistically.

-   Ask for comments and suggestions at the end of the survey;
    respondents are likely to point out areas of concern or satisfaction

-   Keep it short and simple (one page or less whenever possible); your
    user population will be more likely to participate if it does not
    take too much time

Use a font of at least 12-14 points to make it easy to read

[Click on the following links for examples of dental patient
satisfaction surveys]{.mark}:

[www.usetinc.org/images/images_sub/114/CHS%20**Patient**%20**Satisfaction**.doc](http://www.usetinc.org/images/images_sub/114/CHS Patient Satisfaction.doc)

<http://www.nvo.com/emisar/patientsatisfactionsurvey/>

[http://www.dentalclinicmanual.com/chapt5/section_03/topic_03/attachments/DoD%20pt%20sat%20survey%20form.pdf](http://www.dentalclinicmanual.com/chapt5/section_03/topic_03/attachments/DoD pt sat survey form.pdf)

The manner in which you administer a survey will greatly influence the
results you receive. You should choose the method that you feel will
give you the most valid results.

-   All responses must be completely voluntary

-   Administration of the survey must be random

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-   Assure respondents that their care at the clinic will not be
    impacted by their willingness or refusal to participate in the
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-   given to patients in the clinic as they complete their appointment

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-   mailed to a random sample of registered users

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-   administered by a trained surveyor, either by phone or in person (in
    the clinic or at the respondent's home), who poses the questions and
    then marks answers on the form

If your clinic does block scheduling (e.g., all pediatric patients on a
certain half day, or all restorative patients on a certain day), then
the patient mix on any given day will be influenced by the block being
scheduled. Therefore, if the survey is presented to patients as they
complete their appointments, you will need to ensure that a random
sampling of all of your patients is obtained by conducting the survey on
several days of the week.

Bias can also be introduced by only surveying the users of the clinic
and not seeking responses from those who are eligible to use your
services but choose not to. Valuable information can be obtained from
non-users. Therefore, you may want to consider a community-based survey
rather than a clinic-based one. If the community has a local college or
university, or a health professions school or school of public health,
you may be able to utilize local students to conduct a community-based
survey as part of a class assignment or internship.

A Likert scale measures the extent to which a person agrees or disagrees
with the question. The most common scale is 1 to 5. Often the scale will
be 1=strongly disagree, 2=disagree, 3=not sure, 4=agree, and 5=strongly
agree. If true/false or Likert scale responses are used in your survey,
then a simple frequency distribution of the responses for each question
is a simple and effective method to analyze the responses.

[Click on the following internet links for more information in the use
of Likert scales:]{.mark}

<http://www.cultsock.ndirect.co.uk/MUHome/cshtml/psy/likert.html>

<http://www.icbl.hw.ac.uk/ltdi/cookbook/info_likert_scale/>

If the survey was designed to allow easy data entry, then the analysis
of the data by a spreadsheet, database, or statistical software will
simplify the process. As a general rule of thumb, any question that
yields a negative response rate of greater than ten percent of the
respondents identifies an area that should be further investigated as
part of the clinic's QA/I process.

It is generally a good idea to repeat the survey at least twice a year.
Whenever possible, the same questions, worded the same way, should be
used on subsequent surveys to allow for the identification and tracking
of trends. If the wording of questions is changed, then the meaning to
the respondents may change enough to make the responses no longer
comparable from survey to survey. If new items of concern arise between
surveys, then new questions can be added, and items that are no longer
of concern can also be dropped.

Results of patient satisfaction surveys can be most useful in providing
direction for your QA/I program. As indicated in an earlier paragraph,
areas of significant dissatisfaction among your clinic users point to
problems that should be addressed. Areas where the responses from survey
to survey show a negative trend are also areas where QA/I activities
could be focused. Conversely, if your QA/I program addresses an area of
dissatisfaction, and subsequent surveys show positive trends or
resolution, then that question can be dropped from the survey
instrument.

Autodata Systems, on the internet at <http://www.autodata.com/>, offers
a package of software, *Survey Plus 2000*, and a scanner that will
create and read survey forms and automatically compute frequency
distributions and other statistics. While a system such as this is not
necessary, it can save significant time in compiling and analyzing
survey data.

[Click on the following links for examples of dental patient
satisfaction surveys currently in use.]{.mark}

<http://www.dentalclinicmanual.com/chapt5/section_03/topic_03/001-frameset.html>

[http://www.dental.washington.edu/accred2002/Standard%205/Standard%205%20Appendices/5-1K%20Patient%20Satisfaction%20Survey%20and%20Report.pdf](http://www.dental.washington.edu/accred2002/Standard 5/Standard 5 Appendices/5-1K Patient Satisfaction Survey and Report.pdf)

[Other monitoring and assessment activities]{.underline}

-   Sterilizer monitoring

-   X-ray developer

-   Waterline decontamination

-   Curing light intensity

-   Preventive maintenance

-   Licenses and certifications (Credentials Review)

-   Emergency kit expiration dates

-   Fire drills

-   Fire extinguishers

-   Emergency oxygen canisters

-   Nitrous oxide/oxygen conscious sedation units

-   Infection Control

-   Refrigerator temperatures

-   X-ray dosimetry badges

-   other

######## Summary

Quality Improvement can be an integral part of the operations of any
dental program. QI is an ongoing process that should be designed into
every system and process of the organization so that it becomes the
normal way of doing business rather than just a paperwork burden. QI
requires the participation and input of all employees and is best
conducted through team-related activities. While some processes need to
be monitored on a regular basis (daily, weekly, quarterly, etc.), all
functions of the organization should be reviewed at least annually to
ensure that they are performing according to QI plans, strategic plans,
or other organizational objectives.

**APPENDIX I**

**RESPONSIBILITIES AND GUIDELINES FOR IMPLEMENTING**

**THE QUALITY ASSESSMENT SYSTEM**

**Responsibilities And Guidelines For Implementing The Quality
Assessment System**

1.  The overall responsibility for the quality of health care in the
    Area lies with the Area Director, with specific responsibility for
    quality of dental care falling to the Area Dental Consultant or
    other senior Dental Program staff. Other programs implementing this
    system will have administrative lines of authority which will modify
    this requirement. The Chief dentist of every program, however,
    should assume the responsibility for the day-to-day quality of the
    program and services provided.

2.  Private dentists or dental hygienists under IHS contractual
    agreement working in IHS or Tribal clinics should be evaluated
    periodically by a trained evaluator, utilizing the methodology
    described in this chapter and standard IHS evaluation
    criteria/indicators. The need for such reviews should be spelled out
    in the provider's contract, and contract providers should be
    oriented to the review standards/criteria at the time they start
    working.

3.  The person being evaluated must be provided the criteria/indicators
    and standards for the evaluation prior to the evaluation. No
    evaluation can be conducted upon services provided or methods
    employed prior to the time the person being evaluated was provided
    the criteria and standards for the evaluation.

4.  The evaluation will be by personal contact between the evaluator and
    person being evaluated and review of existing records as
    appropriate.

5.  Contact with the Service Unit Director or the Tribal Health
    Administrator is a requirement before the evaluation. A sample
    letter for follow up of this contact is suggested in Appendix VIII.

6.  Tact and discretion must be preeminent throughout the evaluation
    process. The dignity of the person being evaluated must be preserved
    in all instances.

7.  When the quality of a service provided is considered questionable by
    the evaluator, but is not definitely unsatisfactory, the decision
    must be in favor of the person being evaluated and rated
    satisfactory.

8.  Differences in training backgrounds are recognized as sources of
    potential philosophical differences in criteria for dental
    procedures performed by dental practitioners. Differences may also
    arise between the evaluator and person being evaluated as to the
    extent or significance of a deficiency for any criterion. A
    mechanism is provided for addressing these differences. If
    concurrence of satisfactory or unsatisfactory cannot be agreed upon
    through discussion between the evaluator and person being evaluated,
    the criterion will not be counted as unsatisfactory. However, the
    nature of the dispute concerning the criterion will be documented in
    a narrative summary. Where it is possible that the discussion of the
    disputed criterion can take place without the person being evaluated
    returning to observe the deficiency, discussion of the disputed
    criterion will be delayed until the closeout meeting. This process
    can be applied to any disputed criterion in Chapter VII.

9.  The evaluation must include a confidential closeout meeting where
    all reports are signed by both the evaluator and person being
    evaluated. Reports for each survey tool are included in the
    respective appendices.

10. The person being evaluated and responsible administrative
    authorities (Service Unit Director, CEO, Facility Director, Clinical
    Director, Tribal Health Director, and/or other similar titles) must
    be advised of all evaluation findings. Further dissemination of
    findings must be by mutual consent of the person being evaluated and
    responsible administrative authorities.

11. The person being evaluated has the right of appeal for a
    reevaluation by the same or a different evaluator.

**APPENDIX II**

**CRITERIA FOR QUALITY ASSESSMENT BY THE DIRECT OBSERVATION OF PATIENT
CARE**

**Criteria for Quality Assessment by the Direct Observation of Patient
Care**

**General Instructions**

1)  This Technical review tool is designed to assess the quality of care
    provided by an individual provider by direct observation (by a
    trained evaluator) of the services being provided.

2)  The provider being evaluated and the Service Unit/Facility
    director/Tribal Administrator must be notified of the review in
    advance of its taking place. A sample letter is provided in
    Appendix VIII. In all cases, the administrative authority of the
    clinic in question must give permission before the review can be
    performed.

3)  Tact and discretion must be preeminent throughout the evaluation
    process. The dignity of the person being evaluated and of the
    patient must be preserved in all instances. The patient's consent is
    required before the evaluator can check the patient. This is most
    frequently accomplished by the dentist being evaluated introducing
    the evaluator to the patient, explaining the nature of the review,
    and asking if the patient minds having the evaluator observe the
    services being provided. Verbal consent is adequate for this
    purpose.

4)  When the quality of a service provided is considered questionable by
    the evaluator, but is not definitely unsatisfactory, the decision
    must be in favor of the person being evaluated and rated
    satisfactory.

5)  Differences in training backgrounds are recognized as sources of
    potential philosophical differences in criteria for dental
    procedures performed by dental practitioners. Differences may also
    arise between the evaluator and person being evaluated as to the
    extent or significance of a deficiency for any criterion. If
    concurrence of satisfactory or unsatisfactory cannot be agreed upon
    through discussion between the evaluator and person being evaluated,
    the criterion will be marked as "disputed" in the gird and the
    nature of the dispute concerning the criterion will be documented in
    a narrative summary.

6)  The evaluation must include a confidential closeout meeting where
    all reports are signed by both the evaluator and person being
    evaluated.

7)  The person being evaluated and responsible administrative
    authorities must be advised of all evaluation findings. Further
    dissemination of findings must be by mutual consent of the person
    being evaluated and responsible administrative authorities.

8)  The person being evaluated has the right of appeal for a
    reevaluation by the same or a different evaluator.

9)  All criteria must be met to score "Yes"

10) For each category, if procedures were not performed or are not
    applicable, mark NA

**A. Patient Records**

1\) The patient dental records are part of the patient's primary health
care record, and

1.2) the health record is available for review.

*Method to Assess Criterion:* Review of the primary health record.

> *Note:* Criterion #1 does not apply in certain locations where the
> dental clinic is not attached to an outpatient medical facility.
> However, the primary health record should still be accessible for
> review.

2\) The patient's dental health record contains a current (completed
within the last year) health questionnaire containing items of specific
significance to dental practice.

2.1) Documentation exists in the patient record that this information
was updated annually and

2.2) reviewed by the dentist at each visit, with documentation of
changes or "no changes" in the patient's medical status.

> *Method to Assess Criterion:* Review the patient dental record for a
> health questionnaire containing, at a minimum, questions on current
> M.D. care, recent illnesses, cardiovascular disease (including
> rheumatic fever), liver disease, diabetes, convulsions/seizures, drug
> allergies, latex allergy, bleeding tendencies, current medications,
> harmful habits, pregnancy, blood transfusions, and sexually
> transmitted diseases.

3\) For each "Yes" response on the health questionnaire there is
documentation that follow-up questions have been asked.

> *Method to Assess Criterion*: Review the Dental Progress Notes for
> follow-up information related to each "Yes" response on the health
> questionnaire.

4\) All entries in the patient dental record are recorded in ink.

*Method to Assess Criterion:* Review of patient dental record.

5\) All entries recorded in the patient dental record follow
instructions for completing Form IHS 42-1. Services rendered are
recorded on the Dental Progress Notes (Form IHS 42-2) in sufficient
detail to determine: date of service, tooth/teeth, quadrant/sextant,
type of local anesthetic, local anesthetic dosage in milligrams, name
and dosage of other drugs administered, materials used, complications,
provider (signature and degree), procedure code, and fee, if applicable.
Universally understood symbols or a key are provided in clinic protocols
for understanding the recording. Abbreviations used are approved by the
Medical Staff.

*Method to Assess Criterion:* Review of patient dental record.

6\) For emergency visits the SOAP (or similar) format will be used in
sufficient detail to document chief complaint, objective findings,
diagnosis, and treatment plan.

S -- subjective findings, i.e., the chief complaint in the patient's
words (or

paraphrased), such as "it hurts when I chew, patients points to #3."

O -- Objective findings, i.e., the clinical and radiographic findings
such as "tenderness

to percussion tooth #4, or "apical radiolucency tooth #3."

A - Assessment or differential diagnosis, e.g., "acute apical
Periodontitis tooth #4."

P - Plan, or treatment rendered, in adequate detail to stand up in
court.

*Method to Assess Criterion:* Chart review.

**B. Examination and Diagnosis**

1\) Existing hard and soft tissue findings obtained by clinical and
radiographic examination are recorded in patient's dental record.

> *Method to Assess Criterion:* Immediately following the completion of
> the clinical examination provided by the attending dentist, the
> examiner refers to the patient's dental record and clinically examines
> the same patient. The same light, mouth mirror, and explorer used by
> attending dentist are used by the examiner. Determine if radiographic
> findings are identified and recorded.

2\) Other diagnostic aids such as pulp testing, cytology, biopsy, or
blood pressure screening are used and recorded in the patient record
when indicated.

> *Method to Assess Criterion:* Review patient dental record for
> appropriate use of other diagnostic aids. Review patient dental record
> for appropriate use of other diagnostic aids. A blood pressure
> screening is to be performed on all patients at their first visit
> (exam or emergency) within one year of the last blood pressure
> screening. This applies to patients age 18 and older. For those
> patients with a history of hypertension, those currently being treated
> for hypertension, or those who are diabetic, the blood pressure
> screening should be performed at each visit regardless of age.

3\) Diagnosis is consistent with findings.

*Method to Assess Criterion:* Chart review.

4\) A plan of treatment is available in the patient dental record

4.1) and follows, in general, the following order:

> a\. Relief of pain and discomfort, including nonelective surgery.
>
> b\. Elimination of infection and factors predisposing to pathologic
> conditions.
>
> c\. Thorough prophylaxis, instruction in oral hygiene, and other oral
> disease preventive therapies.
>
> d\. Treatment of caries.
>
> e\. Non-surgical periodontal treatment which is incremental and based
> on assessment of the patient.
>
> f\. Elective care.
>
> g\. Documentation of patient acceptance of treatment plan, including
> signed consent by patient, parent, or legal guardian.
>
> h\. Scheduling of minimum of appointments to complete treatment.
>
> *Method to Assess Criterion:* In evaluating the plan of treatment,
> take into account the choice of treatment, the types of restorations,
> and the age, sex, and general health of the patient. The plan should
> reflect progressive changes in the patient's dental status as each
> phase of treatment is to be completed. The plan should be sufficiently
> flexible so that it may be altered to accommodate unanticipated
> results of previous treatment. The plan should be considered tentative
> and subject to modification throughout the course of treatment. Any
> changes in the treatment plan require documentation.

4.2) Treatment plan is consistent with diagnosis.

> *Method to Assess Criterion:* Chart review.

5\) A Screening Exit Exam will be conducted during the last visit for
all routine patients.

> *Method to Assess Criterion*: Chart review and direct observation. It
> is strongly recommended that the Screening Exit Exam for both caries
> and periodontal status be included in the patient\'s initial treatment
> plan. The exit exam must include a final CPITN for those patients who
> were initially diagnosed with any sextants of CPITN 2, 3, or 4.

**C. Radiographs**

All radiographic exposures shall be ordered by the dentist according to
patient conditions, or meet written criteria for type and frequency
described in the clinic policy. The types and frequency of radiographs
should meet the following broad classifications:

1.1) Initial Adult:

> An initial radiographic examination, consisting of posterior bitewings
> supplemented with anterior and/or posterior films and/or panoramic
> radiographs, as required by oral conditions, is recommended for all
> individuals *15 years old and older.* Panoramic or full-mouth
> intraoral radiographic films are appropriate when the patient presents
> with clinical evidence of generalized dental disease or a history of
> extensive dental treatment.

1.2) Initial Child:

> Prior to the eruption of the first permanent tooth, bitewing films
> (where interproximal surfaces cannot be visually inspected) are
> supplemented with anterior and posterior periapical films, as required
> by oral conditions. Individualized radiographic examinations consist
> of a periapical/occlusal or panoramic examination when clinical
> evidence or history indicate the need for additional radiographic
> examination. A full-mouth radiographic exam (panoramic or intraoral
> periapical) is performed *beginning at age 9.*

1.3) Recall:

1\. Bite‑wings and/or periapical radiographs should be taken at
intervals as required by the patient's general condition.

2\. In the absence of specific indications for more frequent
radiographs, a panoramic radiograph or full-mouth intraoral periapical
series should not be taken more often then once every five years.

1.4) Emergency Examination:

An appropriate diagnostic radiographic examination of the area in
question.

> *Method to Assess Criterion:* Review of patient dental record, clinic
> policy manual, and observation.

2\) Dental radiographs are mounted,

3\) Dental Radiographs are labeled with the patient's name, chart
number, and date

4\) Dental Radiographs are contained in the patient's dental record.

5\) Density and contrast of radiographs are such that anatomical hard
and soft tissue landmarks can be differentiated.

6\) Radiographic image size is not distorted in the area of the mouth
under study.

7\) Radiographs disclose no overlapping of image in the area of the
mouth under study, except where tooth alignment does not permit open
contacts.

8\) Radiographs disclose no cone‑cutting.

9\) Bitewing radiographs include the distal surface of the erupted
cuspids and mesial surface of the most posterior erupted teeth.

> *Method to Assess Criteria C2 to C9:* Assess the radiographs taken on
> patients present in the clinic during the evaluation visit and/or
> review radiographs taken within the previous six months, selected
> randomly from the files. The radiographs should be viewed with a
> radiographic illuminator (view box). Apply the applicable criteria to
> each radiograph and determine diagnostic acceptability. The anatomy in
> the area under study should be visible and of diagnostic quality.
>
> Criterion C7 is not applicable for the permanent dentition, unless the
> patient is in the clinic for observation of the dentition to rule out
> crowded teeth as a cause of overlapping.
>
> *Note:* If a radiograph has a deficiency which does not compromise the
> diagnostic value, the radiograph will be considered acceptable.
> However, the deficiency should be pointed out to the person being
> evaluated.

**D. Radiological Protection**

1\) All dental auxiliaries who take radiographs will be currently
certified in radiology.

> *Method to Assess Criterion:* Observe posting of current certificate
> or review documentation showing that auxiliaries are certified.

2\) Lead protective devices are used on each patient during all
exposures.

> *Method to Assess Criterion:* Observe directly whether the lead
> protective devices are placed in a manner that will protect the
> patient. The IHS Manual, Section 3 (Professional Services), Chapter 21
> (Medical Imaging Program), 5E(4) (Procedures Applicable to Dental
> Units) and IHS Circular No. 91-2 (Diagnostic X-Ray Radiation
> Protection) both state, \"A thyroid protection shield shall be used on
> children and teenagers during dental radiographic examinations.\". As
> existing lead apron devices need replacement, lead apron devices with
> integrated thyroid shields should be purchased. Thyroid shields shall
> be used if they are currently available in the dental clinic.

3\) The tube housing or cone shall be stationary and

3.1) positioned in close proximity to the film positioning device or
skin of the patient when the exposure is made.

> *Method to Assess Criterion:* Observe directly whether the tube
> housing or cone is stationary and within 1/4\" or less of the film
> positioning device or skin of the patient when exposure is made. Also,
> observe processed radiographs for evidence of blurred images from
> movement of the tube head.

4\) During exposure, radiographic film is not held in position by
attending staff.

> *Method to Assess Criterion:* Directly observe whether attending
> dental staff is holding film in position during exposure.

5\) During exposure, tube housing or cone is not held by attending staff
or patient.

> *Method to Assess Criterion:* Directly observe whether attending staff
> or patient is holding the tube housing or cone during exposure.

6\) Operator is at least six feet from patient and not in the path of
the primary beam or stands behind protective barrier during exposure.

> *Method to Assess Criterion:* Directly observe the distance and
> location of the operator when the x‑ray machine is activated.

7\) Only necessary persons are allowed in radiographic area during
exposure.

> *Method to Assess Criterion:* Directly observe whether unnecessary
> persons are in the x‑ray area during exposure.

8\) A warning signal is given prior to pushing the x‑ray activator
button.

> *Method to Access Criterion:* Directly observe whether operator calls
> out "x‑ray" or gives some other warning prior to activation of
> machine.

9\) Dosimeters (film badges) are worn by all dentists, hygienists, and
dental assistants.

> *Method to Access Criterion:* Directly observe whether a dosimeter is
> worn by each dental staff member.

10\) Protective devices are properly stored to reduce creasing and
damage.

> *Method to Assess Criterion:* Directly observe whether lead protective
> devices are properly stored to reduce creasing and damage.

11\) Radiological reports are maintained: quarterly report of dosimetry,
annual calibration of radiologic equipment, annual evaluation of patient
lead protective devices.

> *Method to Assess Criterion:* Directly observe whether reports are on
> file and current.

**E. Prevention**

1\) The patient dental record contains an individualized disease
prevention plan based on the patient's status and risk factors:

> a\. Systemic fluoride
>
> b\. Professionally-applied topical fluoride
>
> c\. Self-applied topical fluoride
>
> d\. Fluoride toothpaste
>
> e\. Pit and fissure sealants
>
> f\. Preventive periodontal treatment
>
> g\. Tobacco counseling
>
> h\. OHI and other health education
>
> i\. Recall
>
> *Method to Assess Criterion:* Review of dental record for the above
> information.

2\) Oral health education and

2.1) self-care instructions are provided and

2.1) are consistent with needs identified in the individualized
prevention assessment.

> *Method to Assess Criterion:* Observe what the patient is told during
> the appointment. If communication cannot be observed, question the
> patient about what they were told during the visit and ask if
> appropriate home-care aids were recommended (e.g., fluoride
> toothpaste, fluoride rinses, floss, Perio Aid, Proxabrush, floss
> threaders). Special instructions are given to patients with special
> needs and/or physical handicaps. Ask the patient to demonstrate
> flossing and brushing technique as taught by the provider.

3\) Each dental prophylaxis provided meets the following standards:

> a\. The presence of plaque and calculus is demonstrated to the patient
> or parent before prophylaxis begins. Use of a disclosing solution is
> recommended.
>
> b\. All plaque and other soft debris are removed from tooth surfaces
> (includes flossing of interproximal surfaces to demonstrate plaque
> removal for the patient and/or parent).
>
> c\. All coronal calculus is removed (includes all supragingival
> calculus and subgingival calculus up to 3 mm. below gingival crest).
>
> d\. Each patient indicated for prophylaxis receives toothbrush
> prophylaxis unless rubber cup is required to accomplish stain removal.
>
> *Method to Assess Criterion:* Observe whether prophylaxis procedures
> being provided are explained to the patient by the attending dental
> staff person. Following the completion of the prophylaxis, assess the
> quality of the procedure by inspection of the teeth using mouth
> mirror, explorer, and adequate light.

4\) Persons with one or more new smooth-surface carious lesions, or
whose prophylaxis includes a rubber cup polishing, will be given a
professionally-applied topical fluoride application. A schedule of up to
four applications per year may be followed, based on the presence of
moderating factors listed below. Use currently accepted criteria found
in Section IV of the *IHS Oral Health Program Guide* for determining the
frequency of professionally-applied fluorides.

> *Note:* Professionally-applied topical gel treatments are not
> recommended for patients under five years of age. Fluoride varnishes
> may be used.
>
> *Method to Assess Criterion:* Chart review, including review of
> documentation of any moderating factors, and/or direct observation.
>
> *Note:* Moderating factors for caries risk include: age, present
> caries activity, past caries activity, exposure to other sources of
> fluoride, sugar intake and frequency, amount of plaque, dental
> anatomy, medications, and family history.

5\) Sealants are placed on susceptible unrestored or incipient carious
pit and fissure surfaces of permanent first and second molars within two
years of eruption.

> *Method to Assess Criterion:* Chart review or direct observation.
> Criteria for the use of pit and fissure sealants include: Seal if
> deep, narrow pits and fissures, or other occlusal lesions are present.
> Do not seal if broad, well-coalesced pits and fissures, or frank
> caries are present. Frank caries is defined as gross cavitation with a
> break in the enamel, softness, and usually discoloration.

6\) All sealants placed meet the following standards:

> a\. Adequate isolation of teeth is achieved for placement of sealants.

1\. If four‑handed technique is used, isolation with cotton rolls or
Dri-Aids is acceptable.

2\. If two‑handed technique is used, proper isolation requires rubber
dam or Vac‑Ejector.

> b\. Adequate etching and rinsing techniques are used prior to
> application of sealant.
>
> 1\. Etching solution is applied for 15 to 30 seconds to achieve a
> frosted appearance.
>
> 2\. Etched surfaces are rinsed for at least 15 to 30 seconds or until
> etchant and precipitate are completely removed.
>
> c\. Sealants exhibit adequate retention by remaining intact following
> a reasonable effort to remove with an explorer.
>
> d\. No overt occlusal interferences are present due to placement of
> the sealants.
>
> *Method to Assess Criterion:* Direct observation.

7\) Patients who are tobacco users are asked if they want to quit using
tobacco.

> *Method to Assess Criterion:* Observe the patient record for evidence
> that all patients are asked if they use tobacco and documentation that
> tobacco users have been asked if they want to quit using tobacco.

8\) Tobacco cessation counseling is recommended for patients who
indicate they want assistance in quitting tobacco.

> *Method to Assess Criterion:* Observe the primary health record to
> determine that the patient who wants counseling has been counseled by
> the dental staff or has been referred for counseling (if such services
> are available locally), unless it is documented that the patient
> requests deferment of counseling.

9\) Each patient is placed in a recall program based on his/her
individual risks (see Caries Risk) rather than arbitrary time intervals
such as a 6-month recall. The patient's recall category is consistent
with the diagnosis, treatment received, and medical condition, e.g.,
diabetes, rampant caries, pregnancy, and perio status.

*Method to Assess Criterion:* Review of dental record.

**F. Restorative (Exclusive of Full Cast Restorations)**

1\) Treatment is explained to the patient (parent/guardian) before
services begin.

> *Method to Assess Criterion:* Observe whether the attending dentist or
> dental assistant explains to the patient (parent/guardian) the planned
> treatment services for that visit before those treatment services
> begin.

2\) Rubber dam isolation is utilized unless contraindicated. There is
documentation of the reason for non-use in the chart.

> *Method to Assess Criterion:* Direct observation. All rubber dam
> clamps must be positively blocked (i.e., throat pack, ligation, rubber
> dam) from swallowing or aspiration.

3\) Tooth preparation and restoration are designed to promote success
and patient satisfaction.

> *Method to Assess Criterion:* Ask the patient if he/she has
> experienced any problems with previous restorations, e.g., difficulty
> flossing, food impaction, or unusual discomfort. At a minimum, the
> following aspects of the restoration are observed by direct
> observation:
>
> a\. Caries removal
>
> b\. Preparation design
>
> c\. Base placement
>
> d\. Contacts
>
> e\. Marginal ridge
>
> f\. Lack of overhangs
>
> g\. Embrasure
>
> h\. Contour
>
> i\. Occlusal anatomy
>
> j\. Restorative material
>
> *Note:* Any aspect of the restoration deemed by the evaluator as being
> unsatisfactory to the extent of promoting failure of the restoration
> will be identified to the person being evaluated. If the person being
> evaluated disputes the evaluator's conclusion that the deficiency is
> cause for considering the restoration to be unsatisfactory, there will
> be a discussion of the deficiency identified. If concurrence between
> the person being evaluated and evaluator cannot be reached after
> discussion, the disputed restoration will not be counted as
> unsatisfactory. However, the nature of the dispute will be noted in a
> narrative summary.

4\) Esthetics of anterior restorations satisfy the requirement for
concealment and/or harmony of the restoration.

> *Method to Assess Criterion:* The anterior restoration should be
> esthetically acceptable, and not displeasing to the patient. Ask the
> patient to comment on the appearance of anterior restorations.

5\) Instructions concerning restorative care are given to the patient
(parent/guardian) postoperatively, and

5.1) services planned for the next appointment are explained.

> *Method to Assess Criterion:* Observe whether instructions concerning
> restorative care and an explanation of the services planned for the
> next appointment are given to the patient (parent/guardian) by the
> attending dentist or the dental auxiliary prior to dismissal of the
> patient.

**G. Pediatric Dentistry**

1\) All carious teeth are addressed in the treatment plan.

> *Method to Assess Criterion:* Chart review. The treatment of carious
> anterior deciduous teeth can be addressed either through the IHS
> treatment plan or by indicating that this treatment is to be provided
> at the patient\'s/family's own expense.

2\) All primary posterior teeth with three or more carious surfaces, one
or more carious proximal surfaces, or teeth receiving pulp therapy, are
restored with stainless steel crowns, unless a reason for not using a
stainless steel crown is noted.

*Method to Assess Criterion:* Chart review and direct observation.

3\) Pulp therapy procedures performed in the primary dentition are
consistent with the diagnosis. The diagnosis is supported by
documentation of the clinical and/or radiographic findings in the
patient's chart.

*Method to Assess Criterion:* Review of progress notes and radiographs.

4\) Primary teeth receiving pulpectomy treatment shall have a
postoperative periapical radiograph, or one scheduled within one month.

*Method to Assess Criterion:* Review chart and radiographs.

5\) The child's behavior is documented in the chart for all children age
10 and under and for older children when the behavior is not
age-appropriate.

> *Method to Assess Criterion:* Chart review. The Frankl Scale is
> offered on the following page as only one example of behavior
> documentation which may be used.

[Frankl's Rating Scale]{.smallcaps}\
Categories of Behavior

> *Rating 1:* Definitely Negative (- -). Refuses treatment, cries
> forcefully, is fearful, or portrays any other overt evidence of
> extreme negativism.
>
> *Rating 2:* Negative (-). Is reluctant to accept treatment, is
> uncooperative, portrays some evidence of negative attitude but not
> pronounced, that is, sullen or withdrawn.
>
> *Rating 3:* Positive (+). Accepts treatment, at times is cautious but
> willing to comply with the dentist, but follows the dentist's
> directions cooperatively.
>
> *Rating 4:* Definitely Positive (++). Has good rapport with the
> dentist, interested in the dental procedures, laughs and enjoys the
> situation.

6\) Behavior Management techniques (verbal, physical, and/or chemical)
are documented.

6.1) Only behavior management techniques in which the dentist is trained
and privileged are used.

> *Method to Assess Criterion:* Direct observation and review of charts.
> Review of hospital or facility privileges for approval of privileges
> for the type of sedation being used or documented in the dental record
> as having been used.

7\) Documentation of informed consent is present when chemical
restraints (including nitrous oxide and/or other sedation) and physical
restraints (including Hand Over Mouth, mouth props, and wraps) are used.

*Method to Assess Criterion:* Direct observation and chart review.

8\) The response to behavior management techniques, if used for patients
less than six years of age, is noted in the progress notes.

*Method to Assess Criterion:* Direct observation and chart review.

9\) All sedations must conform to the guidelines published in Section V
of the *Oral Health Program Guide.*

> *Method to Assess Criterion:* Review of documentation in the Dental
> Progress Notes (42-2) or the Dental Outpatient Sedation Record
> (IHS-831) if used. A review of the documentation should address the
> following:
>
> a\. Is the consent statement signed by the parent/guardian?
>
> b\. Is the type and amount of local anesthetic recorded?
>
> c\. Is the amount of each sedative drug used recorded?
>
> d\. Is the indication for the use of sedation recorded on the sedation
> record or in the progress notes?
>
> e\. Has the patient complied with the preoperative NPO instructions?
>
> f\. Is there evidence that a physical assessment was done, i.e., that
> the patient is healthy, current medications are noted, and the airway
> is not obstructed?
>
> g\. Were the respiratory and circulatory systems monitored
> continuously and findings recorded at an interval no longer than 15
> minutes?
>
> h\. Were the patient's condition and time of discharge noted?
>
> If any one of these requirements are absent from the documentation,
> the criterion for sedation is considered unsatisfactory.
>
> *Note:* The form IHS-831 is not required, but is strongly recommended.
> This form can facilitate complete documentation of monitoring when
> more than visual monitoring is required with certain dosages and
> combinations of drugs described in Section V of the *Oral Health
> Program Guide.* If the IHS-831 is used, all the second copies (pink)
> should be maintained as a log.

10\) Only behavior management techniques in which the dentist is trained
and privileged are used.

> *Method to Assess Criterion*: Direct observation and review of charts.
> Review of hospital or facility privileges for approval of the sedation
> technique being used.

11\) A space maintainer is placed when primary molars are prematurely
lost prior to normal exfoliation, or reason for non-provision of a
spacer is noted.

> *Method to Assess Criterion:* Chart review. Determine whether
> indications or contraindications for placement of a space maintainer
> are documented in the dental record.

12\) Arrangements are made for recall examinations for patients with
spacers.

> *Method to Assess Criterion:* Review the patient record for
> arrangements made for recall examination for patients with spacers.

13\) The space-maintaining appliance spans the edentulous area
adequately, allows for normal eruption of the permanent tooth, and does
not impinge upon soft tissue. Orthodontic band-type space maintainers
exhibit smooth marginal adaptation and adequate cementation.

*Method to Assess Criterion:* Direct observation.

14\) Space maintainer design is appropriate for the stage of the
dentition.

*Method to Assess Criterion*: Direct observation

15\) Treatment plan for spacer includes when it should be removed

*Method to Assess Criterion: Chart Review*

**H. Endodontics**

Pulpcapping/Pulpotomy

1\) Indirect Pulp Capping -- There are no longer any biological
indications for indirect pulp capping on permanent teeth (Put a
reference to this statement).

*Method to Assess Criterion*: Direct observation and review of charts.

[2)]{.underline} Direct pulp capping (indicate what size of exposure-
"pin-point" or whatever) is indicated when all of the following
criterion exists:

1.  A clinically vital and asymptomatic pulp is exposed.

2.  Bleeding is controlled at the exposure site.

3.  Exposure permits the capping material to make direct contact with
    the vital pulp tissue.

4.  Minimal microbial contamination of the exposure site has occurred.

5.  Proper coronal seal can be maintained.

6.  Patient is fully informed that endodontic treatment is an
    alternative and may be an eventuality, and that direct pulp capping
    may preclude the option of endodontic treatment in the future.

> *Method to Assess Criterion*: Recorded findings ([subjective and
> objective data]{.underline}) support an assumption of normal pulp
> apical to the exposure/canal orifice(s) with a non-contaminated field.
> A pulp cap assumes an uncontaminated mechanical exposure. Radiographs
> of the involved permanent tooth reveal a radiopaque capping material
> in contact with pulpal tissue. Documentation exists that the patient
> has been placed on active recall to check for resorptive defects or
> accelerated canal calcification.

3\) Pulpotomy may be appropriate if any of the following clinical
conditions exists:

1.  Exposed vital pulps or pulpitis confined to the coronal aspects of
    primary teeth.

2.  As an emergency procedure in permanent teeth until root canal
    treatment can be accomplished.

3.  As an interim procedure for permanent teeth with immature root
    formation to allow continued root development.

*Method to Assess Criterion*:

1.  An appropriate coronal seal is required.

2.  Radiographically there should be evidence of sufficient root
    development for endodontic treatment.

3.  Periodic radiographic examination should show no resorptive defects
    or accelerated canal calcification.

**Non-surgical Root Canal Therapy**

4\) Non-surgical root canal therapy for permanent teeth is indicated if
any of the following conditions exists:

1.  Irreversible pulpitis.

2.  Necrotic pulp with or without evidence of periradicular disease.

3.  Teeth with a pulp that would be compromised during dental
    procedures.

4.  Teeth with a pulp that would be compromised due to adjunctive medial
    procedures.

5.  Traumatically displaced or avulsed teeth.

6.  Treatable resorptive defects.

7.  Cracked or fractured teeth with pulpal involvement (with or without
    clinical symptoms) that can reasonably be expected to maintain
    satisfactory periodontal health.

8.  Teeth with thermal hypersensitivity that significantly interferes
    with normal function, when alternative methods have failed to reduce
    the hypersensitivity.

5\) Findings confirming the diagnosis are established, and competing
diagnoses ruled out. Findings are recorded in the patient\'s dental
record. A preoperative [diagnostic]{.underline} radiograph is included.
A pulpal and periradicular diagnosis is obtained and recorded.

> *Method to Assess Criteria 4 and 5*: Observe the patient\'s dental
> record and determine whether support and documentation of the
> diagnosis is recorded. A preoperative, diagnostic radiograph is
> available. History, clinical signs and symptoms, and appropriate pulp
> and periradicular test results are noted in the patient\'s dental
> record.

6\) Informed consent is obtained for root canal treatment. This should
include a discussion of the nature of the treatment, reasonable
foreseeable risks, reasonable alternatives, and consequences of
non-treatment.

> *Method to Assess Criterion*: Review patient record for the presence
> of an informed consent form indicating procedure, risk and benefit,
> treatment alternatives, patient\'s and dentist\'s signatures and date.

7\) A rubber dam is placed to isolate the operating area and act as a
barrier to prevent aspiration or swallowing of root canal irrigants and
instruments. Use should be documented in progress notes.

*Method to Assess Criterion*: Observe endodontic procedures, determine

documentation in patient chart.

8\) Removal of coronal tooth structure provides adequate access to the
pulp chamber and allow straight line access to the root canal system. A
balance is maintained between conservation of tooth structure and
straight line access.

> *Method to Assess Criterion*: Observe the preoperative and
> postoperative radiographs to determine that the endodontic filling
> materials conform to the original size and shape at the apex and
> progress to a flared conical shape towards the pulp chamber. Observe
> working length and postoperative radiographs to determine whether
> sufficient coronal tooth structure was removed to allow straight line
> access to the root canal system.

9\) CaOH is the interappointment medicament of choice for non-surgical
root canal treatment (when a medicament is desired). Formocresol is not
used as a medicament in permanent teeth (again put reference as to why
not).

> *Method to Assess Criterion*: Observe patient record for documentation
> when medicament is used.

10\) Obturation of all root canals is three dimensional and the
radiographic appearance shows a well obturated root canal system where
the root canal filling extends as close as possible to the apical
constriction of each canal. The root canal system is obturated with a
biologically acceptable non-resorbable semi-solid or solid root canal
obturating material (ADA approved). Root canal sealers are used in
conjunction with the obturating material to establish an adequate seal.

> *Method to Assess Criterion*: Observe the routine preoperative and
> postoperative radiographs and determine the adequacy of the obturation
> with a solid core primary filling material. Observe the radiograph for
> filling length, the canal for proper flare and orientation. Consider
> the density of the fill evaluating voids, spreader or condenser tracks
> and minimal amount of sealer extrusion. Obturation material should be
> as close as possible to the apical constriction of each canal. Observe
> the patient dental record for ADA approved obturation material and
> sealer. Postoperative instructions and recommended follow-up care must
> also be documented upon obturation.

11\) Each case has a proper radiographic documentation. A minimum of two
radiographs for cases with non-overlapping canals (i.e. single canals
and maxillary molars), and a minimum of three radiographs of overlapping
canals (i.e. mandibular molars, lower incisors, multicanaled premolars)
should be available. Thus documentation should include a preoperative,
proper postoperative radiograph(s), and working radiographs of archival
quality (void of fixer stains, underdeveloped, brown, etc.), mounted in
one connective holder and labeled consistent with IHS guidelines.

> *Method to Assess Criterion*: Observe the patient\'s dental record and
> determine if preoperative, working, and postoperative radiographs were
> made. Radiographs are of archival quality, placed in one connective
> holder and labeling consistent with IHS guidelines.

12\) Esthetic restorative material is used on all lingual access
preparations in anterior teeth.

> *Method to Assess Criterion*: Direct observation, radiograph, or
> review of patient\'s dental record.

13\) A cusp-protecting restoration is used on posterior permanent teeth
when either marginal ridge is violated or when remaining enamel
structure is unsupported by dentin and lacks strength.

> *Method to Assess Criterion*: Direct observation, radiograph or review
> of patient dental record for provision of cusp-protecting restoration.

**Traumatized Permanent Teeth**

14\) A thorough history of the trauma including diagnostic radiographs,
vitality testing of all teeth in the involved area, soft tissue exam,
status of occlusion, and proper recording of data are included in the
patient\'s chart.

> *Method to Assess Criterion*: Observe patient\'s chart for diagnostic
> data which include history, radiographs, pulpal and periradicular
> tests, occlusal status, and soft tissue exam.

15\) Incisal trauma involving dentin on vital teeth with no pulp
exposure is restored within 7 days of initial presentation with
composites and a dentin bonding agent.

> *Method to Assess Criterion*: Observe patient record to note time
> interval between trauma and restoration.

16\) All patients with traumatized teeth are placed on sufficient recall
status (1 month, 3 month, 6 month, 1 year) to evaluate pulpal and
periradicular condition.

*Method to Assess Criterion*: Documentation exists that the patient has
been placed on active recall.

17\) Teeth in need of fixation are stabilized using acid-etch/resin
alone or with soft arch wire, or using orthodontic brackets with passive
arch wire. Semi-rigid splints are used for luxated and avulsed teeth
while rigid splinting is used for horizontal root fractures and alveolar
fractures. Arch bar splints are contraindicated in these specific
situations.

*Method to Assess Criterion*: Observe post operative radiographs and
patient record documentation.

**I. Periodontics**

1\) The record contains a recording of CPITN scores (0,1,2,3, or 4)
determined by probing and radiographic evidence of pre-existing
conditions and a

1.1) written diagnosis by ADA-Case Type (Gingivitis, Early
Periodontitis, Moderate Periodontitis, and Advanced Periodontitis) and.
The initial recorded diagnosis is acceptable for the findings.

2.  The diagnosis should be consistent with existing conditions observed
    in the mouth and/or documented.

3.  When definitive periodontal therapy is planned for patients with
    CPITN of 3 or greater, a periodontal work-up should be conducted.
    This includes probing pocket depths, radiographic evaluation, furca
    involvement, mobility, occlusal evaluation, and plaque retentive
    features. *If definitive periodontal services are not planned, the
    periodontal work-up should not be conducted.*

> *Method to Assess Criterion:* Chart review and/or direct examination
> of the patient.

2\) All dentate patients 15 years or older being provided routine dental
care are informed of their periodontal status, treatment needs,
opportunities for self‑care, and have a description of periodontal
treatment planned. If a full scope of periodontal services is not
available at the particular clinic, a chart notation should be made that
the patient has been informed of his/her need for treatment at another
facility.

> *Method to Assess Criterion:* Observe the patient record to determine
> whether patients were informed of their periodontal status and
> treatment needs consistent with their CPITN and periodontal
> assessment.

3\) Periodontal treatment is consistent with, the need indicated by the
initial diagnosis and

3.1) documented

> *Method to Assess Criterion:* Observe records of patients having all
> planned treatment completed within the last year to determine if the
> appropriate treatment plan was provided for sextants with CPITN scores
> of 2, 3, or 4, i.e., prophylaxis, supra and subgingival cleaning,
> surgical and/or non-surgical treatment.

4\) Communication with the patient is professional and on a level so
that the patient understands the educational information and accepts
scaling and root planing procedures. The provider is attentive to the
patient's comfort level.

> *Method to Assess Criterion:* Observe the patient and the provider's
> interaction during the procedure and note if levels of agreement or
> disagreement are acceptable. Question the patient to determine if the
> treatment was acceptable and tolerable.

5\) Supragingival and subgingival cleaning are performed adequately.

> *Method to Assess Criterion:* Observe the patient immediately
> following the procedure to determine if the contents of the pocket
> have been debrided and that irregularities and roughness of the root
> surface adjacent to the pocket have been removed and smoothed.
> Determine whether tissue trauma from scaling procedures is within
> acceptable limits.

6\) Hygienists who administer local anesthesia are appropriately
certified to do so.

> *Method to Assess Criterion:* Question the hygienist about training
> and certification in local anesthesia. Review clinic records to verify
> certification.

7\) The hygienist's progress notes and referrals are countersigned by a
dentist. The hygienist's signature alone is adequate only if covered by
standing orders in the clinic policy and procedure manual.

> *Method to Assess Criterion:* Review the dental progress notes for
> countersignature, or verify that standing orders exist in the clinic
> policy and procedure manual.

8\) A screening exit exam will be included in all treatment plans for
routine patients examined with CPITN scores of 2, 3, or 4.

> *Method to Assess Criterion:* Observe the patient record for the
> presence of an exit exam in the treatment plan, or a final CPITN for
> those completed patients who were initially diagnosed with any CPITN
> scores of 2, 3, or 4.

9\) The patient is placed on a recall based on patient's disease status.

> *Method to Assess Criterion:* Observe the patient record for
> documentation of plans for recall. Discuss the clinic recall policy
> with the clinic staff.

10\) Periodontal surgery has been effective.

> *Method to Assess Criterion:* Observe the patient postoperatively to
> determine that periodontal pockets have been eliminated, the gingivae
> have been contoured to a morphologic and physiologic form, and
> deformities in the alveolar bone have been corrected to a physiologic
> form. Probe all sulcular areas with a calibrated periodontal probe to
> determine whether sulcus depths have been reduced (probe no sooner
> than 2 months post‑surgery).
>
> In the assessment, compare the pretreatment dental record findings
> with the post‑treatment results.

11\) Mucogingival surgery has been effective.

> *Method to Assess Criterion:* Observe the patient postoperatively to
> determine that an increased zone of attached gingivae has been
> attained, undesirable muscle pull on the marginal gingivae has been
> dissipated, and/or the vestibular fornix has been deepened to allow
> for maintenance of health of the periodontium.
>
> In the assessment, compare the pretreatment dental record findings
> with the post‑treatment results.

**J. Removable Prosthodontics**

1\) Pretreatment full‑arch radiographs are available for all removable
prosthetic patients (occlusal, panographic, or full mouth intraoral
series). Current (within 1 year) periapical radiographs are available
for all abutment teeth.

*Method to Assess Criterion:* Review dental record.

2\) The overall oral condition and the condition of selected abutment
teeth promote success of the prosthetic case.

> *Method to Assess Criterion:* A review of the radiographs, clinical
> exam, endodontic status, and perio charting will be used to determine
> the overall oral health and the probability of long-term success of
> abutment teeth selected to support a removable prosthetic appliance.

3\) The appearance of the denture is esthetically acceptable to patient
and examiner.

> *Method to Assess Criterion:* The denture harmonizes with the
> patient's facial appearance. The positioning, shape, and shade of the
> teeth appear natural. Vertical dimension is within normal range. The
> acrylic base material is in good condition. Clasps are not
> unnecessarily visible. The patient expresses satisfaction with
> appearance of the prosthesis. Documentation should be made in the
> chart as to the patient's acceptance of the esthetic appearance of the
> prosthesis.

4\) Stability/retention is acceptable.

> *Method to Assess Criterion:*
>
> a\. Ask patient if dentures stay in place while eating and speaking.
> The stability/retention of the prosthesis is consistent with the
> limitations imposed by the ridge anatomy present.
>
> b\. *Full denture test:* Place forefinger on incisal edge of either
> maxillary or mandibular denture with sufficient force to blanch the
> finger. If denture becomes dislodged, it is considered to lack
> retention/stability.
>
> c\. *Partial denture test:* Place forefinger on any segment of partial
> denture framework and press firmly. If partial denture becomes
> dislodged or tips, it is considered to lack retention.

5\) Flange of prosthetic appliance adapts to the soft tissue borders of
the oral cavity.

> *Method to Assess Criterion:* Gently retract lip to minimum degree
> that will allow you to observe whether flange of prosthetic appliance
> approximates the soft tissue borders. Note if dentures spring away
> from borders or lift up.
>
> *Note:* Not applicable when anatomic conditions make the assessment
> unfeasible. The reason(s) should be stated in the patient's dental
> record.

6\) Occlusion is acceptable.

> *Method to Assess Criterion:*
>
> a\. *Check centric relation:* Close patient's jaw into centric
> relation (and/or acceptable habit position) by placing thumb on
> patient's chin and gently directing mandible to the most posterior
> position, with patient closing slowly at the same time. Note whether
> simultaneous bilateral contact of the teeth occurs, and whether
> substantially all of the teeth on each side touch. If not, or if
> shifting or sliding occurs, then occlusion is considered to be
> inadequate.
>
> *Note:* For all tooth-borne removable partial dentures, the point of
> reference is centric occlusion (functional occlusion).
>
> b\. *Check eccentric relation:* Ask patient to close and move jaw in
> all directions. Observe eccentric premature contact or lack of
> balancing contact on teeth from canine posteriorly and note any
> instability resulting from the eccentric relationship of the
> prosthesis. (Eccentric relation is considered adequate if none are
> noted.)
>
> c\. *Check occluding material:* Determine if unglazed porcelain
> occlusal or incisal surfaces are contacting enamel, gold, alloy, or
> composite resin. If so, rapid wear of the softer occluding surface
> will occur and occlusion must be considered unacceptable.

7\) Vertical dimension and anterior tooth arrangement are acceptable.

> *Method to Assess Criterion:*
>
> a\. *Check "S" sounds:* Ask patient to say key words, such as
> Mississippi, sixty‑six, whiskey, seventy‑seven. When making "S"
> sounds, teeth should not contact. If so, appliance(s) is (are)
> considered inadequate.
>
> b\. *Check "F" and "V" sounds:* Ask patient to say key words, such as
> forty‑four, fine food, vim and vigor, Vivian. When making "F" and "V"
> sounds, the incisal edges of #8 and #9 teeth should contact the
> wet‑dry line of lower lip.
>
> c\. Ask patient if teeth seem too long or too short.

8\) All "Cardinal Rules" of partial denture construction are met.

> *Method to Assess Criterion:*
>
> a\. *Rest seats (depth):* Ask patient to remove partial denture.
> Observe clearance for rest seats with patient in centric occlusion. If
> unable to visualize, then place utility wax in patient's mouth and
> have patient close to centric occlusion. Remove wax and insert
> periodontal probe through wax in central area of identified rest seats
> until point of probe is exposed evenly with wax surface of opposite
> side. Determine visually whether wax in rest seat area is 1 to 1 1/2
> mm thick.
>
> b\. *Rest seat (width):* Observe whether rest seats approximate
> one‑third the width of the tooth (except in cingulum rests), and are
> positioned at a 90 degree angle to long axis of abutment tooth.
>
> c\. *Partial denture base:* Inspect removed partial denture and
> determine whether base material covers all supporting areas. Ask
> patient to replace partial denture in mouth and then use mouth mirror
> to observe whether retromolar pad(s) or tuberosity(ies) are completely
> covered without impingement of soft tissues in flange areas.
>
> d\. *Arms of clasps in undercut zones:* Attempt to dislodge partial
> denture from each abutment tooth by placing finger under retentive
> clasp and applying firm force occlusally. If there is no resistance to
> the force, then retention is considered inadequate. If too much force
> is required, excessive mobility of the tooth occurs, or if the patient
> expresses difficulty in removing it, then retention may be excessive.
>
> e\. *Guiding planes:* Visually determine whether all guiding planes on
> abutment teeth are reasonably parallel to one another.
>
> f\. *Abutment teeth:* Observe that abutment teeth are in a good state
> of repair and well-polished.
>
> g\. *The tissue-bearing area:* Note any areas of tissue impingement,
> inflammation, or hypertrophy related to the partial denture. The
> partial denture should not have caused any apparent tissue damage.

9\) All pertinent information concerning the prosthesis is recorded in
the health progress notes. This must include shade, mould, and lab used.
Also include lab fee quoted to the patient if applicable. A copy of the
lab prescriptions (work orders) should be kept on file in chronological
order.

*Method to Assess Criterion:* Review progress notes and lab files.

**K. Fixed Prosthodontics**

**Crowns (all types, including bridge abutments)**

**Note:** A crown is unacceptable [only]{.underline} if the examiner
recommends replacement of the crown due to one or more deficiencies
noted in the following criteria:

1\) Smooth marginal adaptation.

> *Method to Assess Criterion*: Inspect the margins of the crown to
> determine if the marginal adaptation is acceptable. The marginal
> adaptation of the crown should be considered unacceptable if gingival
> irritation or blanching of the tissues is being caused by the crown or
> if the smaller end of the #17 explorer can be inserted between the
> inner surface of the crown and immediate tooth surface.

2\) Occlusal functions are acceptable.

> *Method of Assess Criterion*: Use articulating paper to assess
> premature contacts in centric and eccentric relations. Also observe
> whether there are heavy wear facets (or shiny areas) in any occluding
> surface by using mouth mirror and/or direct observation. If supra or
> infra occlusion was planned, it must be noted in the patients dental
> record. Question the patient: \"Does this give you any discomfort or
> pain when you eat? Does it seem higher than your other teeth?\"

[3)]{.underline} Contact is present.

> *Method to Assess Criterion*: The contacts with the proximal teeth
> should be in the occlusal 1/3 of the proximal space and tight. Dental
> floss should pass through without tearing or shredding.

4\) Crown contour is physiologic.

> *Method to Assess Criterion*: Inspect the external contours of its
> cross‑arch analog, if a natural tooth. If the mate is not present or
> grossly restored, utilize the contours of the tooth most nearly
> representative of the test tooth. Compare with the aid of mouth
> mirror:
>
> a\) buccogingival contour
>
> b\) linguogingival contour
>
> c\) marginal ridge contour
>
> d\) embrasure spaces have a v‑shape which avoids tissue impingement
>
> e\) total buccolingual width

The health of the tissue around the restored tooth (teeth) will not
differ significantly from other tissue in the mouth four weeks after
cementation.

5\) Crowned, endodontically treated teeth have healthy characteristics
which promote long term success of the case.

> *Method to Assess Criterion*: Review the radiographs, clinical exam
> record, endodontic status, perio charting, and clinical appearance of
> the crowned tooth.

6\) Porcelain or resin shade blends favorably with remaining dentition.

> *Method to Assess Criterion*: Under natural light, inspect the crown
> with its cross arch analog using a Trubyte Bioform 24 button shade
> guide or Vita Lumen shade guide. If the mate is not present or is not
> a natural tooth, compare shades to the adjacent natural or opposing
> teeth. Shade blend should be within one shade of the matching button.

**B. Fixed Bridges**

7\) Pontic(s) meet(s) the principles of form and tissue adaptation.

> [Method to Assess Criterion]{.underline}: Observe the form of
> pontic(s) by using mouth mirror and/or direct observation. Determine
> if:
>
> a\. Facio‑lingual width of the pontic(s) approximate(s) two‑thirds of
> the normal width of the replaced teeth.
>
> b\. Facial contour of the pontic(s) approximate(s) the normal contour
> of the replaced teeth.
>
> c\. Gingival contour, approximating the alveolar process and mucosa is
> (are) convex enabling self‑cleansing capability. Consider
> [concave]{.underline} pontics unacceptable. Thread dental floss
> through the embrasure and pass the floss mesio‑distally between the
> apex of the pontic and the mucosa of the alveolar process. For pontic
> to be considered acceptable, the floss should pass freely without
> impingement or bleeding of involved tissues.

8\) Solder joints meet principles of adequate strength.

> [Method of Assess Criterion]{.underline}: Use mouth mirror and/or
> direct observation and apply following principles for determining
> adequate strength.
>
> a\. Facio‑lingual size of the solder joint should be about one‑half of
> the facio‑lingual width of the existing pontic, and
>
> b\. The occlusal gingival side of the solder joint should be about
> one‑half of the distance from the occlusal (incisal) edge of the
> pontic to its gingival base.

9\) The overall oral condition and periodontal structures of abutment
teeth are adequate to support the prosthetic appliance(s).

> *Method to Assess Criterion*: Clinically observe abutment teeth and
> review the radiographs, clinical exam record, endodontic status, and
> perio charting. Observe that the prosthetic service(s) received is
> compatible with the overall periodontal health and caries control, and
> that it promotes long-term success.

10\) Esthetics are acceptable to the patient and examiner.

> *Method to Assess Criterion*: Question the patient: \"Are you
> satisfied with the appearance of the bridge?\" Determine in your own
> mind whether the existing porcelain or resin surfaces of the pontic
> and crowns are in harmony with the remaining natural teeth. Determine
> whether there is unsightly show of metal when smiling and talking.

11\) Occlusal functions are acceptable.

> *Method to Assess Criterion*: Observe centric and eccentric movements;
> use articulating paper to assess premature contacts in centric and
> eccentric relations. Also, observe whether there are heavy wear facets
> (or shiny areas) on any occluding surface of the bridge by using mouth
> mirror and or direct observation. Question the patient: \"Does the
> bridge give you any discomfort or pain when you eat?\"

12\) Pertinent information concerning the prothesis is recorded in the
dental progress notes. This includes the material used for fabrication
and cementation, the shade, and dental lab used.

> *Method to Assess Criterion*: Review dental record.

**L. Oral Surgery**

1\) The diagnosis leading to extraction or other surgical procedures is
written in the dental record and is consistent with clinical findings.

> *Method to Assess Criterion:* Observe the patient's dental record and
> determine whether documentation for the diagnosis is recorded,
> including the availability of a preoperative radiograph. History,
> clinical symptoms, including temperature and soft tissue findings, and
> possible pulp test results are noted in the patient's dental record.

2\) Appropriate diagnostic preoperative x‑ray(s) is/are available in the
patient's dental record.

> *Method to Assess Criterion:* Review of radiograph to assess presence
> of the entire tooth, including apex of root(s) and surrounding
> anatomy.

3\) All postoperative complications receive appropriate follow‑up
treatment.

> *Method to Assess Criterion:* Chart review. Specifically note use of
> culture and sensitivity tests, antibiotic regimens, I & D procedures,
> and recording of patient temperature.

4\) All pathology reports based on cytology or biopsy are present in the
patient records and in a biopsy log.

> *Method to Assess Criterion:* Review patient's dental and/or medical
> record. Results must be recorded in the patient's progress notes by
> the dentist. When a tissue biopsy is performed, the patient record
> must include documentation of indications for biopsy, a copy of the
> pathology report, and evidence that the patient was notified of the
> results and received proper follow up. An additional \"Biopsy Log\"
> should also be kept. For each case this log will include the
> patient\'s name, chart #, provisional clinical diagnosis, doctor\'s
> name, date, histopathological diagnosis, and date of patient
> notification of results and follow-up.

5\) Appropriate preoperative systemic antibiotic therapy is provided
patients requiring such, as specified by the American Heart Association.

> *Method to Assess Criterion:* Review of patient primary health record.
> Observe that these patients have documentation and/or consultation to
> rule out need for antibiotic prophylaxis. If a prescription is
> written, it is documented that the patient has complied with regimen.

6\) Standard principals of flap design have been accomplished, e.g.,
occlusal portion of flap design to extend at least one tooth adjacent to
the interdental papilla both mesially and distally from the tooth to be
extracted (exception to this would be extraction of the most distal
tooth in the arch). Vertical incisions extend obliquely so that the base
of the flap is wider than its margin, and the tissue of the retracted
flap is not mutilated or torn.

> *Method to Assess Criterion:* Observe the surgical flap procedure on
> patients present in the clinic receiving this service, or observe the
> flap design of revisit patients who receive this service and are
> present in the clinic for postoperative follow‑up or suture removal.

7\) Pathologic tissue is completely removed. There is no evidence of
residual periapical or periodontal pathology, including root fragments
at the surgical site, unless removal is contraindicated.

8\) Alveolar margin is smoothed, and displaced fragments of the alveolus
and foreign particles are removed.

> *Method to Assess Criteria #2 and #3:* The examiner assesses these
> criteria by appropriate instrumentation and palpation, including a
> postoperative radiograph of the operative site when deemed necessary.
> On patients present in the clinic for postoperative follow‑up or
> suture removal, the examiner may assess these criteria by palpation of
> the operative site and by viewing a postoperative radiograph. If root
> tips have been left, documentation exists for the decision, including
> postsurgical radiographs, and documentation exists that the patient
> has been informed and there is provision for recall.

9\) Sterile saline or sterile water is used to irrigate all surgical
sites, including routine extractions.

10\) Soft tissue flap is repositioned into anatomical position and
maintained there with suture or gauze pressure pack.

> *Method to Assess Criterion:* Inspect the surgical flap site to make
> certain the soft tissue is repositioned appropriately over alveolar
> bone without excessive tension.

11\) Oral and written instructions concerning postoperative care of
surgical or extraction services are given to patient (parent/guardian)
and documented in the record.

> *Method to Assess Criterion:* Observe whether oral and written
> instructions concerning postoperative care of surgical and/or
> extraction sites are given to the patient before dismissal.

12\) Informed consent is obtained for oral surgery procedures. This
should include a discussion of risks, benefits, and alternatives to
treatment.

> *Method to Assess Criterion:* Review patient record for the presence
> of formal consent form indicating procedure, risks, benefits and
> treatment alternatives, patient's signature, dentist's name, and date.

13\) All use of conscious sedation for oral surgical procedures is
performed under guidelines listed in the *IHS Oral Health Program
Guide,* Section V.

> *Method to Assess Criterion:* Review the clinic's *Policy and
> Procedure Manual* and the *IHS Oral Health Program Guide* for a
> conscious sedation protocol. See that all providers are properly
> credentialed for procedures they perform, that adequate emergency
> back-up is available, that there is proper CPR/ACLS certification, and
> that the proper monitoring equipment is utilized. This may include the
> pulse oximeter, EKG, and blood pressure device. Also note that proper
> informed consent is present for sedation and that there is adequate
> patient recovery and escort service available.

**M. Orthodontics**

1\) The dental record contains documentation that patients (and/or their
guardian) ages 6 to 20 have been advised of their orthodontic status and
the availability of treatment at the IHS/Tribal facility or the need to
seek private care.

> *Method to Assess Criterion:* Chart review.

2\) Practitioners providing interceptive and corrective orthodontic care
who have not completed long term training in orthodontics can
demonstrate a program of systematic review of selected cases by an
orthodontic consultant. Practitioners providing orthodontic care have
been granted privileges to provide that care and have documented
training to support the level of privileges requested.

> *Method to Assess Criterion:* Review the log of orthodontic patients
> for evidence of review of selected cases by an orthodontic consultant.
> Review practitioner's request for privileges and supporting
> documentation.

3\) The following records of each patient undergoing comprehensive
orthodontic therapy, which is to be provided only by an orthodontic
specialist, are available:

> a\. Orthodontic examination (including the status of the TMJ), which
> is updated within six months of initiation of treatment.
>
> b\. Full mouth or panoramic x‑rays.
>
> c\. Study casts with bite registration recording centric occlusion.
>
> d\. Cephalometric x‑ray with the jaw in centric occlusion.
>
> e\. Pretreatment photographs: 1) full face at rest and smiling;\
> 2) right and left profile; 3) right, left, and anterior intra-oral;\
> 4) maxillary occlusal, and mandibular occlusal.
>
> f\. Treatment objectives established and recorded prior to treatment.
>
> g\. Written informed consent signed by parent/guardian which lists
> treatment objectives, expected outcome and limitations, patient
> compliance expected, reasons for discontinuing treatment before
> completion, and anticipated need for further specialty care.
>
> h\. Documentation of appropriately sealed teeth in children under age
> 14.
>
> i\. All other treatment completed (PTC except orthodontics) within the
> last 6 months.
>
> j\. Documentation that compliance with home care has been demonstrated
> prior to treatment.

*Method to Assess Criterion:* Review of patient's health record.

4\) Assessment of completed cases must be made in conjunction with the
treatment objectives established prior to treatment relative to findings
in records and/or posttreatment cast concerning:

> a\. Molar relationship and cuspid relationship.
>
> b\. Changes in cephalometric form.
>
> c\. Arch expansion.
>
> d\. Axial inclination of anterior and posterior teeth.
>
> e\. Interproximal spacing.
>
> f\. Rotations.
>
> g\. Arch form.
>
> h\. Overbite correction.
>
> i\. Overjet correction.
>
> j\. Soft‑tissue profile.
>
> *Method to Assess Criterion:* Review the hallmarks of a well‑treated
> orthodontic case, which include:
>
> a\. Good intercuspation of teeth.
>
> b\. Cuspids in Class I relationship.
>
> c\. Correction of rotations.
>
> d\. Correction of overbite or open bite.
>
> e\. Correct esthetic inclination of anterior teeth.
>
> f\. Correct root position of teeth (parallel roots).
>
> g\. Good arch form.
>
> h\. General maintenance of cuspid and molar width.
>
> i\. Minimal root resorption.
>
> j\. Minimal gingival recession.
>
> k\. Minimal occlusal interferences in centric relation, in balancing,
> and in working movements.
>
> l\. Minimal decalcification and no caries associated with the
> appliance.
>
> m\. Accomplishment of treatment objectives.

5\) Orthodontic treatment and orthodontic extractions are preceded by an
orthodontic consultation.

> *Method to Assess Criterion:* Review patient dental record for
> evidence of orthodontic consult.

**N. Adjunctive General Services**

1\) Drugs prescribed for and/or administered to dental outpatients or
inpatients are recorded in patient's primary health care record.

1.1)Drugs administered or prescribed are consistent with the written
diagnosis.

> *Method to Assess Criteria #1 and #2:* Review the described health
> problem(s) and determine the appropriateness of the prescribed drug(s)
> and daily dosage. Acceptable references, such as *American Hospital
> Formulary Service* or *Physicians Desk Reference,* may be used to
> resolve any differences of opinion.

2\) Appropriate preoperative systemic antibiotic therapy is provided
patients requiring such, as specified by the American Heart Association.

> *Method to Assess Criterion:* Review of patient primary health record.
> Observe that all patients who are at risk for Subacute Bacterial
> Endocarditis (SBE) have documentation of antibiotic prophylaxis and
> that at each encounter it is documented that the patient complied with
> the prescribed antibiotic regimen.

3\) Any untoward reactions to medication(s) are recorded in the primary
health record. Any allergies to medication(s) are prominently displayed
on the primary health record.

*Method to Assess Criterion:* Review of patient's primary health record.

4\) When a sedative agent or nitrous oxide is administered, the
indication for use, duration, concentration exposure and or dosage,
monitored vital signs, any untoward reactions, restraints used, and
patient status upon dismissal are recorded in the patient record.

*Method to Assess Criterion:* Chart review.

5\) Dentists or hygienists who administer sedative drugs (inhaled, oral,
intramuscular, or intravenous) can demonstrate that they are
appropriately trained to do so and that dentists have been granted
privileges by the medical staff to perform the procedure(s).

> *Method to Assess Criterion:* Review medical privileges and
> documentation of training in sedation for those dentists who
> administer sedative drugs. Review standing orders for hygienists and
> documentation of training in administering nitrous oxide/oxygen
> sedation.

**O. Environmental Health and Safety**

1\) Basic emergency diagnostic and treatment equipment must be available
in case of life‑threatening episodes.

> *Method to Assess Criterion:* Observe that any member of the dental
> staff can promptly locate and bring to the chairside the following
> equipment:
>
> a\. Sphygmomanometer (infant, child, and adult sizes)
>
> b\. Stethoscope
>
> c\. Ambu‑bag and oxygen with mask and bags capable of positive
> pressure ventilation for infants, children, and adults
>
> d\. Oral pharyngeal airways (infant, child, and adult)
>
> e\. Emergency drug kit/crash cart as specified in the operations
> manual of the dental clinic or facility with appropriate dosages for
> children and adults

2\) Emergency drug kit is up-to-date.

> *Method to Assess Criterion:* Inspect the locked emergency drug kit
> and assure that expiration dates have not passed on any medications.

3\) The dental staff has received annual CPR training.

> *Method to Assess Criterion:* Current certification card or list of
> CPR-certified staff should be available.

4\) A clinic emergency plan exists for management of medical emergencies
and is understood by the staff.

> *Method to Assess Criterion:* Inspect the plans and interview staff
> for basic understanding of plan and procedures. Review documentation
> that the plan has been reviewed annually and/or question the staff on
> emergency protocol.

5\) All housekeeping activities have been performed before clinical day
begins.

> *Method to Assess Criterion:* Observe the cleanliness and neatness of
> all areas of the dental clinic. If observation in the morning is not
> possible, then question the dental staff in accordance with the
> acceptability of the housekeeping activities being provided. Suggested
> areas to be considered are cleanliness of floors, walls, furniture,
> cabinets, dental chairs, dental units, wastebaskets, etc.
>
> *Note:* The neatness and cleanliness of all working counter top areas
> are considered to be the responsibility of the dental auxiliary staff.
> Otherwise, supplies and/or materials may be disposed of accidentally
> by non‑dental housekeeping personnel.

6\) The current copy of the IHS Mercury Hygiene Guidelines (located in
Section VI of the *IHS Oral Health Program Guide)* is on file and has
been reviewed and/or studied by all dental staff within the current
fiscal year.

> *Method to Assess Criterion:* The dental officer will show the
> examiner a copy of the guidelines, as well as an attached page which
> contains signatures and dates of all dental staff indicating that they
> have reviewed the guidelines.

7\) The possibilities of mercury toxicity are minimized by the dental
staff through the practice of good mercury hygiene.

> *Method to Assess Criterion:* Observe operations involving mercury
> transfer and determine whether the work surface is smooth, impervious,
> and suitably lipped to confine spilled mercury, and whether the floor
> covering is smooth and impervious. A mercury spill kit is available in
> the facility.
>
> Scrap amalgam should be stored in a closed, labeled container under
> appropriate (e.g., x-ray fixer, commercial solution) liquid barrier.
> Water, mineral oil, or glycerin are not acceptable liquid barriers.
> Pre-encapsulated silver alloy is utilized to minimize the need to
> handle free mercury.

8\) Concentration of mercury vapors in the environment should be below
the threshold limit value (TLV) of 0.025 mg Hg/m3, or in compliance with
the Area Office of Environmental Health (OEH) policy.

> *Method to Assess Criterion:* Ask to see a copy of the most recent
> mercury vapor level survey, and the Area OEH policy concerning mercury
> surveillance for dental clinics. Determine whether the mercury vapor
> level is below 0.025 mg Hg/m3 and/or if the facility is in compliance
> with the Area OEH policy.

9\) Nitrous oxide/oxygen administration logs are maintained which permit
monitoring of the duration of staff exposure to waste anesthetic gas.

*Method to Assess Criterion:* Review nitrous oxide/oxygen log.

10\) Concentrations of waste anesthetic gas are within accepted levels.

> *Method to Assess Criterion:* Review copy of most recent certification
> by the IHS Office of Environmental Health waste gas survey/report or
> records of local monitoring of nitrous oxide.

11\) An infection control policy for the dental facility has been
reviewed and approved by dental and medical staff.

> *Method to Assess Criterion:*
>
> a\. A copy of the most recent release of "Recommended Infection
> Control Practices for Oral Health Programs Serving Native Americans"
> should be available in the dental clinic. This document should contain
> the dated signatures of all dental personnel to verify their review of
> the document, as well as those of the Program Director or Service Unit
> Director and the Chairman of the Service Unit Infection Control
> Committee (or Clinical Director).
>
> b\. The reasons for any exceptions or significant variations to the
> recommended practices which the local facility has decided to adopt
> should be explained in writing, initialed by dental staff, and filed
> with the policy document.

12\) The requirements of the "OSHA Bloodborne Pathogen Standard" are met
by having documentation of an exposure control plan, training, and
immunization record.

> *Method to Assess Criterion:* Review of the dental staff, personnel
> records, and direct observation. Determine whether all dental staff
> have been given the opportunity to be immunized for hepatitis B and
> other diseases. Determine whether a surveillance record of the
> immunization status of each member of the dental staff is available
> for review. (The record should include sero-testing and dates of
> Tuberculin tests. Follow-up action is documented for employees with
> "positive" findings which require attention.)
>
> Those staff members refusing the hepatitis vaccine must be informed of
> the risks and are required to sign a form stating that the vaccine has
> been offered and refused. Refusal of vaccine and notation of possible
> consequences must be recorded.
>
> Written policy should exist to address the management of employees
> involved in patient care who have acute or chronic infectious
> conditions, including colds, flu, herpes or other skin infections, and
> any other known or suspected contagious condition.

13\) Accepted infection control procedures are practiced prior to the
delivery of care.

> *Method to Assess Criterion:* Observe the performance of infection
> control procedures routinely practiced prior to the delivery of care
> for at least 10 patients, if possible. Evaluate each of the following
> components of practice relative to the infection control methods
> recommended by the Indian Health Service.
>
> *Prior to Treatment:*
>
> a\. *Health history:* A summary of findings is documented on Part II
> of IHS-42-1 (or other standard form if IHS forms are not used).
> Significant conditions should be noted clearly in the patient's record
> and addressed prior to treatment.
>
> b\. *Hand washing:* Hands are washed between patient treatment
> contacts and whenever gloves are changed. Nails are cleaned and
> without polish, jewelry is removed, and recent wounds are covered.
>
> c\. *Protective barriers:* Handles and switches on dental lights,
> x-ray equipment, patient records and other noncritical items are
> covered or prepared as recommended in Section VI of the IHS *Oral
> Health Program Guide.*

14\) Accepted infection control practices are maintained routinely
throughout the delivery of care for dental patients.

> *Method to Assess Criterion:* Observe the performance of infection
> control procedures used routinely during the delivery of care based
> upon at least 10 patients, if possible. Evaluate each of the following
> components of practice relative to the infection control methods
> recommended by the Indian Health Service.
>
> *During Treatment:*
>
> a\. *Protective barriers:* For protection of personnel and patients,
> gloves must always be worn when touching blood, saliva, or mucous
> membranes. Gloves must be worn by dental health-care workers when
> touching blood-soiled items, body fluids, or secretions, as well as
> surfaces contaminated with them. Gloves must be worn when examining
> all oral lesions.
>
> Surgical masks, in addition to eye protection with solid side shields
> or chin-length plastic face shields, are mandatory for operator
> protection when splashing or splattering of blood or other body fluids
> or solids is likely.
>
> Fluid-resistant gowns must be worn when clothing is likely to be
> soiled with blood or other body fluids. Home laundering of gowns is
> prohibited. Gowns should be changed when visibly soiled.
>
> A rubber dam is used unless contraindicated.
>
> b\. *Handling of instruments and materials:* Adequate methods are
> employed to minimize "breaks" in aseptic technique during treatment.
> Four-handed dentistry is practiced when possible. The unit dose
> concept is applied and forceps are used to transfer or handle objects
> involved in treatment, especially when small items are removed from or
> placed into storage drawers, tray set-ups and other noncritical
> surfaces.
>
> c\. *Patient records:* Adequate measures are taken to minimize the
> contamination of patient records during and after treatment,
> especially when entries are made in the record.

15\) Accepted infection control procedures are practiced after the
delivery of care.

> *Method to Assess Criterion:* Observe the performance of infection
> control procedures used routinely after the delivery of care based
> upon at least 10 patients, if possible. Evaluate each of the following
> components of practice relative to the infection control methods
> recommended by the Indian Health Service.
>
> After Treatment:
>
> a\. *Operatory decontamination:* Environmental surfaces are
> disinfected with a suitable germicide before the next patient is
> seated. This includes the removal of "dirty" instruments and waste
> materials from the operatory, replacing protective barriers (e.g.,
> headrest and bracket table covers), changing burs and handpieces,
> disinfecting control switches and other noncritical surfaces, and
> other measures recommended by the IHS (refer to "Recommended Infection
> Control Practices for Oral Health Programs Serving Native Americans.")
> All "sharps" must be placed in an approved sharps container.
> Biohazardous waste materials must be disposed of in covered refuse
> containers labeled "BIOHAZARD."
>
> Air/water syringe tips must be autoclaved or disposable and changed
> between patients.
>
> b\. *Use and care of sharp instruments and needles:* Sharp items
> (needles, scalpel blades, endodontic files, orthodontic wires, and
> other sharp instruments) must be considered as potentially infective
> and must be handled with extraordinary care to prevent unintentional
> injuries. A one-handed technique or mechanical capping device must be
> used for the recapping of needles.
>
> Disposable syringes and needles, scalpel blades, worn out and broken
> burs, endodontic files, orthodontic wires, and other disposable sharp
> items must be placed into puncture-resistant containers located as
> close as practical to the area in which they were used.

Review of the last 12 months injury reports.

c\. *Instrument disinfection/sterilization:* In a designated cleanup
area, dirty instruments are adequately cleaned (free of visible debris)
before disinfection or heat sterilization methods are used. Persons
involved in cleaning and decontaminating instruments must wear heavy
rubber gloves to prevent hand injuries and eye protection with solid
side shields. The lid should be in place on the ultrasonic cleaner
during use to avoid splatter. Heat sensitive tape should be used on
bagged or packaged instruments which are to be sterilized. Refer to
"Recommended Infection Control Practices for Oral Health Programs
Serving Native Americans" for the details of accepted practice regarding
external/internal indicators. Sterilizer(s) are monitored on a weekly
basis with biologic indicators (review records on file). Disinfection
solutions should be diluted and replenished according to product
instructions and volume of workload.

d\. *Instrument storage:* Disinfected and sterilized instruments are
placed in storage using accepted methods. The use of clear plastic
autoclave bags is recommended when possible. Sterilized
instruments/instrument packs must exhibit an expiration date (refer to
"Recommended Infection Control Practices for Oral Health Programs
Serving Native Americans" for instrument pack shelf life).

e\. *Handpiece sterilization:* All surgical instruments including
handpieces (high speed, low speed attachments, and prophy angles) must
be used as an alternative.

16\) A written schedule should exist which describes general sanitation
and housekeeping procedures for the dental facility. Housekeeping
services should be available to remove refuse daily and to clean floor
coverings (carpeting is not recommended in dental operatories).

*Method to Assess Criterion:* Review dental clinic policy.

17\) Incoming or outgoing orthodontic or prosthetic appliances are
disinfected, and impressions and casts are handled according to
recommended IHS infection control practices for oral health programs.

> *Method to Assess Criterion:* Direct observation. Laboratory
> instruments and supplies (e.g., rag wheels, case pans, model trimmer,
> knives, and other frequently used equipment) are disinfected or
> sterilized according to an acceptable policy.

**Technical Quality Assessment by Direct Observation of Patient Care**

**Y - Yes N - No N/A - Not Applicable D -- Disputed Findings, summary
needed**

**Record Number**

<table>
<colgroup>
<col style="width: 46%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>Criteria</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>A. Patient Records</strong></td>
</tr>
<tr class="odd">
<td>1) Dental Record is part of Health Record</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>1.1 Health Record present for review</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>2) Current Health History present</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>2.1) Updated Annually</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>2.2) Reviewed/documented each visit</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>3) Health Questionnaire follow-up</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>4) All Entries in ink</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>5) Progress notes sufficiently detailed</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>6) SOAP format for emergency visits</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>B. Examination and Diagnosis</strong></td>
</tr>
<tr class="odd">
<td>1) Hard and soft tissue findings recorded</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>2) Appropriate diagnostic aids are used</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>3) Diagnosis is consistent with findings</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>4) Treatment Plan exists</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>4.1) Follows logical order</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>4.2) Consistent with diagnosis</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>5) Screening Exit Exam</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>C. Radiographs</strong></td>
</tr>
<tr class="odd">
<td>1) Radiographs meet criteria based on patient conditions or type of
exam:</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>1.1) Initial adult</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>1.2) Initial Child</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>1.3) Recall</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>1.4) Emergency</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>2) Radiographs are properly mounted</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>3) Radiographs are properly labeled</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>4) Radiographs are in patient’s record</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>5) Density and Contrast are acceptable</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>6) Image not distorted</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>7) No overlapping</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>8) No Cone-cutting</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>9) Bitewings include proper landmarks</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**Y - Yes N - No N/A - Not Applicable D -- Disputed Findings, summary
needed**

**Record Number**

<table>
<colgroup>
<col style="width: 46%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>Criteria</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>D. Radiological Protection</strong></td>
</tr>
<tr class="odd">
<td>1) Auxiliaries are certified</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>2) Lead protective devices are used</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>3) Tube head stationary</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>3.1) Tube head properly positioned</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>4) Film not held by staff</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>5) Tube not held by staff</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>6) Operator stands in proper position</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>7) Area Properly cleared for exposure</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>8) Warning before exposure</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>9) Dosimeters worn</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>10) Protective devices properly stored</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>11) Radiological Reports maintained</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>E. Prevention</strong></td>
</tr>
<tr class="even">
<td>1) Prevention Plan</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>2) Oral Health Education Provided</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>2.1) Self-care Instruction provided</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>2.2) Consistent with needs</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>3) Prophy meets standards</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>4) Topical Fluoride appropriately provided</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>5) Sealants appropriately placed</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>6) Sealant technique meets standards</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>7) Tobacco users asked about quitting</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>8) Tobacco Cessation Counseling recommended</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>9) Individualized Recall</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>F. Restorative</strong></td>
</tr>
<tr class="even">
<td>1) Treatment explained</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>2) Rubber dam used unless contraindicated</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>2.1) Documentation for non-use</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>3) Prep and restoration meet criteria</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>4) Esthetics of anterior restorations</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>5) Care of restorations explained</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>5.1) Next visit explained</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**Y - Yes N - No N/A - Not Applicable D -- Disputed Findings, summary
needed**

**Record Number**

<table>
<colgroup>
<col style="width: 47%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>Criteria</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>G. Pediatric Dentistry</strong></td>
</tr>
<tr class="odd">
<td>1) All caries addressed in tx plan</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>2) Stainless Steel Crowns used appropriately</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>3) Pulp therapy is appropriate</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>4) Pulpectomies have post-op PA</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>5) Behavior documented</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>6) Behavior management techniques</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>6.1) Appropriate techniques used</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>7) Informed consent documented)</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>7.1) for restraints</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>7.2) For sedation</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>8) Response documented</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>9) Sedations conform to current guidelines</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>10) Training and privileges for sedation</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>11) Space Maintainers used appropriately</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>12) Recall provided for patients with spacers</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>13) Spacer fits appropriately</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>14) Spacer design is appropriate</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>H. Endodontics</strong></td>
</tr>
<tr class="odd">
<td>1) Indirect Pulp Caps</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>2) Direct Pulp Cap</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>3) Pulpotomy</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>4) Indications for endo exist and</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>5) Adequate documentation</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>6) Informed Consent</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>7) Rubber Dam</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>8) Access prep is appropriate</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>9) CaOH medicament</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>10) Proper Obturation</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>11) Appropriate Radiographs</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>12) Aesthetic restoration on anteriors</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>13) Cusp Protection</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>14) Traumatized teeth properly worked up</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>15) Incisal trauma restored appropriately</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>16) Traumatized teeth recalled</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>17) Stabilization for teeth needing fixation</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**Y - Yes N - No N/A - Not Applicable D -- Disputed Findings, summary
needed**

**Record Number**

<table>
<colgroup>
<col style="width: 46%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>Criteria</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>I. Periodontics</strong></td>
</tr>
<tr class="odd">
<td>1) CPITN present</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>1.1) Periodontal Diagnosis present</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>1.2) Diagnosis consistent with conditions</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>1.3) Full work-up for definitive perio treatment</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>2) Patients informed of periodontal status</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>3) Periodontal Treatment is appropriate</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>3.1) And Documented</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>4) Communication with patient is appropriate</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>5) Cleaning is appropriate</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>6) Hygienist certified for Local Anesthesia</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>7) Hygienist’s notes countersigned as needed</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>8) Screening exit exam</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>9) Appropriate perio recall</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>10) Periodontal Surgery is effective</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>11) Mucogingival surgery is effective</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>J. Removable Prosthodontics</strong></td>
</tr>
<tr class="odd">
<td>1) Pre-treatment radiographs</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>2) Oral condition is adequate</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>3) Esthetics acceptable</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>4) Stability/retention acceptable</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>5) Proper flange adaptation</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>6) Occlusion acceptable</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>7) Vertical dimension acceptable</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>7.1)Anterior arrangement acceptable</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>8) Cardinal Rules are followed</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>9) All info about prosthesis is recorded</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**Y - Yes N - No N/A - Not Applicable D -- Disputed Findings, summary
needed**

**Record Number**

<table style="width:100%;">
<colgroup>
<col style="width: 47%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>Criteria</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>K. Fixed Prosthodontics</strong></td>
</tr>
<tr class="odd">
<td>1) Smooth Margins</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>2) Acceptable Occlusion</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>3) Proper contacts</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>4) Physiologic Contours</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>5) Endodontically treated abutments</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>6) Proper porcelain shades</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>7) Pontics meet criteria</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>8) Solder joints are adequate</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>9) Abutment tooth condition is adequate</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>10) Esthetics acceptable</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>11) Occlusion acceptable</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>12) Progress notes adequate</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>L. Oral Surgery</strong></td>
</tr>
<tr class="even">
<td>1) Diagnosis present and appropriate</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>2) Appropriate radiographs</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>3) Post-op complications properly treated</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>4) Pathology reports present</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>5) Antibiotic prophylaxis appropriate</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>6) Flap design is appropriate</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>7) Pathologic tissue completely removed</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>8) Alveolar margins smoothed</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>9) Sterile irrigant</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>10) Flap properly repositioned</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>11) Post-op instructions</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>12) Informed consent</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>13)Conscious sedation follows guidelines</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>M. Orthodontics</strong></td>
</tr>
<tr class="even">
<td>1) Patients advised of orthodontic status</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>2) Practitioner has proper training/privileges</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>2.1) Cases reviewed by orthodontic consultant</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>3) Appropriate Ortho records are available</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>4) Completed cases meet objectives</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>5) Ortho consultation precedes treatment</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**Y - Yes N - No N/A - Not Applicable D -- Disputed Findings, summary
needed**

**Record Number**

<table>
<colgroup>
<col style="width: 45%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>Criteria</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>N. Adjunctive General Services</strong></td>
</tr>
<tr class="odd">
<td>1)Drugs are recorded</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>1.1) Consistent with diagnosis</p>
</blockquote></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>2) Prophylaxis provided when needed</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>3) Medicine reactions and allergies noted</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>4) Sedation properly documented</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>5) Providers administering sedatives have appropriate training and
privileges</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>O. Environmental Health and
Safety</strong></td>
</tr>
<tr class="even">
<td>1) Emergency equipment available</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>2) Emergency drugs up to date</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>3) CPR Training</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>4) Emergency Plan</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>5) Housekeeping</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>6) Mercury Hygiene Guidelines</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>7) Mercury Hygiene</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>8) Mercury Vapors</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>9) Nitrous Oxide Log</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>10) Waste anesthetic gases</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>11) Infection Control Policy</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>12) Blood Borne Pathogens Standard</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>13) Infection Control Procedures prior to care</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>14) Infection Control during Care</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>15) Infection Control after</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>16) Written schedule for sanitation</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>17) Dental Appliances disinfected</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**Summary**

(Within each category subtract NA and D boxes from total number
available to calculate denominator. )

+------------------+--------------+------------------------------------+
| **Category**     | **%          | **Comments**                       |
|                  | Compliant**  |                                    |
|                  |              |                                    |
|                  | Y/ (Y+N)     |                                    |
+------------------+--------------+------------------------------------+
| A.  Patient      |              |                                    |
|     Records      |              |                                    |
+------------------+--------------+------------------------------------+
| B.  Exam         |              |                                    |
|     Diagnosis    |              |                                    |
+------------------+--------------+------------------------------------+
| C.  Radiographs  |              |                                    |
+------------------+--------------+------------------------------------+
| D.  Radiological |              |                                    |
|     Protection   |              |                                    |
+------------------+--------------+------------------------------------+
| E.  Prevention   |              |                                    |
+------------------+--------------+------------------------------------+
| F.  Restorative  |              |                                    |
+------------------+--------------+------------------------------------+
| G.  Pediatric    |              |                                    |
|     Dentistry    |              |                                    |
+------------------+--------------+------------------------------------+
| H.  Endodontics  |              |                                    |
+------------------+--------------+------------------------------------+
| I.  Periodontics |              |                                    |
+------------------+--------------+------------------------------------+
| J.  Removable    |              |                                    |
|                  |              |                                    |
|   Prosthodontics |              |                                    |
+------------------+--------------+------------------------------------+
| K.  Fixed        |              |                                    |
|                  |              |                                    |
|   Prosthodontics |              |                                    |
+------------------+--------------+------------------------------------+
| L.  Oral\        |              |                                    |
|     Surgery      |              |                                    |
+------------------+--------------+------------------------------------+
| M.  Orthodontics |              |                                    |
+------------------+--------------+------------------------------------+
| N.  Adjunctive   |              |                                    |
|     General      |              |                                    |
|     Services     |              |                                    |
+------------------+--------------+------------------------------------+
| O                |              |                                    |
| .  Environmental |              |                                    |
|     Health and   |              |                                    |
|     Safety       |              |                                    |
+------------------+--------------+------------------------------------+

**Technical Feedback And Recommendations**

**(Provide to Person being evaluated at Close-Out Session)**

Person being evaluated

Criterion considered unsatisfactory:
­­­­­­­­­­­­­­­­­\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Describe deficiencies related to this criterion:

Criterion considered unsatisfactory:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Describe deficiencies related to this criterion:

Criterion considered unsatisfactory:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Describe deficiencies related to this criterion:

Criterion considered unsatisfactory:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Describe deficiencies related to this criterion:

Plan of action for correcting deficiency(ies):

Signatures: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_

Evaluator Person being evaluated Date

cc: Service Unit Director/Tribal Health Administrator

**APPENDIX III**

**INDIRECT REVIEW OF CLINICAL QUALITY**

**CHART REVIEW**

**Indirect Review of Clinical Quality Chart Review**

**General Instructions**

General responsibilities and guidelines for conducting quality
assessment reviews are included in Appendix I of this chapter and should
be followed when an outside reviewer conducts a chart review.

11) This chart review tool can be used to assess the quality of an
    individual provider, a targeted aspect of care, or a dental clinic
    as a whole. The entire document can be used or individual criteria
    can be selected, depending on the focus of the survey.

12) When the tool is used for ongoing peer review, it is helpful to have
    all of the providers in the clinic participate in reviewing the
    charts, so that the findings can be used as a learning experience.

13) Whenever possible, the charts being reviewed should be randomly
    selected to eliminate bias from the review process. Medical Records
    or Information Technology personnel can usually develop a random
    selection of records.

14) As a rule of thumb, review 10 charts per provider.

15) Identify a time frame for the review (e.g., only review chart
    entries that were made since the previous chart review: or, for a
    new employee, only review chart entries made after the provider was
    oriented to the chart review process and review criteria).

16) All criteria must be met to score "Yes"

17) For each category, if procedures were not performed or are not
    applicable, mark NA

**Chart Review Criteria**

**A. Every Visit**

1)  A health questionnaire completed by the patient and signed by the
    provider within the past 12 months is present and documentation
    exists that it was reviewed at each visit with the changes or the
    phrase "no changes" recorded. Medical alerts are highlighted.

2)  For patients with American Society of Anesthesiologists (ASA)
    Physical Status (PS) classifications 2-5, appropriate measures have
    been taken to ensure patient safety and appropriate treatment.
    (e.g.- blood pressure, blood sugar, consultations when necessary)
    See ASA website for PS definitions:
    <http://www.asahq.org/clinical/physicalstatus.htm>

3)  Progress notes are legible and clearly describe the treatment
    provided.

4)  Appropriate ADA codes are recorded (including tooth number and
    surface when appropriate) and documentation exists in the progress
    note to justify all codes.

5)  Dental Progress Notes include:

    a.  date of treatment

    b.  signature of the provider(s)

    c.  printed or stamped name of provider(s)

    d.  degree of the provider(s)

6)  Progress notes indicate that dental auxiliaries initial the direct
    patient care procedures performed.

7)  Dental progress notes include a disposition at the end of each
    visit**.** (Next appointment, further dental needs. The purpose is
    to demonstrate continuity of care.)

8)  Documentation of informed consent is present for appropriate
    procedures as defined by the facility. Informed consent includes
    documentation of discussion of risks, benefits, and alternatives to
    treatment.

9)  Patient's pain has been assessed, documented, and adequately
    addressed and/or managed.

10) All entries in the dental record are in ink.

**B. Exam and Treatment Plan**

1)  All hard tissue findings (pathology, abnormalities) are recorded in
    the dental record.

2)  Documentation that radiographs have been read exists in the patient
    record.

3)  Evidence of soft tissue exam is present, either by listing of
    abnormalities or designation of "STN" (Soft Tissues Normal) or "WNL"
    (Within Normal Limits).

4)  The record of patients receiving a complete dental exam contains
    CPITN/PSR scores and a written diagnosis by ADA-Case Type
    (Gingivitis, Early Periodontitis, Moderate Periodontitis, or
    Advanced Periodontitis), based on probing and radiographic evidence.

5)  Orthodontic status (for patients ages 6 to 20) is noted on the
    dental exam sheet.

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6)  Written treatment plan exists for all patients receiving initial or
    recall dental exams.

    a.  Treatment plan is easily understood

    b.  Follows a logical sequence

    c.  Is revised as needed, revisions are dated and initialed

7)  If a full scope of services is not available at the facility, a
    chart notation is made that the patient has been informed of his/her
    need for treatment at another facility.

8)  The patient is placed in a recall program based on his/her
    individual risks and clinic resources, rather than arbitrary time
    intervals.

**C. Drugs Administered or Prescribed**

> 1\) Drugs administered or prescribed are consistent with the written
> diagnosis.
>
> 2\) Drug dosages are within limits recommended by the *Physician's
> Desk Reference* or *American Hospital Formulary Service.*
>
> 3\) All drugs and dosages are entered in the medical and/or dental
> progress notes (including local anesthetic).
>
> 4\) Reactions and allergies to drugs are prominently displayed in
> dental record and on outside of medical chart.
>
> 5\) If the medical history suggests that prophylactic antibiotics may
> be necessary, determination of need or lack of the need is documented.
>
> 6\) Patients who need prophylactic antibiotics receive the
> prophylactic antibiotic regiment currently recommended by the American
> Heart Association.
>
> 7\) Sufficient documentation exists to demonstrate that the patient
> complied with the prescribed antibiotic regimen, was sufficient to
> cover the procedure, and that the dental procedure began after the
> recommended time interval.
>
> **D. Radiographs**

1)  Radiographs are dated and are labeled with name or chart number, and
    operator's initials.

2)  Radiographs are of good diagnostic quality with regard to density,
    contrast, and lack of overlapping, cone-cutting, or distortion. (All
    criteria must be met)

3)  Bitewings include distal surface of erupted cuspid and mesial
    surface of the most posterior erupted tooth in each quadrant. (Check
    all radiographs taken during review date range)

4)  The types and frequency of radiographs meet clinic policies and are
    consistent with ADA/FDA guidelines. Copies of the guidelines can be
    obtained at:
    <http://www.ada.org/prof/resources/topics/topics_radiography_chart.pdf>
    and

> <http://www.ada.org/prof/resources/topics/topics_radiography_examinations.pdf>

**E. Dental Emergency Treatment**

1)  "SOAP" or similar format is used for each dental emergency patient
    to document chief complaint, objective findings, diagnosis, and
    treatment plan in the patient record.

2)  Diagnosis is consistent with subjective and objective findings.

3)  Treatment is consistent with and appropriate for the diagnosis.

4)  Evidence of an intraoral screening exam is present for emergency
    patients, either by listing of abnormalities (e.g., gross caries,
    periodontal disease, soft tissue lesions) or "WNL" (within normal
    limits).

**F. Endodontics**

1)  Preoperative and postoperative radiographs are available for each
    tooth receiving endodontic treatment.

2)  Findings confirming the diagnosis and ruling out competing diagnoses
    are entered in the dental record.

3)  Postoperative radiograph indicates complete obturation of all root
    canals to within 2 mm of and not beyond the radiographic apex
    (refers to primary filling material, not sealer).

4)  Dental record indicates that a non-resorbable primary filling
    material and non-staining sealer are used in the endodontic
    treatment of a permanent tooth, a resorbable filling material is
    used for a primary tooth, and that formocresol is not routinely used
    in permanent teeth.

5)  Chart entries document the following

    a.  Working lengths,

    b.  Reference points, and

    c.  Instrument sizes are recorded in the patient record.

6)  An esthetic restorative material is used to restore each lingual
    access preparation on anterior teeth.

7)  Choice of restoration on each posterior endodontically-treated tooth
    meets the need for cusp protection (i.e., provision of a crown or a
    cusp-protecting amalgam restoration).

8)  Postoperative instructions and recommended follow-up care are
    documented at the obturation appointment.

**G. Oral Surgery**

1)  A preoperative radiograph showing the apex of each root is available
    for all teeth extracted.

2)  If sutures are placed, type and number are documented.

3)  All pathology reports are present in the patient record.

    a.  Evidence that the patient was notified of appropriate follow-up
        is present in the patient record.

4)  Any documented difficult surgical procedure or untoward outcome has
    appropriate follow-up arranged.

**H. Restorative Dentistry**

1)  Restorative materials are used appropriately for satisfactory
    esthetic results and as accepted for use by the ADA.

2)  Recent bitewing radiographs (no older than two years) show absence
    of obvious overhangs, open margins, or open contacts on restorations
    previously placed by the dental staff being evaluated.

3)  In cases where rubber dam is not used, the reason for non-use is
    documented. In clinics where there is no evidence of documentation
    of non-use of the rubber dam, the provider(s) should be questioned
    as to whether the rubber dam is used for all restorations.

**I. Pediatric Dentistry**

1)  An SSC is provided or planned for each primary molar with three or
    more carious surfaces or pulp therapy, unless contraindications are
    documented.

2)  All primary teeth receiving pulpectomies have preoperative and
    post-fill periapical radiographs.

3)  The dental record indicates that space maintenance is provided or
    planned for each prematurely lost primary molar, or reason for
    non-provision is documented, and there is provision for appropriate
    recall (6 months or less).

4)  Documentation of the behavior for all children under the age of 6 is
    documented.

    a.  Behavior management techniques used and their level of
        effectiveness are documented.

**J. Orthodontics**

1)  Request for treatment (x-rays, extractions, restorative, other) from
    an orthodontist is documented in the patient record.

> **For Patients Receiving Orthodontic Care at This Facility:**

2)  Pretreatment full mouth or panographic radiographs are available for
    each patient undergoing orthodontic treatment.

3)  Pretreatment study casts are available for each patient receiving
    orthodontic treatment.

4)  Orthodontic treatment plan and treatment provided are consistent
    with pretreatment findings.

**K. Periodontics**

1)  Patients with 2 or more sextants of CPITN 4 should have a complete
    periodontal chart and treatment plan. This includes probing pocket
    depths, furca involvement, mobility, and occlusal features, with
    documentation. Isolated pockets may be recorded on the examination
    form.

2)  Preoperative radiographs and record of pocket depths of areas
    receiving periodontal treatment are present in the dental chart.

3)  Diagnosis and treatment plan are consistent with preoperative
    findings.

4)  Dental record contains evidence of patient's OH. May include plaque
    score or bleeding index.

5)  The hygienist's progress notes and referrals are countersigned by a
    dentist. The hygienist's signature alone is adequate only if covered
    by standing orders in the clinic policy and procedure manual.

6)  Recall visits for patients receiving perio treatment includes a
    CPITN score.

**L. Preventive Dentistry**

1)  The dental record contains an individualized dental disease
    prevention plan.

2)  Persons with one or more smooth-surface carious lesions, decalcified
    areas, or with other moderating factors will receive a
    professionally-applied topical fluoride application. A schedule of a
    minimum of two and up to four applications per year should be
    followed, based on the presence of moderating factors documented for
    the patient. Moderating factors include: age, present caries
    activity, past caries activity, exposure to other sources of
    fluoride, sugar intake and frequency, amount of plaque, dental
    anatomy, and family history.

3)  Sealants are placed on unrestored, non-carious or incipient carious
    pit and fissure surfaces of all appropriate permanent first and
    second molars within two years of eruption.

4)  The record indicates that patients who are tobacco users are asked
    if they want to quit using tobacco.

5)  The record indicates that tobacco cessation counseling was provided
    or recommended for patients who indicated that they wanted
    assistance in quitting tobacco.

**M. Prosthodontics**

1)  Preoperative periapical radiographs of fixed bridge or partial
    denture abutment teeth are present in the dental record.

2)  Radiographic and other diagnostic findings indicate that the
    periodontal condition of the abutment teeth is adequate to support
    the prosthesis (i.e., Ante's Rule for fixed bridges).

3)  Pretreatment full-arch radiographs (occlusal, panographic, or FMX)
    are available for all full denture patients.

4)  Documentation exists and is readily available that records shades,
    moulds, laboratory and type of metal used

## N. Preoperative Documentation 

##  

1)  The chart contains the patient\'s name, chart \# and age.

2)  The patient\'s chief complaint and history of present illness,
    including a justification/rationale for the procedure to be
    performed in the operating room, are present.

3)  Documentation of allergies and current medications is present.

4)  Documentation of family and surgical history is present.

5)  A review of systems including systemic condition, physical
    examination, and assessment of patient is present.

6)  Planned treatment is documented.

**O. Consent**

1)  A consent is present which includes the diagnosis and proposed
    procedure.

2)  The common risks, benefits, complications and alternatives to the
    proposed treatment and mode of anesthesia are included.

3)  The consent is dated, including time of day, and signed by the
    surgeon, patient or guardian as appropriate, and a witness.

**P. Operative/Postoperative Note**

1.  A preoperative and postoperative diagnosis (if different from the
    preoperative diagnosis) are present.

2.  A detailed narrative of the operative procedure(s) is present and
    contains the following:

a\) operative findings

b\) anesthesia

c\) fluids (as appropriate)

d\) drains

e)  specimens

f)  complications

    1.  Documentation of the patient\'s condition, including any
        complications, upon transfer from the operating room is present.

    2.  Patients going from the operating room to the Intensive Care
        Unit or medical surgical floor have a standard
        admission/transfer order written.

    3.  The surgeon\'s name is included in the note.

**R. Dental Inpatient Documentation**

1.  Patients admitted for overnight stays will have admission orders
    which include the order to admit to the dental service, the
    diagnosis, and current condition of the patient.

2.  The admission orders will include the following as appropriate:

a\) allergies

b\) nursing orders

c\) diet

d\) medications

e\) laboratory tests

g)  IV fluids and rate

    1.  Patients admitted for overnight stays have a discharge summary
        which includes the name of the person dictating, date of
        admission and discharge, and a final diagnosis if different from
        the admitting diagnosis.

    2.  The discharge summary includes the pertinent admission history
        and physical findings, a description of the hospital course, and
        the patient\'s disposition upon discharge.

    3.  The discharge summary includes documentation regarding discharge
        medications and/or dietary instructions as appropriate, and a
        follow-up date and time.

**Chart Review Tool**

Facility:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Provider:
\_\_\_\_\_\_\_\_\_\_\_\_\_ Reviewer:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date Range for Review: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date of
Review: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Record Number**

<table>
<colgroup>
<col style="width: 50%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>CRITERIA</strong></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
</tr>
<tr class="even">
<td rowspan="3"></td>
</tr>
<tr class="odd">
<td colspan="10"><strong>Date of last exam</strong></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>A. Every Visit (Total=__)</strong></td>
</tr>
<tr class="even">
<td><ol type="1">
<li><p>Completed and Signed Medical History, Updated</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="2" type="1">
<li><p>Precautions appropriate for PS</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="3" type="1">
<li><p>Legible Notes</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="4" type="1">
<li><p>Appropriate Codes</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="5" type="1">
<li><p>Complete progress notes</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="6" type="1">
<li><p>Auxiliary initials</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="7" type="1">
<li><p>Disposition</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="8" type="1">
<li><p>Informed Consent</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="9" type="1">
<li><p>Pain Documentation</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="10" type="1">
<li><p>Entries in ink</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>B. Exam and Treatment plan
(Total=__)</strong></td>
</tr>
<tr class="odd">
<td><ol type="1">
<li><p>Hard tissue findings recorded</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="2" type="1">
<li><p>X-rays read</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="3" type="1">
<li><p>Soft tissue findings recorded</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="4" type="1">
<li><p>Periodontal status and diagnosis</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="5" type="1">
<li><p>Orthodontic status</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="6" type="1">
<li><p>Treatment Plan Complete</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="7" type="1">
<li><p>Notation of needed, unavailable services</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="8" type="1">
<li><p>Follow up/ recall consistent with patient needs</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>C. Drugs Administered or Prescribed
(Total=__)</strong></td>
</tr>
<tr class="even">
<td><ol type="1">
<li><p>Consistent with Written Diagnosis</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="2" type="1">
<li><p>Within recommended Limits</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="3" type="1">
<li><p>Entered in Progress Notes (including anesthetic)</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="4" type="1">
<li><p>Reactions and allergies displayed</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="5" type="1">
<li><p>Need for Prophylaxis Determined</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="6" type="1">
<li><p>Prophylaxis Given When Needed</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="7" type="1">
<li><p>Patient Compliance with Prophylaxis</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**Record Number**

<table>
<colgroup>
<col style="width: 48%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td><blockquote>
<p><strong>Criteria</strong></p>
</blockquote></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
</tr>
<tr class="even">
<td rowspan="3"></td>
</tr>
<tr class="odd">
<td colspan="10"><strong>Date of last Exam</strong></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>D. Radiographs (Total=__)</strong></td>
</tr>
<tr class="even">
<td><ol type="1">
<li><p>Radiographs are Dated, labeled and initialed</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="2" type="1">
<li><p>Good Diagnostic Quality</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="3" type="1">
<li><p>Bitewings Include Proper Landmarks</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="4" type="1">
<li><p>Type and Frequency Meet Guidelines</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>E. Dental Emergency Treatment
(Total=__)</strong></td>
</tr>
<tr class="odd">
<td><ol type="1">
<li><p>SOAP used</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="2" type="1">
<li><p>Diagnosis consistent with Findings</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="3" type="1">
<li><p>Tx Consistent w/ Dx &amp; appropriate</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="4" type="1">
<li><p>Screening Exam</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>F. Endodontics (Total=__)</strong></td>
</tr>
<tr class="even">
<td><ol type="1">
<li><p>Radiographs Available</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="2" type="1">
<li><p>Findings Conform Diagnosis</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="3" type="1">
<li><p>Obturation</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="4" type="1">
<li><p>Obturation Material and Sealer</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="5" type="1">
<li><p>Adequate documentation</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="6" type="1">
<li><p>Esthetic Restoration of Lingual Access</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="7" type="1">
<li><p>Cusp Protection on Posteriors</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="8" type="1">
<li><p>Post-Op Instructions</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>G. Oral Surgery (Total=__)</strong></td>
</tr>
<tr class="odd">
<td><ol type="1">
<li><p>Appropriate per-op x-ray</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="2" type="1">
<li><p>Sutures Documented</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="3" type="1">
<li><p>Path Reports Present, adequate, have appropriate
follow-up</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="4" type="1">
<li><p>Appropriate Follow-up for Difficult Procedures</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>H. Restorative (Total=__)</strong></td>
</tr>
<tr class="even">
<td><ol type="1">
<li><p>Materials used appropriately</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="2" type="1">
<li><p>No Overhangs/Open Margins</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="3" type="1">
<li><p>Rubber Dam documentation</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**Record Number**

<table style="width:100%;">
<colgroup>
<col style="width: 46%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td><blockquote>
<p><strong>Criteria</strong></p>
</blockquote></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
</tr>
<tr class="even">
<td rowspan="3"></td>
</tr>
<tr class="odd">
<td colspan="10"><strong>Date of Last Exam</strong></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>I. Pediatric Dentistry (Total=__)</strong></td>
</tr>
<tr class="even">
<td><ol type="1">
<li><p>SSCs used appropriately</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="2" type="1">
<li><p>Pre and Post-op x-rays for Pulpectomies</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="3" type="1">
<li><p>Space Maintenance</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="4" type="1">
<li><p>Behavior and management documented</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>J. Orthodontics (Total=__)</strong></td>
</tr>
<tr class="odd">
<td><ol type="1">
<li><p>Request for treatment Documented</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>For Patients receiving Orthodontic care in the
facility:</strong></td>
</tr>
<tr class="odd">
<td><ol start="2" type="1">
<li><p>Pre Treatment X-rays</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="3" type="1">
<li><p>Pre Treatment Study Models</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="4" type="1">
<li><p>Treatment Consistent with Findings</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><strong>K. Periodontics (Total=__)</strong></td>
</tr>
<tr class="odd">
<td><ol type="1">
<li><p>Perio Work-up</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="2" type="1">
<li><p>Preoperative radiographs</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="3" type="1">
<li><p>Diagnosis and treatment plan are consistent with preoperative
findings</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="4" type="1">
<li><p>OH documented</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="5" type="1">
<li><p>Hygienist’s Progress Notes</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="6" type="1">
<li><p>Recall includes CPITN score</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>L. Prevention (Total=__)</strong></td>
</tr>
<tr class="even">
<td><ol type="1">
<li><p>Individualized Prevention Plan Present</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="2" type="1">
<li><p>Appropriate Topical Fluoride received</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="3" type="1">
<li><p>Sealants Placed Appropriately</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="4" type="1">
<li><p>Tobacco Query</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="5" type="1">
<li><p>Tobacco Counseling</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>M. Prosthodontics (Total=__)</strong></td>
</tr>
<tr class="even">
<td><ol type="1">
<li><p>Radiographs of Abutments</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="2" type="1">
<li><p>Perio Condition Adequate</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="3" type="1">
<li><p>Full Arch X-rays for Dentures</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="4" type="1">
<li><p>Adequate documentation available</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

> **Record Number**

<table>
<colgroup>
<col style="width: 47%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td><blockquote>
<p><strong>Criteria</strong></p>
</blockquote></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
</tr>
<tr class="even">
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>Inpatient/Operating Room Care</strong></td>
</tr>
<tr class="even">
<td colspan="11"><strong>N. Preoperative Documentation (Total
=__)</strong></td>
</tr>
<tr class="odd">
<td><ol type="1">
<li><p>Name, chart # and age documented</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="2" type="1">
<li><p>Chief complaint and history of present illness are
present.</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="3" type="1">
<li><p>Allergies/current meds documented</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="4" type="1">
<li><p>Family and surgical history documented.</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="5" type="1">
<li><p>Review of systems is present.</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="6" type="1">
<li><p>Planned treatment is documented</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>O. Consent (Total =__)</strong></td>
</tr>
<tr class="even">
<td><ol type="1">
<li><p>consent is present</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="2" type="1">
<li><p>Risks, benefits, complications and alternatives are
included.</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="3" type="1">
<li><p>Dated, including time of day, and signed by the surgeon, patient
or guardian, and a witness.</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>P. Operative/Postoperative Note (Total
=__)</strong></td>
</tr>
<tr class="even">
<td><ol type="1">
<li><p>Preoperative/postoperative diagnosis are present.</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="2" type="1">
<li><p>A detailed narrative of the operative procedure(s) is
present</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="3" type="1">
<li><p>Patient’s condition documented</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="4" type="1">
<li><p>Admission/transfer order present</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="5" type="1">
<li><p>The surgeon's name is included</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>Q. Inpatient Documentation (Total
=__)</strong></td>
</tr>
<tr class="even">
<td><ol type="1">
<li><p>Admission orders include appropriate information</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="2" type="1">
<li><p>The admission orders will include the following as
appropriate:</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="3" type="1">
<li><p>Patients admitted for overnight stays have a discharge
summary</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><ol start="4" type="1">
<li><p>The discharge summary includes the pertinent information</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><ol start="5" type="1">
<li><p>The discharge summary documents meds, diet, follow-up</p></li>
</ol></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**Summary and Recommendations**

(Within each category subtract NA and I boxes from total number
available to calculate denominator. )

+------------------------+-------------+-------------------------------+
| **Category**           | **%         | **Comments**                  |
|                        | Compliant** |                               |
|                        |             |                               |
|                        | Y/ (Y+N)    |                               |
+------------------------+-------------+-------------------------------+
| P.  Every Visit        |             |                               |
+------------------------+-------------+-------------------------------+
| Q.  Exam & Tx Plan     |             |                               |
+------------------------+-------------+-------------------------------+
| R.  Drugs              |             |                               |
+------------------------+-------------+-------------------------------+
| S.  Radiographs        |             |                               |
+------------------------+-------------+-------------------------------+
| T.  Emergency Tx       |             |                               |
+------------------------+-------------+-------------------------------+
| U.  Endodontics        |             |                               |
+------------------------+-------------+-------------------------------+
| V.  Oral Surgery       |             |                               |
+------------------------+-------------+-------------------------------+
| W.  Restorative        |             |                               |
+------------------------+-------------+-------------------------------+
| X.  Pediatrics         |             |                               |
+------------------------+-------------+-------------------------------+
| Y.  Orthodontics       |             |                               |
+------------------------+-------------+-------------------------------+
| Z.  Periodontics       |             |                               |
+------------------------+-------------+-------------------------------+
| A.  Prevention         |             |                               |
+------------------------+-------------+-------------------------------+
| B.  Prosthodontics     |             |                               |
+------------------------+-------------+-------------------------------+
| **Inpatient/Operating  |             |                               |
| Room Care**            |             |                               |
+------------------------+-------------+-------------------------------+
| C.  Pre-op             |             |                               |
|     documentation      |             |                               |
+------------------------+-------------+-------------------------------+
| D.  Consent            |             |                               |
+------------------------+-------------+-------------------------------+
| E.  Op/Post-op note    |             |                               |
+------------------------+-------------+-------------------------------+
| F.  Inpatient          |             |                               |
|     documentation      |             |                               |
+------------------------+-------------+-------------------------------+

Recommendations:

**Appendix IV**

**EVALUATION OF COMMUNITY INVOLVEMENT IN ORAL HEALTH PROGRAMS**

**Evaluation of Community Involvement in Oral Health Programs**

**Introduction**

The Evaluation of Community Involvement may be conducted concurrently
with the review of other dental program aspects or reviewed separately.
The community and management evaluation documents, while professionally
conceived, are not limited exclusively to use by dental professionals.
They may be assessed by non-dental persons with general background
knowledge in these areas. Uses for the documents also include
orientation of new staff, self-evaluation by individual professionals,
establishment of program standards, and assessment of program activities
which impact on oral health.

**The following criteria address many in the community-based activities\
that are known to have a positive influence on oral health:**

1.  An ongoing fluoridation program is established at the community
    level. At a minimum this program consists of the following
    components:

> a\. A Service Unit\* Fluoridation Committee/Team or similar work group
> that regularly meets to develop a strategy for increasing the
> percentage of community water system[^1] (CWS) users with fluoridated
> water to 75%[^2] or to maintain the percentage at or above that level.
>
> *Method to assess:* Review Fluoridation Committee/Team/Work Group
> meeting minutes and current and past CWS inventories (See b.).
>
> *\* Any reference to Service Unit fluoridation committees/teams could
> also refer to Tribal or Urban health committees/teams or Area-wide
> initiatives.*
>
> b\. A current plan for promoting fluoridation according to the
> recommendations outlined in the Centers for Disease Control and
> Prevention *Engineering and Administrative Recommendations for Water
> Fluoridation, 1995*[^3]*.* This plan should include a Service Unit CWS
> inventory of fluoridating, non-fluoridating, and naturally fluoridated
> systems; indicate each CWS user population; establish criteria to
> prioritize and target CWSs where fluoridation could be implemented or
> resumed; and specify activities planned to promote implementation at
> targeted sites.
>
> *Method to assess:* Evaluate the fluoridation plan and outcomes.
>
> c\. Resources for fluoride analysis of drinking water, including
> samples from private wells serving American Indian/Alaska Native
> households. These resources should include state or Environmental
> Protection Agency-certified laboratories, and the availability of
> approved and properly calibrated, operated, and maintained field test
> kits (colorimetric, or ion specific electrode) at the Service Unit
> level.
>
> *Method to assess:* Determine if a current listing of certified
> laboratories exists, and if agency-sponsored water testing services
> are available at the Service Unit. Review the availability of field
> test kits.

d.  Cooperatively established criteria that define optimal fluoridation
    status for tribally-owned and operated CWSs at the Service Unit. At
    a minimum, the criteria should include the optimal fluoride level
    and control range; define the frequency of monitoring and split
    sampling by the CWS; the percentage of monitoring results that must
    fall within the control range, and split sample tolerance.

> *Method to assess:* Review the current optimal fluoridation criteria.

2.  Schools with at least 30 percent American Indian/Alaska Native
    (AI/AN) enrollment promote school topical fluoride (mouthrinse,
    varnish, etc) and/or toothbrushing (with a fluoridated dentifrice)
    programs for reducing the incidence of dental caries, unless
    unwarranted due to documented low caries rates.

> *Method to assess:* Survey dental staff and/or school administrators
> to determine how many schools have fluoride mouthrinse and/or
> toothbrushing programs and how many more could be implemented.

3.  A sealant program exists for those schools with at least 30 percent
    AI/AN enrollment. These programs provide pit and fissure sealants on
    permanent molars for at least 80 percent of all AI/AN school
    children six to eight years and 12 to 15 years. An evaluation method
    for retention of sealants should also be conducted.

> *Method to assess:* Review dental data and participate in discussions
> with dental staff and/or school administrators. Conduct random chart
> reviews to determine if 80 percent compliance is being met. Review any
> available retention studies.

4.  Oral health education curricula are provided for schools with at
    least 30 percent\
    AI/AN enrollment.

> *Method to assess:* Survey dental staff and/or school administrators
> to determine how many schools have oral health education curricula and
> how many more schools could be included.

5.  Programs have been established to make oral health services
    available to individuals/families, and target groups at high risk
    for oral disease. These groups may include diabetics, tobacco users,
    Head Start children, and other special population groups as
    identified in the PL 94-437 oral health objectives.

> *Method to assess:* Review community health plan and perform chart
> reviews to determine whether needs of high-risk individuals are
> addressed. The Community-Based Activity Reporting System (CBARS) can
> be used to measure preventive activities by target groups.

6.  The dental program has provided oral health in-service training to
    non-dental health professionals in the past 12 months. An evaluation
    of the training should be conducted.

> *Method to assess:* Review annually the number of presentations to
> non-dental health professionals and the number of participants. CBARS
> should be used to provide documentation. An evaluation method to
> assess appropriateness and effectiveness should also be reviewed.

7.  The dental program participates in community health activities and
    promotes community-based oral health promotion/disease prevention
    programs based on the needs of the community. An evaluation is
    conducted on these programs.

> *Method to assess:* Review dental program participation in
> school-based programs, health fairs, health professions recruitment,
> community meetings, Head Start functions, etc. CBARS should be used to
> document these activities. **These activities should support the oral
> health objectives specified in each Service Unit/Tribal/Urban
> preventive plan.**

8.  Dental clinic staff have identified and participated in effective
    primary health care education or services delivery programs, e.g.,
    diabetes, tobacco education*,* Well Baby, and WIC programs.

> *Method to assess:* Review policies and procedures of dental program
> to assess involvement with other primary health care programs. Ask
> primary health care program directors if dental program could improve
> role in education or services delivery. Review any program
> evaluations.

9.  Local Tribal administration is involved in planning, implementation,
    and evaluation of oral health promotion/disease prevention programs.
    Opportunities for local Tribal participation have been presented and
    explored.

> *Method to assess:* Review documents (Tribal health committee meeting
> minutes and/or correspondence from the dental program) to the Tribe to
> determine what efforts have been undertaken. Determine that dental
> program staff have met at least once in the past year with the Tribal
> health leaders, e.g., Tribal health director, Tribal council, Tribal
> chairman, or council members.

10. Community satisfaction assessments have been conducted during the
    preceding year. Findings have been incorporated into changes in
    programs and policies.

> *Method to assess:* Review data from any available community
> satisfaction assessments and actions which have resulted from this
> process.

11. The Dental Program develops and routinely monitors and evaluates a
    community-based BBTD/rampant caries prevention program.

> *Method to assess:* Review dental prevention plans to assess
> appropriateness and effectiveness of collaborative efforts. Review
> annual dental data reports or other surveys to assess the incidence of
> disease in target population (0-3 years). An annual evaluation method
> should also be in place. Knowledge, skill, and attitude surveys should
> be developed with evaluation at regular intervals to assess program
> progress.

12. An annual evaluation process should be implemented for a select
    number of the criteria.

> *Method to assess:* Review evaluation methods and analysis. Discuss
> findings and how changes have been incorporated into programs.

**Evaluation of Community Involvement in Oral Health Programs**

+------------------------------+---+---+----+-------------------------+
| # CRITERIA                   | * | * | *  | **Comments**            |
|                              | * | * | *N |                         |
|                              | Y | N | /A |                         |
|                              | e | o | ** |                         |
|                              | s | * |    |                         |
|                              | * | * |    |                         |
|                              | * |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 1.  Community Water          |   |   |    |                         |
|     Fluoridation             |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| a.  Service Unit Plan        |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| b.  Fluoridation team has    |   |   |    |                         |
|     met                      |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| c.  Team assesses compliance |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| d.  Reliable mechanism for   |   |   |    |                         |
|     testing                  |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 2.  School fluoride program  |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 3.  School sealant program   |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 4.  School oral health       |   |   |    |                         |
|     curriculum               |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 5.  Oral health services     |   |   |    |                         |
|     available to high risk   |   |   |    |                         |
|     groups                   |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 6.  Oral health in-service   |   |   |    |                         |
|     provided                 |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 7.  Community health         |   |   |    |                         |
|     activities               |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 8.  Participation in health  |   |   |    |                         |
|     ed or primary services   |   |   |    |                         |
|     delivery                 |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 9.  Tribal involvement       |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 10. Community satisfaction   |   |   |    |                         |
|     assessment               |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 11. Community-based ECC      |   |   |    |                         |
|     prevention program       |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 12. Annual evaluation for    |   |   |    |                         |
|     selected criteria        |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+

**Community Feedback Form**

Describe strengths of the community component of the dental program:

Describe any weaknesses of the community component of the dental
program:

Recommendations for improving the community component of the dental
program:

Signatures: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_

Evaluator Evaluatee Date

cc: Service Unit/Tribal Health Administrator

**APPENDIX V**

**IHS CRITERIA FOR THE ASSESSMENT OF**

**DENTAL PROGRAM MANAGEMENT**

**IHS Criteria For The Assessment Of Dental Program Management**

**Introduction**

Management of clinical dental programs in the Indian Health Service
presents the clinical manager with a variety of unique challenges.
Organizational variability between Areas and Service Units,
decentralized management, and Tribal contracting are but a few factors
which contribute to the variability present within dental programs which
serve American Indians/Alaska Natives. Nonetheless, certain core
management elements should serve as a nucleus for the management of
these programs.

In this section of the quality assessment chapter, certain questions are
posed to dental managers. These questions generally require a yes/no
answer or other short response. It should be noted that there is no
mechanism provided to convert the results into a "score." The value of
this format lies in its ability to stimulate communication during the
review process.

This evaluation measures productivity, cost-effectiveness, and
appropriateness of dental services delivered in public health dental
programs which exist in Tribal, Urban, and IHS programs. These data and
calculations are useful as a baseline for determining the present status
of the program and for planning and evaluating planned changes in the
direction of the program. Much of this can only be measured by reviewing
process indicators which are believed to contribute to effectiveness and
efficiency of the program.

After completion of a management QA review, the evaluator will be able
to develop a list of program strengths as well as a list of
recommendations to improve program management.

Since this document is intended for review of core elements, it may be
necessary to add review elements locally to deal with those items unique
to individual programs.

## 

**Management Review Criteria**

## 

## A. Facilities

1\. Patients have privacy for treatment and confidential conversations
in the operatory area. (In open bays signs may be posted informing
patients of the opportunity for more privacy if requested.)

> 2\. Facilities are clean, neat, and in good repair.
>
> 3\. The disabled have access to the dental clinic and operatory area.

**B. HIPAA**

1.  Staff has received HIPAA training

2.  Facility has business agreements with appropriate entities (e.g.
    dental laboratory) **OR**

> unique patient identifiers are removed from any materials leaving the
> dental facility

3.  Workplace practices ensure patient confidentiality for protected
    medical information

**C. Policies And Procedures**

1.  Facility has policy and procedure manual for dental department

2.  Policy and Procedure Manual is updated annually

3.  At a minimum P&P manual covers:

```{=html}
<!-- -->
```
a.  Definition of services available

b.  Protocols for referral of routine and emergency procedures

c.  Standards and procedures for routine clinic operations including

    i.  Procedures requiring informed consent

    ii. Equipment maintenance

    iii. Handling tissue specimens

    iv. Continuing education

    v.  Credentialing

    vi. Privileging

    vii. Standing orders

    viii. Inventory

    ix. Prescription

    x.  Infection Control including bloodborne pathogen exposure plan

    xi. Mercury safety,

    xii. radiological protection

    xiii. N2O policies

    xiv. Response to medical device recall and hazard notices

d.  Patient eligibility including determination of eligibility for
    services and CHS

e.  Appointments

    a.  exams and routine treatment

    b.  Dental urgent/emergency treatment

    c.  Broken or canceled appointments and late arrivals

    d.  Referrals

    e.  Deferred care

f.  Clinic hours

g.  Leave policies

h.  Emergencies

-   Fire

-   Disasters

-   Medical emergencies

i.  Laboratory procedures

j.  Organizational chart

```{=html}
<!-- -->
```
4.  Is there an up-to-date copy of the *IHS Oral Health Program Guide*
    available in the clinic or ready access to the manual on the IHS
    website?

5.  Is a written "Patient Bill of Rights and Responsibilities" posted?

6.  Has a patient satisfaction questionnaire been completed within the
    last year?

7.  Is there a formal mechanism for monitoring patient complaints and
    resolving complaints to improve care?

8.  Is a written Service Unit/Tribal dental plan available which
    includes community and clinical oral health promotion/disease
    prevention objectives?

9.  Has the Service Unit/Tribal dental plan been presented to the Tribal
    health board for approval and/or comment

10. Are dental staff meetings held regularly?

11. Are minutes of previous dental staff meetings available?

12. Has a budget listed by object classes been completed for the current
    fiscal year?

13. Does the budget include both direct and CHS activities?

14. Have equipment replacement lists been updated within the past year?

**D. Staff**

1.  There is a minimum of one FTE chair-side assistant per FTE dentist.

2.  Staff maintains current State licensure, registration, or
    certification as required.

3.  Dentist has a current unrestricted DEA number unless all
    prescriptions are filled at the facility's pharmacy.

4.  Staff has completed continuing education requirements for the past
    calendar year consistent with licensure.

5.  Staff practices within their Dental Practice Act and the Rules of
    the State Board of Dentistry, which govern the practice of dentists,
    dental hygienists, and dental assistants.

6.  All personnel rules, regulations, and policies promulgated by the
    specific Tribe, IHS, and facility are followed.

7.  Is a protocol in place for orientation of new dental staff and
    documentation of orientation to the dental program and hospital or
    clinic?

8.  Does each employee have a current and accurate position description
    or billet description?

9.  Do current standards of performance exist for each dental employee?

10. Have the training needs of each dental employee been identified for
    the current fiscal year?

11. Is the selection of training for employees based on needs identified
    for the Service Unit/Tribal/Urban program and the individual?

12. Is in‑service dental training available to the dental staff?

## E. Access

> 1\. Patients with dental emergencies are seen on the same day they
> call if at all possible.
>
> 2\. A recall system is utilized when appropriate (high risk patients).
> Intervals are based on the dental need of the individual patient.

3.  The facility accommodates patients who require dental clearance for
    medical treatments (transplants, joint replacements, etc.)

4.  The Secretary's Regulations on IHS Eligibility (42 CFR, Section
    36.12, 36.23-24, Section 813, IHCIA) are adhered too.

5.  There is follow-up on all canceled or broken appointments.

6.  The appointment policy is adhered to.

7.  The broken appointment policy has been approved by the Tribal health
    board and communicated to patients/community

8.  Patients are booked no more than three weeks in advance of
    appointments

9.  The recall interval based on each patient's individual disease
    rates, rather than using arbitrary time intervals

10. A call list is available for patients who can respond on short
    notice to fill in broken or canceled appointments.

11. Appointment policies are available as handouts or posted for public
    view?

## F. Infection Control

1.  Infection Control QA has been completed within the last year

2.  Deficiencies have been corrected

3.  Deficiencies and/or changes have been reviewed with the dental staff

### G. Medical Emergency Preparedness

1.  All staff has current CPR certification.

2.  An oxygen tank with an appropriate valve, tubing, and mask is
    available. Dental staff is familiar with its location and use.

3.  Blood pressure is taken on all patients over the age of 16 at least
    once per year.

4.  An emergency kit is readily available.

    a.  All dental staff knows its location and how to use the contents.

    b.  The expiration dates of the drugs are current.

5.  Emergency phone numbers are prominently posted.

6.  The facility has an emergency management protocol.

7.  The staff reviews the emergency management protocol at least
    annually.

## H. Radiation Safety

1\. X-ray machines are inspected at the required intervals.

a.  Deficiencies are corrected in a timely manner.

> 2\. Lead aprons are used on all patients receiving radiographs.

a.  The aprons are x-rayed annually to assure that no damage occurred to
    the lead lining during storage and/or use. This service can usually
    be obtained at a local hospital.

> 3\. Film positioners are used.

a.  Neither patient nor staff holds the film during exposure.

> 4\. Staff is protected from scattered radiation during film exposure.
>
> 5\. All dental assistants who take radiographs are currently certified
> in radiology?

## I. Mercury Hygiene

1\. Premeasured, disposable amalgam capsules are used.

> 2\. The agitator of the amalgamator functions under a protective
> cover.
>
> 3\. Amalgam scrap is stored in tightly closed containers and recycled
> properly.
>
> 4\. Amalgam waste is handled according to the ADA's "Best Management
> Practices," a copy of which can be downloaded at
> <http://www.ada.org/prof/resources/topics/topics_amalgamwaste.pdf>

## J. Chemical Hazards

1\. Staff complies with the OSHA Hazard Communication Standard.
(Evaluate by using the Hazard Communication Compliance Checklist, a copy
of which can be obtained from the OSHA website at
[http://www.osha.gov/Publications/osha3111.pdf#search=\'hazard%20communications%20compliance%20checklist](http://www.osha.gov/Publications/osha3111.pdf#search='hazard communications compliance checklist)\')

> 2\. A written Hazard Communication Program (HCP) is on file and
> accessible to staff.

a.  The HCP is reviewed at least annually and updated as necessary.

> 3\. Material safety data sheets (MSDS) are on file for each hazardous
> chemical.

a.  Any missing MSDS has been requested in writing, and a copy of the
    request is on file.

b.  MSDSs no longer in use are archived and kept for thirty years.

> 4\. The inventory of chemicals, materials, and supplies and the list
> of hazardous chemicals in the HCP accurately reflect all the hazardous
> chemicals and products that are present in the dental clinic.
>
> 5\. Staff participates in hazard communication training at least
> annually.

**K. Public Health / Data Analysis**

1.  If emergency care exceeds 40% of total services provided, indicating
    large unmet dental needs, do Level IV plus V, equal less than 5% of
    total services?

2.  Do Level II (primary care) services comprise at least 15% of total
    services provided, indicating the existence of a clinical prevention
    program?

3.  Does the facility dental chief understand the relationship between
    the "levels of care" concept and the practice of public health
    dentistry?

4.  Do services provided data reveal the absence of procedures that are
    not generally recommended in IHS practice, such as gold foil
    restorations or unilateral removable partial dentures ("Nesbitt"
    partials)?

5.  Does the number of sedative fillings provided (Code 2940) comprise
    less than 5% of the total number of restorations provided?

6.  Do stainless steel crowns comprise at least 80% of primary
    restorations involving three or more surfaces?

**IHS Review Instrument For The Assessment Of Dental Program
Management**

Date\_\_\_\_\_\_\_\_\_\_\_\_

Clinic Site \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Reviewer\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

+-------------------------------+---+---+----+------------------------+
| # CRITERIA                    | * | * | *  | **Comments**           |
|                               | * | * | *N |                        |
|                               | Y | N | /A |                        |
|                               | e | o | ** |                        |
|                               | s | * |    |                        |
|                               | * | * |    |                        |
|                               | * |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| **A. FACILITIES**             |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| 1.  Privacy                   |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| 2.  Clean, Neat, and in Good  |   |   |    |                        |
|     Repair                    |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| 3.  Access for the Disabled   |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| **B. HIPAA**                  |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| 1.  HIPAA training            |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| 2.  Bus. agreements or        |   |   |    |                        |
|     removal of pt ID          |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| 3.  Confidentiality ensured   |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| **C. POLICIES AND             |   |   |    |                        |
| PROCEDURES**                  |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| 1.  Facility has P&P Manual   |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| 2.  Manual Updated annually   |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| 3.  P&P manual covers:        |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| a.  Scope of Services         |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| b.  Referral procedures       |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| c.  Clinic operations         |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| i.  informed consent          |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| ii. Equipment maintenance     |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| iii. Handling tissue          |   |   |    |                        |
|      specimens                |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| iv. Continuing education      |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| v.  Credentialing             |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| vi. Privileging               |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| vii. Standing orders          |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| viii. Inventory               |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| ix. Prescription              |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| x.  Infection Control         |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| xi. Mercury safety            |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| xii. radiological protection  |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| xiii. N2O policies            |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| xiv. Medical device recalls   |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| d.  Patient Eligibility       |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| e.  Appointments              |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| -   Exams/routine care        |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| -   urgent/emergent care      |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| -   Broken/canceled/late      |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| -   Referrals                 |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+
| -   Deferred care             |   |   |    |                        |
+-------------------------------+---+---+----+------------------------+

+------------------------------+---+---+----+-------------------------+
| > **Criteria**               | * | * | *  | **Comments**            |
|                              | * | * | *N |                         |
|                              | Y | N | /A |                         |
|                              | e | o | ** |                         |
|                              | s | * |    |                         |
|                              | * | * |    |                         |
|                              | * |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| **POLICIES AND PROCEDURES,   |   |   |    |                         |
| continued**                  |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| f.  Clinic Hours             |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| g.  Leave Policies           |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| h.  Emergencies              |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| -   fire                     |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| -   Disasters                |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| -   Medical emergencies      |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| i.  Dental Laboratory        |   |   |    |                         |
|     Procedures               |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| j.  Organizational Chart     |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 4.  OHPG available           |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 5.  Patient Bill of          |   |   |    |                         |
|     Rights/Responsibilities  |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 6.  Patient Satisfaction     |   |   |    |                         |
|     Survey                   |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 7.  Patient complaints       |   |   |    |                         |
|     monitored                |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 8.  Service Unit/Tribal      |   |   |    |                         |
|     Dental Plan              |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 9.  Plan presented to Tribe  |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 10. Dental staff meetings    |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 11. Minutes available        |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 12. Budget by Object Class   |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 13. Budget includes direct   |   |   |    |                         |
|     and CHS                  |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 14. Equipment list           |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| **D. STAFF**                 |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 1.  One Assistant per        |   |   |    |                         |
|     Dentist                  |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 2.  Current Licenses         |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 3.  Unrestricted DEA Number  |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 4.  Continuing Education     |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 5.  State Board guidelines   |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 6.  Policies, Rules, and     |   |   |    |                         |
|     Regulations              |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 7.  Orientation protocol     |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 8.  Accurate position        |   |   |    |                         |
|     descriptions/billets     |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 9.  Standards of Performance |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 10. Training needs assessed  |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 11. Training based on needs  |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 12. In-service training      |   |   |    |                         |
|     available                |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+

+------------------------------+---+---+----+-------------------------+
| > **Criteria**               | * | * | *  | **Comments**            |
|                              | * | * | *N |                         |
|                              | Y | N | /A |                         |
|                              | e | o | ** |                         |
|                              | s | * |    |                         |
|                              | * | * |    |                         |
|                              | * |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| **E. ACCESS TO CARE**        |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 1.  Emergencies              |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 2.  Recall                   |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 3.  Accommodates special     |   |   |    |                         |
|     needs                    |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 4.  Eligibility Regulation   |   |   |    |                         |
|     Compliance               |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 5.  Follow-up                |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 6.  Appointment policy       |   |   |    |                         |
|     adhered to.              |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 7.  Broken appointment       |   |   |    |                         |
|     policy approved          |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 8.  Three week limit         |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 9.  Recall interval          |   |   |    |                         |
|     individualized           |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 10. Call list is available   |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 11. Appointment policies     |   |   |    |                         |
|     available                |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| **F. INFECTION CONTROL**     |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 1.  Infection control review |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 2.  Deficiencies corrected   |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 3.  Staff update             |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| **G. MEDICAL EMERGENCY       |   |   |    |                         |
| PREPAREDNESS**               |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 1.  Current CPR              |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 2.  Oxygen Tank              |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 3.  Blood Pressure           |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 4.  Emergency Kit and Drugs  |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| a.  Staff knows location and |   |   |    |                         |
|     use                      |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| b.  Expiration dates current |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 5.  Emergency Phone Numbers  |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 6.  Emergency Plan Review    |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| **H. RADIATION SAFETY**      |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 1.  Inspection Current       |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| a.  Deficiencies corrected   |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 2.  Lead Apron               |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| a.  Apron x-rayed annually   |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 3.  Film Positioners         |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| a.  Films not held by hand   |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 4.  Scatter Protection       |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 5.  DAs certified in         |   |   |    |                         |
|     radiology                |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+

+------------------------------+---+---+----+-------------------------+
| > **Criteria**               | * | * | *  | **Comments**            |
|                              | * | * | *N |                         |
|                              | Y | N | /A |                         |
|                              | e | o | ** |                         |
|                              | s | * |    |                         |
|                              | * | * |    |                         |
|                              | * |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| **I. MERCURY HYGIENE**       |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 1.  Premeasured amalgam      |   |   |    |                         |
|     capsules                 |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 2.  Agitator Covered         |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 3.  Storage of Scrap Amalgam |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 4.  Best Management          |   |   |    |                         |
|     Practices                |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| **J. CHEMICAL HAZARDS**      |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 1.  Hazard Communications    |   |   |    |                         |
|     Standard Compliance      |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 2.  Hazard Communication     |   |   |    |                         |
|     Standard                 |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| a.  Annual review            |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 3.  MSDSs                    |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| a.  Missing MSDS requested   |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| b.  Old MSDSs archived       |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 4.  Supply Inventory/List of |   |   |    |                         |
|     Chemicals                |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 5.  Annual Training          |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| **K. PUBLIC HEALTH / DATA    |   |   |    |                         |
| ANALYSIS**                   |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 1.  Ratio of level I care to |   |   |    |                         |
|     level IV plus V care     |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 2.  Level II at least 15% of |   |   |    |                         |
|     total                    |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 3.  Chief understands the    |   |   |    |                         |
|     relationship between the |   |   |    |                         |
|     "levels of care" and     |   |   |    |                         |
|     public health dentistry? |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 4.  Absence of               |   |   |    |                         |
|     IHS-non-recommended      |   |   |    |                         |
|     procedures               |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 5.  Sedative fillings less   |   |   |    |                         |
|     than 5% of restorations  |   |   |    |                         |
|     provided?                |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+
| 6.  SSCrs at least 80% of    |   |   |    |                         |
|     primary restorations     |   |   |    |                         |
|     involving three or more  |   |   |    |                         |
|     surfaces?                |   |   |    |                         |
+------------------------------+---+---+----+-------------------------+

**Summary And Recommendations**

Date\_\_\_\_\_\_\_\_\_\_\_\_

Clinic Site \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Reviewer\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  ---------------- ------------------------- ----------------------------
  **Category**     **Findings**              **Recommendations**

  Facilities                                 

  HIPAA                                      

  Policies and                               
  procedures                                 

  Access to Care                             

  Infection                                  
  Control                                    

  Emergency                                  
  Preparedness                               

  Radiation Safety                           

  Mercury Hygiene                            

  Chemical Hazards                           

  Public                                     
  Health/Data                                
  Analysis                                   
  ---------------- ------------------------- ----------------------------

**Management Feedback Form**\
(Provide to Evaluatee at Close-Out Session)

Objective considered unsatisfactory:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Describe deficiencies related to this objective:

Objective considered unsatisfactory:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Describe deficiencies related to this objective:

Objective considered unsatisfactory:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Describe deficiencies related to this objective:

Objective considered unsatisfactory:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Describe deficiencies related to this objective:

Program strengths:

**Management Feedback Form, continued**

Plan of action to correct deficiency(ies):

Signatures:

Evaluator Evaluatee Date

cc: Service Unit Director/Tribal Health Administrator

**APPENDIX VI**

**INFECTION CONTROL PROGRAM ASSESSMENT**

**[Infection Control Program Assessment]{.underline}**

***A-acceptable, U-unacceptable, Ob-by observation, Int-by interview,
Cor- corrected, Com-comments***

+-----------------------------------------+---+---+---+---+---+---+------+---+
|                                         | A | U | N | O | I | C | Com  |   |
|                                         |   |   | / | b | n | o |      |   |
|                                         |   |   | A |   | t | r |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| **Personnel Elements**                  |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 1\. Each employee has received training |   |   |   |   |   |   |      |   |
| on infection control                    |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 2\. Each employee has received, is in   |   |   |   |   |   |   |      |   |
| process of receiving, or has            |   |   |   |   |   |   |      |   |
| documentation of declination of         |   |   |   |   |   |   |      |   |
| Hepatitis B vaccination series          |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 3\. Each employee has received an       |   |   |   |   |   |   |      |   |
| annual TB skin test and any appropriate |   |   |   |   |   |   |      |   |
| follow-up for positive tests            |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| **Administrative Elements**             |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 1\. Facility has a written, updated     |   |   |   |   |   |   |      |   |
| Infection Control Policy                |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 2\. Facility has a written policy of    |   |   |   |   |   |   |      |   |
| required vaccinations                   |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 3\. Facility has a postexposure         |   |   |   |   |   |   |      |   |
| management plan that includes toll-free |   |   |   |   |   |   |      |   |
| numbers and websites for access to      |   |   |   |   |   |   |      |   |
| additional information                  |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 4\. Facility has a policy regarding     |   |   |   |   |   |   |      |   |
| work related illnesses and work         |   |   |   |   |   |   |      |   |
| restrictions                            |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 5\. Facility has a policy for           |   |   |   |   |   |   |      |   |
| maintaining the confidentiality of      |   |   |   |   |   |   |      |   |
| employee medical records                |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 6\. An incident log is maintained for   |   |   |   |   |   |   |      |   |
| all occupationally-related injuries and |   |   |   |   |   |   |      |   |
| exposures, including sharps injuries    |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 7\. All occupational exposures are      |   |   |   |   |   |   |      |   |
| investigated according to the           |   |   |   |   |   |   |      |   |
| management plan and steps are taken to  |   |   |   |   |   |   |      |   |
| prevent similar exposures in the future |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 7\. A copy of the most recent CDC       |   |   |   |   |   |   |      |   |
| Guidelines for Infection Control on     |   |   |   |   |   |   |      |   |
| Dentistry is available in the facility  |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 8\. Records are maintained in the       |   |   |   |   |   |   |      |   |
| following areas                         |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| a)  training and in-services in         |   |   |   |   |   |   |      |   |
|     infection control (3 years)         |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| b)  inspection results                  |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| c)  sterilization records (2 years)     |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| d)  health-care associated infections   |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 9\. Exposure control plan is reviewed   |   |   |   |   |   |   |      |   |
| annually for developments in safer      |   |   |   |   |   |   |      |   |
| medical devices                         |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| **Contact Dermatitis and Latex          |   |   |   |   |   |   |      |   |
| Sensitivity**                           |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 1\. Patients are screened for latex     |   |   |   |   |   |   |      |   |
| sensitivity                             |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 2\. The facility can provide a          |   |   |   |   |   |   |      |   |
| latex-free environment for patients and |   |   |   |   |   |   |      |   |
| dental health care personnel (DHCP)     |   |   |   |   |   |   |      |   |
| with latex sensitivity                  |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 3\. The facility has an emergency kit   |   |   |   |   |   |   |      |   |
| with latex free items                   |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 4\. Policies are in place to identify,  |   |   |   |   |   |   |      |   |
| evaluate, and manage DHCP with          |   |   |   |   |   |   |      |   |
| suspected or known latex allergy or     |   |   |   |   |   |   |      |   |
| occupational contact dermatitis         |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+

***A-acceptable, U-unacceptable, Ob-by observation, Int-by interview,
Cor- corrected, Com-comments***

  ------------------------------------------ --- --- ----- ---- ----- ----- ------- --
                                             A   U   N/A   Ob   Int   Cor   Com     

  **Medical History**                                                               

  1\. A thorough medical history is taken on                                        
  each patient                                                                      

  2\. The medical history is reviewed and                                           
  updated at each visit                                                             

  **Preventing transmission of bloodborne                                           
  pathogens**                                                                       

  1\. Each employee has received, is in                                             
  process of receiving or has documentation                                         
  of declination of Hepatitis B vaccination                                         

  2\. Standard precautions are used for all                                         
  patients                                                                          

  3\. Used sharps are placed in a puncture                                          
  resistant container                                                               

  4\. Needles are recapped using either a                                           
  one-handed scoop technique or a mechanical                                        
  device designed for holding the needle cap                                        

  5\. Exposure incidents are followed up                                            
  according to CDC recommendations                                                  

  **Hand Hygiene**                                                                  

  1\. Hands are washed with soap and water                                          
  or cleaned with an alcohol gel before and                                         
  after each patient                                                                

  2\. Sterile gloves are used for                                                   
  appropriate procedures                                                            

  3\. Fingernails and/or jewelry do not                                             
  impair the proper use of gloves                                                   

  4\. All cases of hand dermatitis are                                              
  evaluated for treatment and follow-up                                             

  **Personal Protective Equipment (PPE)**                                           

  1\. A surgical mask and eye protection                                            
  with solid side shields or a face shield                                          
  to protect mucous membranes of the eyes,                                          
  nose, and mouth are worn during procedures                                        
  likely to generate splashing or spattering                                        
  of blood or other body fluids                                                     

  2\. Masks are changed between patients or                                         
  if the mask becomes wet                                                           

  3\. Protective wear (gown, lab coat,                                              
  uniform) is worn when skin or personal                                            
  clothing is likely to become soiled                                               

  4\. Protective clothing is removed before                                         
  leaving work area                                                                 

  5\. Gloves are worn when a potential                                              
  exists for contacting blood, saliva,                                              
  mucous membrane, or other potentially                                             
  infectious material (OPIM)                                                        

  6\. Gloves are changed if they become torn                                        
  and between each patient                                                          

  7\. Sterile gloves are used for all                                               
  surgical procedures (excluding simple                                             
  extractions)                                                                      

  8\. Head and shoe covers are available for                                        
  personnel who request them                                                        

  9\. Protective clothing is changed if                                             
  visibly soiled or if penetrated by blood                                          
  or OPIM                                                                           
  ------------------------------------------ --- --- ----- ---- ----- ----- ------- --

***A-acceptable, U-unacceptable, Ob-by observation, Int-by interview,
Cor- corrected, Com-comments***

  ------------------------------------------ --- --- ----- ---- ----- ----- ------- --
                                             A   U   N/A   Ob   Int   Cor   Com     

  **Sterilization and Disinfection of                                               
  Patient-Care Items**                                                              

  1\. Critical and semi-critical items,                                             
  including handpieces and accessories, are                                         
  heat sterilized before and between uses                                           

  2\. Sterilized items are allowed to dry                                           
  before handling                                                                   

  3\. Disposable items are not reused                                               

  4\. Noncritical patient-care items are                                            
  barrier-protected or cleaned, or if                                               
  visibly soiled, cleaned and disinfected                                           
  after each use with an EPA-registered                                             
  hospital disinfectant.                                                            

  5\. Instrument processing area is divided                                         
  into a "Clean" and "Dirty" area or                                                
  measures are taken to avoid contamination                                         
  of clean instruments                                                              

  6\. Instruments are debrided prior to                                             
  sterilization                                                                     

  7\. Puncture resistant gloves are used for                                        
  instrument processing                                                             

  8\. Masks, protective eyewear, and                                                
  protective clothing are worn when                                                 
  instruments are cleaned manually                                                  

  9\. Ultrasonic cleaner is tested                                                  
  periodically                                                                      

  10\. Internal and external chemical                                               
  indicators are used for each instrument                                           
  package or load of unwrapped instruments                                          

  11 Time, temperature, and pressure are                                            
  recorded for each sterilization load                                              

  12\. Sterilizer is loaded according to                                            
  manufacturer's instructions                                                       

  13\. Container or wrapping system is                                              
  compatible with method of sterilization                                           

  14\. Unwrapped instruments are cleaned and                                        
  dried prior to sterilization                                                      

  15\. If instruments are sterilized                                                
  unwrapped, there is a written policy on                                           
  how they will be labeled and stored                                               

  16\. Internal and external chemical                                               
  indicators are used for each instrument                                           
  package or load of unwrapped instruments                                          

  17\. Time, temperature, and pressure are                                          
  recorded for each sterilization load                                              

  18\. Chemical and biological monitors are                                         
  used                                                                              

  19\. In facilities with a medical clinic,                                         
  biological monitoring is done on the same                                         
  frequency as the medical clinic                                                   

  20\. In the case of a positive spore test:                                        
  problem is corrected, and another spore                                           
  test is run to confirm sterilization                                              
  effectiveness. All affected instruments                                           
  are re-sterilized                                                                 

  21\. Wrapped instruments are marked for                                           
  date of sterilization, sterilizer, and                                            
  load                                                                              

  22\. Sterile packages are inspected before                                        
  use, compromised packages are                                                     
  re-sterilized prior to use                                                        

  23\. Sterile packages are stored in a                                             
  closed or covered cabinet                                                         

  24\. All sterilization equipment is                                               
  FDA-approved                                                                      

  25\. Manufacturers' instructions are                                              
  available for sterilization equipment                                             

  26\. Routine preventive maintenance is                                            
  performed per manufacturers' instructions                                         
  ------------------------------------------ --- --- ----- ---- ----- ----- ------- --

***A-acceptable, U-unacceptable, Ob-by observation, Int-by interview,
Cor- corrected, Com-comments***

  ------------------------------------------ --- --- ----- ---- ----- ----- ------- --
                                             A   U   N/A   Ob   Int   Cor   Com     

  **Environmental Infection Control**                                               

  1\. Cleaning and EPA-registered hospital                                          
  disinfecting products are used correctly                                          

  2\. EPA registered intermediate level                                             
  disinfectants are used for environmental                                          
  surfaces that are not barrier protected                                           

  3\. PPE, as appropriate, is used when                                             
  cleaning and disinfecting environmental                                           
  surfaces.                                                                         

  4\. Surface barriers are used on surfaces                                         
  difficult to clean and changed between                                            
  patients                                                                          

  5\. Contaminated environmental surfaces                                           
  are appropriately cleaned                                                         

  6\. Spills of blood or other potentially                                          
  infectious materials are cleaned and                                              
  decontaminated with an EPA-registered                                             
  hospital disinfectant with low- (i.e., HBV                                        
  and HIV label claims) to                                                          
  intermediate-level (i.e., tuberculocidal                                          
  claim) activity                                                                   

  7\. Facility has an infected waste                                                
  management plan that is consistent with                                           
  state and/or federal regulations                                                  

  8\. Contaminated non-sharp waste is stored                                        
  in a puncture resistant, color coded bag                                          

  9\. Liquid waste is disposed of in a                                              
  sanitary sewer system or in a manner in                                           
  accordance with state regulations                                                 

  10\. There is no carpet or cloth                                                  
  furnishings in patient care, lab, or                                              
  instrument processing areas                                                       

  **Water Quality**                                                                 

  1\. Water used for routine non-surgical                                           
  dental treatment meets EPA standards for                                          
  drinking water (less than or equal to 500                                         
  CFU/ml)                                                                           

  2\. Any device connected to a water system                                        
  that enters the patient's mouth is flushed                                        
  for 20-30 seconds between patients                                                

  3\. Water lines are monitored according to                                        
  manufacturer's recommendations, using                                             
  commercial, self-contained test kits or                                           
  commercial water-testing laboratories                                             

  4\. The facility has a protocol to manage                                         
  water not meeting the EPA standard                                                

  5\. Sterile irrigating solutions are used                                         
  for all surgical procedures                                                       

                                                                                    

                                                                                    
  ------------------------------------------ --- --- ----- ---- ----- ----- ------- --

***A-acceptable, U-unacceptable, Ob-by observation, Int-by interview,
Cor- corrected, Com-comments***

+-----------------------------------------+---+---+---+---+---+---+------+---+
|                                         | A | U | N | O | I | C | Com  |   |
|                                         |   |   | / | b | n | o |      |   |
|                                         |   |   | A |   | t | r |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| **Special Considerations**              |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 1\. Handpieces are removed, cleaned and |   |   |   |   |   |   |      |   |
| sterilized between each patient         |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 2\. Patients are not instructed to      |   |   |   |   |   |   |      |   |
| close lips around suction devices       |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 3\. Gloves are worn when exposing       |   |   |   |   |   |   |      |   |
| radiographs and when handling           |   |   |   |   |   |   |      |   |
| contaminated packets                    |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 4\. Radiography film holders are        |   |   |   |   |   |   |      |   |
| disposed of, heat sterilized or         |   |   |   |   |   |   |      |   |
| disinfected appropriately between       |   |   |   |   |   |   |      |   |
| patients                                |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 5\. Aseptic procedures are used when    |   |   |   |   |   |   |      |   |
| transporting and developing films       |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 6\. Dispensing medication from          |   |   |   |   |   |   |      |   |
| multidose vials:                        |   |   |   |   |   |   |      |   |
|                                         |   |   |   |   |   |   |      |   |
| a\. sterile needle and syringe are used |   |   |   |   |   |   |      |   |
| for each patient                        |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| > b\. Vials are kept out of patient     |   |   |   |   |   |   |      |   |
| > care areas                            |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 7\. Biopsy specimens are stored in a    |   |   |   |   |   |   |      |   |
| sterile, leak-proof container labeled   |   |   |   |   |   |   |      |   |
| with the biohazard symbol               |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 8\. Extracted teeth are handled as      |   |   |   |   |   |   |      |   |
| regulated medical waste unless returned |   |   |   |   |   |   |      |   |
| to the patient                          |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 9\. Extracted teeth to be used for      |   |   |   |   |   |   |      |   |
| educational purposes are appropriately  |   |   |   |   |   |   |      |   |
| sterilized                              |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| **Dental laboratory**                   |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 1\. Appropriate PPE is used for all     |   |   |   |   |   |   |      |   |
| laboratory procedures                   |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 2\. Prostheses and impressions are      |   |   |   |   |   |   |      |   |
| disinfected with an intermediate level  |   |   |   |   |   |   |      |   |
| disinfectant before being handled in    |   |   |   |   |   |   |      |   |
| the laboratory                          |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 3\. Heat-tolerant lab items (e.g., bite |   |   |   |   |   |   |      |   |
| forks, metal impression trays) are      |   |   |   |   |   |   |      |   |
| autoclaved before reuse                 |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 4\. Pumice is mixed with a disinfectant |   |   |   |   |   |   |      |   |
| and changed at least daily              |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 5\. Rag wheels are cleaned and          |   |   |   |   |   |   |      |   |
| disinfected (autoclaved, preferably) at |   |   |   |   |   |   |      |   |
| least daily                             |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 6\. Lathes are cleaned and disinfected  |   |   |   |   |   |   |      |   |
| daily                                   |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 7\. Case pans are cleaned and           |   |   |   |   |   |   |      |   |
| disinfected when visibly soiled and     |   |   |   |   |   |   |      |   |
| after each case is completed            |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| **Tuberculosis**                        |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 1\. The clinic has a written TB control |   |   |   |   |   |   |      |   |
| plan                                    |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 2\. All personnel have baseline         |   |   |   |   |   |   |      |   |
| tuberculin skin tests or chest x-rays   |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 3\. Staff are trained to recognize the  |   |   |   |   |   |   |      |   |
| signs and symptoms of TB                |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+
| 4\. All patients are assessed for       |   |   |   |   |   |   |      |   |
| signs, symptoms, and history of TB      |   |   |   |   |   |   |      |   |
+-----------------------------------------+---+---+---+---+---+---+------+---+

***A-acceptable, U-unacceptable, Ob-by observation, Int-by interview,
Cor- corrected, Com-comments***

  ------------------------------------------ --- --- ----- ---- ----- ----- ------- --
                                             A   U   N/A   Ob   Int   Cor   Com     

  **Infection Control Monitoring**                                                  

  1\. Facility conducts periodic infection                                          
  control monitoring                                                                

  2\. Practices not in compliance with                                              
  infection control standards are addressed                                         

  3\. All healthcare-associated infections                                          
  are evaluated and any trends undergo                                              
  formal evaluation                                                                 

                                                                                    

                                                                                    
  ------------------------------------------ --- --- ----- ---- ----- ----- ------- --

**Appendix VII**

**Sample Letter**

Date:

To:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Service Unit Director/Tribal Health Administrator

Attn:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Dentist/Program Personnel

From:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Evaluator

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Location Area

Subject: Scheduling and Preparation for Dental Quality Assessment
Evaluation Visit.

As previous established in our telephone conversation, I plan to visit
and evaluate your Dental Program on:

Date(s)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ From time:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_to
time:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

For the convenience of those patients and staff involved, it will be
desirable to observe the schedule outline as follows:

Pre-evaluation Conference with dentist

and/or appropriate staff Time:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Evaluation Time:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Post-evaluation Conference with Evaluatee
Time:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Please contact me if any changes in this schedule need to be made. It is
suggested that you review and become familiar with the evaluation
criteria that will be reviewed prior to the evaluation. It would also be
helpful if indicated file material, lists, data, and minutes of
applicable meetings are collected prior to the evaluation visit.

The purpose of the evaluation is to assist you and your staff in the
enhancement of dental care available to the local community, as well as
identifying your dental program needs. It is meant to be an open and
ongoing process contributing to the exchange of information.

I look forward to sharing this educational experience with you.

Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Evaluator

Title:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Location: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Additional comments or instructions:

**Chapter 8,** **Dental Clinic Efficiency and Effectiveness**

**Table of Contents**

A. Introduction, Background, and Purpose

B. Patient Flow and Control of the Appointment Schedule

C. Data Indicators for Dental Clinic Efficiency and Effectiveness

D. Relationship Between Dental Clinic Efficiency and Resource
Requirements Methodology

**Appendices**

I. Controlling an Overloaded Appointment Schedule

II\. Dental Appointment Agreement

III\. Broken Appointment Rate and Walk-In Rate Worksheet (MS Word)

IV\. Patient Flow Questionnaire

V. Efficiency and Effectiveness Data Indicators Worksheet (MS Word)

**Web Links**

#1 Broken Appointment Rate and Walk-In Rate Worksheet (Excel)

#2 Efficiency and Effectiveness Data Indicators Worksheet (Excel)

#3 Reference Value Calculations for Data Indicators (Excel)

**Introduction, Background, and Purpose**

**1. [Introduction]{.underline}**

A key public health principle is to provide the most good for the most
people with the resources that are available. It follows that the
efficient and effective use of available resources is crucial in dental
programs serving American Indians/Alaska Native (AI/AN) communities,
because most programs are insufficiently funded to provide adequate
access for all persons who seek dental care.

**Definitions:**

> Efficiency: The degree to which (health) outputs are achieved in terms
> of productivity and resources allocated (source: United States
> Department of Justice)
>
> Effectiveness: The extent to which an intervention achieves health
> improvements (source: Harvard School of Public Health)
>
> **Characteristics of an Efficient and Effective Dental Program:**

-   Provides access to services for all persons who seek and need care.

-   Provides dental care that is appropriate, of high quality,
    cost-effective, and acceptable to patients.

-   Achieves smooth patient flow throughout the work day.

-   Promotes continuity of patient care, even when there is turnover of
    professional staff.

-   Meets consistently all regulatory requirements and standards of
    practice.

**2. [Background]{.underline}**

Much of the information in this "Dental Clinic Efficiency and
Effectiveness" manual was originally presented in an Indian Health
Service (IHS) training course manual entitled, "Dental Clinic Efficiency
and Effectiveness Management Tools." The latter was developed by the
Clinical Efficiency Workgroup of the IHS Dental Services Delivery
Committee that was in existence at that time. This manual was completed
in July of 1995, but it was distributed only to IHS and Tribal dentists
who took the "Dental Clinic Efficiency and Effectiveness" continuing
education course offered by the IHS dental program. With this current
revision of the IHS [Oral Health Program Guide]{.underline} (OHPG), a
decision was made to include a "Dental Clinic Efficiency and
Effectiveness" chapter available within the OHPG to make this
information available to all dental staff and administrators.

Because evidence-based data on best practices to promote clinical
efficiency and effectiveness in dental programs serving American Indians
and Alaska Natives (AI/AN) are almost non-existent, this document has
its basis in recommendations from recognized experts in the field. This
includes the observations of numerous senior IHS clinicians with
extensive experience working in IHS/Tribal/Urban Indian (I/T/U) dental
programs, as well as dental administrators and consultants working
within the IHS dental program. Some of these clinicians and consultants
have performed literally hundreds of dental program reviews in I/T/U
programs, and the guidelines presented have been tested and modified
over time. The list of recommendations has evolved somewhat since the
1995 manual was completed, both through the addition of new topics and
the elimination of some seldom-used criteria, but the basic information
remains unchanged.

**3. [Purpose]{.underline}**

The primary purpose of this document is to provide ways for local I/T/U
dental programs to evaluate their own programs using various data
indicators and scheduling/patient flow recommendations. This information
can then be used to make improvements in clinical efficiency and
effectiveness in their own programs. Although the provision of dental
program reviews by consultants from IHS Area Offices and Dental Support
Centers is not as widespread as it was several years ago, this manual is
also suitable for use by consultants to review and provide
recommendations to I/T/U dental programs under their purview.

**Patient Flow and Control of the Appointment Schedule**

**1. [Appointment Scheduling]{.underline}**

**Recommendation:** Appoint patients no more than three weeks ahead in
the appointment schedule.

**Rationale:** Many programs have found that when appointments are made
more than three weeks ahead of the designated appointment time, the
broken appointment rate tends to be higher than if the schedule is
restricted to a three-week maximum. Also, if the appointment schedule is
filled too far ahead, there might be insufficient lead time to allow for
the scheduling of meetings and other unforeseen events. Then when
important events arise that must be attended by dental staff, patients
must be rescheduled. Not only is this inconvenient for patients and
staff, but it also results in the schedule being filled even further
ahead, which compounds the problem.

**Implementation:** Ideally every patient who requests an appointment
would receive one, as long as the book is filled no more than three
weeks ahead. Few programs are able to do this, because of a high demand
for dental care and limited resources. If a program has been giving
appointments on demand (providing an appointment for every patient who
asks for one), and if the schedule is filled only four or five weeks
ahead, then it might be possible to bring the schedule back to the
three-week maximum by implementing the patient flow suggestions that are
described in this manual. If the patient load increases, or if the
schedule is already filled far beyond the three-week level, then another
appointment system should be considered.

If a program is overwhelmed with patients, which is the case at many
I/T/U programs, a formal call-in system, such as a weekly call-in, is
typically implemented. An alternative that is used less frequently is a
formal waiting list system.

A more recent scheduling method that some clinics have adopted is the
"walk-in clinic" concept. This scheduling technique is usually found in
clinics that are entirely overwhelmed with patients, and often these
clinics have high broken appointment (BA) rates. This system
automatically takes care of the three-week limit that is recommended for
scheduling, because patients are seen the day they walk in for
treatment. It also has a dramatic effect on lowering the BA rate,
because of the same-day appointments. Many variations of the walk-in
clinic method exist, and many clinics schedule regular patients for part
of the day or certain days of the week and have a walk-in clinic for the
remainder of the hours or days available. A similar technique is the
"same day call-in system." All of the above appointment techniques are
described in more detail in ***Appendix I, "Controlling an Overloaded
Appointment Schedule."***

Approval should be obtained from Service Unit Director or Health Program
Director and from the Tribal Health Committee or Tribal Council before
making any significant changes in appointment policies. Having the
endorsement of the health program administrators and the tribe is
important so they can provide support for the new appointment policies
in the event of complaints by patients. If feasible, patient surveys or
focus groups can be conducted to determine what type of appointment
system the patient population prefers. At a minimum, patients should be
informed that a change in policy is coming.

**2. [Series of Appointments for Patients]{.underline}**

**Recommendation:** In general schedule only one appointment at a time
per patient, rather than setting up a series of appointments for the
patient. One possible exception might be the scheduling of a series for
denture patients who currently do not have an old denture to wear, with
the time interval between appointments approximating the time it will
take for the case to come back from the lab for each step of the
treatment plan.

**Rationale:** Programs that provide a series of appointments for
patients usually do so because they are scheduled well beyond the
recommended three-week maximum. Often this is a response to patient
complaints that the time interval between appointments is too long.
However, providing a series of appointments only fills up the
appointment schedule further ahead, which makes the problem worse. Also,
when a patient misses an appointment in the series there is a question
as to whether the program should wait to see if the patient will appear
for the next one in the series or cancel all remaining appointments in
the series. The experience of many programs has been that if one
appointment in a series is missed, there is a good chance that the next
one in the series will be missed too.

**Implementation:** Set a general policy of scheduling only one
appointment at a time. If in a special case a series of appointments is
deemed necessary (e.g., patient leaving the area for an extended time or
an upcoming important event such as the patient's wedding), the patient
should be informed that if any appointment in the series is missed, then
the other appointments will immediately be canceled.

**3. [Time Allotted for Procedures]{.underline}**

**Recommendation:** Schedule a range of times for various procedures,
rather than scheduling the same amount of time for each patient. The
amount of time scheduled should be commensurate with the amount of time
usually needed for the type and number of procedures planned for that
visit.

**Rationale:** Some programs schedule the same amount of time, usually
one hour, for virtually all patients. This is inherently inefficient,
because many procedures take less than an hour and some take longer.

**Implementation:** Determine how much time each type of procedure
typically takes and schedule accordingly. Many programs have found it
best to schedule more than one column of patients for each dentist, with
one column of patients scheduled for more time-consuming procedures and
one or more columns scheduled for simpler procedures, such as exams,
fluoride treatments, and application of sealants. If expanded functions
dental assistants are used in the program and enough operatories are
available, then two or three patients can be scheduled during the same
period of time for routine restorative procedures.

**4. [Selective Double-Booking of Patients ]{.underline}**

**Recommendation:** Double-book patients who have a history of broken
appointments, unless a ready supply of emergency patients is available
throughout the work day.

**Rationale:** Most programs have found that patients who have missed
appointments in the past are likely to break them in the future.
Providing an additional patient during the same time slot will ensure
that the staff stay busy if the first patient breaks another
appointment. In busy clinics that have emergency patients available at
most times, the emergency patients can fulfill the need for replacement
patients.

**Implementation:** Determine which patients have a history of broken
appointments and routinely double-book those patients, unless emergency
patients are typically available throughout the day. If dental charts
are not available when appointments are made, it is more difficult to
determine which patients have a history of broken appointments. However,
dental receptionists and assistants who have been with the program for a
number of years can usually identify patients who have missed several
appointments in the past.

**5. [Mix of Services for Double-Booked Patients ]{.underline}**

**Recommendation:** If Patient A obtains an appointment through the
normal mechanism but has a history of BAs, resulting in double-booking
with Patient B, then Patient B should be one who requires treatment that
is not dentist-intensive, such as an exam, fluoride treatment,
toothbrush prophylaxis, or application of sealants.

**Rationale:** Dentist-intensive procedures are procedures that require
significant blocks of time for the dentist with little opportunity to
leave the dental chair, such as long surgical procedures, complex
restorative procedures, endodontics, and prosthetic procedures.
Dentist-intensive procedures are not a good choice for double-booked
patients, because both patients might appear for their appointments.
Procedures that do not take a large amount of dentist time are
preferred.

**Implementation:** Train staff to schedule procedures that are not
dentist-intensive for double-booked patients. Exams provide the most
flexibility. If the original patient does indeed break his or her
appointment, then both an exam and some treatment can be provided for
the backup patient. If both patients appear for their appointments, then
the backup patient's appointment can be limited to an exam only.

**6. [Quadrant Dentistry]{.underline}**

**Recommendation:** In general perform quadrant dentistry whenever
possible. This includes treating multiple quadrants when treatment needs
are minimal.

**Rationale**: The IHS has always recommended quadrant dentistry as an
efficient way to perform restorative treatment, as opposed to restoring
one tooth at a time. Operatory setup and cleanup time, greeting and
dismissing the patient, and waiting for anesthesia take about the same
amount of time whether one tooth or a quadrant is restored.

**Implementation:** Plan restorative procedures by quadrant whenever
possible and schedule an appropriate amount of time for quadrant
dentistry.

**7. [Short-Notice Call List ]{.underline}**

**Recommendation:** Maintain a list of patients who can appear on short
notice to fill gaps in the appointment schedule.

**Rationale:** Having a list of patients who can respond on short-notice
enables programs to fill canceled appointments (when there is adequate
notice prior to the scheduled appointment time) and in some cases broken
appointments (if the original appointment was long enough to allow for a
less time-consuming procedure to be provided for the short-notice
patient). This helps to eliminate "down time" in the dental clinic.

**Implementation:** Develop a short-notice call list consisting of
patients who were not able to obtain a regular appointment. The list
might include people who could not get an appointment through a call-in
appointment system or people who are on a waiting list but would like to
come as soon as possible. It is a good idea to discard the list
periodically, such as weekly or monthly, so that it remains current.
Patients should be informed that this is a temporary list and there is
no assurance that they will be called through this mechanism. They
should also be encouraged to continue to seek a regular appointment
using the clinic's standard appointment system. To enhance the
effectiveness of the short-notice list, some programs also write a time
on the appointment slips that is 10 minutes earlier than the actual
appointment time. This provides them with an extra 10 minutes to
determine that a patient has failed an appointment and fill the time
slot with a short-notice patient.

**8. [Considerations for Dental Emergency Patients]{.underline}**

The treatment of dental emergency patients, or "Walk-Ins" (WIs), is a
significant part of most IHS, Tribal, and Urban Indian (I/T/U) dental
programs. Following are four recommendations that many programs have
found helpful with regard to emergency care:

-   Ask emergency patients to call back for their follow-up exam and
    treatment, rather than providing an appointment at the conclusion of
    the emergency visit. See "Scheduling of Follow-up Appointments for
    Emergency Patients" below.

-   After emergency patients call back for a follow-up appointment, an
    exam and basic preventive and restorative treatment should be
    provided prior to more complex treatment such as root canal
    treatment (RCT), crowns, bridges, and removable prosthetics (Levels
    of Care guidelines). See "Type of Follow-up Appointment for
    Emergency Patients" below.

-   If the emergency patient has an abscessed tooth, the dentist should
    explain the sequence of treatment necessary to save the tooth so the
    patient can decide if he or she is willing to go through the
    required steps. See "Early Determination of Feasibility of Root
    Canal Treatment" below.

-   In general perform the necessary emergency treatment at that
    emergency visit whenever possible, rather than providing only pain
    medication and asking the patient to return on another day.
    Exceptions to this would be patients with advanced infections
    requiring antibiotics, where providing definitive treatment would be
    inadvisable on the first visit.

**9. [Need for Designated Emergency Time for Walk-In Patients
]{.underline}**

**Recommendation:** The decision as to whether or not a program should
have a special time set aside to treat WIs should be based on an
analysis of available data, rather than arbitrarily. The alternative to
a designated WI time is to work emergency patients into the schedule
between other patients.

**Rationale:** It is important to treat WI patients efficiently, both to
meet the needs of the emergency patients and to minimize disruption of
appointments for scheduled patients. If the program has only a few WI
patients per day on average, then having a designated emergency time
will result in "down time" that could have been used to treat scheduled
patients. If the program has enough WI patients to warrant a designated
WI time, then it is important to allow the proper amount of time, based
on the average emergency load. Too little designated time results in
disruption of the appointment schedule, while too much designated
emergency time cuts into the amount of time available for scheduled
appointments.

**Implementation:** The first step is to determine the average number of
WI patients per day, the usual range in the number of WIs per day, and
the average number of broken appointments (BAs) per day in the clinic.
There are two ways to approach the question of whether to designate a
special emergency time in the schedule:

Option #1: Divide the average number of WI patients per day and the
usual range in number of WIs per day by the number of dentists available
to see emergency patients (e.g., 5 WI patients per day, with a range of
0 to 8, and a staff of 2 dentists = 2.5 emergencies per day per dentist,
with a range of 0 to 4 emergencies per day per dentist). If the average
number of WIs per day per dentist is three or less, then a special
emergency time is probably not necessary. Other variables might also
influence the decision to assign or not assign a special emergency time
in the schedule, such as if the usual range is very wide (which can
result in days when the dentists are overwhelmed with WIs), if the BA
rate is very low (which allows little time to squeeze in the emergency
patients), or if the BA rate is very high (which provides plenty of time
to see emergency patients).

Option #2: An alternative method is to compare the BA rate with the WI
rate to determine whether a dedicated emergency time is necessary. If
the average number of BAs per day exceeds the average number of WI
patients per day, especially if the discrepancy is large, then adequate
time should exist during the day to see WI patients without setting
aside a special emergency time or emergency team. If the average number
of BAs per day is less than the average number of WIs per day, then a
dedicated emergency time is probably necessary. If the discrepancy is
large, then more time should be set aside to treat emergency patients
than if the discrepancy is small.

If a special emergency time is necessary, it is important to ensure that
the amount of provider time dedicated to the treatment of dental
emergencies is not excessive. If the providers are not kept busy during
the entire emergency time, then consideration should be given to
shortening the WI time in the schedule or decreasing the number of
providers assigned to treat emergency patients.

**10. [Scheduling of Follow-up Appointments for Emergency Patients
]{.underline}**

**Recommendation:** In general, emergency (WI) patients should be asked
to call back for a routine appointment following dental emergency
treatment, rather than providing patients with a follow-up appointment
as they leave the clinic following their emergency visit. An exception
would be patients with severe infections who need a follow-up
appointment to monitor progress on the emergency condition.

**Rationale:** Although the following is anecdotal information only,
many I/T/U dental programs have reported that a large proportion of
emergency patients (on the order of two out of three) who are given a
follow-up appointment as they leave the emergency visit will fail that
appointment. The reason is that many emergency patients are episodic
users who typically appear at the dental clinic only if they are in pain
or have some other dental problem. If offered a follow-up appointment at
the conclusion of the emergency visit, episodic users will almost
invariably accept the appointment, but many of them will fail to appear
at the appointed time.

**Implementation:** Emergency patients should be asked to contact the
clinic for a follow-up appointment in the same way that other patients
seek an appointment. If a call-in system or waiting list system is used,
patients should be instructed to call in at the designated time or asked
to sign up for the waiting list. If the program has a walk-in clinic for
routine dentistry, the emergency patient can be asked to return during a
future walk in time. If the program gives appointments on demand, a
diplomatic way to instruct the emergency patients to call back is to ask
them to phone the clinic in a day or two to let the dental staff know
how they are doing following the emergency treatment, and they will be
given a follow-up appointment when they call. Many programs have found
that patients who follow through and contact the clinic to make an
appointment are more likely to keep the appointment.

**11. [Type of Follow-up Appointment for Emergency Patients
]{.underline}**

**Recommendation:** In most cases the first follow-up appointment for an
emergency patient should be for a complete exam, in order to determine
the patient's overall oral health status and treatment needs. This
follows the Levels of Care guidelines that have long been recommended
for I/T/U dental practices.

**Rationale:** Although there is some controversy about this, most
senior clinicians in I/T/U programs prefer to complete the dental exam
before continuing with treatment that was started during the emergency
visit. For example, if a molar is opened for root canal treatment during
an emergency visit, the next visit would normally be for a complete
dental exam, not continuation of the root canal treatment. The reason is
that often an exam reveals other carious lesions that need to be treated
before they progress to the stage where they might also need root canal
therapy. As mentioned in the previous recommendation, an exception to
the "exam first" guideline would be an emergency patient who has a
severe infection that needs immediate follow-up treatment. In that case
the patient would already have a follow-up appointment from the
emergency visit.

**Implementation:** When an emergency patient contacts the clinic for a
follow-up appointment as they were instructed to do, schedule an exam
appointment for the patient. If time allows, basic treatment can also be
provided at that appointment, following the Levels of Care guidelines.

**12. [Early Determination of Feasibility of Root Canal Treatment
]{.underline}**

**Recommendation:** If an emergency patient requires endodontic
treatment to save a tooth, the dentist should have a frank discussion
with the patient prior to initiation of treatment to allow the patient
to determine whether root canal treatment (RCT) is feasible for him or
her.

**Rationale:** Root canal treatments are often initiated without
adequate discussion with the patient as to what will be involved to save
the tooth. For example, after the dentist accesses a molar for RCT, it
is not unusual for the patient to fail to call back for an exam or miss
an appointment for basic treatment and subsequently fall out of the
system. Then he or she typically returns for emergency treatment after
the tooth becomes symptomatic again. If at that second emergency visit
the necessary treatment sequence is explained more thoroughly, the
patient will sometimes state that if he had known so much was involved
he would have chosen to have the tooth extracted at the first visit.

**Implementation:** The dentist should explain the sequence of treatment
necessary to save the tooth so the patient can decide if he or she is
willing to go through the required steps. This sequence is based on
Levels of Care, and the patient should be informed that basic treatment
will be provided prior to completion of the RCT, and then a final
restoration will be needed to protect the tooth receiving RCT. If the
sequence is accepted by the patient, the tooth is opened for RCT during
the emergency visit. If the patient is unable or unwilling to commit to
the treatment sequence, an alternative is extraction at that emergency
visit so the patient will not have to endure any more pain needlessly.
If the patient is not interested in receiving an exam and basic
treatment first, another alternative is to seek root canal treatment
privately, at the patient's expense. If the patient is "on the fence"
when deciding how to proceed, then it is best to err on the conservative
side and open the tooth for RCT. If this patient fails to seek follow-up
appointments and presents again with a toothache in the same tooth, then
the options should be presented again. Usually at this visit the patient
will find it easier to make a decision, and that decision is often to
choose extraction. No one likes to see patients lose teeth, but in the
case of episodic users it is often the choice that patients find most
feasible for themselves.

**Note:** These discussions should be documented in the progress notes
for risk management reasons. Some programs use an endodontic information
sheet or consent form that discusses the pros and cons of endodontic
treatment and the necessary sequence of treatment, with documentation in
the progress notes that an information sheet was provided or a consent
form was signed.

**13. [Addressing the Broken Appointment Problem ]{.underline}**

Broken appointments (BAs) are an almost universal problem in I/T/U
dental programs. Following are some basic recommendations that many
programs have found useful in dealing with BAs. The recommendations are
divided into two categories: Preventing Broken Appointments and
Compensating for Broken Appointments once they occur.

**Preventing Broken Appointments**

-   Schedule patients no more than three weeks ahead in the appointment
    book or computerized appointment system.

-   Routinely ask emergency patients who need a follow-up exam
    appointment to call back for that appointment, rather than
    scheduling it at the conclusion of the emergency visit. Many
    emergency patients are episodic users who will accept a follow-up
    appointment but then fail to keep it. An exception would be patients
    with severe infections that need to be scheduled for follow-up to
    prevent serious consequences.

-   Have a BA policy in the form of a BA agreement or "contract" that is
    signed by the patient or parent/guardian, and give a copy of this
    agreement to the patient (Dental Appointment Agreements are
    discussed below in more detail).

-   Use patient reminders such as phone calls, letters, or email
    messages to remind patients of their appointments.

    **Compensating for Broken Appointments**

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-   Maintain a short-notice call list and use it to fill gaps in the
    appointment schedule.

-   Double-book patients who have a history of BAs. It works best if the
    extra patient is for a simple procedure such as an exam, in order to
    provide flexibility in case both patients appear for their
    appointments.

-   Use emergency patients to fill BAs whenever possible.

-   Consider asking patients who have a history of BAs to come in 10
    minutes before their scheduled appointment time. Then if the patient
    has not appeared by the actual appointment time, the staff can start
    looking for a short-notice patient.

-   Follow the Levels of Care guidelines so that basic preventive and
    restorative services are provided first in the treatment plan, prior
    to the provision of more complex treatment such as root canal
    treatment (RCT), crowns, bridges, and removable prosthetics. See
    explanation in "Following Levels of Care Guidelines" below.

The rationale and implementation of some of these recommendations have
already been addressed earlier in this manual. Details on the remaining
recommendations are provided below.

**14. [Dental Appointment Agreement (BA Contract)]{.underline}**

**Recommendation:** Have a Dental Appointment Agreement or BA contract
that is signed by the patient or parent/guardian, and give the patient a
copy of the agreement.

**Rationale:** The use of BA policies has been in place in most I/T/U
dental programs for many years. More recently several programs have gone
beyond simply having a BA policy and have developed a Dental Appointment
Agreement or BA contract that is signed and dated by the patient or
parent/guardian. Proponents of the contract format have reported that it
has helped to reduce the BA rate. Some patients have even stated upon
arrival in the clinic that they were going to skip their appointment,
but then they remembered the form they signed and thought they had
better keep the appointment.

**Implementation:** The first step is to seek approval from the Health
Director, Tribal Health Committee, and any other pertinent Tribal
entities before adopting a Dental Appointment Agreement. As with other
changes in appointment policies, having the endorsement of the health
program administrators and the tribe is important so they can provide
support for the new appointment policies in the event of complaints by
patients. The written contract begins by stating the BA policy, e.g., if
two appointments are missed within a six-month period, then the patient
is eligible only for emergency care for the next six months. At the
bottom of the form there is a place for the patient or parent/guardian
to sign and date the form to confirm that he or she understands the BA
policy and agrees to the terms of the agreement. Then a copy of the form
is provided to the patient or parent/guardian so he/she can refer back
to it in the future. Ideally this would be a copy of the signed form,
but if a copy machine is not readily available in the dental clinic then
a copy of the blank form will suffice. The original of the form is
placed in the dental chart. ***Appendix II*** is a sample ***"Dental
Appointment Agreement."***

Some clinics have also reported that the contract format seems to help
reduce the BA rate even if the policy is not rigorously enforced. Other
programs enforce the policy strictly, some to the point of requiring
patients to come in for a talk with a designated "BA Manager" after
missing a single appointment. If the policy is enforced, it is important
to enforce it equitably and without favoritism. Having the Health
Director and Tribal Council behind the policy is important in cases
where certain patients who are denied an appointment immediately
complain to the council (every clinic has them).

**15. [Appointment Reminders]{.underline}**

**Recommendation:** Consider using patient reminders, such as phone
calls, letters, or email messages, to remind patients of their
appointments.

**Rationale:** Although some programs have found that reminders make no
difference in the BA rate, other programs have found that they have
substantially reduced BAs. Many I/T/U programs currently do remind
patients of their appointments. This is usually done via a phone call a
day or two prior to the appointment. In cases where the patient does not
have a phone, letters are typically mailed a week ahead of the
appointment. Reminders might not be practical in clinics that have no
receptionist, especially if patient care would suffer when the person
making the calls is needed in the clinic. Also, there is a school of
thought that suggests that reminders not be used at all, because
patients become too dependent on them. The theory is that if for some
reason reminder calls cannot be made for a period of time, the BA rate
might actually increase. For these reasons, the use of appointment
reminders is optional, depending on the program's preferences and the
perceived results following the use of reminders.

**Implementation:** The dental receptionist or other designated staff
member is assigned to make the phone calls and/or mail the reminder
letters. The widespread use of answering machines and cell phones in
recent years has complicated the use of phone reminders. If a message is
left on an answering machine, there is no assurance that the patient
checks messages or that another family member has not erased the message
before the patient hears it. Also, if the clinic is given a land phone
line number but the patient uses a cell phone for most calls, then he or
she might never receive the call. It is a good idea to ask patients for
their cell phone numbers if that is the phone they usually use.

**16. [Adjusting Time on Appointment Slip ]{.underline}**

**Recommendation:** Consider listing a time on the appointment slip that
is 10 minutes earlier than the actual appointment time, at least for
patients who have a history of BAs or who are chronically late. An
alternative is to ask patients to appear 10 minutes in advance of their
appointment time for updating of paperwork.

[]{.mark}

**Rationale:** While not in widespread use, some programs routinely list
a time on the appointment slip that is 10 minutes earlier than the time
designated in the appointment book or computerized schedule. Other
programs do the same thing, but only for patients who have a history of
BAs or who are chronically late. In both cases, if the patient has not
appeared by the actual appointment time, the staff can be reasonably
certain a BA has occurred and can start looking for a short-notice
patient to fill the empty slot in the schedule.

Still other programs might choose not to follow this practice because
doing so sets somewhat of a double standard. That is, if the program is
asking the patient to arrive at a certain time, the program has an
obligation to see the patient at that time as well. For these programs
the alternative of asking the patient to appear 10 minutes in advance of
the appointment to update paperwork might be more acceptable. This is
likely to be most effective if the appointment slip includes a written
request to arrive 10 minutes prior to the listed time, as opposed to
expecting patients to remember this instruction.

**Implementation:** As has already been mentioned, among programs that
use these techniques some use them for all patients, while others use
them only for patients who have a history of BAs or who are chronically
late for their appointments. The actual act of adjusting the appointment
time or including a statement on the slip to come in 10 minutes prior to
the listed time is self-explanatory. If asking patients to come in early
is a standard practice in the clinic, and if the clinic uses a BA
contract (see #14, above), then the contract should state the clinic's
policy.

**17. [Following Levels of Care Guidelines ]{.underline}**

**Recommendation:** Follow the Levels of Care guidelines when scheduling
patients so that basic preventive and restorative services are provided
first in the treatment plan, prior to more complex treatment such as
root canal treatment (RCT), crowns, bridges, and removable prosthetics.

**Rationale:** There are many reasons to apply Levels of Care
principles, and one of them relates to BAs. Many patients who miss
appointments, especially episodic users, will do so early in the
treatment plan. Because exams and basic services are by nature less
time-consuming than complex services, having a BA for a short
appointment impacts the schedule less than a BA for a long appointment.

**Implementation:** Write treatment plans with Levels of Care guidelines
in mind and follow the sequence of treatment written in the plan.

**18. [Tracking Broken Appointment Rate ]{.underline}**

**Recommendation:** Programs should track their BA rate over time to
determine whether the rate is increasing, decreasing, or staying the
same.

**Rationale:** Knowing the BA rate is helpful for making decisions on
scheduling, improving access to dental care, and other program
management issues. As changes are made in the dental program, such as
making scheduling changes, the effect of these changes on the BA rate
can be determined. Also, if the BA rate changes over time, it might be
necessary to adjust the dental emergency time, as previously described.

**Implementation:** Select a method for determining the BA rate and
assign a staff member to collect the necessary data and monitor the BA
rate over time. It is helpful to have this information presented at
dental staff meetings on a periodic basis, such as monthly or quarterly.
For those familiar with Quality Improvement data analysis techniques
(see chapter 7, pages F-9 through F-11 of the OHPG), the use of a run
chart or control chart is a simple visual technique to present the data.

**19. [Determining Broken Appointment Rate ]{.underline}**

Following are three methods for determining the BA rate:

1)  **Tracking the BA rate on a daily basis**

> Some clinics have assigned the receptionist or a dental assistant to
> track the number of patients scheduled and the number of BAs at the
> end of each work day (see ***Appendix III*** for a sample Microsoft
> Word tally sheet, ***"Broken Appointment Rate and Walk-In Rate
> Worksheet (MS Word)."*** Although not needed to calculate the BA rate,
> the number of WI or emergency patients is also included to enable the
> program to calculate the average number of WIs per day and the BA/WI
> ratio.
>
> As an alternative, the data can be entered into an Excel spreadsheet
> with embedded formulas for calculating the BA rate, WI rate, and BA/WI
> ratio (***Web link #1***). To gain access to the Excel spreadsheet,
> click on ***"Broken Appointment Rate and Walk-In Rate Worksheet
> (Excel)"*** in the table of contents. Some programs prefer a paper
> worksheet and some prefer the electronic method, just as some programs
> prefer a paper appointment book and others choose an electronic
> appointment system.
>
> The BA rate is calculated by dividing the number of BAs by the number
> of patients scheduled that day (excluding WI patients) and multiplying
> by 100. This provides a BA rate as a percentage of number of patients
> scheduled. Example: 3 BAs in a day divided by 14 patients scheduled
> equals .214, or a BA rate of 21.4 percent.
>
> Tracking the BA rate daily typically takes only a few minutes per day
> of the receptionist's time and is the most accurate way to calculate
> the BA rate, because it includes every clinic day and does not depend
> on the quality of data entered into the RPMS Dental Data System. Using
> this method, the BA rate can also be calculated for any time period
> needed if the BA worksheets are saved in a file or if the electronic
> spreadsheets are saved in a folder.
>
> **Note:** Some programs also track "Canceled but Unfilled"
> appointments and add these to the BAs when calculating the BA rate.
> Most programs define a "canceled appointment" as one where sufficient
> notice is given by the patient to enable the staff to find a
> replacement patient prior to the appointment time. If a canceled
> appointment is not filled with another patient, then the effect on
> patient flow is the same as for a broken appointment.

2)  **Using a sample of days from the appointment schedule**

> This method involves using either a random sample of 20 or 30 days or
> selection of a typical month or two from the appointment schedule,
> whether it is an actual appointment book or day sheets from a
> computerized appointment schedule. The number of scheduled
> appointments and the number of BAs are determined from the sample, and
> then a percentage is calculated as in the preceding example. The
> accuracy of this method depends on whether the sample chosen is
> representative of the total number of days that patients are treated.
> As in the preceding method, some programs might choose to include
> canceled but unfilled appointments with the BAs. Either ***Appendix
> III* (MS Word)** or ***Web Link #1 (Excel)*** version of the
> ***"Broken Appointment Rate and Walk-In Rate Worksheet"*** can be used
> to calculate the BA rate from the appointment schedule sample.

3)  **Using the Annual Basic Measures Report from the RPMS Dental Data
    System**

> The clinical efficiency data indicators contain a formula for
> calculating the BA rate using data from the Compiled Statistical
> Reports (RCST) in the RPMS Dental Data System. The Annual Basic
> Measures component of the Compiled Statistical Reports provides the
> data needed to calculate the BA rate. The formula is as follows:
>
> BAs / (Dental Visits Past 12 Months + BAs -- Emergency Visits) X 100
>
> Example: From Annual Basic Measures Report, Broken Appointments =
> 1426, Dental Visits Past 12 Months = 8164, and Emergency Visits =
> 2319, which when plugged into the formula results in the following
> calculation:
>
> 1426 / (8164 + 1426 - 2319) X 100 = 1426 / 7271 X 100 = 19.6 %
>
> This method relies on the accuracy of the procedure codes that have
> been entered into the RPMS Dental Data System. If the data entries are
> complete and accurate, results obtained with this method should
> compare favorably with the other methods. If data are missing or
> entered inaccurately, then this method will be less reliable. The
> advantages of this method are ease of calculation and the ability to
> compare current BA rates with those of previous years.

**20. [Clinic Opening Time vs. Time First Patient is Seen
]{.underline}**

**Recommendation:** In general the first patient should be seated and
seen within 15 minutes of clinic opening time.

**Rationale:** The most efficient I/T/U dental programs typically see
the first patient either at the clinic opening time or within 15 minutes
thereafter. However, in some other programs a significant amount of time
passes between the clinic opening time and the time when the first
patient is actually seen. In extreme cases the discrepancy is an hour or
more, such as when providers work 10-hour days and the auxiliary staff
are on eight-hour days. Excessive amounts of set-up time before the
first patient is seen generally results in wasted time, and there is a
tendency for some providers to routinely appear late for work because
patients will not be seen immediately after the clinic opens.

**Implementation:** Schedule and see the first patient either at or
shortly after the designated clinic opening time. Ideally, one staff
member should have flexible hours to allow him or her to start work
before regular clinic opening time, so that x-ray film processors can be
started, dental units turned on, etc. This will enable the providers to
start seeing patients exactly at the designated time when the clinic
opens or very soon thereafter. The staff member who comes in early
usually is allowed to leave work before the close of the clinic day to
avoid an overtime situation.

**21. [Time Last Patient Completed vs. Clinic Closing Time
]{.underline}**

**Recommendation:** Schedule patients late enough in the day so the last
patient is typically completed no more than 30 minutes prior to the
designated clinic closing time.

**Rationale:** Clean-up time is needed at the end of the day to process
instruments and clean the operatories, but the amount of time should not
be excessive. While the auxiliaries are performing clean-up duties, it
is assumed that the providers will be using this time to complete all
unfinished dental charts for the day.

**Note:** Ideally progress notes are completed immediately following
each patient's treatment, but they should always be completed by the end
of the day.

**Implementation:** Receptionists and assistants who schedule patients
can fine-tune their scheduling practices over time so that the last
patient of the day is typically completed within 30 minutes of, but not
beyond, the clinic closing time.

**22. [Alternative Work Schedules ]{.underline}**

**Recommendation:** If a program changes from standard eight-hour work
days to an alternative work schedule, such as nine-hour days or 10-hour
days, productivity and access to dental care should be maintained at
least at levels present prior to the change.

**Rationale:** Many programs have adopted alternative work schedules,
which typically involve working four 10-hour days each week with one day
off, working nine-hour days with a day off every two weeks, or some
variation of these methods. Alternative work schedules are sometimes
initiated because a program has an adequate number of dental staff
members but is short of dental operatories. In that case, expanding the
number of hours a clinic is open in effect increases the number of
operatory hours available per week. In other cases, extended hours are
used if the staff have extremely long distances to travel from their
homes to the clinic, which results in fewer commutes per week. In most
cases, however, alternative work schedules are adopted as a perk for
employees to give them three-day weekends either every week or every
other week. In some programs that have perpetual staff vacancies,
alternative work schedules are perceived as the only way the program can
attract candidates to fill the vacancies. Whatever the reason for the
adoption of alternative work schedules, it is important that former
levels of productivity and access to care are maintained.

**Implementation:** Prior to initiating alternative work schedules,
programs should determine baseline levels for access to dental care,
broken appointment rate, and standard productivity measures. Then after
adoption of the alternative schedules programs should monitor these
indicators to ensure that access to care and productivity are maintained
at least at prior levels. Maintaining productivity is a concern in many
programs that use alternative work schedules, because of the fatigue
factor inherent in performing technical procedures for many hours,
problems with broken appointments early and late in the day,
coordination with medical records and pharmacy if they are on different
hours, and other factors. Prior to adopting alternative schedules,
special consideration should be given to ensuring that providers and
assistants are available to work with each other throughout the work
day. This might seem obvious, but in programs that offer free choice
among several work schedules, it is not unusual to have most of the
providers working 10-hour days and most of the dental assistants working
eight-hour days. This sometimes results in two hours per day that are
entirely non-productive, because no assistants or few assistants are
available early or late in the day. These issues should be discussed
prior to initiating alternative schedules, and staff should be made
aware that choices in schedules might be restricted to ensure that
patient care is not adversely affected. As with any major change in
program policy, alternative schedules must be approved by the health
program director.

**23. [Non-Clinical Activities for Providers ]{.underline}**

**Recommendation:** The non-clinical activities of providers should be
kept at the minimum level possible and should correspond to the
provider's billet/job description and level of responsibility.

**Rationale:** The amount of provider time that must be spent in
non-clinical activities will depend on the size and complexity of the
program, the provider's position in the program, and other factors, such
as whether or not the clinic is accredited (resulting in required
attendance at various committee meetings). The amount of time spent in
non-clinical activities should be kept to the minimum possible in order
to maintain clinical efficiency and access to dental care.

**Implementation:** Schedule an amount of administration time for
providers that is the minimum necessary for non-clinical activities and
commensurate with the level of responsibility of the provider. For
example, a dental chief in a complex program will need more time for
non-clinical activities than a staff dentist in the same program.
Administration time needed for the dental director of a small to
medium-sized program should fall somewhere between these two extremes.

**24. [Scheduling Multiple Patients Per Time Block Per Dentist and Using
Multiple Operatories ]{.underline}**

**Recommendation:** Each dentist should routinely schedule more than one
patient at the same time, either by using two or more columns in the
appointment book/computerized schedule or by scheduling at least two
patients per time block in one column.

**Rationale:** Assuming that each dentist has at least two dental
operatories and two dental assistants available, it should be possible
to schedule multiple patients per unit of time. If expanded functions
restorative is performed in the clinic, one dentist can treat as many as
three patients simultaneously using three chairs and three expanded
functions assistants. If expanded functions are not utilized, then one
column can be reserved for restorative treatment and one or more columns
set aside for exams and simple treatment procedures.

**Implementation:** It is important to schedule a mix of patients that
is conducive to good patient flow. Dentist-intensive procedures, which
require that the dentist remain at one chair for an extended period of
time, should be offset with procedures that do not require a large
amount of dentist time. This would include exams, preventive treatments
that could be performed by a dental auxiliary (e.g., toothbrush
prophylaxis and topical fluoride treatments), and other procedures that
take a minimum amount of dentist time.

**25. [Standardization of Operatories and Tray Setups ]{.underline}**

**Recommendation:** Operatories and tray setups should be standardized
so that providers and auxiliaries who move from one operatory to another
can easily find necessary supplies and materials.

**Rationale:** Time is wasted if staff members cannot readily find
necessary instruments, supplies, and materials.

**Implementation:** The dental manager and staff should examine all
operatories and make necessary changes to make sure the drawers are
standardized to the extent possible. Two possible exceptions to this
rule include operatories used exclusively by a dental hygienist and
operatories that are used exclusively for specialty treatment (usually
pertains only to large clinics).

**26. [Unit Dose Concept ]{.underline}**

**Recommendation:** The unit dose technique should be used for tray
setups, both for efficiency and for infection control.

**Rationale:** When trays are used that contain all items normally
required to treat the patient, including disposable items that are added
to the instrument pack such as cotton rolls, floss, cotton applicators
with topical anesthetic, and gauze squares, the staff are able to
function more efficiently. There are also likely to be fewer breaks in
infection control if the countertops are kept free of cotton roll
dispensers, anesthetic dispensers, cotton applicator jars, and floss
dispensers. The unit dose technique makes it possible to eliminate these
and similar items from the operatory counters, because the items are
added to the trays prior to initiation of treatment.

**Implementation:** Place all unnecessary items that traditionally were
stored on the countertops under cover to prevent contamination and add
these items to the tray setups prior to starting a patient's treatment.

**27. [Use of Expanded Functions Dental Assistants (EFDAs)
]{.underline}**

**Recommendation:** If the use of EFDAs is feasible, based on applicable
dental practice laws and regulations, dental assistant qualifications,
the number of dental assistants available, and the number of operatories
available, then expanded functions should be used.

**Rationale:** The provision of expanded functions restorative and
periodontal treatment by dental assistants trained to provide these
services can significantly improve clinical efficiency and access to
care in a dental program.

**Implementation:** If the program already has trained EFDAs but they
are not being utilized, the reason for non-utilization should be
identified. Some common reasons for lack of EFDA utilization when
trained assistants are available include having dentists in the program
who lack experience with expanded functions or question its efficacy,
lack of desire among the EFDAs to perform the duties (even though their
pay grade might be based on EFDA designation), or regulatory issues
(such as if tribal programs decide to follow state dental practice act
requirements). With the exception of regulatory issues, these reasons
should not be beyond the ability of the program to change.

In clinics with adequate numbers of operatories and trained EF
restorative staff, an "EF Clinic" is encouraged, in which dentists
prepare the teeth and the restorations are placed by EFDAs for a series
of scheduled restorative patients. An efficient EF Clinic functions best
with at least three operatories and three EFDAs committed to expanded
functions. In clinics with an inadequate number of dental operatories or
dental auxiliaries for a true EF Clinic, there are cases where some EF
can still be performed. For example, if the dentist has another patient
waiting and has an EFDA available, then the EFDA can place the
restoration while the dentist sees the other patient.

If the program desires to begin the use of expanded functions but does
not currently have trained EFDAs, assistants can be selected for basic
EFDA training, which includes follow-up clinical work. This can be
followed by advanced EFDA training at a later time. Another alternative
is to try to find a dental assistant who has already received EFDA
training from the IHS, but assistants with this training who are looking
for work are difficult to find.

**Note:** The definition of "expanded functions dental assistants" as
used here refers to IHS-trained EFDAs. Basic EF Restorative enables
assistants to place permanent restorations in teeth that have been
prepared by a dentist. Many states have EF designations for dental
assistants, but the duties that these state-defined EFDAs are authorized
to perform are typically much more limited than duties performed by IHS
EFDAs.

**28. [Delegation of Duties to Auxiliaries ]{.underline}**

**Recommendation:** Auxiliaries should be delegated duties that are in
line with their level of training. However, auxiliaries should not be
assigned duties above their level of training, e.g., assistants who have
not had EFDA training should not be expected to perform EFDA duties.
Conversely, assistants should not be expected to perform basic
housekeeping duties if housekeeping staff are available, especially if
these extra duties diminish patient care.

**Rationale:** Optimum use of auxiliaries relieves dentists of duties
that hygienists, assistants, and other staff can perform, which leaves
the dentists free to perform duties that only they can perform.
Likewise, hygienists and EFDAs can be utilized more efficiently if they
perform predominantly hygiene and expanded functions duties, as opposed
to basic dental assisting duties.

**Implementation:** Delegate duties along the guidelines stated above.

**29. [Cross-Training for Receptionists ]{.underline}**

**Recommendation:** Small programs that are short of dental assistants
but have a receptionist should consider cross-training the dental
receptionist to perform at least some basic chairside dental assisting
duties.

**Rationale:** Small programs, which typically have one dentist and two
dental assistants, are at a distinct disadvantage when one assistant is
out of the office. This is a critical problem in those few programs that
have only one assistant. Working with only one chairside assistant
adversely affects clinical efficiency, and if the schedule is booked for
a staffing pattern of two assistants, the clinic is likely to run behind
schedule when one assistant calls in sick or cannot be at work for some
other reason. For programs that have only one dental assistant, the loss
of that assistant for a day is a major problem, because the dentist has
to work alone. If the dental receptionist has been cross-trained to take
radiographs, perform basic chairside duties, clean operatories, and
process instruments, moving the receptionist into the clinic when needed
can help the program to function more efficiently. The receptionist will
get behind in his or her duties, but in a small program it is probably
more important to have the services of an assistant rather than a
receptionist for that day. In large programs with multiple dentists,
moving the receptionist out of the front office is probably not feasible
in most cases, because of the complexity of the program and heavier
patient load.

**Implementation:** In small programs provide on-the-job training in
basic assisting duties for the receptionist.

**30. [Range of Recall Intervals ]{.underline}**

**Recommendation:** Recall systems should be based on individual disease
rates, not arbitrary time intervals, and the range of recall intervals
in the program should be sufficiently wide to accommodate patients with
high rates of dental disease to very low rates of disease.

**Rationale:** The IHS dental program has long recommended having a
recall system, at least for high-risk patients. Even though they might
have a large backlog of patients, some programs employ a relatively
small range of time intervals for the recalls, such as three months for
patients at high-risk for caries or periodontal disease to six months
for all other patients. This follows the narrow range of recall
intervals used in many private practices, but for which there is no
solid scientific basis.

The IHS has typically used a much wider range of recalls, from three
months for high-risk patients to one year or longer for low-risk
patients. In programs where it is difficult for patients to obtain
access to routine dental care, having a sufficiently wide range of
recall intervals will enable the program to treat more patients with the
limited resources available.

**Implementation:** In programs where appointments cannot be given on
demand without filling the schedule more than three weeks ahead (which
includes the vast majority of I/T/U programs), patients should be
identified who have low enough disease rates that they can be recalled
at one-year or longer intervals. Patients with high disease rates should
still be recalled at three-month or six-month intervals, but moving
low-disease patients into longer intervals will open up appointment
slots for other patients.

In response to patients who have low rates of disease but who still want
to come in for a six-month checkup and prophylaxis, they can be informed
that they are taking such good care of their mouths that they only have
to come in every year (or longer) and that this opens up space for
people who are not now able to receive routine dental care in the
clinic. Furthermore, they can be informed that if they have any problems
during the interim, they can come in as emergency patients.

**31. [Patient Flow Questionnaire ]{.underline}**

***Appendix IV, "Patient Flow Questionnaire,"*** is a worksheet or
questionnaire relating to scheduling and patient flow issues. It can be
used either by program managers for self-review or by dental consultants
as a pre-site visit questionnaire to facilitate a dental program review.
When the recommendations in this "Patient Flow and Control of the
Appointment Schedule" section are compared with current practices as
stated in the questionnaire, the program manager or reviewer should be
able to identify and provide solutions to scheduling and patient flow
problems.

**Data Indicators for Dental Clinic Efficiency and Effectiveness**

**1. [Introduction]{.underline}**

Several data indicators are available to I/T/U programs for analyzing
clinical efficiency and effectiveness. Most of these indicators are
based on the Resource and Patient Management System-Dental Data System
(RPMS-DDS) software that is available at most, but not all, I/T/U
programs. For programs that use RPMS, it is possible to calculate
numerous workload and access to care measures that when taken together
provide an excellent overview of the efficiency and effectiveness of
local programs.

A special data report has been developed within the RPMS-DDS to provide
the specific data that are needed to calculate these workload
indicators. This is the Basic Measures Report (BMR), which is a
component of the Compiled Statistical Reports module (RCST). The RCST
provides permanent retrospective reports for observing local program
trends over time. While the RCST reports separate data for Indian
patients and non-Indian patients, they do not separate workload totals
by care provider or by reporting facility. Therefore, in service areas
with multiple facilities, it is not possible to separate data for
separate facilities or individual providers. Other reports, such as the
Service Minute/Level of Care report (RSVC), provide separate data by
dentist and by facility and can be used to make rough allocations of BMR
data within the service area.

**Note:** As a compiled statistical report, the BMR has its data
compiled automatically by RPMS Taskman on the 10^th^ day following the
end of each quarter. Therefore, if a program has fallen behind on data
entry, some data might not be entered until after that quarter's
statistics have been compiled. That means, for example, that the number
of broken appointments on the BMR might be lower than the number found
on the Visits by Facility and Dentist Report (RDEN) for the same period
of time, because the RDEN statistics are not compiled until the user
runs the RDEN report.

**Subnote:** In some programs the RPMS site manager has made the
decision to "turn off" the automatic compilation of RCST reports by
Taskman. In that case, the dental program staff at that site should
manually compile the RCST report on a quarterly basis, and the concern
mentioned in the above note will not be an issue.

Other data indicators do not depend on the availability of RPMS-DDS
data. This includes number of dentists, total number of dental staff,
and number of dental operatories available in the program. Another
important data element is patient population, which can be determined
either with the RCST report or by non-RPMS means, such as tribal
enrollment numbers.

These data indicators have been incorporated into two versions of a
worksheet for applying the various indicators to specific dental
programs, either via self-assessment or as part of a formal dental
program review. ***Appendix V*** is the MS Word version of the
***"Efficiency and Effectiveness Data Indicators Worksheet."*** ***Web
link #2*** is an Excel spreadsheet version of the worksheet that
contains embedded formulas for automatic calculation of the indicator
values. To gain access to the Excel spreadsheet, click on ***"Efficiency
and Effectiveness Data Indicators Worksheet (Excel)"*** in the table of
contents.

**2. [Dental Clinic Efficiency Indicators]{.underline}**

**Program Resources and Staffing Patterns:**

Many of the clinical efficiency indicators require knowing the extent of
resources that are available in a local program to provide services
during the period being evaluated, as follows:

-   Annual patient population count

-   Number of dentists in full-time equivalents (FTEs)

-   Number of total dental positions in FTEs, including dentists, dental
    hygienists, assistants, receptionists, billing clerks, lab
    technicians, etc.

-   Number of dental operatories available, including the overall total
    and the number of operatories available for dentists only

Once these resources have been identified, calculations can be made for
several indicators, as follows:

1)  **Patient Population to Dentist Ratio**

> **and**
>
> **Patient Population to Dental FTE Ratio**
>
> Data Elements: Facility Users Past 36 Months / \# of Dentists
>
> and
>
> Facility Users Past 36 Months / \# of Dental FTEs
>
> These are rough but widely-accepted measures used by many federal,
> state, and local public health agencies to compare the health
> resources available in underserved areas. In order to provide adequate
> access to dental care for the population being served, an adequate
> number of dental providers and auxiliary staff must be available.
>
> **Recommendation: The IHS recommends a ratio of 1,200 patients per FTE
> dentist and 500 patients per FTE dental position.**
>
> Even though most I/T/U programs currently exceed the desired ratios,
> some by a substantial amount, these recommendations serve as
> guidelines for programs that are making plans to expand current dental
> clinics or build new facilities.

2)  **Number of Dental Operatories Available per Dentist**

> Data Elements: \# of Clinic Operatories / \# of Dentists
>
> **Recommendation: At least two dental operatories should be available
> per dentist, excluding operatories used primarily by a dental
> hygienist.**
>
> If the ratio of dental operatories to dentists is less than 2:1, the
> clinic is likely to experience bottlenecks in patient flow, because
> the dentists must routinely wait for an empty operatory before
> treating the next patient. A ratio of 2.5 to 3.0 operatories per
> dentist will enable the program to function at peak efficiency. If
> expanded functions (EF) restorative services are routinely provided in
> the clinic, 3.0 chairs should be available per dentist for the EF part
> of the program.

3)  **Number of Dental Assistants Available per Dentist**

> Data Elements: \# of Dental Assistants / \# of Dentists
>
> **Recommendation: At least two dental assistants should be available
> per dentist, with a ratio of three assistants being more appropriate
> for expanded functions restorative programs.**
>
> If there are fewer than 2.0 assistants available per dentist, the
> clinic is likely to experience difficulty in maintaining smooth
> patient flow. Having an insufficient number of dental assistants means
> that multiple operatories cannot be used efficiently, because the
> dentist will invariably find himself or herself working alone at times
> when it would be more efficient to have a chairside assistant. As with
> the number of dental operatories, clinics utilizing EF will typically
> need 3.0 EF assistants per dentist for the EF portion of the program.
>
> **Note:** Combining the ratios from this recommendation and the
> preceding one results in an overall recommendation to provide at least
> two operatories and two assistants per dentist, exclusive of dental
> hygiene operatories. This also translates to a ratio of one assistant
> per operatory.

**Workload Indicators Using RPMS Dental Data System:**

The RPMS-DDS reports described earlier, especially the Basic Measures
Report, can be used in conjunction with facility data, staffing data,
and patient population to calculate several workload indicators, which
are listed below.

Programs are encouraged to apply these workload indicators to their own
local data and to track the indicators over time to identify changes in
productivity within the program. However, for programs that have not
tracked their own data in the past and programs that do track their own
data but want to know how their productivity compares with that of other
programs, rough productivity guidelines are available in this document.
These guidelines are known as Reference Values.

> **Relative Value Units and Reference Values**
>
> Some of the workload measures are expressed in Relative Value Units
> (RVUs), which are a productivity measure that recently replaced a
> previous measure known as Service Minutes (SM). SMs were used by the
> IHS for more than 30 years, and nationwide IHS program and tribal
> program averages were calculated for each of these workload
> indicators. These nationwide averages were known as "Reference Values"
> and provided clinicians and program managers with a way to determine
> whether productivity at a program was high, low, or average compared
> to other programs.
>
> The last time these nationwide averages were calculated for the IHS
> dental program dates back to fiscal year 1994. Obviously, the
> Reference Values have been in need of updating for many years. More
> recently, the conversion from SMs to RVUs dictates that the Reference
> Values now be expressed in the new RVU productivity units. Since 1994
> the downsizing of IHS Headquarters and Area Offices and other factors
> have made the collection and calculation of national averages
> difficult, if not impossible. Because of the difficulty in obtaining
> nationwide averages, a decision was made to use Reference Values from
> a representative IHS Area for which these data were available. This
> Area consists of IHS, Tribal, and Urban Indian dental programs. Note:
> The one exception to using the representative Area for Reference
> Values is for the Annual Access to Dental Care indicator, which is
> based on the actual nationwide average for I/T/U programs.
>
> Reference Values from the representative Area are not available for
> all of the workload indicators in this document, but they are
> available for the following measures:

-   Total Visits per Dentist

-   Total Visits per Operatory

-   RVUs per Patient Visit

-   RVUs per Dental FTE

-   RVUs per Dentist

-   RVUs per Operatory

-   RVUs per Patient

> Reference Values are not included in the written descriptions of the
> workload indicators below, but they are included in the Data Indicator
> Worksheets that are included in this manual. The Excel spreadsheet
> that was used for calculating these Reference Values is included as
> ***Web link #3***, which can be obtained by clicking on ***"Reference
> Value Calculations for Data Indicators (Excel)"*** in the table of
> contents.
>
> **Note #1:** When Reference Values were last calculated from 1994
> productivity data, separate levels were listed for IHS-managed
> programs and Tribal programs. At that time average productivity levels
> for IHS-managed programs were higher than for Tribal programs for many
> of the indicators, primarily because IHS programs were typically
> larger and more likely to utilize expanded functions dental assistants
> in their programs. However, in the representative IHS Area that is
> being used for the current Reference Values the relationship between
> productivity in IHS and Tribal programs has reversed, with the Tribal
> programs being more productive than the IHS programs. In this Area the
> Tribal programs tend to be larger than those in most other Areas, and
> due to the availability of expanded functions training programs within
> the Area, expanded functions are utilized by many of the Tribal
> programs in that Area. In an attempt to consolidate and simplify the
> Reference Values, only the overall averages for I/T/U programs are
> provided on the worksheets.
>
> **Note #2:** Because of the widespread use of expanded functions in
> both IHS and Tribal programs in the representative Area, the Reference
> Value levels for many of the workload indicators might be difficult to
> achieve in programs that do not utilize expanded functions. In those
> programs, perhaps the best way to evaluate efficiency and productivity
> would be to monitor the workload indicators over time to determine an
> acceptable range of productivity levels. Ideally, all IHS Areas would
> collect these data and use them to develop Area-wide productivity
> expectations. This would be especially useful in Areas where most
> programs do not utilize expanded functions, which makes the Reference
> Values in this manual less applicable. As a starting point for
> developing efficiency/productivity expectations in Areas that do not
> typically utilize expanded functions, a "ballpark" estimate might be
> to use approximately 75 percent of the current Reference Values as
> initial benchmarks for workload indicators that are the most dependent
> on expanded functions, such as RVUs per dentist.
>
> **Note #3:** For senior IHS and Tribal staff who are familiar with
> productivity measures in terms of SM but who are not yet accustomed to
> using RVUs, there is a way to make a rough estimate of RVU values in
> terms of the old SMs. In many programs, especially those that focus on
> basic services rather than specialty services, RVU production is
> approximately 10 percent of SM production.

For ease of use, the terms used to describe the workload indicator data
elements are expressed in the exact wording found in the Basic Measures
Report.

1)  **Visits per Dentist**

> Data Elements: Dental Visits Past 12 Months / \# of Dentists
>
> This indicator measures the average number of patient visits per
> dentist for the period being evaluated. Because most programs track
> the number of dental visits, this measure is also likely to be
> available even in programs that do not have access to RPMS data. In
> that case it becomes an important measure, because it might be the
> only workload indicator that the program can easily obtain.

2)  **Visits per Operatory**

> Data Elements: Dental Visits Past 12 Months / \# of Operatories
>
> This indicator provides a general measure of how efficiently resources
> are being utilized to provide access to care. The number of dental
> operatories serves as a stable common denominator across all programs.
> Indicator values reflect the effects of local appointment policies,
> broken appointment management, and other patient flow and efficiency
> issues.

3)  **Relative Value Units per Patient Visit**

> Data Elements: Relative Value Units / Dental Visits Past 12 Months
>
> This indicator measures how much dental treatment was provided per
> visit, on average.

4)  **Relative Value Units per Dental FTE**

> Data Elements: Relative Value Units / \# of Dental FTEs
>
> This indicator measures productivity per dental employee, without
> regard to the employees' positions. Programs that utilize expanded
> functions tend to have higher RVU/FTE values, so this measure is most
> useful when comparing like programs with regard to EF usage.

5)  **Relative Value Units per Dentist**

> Data Elements: Relative Value Units / \# of Dentists
>
> This indicator measures dental team productivity without regard to the
> number and type of auxiliary staff available. If programs with dental
> hygienists are compared with programs without hygienists, it is most
> meaningful if the RVUs provided by hygienists are excluded from the
> calculation. This is not as easy to do as it might seem, because the
> RPMS-DDS software reports all dental hygiene services under a
> dentist's name, with the hygienist listed as an auxiliary provider.

6)  **Relative Value Units per Operatory**

> Data Elements: Relative Value Units / \# of Dental Operatories
>
> This indicator provides a common denominator for comparing
> productivity across all programs.

**3. [Dental Program Effectiveness and Access to Dental Care
Indicators]{.underline}**

An important aspect of dental program effectiveness is the level of
access to dental care, or the ability of patients to obtain needed
dental treatment when they request it. In general the goal is to provide
at least the same level of dental access to AI/AN communities as is
available to most communities in the United States. These goals are
based upon the assumption that most individuals will be better able to
maintain good oral health if they are able to see a dentist regularly,
e.g., at least once per year.

Any calculation of dental access requires as accurate an estimate of the
user population as possible. The RPMS-DDS Basic Measures Report provides
data on "Facility Users Past 36 Months," which traditionally has been a
widely-accepted measure of user population. This measure represents an
unduplicated count of patients who had at least one appointment in any
portion of the medical facility during the past three years. If programs
prefer to use other measures of patient population, they have the option
to use them.

**Access to Care Indicators Using RPMS Dental Data System:**

1)  **Proportion of Population Served Annually (Annual Access to Dental
    Care)**

> Data Elements: Dental Users Past 12 Mo. / Facility Users Past 36 Mo. X
> 100
>
> This indicator measures population penetration or utilization rate,
> which is the proportion of the community or population base that has
> gained access to dental services during the preceding year. Annual
> access to dental care has been a Government Performance and Results
> Act of 1993 (GPRA) objective for the IHS dental program for many
> years. Typically only Indian user counts are included in both the
> numerator and denominator of this indicator in order to measure access
> for AI/AN people.

2)  **Proportion of Patients Treatment Planned**

> Data Elements: Patients Treatment Planned / Dental Users Past 12 Mo. X
> 100
>
> This indicator measures the proportion of patients who receive a
> treatment plan annually, based on a count of routine exam codes
> (0150 + 0120).

3)  **Proportion of Patients Completed**

> Data Elements: Pts. Planned Tx. Completed / Pts. Tx. Planned X 100
>
> This indicator measures the proportion of patients who have received
> an exam/treatment plan who actually had at least their basic (Levels I
> to III) treatment completed (code 9990). This measure is reliable only
> if programs routinely use the 9990 code when a patient is completed.

4)  **Relative Value Units per Patient**

> Data Elements: Relative Value Units / Dental Users Past 12 Months
>
> This indicator measures how much dental treatment was provided per
> patient, on average. In programs where comprehensive care is the rule,
> the number of RVUs per patient will obviously be higher than in
> programs where treatment is limited primarily to emergency care and
> basic care.

**Relationship Between Dental Clinic Efficiency and Resource
Requirements Methodology**

Even though dental clinic efficiency can be enhanced with good
scheduling techniques and other effective management practices, there
are limits to what can be accomplished if the clinic is too small or if
the program is short-staffed. In clinics that are overwhelmed with
patients, the only realistic and lasting solution is to combine
efficient clinical practices with adequate resources in the form of
facility size and dental staff. Below is the Resource Requirements
Methodology chart that has been developed by the IHS to provide programs
with an estimate of resource needs based on the program's service
population.

If a program's current service population calls for a clinic size and
number of dental staff that are well beyond what is currently available,
then in addition to improving clinic efficiency programs should pursue
all available options for expanding the clinic and staff to levels that
better match the population.

**Dental Staff and Facility Recommendations Based on Service
Population**

  ------------------ -------------- ----------------- -------------- -----------------
  **Population       **Dentists**   **Auxiliaries**   **Total        **Operatories**
  Range**                                             Staff**        

  0 - 700            0              0                 0              0

  701 - 906          1              2                 3              3

  907 - 1284         1              3                 4              4

  1285 - 1789        1.5            5                 6.5            5

  1790 - 2421        2              7                 9              6

  2422 - 2673        2              8                 10             7

  2674 - 2926        2              9                 11             8

  2927 - 3431        3              10                13             9

  3432 - 4042        3              12                15             10

  4043 - 4547        4              13                17             11

  4548 - 5052        4              15                19             12

  5053 - 5557        4              17                21             13

  5558 - 6063        5              18                23             14

  6064 - 6315        5              19                24             15

  6316 - 6821        6              20                26             16

  6822 - 7073        6              21                27             17

  7074 - 7578        7              22                29             18

  7579 - 7831        7              23                30             19

  7832 - 8336        8              24                32             20

  8337 - 9094        8              27                35             21

  9095 - 9600        9              28                37             22

  9601 - 10,105      9              30                39             23

  10,106 - 10,610    9              32                41             24

  10,611 and over    Revert to the                                   
                     beginning of                                    
                     the chart to                                    
                     identify                                        
                     additional                                      
                     resources                                       
                     required to                                     
                     meet need in                                    
                     excess of                                       
                     10,610                                          
                     population                                      
  ------------------ -------------- ----------------- -------------- -----------------

It is recommended that no dental clinic contain more than 24
operatories. Larger clinics tend to be inefficient, and they can present
access problems for dispersed populations.

Note: Auxiliaries include dental assistants, dental hygienists,
receptionists, and clerks.

**Appendix I**

**Controlling an Overloaded Appointment Schedule**

**Goal: To schedule patients no more than three weeks in advance of
their appointments.**

**Tip #1: Ask emergency patients to call back for a regular exam
appointment rather than scheduling the appointment at the end of the
emergency visit.** Virtually all emergency patients will accept a
routine appointment if it is offered, but in most programs a large
proportion of these emergency patients are episodic users who will not
appear for the appointment. Asking them to call back will help you to
screen out those patients who are not really interested in routine care.
This will save you several slots in the appointment schedule as well as
lower the broken appointment rate.

**Tip #2: Instead of using six months as the "standard recall interval"
for patients with low to moderate disease rates, extend the interval to
one year or longer.** You should still recall patients at high risk for
periodontal disease or caries on a more frequent basis, e.g., every
three months to six months, but patients at low to moderate risk for
dental disease can be recalled less frequently. Historically, the
standard recall interval in most IHS/Tribal/Urban Indian dental programs
nationwide has been one year. The dental literature does not support the
need for six-month recalls for patients with relatively low disease
rates. From a public health standpoint, if you have patients who must
wait a long time for an appointment, you will do more good for your
population if you will use a 12-month recall for most patients and save
the three-month, four-month, and six-month recalls for those patients
with high disease rates. Extending the standard recall interval also
will save you slots in the appointment schedule.

**Tip #3: Schedule only a patient's next appointment, rather than the
full treatment series.** Programs sometimes trap themselves by giving a
patient a whole series of appointments at once, in order to decrease the
patient's waiting time between appointments. If you are booked ahead no
more than three weeks, scheduling a series of appointments is generally
not necessary, especially for routine restorative dentistry. If you are
booked beyond three weeks, giving patients multiple appointments will
only fill up the schedule further ahead.

**Tip #4: If your appointment schedule is still booked too far ahead
after adopting Tips #1, #2, #3, consider using a call-in system or
waiting list system.** Both systems can work, but most programs prefer
the call-in method rather than a waiting list, assuming that most
patients have access to telephones. Whichever system you use, make sure
that the system has been approved by your Program Director and Tribal
Health Board or Tribal Council to provide you with support for the
policy.

**[Recommendations that Apply to Both Call-In and Waiting List
Systems]{.underline}**

1)  **To start either system, you need to "bite the bullet" and stop
    appointing new patients until your schedule is down to the
    three-week maximum.** Patients needing exam appointments should be
    told that you are starting a new appointment system and cannot make
    any new appointments at this time. Then give them an estimate as to
    when you expect to start making appointments again.

2)  **With either system, once a patient receives a dental exam he or
    she should be given subsequent appointments until at least basic
    treatment has been completed.** In other words, the patient does not
    need to go through the call-in or waiting list mechanism again for
    follow-up preventive treatment, restorative appointments, simple
    endodontic treatment, etc. It will be the decision of your program
    as to whether you will also complete the patient's specialty
    treatment (such as molar root canal treatments, crown and bridge,
    partial and full dentures, etc.) as part of this appointment
    sequence or whether you will defer these types of procedures to a
    specialty treatment waiting list.

3)  **The number of new exam patients that you can appoint each week
    from the weekly call-in system or from the waiting list will be
    approximately the number of patients whose treatment you have
    finished during the previous week.** For example, assume that it is
    the first week of August. Your appointment book is full for the
    first two weeks of August, and the third week of August is partially
    filled with patients needing subsequent appointments. There should
    be some slots available during the third week approximately equal to
    the number of patients that you finished during the last week of
    July. Note: If your staff members go to a meeting and the clinic is
    closed for a week, then you would not add any new patients until
    your appointment book once again reaches the three-week level.

4)  **The total number of patients scheduled for the slots available
    will include patients from the recall system and patients from the
    call-in system or waiting list system.** This will be addressed
    later, under "Recall Appointments."

**[Specifics for Call-in System]{.underline}**

1)  **A designated time is selected during which new patients (including
    emergency patients who need to call back for complete exams) can
    make appointments by telephone.** This is usually done once per week
    at a time that is convenient for the dental staff and for patients.
    For example, you might want to have people call in at 8:00 AM every
    Tuesday in order to avoid the problem of Monday holidays and the
    large number of emergency patients typically seen on Mondays.

2)  **Do not begin taking calls until [exactly]{.underline} the
    designated call-in time.** If you start taking calls at 7:45 or 7:55
    when your designated time is 8:00, it is going to be difficult to
    explain to people who call in at 8:00 why all the slots are already
    full.

3)  **When the number of slots available for call-in patients has been
    filled, tell subsequent callers that the book is full and that they
    can try again next week.** It is also a good idea to ask these
    callers if they would like their names to be placed on a
    short-notice call list in case someone cancels an appointment during
    the week. Even though the chances of patients getting in this way
    might be slim, it does give them some hope.

**[Specifics for Waiting List System]{.underline}**

1)  **When patients (including emergency patients needing a complete
    exam) ask for an appointment, their names are placed on a waiting
    list.** The list should include columns for the date the name is
    entered, the date the letter is mailed telling the patient that
    his/her name has come up on the waiting list, and the date that the
    patient responds to the letter. The list can either be in written
    form or maintained as a computer spreadsheet or word processing
    document.

2)  **The patient is asked to address an envelope (to ensure that the
    correct current address is listed on the envelope)**. If the patient
    calls in, the receptionist can fill in the name and address from
    information gained over the phone. The envelope is then filed until
    the patient's name comes up on the waiting list.

3)  **When the patient's name is reached on the list, a notification
    letter is generated and mailed to the patient.** **The letter should
    [not]{.underline} include an appointment time**. It should merely
    state, "Your name has come up on the waiting list. Please call the
    dental clinic by August 12, 2007 (for example) to set up an
    appointment time." If the patient is late in responding because he
    or she was out of town for several days, you might want to go ahead
    and provide an appointment when he/she calls. Late responses usually
    are not so common as to be a problem.

4)  **It will take some experience with the system to determine how many
    letters to send out to get enough responders to fill the slots
    available in the appointment schedule**. Not everyone who is sent a
    letter will respond. You might start by mailing twice as many
    letters as you have slots available, and then adjusting the number
    from there.

**[Recall Appointments]{.underline}**

Recall patients will be competing for available appointments with the
call-in or waiting list patients. One way to handle this is to schedule
the high-risk patients when they respond to the recall notice, because
of their high priority. Fortunately, some of these high-risk patients
will need only a prevention appointment with an assistant or hygienist,
which takes pressure off the dentist's schedule. If a call-in system is
in place, low-risk to moderate-risk patients can be sent a letter
reminding them that it is time for them to seek an appointment via the
call-in system. If a waiting list system is being used, low-risk to
moderate-risk patients can be instructed to sign up for the waiting list
in a certain number of months, depending on the length of the list. The
idea is to time the patient's name coming up on the list with the
desired recall time. The program might choose to send a letter at the
appropriate time to remind patients to sign up for the list.

**[Alternative Scheduling Methods]{.underline}**

Some programs are so overwhelmed with patients seeking appointments that
nothing seems to work satisfactorily, resulting in high levels of
frustration for both patients and dental staff. Some of these programs
have explored new methods for appointing patients, including the Walk-In
Clinic concept and the Same Day Call-In appointment system.

> **[Walk-In Clinics]{.underline}**
>
> The Walk-In Clinic concept typically involves setting aside either a
> certain amount of time each day or certain days each week to treat
> walk-in patients. This is similar to the walk-in time that many
> programs set aside for emergency care, but it goes beyond that to
> provide basic restorative and preventive care on a walk-in basis. Most
> programs using this method are large programs with several dentists on
> staff, but some smaller programs have also found the technique useful
> for at least some of the treatment time available.
>
> Programs that provide walk-in appointments for routine care vary in
> the operating details, especially in how the patient is supposed to
> contact the clinic. Following are two examples of ways that a Walk-In
> Clinic can be managed:

1)  Some programs require patients to appear in person when the clinic
    first opens in the morning, so they can request a walk-in
    appointment. Then they are given an appointment time to return later
    that day. When all available slots are full, additional patients who
    arrive are asked to return for the next scheduled Walk-In Clinic.

2)  Other programs require patients to appear in person either first
    thing in the morning or first thing in the afternoon to sign up for
    Walk-In Clinic, but a specific appointment time is not given to each
    patient. Instead walk-in patients are asked to remain in the
    facility until it is their turn, much like the manner in which
    emergency time is handled in many programs. When the maximum number
    of walk-in patients that can be treated during the time available
    have signed up, subsequent patients are asked to return for the next
    scheduled Walk-In Clinic.

> In some programs the Walk-In Clinic is the only method available to
> patients for obtaining routine care. In other programs the Walk-In
> Clinic is only one way to receive basic dental care, with other
> options available for some of the appointment slots, such as a call-in
> system. In almost all programs specialty care is scheduled via regular
> appointments, because of the time-consuming nature of these
> procedures.
>
> **Advantages of Walk-In Clinics:**

-   Broken appointments for the Walk-In Clinic are few in number or
    almost non-existent.

-   Persistent patients are rewarded with good access to dental care. In
    some cases motivated patients are able to receive all of their basic
    care within a few days.

-   The number of complaints from people who could not obtain a routine
    care appointment in the past might be reduced, because they can get
    in for treatment the next day if they appear early enough in the
    morning.

> **Disadvantages of Walk-In Clinics:**

-   Busy patients who have demanding jobs or other commitments might
    find it virtually impossible to stand in line in the morning and
    perhaps be required to remain in the clinic for many hours.

-   Patients are required to access the Walk-In Clinic for each
    subsequent appointment to complete basic care, instead of accessing
    the system only once as in more traditional appointment systems.

-   Because of the large number of walk-in patients who might appear
    every day (especially in large programs), adequate numbers of
    receptionists and/or assistants are required to handle the rush of
    patients.

-   On some days there might not be enough patients to fill all of the
    available walk-in appointment slots (especially in smaller
    programs). This requires that a short-notice call list be available
    to fill in the gaps.

> **[Same Day Call-In System]{.underline}**
>
> In the Same Day Call-In System patients are asked to call the clinic
> first thing in the morning, at which time each patient is given an
> appointment time for later that day (or in some programs for the
> following day). When all available slots are full, other patients who
> call are asked to call again the next day. Aside from calling rather
> than walking in to access the clinic, this type of system functions
> like a typical Walk-In Clinic.
>
> **Advantages of Same Day Call-In System:**

-   The broken appointment rate is typically very low.

-   Motivated patients who are persistent have good access to dental
    care.

-   Complaints from patients might also be reduced, depending on how
    busy the clinic phone lines are and how difficult it is to get
    through by phone.

> **Disadvantages of Same Day Call-In System:**

-   For patients the main disadvantage is finding the time to spend on
    the phone while trying to reach the clinic over phone lines that
    might be jammed with calls.

-   The call-in process must be repeated for each subsequent basic care
    appointment.

-   An adequate number of receptionists or assistants must be available
    to take phone calls every morning.

-   The staff members who take calls might be faced with upset patients
    who finally got through by phone only to find that all appointment
    slots have been taken.

-   Staff members must deal with the problem of what to do with patients
    who walk into the clinic and demand an appointment instead of
    calling. A determination must be made as to whether walk-in patients
    can also receive an appointment and, if so, whether phone calls or
    walk-ins will have priority for appointment slots.

> **[Summary of Alternative Scheduling Methods]{.underline}**
>
> In general walk-in and same day call-in systems seem to function best
> in programs where the alternative system is not the only way for
> patients to obtain an appointment for routine dental care. People with
> demanding jobs and other commitments tend to be more satisfied with
> traditional appointment systems in which they have to access the
> clinic once per year for an exam but then receive follow-up
> appointments for basic care without having to "jump through hoops" for
> each subsequent appointment. People who have the time to wait might
> prefer just showing up on the day they desire treatment. The ideal
> blend for very busy programs might be to provide some appointment
> slots for standard basic care appointments and others for walk-in or
> same day call-in patients. This can be accomplished either by
> scheduling separate days for each type of appointment or designating
> different times of day for each type, such as having a Walk-In Clinic
> in the morning and regular scheduled appointments in the afternoon.

**[Dealing with Complaints about a New Appointment System]{.underline}**

Keeping the time interval between appointments at a reasonable length is
important to most patients. If patients complain when you initiate a
call-in or waiting list system, inform them that once they get into the
system, the new method will decrease the length of time between
appointments. In the long run, they will probably finish their treatment
sooner than if the schedule continued to be booked a month or several
months ahead. In the case of walk-in or same day call-in systems,
patients can be informed that if they are willing to appear in the
clinic or call the clinic early in the morning, they will have a good
chance of being seen that same day.

# Appendix II

# Dental Appointment Agreement

It is important for patients to keep their dental appointments, because
broken appointments result in lost time that could have been used to
treat other patients.

### 

### Rescheduling Appointments

The dental staff understand that sometimes situations arise that require
rescheduling of your appointment. If you need to reschedule, please call
the dental clinic as soon as you know that you will not be able to keep
the appointment, preferably at least 24 hours before the appointment
time.

### Broken Appointments

If you miss a scheduled appointment or cancel it at the last minute, a
broken appointment will be recorded in your dental chart. If you are
more than 10 minutes late for an appointment, a broken appointment will
also be recorded, and you may have to be rescheduled if there is not
enough time to complete your procedure. It is not fair to keep other
patients waiting because someone showed up late.

If you have 2 broken appointments during the past 6 months, you will not
be able to make a regular appointment for a period of 6 months from the
date of the second broken appointment. You are still eligible for
emergency dental care during that time.

I understand the Dental Appointment Agreement and agree to follow the
terms of the broken appointment policy.

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Patient Name (please print) Date**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Patient or Parent/Guardian Signature

**Appendix III**

**Broken Appointment Rate and Walk-In Rate Worksheet**

# [Day \#]{.underline} [Date]{.underline} [\# Pts. Scheduled]{.underline} [\# BAs]{.underline} [\# WIs]{.underline} 

1 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

2 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

3 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

4 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

5 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

6 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

7 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

8 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

9 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

10 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

11 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

12 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

13 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

14 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

15 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

16 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

17 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

18 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

19 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

20 \_\_\_\_\_\_\_\_\_\_\_ ­­­­ \_\_\_\_\_

Totals \_\_\_\_\_\_\_ \_\_\_\_\_\_\_ \_\_\_\_\_\_\_

**[Calculations for Broken Appointment Rate and Walk-In
Rate]{.underline}**

BA Rate = Total \# BAs / Total \# Pts. Scheduled X 100 = / X 100 =
\_\_\_\_\_ %

Avg. \# Walk-Ins per Day = Total \# Walk-Ins / Total \# of Days = / =
\_\_\_\_\_ / Day

Range in \# of Walk-Ins per Day = Least \# per Day to Greatest \# per
Day = \_\_\_\_\_to\_\_\_\_\_

Ratio of BAs to Walk-Ins = Total \# BAs / Total \# Walk-Ins = / =
\_\_\_\_\_ : 1

**Appendix IV**

**Patient Flow Questionnaire**

Facility: [\_\_\_\_]{.underline} Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Appointment Scheduling (Routine Dental Care)]{.underline}**

1.  How many weeks ahead is the appointment book filled with patients?

2.  When an eligible patient asks for an appointment for a dental
    checkup, is your program able to schedule the patient immediately
    (**appointments on demand**)?

3.  If your program is not able to provide appointments on demand, are
    patients asked to call back at a certain time, at which time a
    limited number of appointments are given out to the first people who
    call (**call-in system**)?

> If so, describe the mechanism:
>
> Approximately how many appointments are given out at each call-in
> time?

4.  If your program is not able to provide appointments on demand, are
    patients asked to place their names on a waiting list and told they
    will receive an appointment at a later date (**waiting list
    system**)?

> If so, describe the mechanism for giving an appointment to people on
> the list:

5.  Does your program have a **walk-in clinic or same day call-in system
    for routine dental care**, in which patients who need non-emergency
    treatment are asked to walk in or call in early in the morning to
    obtain an appointment for later that same day or the next day?

> If so, describe the mechanism:

6.  Are there exceptions to your appointment policy that gives priority
    to certain patients (such as **prenatal patients**, **diabetics**,
    or **children**)?

7.  Once a patient gets into your appointment system, does the patient
    receive follow-up appointments for all routine treatment without
    needing to go through a call-in system or waiting list system for
    each new appointment?

8.  Other than denture patients, is more than one appointment ever
    scheduled for a patient at one time for routine treatment, instead
    of giving the patient one appointment at a time?

> If so, why is a series given?
>
> If a series is given and the patient misses one appointment in the
> series, what happens to the remaining appointment(s)?

9.  Is virtually every patient given the same amount of time in the
    appointment book (such as one hour), or is there a range of times,
    depending on the procedure(s) to be performed?

> What is the range in times given for appointments?

10. Is a short-notice call list in place to fill canceled appointments?

> If so, how often is the list actually used to fill openings in the
> schedule?

11. Are treatment plans completed in as few appointments as is feasible,
    e.g., is quadrant dentistry provided most of the time?

12. Are **Levels of Care** principles followed in individual treatment
    plans (emergency care, preventive care, and routine restorative
    completed before specialty care)?

**[Emergency Patient Flow]{.underline}**

13. Is a special emergency time set aside to treat emergency patients,
    or are all emergency patients worked in between other patients?

> If there is a special emergency time, what are the emergency hours?
>
> If there is a special emergency time, how many dentist-hours are set
> aside each day to provide emergency dental care?

14. Instead of having a walk-in emergency clinic, are emergency patients
    asked to call the clinic and given a scheduled emergency appointment
    during the same or the next day?

15. For patients receiving emergency treatment, are those patients who
    need a follow-up exam and other treatment given the follow-up
    appointment as they leave the clinic after the emergency visit?

16. If emergency patients are not given a follow-up appointment as they
    leave from the emergency visit, how do they obtain an appointment?

17. If a molar tooth is opened for root canal treatment during an
    emergency visit, when the patient obtains a follow-up appointment is
    the next appointment typically for an exam or for root canal
    treatment?

**[Broken Appointments (BAs)]{.underline}**

18. If your program has a high broken appointment rate, do you routinely
    overbook patients to compensate for missed appointments?

> If so, how many extra patients per day are scheduled?

19. Does your program routinely double-book patients who have a history
    of broken appointments?

> If so, is the additional patient scheduled for an exam or other simple
> procedure to provide flexibility, in case both patients keep their
> appointments?

20. Are patient reminders used, such as phone calls, cards, or letters?

> If so, describe the mechanism:
>
> What is the staff\'s impression of their effectiveness?

21. Is a broken appointment policy in effect?

> If so, is the policy in the form of an agreement or "contract" that is
> signed and dated by the patient?
>
> Is the patient provided a copy of the BA agreement?
>
> If a BA policy is in place, is it rigidly enforced?

**[Use of Provider Time and Operatories]{.underline}**

22. [Morning Time Management]{.underline}

> What time does the clinic open in the morning?
>
> What time is the first patient scheduled in the appointment book?
>
> What time is the first patient actually seen on average?
>
> Are all staff, including the dentists, typically at work at the clinic
> opening time?

23. [Lunch]{.underline}

> What is the starting time and ending time of the scheduled lunch break
> for the dental staff?

24. [Afternoon Time Management]{.underline}

> What time is the first afternoon patient scheduled to be seen?
>
> What time does the clinic close in the afternoon?
>
> What time is the last patient of the day scheduled to be seen?
>
> What time is the last patient for the day typically completed?

25. Do all members of the dental staff work the same hours, or are there
    alternative work schedules?

> If alternative schedules are in place, list the types of schedules
> available at the clinic and which staff are on which schedule?

26. Does the dentist(s) have a specified time set aside for
    administrative activities?

> If so, how much time and when?

27. How many dental providers (dentists and dental hygienists) work at
    your clinic?

Dentists= RDHs= Total=

28. How many chairside dental assistants does your program have?

> DA / Dentist ratio=

29. How many front office staff (receptionists, dental billing clerks,
    etc.) does your dental program have?

30. [Operatory Utilization]{.underline}

> How many operatories are available in the clinic?
>
> How many operatories are used by a dentist?
>
> How many operatories are used by a dental hygienist?
>
> Operatory / Dentist ratio (exclusive of RDH operatories) =
>
> Are there operatories that stay empty a significant amount of time?
>
> If so, why are the operatories not used?

31. [Standardization and Unit Dose]{.underline}

> Are operatories standardized (drawers in one operatory set up the same
> as drawers in the other operatories, except for specialty chairs,
> hygiene chairs)?
>
> Are tray setups standardized?
>
> Is the unit-dose technique used for setting up trays?

32. If the number of staff members is small, especially if there is only
    one dental assistant, is the receptionist cross-trained to perform
    dental assisting duties?

**[Recall System]{.underline}**

33. Is a recall system in place, at least for the highest-risk patients?

> Which patients are included in the recall system (ex. all patients,
> prophy patients only, perio patients only, or patients at high risk
> for caries)?

34. Is the recall interval individualized for each patient\'s needs?

35. What is the range of recall intervals used at the clinic for various
    patients (shortest recall interval and longest recall interval)?

> At what interval are most patients recalled?

**[Expanded Functions (EF)]{.underline}**

36. Have any of the dental assistants received training in EF
    restorative (place restorations) or EF perio (perform prophys)?

> If so, which assistants have received which training?
>
> If your program has EF-trained assistants, to what extent are they
> performing EF duties?
>
> If your program has EF-trained assistants and they are not performing
> EF duties routinely, what is the reason for EF not being utilized?

**[Recordkeeping and Data Analysis]{.underline}**

37. Are all entries in the dental record completed and all charts
    securely filed by the end of each workday?

38. Who writes the procedure codes in the Dental Progress Notes?

39. How soon after a patient visit are procedure codes for that visit
    entered into the Dental Progress Notes?

40. Who enters the procedure codes into the RPMS Dental Data System?

41. What is the length of the time interval between treatment of the
    patient and entry of the data into RPMS?

42. Are RPMS workload reports printed periodically and used to aid in
    the management of the dental program?

> If so, which reports are used?
>
> RDEN (First Visits and Revisits)?
>
> RSVC (Services, Relative Value Units, & Levels of Care)?
>
> RCST (Compiled Statistical Reports, incl. 3-Year User count)?
>
> SCOM (Tracking of specific procedure codes, age groups)?
>
> Does your program desire assistance in gaining access to and printing
> any of the reports listed above?

43. Current Dental Staff

> Please list the names of the current members of your dental staff and
> their positions in the space below (note: for part-time employees,
> please list which days they work).
>
> Name Position

**Appendix V**

**Efficiency and Effectiveness Data Indicators Worksheet**

Facility:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Instructions: Use data from the RPMS-DDS Basic Measures Report for the
previous 12 months or most recent fiscal year.*

***[Reference Values]{.underline}***

1\. **Population to Care Provider Ratio**

Facility Users Past 36 Months / \# of Dentists = ­\_\_\_\_\_\_\_\_
*1,200:1*

Facility Users Past 36 Months / \# of FTEs = \_\_\_\_\_\_\_\_ *500:1*

2\. **Operatories per Dentist**

\# of Clinic Operatories / \# of Dentists = \_\_\_\_\_\_\_\_ *2:1 or
more*

3\. **Dental Assistants per Dentist**

\# of DAs / \# of Dentists = \_\_\_\_\_\_\_\_ *2:1 or more*

4\. **Visits per Dentist**

Dental Visits Past 12 Months / \# of Dentists = \_\_\_\_\_\_\_\_ *1,926*

5\. **Visits per Operatory**

Dental Visits Past 12 Months / \# Operatories = \_\_\_\_\_\_\_\_ *658*

6\. **Relative Value Units per Patient Visit**

Relative Value Units / Dental Visits Past 12 Months = \_\_\_\_\_\_\_\_
*5.3*

7\. **Relative Value Units per Dental FTE**

Relative Value Units / \# of FTEs = \_\_\_\_\_\_\_\_ *2,697*

***[Reference Values]{.underline}***

8\. **Relative Value Units per Dentist**

Relative Value Units / \# of Dentists = \_\_\_\_\_\_\_\_ *10,146*

9\. **Relative Value Units per Operatory**

Relative Value Units / \# of Operatories = \_\_\_\_\_\_\_\_ *3,467*

10\. **Broken Appointments per Scheduled Visit (% BA Rate)**

Broken Appts / (Dental Visits Past 12 Months + Broken Appts --

Emergency Visits) X 100 = \_\_\_\_\_\_\_\_ *Not Available*

11\. **Proportion of Population Served Annually (Annual Access to Dental
Care)**

Dental Users Past 12 Months / Facility Users Past 36 Months

X 100 = \_\_\_\_\_\_\_\_

*Goal = 60%*

*Actual IHS-wide Access (2006) = 23%*

12\. **Proportion of Patients Treatment Planned**

Pts Treatment Planned / Dental Users Past 12 Months

X 100 = \_\_\_\_\_\_\_\_ *Not Available*

13\. **Proportion of Patients Completed**

Pts Planned Tx Completed / Pts Treatment Planned X 100 =
\_\_\_\_\_\_\_\_ *Not Available*

14\. **Relative Value Units per Patient**

Relative Value Units / Dental Users Past 12 Months = \_\_\_\_\_\_\_\_
*10.9*

[^1]: A community water system is defined as a water system which
    supplies drinking water to 25 or more of the same people year-round
    in their residences (Source: U.S. Environmental Protection Agency).

[^2]: Healthy People 2010 Oral Health Objective 21.9: Increase persons
    on public water receiving fluoridated water to 75%.

[^3]: CDC Morbidity and Mortality Weekly Report, Recommendations and
    Reports, September 29, 1995/Vol. 44/No. RR-13.