[FACILITY NAME] Dental Policy and Procedure Manual

Reviewed and Approved:

Date Health Services Director

Date Clinical Director

Date Chief, Facility Dental Services

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CLINICAL PROGRAM ________________________________________________________5 DENTAL PROGRAM - Section 1 _____________________________________________6 ORGANIZATIONAL CHART - Section 2______________________________________9 SUMMARY OF DENTAL PROGRAM - Section 3 _____________________________10 ORIENTATION OF NEW EMPLOYEES - Section 4 ___________________________12 ORIENTATION FOR DENTAL OFFICERS - Section 5_________________________13 APPOINTMENT PROCEDURES - Section 6 __________________________________15 TAKING MEDICAL HISTORIES - Section 7 _________________________________16 SCHEDULE OF SERVICES - Section 8 ______________________________________18 EMERGENCY DENTAL CARE - Section 9 ___________________________________20 HEALTH CONSUMER HANDOUT - Section 10_______________________________21 FAILED AND CANCELED APPOINTMENTS - Section 11 _____________________22 COMPLETED TREATMENT - Section 12 ____________________________________25 REFERRAL PROCEDURE - Section 13 ______________________________________25 SCHEDULE OF SERVICES, EXCLUSIONS, AND LIMITATIONS - Section 14 ____29 CLASSIFICATION OF PRIVILEGES - Section 15 _____________________________33 DENTURE PROGRAM - Section 16 _________________________________________34 INFORMED CONSENT - Section 17 _________________________________________38 PEDIATRIC DENTISTRY INFORMED CONSENT - Section 18_________________39 CONSCIOUS SEDATION - Section 19 _______________________________________41 REPORTING CHILD AND ELDERLY ABUSE - Section 20 _____________________54 PATHOLOGY - Section 21 _________________________________________________56 ON GOING PROGRAMS - Section 22________________________________________57 ORAL DISEASE PREVENTION / HEALTH PROMOTION - Section 23 __________58 DENTAL DISEASE PREVENTION PLAN - Section 24 _________________________61 HUMAN RESOURCES - Part II _______________________________________________67 SCHEDULING PROCEDURES - Section 25 __________________________________68 RECORD KEEPING - Section 26 ____________________________________________69 STAFF ASSIGNMENT - Section 27 __________________________________________70 TRAINING - Section 28 ____________________________________________________72 LEAVE - Section 29 _______________________________________________________73 2

DRESS CODE - Section 30 _________________________________________________75 ENVIRONMENT - Part III. ___________________________________________________76 INFECTION CONTROL - Section 31 ________________________________________77 RADIOLOGICAL PROTECTION - Section 32 ________________________________85 MEDICAL EMERGENCIES IN THE DENTAL CLINIC - Section 33 _____________86 FIRE PLAN - Section 34 ___________________________________________________91 PATIENT SEDATION - Section 35 __________________________________________92 STANDING ORDERS FOR DENTAL AUXILIARY STAFF - Section 36 __________95 MERCURY HYGIENE - Section 37 __________________________________________96 SAFETY - Section 38 ______________________________________________________98 PRECIOUS METAL RECOVERY - Section 39 ________________________________99 REQUISITION OF SUPPLIES - Section 40 __________________________________100 CONTINUOUS QUALITY IMPROVEMENT (CQI) PLAN - Section 41 __________101 MAINTENANCE - Section 42 ______________________________________________112 PHARMACY / PRESCRIPTIONS - Section 43 _______________________________113 USE OF DENTAL LABORATORIES - Section 44_____________________________114 MEDICAL RECORDS - Section 45 _________________________________________115 APPENDIX - 1: DENTAL ABBREVIATIONS AND INITIALS _________________117 APPENDIX - 2: DENTAL STAFF SIGNATURES AND INITIALS ______________118

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CLINICAL PROGRAM

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DENTAL PROGRAM - Section 1 SUBJECT:

DENTAL PROGRAM POLICY AND PROCEDURES

PURPOSE:

The purpose of the dental program is to provide quality clinical and preventive dental services in a friendly and efficient manner to those eligible for care at the [Facility Name]. This manual will act as a guide of procedure to follow policies set by the [Facility Name], and the Dental Clinic. All entries into this manual effect the Dental Staff that includes the dentists, hygienists, dental therapist, dental assistants, and receptionists. Dental providers are those delivering care to patients as individuals following supervisory and policy guidelines. This includes the dentists, hygienists, and dental therapist. Dental auxiliaries are the dental assistants and the receptionists and do not work independently

STAFF AUTHORIZED TO PERFORM THIS POLICY: All members of the dental are involved in the provision of dental care at it highest level with finite resources available to provide this care. EFFECTIVE DATE:

__________________

DATE REVIEWED/REVISED: ___________/

/

APPROVED BY:

Chief Dental Officer, Clinical Director, and Quality Officer

DISTRIBUTION:

Dental Policy and Procedures, Medical Staff Policy and Procedures,

Mission Statement: The [Facility Name] is dedicated to the healing and well being of the individual, family and community. Vision Statements: •

To commit ourselves to Continuously improve all that we do.

•

To provide our customers with the best possible health care and to support them in their healing process.

•

To provide and educate the customer in the practice of good health.

•

To focus our daily affairs on our staff and community in order to provide quality services and information in a trustworthy manner.

The dental department will serve as an integral part of the [Facility Name] providing services in the diagnosis, treatment and prevention of dental disease. This treatment may include emergency care, oral surgery, restorative procedures, root canal therapy, prosthetics, and most services required by children. Services will be based on established priorities as listed in the Schedule of Oral Health Services for the Indian Health Service and on available appointments. The dental clinic will also serve as a referral center. Referrals will be made based on established priorities and available resources.

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Policy The policy of the dental department will be implemented through an organizational chart, which is shown, and through a series of procedures that follow. This department is part of the entire facility and works within its guidelines. This department does not function independently. The many patients seen buy the dental clinic and staff of the dental clinic require services from other departments of the facility. This departmental policy and procedure manual is tied to many of the departments to point out the procedures to initiate services.

Organizational Integration: The dental department is a portion of the clinical division of the [Facility Name] that is supervised by the Medical/Clinical Director. This division may include Behavioral Health, Nursing Services, Laboratory, Radiology, Dietetics, Medical, Dental, and Pharmacy. Scheduled meetings are held to discuss concerns and interaction with the Support Services Division. Organizational tables will outline this interaction and will follow this section.

Short Range Goals: Short term planning looks at departmental activities over the next two to five years. Short-term goals are devised as a process to attain the Long Range Planning Goals. These goals are given in the next paragraph. Short Range Planning include the following: •

Increased utilization of alternate resources to purchase crowns and removable prosthetics.

•

Increased presence in community based activities such as schools, senior citizen facility, head start and other congregations of community members.

•

Increased communications with tribal officials and community in addressing their concerns for dental care.

•

Increase monitoring of services provided not only in the clinic; but also monitor all activities outside the clinic in the community.

•

Increase patient interaction and determination of treatment offered. Use of patient input to solve delivery of dental care inadequacies.

Long Range Goals: Departmental planning is again tied to resources and planning of the entire Facility. This planning includes annual review of equipment, personnel, and patient demand. This is actually a strategic planning procedure that is used to function within a five year plan. Additions and modifications to this plan affect both clinical and community components of the dental department. Plans for staffing, procurement and departmental renovation are submitted to facility administration for approval and funding. Committee of the departments or services involved accomplishes planning for projects that concern or run jointly. This long-range plan includes: •

Expansion of provided procedures to include crowns, partial dentures, full dentures and molar root canals. These procedures require more intensive human resources of the staff and more financial consideration than the procedures currently provided by this clinic. This plan also includes more aggressive third party participation.

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•

Plans to accomplish this include a means of charging additional financial consideration to the patient at cost, demonstrated proof that basic care of the community is being addressed.

•

Expansion of community contact to include screening and educational programs for target populations that include the elderly, the young, those with specific medical needs; diabetics for example and other groups requiring primary attention of this community.

•

Continued interaction with the private and public sector dental colleges and organizations, including Federal and State.

•

Working with staff attitudes to become more patient oriented in action and policy.

Budget: The departmental budget is developed each fiscal year. This planning includes the recurring allowance and expected expenditures for salary, transportation, training, supplies, and equipment. This budget is developed with the help of the facility’s finance officer, administrative officer and area dental consultant. Budgeted items that are planned by several departments are negotiated prior the beginning of the fiscal year. The organizational structure of the facility and the department do not allow this department to work independently when delivery of care is comprehensive in its nature. The mouth and oral structure are only a portion of the patient and the total patient is our concern. Medical complications, patient education, and treatment of that patient in the dental department are coordinated with all patient care delivery departments and support departments. Staffing levels are determined by the tasks involved in delivery of dental care to this community and these levels are also determined by a budgetary component with remote decisions effecting the number of employees in this department. Recommend staffing levels include ## dentist providers, ## dental hygienist, ## receptionists, and ## dental assistants. Staff competency is measured by multiple means. Positions descriptions are in place for all staff. This position also has a performance appraisal plan to measure the incumbent's performance and is done annually. Other factors include annual continuing education for all employees in dental specific, human relations, and environmental topics. The staff also has annual radiographic, CPR, blood borne pathogens, and safety competency documented by examination.

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ORGANIZATIONAL CHART - Section 2

This department is an integral portion of the facility. The organization chart is found in the facility’s policies and procedures.

[INSERT FACILITY ORGANIZATIONAL CHART]

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SUMMARY OF DENTAL PROGRAM - Section 3 DESCRIPTION AND ORGANIZATION The Facility Dental Program is directly responsible to the Facility Director appointee. The Dental Programs is the responsibility of the Chief, Facility Dental Officer (CFDO). The dental clinic contains ## dental operatories, one sterilizing area, a darkroom, a dental laboratory, a pornographic x-ray room, a waiting room and ## offices. All dental operatories are in the open bay configuration. ## full time dentists, ## full time permanent auxiliaries, ## full time temporary auxiliary trainees, a receptionist and a full time hygienist staff the dental clinic. Referrals to private specialists are provided through contract health service funds.

SCOPE OF WORK The dental program is designed to provide comprehensive dental services to the entire family through patient education in oral health maintenance, disease prevention, diagnosis and treatment of oral health problems. The Indian Health Manual, Part 3, Chapter 2, outlines goals, objectives, organization and operations summary. Each adult is responsible for his/her dental health. Parents/legal guardians are responsible for the dental health of their legal wards. Dental care will be provided in accordance with the Indian Health Service Dental Program Schedule of Services (See Section IX). Basic dental services (i.e.: emergency, diagnostic, preventive and restorative) will be provided first. Higher levels of dental services (i.e.: rehabilitative) will be provided when basic services are being provided to all health consumers who request treatment and resources still allow additional dental services to be provided. The dental program also serves in a management role to: •

Develop and coordinate the dental program for the facility.

•

Determine and evaluate dental needs and resource requirements.

•

Make equitable distribution of personnel and financial resources.

•

Participate in facility policy and program planning.

CLINIC HOURS Dental services will be available Monday through Friday in from [8:00 AM to 4:30 PM]. The clinics will be closed from 12:00 PM to 1:00 PM daily for lunch. The clinic is also closed every Wednesday morning from 8:00 AM to 10:00 PM for maintenance, cleaning, meetings and training

AFTER HOURS AND EMERGENCY COVERAGE Emergency treatment will be provided in accordance with the facility policy for emergency care. See Section VIII of this manual for treatment and referral policy.

PATIENT BILL OF RIGHTS The Patient Bill of Rights for the facility Dental Program is on file in the dental clinic and is the same policy used in the facility. A copy is available to health consumers upon request. (Copy is following this page)

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PRIVACY ACT (PL. 93-579) Confidentiality of patient records will be maintained according to the Tribal facility adopted Privacy Act The release of information will be performed in accordance with the Privacy Act.

GRIEVANCE Grievance concerning the dental program can be brought by health consumers directly to either the Facility Dental Officer, Medical Director/Clinical director or Facility Director. The grievance will be fully investigated and the health consumer informed of the findings in a timely manner.

RELEASE OF INFORMATION Any release of patient information must be authorized by the health consumer, the health consumer's legal guardian or by court order. Any other means of the release of information concerning a patient's medical record is prohibited by the release of information act.

INFORMED CONSENT Informed consent for dental treatment will be obtained in writing from all health consumers (18 years and older) or from the parent or legal guardian of a minor. In the case of a minor who is not accompanied by a parent or legal guardian, relief of pain and prevention of the spread of infection will be accomplished with medication until legal written consent can be obtained. The forms will be kept in the patient dental chart. (See Section IX of the Oral Health Program Guide OHPG)

This topic is discussed in the Informed Consent Section of this manual.

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ORIENTATION OF NEW EMPLOYEES - Section 4 When reporting for duty the employee will be given the standard General Orientation form by their supervisor, other facility departments, and facility management.

Dental orientation will consist of the following: Review the Clinic Policy, Procedures, Rules and Regulations within seven days. Review Oral Health Program Guide within two weeks. Review Clinical Specialties in General Practice within two weeks. A copy of the completed orientation form will be filed in the employees record. The standard orientation form can be obtained from the personnel office. Orientation will be conducted by the FCDO, their designate.

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ORIENTATION FOR DENTAL OFFICERS - Section 5 Dental Officer's Name: _______________________________________ E.O.D.: _________________________

GENERAL FACILITY ORIENTATION

DATE GIVEN

FACILITY ORIENTATION PACKET GIVEN. ADMINISTRATIVE PAPER WORK FOR PAYROLL DEDUCTIONS, HOUSING ALLOWANCE, AND TRAVEL VOUCHER INTRODUCE NEW EMPLOYEE TO DENTAL STAFF, DENTAL CLINIC, DENTAL EQUIPMENT, EMERGENCY KIT, AND PROCEDURES. PROVIDE KEYS TO THE CLINIC. EXPLANATION OF COMMUNICATION PROCEDURES, P.A. SYSTEM, TELEPHONE POLICY. TOUR OF THE FACILITY AND INTRODUCTION TO THE STAFF. LEAVE POLICY INTRODUCTION TO CLINIC AND TRIBAL PERSONNEL INTRODUCTION AT EXECUTIVE COMMITTEE MEETING INTRODUCTION TO CHR'S, WIC, AND HEAD START PERSONNEL.

ORGANIZATIONAL STRUCTURE FACILITY AND DEPARTMENTS. REVIEW OF FIRE PLAN. REVIEW OF DISASTER PLAN GRIEVANCE PROCEDURES PRIVACY ACT AND PATIENT RIGHTS

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FACILITY POLICY MANUAL PROPERTY CUSTODIAL PROCEDURES

DENTAL DEPARTMENT ORIENTATION DENTAL POLICY AND PROCEDURES SYNOPSIS OF DENTAL PROGRAM WORK SCHEDULE REVIEW OF RECORD KEEPING REVIEW ORDERING OF SUPPLIES REVIEW ORAL HEALTH PROGRAM GUIDE COMPLETE STANDARDS OF PERFORMANCE REVIEW CLINICAL SPECIALTIES MANUAL

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APPOINTMENT PROCEDURES - Section 6 SUBJECT:

APPOINTMENT PROCEDURES

PURPOSE:

To insure that appointments are issued fairly with targeted groups receiving priority in dental attention

STAFF AUTHORIZED TO PERFORM THIS PROCEDURE: All members of the dental staff that have been trained to obtain medical histories including, receptionists, dental assistants, dental hygienists, and dental officers. EFFECTIVE DATE:

_______

DATE REVIEWED/REVISED: ________/

/

APPROVED BY:

Chief Facility Dental Officer, Clinical Director, And Medical Records

DISTRIBUTION:

Dental Policy and Procedures, Medical Staff Policy and Procedures, Out Patient Policy and Produce

To receive an appointment the health consumer must first become registered for care at the facility. The health consumer will be given an appointment for prophylaxis and examination when requested. Health Consumers with scheduled appointments will report to the dental clinic and sign the dental register. The dental receptionist will check the posted appointment schedule and notify the dental auxiliary that a health consumer is waiting. Notification for expanded function patients shall be placing the chart in the file holder in the clinic, thus indicating that the health consumer is waiting. When a chair is available a dental auxiliary will seat the health consumer. Health Consumers reporting more than 15 minutes late for an appointment may have to be rescheduled. To avoid being charged with a broken appointment they may be given the option of waiting until all the other scheduled patients have been seen to complete their treatment planned for that day if it is determined by the treating dental officer that enough time will be available. Should the health consumer decide to reschedule their appointment after coming in late they will be charged with a broken appointment. [This section should be based on a facility poilcy]

Scheduling Priorities CHILDREN AND YOUNG ADULTS Health Consumers 20 years old and younger will be given the highest priority of treatment. Health Consumers 20 years old and younger will have to make their appointments in person or have their parents make their appointments.

ADULTS Health Consumers 21 years old and older will receive up to Level III dental services (see Dental Service Priorities) to the extent those under 21 years will not be excluded for care within a three week time from initial requesting of dental care.

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TAKING MEDICAL HISTORIES - Section 7 SUBJECT:

TAKING MEDICAL HISTORIES

PURPOSE:

To insure that medical considerations of all patients seen by this department are taken into account

STAFF AUTHORIZED TO PERFORM THIS PROCEDURE: All members of the dental staff that have been trained to obtain medical histories including, receptionists, dental assistants, dental hygienists, and dental officers. EFFECTIVE DATE: _______ DATE REVIEWED/REVISED: _______ APPROVED BY:

/

______

/

Chief Facility Dental Officer Clinical Director Outpatient Nursing Supervisor

DISTRIBUTION:

Dental Policy and Procedures Medical Staff Policy and Procedures Out Patient Policy and Produce

All patients presenting to the Facility Dental Clinic will be given a medical history to complete. New patients or those patients that have not been seen in the past 12 months will be required to complete and sign and date this form (IHS 42-1 page 2). The health history taken incorporates the Facility Policies and IHS Dental Policies for documentation of individual patient's health status. As the patient enters the clinic, the receptionists give them a blank form and instructions for filling the form. If the individual completing the form is unable to complete the form because of the nature of the question, they are instructed to leave it blank to be filled in on interview with the dental provider. When the patient is seated in the dental operatory, the dental assistant and later the dentist will interview the individual or their guardian as to the questions on the form. If there is a discrepancy in the replies to the questions, further investigation is initiated. The medical chart is obtained. If the provider is still unable to answer the question to their satisfaction, a medical provider sends the individual to the Out patient department with a completed PCC document requests examination. The examination by the medical provider is followed by a routing of the PCC or verbal consult with the dental provider as to the answer to the initial question. Dental Procedures will not be initiated until there are no questions remaining in the health history. If problems are found, correction of the problem is determined and initiated. These problems are noted on the bottom of the IHS 42-1 page 1 and a medical caution sticker is placed on the front of the individual's dental chart. Notation will also be made to enter in the RPMS to be obtained when requesting a health summary.

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Patients for subsequent visits to the dental clinic, within one year of the initial completion of the medical history, are asked if there is any change in their health statues. The dental provider initials the form in the proper location. Sedation patient's medical histories are examined prior to the suggestion or scheduling the individual for dental procedures. If there is any question, the patient is sent to the out patient clinic for examination and clearance. For these individuals, a pre-sedation appraisal of their health is determined. This is documented in the patient sedation record. During all sedation procedures, the individual is monitored with a post sedation evaluation being preformed by the dental provider. Training for the evaluation procedures is documented in the dental policy and procedure manual.

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SCHEDULE OF SERVICES - Section 8 ORAL HEALTH PRIORITIES / ORAL HEALTH BENEFITS In order to provide dental services of the highest quality to the most people with the resources available to the Facility Dental Program, priorities must be established. The purpose of these priorities is to maximize the benefits of dental care to as many eligible Indian health consumers as possible. The Facility Dental Program has adopted the IHS Schedule of Oral Health Services as policy for dental service priorities. The following is a summary of available dental services in order of highest priority to lowest priority for the Facility, with examples of common services in each Level. A detailed listing of all dental services by Level of Care is found in the Schedule of Oral Health Services, which is located in the Oral Health Program Guide.

DENTAL SERVICE PRIORITIES Emergency dental care to all Indian people with pain or infection. Extractions as necessary Temporary fillings as necessary Pulpotomy or pulpectomy as necessary Antibiotics and analgesics as necessary

Preventive dental services Teeth cleaning and oral hygiene instruction Topical fluoride application Topical application of sealants

Basic diagnostic and restorative services listed with highest priority first Examination and necessary radiographs Routine restorations (amalgams, composites, pre-formed crowns for primary teeth) Space maintainers for primary and mixed dentition patients and Interceptive Orthodontics. Limited periodontal treatment (scaling and root planning) Endodontics for anterior teeth Limited Rehabilitative dental services Large, complex Cast crowns for endodontically treated teeth, primarily those treated by the IHS/Tribal dental program. Indication for castings to be determined by the treating dental officer Endodontics (root canals) on bicuspid teeth Rehabilitative dental services Removable full or partial dentures Periodontal surgery

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Endodontics (root canals) on bicuspid and first molar teeth Fixed bridgework Complex rehabilitative dental services Periodontal surgery with osseous or soft tissue grafts Comprehensive orthodontics Maxilo-facial prosthetics Services in the higher Levels of Care, (IV, V, and VI), will be provided on an extremely limited basis due to limitations of staff and resources. Each dental officer may elect to provide a limited number of rehabilitative dental services based on his or her experience and training. These rehabilitative services are justified to maintain professional competency in clinical dentistry.

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EMERGENCY DENTAL CARE - Section 9 A dental emergency should include one of the following:

• • • • • •

Severe pain that started within the past 2-3 days. Severe pain that keeps the health consumer awake at night. Swelling in the face due to an abscessed tooth. Fever due to an abscessed tooth. Excessive bleeding from a recent extraction site. Teeth that have recently been knocked out or broken in an accident. • A facial injury with possible maxillary or mandibular fracture. When emergency health consumers present for treatment, they will sign the dental register at the reception window. Emergency care referrals will be made to the dental clinic by the Ambulatory Care clinics. These referrals will be presented by the use of a PCC referral form during regular working hours. After regularly scheduled hours, verbal instructions will be taken by the dentist on call in order to assess patient needs. This dental provider will speak directly to the medical provider to ascertain the nature of the complaint. Appropriate transfer of the patient to dental referral services or delivery of dental care service will be determined by the dentist on call. During regular dental hours, the dental receptionist will assemble the necessary dental forms and inform the assistant that an emergency health consumer is waiting by placing the patient's chart in the clinic file holder. The assistant will obtain a panoramic x-ray if one is not present in the chart. If one is in the chart a periapical radiograph will be taken of the area of the chief complaint. X-rays will not be taken during the first trimester for any pregnant health consumers unless directed by the dental officer seeing the health consumer. The assistant will inform the dental officer that an emergency health consumer is ready and waiting. Emergency health consumers will be treated on a time available basis. The dental officers have clinical schedules appointed 3 to 4 weeks in advance of treatment. Emergency health consumers will receive treatment the day they report to the clinic with their chief complaint, schedule permitting. The health consumer will be given medication for relief of pain and/or infection and rescheduled or referred if treatment cannot be rendered that day. The dental officer assigned to Officer of the Day will be responsible for treatment of emergency health consumers. Emergency health consumers will be seen in the Dental Clinic between 8:00 AM and 4:00 PM Monday, Tuesday, Thursday and Friday as they present themselves after signing in patient registration. Wednesday hours will be from 10:00 PM to 4:00 PM.

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HEALTH CONSUMER HANDOUT - Section 10 EMERGENCY HEALTH CONSUMERS (WALK IN PATIENTS) Health Consumer's who are having uncontrollable pain from their teeth or their gums need to sign in at the dental clinic. Emergency health consumers are urged to report to the dental clinic Monday through Friday at 8:00 a.m. or 1:00 p.m. The clinic will be closed on Wednesday mornings for maintenance from 8:00 a.m. – 10:00 a.m. Emergency health consumers do not have appointments and will not be given appointments for emergency treatment. Sign-ins for emergency treatment will not be accepted after 4:00 PM. Each days schedule for the dental clinic has been arranged so as to provide the maximum amount of dental work to the most health consumers, and emergency health consumers will be worked into this schedule. BE PATIENT, YOU MAY HAVE TO WAIT. We will do everything possible to see you as soon as we can. Those individuals will then be worked into the schedule for that morning or afternoon to relieve the pain. THE EARLIER YOU REPORT TO THE CLINIC AND SIGN IN, THE BETTER YOUR CHANCES ARE FOR BEING SEEN QUICKLY. The emergency services usually consist of extractions or temporary fillings. If we cannot treat you here for medical, dental or time reasons, you will be referred to the appropriate source. Health Consumer's having uncontrollable pain on the weekend, report to an emergency room where pain-relieving treatment will be given. You must notify the Contract Health Service (CHS) Office immediately, but no later than 72 hours of an emergency service. CHS Office Phone #: _______________ Facility Dental Department Phone #: ________

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FAILED AND CANCELED APPOINTMENTS - Section 11 SUBJECT:

FAILED AND CANCELED APPOINTMENTS PROCEDURES

PURPOSE:

The purpose of this policy is to create an understanding of the workings of the Facility Dental Clinic so that the clinic and the population it serves can work together in providing a constant quality of care.

STAFF AUTHORIZED TO PERFORM THIS PROCEDURE: All members of the dental staff that have been trained to obtain medical histories including, receptionists, dental assistants, dental hygienists, and dental officers. EFFECTIVE DATE:

___________

DATE REVIEWED/REVISED: ___________ /

/

APPROVED BY:

Chief Facility Dental Officer, Clinical Director, and Facility Director

DISTRIBUTION:

Dental Policy and Procedures, Medical Staff Policy and Procedures, Out Patient Policy

BACKGROUND The dental clinic is a complex and dynamic care delivery system. It runs by scheduling appointments with the assumption that those appointments will be kept. Appointments are made with the direction of a dentist estimating the need of the health consumer and the amount of time that will be needed at the next appointment. If a health consumer does not keep their appointment, the dentists and their assistants have no health consumers to deliver care to and the community suffers because some member of the community could have been seen in that spot. This policy enables the community to get the best use of dental services. This policy will allow a greater number of tribal members to be seen in a shorter amount of waiting time. This policy it designed so that: Emergency services will always be available to health consumers on a walk-in clinic basis. Patients will not be abandoned if care is deferred for a period of time

A.

DEFINITIONS:

WALK-IN CLINIC: This clinic will care for acute emergencies on a daily basis Monday through Friday from 8 AM to 4:00 PM (the clinic will be closed each Wednesday morning from 8 AM to 10:0 AM for clinic maintenance and hospital meetings). This clinic will also handle some treatment of routine patients. ROUTINE HEALTH CONSUMER: This is a health consumer that has received a scheduled appointment. CANCELED APPOINTMENT: This is when a health consumer is unable to come for a scheduled appointment and phones one day in advance to reschedule their appointment.

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BROKEN APPOINTMENT: This is: (1) an appointment that is missed completely, (2) when the health consumer is more than 15 minutes late by the clinic clock and has not called one full day ahead of the appointment to reschedule. WAITING LIST: (When necessary based on demand) This is a list of adults older than 18 years of age who want to receive care. Due to the inability of the clinic to meet the demand for health consumer care in the past, the list will serve as a health consumer pool and will be called as soon as possible considering clinic demand. Adults are notified by letter and/or phone for the availability of routine care and given a 15-day period to respond and schedule their initial appointment.

B.

POLICY FOR CHILDREN (18 YEARS OF AGE AND YOUNGER

A child who does not come on time to the clinic for their first scheduled appointment will be considered a BROKEN appointment and will not be rescheduled for routine care for six months from the BROKEN appointment. A child in routine care who has two BROKEN appointments is the past six months will not be rescheduled for routine dental care for a period of six months from the BROKEN appointment. CANCELED appointments will have no effect on a child's' ability to receive routine dental care.

C.

POLICY FOR ADULTS (19 YEARS OF AGE AND OLDER)

An adult who does not come on time to the clinic for their first scheduled appointment will be considered a BROKEN appointment and must sign up on the Waiting List to wait until called again from the list. An adult in routine care who has two BROKEN appointments in the past six months will not be rescheduled for routine dental care and must sign up on the Waiting List to be rescheduled at a later date. CANCELED appointments will have no effect on an adult’s ability to receive routine dental care. When a health consumer is charged with a failed appointment they will be given a new appointment and informed of the policy on failed appointments, which they signed. They will also be informed that if they fail another appointment they will not be rescheduled for routine care for at least one year. A note will be made in the health consumer's chart stating they failed an appointment. Health Consumers failing two appointments will be sent a letter informing them of their ineligibility to be rescheduled. Exceptions to the above policy will be at the discretion of the treating dental officer and in agreement with the Facility Dental Officer. Health Consumers who fail two appointments will still be eligible for emergency care. A canceled appointment is one in which the dental clinic has been notified 24 hours in advance that the health consumer will not be able to keep that appointment. Health Consumers reporting their inability to keep their appointment will be rescheduled at a more convenient time. Habitual canceling of scheduled appointments will result in emergency care only for a period of one year.

HEALTH CONSUMER LETTER FOR BROKEN APPOINTMENTS To increase services to all health consumers the following policy is in effect. You can be rescheduled only twice. If you are credited with three failed appointments you WILL NOT be

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scheduled for another appointment for at least six months. You will be charged with a failed appointment when: You do not come to the dental clinic for your appointment. When you sign in at the dental clinic 15 minutes or more after your appointment time. When you do not cancel your appointment at least 1 day ( 24 hours ) before your appointment time. I understand the above policy. Signature Date

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COMPLETED TREATMENT - Section 12 At the time a health consumer receives an initial examination a treatment plan is written by the examining dental officer. This treatment plan will list the procedures that will be done for that health consumer. These procedures will be based upon established priorities, the dental officer's skills and available time and resources. When the treatment plan is completed a health consumer will receive emergency care until they require regular care. A dental officer or hygienist may recall a health consumer as frequently as he/she feels it is necessary to prevent serious dental problems.

REFERRAL PROCEDURE - Section 13 INTRA-FACILITY REFERRALS A. Emergency Patients Referred to Dental Regular Working Hours: Emergency health consumers are referred to the dental clinic during regular work hours from any medical care department or school-nursing department using a PCC or facility referral. This referral can come from Out-Patient, Community Health Nursing, WIC, or MCH. After Hours: Health consumers who are experiencing sever pain may go to an emergency room or dental treatment facility, but must notify the Facility’s CHS office immediately or at least within 72 hours from time of treatment. Only emergency treatment services should be provided by an emergency room or dental treatment facility.

B.

Routine Patients Referred to Dental

These health consumers can be self referred or referred in the same manner as above in A.1. The health consumer presents themselves to the dental receptionists with an "in-house" referral form or verbally requests that an exam appointment be made.

C.

All Health Consumers Referred from Dental

All health consumer referrals made from the dental clinic to any department in the hospital is made using a PCC form. All demographic coding, dental subjective and objective findings must be completed.

INTER-FACILITY REFERRALS A.

Emergency Patients Referred to Dental

These health consumers can receive care as above in Section A.1. And A.2.. They can also self refer.

B.

Routine Patients Referred to Dental

These health consumers can receive an appointment for routine care via self-referral, telephone request, written request or as described in B.1. Above.

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C.

All Patients Referred from Dental

The dental records of that health consumer will accompany all health consumer referrals made from the dental clinic to another facility. The health consumer prior to the release of the dental records must complete a release of information form.

D.

Referrals to IHS facilities outside the facilities:

[This needs to be addressed by Facility Management and CHS Office]

OUTSIDE FACILITY REFERRALS A.

Emergency Patients Referred to Dental

These health consumers will receive dental services by presenting themselves at health consumer registration requesting a dental visit. After hours request will be made through the Emergency Room.

B.

Routine or Special Request Patients to Dental

These health consumers will present themselves to patient registration requesting a dental visit. Written instructions must accompany the health consumer or be delivered to the clinic prior to the request for a dental visit. If follow-up visits to the dental clinic are necessary, arrangements will be made to finish the required work.

C.

All Patients Referred from Dental

These health consumers must have a referral initiated, for work covered under the Facility’s Contract Health Guidelines, that includes the reason for referral, estimated cost, priority and third party eligibility entered on the form. The health consumer takes the form to Contract Health so that a contract can be written. Endodontics, Oral Surgery and Pedodontic contracts exists must have a referral for specialty work. The Chief Facility Dental Officer must first authorize emergency visits to private dentist so that Service Unit Contract Health Guidelines are met. To private sector dental practitioners: The dental officer completes an HSA-199 listing the procedure (s) needed and PMH. This is then given to the dental receptionist. Referrals will be made to contract providers and they shall be provided with the health consumer's HRSA 57 form. The receptionist calls the private dental office and schedules an appointment. The receptionist completes the HSA-199 and forwards the original to the CHS clerk, placing one copy in the health consumer's record. The CHS clerk will complete the HRSA 57 form and mails it and one copy of the referral form (HSA-199) to the provider.

USE OF CONTRACT FUNDS The Facility CHS Office will be responsible for the allocation of Dental CHS funds. When obligating these funds the following policies will be used: The health consumer must be registered for care at the facility to be eligible for contract funds. Contract money may be used to pay for laboratory services.

26

Contract money will be used based on the Facility’s priorities for contract dental services. Contract money will not be used to provide orthodontic treatment. Contract funds will not be used to provide surgical TMJ "treatments" or care.

27

REFERRAL LETTER

Dear Doctor:

__________________________ Health Center health consumers are being referred to your office for dental treatment. I would like to call your attention to the attached Schedule of Services and the section entitled: Definitions, Limitations and Exclusions. Because we have a Provider Agreement, Level I through III services may be performed and claims submitted without prior approval. Any higherlevel services must be pre-approved prior to completion, unless specifically authorized by my written referral. At no time may the health consumer be billed for CO-payment under these provisions for care. Additional services will be approved or disapproved based on the availability of funds.

Sincerely,

_________, D.D.S. Chief Facility Dental Officer

________________ Health Center Director

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SCHEDULE OF SERVICES, EXCLUSIONS, AND LIMITATIONS Section 14 1.

Schedule of Services (Combined Levels I through III)

0110

Initial oral exam

0210

Intraoral X-rays, complete series

0220

Periapical x-ray, 1st one

0230

Periapical x-ray, each additional one

0240

Intraoral occlusal x-ray

0270

1 bitewing x-ray

0272

2 bite wing X-rays

0273

3 bite wing X-rays

0274

4 bite wing X-rays

0330

Panoramic x-ray

1110

Adult prophylaxis, age 15 and over

1120

Child prophylaxis, age 14 and under

1204

Child prophylaxis with topical fluoride application

1231

Adult prophylaxis with topical fluoride application

1351

Sealant application per permanent molar tooth

1510

Fixed unilateral space maintainer

1515

Fixed bilateral space maintainer

2110

Amalgam one surface deciduous tooth

2120

Amalgam two surface deciduous tooth

2130

Amalgam three surface deciduous tooth

2140

Amalgam one surface permanent tooth

2150

Amalgam two surface permanent tooth

2160

Amalgam three surface permanent tooth

2161

Amalgam four surface permanent tooth

2330

Composite restoration one surface

2335

Composite restoration incisal angle

2932

Plastic prefabricated crown - deciduous cuspids only

2830

Stainless steel crown - deciduous molars only

2954

Steel post and core

2940

Sedative filling for a vital tooth

29

2950

Crown build-up pin retained ( only for endodontically treated teeth prior to crown fabrication )

3220

Vital Pulpotomy - deciduous cuspids and molars only

3310

Anterior root canal therapy only - submit final x-ray

3320

Bicuspid root canal - submit final x-ray

3330

Molar root canal - submit final x-ray ** requires prior authorization of Facility Dental Officer

4340

Periodontal scaling and root planning entire mouth

4341

Periodontal scaling fewer than 12 teeth

2790

Full cast gold crown - (only for endodontically treated bicuspids and molars) ** requires prior authorization of Chief Dental Officer

7110

Single tooth extraction

7120

Each additional tooth extracted

7210

Surgical extraction of erupted tooth with muco-periosteal flap

7285

Biopsy of oral tissue (hard)

7286

Biopsy of oral tissue (soft)

7510

I & D Intraoral

9110

Palliative (emergency) treatment of dental pain, minor procedure

DEFINITIONS, LIMITATIONS AND EXCLUSIONS 0110 EXAMINATION As part of the dental examination, the dentist will explain to the health consumer all his or her treatment needs. The dentist or his/her representative will inform the health consumer of those treatments the IHS/Tribal program may cover and those it will not, and any treatment alternatives the health consumer may have for treatment. 0210 INTRAORAL X-RAYS, COMPLETE SERIES A radiographic survey of the teeth and supporting structures are necessary for accurate diagnosis. A complete series consists of 14-20 periapical films including bitewings. 1110 ADULT PROPHYLAXIS (AGE 15 AND OVER) The Indian Health Service defines dental prophylaxis as: A therapeutic procedure that prevents and/or cures simple gingival disease. The prophylaxis must consist of two distinct phases:

A. Educational Phase Stain the teeth completely and explain to the health consumer the relationship of plaque to dental disease. Demonstrate the removal of interproximal plaque with floss. Have the health

30

consumer demonstrate the ability to remove stained material with toothbrush and floss. During return visits, reinforce the methods of personal oral hygiene.

B. Therapeutic Phase Remove coronal calculus with cavitron and or hand instruments. Remove interproximal plaque with floss. Polish the coronal surfaces of the teeth with rubber cup and fluoridated prophylaxis paste. 1120 CHILD PROPHYLAXIS (14 YEARS OLD AND YOUNGER) Same definition as a 1110. Note: a toothbrush may be used to polish the coronal surfaces of the teeth of young children. Local anesthesia, the placement of rubber dam, tooth preparation, the placement of necessary cavity liners, bases or pulp caps direct/indirect, the placement of retentive pins or acid etch, the adaptation of the matrix, the placement of the restorative material, the carving or shaping of the restoration and polishing the completed restoration are included in the code for the restoration.

NOTE: A buccal pit or lingual pit or grove restoration placed in a posterior tooth in addition to a MO, DO, or MOD is not coded as a separate restoration. If desired the additional pit or groove can be reported as an additional surface. 2330

Composite resin - one surface This code describes a class III restoration placed in an anterior tooth, a class V restoration placed at the gingival portion of a tooth. Note: A class III restoration where only the mesial or distal surface is cariously involved is considered a one surface restoration. Lingual access to a mesial or distal carious lesion does not constitute a two surface restoration.

2335

Composite resin involving the incisal angle This code describes a class IV restoration placed in an anterior tooth that replaces the incisal angle. The restoration may or may not include the use of pin retention.

2930

Stainless steel crown This code is used to describe the stainless steel crowns placed on deciduous teeth only. Stainless steel crowns will not be placed on permanent teeth.

2954

Steel post with composite or amalgam in addition to crown This code describes the placement of a steel post with composite or amalgam build-up prior to placement of a temporary crown in the anterior or a full gold cast crown in the posterior.

2950

Crown build-up pin retained This code describes a pin retained crown build-up. This code should be used to report crown build-up prior to preparation and placement of a cast restoration. Note: Procedures 2892 and 2950 will only be authorized when periodontal disease does not compromise the tooth, missing teeth do not compromise the integrity of the arches; several teeth do not require major reconstruction treatments.

3220

Pulpotomy

31

A Pulpotomy is a covered benefit in the treatment of pulpal pathology in deciduous molar and cuspids only. 33103330

Endodontics - General Instructions These procedures include diagnosis, treatment planning, local anesthesia, radiographs, cultures, rubber dam placement, intermediate canal preparation, temporary restorations, and follow up care. Root canal therapy is a covered benefit in treatment of pulpal pathology in permanent anterior, bicuspid and first molar teeth only, excluding the final permanent restoration and crown build-up. Each code may be entered only once per tooth and is entered only after permanent filling of the root canal (s). Root canal procedures will be authorized only in cases where: periodontal disease does not compromise the success of the treatment, already missing teeth do not jeopardize the integrity of the arches, and no more that two posterior teeth are endodontically involved. Documentation of the completed Endodontic procedure ( x-ray showing the final root canal filling material in place ) must accompany the HSA-57 document before payment for that service will be issued.

2790

Full cast gold crown Will be authorized only for bicuspid and first molar endodontically treated teeth. In cases where: periodontal disease does not compromise the success of the tooth, already missing teeth do not jeopardize the integrity of the aches, and no more than two posterior teeth are endodontically involved so as to require crowns.

EXCLUSIONS The attending dentist shares the responsibility with the Chief Dental Officer in determining if the health consumer is eligible for any other third party payment prior to submitting the claim forms. The IHS/Tribal program will reimburse for deductibles or CO-payments for those services covered under this program package. Services with respect to congenital or developmental malformations, cosmetic surgery or dentistry for purely cosmetic reasons including but not limited to: cleft palate, maxillary and mandibular malformations, enamel hypoplasia, fluorosis and anodontia. All hospital costs and any additional fees charged by the dentist for hospital treatment. A Pulpotomy is not a covered benefit for permanent teeth; i.e., it is not considered acceptable treatment for a permanent tooth. The IHS/Tribal program will not pay for broken or canceled appointments. The IHS program will not pay for the use of Nitrous Oxide and root canal pastes of similar composition. These materials do not have the acceptance of the ADA nor does the FDA approve them for use. Therefore their use is not currently indicated in the treatment of IHS health consumers. The IHS/Tribal program will not pay for the restoration of primary incisors. Treatment for symptomatic, carious, primary incisors shall be extraction.

32

CLASSIFICATION OF PRIVILEGES - Section 15 Will follow Medical/Dental Staff By Laws and the IHS Program Guide. Copies are on file in the Chief of the Dental Department and in Facility Administration. Dental Privileges Request Forms and Application for Appointment to the Medical Staff (IHS Program Guide, Appendix C.5 & B.1) is completed by each dental officer, and a copy kept in Personnel, by Chief, Facility Dental Officer. All visiting and temporary staff will follow the guidelines outlined in the Medical Dental Staff By Laws. Credentials will be checked prior to any providers’ delivery of services. All non-licensed staff will be assigned to a mentor for direction and oversight.

33

DENTURE PROGRAM - Section 16 This program is designed to construct dentures for the beneficiaries of the Tribal program. The guidelines are laid out in the following letter that must be signed with the original going into the chart and a copy to the health consumer.

34

DENTURE PROGRAM LETTER TO PATIENTS [Facility] Dental Clinic

Dear Denture Patient This letter will explain several things about the program that has been set up to make your dentures. First, there is a limited budget that we must use in this program. Enough money has been obtained to make [#] sets of dentures so this is the total that we can make each year. Some of your waiting time comes from this limitation of money that the clinic has to spend for dentures. Second, the program is designed for those who have never had a denture or have had the same denture for more that ten years. These health consumers will be considered first and all others will be considered next. Third, the time that it takes to make a denture will be approximately five appointments over a 9week period. Most of this time is due to mailing each step of the denture to a laboratory in [Lab location]. Fourth, many people in this community want dentures. If your want them made here, we will expect you to make each appointment without breaking two (2) appointments. If you do break 2 appointments, you will be dropped from the list and must get back on the list (at the bottom) if you want dentures made in this clinic. These steps seem pretty "hard nosed" but we feel that if you know the rules, you can help others and us in the community who need "new teeth". To continue with the program, we ask you to sign this letter in the space below after reading so that we know that you understand the policies. This letter will be filed in your dental chart for documentation.

_____________________ PATIENT

DATE

35

DENTURE PROGRAM MATERIALS AND EQUIPMENT #1 1’ IMPRESSIONS ALGINATE TRAYS MAX/ MAND. ALGINATE RED BOXING WAX SPATULA AND MIXING BOWL

AFTER TAKING IMPRESSIONS, POUR UP CASTS. ONE LAYER OF WAX OVER RIDGES AND FABRICATE CUSTOM TRAY APPROX. 2 mm FROM DEPTH OF VESTIBULE #2 2' IMPRESSIONS CUSTOM TRAYS IMPREGUM AND ADHESIVE BOWL OF ICE WATER WATER BATH WITH WATER MIXING PAD AND SPATULA ELASTICON (SYRINGE OR REG.) WHITE IOWA WAX (POST DAM) TORCH OR BUNSEN BURNER MATCHES **SEND TO LAB FOR TRIAL BASES AND WAX RIMS APPLY IMPREGUM ADHESIVE TO CUSTOM TRAY FLANGES, BORDER MOULD WITH IMPREGUM THAT HAS BEEN PLACED IN ICE WATER UNTIL IT IS NOT STICKY. DO BUCCAL OR LINGUAL ALL AT ONCE. GRIND OUT WAX SPACER AND EXTRA IMPREGUM. REDUCE BORDER MOULD 2 MM. FINAL WITH ELASTICON SYRINGE OR REGULAR WITHOUT ADHESIVE. IF BAD RESULT, RIP OUT ELASTICON AND RETAKE FINAL. IOWA WAX IS TO PUT POST DAM IN IMPRESSION. #3 VERTICAL TRIAL BASES WITH WAX RIMS TORCH OR BUNSEN BURNER WAX SPATULA LAB KNIVES - BUFFALO SMALL LAB KNIVES - RED HANDLED HEAT PLATE WITH HANDLE MATCHES FRANKLIN PLANE AEOLUS ACRYLIC BUR STRAIGHT HANDPIECE NOSE 36

MOULD AND SHADE GUIDES (TEETH) **SEND TO LAB TO SET TEETH AND WAX TRY-IN INCLUDE TEETH NEEDED CHECK LENGTH OF MAX. WAX RIM COMPARED TO RELAXED LIP. RIM SHOULD FILL LIP TO NATURAL CONTOURS AND EXTEND IN AN ARCH AT THE COMMESURES. CHECK CURVE OF WILSON WITH FRANKLIN PLANE. ESTABLISH VERTICAL LEAVING 2-3 MM BETWEEN WAX RIMS. SHAPE OF RIMS SHOULD MATCH IN A HARMONIOUS APPEARANCE. IT SHOULD LOOK NATURAL. MARK MIDLINE ON MAX. RIM. PICK TEETH AND SHADE. #4 WAX TRY-IN HANAU TORCH MATCHES PATIENT MIRROR ACRYLIC BUR STRAIGHT HANDPIECE NOSE WAX SPATULA DENTURE ADHESIVE **SEND TO LAB FOR FINAL WAX AND Processing LOOK FOR NATURAL APPEARANCE, LIP FULLNESS, AND STABLE BITE. USE ADHESIVE IF NEEDED, RESET TEETH AS NECESSARY. LET HEALTH CONSUMER ASSESS LOOK AND COLOR #5 DELIVERY ACRYLIC BUR STRAIGHT HANDPIECE NOSE CHECK BITE AND DENTURE EXTENSION, ADJUST AS NECESSARY. TELL HEALTH CONSUMER TO RETURN IN 48 HRS OR AS NEEDED FOR ADJUSTMENT

37

INFORMED CONSENT - Section 17 SUBJECT:

INFORMED CONSENT

PURPOSE:

This policy is designed to inform the health consumer of all information concerning his/her dental problems and the consequences of any and all treatment that may be proposed prior to any treatment rendered. Routine dental treatment is implied when the health consumer requests an examination. This implied consent will be applied to all non-invasive or non-constrained treatment (for children requiring behavior modification or sedation).

STAFF AUTHORIZED TO PERFORM THIS POLICY: All members of the dental staff that have been trained to obtain medical histories including, receptionists, dental assistants, dental hygienists, and dental officers. EFFECTIVE DATE:

______________

DATE REVIEWED/REVISED: _________

/ __

/

APPROVED BY:

Chief Dental Officer, Clinical Director, Medical Records, and HSA

DISTRIBUTION:

Dental Policy and Procedures, Medical Staff Policy and Procedures, Out Patient Policy and Produce, Emergency Room Policy and Procedures, Medical Records

Informed consent will be used in the cases of tooth extraction or invasive surgical intervention. Any procedure requiring the need for informed consent will use the standard HHS form (adopted by IHS forms committee but not yet receiving a number designation). This form will be explained to the health consumer by the provider or dental assistant and signed by health consumer or guardian, provider and a witness. Informed consent will also be use for pediatric health consumers when behavioral or sedation techniques are employed. The following form will be used to explain procedures to the health consumer's attending guardian and the guardian's signature will be placed on IHS form 831 (Sedation Record).

INSERT Health Consumer consent form INSERT IHS Form 831 INSERT IHS Form 42-1 page 1 and 2

38

PEDIATRIC DENTISTRY INFORMED CONSENT - Section 18 HEALTH CONSUMER MANAGEMENT TECHNIQUES And ACKNOWLEDGMENT of RECEIPT of INFORMATION Informed consent indicates your awareness of enough information to allow you to make an informed personal choice concerning your child's dental treatment after considering the risks, benefits and options. Please read this form carefully and ask about anything you do not understand. We will be pleased to explain it. It is our intent that all professional care delivered in our dental clinic shall be of the best possible quality we can provide for each child. Providing a high quality of care can sometimes be made very difficult, or even impossible, because of the lack of cooperation of some child health consumers. Among the behaviors that can interfere with the proper provision of quality dental care are: hyperactivity, resistive movements, refusing to open the mouth or keep it open long enough to perform the necessary dental treatment, and even aggressive or physical resistance to treatment such as kicking, screaming and grabbing the dentist's hands or the sharp dental instruments. All efforts will be made to obtain the cooperation of child dental health consumers by the use of warmth, friendliness, persuasion, humor, charm, gentleness, kindness and understanding. There are several behavioral management techniques that are used by dentists to gain the cooperation of child health consumers to eliminate disruptive behavior or prevent health consumers from causing injury to themselves due to uncontrollable movements. The more frequently used pediatric dentistry behavior management techniques are as follows:

Tell-Show-Do The dentist or assistant explains to the child what is to be done using simple words and repetition and then shows the child what is to be done by demonstrating with instruments on a model on the child's or dentist's finger. Then the procedure is performed in the child's mouth as described. Praise is used to reinforce cooperative behavior.

Positive Reinforcement This technique rewards the child who displays any behavior, which is desirable. Rewards include compliments, praise, a pat on the back, a hug or a prize.

Voice Control Changing the tone or increasing the volume of the dentist’s voice gains the attention of a disruptive child. Content of the conversation is less important than the abrupt or sudden nature of the command.

Mouth Prop A rubber or plastic device is placed in the child's mouth to prevent closing when a child refuses or has difficulty maintaining an open mouth.

Physical Restraint by the Dentist The dentist restrains the child from movement by holding down the child's hands or upper body, stabilizing the child's head between the dentist's arm and body, or positioning the child firmly in the dental chair.

39

Physical Restraint by the Assistant The assistant restrains the child from movement by holding the child's hands, stabilizing the head, and/or controlling leg movements.

Papoose Board and Pedi-Wraps These are restraining devices for limiting the disruptive child's movements to prevent injury and to enable the dentist to provide the necessary treatment. The child is wrapped in these devices and placed in a reclined dental chair.

Sedation Sometimes drugs are used to relax a child who does not respond to other behavior management techniques or who is unable to comprehend or cooperate for dental procedures. These drugs may be administered orally or by gas (nitrous oxide and oxygen). The child does not become unconscious. Your child will not be sedated without your being further informed and obtaining your specific consent for such procedure.

Informed Consent is located on Form 831IHS

40

CONSCIOUS SEDATION - Section 19 Guidelines for Pharmaco-sedation SUBJECT:

Guidelines for Pharmaco-sedation

PURPOSE:

The goals for the management of Pharmaco-sedation in the ambulatory patient are: Patient welfare, Control of patient behavior, Production of positive psychological response to treatment and return to pretreatment level of consciousness by time of discharge

STAFF AUTHORIZED TO PERFORM THIS PROCEDURE: All members of the dental staff that have been trained to obtain medical histories including, receptionists, dental assistants, dental hygienists, and dental officers are qualified to perform this procedure. EFFECTIVE DATE: ___________________ DATE REVIEWED/REVISED: _________________/________/ APPROVED BY:

Chief Dental Officer, Clinical Director

DISTRIBUTION:

Dental Policy and Procedures, Medical Staff Policy and Procedures

Introduction Pharmaco-sedation 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 Pharmaco-sedation in the ambulatory patient are: • Patient welfare • Control of patient behavior • Production of positive psychological response to treatment • Return to pretreatment level of consciousness by time of discharge

Definition of Terms 41

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

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

•

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

•

Conscious Sedation: A controlled, pharmacologically-induced, minimally depressed level of consciousness that retains the patient's ability to maintain a patent airway independently and continuously, and respond appropriately to physical stimulus 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: The elimination of all sensation, accompanied by a loss of consciousness, by the use of inhalation or parental agents.

General Considerations •

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

•

Privileging: Each dental program should use a Dental Privileges Request Form. Dentists requesting privileges for Pharmacological 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 that can result in enhanced sedative effects and/or untoward events; therefore, particular attention should be paid to doses used in children. To avoid 42

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 examination 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 (American Society of Anesthesiologists) Class I or II may be considered candidates for conscious sedation or deep sedation. Patients in ASA Class III or IV present special problems and require individual consideration and should be treated in a hospital setting. General anesthesia requires consultation with an anesthesiologist, 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. A responsible adult should accompany adult patients.

43

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 times during the past year or continuing education every two years at minimum. An individual trained and competent in the monitoring of sedated patients should appropriately monitor any patient given a sedating agent in the clinic. Administration of agents with patients returning to the waiting room for onset of sedation is not acceptable. 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 Generic Name

Brand Name

Lidocaine Mepivacaine Mepivacaine Prilocaine Bupivacaine

Xylocaine Carbocaine Carbocaine Citanest Marcaine

Max. Rec. Conc. (%) 2 2 3 4 0.5

Dose (Mg/Kg) 4.4 6.6 6.6 7.9 2.0

Mg per Carpule 36 36 54 72 9

44

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, positive pressure ventilator, adequate suction apparatus with tonsillar suction tip, oral and nasal airways, and IV kits. The equipment and supplies should be appropriate for both pediatric and adult patients. If narcotic drugs are administered, 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 flow meter capable of delivering 100% O2 must be used, and only flow meters that require 20% minimum O2 flow rate are acceptable. Normal operation should be restricted to 50% or less N2O.

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

45

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 pre-procedurally 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.

46

General Requirements for the Monitoring and Documentation for Oral and Parental 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)

47

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 pre-sedation level of responsiveness or the level as close as possible for that person has been achieved. 9.

Responsible individual is available.

48

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 staffs 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 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. Staffing -No additional staff is required for Nitrous Oxide-Oxygen sedation Armamentarium -Other than a properly functioning Nitrous Oxide-Oxygen delivery system and scavenging system, no additional armamentarium is required. Pre-op evaluation -A review of the dental medical history form is required. -Evaluation of airway patency and respiratory system 49

-Potential contraindications include the following: • Upper respiratory infection, respiratory diseases, or asthma • Lobar emphysema • Possible bowel obstruction • Patients with severe emotional disturbances Monitoring -Only visual and verbal monitoring of the patient is required. Pulse oximetry is recommended, but not required. Documentation -Documentation must include the concentration of Nitrous Oxide used, duration, effectiveness, and duration of oxygen flush

50

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 dental assistants present for proper monitoring and support, one to assist in the dental procedure and one to monitor the patient. At least one assistant 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 51

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 trained individual from the time the sedating agent is administered until discharge from the facility must constantly observe a sedated patient. Documentation -Oxygen saturation and heart and respiratory rates should be recorded intermittently on a time-based record throughout the procedure and until the patient is discharged. -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.

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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. A qualified person on appropriate patients without medical consultation may administer General Anesthesia in an adequate facility, with provision for recovery, if local Policies and Procedures so permit.

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REPORTING CHILD AND ELDERLY ABUSE - Section 20 POLICY: This policy is to insure that appropriate medical care and emotional support be given to those experiencing abuse and mistreatment from others and to report this suspicion to the proper authorities. This policy is designed to comply with [STATE of] Criminal Code. [identify State’s regulation that] protect those from civil and criminal liability if the report is made in good faith. PROCEDURE: Provide appropriate medical care for an injury or illness that may be present. Obtain a history from patient, parents or appropriate source. Obtain essential laboratory test or radiological exam deemed necessary by the provider. Contact the proper authorities • Social Services [Phone #] • County Dept. of Social Services [Phone #] CASES WHERE SUSPICION SHOULD BE NOTED: • Frequent visits to the Emergency Department with un-explained injuries should be noted. • Evasion, contraindications and conflicting statements about circumstances involved; especially if marked discrepancies between clinical findings and historical data are elicited. • Observation of the appearance of neglect should be noted. • Poor or malnutrition • Multiple fractures or soft tissue injuries from any source including cigarette burns, or belt buckle origin. • Unexplained head injuries. INTRODUCTION: Willful physical abuse by adults is a significant cause of disability or death in young children. Reporting of suspected cases is mandatory. "In an attempt to protect children, the law requires care providers to report their suspicions to the police department or any special children's protective service operating in the community so that cases can be investigated and appropriate measures taken for the safety of the child. State law protects physicians and dentists against liability for reporting. Once suspicion of willful injury has been aroused or confirmed, protective hospitalization is mandatory to prevent possible repetition." The physician or dentist will notify the Tribal Police Department and the Social Services Department of their suspicions. Dentists will request an examination by the medical staff. The physician will admit the child to the hospital if it is deemed necessary for treatment or if, in their judgment, there is danger of the child being further mistreatment upon returning to the home. This also applies to the elderly.

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When a child under 18 years of age is brought to the Facility and appears to have been neglected, battered or sexually assaulted, it is the responsibility of any professional person to report the incident to the County Department of Social Services. The individual calling Social Services will have to give their name, but law when reporting such cases protects the individual. In reporting suspected events, give only factual information from your observation. The County Social Services is responsible for investigating and notifying a local law enforcement agency. The hospital may retain the temporary custody of the child by order of a physician or the Hospital Administrator. Patient information that should be record: Health History, Physical examination, Laboratory tests, radiographs, and photographs of the injury. •

See IHS Circular No. 64.7 (5 Mar 1982).

•

Facility Policy and Procedure Manual

55

PATHOLOGY - Section 21 Purpose: To establish a uniform method of dealing with biopsy and tissue, this policy will meet the following procedural guidelines. All criteria listed in Section C Pathology of the Quality of Dental Care Manual will be met. In the dental clinic the dental officer treating the health consumer will determine what tissue will be sent to the pathologist for microscopic study. Form SF-515 Tissue Examination form will be completed and submitted with the tissue to the Department of Pathology at the Bethesda Naval Dental Unit, Bethesda, MD [or local pathology lab]. When the report is returned from the pathologist, the dental officer will initial the report and one copy will be filed in the patient’s medical/dental chart. Notation will be entered in the tissue specimen log located in the dental clinic.

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ON GOING PROGRAMS - Section 22 Continuing Dental Education Quarterly the Dentist or Dental Assistant Supervisor arranges for in-service training for all dental auxiliary staff. Each staff member is encouraged to attend continuing education courses and maintain a record of such courses. Annually the dental staff will submit a list of all continuing education received. A list of the educational courses taken by the dental officers will be submitted to the Clinical Director of the Facility.

Committee Assignments Staff members may be assigned to represent the dental department on various clinic committees. These committees are outlined in the Facility Policy and Procedure manual. All dental committees and dental members on committees are outlined there.

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ORAL DISEASE PREVENTION / HEALTH PROMOTION - Section 23 Purpose: To outline the current HP/DP Program of the [Facility Name] Dental Clinic. The prevention measures listed in the IHS Dental Quality Assurance Document will be met. All new examinations will have the following prevention plan label placed on the 42-1. Those areas of the prevention plan that will be implemented will place a mark. All children under thirteen years of age shall have a fluoridation status sticker fixed to the lower right hand corner of their medical record. If it has been determined that the child's water supply is fluoride deficient, appropriate measures shall be taken. Children on fluoride deficient water systems or on one that is undetermined will receive a plastic container that will be used to collect a water sample from their main source of drinking water. The parent will be informed to bring the water sample with them on their next clinic visit. The dental clinic will send the samples to Tribal Water and Sewer Department to have the fluoride level assayed using an ion probe. A report will be forwarded to the dental clinic of the fluoride level of the water sample for recording in individual patient charts. Supplemental fluoride will be prescribed for health consumers with deficient levels in their water supply. The dental receptionist will mail out letters to each person having their water analyzed stating the results of the test and informing them of any need for supplemental fluoride.

Supplemental fluoride will be based on the following:

Children

Caries Rate, New Lesions Per Year 3 or more

Caries Rate, New Lesions Per Year less than 3

Water Fl less than or equal to 0.7 ppm

Systemic Fl.

Systemic Fl.

Fl Toothpaste

Fl Toothpaste

Fl Rinse

Topical Fl

Topical Fl Greater than 0.7 ppm

Fl Toothpaste

Fl Toothpaste

Fl Rinse Topical Fl Unknown

Fl Toothpaste

Fl Toothpaste

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Children

Caries Rate, New Lesions Per Year 3 or more Fl Rinse

Caries Rate, New Lesions Per Year less than 3

Topical Fl

Adults Those with smooth surface caries or root caries should receive recommendations to use Fluoride toothpaste, topical fluoride, and daily fluoride rinse. When fluoride tablets are prescribed the following recommendations will be used: mg. of Fl. per day supplement

Age

Fluoride Level Less < 0.3 ppm

0.3 to .07 ppm

> 0.7 ppm

2 wk. - 3 yrs.

0.25

0.25

0

3-5 yrs

0.5

0.25

0

5-12 yrs

1.0

0.5

0

Breast-fed

0.25

0.25

0.25

Prescriptions will be refilled for a period of three months without further dental evaluation unless the health consumer changes addresses and water source. When fluoride rinse is checked the health consumer will be given a recommendation for a daily rinse. It will be necessary for the health consumer to obtain the rinse at his/her own expense. Fluoride rinse will be used only for patients five years or older. Dentulous patients will be advised to use fluoride toothpaste. (Aim, Colgate, Aqua-fresh, Gleem, Crest) Topical fluoride application will consist of placing three pea size drops of fluoride gel on an upper disposable tray, three pea size drops of fluoride gel on a lower disposable tray, spreading these drops evenly over the tray surface, placing the tray over the teeth and allowing the tray to remain in place for four minutes. Health Consumers presenting with one new smooth surface caries will be given a topical fluoride treatment. Teeth needing sealants will be marked with an "S" on the examination form 42-1. Teeth with sealants in place will be marked with "SI" (sealant intact) on the examination form. Dietary counseling will be implemented on those health consumers with rampant caries. A referral shall be made to the clinic's nutritionist.

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The dentist, hygienist, or therapist who has received training in this phase of dentistry will do scaling. All patients with type II and III periodontal status will receive scaling. Recall, Oral Health Instruction include oral hygiene reinforcement at each subsequent dental visit CPITN (COMMUNITY PERIODONTAL INDEX TREATMENT NEEDS) Perio type will be marked for all new patients as follows for each sextant of the mouth based on the most severe pocket in the sextant:

0

no disease

1

gingival bleeding, no calculus, no pocket formation

2

supra or subgingival calculus with no pocket formation

3

4 - 5 mm pockets present

4

6 mm pockets or greater present

"Informed / perio" indicates that the health consumer has been informed of their periodontal status; that the health consumer has been informed that they should seek care from a private periodontist without financial help from the IHS; that information on periodontal disease has been given to the health consumer. "Informed / ortho" indicates that the health consumer has been informed of the need for orthodontic treatment, and that any orthodontic treatment will have to be at the health consumer or parent's expense. Newly diagnosed diabetics or health consumers on Dilantin therapy will be given priority treatment which will include those services provided to a new adult health consumer. Newly diagnosed diabetics will be referred from the outpatient clinic. Upon receiving the referral an examination appointment will be given to the health consumer. At the first appointment the health consumer will be informed of the effect of diabetes on the oral tissues as well as receive the treatment given to all new health consumers. Children reporting for well baby medical exams and immunizations shall be directed to the dental clinic as part of their early childhood development. A dental officer will examine beginning at six months of age the child and the parents shall be given information on baby bottle caries and techniques for preventive home care for the infant's dental needs. It shall be determined at this visit the fluoride status of the child's water supply and any necessary supplementation shall be made if necessary. Parents will also be advised that the dental program wishes to begin clinical preventive care with their children at the age of two and that they should return then for preventive treatment. A recall postcard will be completed and filed for the child to be mailed out the month of their second birthday for an examination and cleaning appointment.

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DENTAL DISEASE PREVENTION PLAN - Section 24 [Tribal Site] Submitted by: Facility Dental Clinic PROBLEM The high rate of Dental Disease found in the [Tribal Name] Indians typifies the disease found among the United States Indian population. Restorative tactics have not been effective, and so an emphasis had to be placed on dental disease prevention in an attempt to impact the increasing disease. High prevalence of dental caries High rate of Early Childhood Caries High prevalence of periodontal disease Use of smokeless tobacco Low awareness of oral health Sports injuries to the oral cavity

GOAL We focused on these five areas of disease prevention: To decrease pit and fissure decay rate To decrease Early Childhood Caries (ECC) To create tobacco use cessation program To increase oral hygiene instruction To minimize trauma to the oral cavity from athletic sports

OBJECTIVES 1.

Our first goal was to increase our sealant application on permanent first molars to twice that of our Class I amalgam rate on first molars.

13.

Our second goal was to decrease ECC to half that of the national percentage.

14.

Our third goal was to initiate a program to offer students a smoking and smokeless tobacco cessation program.

15.

Our forth goal was to provide the community with a diverse range of oral disease prevention programs to address every age group

16.

Our last goal was to provide custom fit mouth guards to our athletic community to minimize dental trauma emergencies.

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Our overall objective was to encourage the Tribal beneficiaries we serve to become more aware of their dental disease in order that they may take ownership and initiate their own dental disease prevention.1

ACTIVITIES Sealants In our attempt to decrease pit and fissure decay our prevention officers and assistants coordinated a comprehensive sealant program using the principals and teachers in our local elementary schools. Our goal was to seal all non-carious permanent molars on students under age 12. The community supported this project. One half day each week our dentists and assistants apply sealants until our goal is reached. We will only link up with the reservation school(s) and other elementary schools in the area with Native American children. With current data in hand, we hope to project a gradual decline in our pit and fissure decay over the next few years. Our sealant rate is shown to be almost 3 times that of our pit and fissurefilling rate.

Fluoridation City or Tribal water systems have been fluoridated for the last [#] years. Water fluoridation plays an important role in decay prevention and remains a high priority. A fluoride rinse program is also in effect in the reservation schools. We have done in service meetings with the schoolteachers on the importance of fluoride, and have sent letters explaining the benefits of fluoride to parents of children not participating in the rinse program. If a household is not on city water, the parent is asked to obtain a water analysis cup and return it to the dental clinic to be checked for natural fluoridation. A fluoride prescription is given to the pharmacy to prescribe the recommended dose/age and our RPMS system monitors the compliance of our patients.2

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TOBACCO ABUSE The use of tobacco among high school age students is high. We want to obtain information on tobacco use and if students are interested in quitting. We also hope to determine where the students stand with respect to their knowledge of tobacco's effects on their health. Following the analysis of this data, we hope to initiate a tobacco cessation program through the school in the following year. (See appendix #7)

School Education [Develop your own School Education Program]

Example: Our primary target of dental education is in the schools’ curriculum. Throughout the school year, the Dental clinic staff will conduct presentations on oral hygiene instruction to elementary and high school classes. "Tell, show, do" method is used in the classroom to best instill a behavior change with brushing and flossing habits. In addition, other dental related topics are presented as requested by individual teachers. These topics include periodontal disease, smokeless tobacco, sports injuries and prevention, and dental career opportunities. Through these classes, there is an increase in dental health awareness and hopefully an impact is made on the prevalent disease and trauma seen in this population. Another way the dental clinic has attempted to increase student's dental awareness was to involve a third grade class in a presentation to be made at a Parent Teacher Organization Meeting. The students on sealant application performed a puppet show and how sealants protect one's teeth. The program was an effective way to get an important message out. Participation in three local school's health fairs is another method of placing an emphasis on dental health. In a non-threatening environment, students are able to ask individual questions on oral hygiene and their concerns about smokeless tobacco, in addition to getting information on dental careers. Brushes, floss and pamphlets are distributed, making the dental booth a favorite.

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EARLY CHILDHOOD CARIES [Develop your own School Education Program]

Example: Since our clinic is located in an ambulatory facility, we are able to tap into a wide range of resources including WIC, Well Baby Clinics, and Immunization Clinics. We are able to target all of our new mothers and give them a tippy cup, show pictures of ECC teeth and, most important, teach them the responsibility of keeping their kids from ECC. We feel this education is important not only to prevent ECC but also to prevent cavities in their permanent dentition. It has been shown that babies with ECC are prone to have 3.5 times the decay rate of children without ECC.1 Our ECC education has also been branched into the community including evening Head Start parent programs and a Christmas parade float ECC project.

COMMUNITY PROGRAMS [Develop your own Education Program]

Example: It's Fall Festival time and it brings the vast majority of its population to the Indian Ceremonial Grounds for Indian food, crafts, music and contests. The Dental Clinic had a booth at the Festival this year distributing healthy snacks, toothbrushes, floss, toothpaste, tippy cups and sugarless gum. A wheel was constructed which was spun by contestants following the correct response to a question on Dental health. Participants "spun and won" prizes and were also able to obtain information on all aspects of dental disease. Dental staff was present to answer questions. Our booth was a popular stop. Dental screenings are conducted at area nursing and "special" homes in an attempt to reach a population unable to easily access our facilities. Education is also provided, teaching oral hygiene and stressing its importance in one's well being. Not only are these presentations important to the residents of these facilities, but they also remind the staffs of the need to place an emphasis on oral hygiene. All diabetic patients seen in the hospital are referred to the Dental Clinic for a dental screening. Education on oral hygiene and a basic treatment plan is discussed. Patients have an opportunity to learn how important good oral hygiene is with respect to their diabetes. Throughout the year, dental articles written by staff dentists have been printed in the Tribal newsletter. This has been a method of reaching many people with information on dental disease and its prevention. We are attempting to increase dental awareness and encourage good oral hygiene. The "One Feather" has also printed pictures and articles on many of the community and school programs in which the dental clinic has been involved, showing its commitment to good oral health.

TRAUMA PREVENTION [Develop your own Program]

Example:

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In the past, the high School football team had been wearing basic "boil and form" mouth guards. This year the Dental clinic made custom mouth guards for the team. A dental team went to the school, made alginate impressions and poured up models. Using their school colors, individual mouth guards were constructed. The team found them more comfortable and wearing compliance went up. Even the quarterback could call his signals easier. The best outcome was the absence of dental trauma due to the 1990 football season. Mouth guards are also available to participants in any other sport upon request.

RESOURCES [Develop your own]

Example: Our greatest resource is the entire dental staff and their dedication to the focus that has been placed in the preventive effort. Utilizing this core of motivated health care providers, we have been able to initiate and expand programs by networking with other hospital programs, Head Start, the Tribe, community businesses, nursing and "special" homes, and the schools. We have found that others interested in dental disease prevention have matched the immense amount of time dedicated to prevention by our staff. By making our commitment known to the community, we have been surprised at the willingness of others to support our prevention programs. In the last year, over 20 businesses in the area have donated money or prizes to contests and health promotion activities. Massive school sealant programs have been supported by the school administration. School fluoride programs are funded by the State and supported by the school nurses and teachers. Water fluoridation is funded by the tribe and supported by the city water consumers. And, administrative time is granted to all dental staff for hospital programs and community presentations. It is not a single grant or person that encompasses our prevention program, but rather a community that has pulled together for a cause.

EVALUATION The evaluation of the Tribal Dental Disease Prevention Program will include the following: Obtaining baseline dental disease data Continuing to monitor sealant and restoration placement to determine effectiveness of sealants Continuing to observe a decrease in the Early Childhood Caries rate in the yearly Head Start survey Determining tobacco use prevalence in the High School population and their desire for cessation programs Benefiting from the continued participation by the clinic staff and community in our prevention initiative's.

BIBLIOGRAPHY 1.

Oral Health Survey of Native Americans. 1985, US PHS/IHS DOC # 0065N.

65

17.

"Smokeless Tobacco Use and Attitudes toward Smokeless Tobacco among Native Americans and Other Adolescents in the Northwest", Roberta L Hall, Ph.D. and Don

18.

Oral health, pp. 119. Chapter 18. In Promoting Health/Preventing Disease: Year 2000 Objectives for the Nation. US. Department of Health and Human Resources, September 1989.

19.

State Health Agency Dental Health Activities. Public Health Foundation, Washington, D.C. 1983.

20.

Youth Risk Behavior Survey. Mary Wachacha, Cherokee Health Education Department, October 1990.

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HUMAN RESOURCES - Part II

67

SCHEDULING PROCEDURES - Section 25 [Develop your procedures]

Example: !

Expanded function dental procedures shall be operational four days per week. Normally, a minimum of two therapists and one dental assistant will work in the expanded duties section

!

Each dental officer will work a minimum of one day in the expanded duties section.

!

The dental assistant supervisor will make up the weekly duty schedule for the two dental therapists, the three dental assistants, the dental receptionist, plus any additional temporary staff. This schedule will include the following activities: expanded function, specialty, emergencies, prophy exam and fluoride, and clean-up and stocking duties.

!

One master appointment schedule will be maintained at the front desk. The dental receptionist will schedule health consumers and record their appointments in the master schedule.

!

Health Consumer appointment scheduling will remain flexible enough to allow for adjustments in the workload which may be necessary to reflect variations in health consumer flow, clinic staffing, and referral priorities. The dental officers and the assistant supervisor will work together in effecting schedule management. Final responsibility will be that of the chief dental officer.

!

Expanded duties restorative dental care will be operational on Monday, Tuesday, Wednesday, Thursday, and Friday PM.

!

New health consumers will be scheduled on Tuesdays, alternate Wednesdays, Thursdays, and Friday afternoons. New adult health consumers will be scheduled with the hygienists and the clinic staff shall see children and young adults.

!

Wednesday mornings will be scheduled for clinic clean-up and unit restocking; dental provider staff meetings and employee committee meetings. Health Consumers will not be scheduled on Friday mornings unless contract dental personnel are available.

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RECORD KEEPING - Section 26 The medical or dental record [some facilities have separate records] will contain the following dental records: HSA 42-1, HSA 42-2, panoramic x-ray, bitewing and periapical X-rays, a dental health history form, and referral and consultation forms. The dental X-rays will have holes punched in them and inserted on the left side of the patient's health record below all other dental records. The dental records will be placed in a designated section on the left side of the patient's medical record in the following order - top to bottom:

1.

All 42-2's together, newest on top

2.

HSA 42-1, current on top

3.

Medical history

4.

Consultations and referrals

5.

Radiographs

By 2:30 p.m. the dental receptionist will give medical records a list of patients names having appointments the next working day. In the event that medical records personnel cannot pull the medical charts, the dental clinic will send the receptionist or other auxiliary to assist in obtaining the patient charts. On all emergency procedures the dental officer will use the S.O.A.P. format in record keeping.

1.

SUBJECTIVE

S-COMPLAINT

2.

OBJECTIVE

O-OBSERVATION OF PROBLEM

3.

ASSESSMENT

A-DIAGNOSIS

4.

PLAN

P-TREATMENT

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STAFF ASSIGNMENT - Section 27 [Develop your own Staffing requirements]

Example: The full time, permanent Dental Clinic staff will consist of two general dental officers and five auxiliary personnel. The auxiliary personnel will be composed of one dental assistant supervisor ( a therapist ), one additional dental therapist, two chair side dental assistants, and one dental receptionist. The two dental officers will alternate on expanded function and specialty duty. PROPHYLAXIS, fluoride and examination will be considered as an expanded function activity for scheduling purposes. The dental officer assigned to specialty duty will work with one dental assistant in operatory number 1. The dental officer assigned to expanded function duty will work with the two dental therapists and one dental assistant using operatories 2,3,4, 5 and 6. Treatment of dental emergency health consumers will be the responsibility of the dental officer assigned to expanded function duty. Emergency dental health consumers will initially be worked up in operatory number 2. The expanded duties schedule will always be operational should one of the dental officers be on leave. In the event that both dental officers are on leave and clinical coverage cannot be arranged the auxiliary staff shall see health consumers to apply preventive sealants and polish completed amalgam restorations. When available the dental hygienists will schedule health consumers through the dental receptionist. The hygienists will be responsible for starting new adult health consumers and seeing referrals from the dental officers. The dental hygienists shall be assigned to operatory numbers 1, 2 and 7. New adult health consumers will be examined and treatment planned by the dental officer assigned to exam duty. The hygienists will primarily work unassisted, but may be assigned an assistant depending upon staffing for the day. When available, contract dental personnel shall be assigned to any free operatory. The contract dental personnel shall see specialty dental assignments referred to them by the full time dental officers. Additional temporary providers, volunteers, and non-permanent employees will be assigned into the clinic schedule to expand services when available.

DUTIES OF THE STAFF The chief facility dental officer will develop, coordinate and evaluate the dental program. He/she will be responsible for the authorization, obligation and justification of funds for the contract dental care program. The chief dental officer will be responsible for career development activities of the dental officer (s) under him. The chief dental officer will provide dental health services to the designated population. The advanced staff dental officer (s) designated will act as chief in the absence of the chief. He/she will be primarily responsible for providing direct clinical services. He/She will also serve as the Chairperson of the Dental Health Promotion / Disease Prevention committee.

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A staff dental officer will be responsible for ordering all necessary supplies and maintaining inventory and budget control. A staff dental officer will serve as a member on the Equipment and Supply Committee, and the Diabetic Committee.

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TRAINING - Section 28 Purpose Training of employees is an indispensable portion of the functions of this clinic. Training assures the duplication of quality procedures that in turn applies to each member of the dental team. Training will be used to inform and demonstrate abilities necessary to protect patients, provide dental care, and promote team cohesiveness to fulfill the mission of the department.

In-Service This training will be arranged through the Facility Administration, Health Educator, Nurse Education and Dental Department Personnel that will be preformed in the facility. This training will be specific and will fulfill specific objectives of orientation, safety, hazardous situations, record keeping, and dental care. Outside presenters will be obtained to provide training for those topics that cannot be provided by this facility.

Out of Facility Training This training will provide annually as resources permit. As resources become a factor, prioritization will be come a factor that will be imposed by the Chief Facility dental officer, and dental providers. Each year, the IHS Dental Training Schedule will be presented. Each employee will be provided a choice of courses to attend. This choice will be brought to the Dental Supervisor for counseling and nomination to Facility Administrator.

Need for Training Training needs will be determined by annual employee performance evaluations, both periodic and final. Observation of lack of skills, understanding, and misunderstanding of procedures will indicate counseling for the individual. At this point education will be advised to correct or improve the performance of the individual.

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LEAVE - Section 29 ANNUAL LEAVE [Follow your Facility’s Personnel Policy for leave]

Example: Approval of annual leave for dental auxiliary personnel will be at the discretion of the supervisor. Approval of annual leave for the dental assistant supervisor and any dental officer will be at the discretion of the dental officer in charge. All requests will be made to your immediate supervisor. Annual leave greater than one hour will have to be applied for in advance. Extended annual leave must be applied for and approved in advance of scheduling patients in the clinic. This will usually require a minimum of three weeks notice of intent to take leave. Any employee who reports to work after 8:30 a.m. and has failed to call before 8:30 a.m. may be charged with AWOL. When an employee reports 15 minutes or more late for work it will be charged against their leave record. This may be Annual Leave (AL), Leave Without Pay (LWOP), Absence Without Leave (AWOL) or Sick Leave (SL) based upon the circumstances involved in the late reporting. If an employee has not applied for annual leave and requests leave due to an emergency the following procedure will be used: Call the clinic and request the leave over the phone, and when possible: Report to the clinic by 9:00 a.m. and show cause for request of additional leave. If sufficient support staff is present additional leave may be granted. Complete and sign the SF-71 before going on leave.

SICK LEAVE Example All telephone requests for sick leave will be made before 8:30 a.m. All requests for sick leave will be made to your immediate supervisor. The supervisor may request a physician's statement, as deemed appropriate. The physician's statement must be in writing stating the physician has examined the employee and found the employee unable to perform their duties. Signing of the SF-71 by the physician will not constitute a physician's statement. Sick leave for scheduled appointments must be applied for in advance. If a written physician's statement is requested and is not furnished when the employee returns to work, the employee may be charged with AWOL for the entire leave in question.

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ABSENCE WITHOUT LEAVE (AWOL) When an employee does not call to request leave or report to the clinic by 8:30 a.m. When a written physician's statement is requested and not furnished. Any time an employee is absent from work without approved leave.

TARDINESS When an employee reports 5-15 minutes late for work they will be counted as tardy. If an employee is habitually tardy they will be counseled. If after counseling the employee continues to be tardy they will be charged with AWOL. If after two counseling sessions the employee continues to be tardy a letter of reprimand will be issued or corrective disciplinary action will be proposed.

LEAVE WITHOUT PAY (LWOP) Leave without pay will be considered on an individual basis within regulatory requirements.

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DRESS CODE - Section 30 Chairside dental auxiliary personnel shall wear a full coverage water impervious gown. Scrub dress is to be worn in all patient contact areas while working with patients. Clean, wrinkle free dresses, slacks, shirts, etc. are acceptable; while clothing such as jeans, sweatshirts, tank tops are not acceptable when working outside the clinic patient areas. Clean, polished shoes are acceptable. Tennis shoes, sandals and thongs are not acceptable when working outside clinic patient areas. In patient treatment areas, clean tennis type shoes are allowed with scrub attire. Hair should be groomed and kept neat. A gown shall be worn over the employee's uniform to prevent blood and bodily fluids from contaminating the employee's clothes while working. The gown must be either discarded daily or cleaned if it is not disposable. Commissioned Officers shall follow all Local Authority Uniform Instructions when not working in patient care areas.

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ENVIRONMENT - Part III.

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INFECTION CONTROL - Section 31 BACKGROUND Dental personnel are exposed to a wide variety of microorganisms in the blood and saliva of patients they treat in the dental operatory. Infections may be transmitted by blood or saliva through direct contact, droplets, aerosols, or by indirect contact with contaminated instruments. Patients and dental staff also have the potential of transmitting infections to each other. A common set of infection control strategies should be effective for preventing the full spectrum of infectious diseases caused by blood born microorganisms. Because all infected health consumers cannot be identified by history, physical examination, or readily available laboratory tests other preventive measures must be strictly adhered to. All dental staff fall within the following category: Category 1 - All procedures or other job-related tasks that involve an inherent potential for mucous membrane or skin contact with blood, body fluids, or tissues, or a potential for spills or splashes of blood or body fluids. Category 2 - Dental Receptionists

INFECTION CONTROL PROGRAM The Dental Program has adopted the Infection Control procedures prescribed in Recommended Infection Control Practices for Oral Health Program Serving Native Americans, Indian Health Service. A copy of this document is found in Oral Health Program Guide in the Office of Chief, Facility Dental Officer and in the Appendix attached. The procedures specific to this clinic are outlined below. It is the policy of the Dental Program that the following procedures should be routinely used in the care of all dental health consumers.

PHYSICAL ENVIRONMENT PHYSICAL FACILITY The Dental Clinic consists of [#] operatories where routine dental care is performed and three isolated operatories where surgery and emergency services are performed. The sterilization area is centrally located in the clinic.

AUTHORIZED EATING AREA [Designate authorized eating area in the facility] This area will be kept free of all food and drink spills and cleaned as needed promptly after use by Dental Personnel. Hand washing guidelines will be followed before returning to duty. All protective clothing shall be removed before entering this area. No food or drinks shall be stored in the laboratory refrigerator where potentially infectious materials are stored. A refrigerator in the designated eating area is provided.

HAND WASHING AND CARE OF HANDS. 77

Hands must always be washed between health consumer treatment contacts (following removal of gloves), after touching inanimate objects likely to be contaminated by blood or saliva from other patients, and before leaving the operatory. The rationale for hand washing after gloves have been worn is that gloves become perforated, knowingly or unknowingly, during use and allow bacteria to enter beneath the glove material and multiply rapidly. For many routine dental procedures, such as examination and non-surgical techniques, hand washing with plain soap appears to be adequate, since soap and water will remove transient microorganism acquired directly or indirectly from health consumer contact. For surgical procedures, an antimicrobial surgical hand-scrub should be used. Extraordinary care must be used to avoid hand injuries during procedures. Dental staff who have open lesions or weeping dermatitis should refrain from all direct health consumer care and from handling dental patient-care equipment until the condition resolves. Hand washing facilities are found in all clinic treatment areas.

DISPOSAL OF WASTE MATERIALS. All sharp items (especially needles), tissues, or blood should be considered potentially infective and should be handled and disposed of with special precautions. Disposable needles, scalpels, or other sharp items should be placed intact into puncture-resistant containers before disposal. Blood, suctioned fluids, or other liquid waste may be carefully poured into a drain connected to a sanitary sewer system. Other solid waste contaminated with blood or other body fluids should be placed in sealed, sturdy impervious bags to prevent leakage of the contained items. Such contained solid wastes can then be disposed of according to the Area solid waste disposal policy.

TRAFFIC FLOW The receptionist at the front desk monitors patient flow through the clinic. This clinic area will be restricted to employees, health consumers and guardians of young health consumers whose presence is needed. Traffic for employees will be restricted in the sterilization area. Entry and flow is from left to right with contaminated materials disposed of and instruments cleaned.

CLEANING SCHEDULE Dental staff personnel prior to the beginning of the clinic schedule shall perform daily cleaning. This cleaning will also be performed between patient placement in the dental operatories. Major cleaning of equipment and operatories will be assigned and accomplished each Wednesday morning.

CLEANING BETWEEN PATIENTS INDICATIONS FOR HIGH-LEVEL DISINFECTION/STERILIZATION OF INSTRUMENTS.

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Surgical and other instruments that normally penetrate soft tissue and/or bone (e.g., forceps, scalpels, bone chisels, scalers, and surgical burs) should be sterilized after each use. Instruments that are not intended to penetrate oral soft tissues or bone (e.g., amalgam condensers, plastic instruments, and burs) but that may come into contact with oral tissues should also be sterilized after each use, if possible; however, if sterilization is not feasible, the latter instruments should receive high-level disinfection.

METHODS FOR HIGH-LEVEL DISINFECTION OR STERILIZATION. Before high-level disinfection or sterilization, instruments should be cleaned to remove debris. Cleaning may be accomplished by a thorough scrubbing with soap and water or a detergent, or by using a mechanical device (e.g., an ultrasonic cleaner). Persons involved in cleaning and decontaminating instruments should wear heavy-duty rubber gloves to prevent hand injuries. Metal and heat-stable dental instruments should be routinely sterilized between use by steam under pressure (autoclaving), dry heat, or chemical vapor. The adequacy of sterilization cycles should be verified by the weekly use of spore-testing devices. Heat and steam-sensitive chemical indicators may be used on its outside of each pack to assure it has been exposed to a sterilizing cycle. Heat-sensitive instruments may require up to 10 hours exposure in a liquid chemical agent registered by the U.S. Environmental Protection Agency (EPA) as a disinfection/sterilant; rinsing with water should follow this. High-level disinfection may be accomplished by immersion in either boiling water for at least 10 minutes or an EPA-registered disinfectant/sterilant chemical for the exposure time recommended by the chemical's manufacturer.

EQUIPMENT AND SUPPLIES CLEAN Supplies will be obtained from several sources. Instruments and materials that contact patients will come from sterile holding areas in the operatories, central dental sterilization area or noncontact items from dental storage. Dental personnel will transport these items. These items will be kept in storage areas in each operatory, central sterilization and dental supply areas. These items will be assembled in the patient treatment area at each operatory.

SOILED/CONTAMINATED These items will be disassembled in the dental sterilization area. All items are to be returned to the sterilization area. These items will be transported from the clinic by house keeping personnel each evening after clinic closure. They will be stored in Sharps containers; contaminated disposable materials will be put in red garbage bags and reusable instruments sterilized. Ultra sonic cleaned for 5 minutes

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Rinsed scrubbed with running water Rinsed Drip Dry Autoclave sterilization 20 minutes in towels, bags with indicator tape or placed in gluteraldehyde solution for a specified time. Inspect and return to storage area.

DISPOSITION OF Ultra sonic solutions will be poured into the drain. Spent radiographic solutions will have precious metals removed and poured into drain. Spent gluteraldehyde solutions will be poured into the drain. Linen will be removed and placed in a special hamper in which all soiled linen is placed. House keeping removes the hamper on a daily basis for laundered items. Contaminated trash will be placed in Red garbage bags and removed by house keeping and is incinerated. Other trash items will be placed in clear garbage bags and removed by the same personnel. Needles, syringes or sharp instruments. - Sharp items (needles, scalpel blades, and other sharp instruments) should be considered as potentially infective and must be handled with extraordinary care to prevent unintentional injuries. Disposable syringes and needles, scalpel blades, and other sharp items must be placed into puncture-resistant containers labeled as biohazard located as close as practical to the area in which they were used. To prevent needle-stick injuries, disposable needles should not be recapped; purposefully bent or broken; removed from disposable syringes; or otherwise manipulated by hand after use. If it becomes necessary to recap a needle, the cap should be held with an instrument, not in the hands. Recapping of a needle increases the risk of unintentional needle-stick injury. There is no evidence to suggest that reusable aspirating-type syringes used in dentistry should be handled differently from other syringes. Needles of these devices should not be recapped, bent, or broken before disposal. If it does become necessary to recap the device, the cap should be held with an instrument (i.e., hemostat) to prevent needle-stick injuries. A new (sterile) syringe and a fresh solution should be used for each health consumer. All instruments sent to another facility or maintenance will be sterilized prior to being sent out of the dental clinic.

PERSONNEL IMMUNIZATIONS The Employee Health Program includes immunizations appropriate for age: rubella titer upon entrance to duty for all employees and immunizations if no antibodies; and TB screening. Hepatitis B vaccine is available and strongly recommended for all Dental Personnel with non-immune titer.

EXPOSURE INCIDENT

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In case of an exposure incident the employee of the dental clinic shall follow the protocol as prescribed by the facility. (See Facility Infection Control Manual Chapter 6)

CLOTHING For protection of personnel and patients, gloves must always be worn when touching blood, saliva, or mucous membranes. Dental staff must wear gloves 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. All work must be completed on one health consumer, where possible, and the hands must be washed and re-gloved before performing procedures on another health consumer. However, when gloves are torn, cut, or punctured, they must be removed immediately, hands thoroughly washed, and re-gloving accomplished before completion of the dental procedure. Repeated use of a single pair of gloves is not recommended, since such use is likely to produce defects in the glove material, which will diminish its value as an effective barrier. Surgical masks and protective eye-wear or chin-length plastic face shields must be worn when splashing or spattering of blood or other body fluids is likely, as is common in dentistry. Reusable or disposable fluid resistant gowns, or laboratory coats, must be worn when treating patients. If reusable gowns are worn, they may be washed, using a normal laundry cycle. Gowns must be changed daily or when visibly soiled with blood. All protective clothing is to be removed when leaving the clinical area including the reception area, waiting room and laboratory. Impervious-backed paper, aluminum foil, or clear plastic wrap may be used to cover surfaces (e.g., light handles or x-ray unit heads) that may be contaminated by blood or saliva and that are difficult or impossible to disinfect. The coverings should be removed (while dental staff are gloved), discarded, and then replaced (after UN-gloving) with clean material between patients. All procedures and manipulations of potentially infective materials should be performed carefully to minimize the formation of droplets, spatters, and aerosols, where possible. Use of rubber dams, where appropriate, high-speed evacuation, and proper patient positioning should facilitate this process.

RESTRICTED ASSIGNMENT Reporting Illness, Open Cuts, Open Sores and Accidents: These will be reported to and treated by the Employee Health Program as prescribed by the Facility Infection Control manual. Any staff member with an infection will report to the Infection Control Officer and take necessary precautionary measures to avoid spreading the infection. Exposure to Communicable Disease or Body Fluids will be reported to the Infection Control Officer of the department and the hospital for treatment and counseling. An incident report form will be completed and given to the area supervisor. A physician acting as Officer of the Day will determine fitness for duty.

PRECAUTIONS IN PATIENT AREAS TO AVOID SPREAD OF DISEASE

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At the completion of work activities, counter tops and surfaces that may have become contaminated with blood or saliva should be wiped with absorbent towels to remove extraneous organic material, then disinfected with a suitable chemical germicide. A prepared iodophor solution is very effective germicide that doesn't corrode metal surfaces. A 1:256 dilution will be the clinic standard surface disinfectant. Sodium Hypo-chloride solutions may also be used for surface disinfection. Routine sterilization of headpieces between patients is a necessity, however, not all headpieces can be sterilized. All headpieces will be sterilized prior to their use in patient care delivery. The present physical configurations of a few headpieces do not readily lend them to high-level disinfection of both external and internal surfaces, therefore, when using headpieces that cannot be sterilized, the following cleaning and disinfection procedures should be completed between each patient: After use, the handpiece should be flushed with water, then thoroughly scrubbed with a detergent and water to remove adherent material. It should then be thoroughly wiped with absorbent material saturated with a chemical germicide that is myco-bactericidal at use-dilution. The disinfecting solution should remain in contact with the handpiece for a time specified by the disinfectant's manufacturer. Ultrasonic scalers and air/water syringes should be treated in a similar manner between patients. Following disinfection, any chemical residue should be removed by rinsing with water. Because water retraction valves within the dental units may aspirate infective materials back into the handpiece and water line, check valves should be installed to reduce the risk of transfer of infective material. While the magnitude of this risk is not known, it is prudent for water-cooled headpieces to be run and to discharge water into a sink or container for 20-30 seconds after completing care on each patient. This is intended to physically flush out patient material that may have been aspirated into the handpiece or water line. Additionally, there is some evidence that overnight bacterial accumulation can be significantly reduced by allowing water-cooled headpieces to run and to discharge water into a sink or container for several minutes at the beginning of the clinic day. Sterile saline or sterile water should be used as a coolant/irrigation when performing surgical procedures involving the cutting of soft tissue or bone. Personnel are to wear gloves, protective eye wear, and wash hands between gloving for each patient. All exposed areas that are touched by the providers are to be protected and cleaned between each patient.

APPROPRIATE IN-SERVICES In-services regarding Infection Control take place on at least an annual basis and any time deemed necessary. In-services training provides the following:

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A copy of the OSHA standard.

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Explanation of epidemiology of blood borne disease.

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Modes of transmission.

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Explanation of the Dental Clinic infection control program.

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Recognizing exposed tasks.

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Explanation of appropriate work practice controls. 82

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Use of personal protective equipment and basis for appropriate selection of it.

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Information on hepatitis B vaccine.

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Who to contact in an emergency.

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Procedures to follow when exposure incident occurs

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Explanation of labels used.

Training records for each employee shall include the following:

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Dates of training.

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Content

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Name or names of instructors.

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Attendees. DECONTAMINATION OF LABORATORY SUPPLIES AND MATERIALS.

Blood and saliva should be thoroughly and carefully cleansed from laboratory supplies and materials that have been used in the mouth (e.g., impression materials, bite registration), especially before polishing and grinding intra-oral devices. Materials, impressions, and intra-oral appliances should be cleaned and disinfected before being handled, adjusted, or sent to a dental laboratory. These items should also be cleaned and disinfected when returned from the dental laboratory and before placement in the patient's mouth. Because of the ever-increasing variety of dental materials used intra-orally, dental staff is advised to consult with manufacturers as to the stability of specific materials relative to disinfection procedures. A chemical germicide that is registered with the EPA as a "hospital disinfectant" and that has a label claim for myco bactericidal (e.g., tuberculocidal) activity is preferred, because mycobacterium represent one of the most resistant groups of microorganisms, therefore, germicides that are effective against mycobacteria are also effective against other bacterial and viral pathogens. Communication between a dental officer and a dental laboratory with regard to handling and decontamination of supplies and materials is of the utmost importance. Dental Laboratory Infection Control Procedures are found in the Oral Health Program Guide Chapter VII: Section 8.

PATIENTS MEDICAL HISTORY. Always obtain a thorough medical history. Include specific questions about medications, pregnancy, cardiovascular disease including rheumatic fever, liver disease, diabetes, convulsion/seizures, bleeding tendencies, harmful habits, current illness', hepatitis, recurrent illness', unintentional weight loss, lymphadenopathy, oral soft tissue lesions, or other infections.

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The medical history is to be reviewed at each health consumer visit. Medical consultation may be indicated when a history of active infection or systemic disease is elicited.

HANDLING OF BIOPSY SPECIMENS. In general, each specimen should be put in a sturdy container with a secure lid to prevent leaking during transport. Care should be taken when collecting specimens to avoid contamination of the outside of the container. If the outside of the container is visibly contaminated, it should be cleansed and disinfected, or placed in an impervious bag.

PATIENT PLACEMENT COMMUNICABLE PATIENTS NOT IN PUBLIC WAITING AREAS Communicable patients will be reappointed unless the case is emergent, upon which the client will be taken directly to an operatory and necessary precautions taken.

APPROPRIATE ISOLATION FOR DIAGNOSIS Standard and transmission based precautions will be taken with all patients.

RESPONSIBLE INDIVIDUALS The responsibility for implementation of this policy lies with all Dental staff. However, primary responsibility for implementation and continued compliance lies with the Health Director. Physician Infection Control Officer of the Facility will co-ordinate all infection control activities, monitoring and Hospital Infection Control meetings. Infection Control Dental Officer will establish written policies and procedures for infection control and submit them to the Chief, Facility Dental Officer for review. They will also investigate post-op infections and cross contamination and report their origin. They will review these findings with the Infection Control Dental Assistant to assure policies and procedures are followed and report to Chief, Dental Officer, Provider Staff and Dental Staff. Orientation by hospital, Infection Control Officer and Dental Staff will be used to orient and train all new dental staff in infection control. Infection Control Dental Assistant will aid and supervise all dental staff in the daily implementation of the policies and procedures. They will train new staff in infection control and continually review standards with existing staff. They will run biological indicator tests on each autoclave weekly and log results. They will inspect, repackage and re-sterilize all sterile packaged instrument monthly. Facility Infection Control Committee will review and approve all policies and procedures related to infection control prior to implementation.

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RADIOLOGICAL PROTECTION - Section 32 All criterions listed in section "Radiological Protection" of the Quality of Dental Care Document will be met. Every year all lead aprons used for x-ray protection will be sent to the x-ray department for evaluation. All aprons, which fail the inspection, will be discarded. The Chief of Dental Services will maintain a record of this testing. Each staff member shall be shown the radiation detection report each quarter that it is issued. Each staff member will initial the report and the Chief of Dental Services will keep a copy on file in his office and Chief of the Radiology Department will keep a copy. "X-ray", will be loudly announced before any staff member begins to take any radiograph. This announcement will serve to inform all personnel in the area to stand clear of the path of the radiation beam. The operator will also inform patients who are moving to and from the operatories to stand clear of the path of the x-ray beam. A conspicuous sign shall be posted in the panoramic x-ray area announcing to all personnel that "WARNING! PERSONNEL SHOULD NOT BE IN THIS AREA DURING X-RAY USE". The dental assistants shall yearly be evaluated on their clinical radiographs and radiological safety according to the IHS radiological criteria for quality care.

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MEDICAL EMERGENCIES IN THE DENTAL CLINIC - Section 33 PURPOSE The health consumer in the dental clinic should be protected while receiving dental care in the service unit dental clinic. To insure their safety, a policy will be in place to insure quick and efficient response to any emergency arising in the dental clinic.

CODE BLUE This is the code that is called when a patient or any individual in the facility is not breathing. First check the vital signs of the individual not breathing and call for help if there is not respiration or pulse. The code is phoned to the telephone operator ext. "0". The individual calling the operator will state "Code Blue condition" and the location where the individual not breathing is located. After calling the operator, return to the location of the individual not breathing.

DENTAL EMERGENCY - PERSONNEL Dental officers in the Indian Health Service should be aware that urgent or emergent medical and dental situations might 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.

DENTAL EMERGENCY - EQUIPMENT AND MEDICATIONS Equipment for providing supplemental oxygen to hypoxic patients should be available in all IHS dental clinics. This equipment should provide capabilities for forced respiration through the use of a Ambu 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. Emergency medications will be stored in a box to be located in the surgical area of each dental clinic. This equipment and medication will be checked on a weekly basis to insure the preparedness of each. Medications will be monitored each month by pharmacy. The dental emergency kit will include:

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Positive pressure oxygen

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Ambu-bag

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Sphygmomanometer and Stethoscope

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Benadryl 50 mg/ml injectable

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Tubex Hypodermic Syringe

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5% Dextrose 86

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Butterfly I-V set

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Epinephrine 1:1000 Tubex x 2

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TRAINING CPR All dental staff should be trained in cardio-pulmonary resuscitation and maintain current certification. Courses may be obtained through local American Red Cross units to assist in meeting certification requirements. In-service training and mock emergency situations will be staged on a periodic basis to insure the following of this procedure:

MEDICAL HISTORY/PREVENTION - Major Systems Review Χ

Circulatory

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Respiratory

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Endocrine

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Digestive

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Allergies

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Disease, Medications

RECOGNIZING EMERGENCIES Χ

Patient's color: flush, pallor, cyanosis (blue)

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Patient alertness: dizziness, excitability

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Patient's respiration: ventilation

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Pulse, Blood Pressure

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Skin: itching, rash, sweating

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Vomiting, nausea

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Convulsion

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Pain

PROCEDURES Χ

Call the dentist

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Call the physician "0", Code Blue, location

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Retrieve emergency equipment

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Support patient

RECORD KEEPING MECHANISM STAFF ASSIGNMENTS

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Dentist stays with patient! The provider will assess the situation and assign tasks to dental assistants and auxiliary personnel. Their responsibility will be to monitor the patients vital signs and maintain airway, support breathing and monitor circulation until medical assistance arrives. Dental assistant assigned to that section and assisting with that patient, will inform the dental receptionist to call the physician on call or call a code to the front desk. This individual will get Oxygen tank from the dental supply area and emergency kit from the dental surgical area. Additional individuals in the area assist in record keeping. Dental Receptionists will call physician or the Code. Remember to state need and location of the emergency clearly and calmly.

DIFFERENT SITUATIONS: Syncope (fainting) Χ

Smelling salts

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Wet washcloth

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Blood Pressure Cuff

Hyperventilation Χ

Get paper bag

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Talk to the patient to calm them

Allergic or Toxic Reaction Χ

Get drug kit and oxygen stat

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Obtain medical help

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Support respiration

Coronary (Angina Χ

Get oxygen tank and drug kit

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Get patients nitroglycerine, if none, get the nitro-glycerin drug kit

Asthma Χ

Get patients inhaler

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Get oxygen tank

Insulin shock Χ

Get emergency drug

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Get out glucose water

Diabetic Coma Χ

Check if patient took medication prior to appointment

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Support respiration and call physician on call 89

Airway obstruction Χ

Heimlich abdominal thrust and back blows

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Check for obstruction visibly

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High speed suction sweep

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Crycothyrotomy

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Get oxygen tank

Cardiopulmonary Emergency Χ

Call code stat

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Get oxygen tank and emergency kit stat Blood Pressure cuff and stethoscope

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Support respiration, maintain airway and monitor pulse

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2 assistants and 1 Dentist (1 assistant takes notes and other aids with /person CPR)

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FIRE PLAN - Section 34 FIRE EVACUATION PLAN The evacuation of the dental clinic in care of fire is outlined in the Facility’s Fire and Safety Manual. A map of-- escape routes is posted in the hall across from the dental OD and in the Dental Waiting Area. Become familiar with this map and evacuation procedures. A copy of the evacuation plan is located in the office of Chief, Facility Dental Officer. There are assigned locations of specific dental personnel as described in the plan When a fire is discovered in the dental area the person discovering the fire will dial 0 and to the operator, " Code Red, dental clinic " Patients in the area will be moved out of the fire area either through the west exit or through the back door and out the east of the building. The dental assistants will be responsible for moving these patients and staying with them once they are out of the building. If a dental officer is treating a health consumer, the dental officer will determine if it is best to interrupt treatment to move the health consumer or to continue treatment. If practical a dental officer will obtain a fire extinguisher and attempt to extinguish the fire.

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PATIENT SEDATION - Section 35 PURPOSE Sedation and the granting of privileges to use sedation by dentists in the Facility require documentation and/or demonstration of competence to the Chief, Facility Dental Program. The policies and procedures for the use of nitrous oxide will be followed to safely and effectively utilize nitrous oxide and/or oral conscious sedation in the Dental Department.

QUALIFICATIONS OF PROVIDERS Providers must be qualified by having received formal training. This training must include: Χ

The use of equipment

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Adequate medical history and patient assessment

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Recognition of medical problems which may exist,

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Limitations of the treatment

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Dosages and administration

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Signs and symptoms of adequate/inadequate

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Complications and their treatment if

All dental officers using nitrous oxide/ oral sedation must have a record stating that training was received in nitrous oxide/ oral sedation techniques. This will be filed in the dental officers personnel record in the dental clinic.

CRITERIA The clinic must have a completed environmental survey for nitrous oxide use and must met standard environmental safety standards as determined by Occupational Safety and Health Administration of the U.S. (OSHA) and IHS Environmental Health. Nitrous Oxide analgesia must be indicated for use with dental patients who are apprehensive or for behavior management as indicated by accepted dental practices. All patients will be assessed prior to nitrous oxide/ oral sedation use and discovered contraindications will cancel its use. These contraindications may include:

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Patient guidelines for administration are included in ASA guidelines for patient assessment

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Patients with respiratory difficulties which restrict airway

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Patients undergoing psychiatric care or with a history of drug abuses or who are ill unless prior approval is obtained from a physician

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Patients who have demonstrated an adverse reaction to nitrous oxide in the past

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Patients who could be effectively treated without the use of nitrous oxide

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Medical or Dental Staff trained in emergency procedures must be immediately available at all times that nitrous oxide analgesia is being administered, as well as emergency equipment and medications that may be needed.

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The patient must have the ability to cooperate and respond to oral commands at all times during analgesia administration.

An in-depth discussion of the above factors is presented in Sedation: A Guide to Patient Management, by Stanley Malamed. This publication is in the bookshelf of the Chief, Dental Department. And should be read before any authorization to perform any such procedures. The pre-evaluation is found in Chapter 5 of the reference. Monitoring The patient will be monitored by observing movement of the chest, the carotid pulse, verbal response and eye movement and oxygen saturation with a pulse oximeter when nitrous concentrations are above 30% or if oral sedation is used Nitrous oxide/ oral sedation guidelines listed in the dental specialties manual under Pediatric Dentistry will be followed. Patient assessment, and parent counseling will be completed before administration of any sedation mechanism Documentation of the assessment, medications used, times of administration, concentrations, post assessment and evaluations of effectiveness will be performed A record will be maintained in the patient' chart registering duration and ratio of nitrous oxide/oxygen used, and any complications encountered in the course of treatment. The IHS Form 831 will be used to record this. A log (copy of IHS #831) will be used to document nitrous usage and remarks for each patient. Health consumer consent for pediatric dentistry will be completed before the providers employ behavior management techniques. Monitoring will begin when the patient enters the clinic via observation by dental staff, when medication has been given. As effect of medication is observed, monitoring with pre chordal stethoscope or pulse oximeter or when oxygenation segment of nitrous oxide administration is begun. Monitoring continues throughout the procedure until signs of arousal or after post oxygenation of nitrous oxide administration with it is the sole means of sedation.

EQUIPMENT Nitrous Oxide analgesia delivery equipment must have a fail-safe oxygen flow device. Proper life support equipment must be readily available. Nitrous Oxide scavenging mask and equipment must be working at the time of analgesia initiation. Nitrous Oxide equipment must be stored in a restricted area at all times when not in use. Maintenance of this equipment will be checked on a routine weekly inspection and before each usage. All rubber equipment will be checked for contaminated waste, and cracking. Back pressure will be tested for discovery of leaking hoses and manifolds.

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The scavenger system will always be utilized when administering nitrous oxide The dental clinic will be locked at night and during the weekends to secure all nitrous oxide oxygen equipment. The equipment, which is used to administer nitrous oxide-oxygen, should be checked weekly for gas leaks. Any hoses or bags that leak should be replaced. Each month, the hoses and bags will be checked. Medication will be obtained from the pharmacy by PCC/ prescription form Pulse oximeter will be used with tape read out documentation obtained.

CURRENT DENTAL STAFF [List current dental staff authorized]

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STANDING ORDERS FOR DENTAL AUXILIARY STAFF - Section 36 New patients and emergency patients will be given a Dental Health History Form and consent for treatment to complete. At the initial appointment and every year thereafter have the health consumer sign the following policy and place the signed policy in the patient's record as an incorporation in the dental Health Questionnaire. Staff members will assemble and properly fill out forms 42-1, Patient Service Record, and 42-2, Patient Progress Notes. The assistant will review the Health History Form, check with the patient for any changes in health status, date and initial the form. Blood pressures are recorded in the patients Health Summaries and will be noted at each visit to the Dental Clinic. Blood pressures will be taken and recorded on all new patients 30 years old and older with a history of hypertension. This will be done on the health consumer's first visit of the year and on emergency patients 30 years old or older at each emergency visit if a recent reading cannot be found in the patient Health Summary. The information shall be entered on form 42-1 under Part II and on 42-2 on the first line of the progress notes. Dental auxiliaries trained and certified in dental radiography shall take bitewing X-rays for each new health consumer if the existing bitewings are 1 year old or older. Emergency patients with panoramic x-rays in their charts less than 5 years old 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.

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MERCURY HYGIENE - Section 37 Criterion #5 under Section "T" on environment will be met. The guidelines accepted the IHS publishes those guidelines in the Journal of The American Dental Association Pre-encapsulated mercury/silver amalgam restorative material will be used to decrease the chances of mercury contamination. Scrap amalgam will be stored in closed containers submerged in unused X-ray fixing solution or glycerin. The Chief Dental Officer will be notified of any spills. Appropriate measures will then be taken to contain the spill by use of a mercury contamination kit. Environmental Health Services personnel will periodically determine the mercury vapor level the clinic. The Chief of Dental Services will maintain a record of these evaluations in his office. The Chief of Dental Services will maintain a record stating that all dental personnel have received and reviewed a copy of the mercury hygiene standards. The standards will be reviewed yearly.

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SUBJECT:

SAFETY PROCEDURES

PURPOSE:

To insure that this department maintains a safe environment for patients, staff, and those in the department

STAFF AUTHORIZED TO PERFORM THIS PROCEDURE: All members of the dental staff including, receptionists, dental assistants, dental hygienists, and dental officers. EFFECTIVE DATE:

________

DATE REVIEWED/REVISED: _________/ APPROVED BY:

Chief Dental Officer, Safety Officer

DISTRIBUTION:

Dental Policy and Procedures, Safety Manual

/

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SAFETY - Section 38 All dental personnel will have safety glasses and / or goggles. These glasses and / or goggles will be worn when the individual is using the high or slow speed handpiece or is assisting when these headpieces are being used. The Chief, Facility Dental Officer will delegate the authority of requiring protective wear for dental personnel to the provider in charge of their assigned area of dental care delivery Safety glasses and goggles will be provided to the employee and patients at no cost to the employee. Trays will be fabricated in the lab away from any open flames The lathes in the dental lab will have protective shields on them. Filtered glasses will be furnished to the employee for working with the light source for light cured restorative materials. There will be no smoking in the dental clinic or in the dental offices. The Facility Safety Policy and Procedure will be adhered to on all occasions and a copy of this document is found in the office of the Chief Facility Dental Officer. All dental personnel will be familiar with Facility Fire, Safety and Disaster Plan. All dental personnel will know the emergency codes and how to report them to the correct location for emergency response. All dental personnel will adhere to protocol within the Infection Control Policies and Procedures manual. All job injury related incidents would be reported according to protocol set forth by the hospital. (see document Facility Fire, Safety and Disaster Plan) All OSHA safety regulations will be strictly followed. Posted notification of guidelines will appear in the sterilization area and a copy of the regulations kept in the Chief, Facility Dental Officer’s office. Eye wash stations will be located in each section of the dental clinic for quick access as needed.

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PRECIOUS METAL RECOVERY - Section 39 PURPOSE The Facility Dental Officer will be responsible for all scrap precious metal collected in the dental clinic to specific officials for their disposal

PROCEDURE At the end of each quarter the Staff Dental Officer will turn all scrap precious metal over to the Property Custodial Officer. The Property Custodial Officer will issue a receipt for the scrap metal. The Staff Dental Officer will maintain a record of receipts received from the Property Custodial Officer. All silver scrap will be placed in a container located in the Dental Sterilization Area. The container will be marked amalgam scraps. The scraps shall be stored under a hypo solution or glycerin. Silver scraps collected in the vacuum system will not be saved due to the potential for transmission of disease All gold removed from a health consumer will be given to the health consumer. If the health consumer does not want the gold it will be placed with the silver scrap. A silver recovery system will be installed on all X-ray film processors. The discharge from this system will be monitored weekly to determine when the recovery cartridges should be replaced. These cartridges will be turned over to the Property officer 'dry' and the form will state "gross weight" of cartridge. All out of date and non-diagnostic radiographs will be collected and given to the Facility Property Officer along with the silver recovery form.

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REQUISITION OF SUPPLIES - Section 40 PURPOSE The Facility Dental Officer will be responsible for maintaining the supply system, the Dental Assistant Supervisor shall act as the alternate.

PROCEDURE [Example] Supplies for the Clinic will come from three sources. One is (primary) the Central Supply Service Center at Ada, Oklahoma. The other sources are from (secondary) manufactures with GSA contracts and (tertiary) open purchasing supplies from the manufacturers. Monthly an issue book will be sent from Central Supply Service Center to the dental clinic. Within three days of receiving the book, the items needed should be recorded and the book returned to Central Supply. When Central Supply delivers the order the issue book will need to be signed and returned to the facility supply clerk. The staff dental officer shall keep a register of computer generated stock issues for each month with cost/quantity data on file in the clinic. Outside purchases should be obtained from vendors with a government contract or at the lowest possible price. Form 393 will need to be completed and submitted to the Chief Dental Officer for approval. After approval the form will be submitted to the facility administration for processing. Approval will be based on available funding resources. The staff dental officer shall maintain a register of all purchases utilizing direct issue funds. If a shortage of needed supplies should occur during the month, an emergency requisition may be prepared and haveGeneral Services process it with the Health Director's approval.

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CONTINUOUS QUALITY IMPROVEMENT (CQI) PLAN - Section 41 PURPOSE The purpose of this CQI plan is to continuously improve the quality of care provided to health consumers by members of the Dental Department. This will be accomplished thought the efforts of the Dental Staff both inter and intra-departmentally within the Service Unit.

RESPONSIBILITY The individual responsible for the quality assurance and improvement activities of the Dental Department is the Chief, Dental Department. The chief may delegate this responsibility to other members of the dental staff as well as to the staffs of satellite facilities. The entire staff of the Dental Department will be involved in the CQI processes. It shall also be the responsibility of the dental QA/QI Coordinator to coordinate interdepartmental activities with the CQI programs of those departments so as to provide for quality improvement throughout the facility.

SCOPE OF SERVICES OF THE DENTAL DEPARTMENT Dental services in the facility are provided to health consumers determined eligible by the Patient Registration Department. All age groups are treated, within the scope of services offered according to priorities. The dental program attempts to provide a comprehensive level of general dental services to these eligible people while following public health principles in the provision of this care. In general, the majority of the services provided by the program are either emergency services (Level I on the IHS schedule of services), or are based on the prevention of diseases and the early intervention of the disease process (Level II and III of the schedule of services). More advanced care such as prosthodontics, molar endodontics, advanced periodontics, and oral surgery (Levels IV, V, and VI of the schedule of services) are provided on a limited basis, if at all. The following provides services within the Dental Department:

Χ

Dentists who are appropriately credentialed and are members of the medical staff of the facility.

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Dental consultants who have been granted clinical privileges to practice in the Facility

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Dental student/trainees who have obtained volunteered or trainee status, under the direct supervision of a dentist member of the medical staff.

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Dental hygienists

Χ

Dental assistants who have received appropriate certification in radiology, periodontal therapy, expanded functions, and pit and fissure sealants, under the supervision of a dentist and in accordance with the department's policies and procedures.

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Location and time of services Outpatient Services: Dental Clinic. Hours for these services are provided 8 AM to 4:30 PM Monday, Tuesday, Thursday and Friday. Wednesday hours are from 12:30 PM to 4:30 PM.

IMPORTANT ASPECTS OF CARE Important aspects of care are those aspects of care (diagnosis, services, types of patients, etc) that have major impact on the dental program due to being high volume, high risk, or problem prone. Additionally, other high priority key functions, processes, procedures, diagnoses, treatments, activities, etc. are important in determining the quality of patient care. See addendum to this plan for important aspects of care.

INDICATORS The dental staff as a group will develop a set of indicators of quality of care for each of the important aspects of care being monitored. Each indicator will be objective, measurable, and based on current knowledge and clinical experience. Each indicator will specify a patient care activity, event, or outcome that is to be monitored and evaluated to determine if patient care conforms to current standards. Indicators for the chosen important aspects of care for the dental program are attached to this plan as an addendum. Additionally, certain unpredictable occurrences in the dental clinic (usually small in number but with very high morbidity or mortality) are of such importance that all such occurrences must be carefully examined, even though objective criteria cannot be formulated in advance for them. Examples of such sentinel events would include:

Χ

Deaths in the dental clinic

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Allergic reactions/anaphylactic reactions to medications.

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Formal complaints or lawsuits.

In addition to other processes set into motion by such events, dentists review each sentinel event and a Quality Improvement Activities Summary submitted to the QA/QI Coordinator for the facility to be reviewed by the QA/QI Committee.

THRESHOLD FOR EVALUATION Each indicator in the CQI Program will have thresholds established based on QA documents, national averages, recommendations of IHS specialty consultants, and other generally accepted sources. The source of each threshold will be listed. Comparison of the gathered data for each indicator with the appropriate threshold will then determine if further evaluation is indicated. Due to the high potential for morbidity or mortality, all sentinel events will be reviewed. All indicators appended to this plan will have the threshold and its source indicated.

COLLECTION AND ORGANIZATION OF THE DATA 102

Routine collection of information in the Dental Department concerning important aspects of patient care will be made utilizing medical and dental records, monthly computer printouts, appointment logs, recall files, RPMS, environmental health reports, maintenance records, health consumer satisfaction surveys, etc. The data source for each indicator is identified with the indicator, as is the frequency of collection and the responsibility for collection and analysis of the data.

EVALUATION OF DATA Once data have been collected and organized, they are evaluated to determine whether there is a problem and/or opportunity for care improvement. Evaluation of the data will determine if thresholds have been exceeded or if trends have been established. Other forms of feedback besides exceeded thresholds, such as staff or health consumer reports or suggestions, bench-marking with similar facilities in the Area, important single events, etc., can also be used to identify other opportunities to improve care.

ACTIONS TO IMPROVE CARE AND SERVICES If the evaluation identifies a problem, department staff should determine what action is necessary to solve the problem. A plan of corrective action identifies who or what is expected to change; who is responsible for implementing action; what action is appropriate in view of the problem's cause, scope, and severity; and when change is expected to occur. Emphasis will be placed on focusing actions on processes of care rather than of individuals. If a needed action exceeds the department's authority, recommendations are forwarded to the Facility QA/QI Committee. To be effective, corrective action must be appropriate for the problem's cause. Three common causes of problems are:

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Insufficient knowledge, skills or attitudes

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Defects in the system;

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Deficient behavior or performance. ASSESSMENT OF EFFECTIVENESS OF ACTIONS AND ASSURANCE THAT IMPROVEMENT IS MAINTAINED

After an appropriate time has elapsed since a corrective action has been taken, reevaluation must occur to see if the corrective action was successful. This assessment of action and documentation will be used to show sustained (trend analysis) improvement in the quality of patient care.

COMMUNICATION OF RELEVANT INFORMATION TO ALL STAFF

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It is essential that monitoring and evaluation information be communicated to the necessary individuals and departments throughout the community. Such interaction of information will begin with dental department staff meetings. Minutes of these meetings will be kept, and reports will be forwarded to the Health Director, QA/QI Coordinator and medical staff according to the bylaws and rules and regulations of the medical/dental staff. Integrating quality improvement information contributes to the detection of trends, performance patterns, or potential problems that affect more than one clinic or department of the facility. It also allows the information gathered to be used in granting and reassessing privileges and in conducting other performance evaluations such as employee performance standards.

RESPONSIBILITIES, PERFORMANCE EVALUATION Employees will perform only those tasks for which they are adequately trained, for which they possess the necessary skills, and for which they have been granted clinical privileges. Position descriptions will be available for each position. Employee Performance Management Systems (EPMS) evaluations will be conducted annually with reviews at least every six months for each civil service employee. Commissioned Officers will be evaluated annually using the Commissioned Officers' Effectiveness Report (COER). All members of the dental staff are responsible for knowing the contents of this QI plan and of all of the standard QI documents utilized by the program. The chief of the dental program will circulate these documents to the staff annually, and a signature sheet will be provided to document that each staff member has read the document.

RISK MANAGEMENT Incident and accident reports will be completed and processed as per Facility policy Valid health consumer and employee complaints will be referred to the appropriate staff for appropriate management All Dental Department staff will maintain basic CPR certification All dental assistants will maintain IHS Radiology certification. All dental staff will receive Electrical Safety, Fire Safety, Infection Control, and Hazard Communications training as per service unit safety guidelines Annual review of medical emergencies in Dental Department will be conducted Any other risk management issue will be properly followed Quarterly quality assurance activity report will be submitted to the Quality Assurance Committee Chairman. Quarterly, dental officer will have a minimum of three patient records audited. Records will be selected at random from patients seen by the dental officer during the preceding two months. Auditing criteria will be established by a consensus of all dental officers. Quarterly, radiation dosimeter reports will be reviewed and made available to all dental staff members. Annually, the x-ray department for leakage will check lead aprons

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Annually, x-ray units will be evaluated to assure they meet IHS radiation protection standards Weekly, used nitrous oxide units will be checked for leaks if they have been active Quarterly, nitrous oxide units will be checked to ensure that the fail safe system functions correctly if they have been used. Every two years nitrous oxide levels will be measured to assure that safety levels suggested by the National Institute of Occupational Safety and Health are being achieved. Every two years mercury vapor levels in the clinic will be evaluated to assure they meet safety standards established by the National Institute of Occupational Safety and Health. Annually, all health consumers seen during a one-week evaluation period will complete health consumer satisfaction questionnaire. Every three years a quality of dental care review will be completed using the criteria in the IHS Quality of Dental Care Document. A public health dental officer from outside the clinic will complete this.

(Insert Risk Management Check Sheet)

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ANNUAL

2002

2003

2004

2005

2006

CPR CERT IHS RADIOLOGY SAFETY INFORMED. CONTROL M.S.D.S. MED EMERGENCY LEAD APRON X-RAY UNITS N2O LEVELS Hg VAPOR DENTAL QA CONSUMER

QUARTERLY

2002

2

ND

3

RD

4

TH

2003

2n d

3rd

4th

QA REPORT

RECORD AUDIT RADIATION

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ANNUAL REAPPRAISAL The effectiveness of the Dental Department's CQI Program will be evaluated annually by the Chief, Facility Dental Officer (or his designee) and the facility QA/QI Coordinator. This annual reappraisal of the CQI Program will include evaluation of the organization, including the scope, effectiveness, objectiveness, comprehensives of the current activities, and community input from tribal sources or patient satisfaction surveys. The results of this evaluation will be reported to the Facility Director

CONFIDENTIALITY All QI records shall be maintained in accordance with the Privacy Act, Freedom of Information Act, and other local confidentiality policies as applicable.

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SCOPE OF CARE/SERVICES: DENTAL AMBULATORY SERVICE ASPECT OF CARE/SERVICES:

RISK MANAGEMENT, Standard and transmission based PRECAUTIONS

INDICATORS: All providers observe #1 adequate standard and transmission-based precautions during the delivery of dental care. These should include:

Χ Use of barriers between the provider and patient, e.g., eye protection, masks, gloves. Χ When recapping needle, use of one-handed needle capping technique or recapping device. Disinfecting of all treatment surfaces after patient dismissal is completed. Χ No cross-contamination of disinfected surfaces occurs, i.e., use of cotton pliers to retrieve sterile instruments, removing gloves or using a protective barrier to pick up the item. Χ Re-gloving after each violation of barriers is observed. Χ Hazardous infectious waste is placed in red bags of containers labeled "BIO-HAZARD" and marked with the universal biohazard symbol. THRESHOLDS, LEVELS, PATTERNS/TRENDS, OR BENCHMARKS FOR EVALUATION #1 each reported occurrence is reviewed.

SAMPLES #1 Observation by dental staff and documentation of each occurrence of failure to meet OSHA's Blood borne Pathogens Standard.

METHODOLOGY #1 On-going review of documentation at monthly dental provider meetings, or monitor one to two months and review.

DATA SOURCES #1 Slips are marked by each dental employee observing the occurrence and placed in marked boxes in the dental clinic.

RESPONSIBILITY/COMMUNICATION: The reviewing dentist will rate the variations in care using a "severity" scale. The Chief, Facility Dental Officer summarizes the findings of the quarterly reviews and reports to the Quality team, the QA/QI Committee, and medical/dental staff. The summary includes indicator measurement results, conclusions, recommendations, and actions planned/taken.

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SCOPE OF CARE/SERVICES: HEALTH CONSUMER SATISFACTION ASPECT OF CARE/SERVICES:

WAITING TIME, PROMPT TREATMENT, AND SATISFACTION WITH SERVICES

INDICATORS: #1 Established acceptable waiting time is 15 minutes for scheduled patients. Scheduled patients are seen within this average waiting time. #2 established acceptable waiting time for walk-in patients is 60 minutes. Walk-in patients are seen within the acceptable time. #3 Health Consumers receive prompt completion of dental treatment within one year and/or no more than six visits per year. #4 A health consumer satisfaction survey, given at least annually, indicates health consumers are satisfied with the waiting time for scheduled patients and for walk-in patients.

THRESHOLDS, LEVELS, PATTERNS/TRENDS, OR BENCHMARKS FOR EVALUATION: #1 - #2 90% #3 - #4 95%

SAMPLES: #1-2All patients signing in to be seen in the dental clinic during the monitoring period of two weeks. #3 All patients who had an examination over one year ago and are still in treatment. #4 all patients seeking dental care during the monitoring period of one month.

METHODOLOGY: A sign-up sheet that indicates the sign-in time can also indicate the time that the health consumer was called in to be seen. The waiting time for individuals and acceptable waiting time can be established at Facility using health consumer feedback and recommendations from administrative staff. The DDS software can be used to determine if patients were under treatment longer than one year. An approved IHS dental satisfaction survey is available for use in indicator #4.

DATA SOURCES: Sign-up sheets, DDS, Health Consumer Satisfaction Survey

RESPONSIBILITY/COMMUNICATION: The reviewing dentist will rate the variations in care using a "severity" scale. The Chief, Facility Dental Officer summarizes the findings of the quarterly reviews and reports to the Quality team, the QA/QI Committee, and medical/dental staff. The summary includes indicator measurement results, conclusions, recommendations, and actions planned/taken.

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SCOPE OF CARE/SERVICES:

DIAGNOSIS OF EMERGENCY DENTAL PAIN

ASPECT OF CARE/SERVICES:

S.O.A.P. FORMAT

INDICATORS: #1 all emergency dental visits are documented with the S.O.A.P. format. #2 the patient's chief complaint is addressed. #3 Objective findings are completed and documented including clinical and radiographic observations. #4 the diagnosis is consistent with and based on the subjective and objective findings. #5 the treatment plan is definitive in nature and appropriate for the diagnosis.

THRESHOLDS, LEVELS, PATTERNS/TRENDS, OR BENCHMARKS FOR EVALUATION: #1 - #2 - #3 - #4 - #5 are 90%

SAMPLES: #1 - #2 - #3 - #4 - #5 The Dental Data System is capable of selecting all patient records which contain the 0130 and 9170 code.

DATA SOURCES: #1 - #2 - #3 - #4 - #5 Emergency sign-up sheets, DDS software, Patient charts.

RESPONSIBILITY/COMMUNICATION: The reviewing dentist will rate the variations in care using a "severity" scale. The Chief, Facility Dental Officer summarizes the findings of the quarterly reviews and reports to the Quality team, the QA/QI Committee, and medical/dental staff. The summary includes indicator measurement results, conclusions, recommendations, and actions planned/taken. It includes results of previous follow-up for indicators previously monitored.

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SCOPE OF CARE/SERVICES:

RISK MANAGEMENT

ASPECT OF CARE/SERVICES:

INFORMED CONSENT

INDICATORS: #1 Written informed consent is obtained whenever a tooth is extracted. #2 Consent is obtained for all routine dental care at the time the treatment plan is presented. #3 Parents or legal guardians are available to give informed consent whenever a child under the age of majority is treated in the dental clinic (excluding legally emancipated minors and life-threatening emergencies. #4 Written informed consent is obtained for all sedation procedures requiring pulse oximetry by IHS guidelines. #5 Written informed consent is obtained for all surgical procedures (e.g., biopsies, perio surgery, impactions, etc.)

THRESHOLDS, LEVELS, PATTERNS/TRENDS, OR BENCHMARKS FOR EVALUATION: #1 - #5 85% (i.e., all cases where informed consent was not obtained need to be reviewed)

SAMPLES: #1 Random sample of 5% of cases having extractions or 30 cases, which ever is greater. #2 Random sample of 5% of exam patients or 30 exam records. #3 Sample of 5% or 30 records of patients under majority age. #4 Review all charts of patients receiving sedation. #5 Random sample of 5% or a minimum of 30 surgical procedures.

METHODOLOGY: #1 Extraction patients can be identified by using the DDS software. #2/3

Identify these patient using the DDS software for 0110, 0120 and 0130 codes. Review the charts for either a signature from the health consumer/parent/guardian, or a statement that the treatment plan was discussed with the health consumer and accepted.

#4 Use DDS software to identify patient who have received sedation using codes 9230, 9240, 9250, and 9260. #5 Use DDS software, biopsy logs of patients who have been coded as having received a surgical procedure in the 4000 or 7000 ADA code series.

DATA SOURCES: DDS, Biopsy Logs, Sedation Logs to identify specific patient health records to be reviewed.

RESPONSIBILITY/COMMUNICATION: The reviewing dentist will rate the variations in care using a "severity" scale. The Chief, Facility Dental Officer summarizes the findings of the quarterly reviews and reports to the Quality team, the QA/QI Committee, and medical/dental staff. The summary includes indicator measurement results, conclusions, recommendations, and actions planned/taken.

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MAINTENANCE - Section 42 PURPOSE To maintain equipment and facility to comply with infection control standards of the CDC, OSHA, and the State of North Carolina.

PROCEDURE Each unit will have a logbook pertaining to maintenance. Any maintenance that is required is entered into the book for that particular unit. The staff dental officer for maintenance required will check the logbooks weekly. If maintenance is required the staff dental officer will complete the necessary maintenance requests, refer them to bio-medical engineering or refer them to maintenance personnel. The staff dental officer will initial the logbook as the maintenance is completed. Should the bio-medical engineering be contacted, they will check the equipment and note in the logbook their findings. When the equipment is repaired the engineer will note the repair in the log. If funds are available a contracted vendor makes quarterly maintenance visits. The vendor shall provide a copy of maintenance performed for each dental unit and the staff dental officer will maintain these records.

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PHARMACY / PRESCRIPTIONS - Section 43 PURPOSE To maintain adequate communication between the Pharmacy and Dental Department, these procedures will outline the interaction.

PROCEDURE When it is determined by a dental officer that a health consumer will require medication prior to or after treatment, a prescription shall be written on a "PCC Form" and transported by the health consumer to the pharmacy. The pharmacists will notify health Consumers when the prescription is filled. The prescription shall be written in standard form in the outpatient notes or on the 42-2 Dental progress notes. If written in the dental progress notes, a note in the outpatient notes shall indicate a dental visit, and to refer to the dental progress notes. Prescriptions shall be written utilizing medications available through the pharmacy and on the formulary Prescriptions placed by phone to private pharmacies may occasionally be necessary. It will be the duty of the treating dental officer to call the pharmacy chosen by the health consumer in the event this becomes a necessary course of action. Consultation with the Chief Pharmacist for the use of a DEA number will be the responsibility of the treating dentist.

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USE OF DENTAL LABORATORIES - Section 44 Dental laboratories are used to fabricate dental appliances that we are unable to fabricate in the Facility Dental Clinic. These appliances require a laboratory prescription and all cases must adhere to infection control policy and procedure and contract health guidelines. Laboratory cases are cleared prior to scheduling by the Dental Officer in charge of Contract Health. This will determine the correct resources prior to initiating treatment.

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MEDICAL RECORDS - Section 45 Purpose To insure confidentiality and patient privacy, prevent loss, tampering and unauthorized access, the hospital Medical Records policies will be followed. Refer to Hospital Policy and Procedure Manual.

Confidentiality All patient information is coincidental. Privacy Act must be read signed and placed in each employees personnel file. The dental staff, medical staff and personnel from Medical Records access dental file information. Information can only be copied or removed from the dental file upon signed request from the patient. The clerk must return information that is removed, or staff member making copies of this information or by legally served subpoena from a legal body. Patient records contain information that is vital for the treatment of individuals. This information is coincidental and must be guarded at all times for observation by parties not named in the above paragraph. Records are not to be left open in patient areas and charts are not to be left in public areas unguarded. The RPMS system will maintain a 300 second shutdown and all PC terminals will have a screen-blanking program with password protection.

Data The data collected by the dental department in outlined in the Oral Health Program Guide section IX. This data is entered into the chart and later into the RPMS system. Data will follow a uniform structure of procedure-oriented notation for routine care and S.O.A.P. format for non-scheduled visits. Standard abbreviations and forms will be used for the dental charts and notations in them. All data must be entered into the dental chart be the end of the day of the patient visit. Charts are not to be kept in doctor’s offices or any location beside the dental clinic file cabinets. All charts must be filed by the end of each day with the exception of charts that are 'pulled' for future appointments. Provider signatures must all be original

Monitoring of Patient Charts The dental provider staff will audit aspects of the patient charts randomly on a monthly basis. These charts will be evaluated for completeness with specific notations sought. (ie: patient follow-up, reading of radiographs, etc.). Improvement of performance in evaluated by the use of the RPMS system and the Continual Quality Improvement Plan. The CQI plan also is a monitor for the each employee Annual Performance Appraisal (EPMS).

Training in Information Management

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Training for dental documentation, CDE, and regulation adherence (OSHA) will be performed on-site or arranged off site to fulfill requirements for the facility or the department. This training will be recorded on the RPMS system.

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APPENDIX - 1: DENTAL ABBREVIATIONS AND INITIALS Place the Recommended Abbreviations and Symbols For Use in Dental Records. The Dental Services Delivery Committee distributes these.

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APPENDIX - 2: DENTAL STAFF SIGNATURES AND INITIALS I, the undersigned have read the Dental Department Policy and Procedure Manual and have had an opportunity to ask questions of policies I do not understand.

NAME

INITIALS

DATE

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DENTAL POLICY AND PROCEDURE MANUAL General Instructions The following Dental Policy & Procedure (P&P) Manual is provided to you as a general guide to assist you in developing your Facility Dental Program Policies & Procedures. This manual may in fact, represent more detail and scope than required for your dental program needs. Utilize this document, as a resource to customize P&P based on your facility needs. Other facility documents (Medical Staff By-Laws, Fire & Safety Codes, Personnel Policies) are referenced in this P&P manual; therefore, you will need to edit this manual to relate closely with your other Facilities Policies & Procedures.

Byron G. Jasper, DDS Acting Area Dental Officer Nashville Area Office

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