291-124-0042 Dental Care and Treatment (1) Dental care procedures will be conducted in a clinically appropriate manner by appropriately credentialed personnel in an appropriate setting. (2) Dental care and treatment is authorized and provided according to priorities established by the chief of medicine and the dental director. Dental care is subject to peer review. Dental care and treatment will be provided, authorized, and prioritized based on four levels of care. (3) Level 1 Dental Care: (a) Level 1 Dental Care (or medically mandatory dental care) is defined as care that is essential to life and health, without which rapid deterioration may be an expected outcome and where medical or surgical intervention makes a very significant difference or has a very high cost-effectiveness. Level 1 care and treatment may include but is not limited to: (A) Acute problems, potentially fatal, where treatment prevents rapid deterioration of health (for example, treatment for severe cellulitis, osteomyelitis, or serious oral pathology); (B) Acute problems, potentially fatal, where treatment prevents deterioration but does not necessarily allow for full recovery (for example, treatment for severe oral pathology); or (C) Other conditions of care identified as Level 1 dental care in Exhibit 1. (b) Level 1 dental care shall be routinely povided to all AICs by the department. A treating provider may authorize Level 1 dental care. In emergency situations, nursing staff may authorize Level 1 dental care. (4) Level 2 Dental Care: (a) Level 2 dental care (or presently medically necessary dental care) is defined as care without which an AIC could not be maintained without significant risk of further serious deterioration of the condition, or significant reduction of the chance to repair the condition after release or without significant pain or discomfort. Level 2 dental care may include but is not limited to: (A) Acute or chronic conditions where treatment facilitates a return to oral health e.g., exodontic procedures, treatment for infected or inflamed oral structures, fillings for dental cavities; (B) Upper or lower dentures for those who have no remaining teeth; (C) Chronic conditions where treatment causes a return to previous state of health, e.g., fillings for dental cavities, treatment of various infectious disorders; (D) Comfort care such as pain management, except chronic pain management that may be referred to institution physicians; (E) Proven effective preventive care for adults, e.g., debridement of calculus, home care instructions; or (F) Other conditions or care and treatment identified as Level 2 dental care in Exhibit 1. (b) Level 2 dental care may be routinely provided to AICs upon request and may be authorized by any institution staff dentist. Treatment decisions are subject to periodic review by the chief medical officer or dental director for utilization review and appropriateness. (5) Level 3 Dental Care: (a) Level 3 dental care (or medically acceptable but not medically necessary care and treatment) is defined as care for conditions where treatment may improve the quality of life for the AIC but with minimal overall medical impact, e.g., dental prosthetic appliances, removal of impacted wisdom teeth. Level 3 dental care may include, as an example, dental prosthetic devices and other conditions or care and treatment identified as Level 3 dental care in Exhibit 1. (b) Level 3 dental care may be authorized on a case-by-case basis. Level 3 dental care procedures, whether performed onsite or offsite, require review and authorization by the Therapeutic Levels of Care (TLC) Committee as provided in OAR 291-124-0042(8). (6) Level 4 Dental Care (Of Limited Medical Value): (a) Level 4 dental care (or care and treatment of limited medical value) is defined as elective care that may be valuable to a certain individual but significantly less likely to be cost-effective or to produce substantial long-term gain or improvement, or care that does not result in a reliable outcome that is corroborated by evidence-based data. Level 4 Care includes conditions where alternate treatments are available or where treatment gives little improvement in the overall quality of life, offers minimal palliation of symptoms, or is exclusively for the convenience of the individual. Examples may include: fixed bridgework; TMJ surgery; orthodontics; endodontics (root canals); custom crowns; and dental prostheses that are considered predominately cosmetic in nature. Other Level 4 dental care is identified in Exhibit 1. (b) Level 4 dental care is generally not provided. However, Level 4 dental care may be approved by the TLC Committee if significant and compelling overriding circumstances exist, Refer to OAR 291-124-0042 (14)(a). (A) If level 4 dental care is not authorized by the TLC Committee, the AIC may obtain Level 4 dental care as provided in OAR 291-124-0085. (B) The department is not obligated to carry out any recommendations or treatment plans formulated by any outside providers if ongoing care is required. (7) Exceptions: (a) The four defined Levels of dental care are general categories of diagnoses, therapies, or procedures. (b) Depending on the individual circumstances, the department may consider additional factors in deciding whether to provide particular care, or whether it is appropriate to apply a specific level of care to an individual AIC. (c) Any individual case may be referred for further clinical review pursuant to OAR 291-124-0042(8) to determine whether to authorize or not authorize dental care and treatment. (8) Clinical Review: (a) For all Level 3 and Level 4 dental care, individual cases must be referred to the dental director for clinical review. The dental director may form a review committee (Therapeutic Levels of Care Committee or TLC Committee) comprised of one or more department dentists, and the Health Services Chief of Medicine to review care and treatment requests on a case-by-case basis. The final authority in any review is the Health Services Chief of Medicine or designee, e.g., dental director. (b) Factors that the Health Services dental director and a review committee may consider, either singularly or in combination, when deciding whether specified care and treatment should be provided include: (A) The urgency of the care and the length of the AIC's remaining sentence. Whether the care could be delayed without causing a significant progression, complication, or deterioration of the condition; (B) The necessity of the care, including: (i) Any relevant functional disability and the degree of functional improvement to be gained; and (ii) Medical necessity, or the overall morbidity and mortality of the condition if left untreated. (iii) Pre-existing Conditions: Whether the condition existed prior to the AIC’s incarceration. If no treatment was provided in the community, the reasons for not obtaining prior treatment should be ascertained; (iv) The probability the procedure or therapy will have a successful outcome along with relevant risks; (v) The availability of clinically acceptable alternative treatments; (vi) The AIC's desire for the procedure and the likelihood of the AIC's cooperation in the treatment efforts; (vii) A risk-benefit analysis; and (viii) A cost-benefit analysis. (c) After completion of a review, dental staff will schedule an appointment with the AIC to discuss the review decision and next steps, as applicable. (9) Emergency Dental Treatment: Emergency dental treatment is available to all AICs during hours that Health Services staff members are on duty and may include treatment for pain, swelling, infection, bleeding, and suspected injuries. (10) Non-emergency Dental Treatment: Non-emergent dental treatment may be accessed and acquired by AIC request, by referrals from the initial dental screening and exam, periodic or emergency dental examinations, and Health Services staff. Treatments will be prioritized as provided by the following criteria: (a) All Level 1 and Level 2 procedures may be indicated and completed by the attending dentist upon recommendation. If any Level 1 or Level 2 procedures require referral to an outside provider, the TLC Committee must review the referral. However the review may take place after the referral if the treatment is of an urgent nature. (b) Level 3 and Level 4 procedures will only be performed after approval from the Therapeutic Levels of Care Committee. (11) Periodontal Treatment: Periodontal treatment will be provided upon recommendation of the dentist and will be prioritized according to the severity of the condition. (a) Emergent periodontal treatment will be available to all AICs and may be scheduled by the dentist after evaluation of the AIC, or by an interview request from an AIC stating an urgent condition (i.e., pain, swelling, and/or bleeding.) (A) AICs will be scheduled on an emergency basis and the specific problem will be addressed. The initial treatment will usually consist of gross debridement. (B) The need for follow-up treatment will be documented and the AIC will be scheduled as time permits. (b) Routine Treatment is divided into two classes. (A) Class I includes AICs whose periodontal conditional has progressed to the point that surgical intervention is needed. Health Services will try and stabilize the condition, maintain the AIC’s dentition until extraction of the affected teeth becomes necessary. The treatment may consist of gross debridement or hand scaling or both. AICs may go to an outside provider for surgical intervention pursuant to OAR 219-124-0085. (B) Class II includes AICs with good oral hygiene and minor periodontal conditions. AICs will be scheduled, time permitting for preventative treatment. These appointments will be scheduled by an AIC sending in a written request for treatment. (c) Additional periodontal procedures may be performed if authorized pursuant to OAR 291-124-0042(8). (12) Periodic dental exams will be available to AICs serving more than a one-year sentence. Exams will be made available on an annual basis; however, the interval may vary depending on the specific needs of the AIC as determined by the attending dentist. (13) Dental Prostheses: Dental prosthetic appliances are generally considered elective care; however, they may be made available to AICs as a co-pay service if certain criteria are met. (a) Dental prosthetic appliances or procedures may include: (A) Complete Denture: A dental prosthetic appliance that replaces all teeth in upper or lower arch. (B) Partial Denture: A dental prosthetic appliance that replaces some teeth in the upper or lower arch. A “cast partial denture” is made on a frame that is cast metal. An “acrylic partial denture” does not have a cast metal frame and is used when the remaining natural teeth are not strong enough to support a cast partial denture. A “flipper” is an acrylic partial denture designed predominately as a cosmetic appliance, replacing one to four teeth missing in the front part of the mouth. (C) Reline: A procedure that is done to improve the fit of a denture or partial. (b) To be eligible for the co-pay service, an AIC must demonstrate two years remaining on their DOC sentence from the date of their first request for the prosthesis. (A) Approval for Partial Denture: (i) If an AIC meets the two-year threshold and requests a partial, the request must be submitted for review and approval by the TLC Committee. (ii) Partial dentures will generally not be provided if the TLC Committee determines the AIC demonstrates sufficient existing occlusion, or if the remaining teeth are not sound enough to sustain a partial denture adequately. (iii) Partial dentures also will not be provided if the TLC Committee determines the appliance is predominately cosmetic in nature, unless the TLC Committee determines that overriding circumstances allow approval, e.g., an AIC who entered DOC physical custody with all upper anterior teeth present, and then requires removal of one or more of those anterior teeth during incarceration. (B) Approval for Complete Denture: If an AIC meets the two-year threshold and requests a denture, no review or approval by the TLC Committee is required. (c) If an AIC fails to meet the two-year threshold, the TLC Committee may review the request for approval and may approve the request if overriding circumstances exist. Overriding circumstances may include an AIC who entered DOC physical custody completely edentulous requiring no extractions or prep work, or an AIC requiring minimal prep work who falls one or two months short of the two-year threshold. (d) Health Services may participate in a co-pay service for dental prostheses or relines for each AIC a maximum of once every five years. If replacement is necessary prior to five years, the case must be sent to the TLC Committee for review. (e) An AIC who requests a dental prosthesis must sign a request for withdrawal of funds for the following amounts: (A) Complete Denture - $280 (B) Partial Denture (Cast or Flex) - $310 (C) Acrylic Partial Denture - $270 (D) Flipper - $150 (E) Reline Partial or Denture - $110 (F) Occlusal Splint - $40 (G) Denture or partial repairs - By reported cost (f) An AIC shall be responsible to pay laboratory fees for any repairs unless provider or laboratory error can be demonstrated. (14) Dental Root Canals and Custom Crowns: Dental root canals and custom crowns are not generally provided by the department. (a) The department may approve an AIC request for a dental root canal or custom crown on a co-pay basis if a sufficient number of compelling overriding circumstances are present. Examples of overriding circumstances include the following: (A) Required for Approval: For new AICs, a dental examination that reveals a low decay rate with no deep caries on any specific teeth; for other AICs, recall examinations that reveal a low decay rate and good oral hygiene. (B) Required for Approval: An absence of significant periodontal disease on the tooth in question. (C) Other overriding circumstances for consideration: (i) If the AIC is new to the department, the AIC demonstrated good dental care prior to incarceration, including regular trips to the dentist for check-ups. (ii) The tooth is in an arch displaying no missing teeth. (iii) The tooth has an opposing tooth in the opposite arch placing it firmly in function. (iv) The tooth has a specific and significant strategic purpose with regard to overall function. (v) The tooth is an upper anterior and all other upper anteriors are present and in good shape. (vi) Treatment is required due to a previous trauma and not gross neglect of the teeth. (vii) The tooth deteriorated while in DOC custody, despite repeated requests for treatment. (viii) The tooth has a favorable long-term prognosis. (ix) The AIC expended considerable resources on their dentition prior to incarceration. (x) For custom crown requests, the AIC has more than five years remaining to serve. Stainless steel crowns are a clinically acceptable alternative for those with less than five years remaining. (b) All requests for root canals and custom crowns (a full coverage dental crown that is custom-made for a specific tooth by a dental laboratory) must be reviewed and approved by the TLC Committee. (c) A request for a stainless steel crown (a full coverage crown that is prefabricated, and is not custom-made in a dental laboratory) does not require approval by the TLC Committee. (d) The department charges a co-pay amount for any root canals and custom crowns that are approved by the TLC Committee. An AIC who is approved for a root canal or custom crown must sign a request for withdrawal of funds for the following amounts: (A) Custom Crown Full Metal - $120 (B) Custom Crown Porcelain / Metal - $120 (C) Custom Crown Full Ceramic - $120 (D) Root Canal Anterior Tooth - $100 (E) Root Canal Bicuspid Tooth - $140 (F) Root Canal Molar Tooth - $180 (15) Elective Dental Treatment: (a) Pursuant to OAR 291-124-0085, AICs may utilize the services of outside providers for any elective dental treatment that has not been authorized for completion within the department. Requests to purchase outside dental care require review and approval from the TLC Committee to ensure the procedures are medically appropriate and are consistent with community standards for dental care and the department’s concerns for institution security. (b) An AIC may initiate a request for elective dental treatment. (c) A staff dentist will assess the AIC to substantiate the dental procedure in question and submit the case to the TLC Committee for approval and review prior to referral to an outside provider. (d) If the requested elective dental procedure is approved, the AIC may purchase and receive the treatment pursuant to the procedures set forth in OAR 291-124-0085. [ED. NOTE: To view attachments referenced in rule text, click here to view rule.] Statutory/Other Authority: ORS 179.040, 423.020, 423.030 & 423.075 Statutes/Other Implemented: ORS 179.040, 423.020, 423.030 & 423.075 History: DOC 6-2020, amend filed 04/10/2020, effective 04/10/2020 DOC 3-2018, adopt filed 05/03/2018, effective 05/03/2018 DOC 18-2017, temporary adopt filed 11/08/2017, effective 11/08/2017 through 05/05/2018 DOC 17-2017, temporary adopt filed 11/07/2017, effective 11/07/2017 through 05/05/2018