[Facility]

Dental Policy and Procedure Manual Template

This document is a template for you to construct a comprehensive dental policy and procedure
manual. This document CANNOT be used as is. You must examine each procedure and match
the policy to your practices.

Throughout the document you will see type in Bold and type in italics. Bold type usually
means you must insert a specific name (facility, department, individual or State). Italicized type
usually indicates an example.

Check each policy for your facility’s unique requirements and practices.

Many policies are based on professional organizations’ recommendation s or guidelines. Those

policies include a statement such as:

This facility adheres to the [Organization] guidelines for [topic]. According to the
[organization’s] [Year] [position, policy or clinical guidelines]:
You may elect to include this statement and then use the entire recommendation or
guideline in quotes.
It is recommended you use the authoritative source whenever possible. You may use the
above statement and simply insert your facility’s name, the topic, the organization, date and
type of recommendation in the bold sections.

For more information or assistance in using this document contact:

M. Catherine Hollister, RDH, MSPH, PhD
Director-Nashville Area Dental Support Center
United South and Eastern Tribes, Inc.
711 Stewarts Ferry Pike
Nashville, TN 37214
mary.hollister@ihs.gov

Original Template: 2009

Revised: 2012

1
Acknowledgements:

Thanks to all of the dental programs and individuals who have contributed to this document.
Those who have contributed enitre policies, statements, recommendations or assisted in
revising or editing include:

Joyce Biberica, DDS, MS Tim Ricks, DDS, MPH

Cherokee Indian Hospital Authority Nashville Area Office

Harry Brown, MD Jeffrey Stuart, DDS

Nashville Area Office Catawba Health Center

Cherokee Indian Hospital Authority Michael Vito, DDS

Dental Policy and Procedures Manual Cattauagus Health Center
Seneca Nation
Kit Grosch, MPH
Nashville Area Office

Cathy Hollister, RDH, MSPH, PhD

United South and Eastern Tribes, Inc.

Byron Jasper, DDS

United South and Eastern Tribes, Inc

Dana Johnson DDS

Passamaquoddy Indian Township Health
Center

Northern Navajo Medical Center

Shiprock, NM

John Otteson, DDS

Oneida Nation Health Center

Pat Planck, RDH

Oneida Nation Health Center

Nick Porcello
Lionel R. John Health Center
Seneca Nation

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 Sample Policy Authorization Formats

Single Title Page to cover all policies

[Tribe or Facility] Dental
Policies and Procedure Manual

Policy/Procedure Type: Department(s):

□ Administrative Dental
□ Interdepartmental
 Departmental
Effective Date:

Revision Date:
Supersedes:

Signatures:
___________________________/_____________
Date
___________________________/_____________
Date
___________________________/_____________
Date

Header for each individual policy

Policy & Procedure Statement

Subject: Policy Name

Effective Date:
Revision Date:
Supersedes:

P&P Number: A.1

Signatures:

3
 Table of Contents
Sample Title Page with Signatures.....................................................3
Section A: Administration
A.1. Dental Program Policies and Procedures...................................6
A.2. Organizational Chart...................................................................9
A.3. Dental Program Summary...........................................................10
A.4. New Employee Orientation..........................................................12
A.5. Ordering/Requisitioning Supplies...............................................15
A.6. Privileging/Credentialing.............................................................16
A.7. Documentation.............................................................................17
A.8. Pain Documentation....................................................................19
A.9. Medical Records..........................................................................22
A.10. Staff Assignments and Duties....................................................23
A.11. Staff Training..............................................................................24
A.12. Students, Trainees and Volunteers...........................................25
A.13. Leave.........................................................................................28
A.14. Dress Code................................................................................30
A.14. Patient Satisfaction....................................................................31

Section B: Clinical Services

B.1. Appointment Procedures.............................................................34
B.2. After Hours, Emergency Dental Care, and Triage.......................37
B.3. On Call.........................................................................................40
B.4. Guidelines for Prenatal Oral Health Care...................................41
B.5. Intoxicated Persons.....................................................................42
B.6. Standing Orders for Dental Auxiliary Staff..................................43
B.7. Medical History............................................................................44
B.8. Schedule of Services...................................................................46
B.9. Completed Treatment..................................................................51
B.10. Referral Procedures..................................................................52
B.11. Dental Laboratory .....................................................................54
B.12. Protective Stabilization..............................................................56
B.13. Caries Stabilization....................................................................58
B.14. Informed Consent......................................................................59
B.15. Radiography..............................................................................61
B.16. Pharmacy/Prescriptions.............................................................66
B.17. Dental Pain Management..........................................................67
B.18. Pharmacological Management of Oral Infections.....................78
B.19. Extracted Teeth..........................................................................84
B.20. Hypertension Screening and Treatment Guidelines.................85
B.21. Premedication to Prevent Infective Endocarditis......................86
B.22. Premedication for Patients with Complete Joint Replacement.89
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B.23. Medical Emergencies in the Dental Clinic................................96
B.24. Reporting Domestic Violence....................................................99
B.25. Pathology...................................................................................101
B.26. Clinical Oral Disease Prevention/Health Promotion.................102
B.27. Nitrous Oxide.............................................................................103
B.28. Conscious Sedation..................................................................108

Section C: Environment
C.1. Infection Control..........................................................................119
C.2. Radiological Protection...............................................................135
C.2. Equipment Maintenance and Product Recalls............................136
C.3. Nitrous Oxide Safety...................................................................136
C.4. Fire Plan......................................................................................139
C.5. Mercury Hygiene.........................................................................140
C.6. Safety...........................................................................................144
C.7. Precious Metal Recovery............................................................146
C.8. Hazardous Communications.......................................................147

Section D: Quality Assurance

D.1. Continuous Quality Improvement (Clinical)................................174

D.2. Risk Management/Program Monitoring......................................177
Program Monitoring Tool ............................................................178
Sample Employee Training Tracking Form.................................194
Sample Facility Review Tracking Form......................................195

Section E: Community Health

E.1. Community Health Promotion/Disease Prevention.....................196
E.2. Head Start/Preschool..................................................................199
E.3. Infection Control for Portable Settings........................................200
E.4. Oral Health Surveillance ............................................................202

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SECTION A—ADMINISTRATION
A.1 DENTAL PROGRAM POLICIES AND PROCEDURES
PURPOSE
The purpose of the dental program is to provide quality clinical dental services in a
professional and efficient manner to those eligible for care at [Facility] Health Department.
This manual will act as a guide of policies to follow procedures set by the [Facility] Health
Department, and the Dental Clinic.

PROCEDURE

Mission Statement
The [Facility] Health Department is dedicated to the healing and well being of the individual,
family and community.
Vision Statement
 To commit ourselves to continuously improve all that we do.

 To provide our patients with the best possible health care and to support them in
their healing process.
 To support healthy lifestyle choices and educate on health related issues.
 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] Health Department
providing services in the diagnosis, treatment and prevention of oral disease. This treatment
may include emergency care, preventive services, oral surgery, restorative procedures, root
canal therapy and prosthetics.
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.

Policy Implementation
The policy of the dental department will be implemented through an organizational chart,
(See Policy A.2), and through a series of policies and procedures that follow. This department
is part of the entire facility and works within its guidelines. This department does not function
independently. Many patients seen by the dental clinic and staff of the dental clinic require
services from other departments of the facility.
Organizational Integration
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
structures are only a portion of the patient and the total patient is our concern. Medical
6
complications, patient education, and treatment of that patient in the dental department are
coordinated with all patient care delivery departments and support departments.
The dental department is a portion of the clinical division of that is supervised by the health
director. 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.
Short Range Planning include the following:

 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 in the clinic and activities outside the
dental clinic.
 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 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. Committees of the departments or services
involved accomplish planning for projects that concern or run jointly.
This long-range plan includes:
 More aggressive third party participation. This includes Patient Registration,
Benefits Coordination, Coding and Billing.
 Expansion of community contact to include screening and educational programs
for target populations that include the elderly, the young, those with specific
medical needs; for example diabetics 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.
 Become more patient oriented in action and policy.

Budget
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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 by the health director. Budgeted items that are planned
by several departments are negotiated prior the beginning of the fiscal year.
Staffing
Staffing levels are determined by the tasks involved in delivery of oral health care to this
community and these levels are also determined by a budgetary component with remote
decisions affecting the number of employees in this department. Recommend staffing levels
include (state desired staffing levels).
Staff Competency
Staff competency is measured by multiple means. Positions descriptions are in place for all
staff. Each 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 necessary to maintain licensure and as required by the [State] and the [Facility]
Health Department.

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A.2 ORGANIZATIONAL CHART

[INSERT FACILITY ORGANIZATIONAL CHART]

A.3 DENTAL PROGRAM SUMMARY
PURPOSE
To identify staff lines of authority and responsibility, describe the physical components of the
dental program, and general principles of oral health care delivery.

PROCEDURE
Description and Organization
The [Facility] Dental Program is directly responsible to the health director. The Dental Program
is the responsibility of the [individual].
Staff
[Staff, eg. Dentist, dental assistant, hygienists, receptionist, others] staff the dental clinic.
Referrals to private specialists are provided through contract health service funds or other
funds identified by the [Facility] Health Department.
Scope of Work
The dental program is designed to provide basic preventive and restorative dental services to
the entire family through education, disease prevention services, diagnosis and treatment of
oral health problems.
Each adult is responsible for his/her dental health. Parents/legal guardians are responsible for
the dental health of their legal wards.
Medically Necessary Care
This facility adheres to the American Academy of Pediatric Dentistry’s (AAPD) guidelines for
medically necessary care (MNC). According to the AAPD’s 2011 guidelines:
MNC is defined as:
“Medically necessary care (MNC) is the reasonable and essential diagnostic, preventive, and
treatment services (including supplies, appliances, and devices) and follow-up care as
determined by qualified health care providers in treating any condition, disease, injury, or
congenital or developmental mal-formation. MNC includes all supportive health care services
that, in the judgment of the attending dentist, are necessary for the provision of optimal quality
therapeutic and preventive oral care. These services include, but are not limited to, seda-tion,
general anesthesia, and utilization of surgical facilities. MNC must take into account the
patient’s age, developmental status, and psychosocial well-being, in addition to the setting
appropriate to meet the needs of the patient and family.” (AAPD, 2011. Available online at
http://www.aapd.org/media/Policies_Guidelines/D_MedicallyNecessaryCare.pdf)

Providing Medically Necessary Care:

“Dental care is medically necessary to prevent and eliminate orofacial disease, infection, and
pain, to restore the form and function of the dentition, and to correct facial disfiguration or
dysfunction. MNC is based upon current preventive and therapeutic practice guidelines
formulated by professional organizations with recognized clinical expertise. Expected benefits
of MNC outweigh potential risks of treatment or no treatment. Early detection and management
of oral conditions can improve a child’s oral health, general health and well-being, school
readiness, and self-esteem. Early recognition, prevention, and intervention could result in
savings of health care dollars for individuals, community health care programs, and third party
payors. Because a child’s risk for developing dental disease can change over time, continual
professional reevaluation and preventive maintenance are essential for good oral health. Value
of services is an important consideration, and all stakeholders should recognize that cost-
effective care is not necessarily the least expensive treatment.
The AAPD encourages:
1. oral health care to be included in the design and provision of individual and community-
based health care pro-grams to achieve comprehensive health care.
2. establishment of a dental home for all children by 12 months of age in order to institute
an individualized pre-ventive oral health program based upon each patient’s unique caries
risk assessment.
3. health care providers who diagnose oral disease to either provide therapy or refer the
patient to a primary care dentist or dental/medical specialist as dictated by the nature and
complexity of the condition. Immediate intervention is necessary to prevent further dental
destruction, as well as more widespread health problems.
4. evaluation and care provided for an infant, child, or adolescent by a cleft lip/palate,
orofacial, or craniofacial de-formities team as the optimal way to coordinate and deliver
such complex services.
5. the dentist providing oral health care for a patient to determine the medical indication
and justification for treatment. The dental care provider must assess the patient’s
developmental level and comprehension skills, as well as the extent of the disease
process, to determine the need for advanced behavior guidance techniques such as
sedation or general anesthesia.” (AAPD, 2011. Available online at:
http://www.aapd.org/media/Policies_Guidelines/P_MedicallyNecessaryCare.pdf)

These principles of Medically Necessary Care will be applied to all dental services for patients
of all ages.

Patient Rights
Describe process of informing patients of their rights.
Example:
Upon registration patients are informed of their rights and responsibilities. Each patient or
parent/guardian acknowledges understanding of these policies by signing a form which is kept
in their patient registration chart.
Protected Information
The confidentiality of patient records will be maintained according to the Privacy Act of 1974
and Health Insurance Privacy and Accountability Act (HIPAA). Any release of patient
information not covered under “Routine Uses” provision of the Privacy Act and/or HIPAA must
be authorized by the patient, the patient's legal guardian or by court order. Patients are
informed of their HIPAA rights at registration.

Grievances
Grievances concerning the dental program can be brought by patients directly to the
[appropriate individual]. The grievance will be fully investigated and the patient informed of
the findings in a timely manner.
A.4 NEW EMPLOYEE ORIENTATION
PURPOSE
To ensure each dental clinic employee receives personnel policies of [facility] and all
information necessary to deliver quality dental care.

PROCEDURE
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:

[Revise as needed]
Review the Dental Clinic Policy, Procedures, Rules and Regulations within seven days.
Complete Dental Clinic Orientation Checklist within two weeks.
A copy of the completed orientation form will be filed in the employee’s record.
The standard orientation form can be obtained from the [personnel office].
Orientation will be conducted by [appropriate individual].
ORIENTATION FOR DENTAL STAFF
[Sample Orientation Checklist. Revise as needed]
Name: _______________________________________
Employed On Date: _________________________

GENERAL FACILITY ORIENTATION DATE GIVEN or

NA

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

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

A.5 ORDERING/REQUISITIONING SUPPLIES

PURPOSE
To establish an efficient system for monitoring and procuring supplies necessary for the dental
clinic and related community dental programs.

PROCEDURE
The [appropriate staff] will be responsible for maintaining the supply system, the
[appropriate staff] shall act as the alternate.
Ordering Supplies
[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 have General Services process it with the Health Director's approval.
Inventory
Describe system of monitoring inventory
A.6 PRIVILEGING/CREDENTIALING
PURPOSE
The primary purpose of this process is to ensure that only practitioners who are qualified and
competent to practice are delivering services to patients. The process not only helps to
enhance patient safety, but it also helps to protect the health care organization from liability.
Credentialing is the process of documenting the licensure, professional education and training,
experience, current competence, and health status of a practitioner. Privileging is establishing
the manner in which a practitioner is allowed to practice (i.e., the scope of practice and types
of procedures carried out by the medical practitioner).

PROCEDURE
[Facility] Dental Program will follow Medical/Dental Staff Bylaws or other guidance established
by the Facility’s Governing Body. Copies are on file [location].
Dental Privileges Request Forms and Application for Appointment to the Medical Staff are
completed by each dentist, [and hygienist if Bylaws specify dental hygienists as providers]
and a copy kept in [location].
All visiting and temporary staff will follow the guidelines outlined in the Medical Dental Staff
Bylaws or other guidance established by the Governing Body. 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.

Each dental program should use a Core Dental Privileging Request Form. Dentists [and
hygienists if appropriate] requesting privileges for clinical services must specify categories for
which privileges are requested. Full or limited privileges will be granted or denied on the basis
of the requesting the provider’s documented training and experience. Documentation of
licensure, training and experience in the form of an appropriate training certificate or a letter
specifying past experience from the requesting dental provider’s current or immediate past
dental supervisor must accompany the Dental Privileges Request Form. [Insert Privileging
Application form]
A.7 DOCUMENTATION
PURPOSE
To ensure adequate record keeping for all services provided by the dental clinic.

PROCEDURE
Dental Record

The dental record may be maintained in a hard copy (paper chart) or in an electronic dental
record. Regardless of format, the minimal requirements of the dental record are:
1. Medical history
2. Pain documentation
3. Progress notes including all clinical impressions, treatments, medications, procedure
codes, and next visit needs
4. Examination and treatment plan form (for comprehensive care)
5. SOAP format (required for Emergency Care)
6. Consultations and referrals if needed
7. Laboratory prescriptions and results if needed
8. Radiographs and documentation that x-rays were read
9. Provider’s signature with credentials (may be an electronic signature for EDR)

Documentation
At every dental visit the dental provider will update and sign or initial the medical history.
Medical history update may be done on the medical history form or in the progress note. All
dental services will be documented in ink, contain the date and services provided, and contain
the provider’s signature with credentials. Precautions needed for specific physical status will be
noted as needed (e.g. appropriate premedication, laboratory test results, or blood pressure
recorded for patients with a history of hypertension)
Informed consent will be obtained for all routine services. See “Informed Consent” Policy B.13
for a full description of informed consent procedures.

Pain Assessment and Documentation

Progress notes will indicate the patient’s pain (0-10 scale) at each dental appointment. See
Policy A.7 for complete pain assessment and documentation.

Emergency Visits
The dentist will use the S.O.A.P. format for all emergency visits.
1. SUBJECTIVE S-COMPLAINT, PATEINT’S REPORT OF SYMPTOMS
2. OBJECTIVE O-OBSERVATION OF PROBLEM, RESULTS OF
DIAGNOSTIC TESTS
3. ASSESSMENT A-DIAGNOSIS
4. PLAN P-TREATMENT PROVIDED

Routine Care
A comprehensive examination form will be completed at the initial dental exam, in the event of
significant medical or dental changes, or at least every 3 years. The examination form will
contain a record of findings in the oral cavity for hard and soft tissues, periodontal screening,
temporomandibular joint health, orthodontic status, and documentation that radiographs have
been read by the dentist, and radiographic results. A treatment plan based on the results of the
examination will be completed. Updates or changes to the treatment plan will be dated and
initialed by the dentist as needed. Upon completion of the examination form, the dental
provider will explain the findings of the exam to the patient or parent/guardian and obtain
informed consent for the proposed treatment plan.
A.8 PAIN DOCUMENTATION
PURPOSE
To establish consistent procedures for assessing and documenting patient’s pain, using an age
appropriate assessment tool.

PROCEDURE

Progress notes will indicate the patient’s pain (0-10 scale) at each dental appointment. If pain
is indicated, progress notes will include a description of pain intensity and quality (e.g. location,
duration, exacerbating or relieving factors) and management strategies. (See Attached Adult
and Pediatric Pain Scale Assessment tools)

If a patient’s pain cannot be adequately managed by the treating dentist, the patient will be
referred for appropriate assessment and treatment. (See Pain Management Policy #B.16)
Adult Pain Assessment Scale

0 1 2 3 4 5 6 7 8 9 10
No Mild Moderate Severe Very Worst
Pain Pain Pain Pain Severe Possibl
Pain e
Pain

Pain Assessment Scale Key:

0 = No Pain
1-3 = Mild Pain – MILD PAIN ANNOYING – pain is present but does not limit activity
4-5 = Moderate Pain – NAGGING PAIN, UNCOMFORTABLE, TROUBLESOME – can do most activities
with rest periods
6-7 = Severe Pain – MISERABLE, DISTRESSING – unable to do some activities because of pain
8-9 = Very Severe Pain – INTENSE, DREADFUL, HORRIBLE – unable to do most activities because of
pain
10 = Worst Possible Pain – WORST PAIN POSSIBLE, UNBEARABLE – unable to do any activities
because of pain
 Pediatric Pain Assessment Scale

0 1 2 3 4 5 6 7 8 9 10
No Hurts Hurts Hurts Hurts Hurts
Hurt Little Little Even Whole Wors
Bit More More Lot t

Pain Assessment Scale Key:

0 = No Hurt
1-3 = Hurts Little Bit – MILD PAIN ANNOYING – pain is present but does not limit activity
4-5 = Hurts Little More – NAGGING PAIN, UNCOMFORTABLE, TROUBLESOME – can do most activities
with rest periods
6-7 = Hurts Even More – MISERABLE, DISTRESSING – unable to do some activities because of pain
8-9 = Hurts Whole Lot – INTENSE, DREADFUL, HORRIBLE – unable to do most activities because of
pain
10 = Hurts Worst – WORST PAIN POSSIBLE, UNBEARABLE – unable to do any activities because of
pain
A.9 MEDICAL RECORDS

PURPOSE
To ensure confidentiality and patient privacy and prevent loss, tampering and unauthorized
access, the [Facility] Medical Records policies will be followed.
PROCEDURE
Confidentiality
All patient information is confidential. Privacy Act and HIPAA training must be completed within
30 days of employment. Documentation of completed training will be placed in each
employee’s personnel file. Information not covered under “Routine Uses” in the HIPAA rule can
only be copied or removed from the dental file upon signed request from the patient. All
information in a patient’s record is subject to HIPAA regulations.
Records are not to be left open in patient areas and charts are not to be left in public areas
unattended. Schedules with names and procedures will not be left in areas visible to patients.
Computer terminals will be situated in such a manner that information cannot be seen by non-
staff. Computer terminals will not be left unattended while the employee is logged on
(exception: employee uses computer “lock” function).
Data (Hard Copy Charts)
All patient visit data must be entered into the dental record by the end of the day of the patient
visit. Charts must be monitored or kept in a secure location at all times. All charts must be filed
by the end of each day with the exception of charts that are 'pulled' for future appointments.
“Pulled” charts must be kept in a secure location. Patient visit data must be entered into the
computer system no more than [## days] following the dental visit.
Training in Information Management
Training for dental documentation will be performed on-site or arranged off site to fulfill
requirements for the facility or the department. This training will be documented by [CE
coordinator].
A.10 STAFF ASSIGNMENTS AND DUTIES
PURPOSE
To describe staff requirements necessary to provide quality oral health services.

PROCEDURE
[Develop your own Staffing requirements]
Example:

The full time, permanent Dental Clinic staff will consist of two general dentists and five auxiliary
personnel. The auxiliary personnel will be composed of one dental assistant supervisor, one
dental hygienist, two chair side dental assistants, and one dental receptionist.
When available the dental hygienists will schedule patients through the dental receptionist.
The hygienists will be responsible for starting new adult patients and seeing referrals from the
dentists. New adult patients will be examined and treatment planned by the dentist 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 dentists
Additional temporary providers, volunteers, and non-permanent employees will be assigned
into the clinic schedule to expand services when available.
Wednesday mornings no patients will be scheduled. Staff will use this time to attend meetings,
stock dental units, complete required documents, or other administrative duties.

Duties of the Staff

The [Program Director] 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 [Program Director] will be responsible for career development activities of
the dental staff under him/her. The [Program Director] will provide dental health services to
the designated population according to clinical skills and privileges granted by the facility.
The [appropriate staff] is responsible for assigning duties to the dental staff. Staff assignment
duties may be delegated to [appropriate staff].
The [appropriate staff] will act as Program Director in the absence of the Director.
[Appropriate staff] will serve as the Chairperson of the Dental Health Promotion / Disease
Prevention committee. He/she will monitor ongoing HP/DP activities and make
recommendations to the [Program Director] regarding clinical and community HP/DP
activities.
A [appropriate staff] will be responsible for ordering all necessary supplies and maintaining
inventory and budget control. A [appropriate staff] will serve as a member on the
[appropriate committees or work groups].
Include other staff assigned duties as needed.
A.11 STAFF TRAINING

PURPOSE
Training of employees is an indispensable portion of the function of the clinic. Training
ensures that consistent quality procedures are provided in the dental clinic and community.
PROCEDURE
Training will be used to develop and improve abilities necessary to protect patients, provide
high quality dental care, ensure effective programs and promote team cohesiveness to fulfill
the mission of the department. Training may be provided through in-services at the facility,
external continuing education (CE) courses, online CE courses, agency sponsored conference
calls, or other distance learning mechanisms.
In-Service
This training will be arranged through the [CE coordinator]. This training will be specific and
will fulfill specific objectives such as orientation, safety, infection control, Occupational Safety
and Health Administration (OSHA) requirements, Privacy Act/HIPAA, hazardous situations,
record keeping, and other required topics. Outside presenters will be obtained to provide
training for those topics that cannot be provided by this facility.
Continuing Education
Continuing education (CE) will be provided annually as resources permit. If resources become
limited, prioritization will be done by the [Program Director]. Preference for external CE will be
given to staff members who must obtain continuing education to maintain licensure and/or
certification.
Employees are responsible for finding appropriate CE courses, determining if those CE
courses fulfill State requirements, and requesting CE through the supervisor. Each licensed or
certified dental staff member is responsible for completing adequate continuing education to
maintain licensure or certification. Individual staff members are responsible for maintaining
documentation of CE courses and reporting CE to the State licensing board as required.
Training needs will be determined by employee performance evaluations. Training requests
must be submitted to and approved by [appropriate individual]. Each staff will identify long
and short term training goals. Training priorities will be set by:
1. Improvement of skills necessary for job performance.
2. New techniques to be used in assigned clinical duties.
3. New clinical duties.
4. Acquiring skills that are identified as needs of the facility or department.
A.12 STUDENTS, TRAINEES and VOLUNTEERS

PURPOSE

The [facility] may utilize students, trainees, and volunteers either in the provision of direct care
or in direct support of health care services at the clinic.
The purpose of this policy is to outline the guidelines at [facility] for the provision of care for
student externs, trainees, and volunteer health care providers.

PROCEDURE

Each student, trainee, or volunteer (herein referred to as volunteer) who provides direct care at
the [facility] shall secure authorization from the [facility] Medical Director prior to providing
any direct care on patients. [Insert types of documentation required] shall be furnished at
least [time period required for document submission] prior to reporting for work.

All volunteers will comply with all [facility] policies and procedures.

All volunteers will have a position description that includes qualifications and major duties;
other duties may be assigned as appropriate to the position. All volunteers will be given an
orientation that includes but is not limited to:

Mission and goals of [facility];

HIPAA/Privacy Act;
Role and responsibilities of the student/trainee;
Employment policies governing volunteers;
Clinic eligibility and appointment policies;
Clinical policies pertinent to the volunteer’s scope of work;
Working hours including lunch and other breaks;
Required patient record documentation;
Grievance Policy;
Relationship of the various clinic departments;
Organizational Chain of Command;
Location of lunch area, restrooms, Director’s office, etc.;
Infection Control and Safety policies.

All volunteers will wear an identification badge while on site at [facility], and to return the
identification badge [time when badge is to be returned] Example: at the end of the
volunteer service, or upon final checkout.

Volunteers Providing Direct Patient Care Services

All volunteers providing direct care to patients will be introduced to the patient by the
supervisor, or his/her designee, as a student/trainee/volunteer. The patient may refuse to
be treated by the student/trainee/volunteer. The patient may accept to be treated by the
student/trainee/volunteer by signing the Student Volunteer Form (attached). At all times
when the student/trainee/volunteer is present, the supervisor is responsible for the
provision of care, communication with the patient, and any follow-up care required.
If the student is in a formal externship agreement, a Collaboration Agreement or Affiliation
Agreement must be signed and approved by the [facility] Clinic Director prior to the
student’s arrival.

Attach Externship Agreement form(s)

 DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
PATIENT CONSENT TO TREATMENT BY A
VISITING DENTAL OR DENTAL HYGIENE STUDENT

Clinical services at IHS dental facilities are sometimes provided by dental or dental hygiene students
visiting the clinic. These students are in the process of earning a degree from a dental or dental hygiene
school.

I have been introduced to ________________________________________________________

(Name of student, plus title: “dental student” or “dental hygiene student”)

Visiting from ___________________________________________________________________

(Name of Professional Institution)

I understand this student will be providing clinical services for me today. I am aware this student has not
yet earned a dental or dental hygiene license. I understand that all services provided by the student will
be under the supervision of a licensed dentist or dental hygienist who is at this clinic while the student is
treating me.

I understand it is my right to stop a procedure at any time if I do not feel comfortable with the student,
and I may ask for a second opinion from the supervising licensed dentist or dental hygienist. I understand
I have the right to be treated by a licensed dentist or dental hygienist. I understand that I may revoke or
withdraw my consent to treatment by this student at any time.

I give my permission or consent to be treated by this dental or dental hygiene student. I agree that I have
had the chance to ask any questions I have about these arrangements.

__________________________________________________ ____________________
(Signature of Patient) (Date)

__________________________________________________ ____________________
(Signature of Legal Guardian, If necessary) (Date)

__________________________________________________ ____________________
(Signature of Student) (Date)

__________________________________________________ ____________________
(Signature or Supervising Dentist or Dental Hygienist) (Date)

IHS-950 (9/04)
A.13 LEAVE
PURPOSE
To ensure compliance with [facility] leave policies.

PROCEDURE
Annual Leave
[Follow your Facility’s Personnel Policy for leave]
Example:

Approval of annual leave for dental personnel will be at the discretion of the 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 Absent Without Leave (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), 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.
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.
 Absent 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.
A.14 DRESS CODE
PURPOSE

To ensure all employees are appropriately attired to deliver professional services in a safe and
efficient manner.

PROCEDURE

Chairside dental personnel shall wear a full coverage water impervious gown. The gown must
be either discarded daily or cleaned if it is not disposable. Gowns must not be worn outside of
patient care areas.
Medical scrubs, clean, casual dresses, slacks, shirts, etc. are acceptable; clothing such as
jeans, sweatshirts, tank tops are not acceptable when working in patient care areas.
Clean, polished shoes, clinical shoes, or athletic shoes are acceptable. At no time may open
toed shoes be worn in patient care areas or dental laboratory.
Finger nails should be smooth and not interfere with wearing gloves necessary for patient care.
Rings or other jewelry must be smooth and not interfere with wearing gloves necessary for
patient care.
Hair should be clean, groomed and kept neat.
[if applicable]Commissioned Officers shall follow all Local Authority Uniform Instructions when
not working in patient care areas.
A.15 PATIENT SATISFACTION

PURPOSE
To solicit patient attitudes and level of satisfaction regarding oral health services provided by
[facility]

PROCEDURE
[Frequency] patients will be asked to complete a Patient Satisfaction survey.
Describe Process.
Example:
Patient satisfaction surveys forms will be given to patients who visit the dental clinic in the 1 st
week of the April and the 1st week of September. Surveys will be distributed to patients as they
check in with the instructions to complete the survey and deposit the form in a box at the
reception desk.
Attach Patient Satisfaction Form
Results
Results of the patient satisfaction survey will be communicated to facility administration and to
each member of the dental staff and. Areas of poor satisfaction will be addressed in a staff
meeting, through continuing education, or other appropriate means.
 Sample Patient Satisfaction Survey
Instructions:

Please answer the following questions regarding your MOST RECENT visit to the dental clinic.

Date of Visit ________________Provider_________________

Type of Visit Appointment Walk in

(Circle One)

Good Fair Poor

How satisfied were you with:
  
Length of your dental appointment
Scheduling appointments
Reminder Cards
Staff timeliness
Receiving appropriate dental
treatment
Receiving treatment options
Dentist (courteous and
professional)
Dental hygienist (courteous and
professional)
Dental Assistant (courteous and
professional)
Receptionist (courteous and
professional)
Quality of dental care provided
Ability to ask questions
Receiving a follow up appointment
Confidentiality
Referral policy
Pain control
Overall Dental Care
Compliments or Comments:
Section B: Clinical Services
B.1 APPOINTMENT PROCEDURES
PURPOSE
The purpose of this policy is to create a mechanism of efficient scheduling to ensure timely
dental services for eligible recipients.

PROCEDURE

Definitions
BROKEN APPOINTMENT:
This is: (1) an appointment that is missed completely, (2) when the patient is more than
15 minutes late by the clinic clock and has not called one full day ahead of the
appointment to reschedule.
CANCELED APPOINTMENT:
This is when a patient is unable to come for a scheduled appointment and phones one
day in advance to reschedule their appointment.
OPEN ACCESS
Patients are seen without an appointment as they present to the clinic
ROUTINE PATIENT:
This is a patient that has received a scheduled appointment.
SHORT CALL LIST: (When necessary based on demand)
This is a list of patients who have been treatment planned for routine dental services.
Due to the inability of the clinic to meet the demand for patient care in the past, the list
will serve as a patient pool and will be called as soon as possible considering clinic
demand. If time permits, 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 appointment.
WALK-IN CLINIC:
This clinic will care for acute emergencies on a daily basis [hours]. This clinic will also
handle some treatment of routine patients.

Open Access
High risk groups of eligible beneficiaries including [insert current high risk groups such
as Head Start children, children age 0-3, diabetes patients] will have Open Access to
the dental clinic for preventive services including [insert services such as screening,
fluoride varnish, OHI, exams]. Patients seen in Open Access will receive follow up care
as needed according to the Patient Appointment procedures. Patients may report to
Patient Registration before or after the Open Access visit.
 Patient Appointments
To receive an appointment the patient must first become registered for care at the facility.
Patients must meet eligibility requirements as determined by [facility] in order to schedule a
routine appointment.
The registered patient will be given an appointment for [procedures that may be requested]
when requested.
Patients 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 patient is waiting. When a chair is available a dental auxiliary will seat
the patient.
Patients 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 had their planned treatment completed for that day.
The dentist will then determine if enough time permits to provide some dental care for those
patients who are waiting. If the patient decides to reschedule his/her appointment after coming
in late he/she will be charged with a broken appointment. [This section should be based on a
facility policy]

Scheduling Priorities
Describe priorities for dental appointments
Example
1) Emergency dental needs (See Policy B.4)
2) Severe Medically compromised (e.g.,pre-organ transplant, or pre-chemo/radiation
therapy)
3) Children
4) Deploying military personnel
5) Students (to accommodate school schedule/breaks)
6) Adults
B.2 AFTER HOURS, EMERGENCY DENTAL CARE, and TRIAGE

PURPOSE
To establish criteria and procedures for emergency dental treatment during and after routine
dental clinic hours.

PROCEDURE
Definition
A dental emergency may include but not be limited to one of the following:
 Severe pain that started within the past 2-3 days
 Severe pain that keeps the patient awake at night
 Facial swelling
 Fever due to an oral infection
 Excessive bleeding following dental treatment
 Teeth that have recently been loosened, knocked out or broken due to trauma
 A facial injury with possible maxillary or mandibular fracture.

Intake Procedures
(Describe procedures followed for emergency patient intake and processing)
Example: Clinics with On Call Dentists
When emergency patients call or present for treatment, medical or dental staff may use the
triage questions listed above to determine if the patient can wait to be seen in the dental clinic
or should be immediately referred to the Emergency Room. Patients to be seen in the dental
clinic 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 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.
Example: Clinics without On Call Dentists
When emergency patients call or present for treatment, medical or dental staff may use the
triage questions listed above to determine if the patient can wait to be seen in the dental clinic
or should be immediately referred to the Emergency Room. Patients to be seen in the dental
clinic 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 referral form during regular working hours.
After regularly scheduled hours, patients should report to the Emergency Room for
assessment and emergency care based on the Triage Protocols. Appropriate transfer of the
patient to dental referral services or [Facility] dental clinic during routine clinic hours will be
determined by the attending physician.

Scheduling
Emergency patients will be treated on a time available basis. Emergency patients will receive
treatment the day they report to the clinic with their chief complaint, schedule permitting. The
patient will be given medication for relief of pain and/or infection and rescheduled or referred if
treatment cannot be rendered that day.
Emergency patients will be seen in the Dental Clinic [hours].
Patients with dental emergencies after normal clinic hours will report to [appropriate location].
 Dental Triage Guide

Medical or dental staff may triage patients to determine dental emergency needs and necessary
immediate interventions. If patients call with an oral health complaint, the following triage protocol is
suggested.

Complaint Suggested Therapy Patient Disposition/Follow up

Severe pain that started within Pain medication Emergency Dental Clinic or next
the past 2-3 days available scheduled appointment

Severe pain that keeps the Pain medication Emergency Dental Clinic or next
patient awake at night available scheduled appointment

Facial swelling (mild), w/o fever, Pain medication and antibiotics Emergency Dental Clinic or next
no airway restriction available scheduled appointment

Facial swelling(moderate-severe) Pain medication and antibiotics Emergency Dental Clinic (same
w/ fever, no airway restriction day) or ER

Airway sequelae (e.g.,unable to If Dentist available immediate Immediate dental or ER

open mouth, and/or can’t stick dental evaluation. If no Dentist evaluation
out tongue, and/or sublingual available, ER referral
swelling, and/or uvula deviation

Any airway restriction Immediate evaluation and Immediate emergency care

Oral bleeding
Trauma that leads to (e.g.,loose,
broken, or avulsed teeth, or
where facial fractures are
suspected)
treatment
If Dentist available immediate
dental evaluation. If no Dentist
available, ER referral
If tooth knocked out, place tooth
in milk (if possible) then ER
referral for C spine/neurological
clearance
Immediate dental or ER
evaluation and treatment
ER. After cleared by a physician,
have the patient follow up with
the dental clinic

(Catawba Dental Clinic, Dr. Jeffrey Stuart, 2008)

B.3 ON CALL

(include this policy only if your facility has an active “On Call” program. For
those clinics without an “On Call” program, See Policy B.2 “After Hours,
Emergency Care, and Triage”)

PURPOSE:

To provide for consultative services in the event of dental emergencies at the [Facility] during the
hours that the dental clinic is closed.

POLICY:

The Dental Program shall have one Dentist in “on call” status at all times. The “on call” dentist will
be available by cell phone at all times for the purposes of providing verbal consultation in regards
to dentally related matters to other [Facility] professional staff members.

PROCEDURES: (Describe Dental Call schedule and procedures)

Example:

1. All dentists working within the [Facility] Dental Department are required to rotate pulling
dental call for one week at a time. To ensure fairness, there will be a separate rotation for
the 10 annual Federal Holidays. If a dentist has a conflict and cannot pull call for a week
that they are scheduled to be on call, it is their responsibility to find another dentist to
trade call weeks with. Such trades must be appropriately recorded on the call schedule
and both dentists must agree to the trade.
2. The Deputy Chief of the Dental Program will have the responsibility of preparing and
updating the dental call schedule.
3. Dental call will start at 8:00am on each Wednesday and end at 8:00am the following
Wednesday.
4. The dentist on call should be available at all times by cell phone. Given that travel within
the region, including to and from available housing, will often take dentists through areas
without cell phone coverage, it is essential that dentists on call check their cell phone
messages on a frequent and recurring basis. Any messages from the [Facility] in
regards to a dental emergency must be returned as soon as possible.
5. Because the standard of care is often difficult or impossible to meet without a trained
dental assistant and there are no dental assistants available after-hours, on call dentists
are only available for phone consultation. The vast majority of general dental
emergencies are easily treated with antibiotics and/or analgesics until the dental clinic
opens the following day. Cases involving facial fractures or severe life threatening
swellings or infections are beyond the scope of general dentists and should be referred
directly to an oral surgeon.
6. A dental emergency kit is kept in the Emergency Room for use by the ER staff. On each
Wednesday, the new on call dentist is responsible for:
a. Restocking the ER’s dental emergency kit.
b. Advising the ER staff that they are on call and giving them the appropriate contact
information the ER staff will need in order to contact them in a timely manner.
B.4 GUIDELINES for PRENATAL ORAL HEALTH CARE

PURPOSE
To establish guidelines for the treatment and prevention of oral diseases during
pregnancy and to promote the overall oral health of women and infants.

PROCEDURE
This facility adheres to the National Maternal and Child Oral Health Resource
Center guidelines for treatment during pregnancy. Recommendations of the
NMCOHRD’s 2008 guidelines include:
General Dental Health Services:
 Oral hygiene and oral health during pregnancy is important to overall health of
the mother and fetus
 Oral health care during pregnancy is safe and effective and is essential for the
pregnant woman and the fetus
 Diagnosis (including necessary dental X-rays) and treatment for conditions
requiring immediate attention are safe during the first trimester of pregnancy
 Necessary treatment can be provided throughout pregnancy; however the
period between the 14 th and 20th week of pregnancy is the best time to provide
treatment
 Delaying necessary treatment could result in significant risk to the mother and
indirectly to the fetus

Dental provider will consult with the prenatal care Heath Professional in cases of:
 Deferring treatment because of pregnancy
 Co-morbid conditions or medication use (e.g. diabetes, hypertension,
heparin use) that may affect management of oral problems
 Intravenous sedation or general anesthesia to complete dental
procedures
B.5 INTOXICATED PERSONS

PURPOSE
To provide a protocol for the treatment of intoxicated persons who present themselves to the
dental clinic requesting care.
This policy is necessary for the following reasons:

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

instructions.

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

3. Intoxicated patients cannot give adequate medical histories.

4. Intoxicated patients cannot be given appropriate pain medications due to the

possible interactions between the pain medication and the intoxicating substance.

5. Intoxicated patients may become abusive, unmanageable and violent while receiving
treatment.

PROCEDURE

Intoxicated individuals will not be treated in the dental clinic, except in cases of life threatening
emergencies.

If a patient, in the judgment of the treating dental provider, is under the influence of alcohol or
other intoxicating substances, he/she will be asked to leave the clinic and return when no
longer impaired for care. Security will be called to remove the intoxicated patient if he should
become belligerent or abusive.

Other dental staff such as receptionists who observe behavior believed to be caused by
alcohol or other intoxicating substances will alert the dental provider who will then make the
decision to treat the patient or defer treatment until the patient is no longer impaired.

Patients who repeatedly present to the dental clinic in an intoxicated state will be referred to
their medical provider or appropriate behavioral health program.
B.6 STANDING ORDERS FOR DENTAL AUXILIARY STAFF

PURPOSE
To establish authorization for dental auxiliary personnel to provide dental procedures allowed
under the [State dental practice act or IHS regulations].

PROCEDURE
Dental Receptionist
The dental receptionist or dental staff member who checks patients or parent/guardian in for
dental treatment will give all new patients and emergency patients a Dental Health History
Form to complete. The dental staff member who seats the patient will check the form for
completeness and help the patient complete the form if needed.
Dental Assistants
Dental assistants trained to take blood pressures will take and record in the patient’s health
record blood pressures on all new patients 30 years old and older with a history of
hypertension. This will be done on the patient's first visit of the year and on emergency
patients 30 years old or older at each emergency visit if a reading taken within 30 days cannot
be found in the patient’s medical or dental record.
Dental assistants trained and certified in dental radiography shall take a periapical x-ray in the
area of the chief complaint for emergency patients. The dentist shall be consulted in the case
of "loose", exfoliating primary teeth prior to taking a periapical radiograph.
Dental assistants who perform direct services for patients (e.g. oral hygiene instructions,
patient counseling for tobacco cessation, sealants, fluoride treatments, etc.) shall have the
charts reviewed and signed by the supervising dentists.
Dental Hygienists
Initial Treatment
Dental hygienists will follow treatment plans determined at the initial exam and perform
all services allowed by [IHS guidelines for sites following IHS guidelines, or State Practice
acts for tribal sites.] [For States or IHS sites allowing unsupervised dental hygiene
services or assessments, insert allowed services and procedures here.] Hygienists may
assess for and place sealants on pits and fissures on teeth that have not been treatment
planned for restoration. OR Hygienists may review medical history and provide appropriate
basic preventive services including prophylaxis, fluoride treatments, and determine the need
for and place sealants prior to a comprehensive dental examination.
Recall
The dental hygienist may determine the patient’s risk category and establish an appropriate
recall schedule. For patients of record, X-rays and clinical services will be provided without a
reassessment by a dentist. (See Radiography Policy B.14. for radiography frequency
guidelines) Upon completion of treatment, dental hygienists will complete the patient record
and sign the chart with name and credentials. No co-signature is needed for services provided
by a dental hygienist.
B.7 MEDICAL HISTORY

PURPOSE
To ensure that appropriate precautions are provided according to each patient’s physical status
as determined by medical history, physician’s recommendations, and/or risk factors.

PROCEDURE
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. A new form must be completed at least every 24
months.

As the patient enters the clinic, the receptionists will give them a blank form and instructions for
completing 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. Family members or staff members may assist patients with
literacy, language or sight issues who cannot read or understand the form. The patient’s or
parent/guardian signature on the Medical History form indicates that all statements are true
and gives consent for the dental provider to initiate screening, examination and diagnostic
services. Informed consent including a full discussion of treatment needs, risks, benefits and
alternative treatments will be obtained following the completion of the examination form. (See
Informed Consent Policy B.13)
When the patient is seated in the dental operatory, the dental assistant and later the dental
provider will interview the individual or their guardian as to the questions on the form.
If there is inadequate information to determine appropriate precautions for dental treatment
based on the responses or if there is a discrepancy in the replies to the dental provider’s
questions, further investigation is initiated. If necessary the medical chart is obtained. If the
dental provider is still unable to answer the question to his/her satisfaction, the patient will be
referred to the [appropriate clinic or referral site] with a completed referral form indicating
the specific medical evaluation request. The examination by the medical provider is followed by
a routing of the results via [appropriate mechanism] or verbal consult with the dental provider
to answer to the initial question.
Dental procedures will not be initiated until there are no questions remaining in the health
history.
If medical alerts are found, precautions for those alerts are determined and initiated. These
alerts and/or precautions are noted on the bottom of the Examination Form and a medical
caution sticker is placed on the front of the individual's dental chart. Notation will also be made
to print a current Health Summary at each dental visit.
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. For EDR clinics: Completed and signed medical history
forms are scanned into the Electronic Dental Record.
[Delete this paragraph if not applicable]
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. (See Sedation Policy B.25 for a full description of required
documentation)
B.8 SCHEDULE OF SERVICES

PURPOSE

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 patients as possible.
This facility adheres to the IHS guidelines for service priorities. In accordance with the IHS’s
2007 Oral Health Program Guide, 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.

PROCEDURE
Dental Service Priorities

Schedule of Services (IHS Oral Health Guide: Section V)

Level I — Emergency Care

Includes those dental services which are necessary to relieve or control acute oral conditions,
such as: serious bleeding, a potentially life-threatening difficulty, maxillo-facial fractures, and
swelling and severe pain, or other signs of infection. Other conditions which the patient may
determine to require urgent attention are also classified as Level I care (e.g., prosthodontic
repairs).
Procedures which are frequently reported in this category of care are listed below:
• Emergency oral examination (limited to problem area)
• One or more periapical radiographs associated with the problem
• Simple tooth extractions
• Temporary or sedative restorations
• Palliative procedures
• Prescription medications for pain and infection
• Endodontic access preparations
• Draining of oral abscesses
• Denture repairs and other urgent repairs

Level II — Primary (Preventive) Dental Care

The procedures classified as primary care are those which prevent the onset of oral disease.
Clinical services to individual patients and community health activities are included in Level II
care.
The primary care services most frequently provided are:
• Adult prophylaxis with or w/o topical fluoride
• Child prophylaxis with or w/o topical fluoride
• Sealants by tooth or quadrant
 • Preventive (self-care) training
• Periodontal recall procedures
• Athletic mouthguards
• Water fluoridation activities
• Group education
• Tracking of number of children receiving supplemental fluorides per month

Level III — Secondary Dental Care

Level III services are those deemed necessary for routine diagnosis and treatment to control
the early stages of disease. Level III procedures are generally not complicated in nature, and
one or more of these services can usually be completed in one appointment.
The Level III procedures commonly reported include the following:
• Initial or periodic oral exam
• Bitewing and panoramic radiographs
• Diagnostic casts
• Space maintainers
• Amalgam restorations (1,2,3-surface)
• Composite restorations (1,2,3-surface)
• Stainless steel crowns (primary teeth only)
• Therapeutic pulpotomy (primary teeth only)
• Anterior endodontics (one canal)
• Periodontal scaling/root planing
• Biopsy, excision of lesion

Level IV — Limited Rehabilitation

Rehabilitative care is that which restores oral structures to an improved condition and form.
Limited rehabilitation is defined by the IHS as those dental procedures which are more
complex and costly to provide than Level III care in controlling disease and restoring function.
The following Level IV services are those most frequently utilized:
• Complex amalgams (4 or more surfaces)
• Cast onlays or crowns with or w/o porcelain
• Post and core restoration
• Crown buildups
• Acid etch (Maryland) bridge
• Bicuspid endodontics (two canals)
• Apicoectomy/retrograde filling
• Gingivoplasty
• Limited/interceptive orthodontics
Level V — Rehabilitation
The dental services classified into this level are rehabilitative procedures which require more
clinical chairtime, additional knowledge and skill of the care provider, and usually greater
expense than the limited rehabilitative services listed under Level IV care. Level V services
usually require multiple appointments to complete, are usually associated with a rehabilitative
plan for the entire mouth, and generally require a substantial patient copayment to cover
professional fees in dental insurance and other third party programs.
The Level V services most frequently provided are:
• Molar endodontics (3 or more canals)
• Periodontal surgery (mucogingival and osseous)
• Complete and partial dentures
• Denture rebase (laboratory)
• Fixed bridgework (retainers and pontics)
• Surgical extractions (impactions)
• Analgesia (e.g., nitrous oxide)

Level VI — Complex Rehabilitation

Level VI includes those services which usually require more time, skill, and cost than the
rehabilitative procedures classified under Levels IV and V. A substantial portion of patients may
require referral to specialists for complex rehabilitative treatment; however, referrals must be
justified by special circumstances which warrant the associated higher costs. Level VI services
may not predictably improve the overall prognosis of many patients. Thus, careful patient
selection is a critical factor in the provision of Level VI care.
Complex rehabilitation includes the following procedures:
• Cephalometric or TMJ radiographs
• Occlusal adjustment (complete)
• Periodontal surgery
– osseous or soft tissue grafts
– repositioned flaps
• Overdentures
• Consultation for speciality services
• Precision attachment prosthetics
• Comprehensive orthodontics (Class I, II, or III)
– case analysis & work-up
– fixed appliances (usually full-banding)
– orthodontic care follow-up visits
– post-treatment stabilization
• Surgical extractions (bony impactions) and unusual or complex oral surgery
• Maxillo-facial prosthetics
• Intravenous (IV) sedation, general anesthesia
Level X — Exclusions
Level X comprises those services which are not classified as billable procedures in programs
serving American Indians/Alaska Natives.
Excluded services have one or more of the following characteristics, as determined by the
Indian Health Service:
• A highly variable rate of success

• Difficult to monitor in terms of appropriateness or effectiveness

• Not universally defined or accepted for reporting purposes

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

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

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

The following procedures are examples of exclusions which are frequently reported:
• Caries susceptibility tests
• Oral hygiene instruction (included in prophylaxis)
• Removable unilateral space maintainers
• Silicate restorations
• Gold foil restorations
• Cast inlay (2-surface)
• Porcelain inlays or crowns
• Full resin or resin/metal crowns
• Direct pulp caps
• Endodontic implants, hemisection
• Gingival curettage
• Coronal splinting
• Unilateral cast partials
• Chairside denture relines
• Alveolar/mandibular implants
• Prosthetic stress breakers
• Tooth implant/transplant
• Myo-functional therapy
• Pulpotomy in permanent tooth
• Odontoplasty
• Behavior management
• Broken appointments
B.9 COMPLETED TREATMENT

PURPOSE
To establish a mechanism to ensure continuity of care for all dental patient who receive a
comprehensive examination.

PROCEDURE
At the time a patient receives a comprehensive examination/[or initial assessment by a
dental hygienist (if following IHS standards or permitted by the State practice Act)] a
treatment plan is written by the dental provider. This treatment plan will list the procedures that
will be done for that patient. These procedures will be based upon established priorities, the
dental provider’s skills and available time and resources.

[For dental clinics using RPMS or the IHS EDR] When the initial treatment plan is
completed, a code of 9990 will be entered into the RPMS system. After scheduled treatment is
completed, it is the patient’s responsibility to contact the dental clinic if further dental services
are required.
OR
When all services in Level I-III have been completed, a code of 9990 will be entered in the
dental record. (IHS recommendation) After scheduled treatment is completed, it is the
patient’s responsibility to contact the dental clinic if further dental services are required.

A dentist or hygienist may recall a patient as frequently as he/she feels it is necessary to

maintain oral health.
B.10 REFERRAL PROCEDURES

PURPOSE
To establish a procedure for referrals for oral health services for eligible recipients.

PROCEDURE
Intra-Facility Referrals
Emergency Patients Referred to Dental
[Insert facility procedures]
Sample:
Regular Working Hours:
Emergency patients 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 Clinics, Community Health Nursing, WIC, or
MCH.
After Hours:
Patients who are experiencing severe 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.

Routine Patients Referred to Dental

These patients can be self referred or referred in the same manner as above. The patient may
present to the dental receptionist with an "in-house" referral form or verbally request that an
exam appointment be made.
All Patients Referred from Dental

All patient referrals made from the dental clinic to any department in the hospital are made
using a PCC form. All demographic coding, dental subjective and objective findings must be
completed.
Inter-Facility Referrals (For programs with multiple dental clinics)
Emergency Patients Referred to Dental
These patients can receive care as above. They can also self refer.
Routine Patients Referred to Dental
These patients can receive an appointment for routine care via self-referral, telephone request,
written request or as described above.
All Patients Referred from Dental
The dental records of that patient will accompany all patient referrals made from the dental
clinic to another facility. HIPAA regulations that govern transfer of information within the facility
network will be followed for information transfer.
 Referrals to External Providers

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

All Patients Referred from Dental to External Providers

These patients 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 patient takes the form to Contract Health so that a contract
can be written. Endodontics, Oral Surgery and Pedodontic services done by an external
provider must have a referral for services to be provided. The [Dental Program Director]
must first authorize emergency visits to external providers so that Contract Health Guidelines
are met.
To external provider:
The dentist completes an HSA-199 listing the procedure(s) needed. The completed
form is then given to the dental receptionist. Referrals will be made to contract
providers.
The [appropriate dental staff] calls the external provider and schedules an
appointment.
The [appropriate dental staff] completes the HSA-199 and forwards the original to the
Contract Health Services (CHS) clerk, placing one copy in the patient's record. The
CHS clerk will complete the HRSA 57 form and mail it and one copy of the referral form
(HSA-199) to the external provider.

Use of Contract Health 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:

Revise as needed to comply with CHS policies.

The patient must be registered for care at the facility to be eligible for contract funds.
Contract money may be used to pay for laboratory services.
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.
B.11 DENTAL LABORATORIES

PURPOSE
To establish procedures for using external dental laboratories and to establish guidelines for
laboratory fees to be paid.

PROCEDURE
Use of Dental Laboratories
Dental laboratories are used to fabricate dental appliances that cannot be fabricated in the
Facility Dental Clinic. These appliances require a laboratory prescription and all cases must
adhere to infection control policy and procedure, HIPAA requirements, and contract health
guidelines. Because the dental laboratory is involved with the care of the patient, no HIPAA
Business Associate Agreement is required. It is the responsibility of the dental laboratory to
maintain confidentiality while the case in the laboratory and during shipment to the dental
facility.
Dental Laboratory Fees
Laboratory cases are cleared prior to scheduling by the [appropriate individual] in charge of
Contract Health. This will determine the correct resources prior to initiating treatment.
The patient or parent/guardian is responsible for all dental laboratory costs. Lab fees vary. An
estimate will be given to the patient or parent/guardian at the examination appointment or at
the time the need for the service is determined. This is an estimate only; patients will be
responsible for unforeseen laboratory charges.

The estimated fee must be paid in advance by certified check or money order made out to the
dental lab performing the service. Fees must be paid on or before the day of the dental
appointment. If you arrive for your dental appointment and the lab fee has not been paid, the
patient’s appointment will be rescheduled to allow more time to pay the fee.

Lab fees are ONLY refundable before the case is sent to the lab. If the patient does not keep
the appointment for the delivery of the device the lab fee will not be refunded. If the device
must be remade, the patient is responsible for paying the additional laboratory fee.
Sample Handout to Patients
Dental Laboratory Fees

Your treatment includes work that must be completed at a dental laboratory. Because [Health
Center Name] must pay the dental laboratory for this service, lab fees are not a covered
benefit. If you would like to have this treatment completed, you must pay the laboratory fee.
This only applies to services done at an external dental laboratory. Payment of dental
laboratory fees will be made according to the following procedures.

1. The patient or parent/guardian is responsible for all dental laboratory costs. Lab fees
vary. An estimate will be given to you at the examination appointment or at the time the
need for the service is determined. This is an estimate only; patients will be
responsible for unforeseen laboratory charges.

2. The estimated fee must be paid in advance by certified check or money order made
out to the dental lab listed below. Fees must be paid on or before the day of the dental
appointment. If you arrive for your dental appointment and the lab fee has not been
paid, we will be happy to reschedule your appointment to allow you more time to pay
the fee.

3. Lab fees are ONLY refundable before the case is sent to the lab. If you do not keep
your appointment for the delivery of the device your lab fee will not be refunded. If you
need to have the device remade you will have to pay another lab fee.

_______________ _________________ __________

Patient Chart Number Date

__________________________________________ __________________________
Procedure(s) Lab Fee Estimate

______________________________________________________
Dental Laboratory

I have read and understand the above policy. I agree to pay the estimated lab fees before
any dental treatment requiring laboratory work is done.

_________________________________ _______________________
Patient or Parent/Guardian Signature Date

_________________________________ _______________________
Dentist Signature Date
B.12 PROTECTIVE STABILIZATION

PURPOSE
To establish procedures for the safe protective stabilization of patients during dental
treatment.

PROCEDURE
This facility adheres to the American Academy of Pediatrics Dentistry’s’ (AAPD) guidelines
for protective stabilization. The policy will apply to all patients, regardless of age. According
to the AAPD’s 2006 Guideline for Behavior Guidance for the Pediatric Dental Patient:
The following is a statement by the American Academy of Pediatric Dentistry. Revise
as needed for your facility.

“The use of any protective stabilization in the treatment of infants, children, adolescents, or
persons with special health care needs is a topic that concerns health care providers, care
givers, and the public. The broad definition of protective stabilization is restriction of
patient’s freedom of movement, with or without the patient’s permission, to decrease risk
of injury while allowing safe completion of treatment. The restriction may involve another
human(s), a patient stabilization device, or a combination thereof. The use of protective
stabilization has the potential to produce serious consequences, such as physical or
psychological harm, loss of dignity, violation of a patient’s rights, and even death. Because
of the associated risks and possible consequences of use, the dentist is encouraged to
evaluate thoroughly its use on each patient and possible alternatives.
Partial or complete stabilization of the patient sometimes is necessary to protect the
patient, practitioner, staff, or the parent from injury while providing dental care. Protective
stabilization can be performed by the dentist, staff, or parent without the aid of restrictive
device. The dentist should always use the least restrictive, but safe and effective,
protective stabilization. The use of a mouthprop in a compliant patient is not considered
protective stabilization.
The need to diagnose, treat, and protect the safety of patient, practitioner, staff, and
parent should be considered for the use of protective stabilization. The decision to use
protective stabilization should take into consideration:
1. alternative behavior guidance modalities;
2. dental needs of the patient;
3. the effect on the quality of dental care;
4. the patient’s emotional development;
5. and the patient’s physical considerations.
Protective stabilization, with or without a restrictive device, performed by the dental
team requires informed consent from a parent. Informed consent must be obtained and
documented in the patient’s record prior to the use of protective stabilization. Due to the
possible aversive nature of the technique, informed consent should also be obtained prior to a
parent’s performing protective stabilization during dental procedures. Furthermore, when
appropriate, an explanation to the patient regarding the need for restraint, with an opportunity
for the patient to respond, should occur.
In the event of unanticipated reaction to dental treatment, it is incumbent upon the
practitioner to protect the patient and staff from harm. Following immediate intervention to
assure safety, if techniques must be altered to continue delivery of care, the dentist must have
informed consent for the alternative methods. The patient’s record must include:
1. informed consent for stabilization;
2. indication for stabilization;
 3. type of stabilization;
4. the duration of application of stabilization;
5. frequency of stabilization evaluation and safety adjustments;
6. behavior/evaluation rating during stabilization.

Objectives: The objectives of patient stabilization are to:

1. reduce or eliminate untoward movement;
2. protect patient, staff, dentist, or parent from injury;
3. facilitate delivery of quality dental treatment.

Indications: Patient stabilization is indicated when:

1. patients require immediate diagnosis and/or limited treatment and cannot cooperate
due to lack of maturity;
2. patients requires immediate diagnosis and/or limited treatment and cannot
cooperate due to mental or physical disability;
3. the safety of the patient, staff, dentist, or parent would be at risk without the use of
protective stabilization;
4. sedated patients require limited stabilization to help reduce untoward movement.

Contraindications: Patient stabilization is contraindicated for:

1. cooperative nonsedated patients;
2. patients who cannot be immobilized safely due to associated medical or physical
conditions;
3. patients who have experienced previous physical or psychological trauma from
protective stabilization (unless no other alternatives are available);
4. nonsedated patients with nonemergent treatment requiring lengthy appointments.

Precautions: The following precautions should be taken prior to patient stabilization:

1. tightness and duration of the stabilization must be monitored and reassessed at
regular intervals;
2. stabilization around extremities or the chest must not actively restrict circulation or
respiration;
3. stabilization should be terminated as soon as possible in a patient who is
experiencing severe stress or hysterics to prevent possible physical or
psychological trauma. “
B.13 CARIES STABILIZATION

PURPOSE
According to the American Academy of Pediatric Dentistry and endorsed by the Indian Health
Service, caries stabilization using an Interim Therapeutic Restoration is an effective means of
treating small carious lesions. Frequently these restorations remain in primary teeth until
exfoliation. “The American Academy of Pediatric Dentistry (AAPD) recognizes that unique
clinical circumstances can result in challenges in restorative care for infants, children,
adolescents, and persons with special health care needs. When circumstances do not permit
traditional cavity preparation and/or placement of traditional dental restorations or when caries
control is necessary prior to placement of definitive restorations, interim therapeutic
restorations (ITR)1 may be beneficial and are best utilized as part of comprehensive care in
the dental home … The AAPD recognizes ITR as a beneficial provisional technique in
contemporary pediatric restorative dentistry. ITR may be used to restore and prevent dental
caries in young patients, uncooperative patients, patients with special health care needs, and
situations in which traditional cavity preparation and/or placement of traditional dental
restorations are not feasible. ITR may be used for caries control in children with multiple
carious lesions prior to definitive restoration of the teeth .” (AAPD, 2008, available online at:
http://www.aapd.org/media/Policies_Guidelines/P_ITR.pdf )

PROCEDURE:

Goal of Interim Therapeutic Restorations

To provide treatment without local anesthetic using fluoride-releasing glass ionomer on teeth
diagnosed with neither necrotic nor irreversible pulpitis. This procedure can be done by general
dentists and their staff, often avoiding dental treatment under general anesthesia. (IHS, 2012.
Available online at: http://www.ihs.gov/doh/documents/ecc/NewECCPacket/Fillings.pdf )

Indications

Interim Therapeutic Restorations are indicated for infants, children, adolescents and children
with special health care needs when conventional restorative care is not available or needs to
be deferred. (IHS, 2012)

Placement and Follow Up

The ITR procedure involves removal of caries using hand or slow speed rotary instruments
with caution not to expose the pulp. Leakage of the restoration can be minimized with
maximum caries removal from the periphery of the lesion. Following preparation, the tooth is
restored with an adhesive restorative material such as self-setting or resin-modified glass
ionomer cement.11 ITR has the greatest success when applied to single surface or small 2
surface restorations.12,13 Inadequate cavity preparation with subsequent lack of retention and
insufficient bulk can lead to failure. 12 Follow-up care with topical fluorides and oral hygiene
instruction may improve the treatment outcome in high caries-risk dental populations. (AAPD,
2008)
B.14 INFORMED CONSENT

PURPOSE
According to the American Dental Association, “A consent form is a document that a patient
has knowingly consented to a particular treatment. The key is the discussion between the
dentist and the patient during which the treatment, its risks and benefits and alternatives, are
all discussed. An informed consent form is evidence this discussion took place. It should be
signed and dated by the patient.”
The purpose of this policy is to identify procedures that require informed consent and to
establish procedures for obtaining and documenting informed consent.

PROCEDURE
Following a comprehensive examination, the dentist will develop a proposed treatment plan.
The dentist will explain the proposed treatment, risks and benefits of treatment, and
consequences of non-treatment. The patient or parent/guardian will have the opportunity to
ask questions about the proposed treatment. Slight and/or unanticipated protective
stabilization may be included in the treatment plan. The patient’s (parent/guardian) signature
on the treatment plan form will indicate informed consent for proposed routine treatment.

A separate Informed consent form will be used for cases of:

(List Procedures) IHS recommends consent forms for:
Tooth extraction
Invasive surgical intervention
Endodontics
Protective stabilization (with or without restrictive device)
Nitrous oxide analgesia/anxiolysis
Conscious sedation
Complex pediatric cases (see following section)
Use of extracted teeth or soft tissues to be used for educational or research purposes

Any procedure requiring the need for specific informed consent will use the [form name or
number] This form will be explained to the patient by the provider or dental assistant and
signed by patient or parent/guardian, provider and a witness.

Treatment of Minors
Informed consent for dental treatment will be obtained in writing from all patients (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, emergency care to treat bleeding, extreme pain,
prevent the spread of infection or other severe conditions will be accomplished with minimal
medical and/or surgical intervention required to stabilize the patient and prevent permanent
injury until legal written consent can be obtained. The forms will be kept in the patient’s dental
chart.
INSERT Appropriate Forms
(Informed consent MUST INCLUDE benefits, risks, and alternatives)
B.15 RADIOGRAPHY

PURPOSE
To set general guidelines for prescribing dental radiographs.
PROCEUDRE
General Procedures
1. All dental radiographs will be taken using appropriate lead aprons with cervical collars.
2. Non-licensed staff taking radiographs will have documentation of appropriate Radiology
training as required by [insert State or IHS].
Type and Frequency of Radiographs

The following radiograph recommendations are consistent with the American Dental
Association (ADA) 2004 guidelines for dental radiographic examinations. See
http://www.ada.org/sections/professionalResources/pdfs/topics_radiography_examinations.pdf

for the full ADA Guidelines for Prescribing Dental Radiographs document.
The recommendations are subject to clinical judgment and may not apply to every patient.
Patient Age and Developmental Stage
Type of Children Child with Adolescent Adult Edentulous
Encounter with Primary Transitional Dentition Dentate or Adult
Dentition Dentition (prior to the Partially
(prior to the eruption of Edentulous
eruption of 3rd molars)
the 1st
permanent
tooth)
New Patient* 1. Selected 1. Panoramic 1. Panoramic film Individual
being occlusal or film exam based
2. Posterior bitewings as
evaluated for periapical on clinical
2. Posterior needed
dental films signs and
bitewings
disease 3. Selected periapical films symptoms
2. Posterior
and/or 3. Selected
bitewings
dental periapical
development
Recall* with 1. Posterior bitewings at 6-12 month interval Not
clinical applicable
2. Selected periapical films as needed
caries or
increased
risk of
caries**
Recall with 1. Posterior bitewings at 12-36 month intervals Not
no clinical applicable
2. Selected periapical films as needed
caries and
not at
increased
risk for
caries**
 Patient Age and Developmental Stage
Children Child with Adolescent Adult Edentulous
with Primary Transitional Dentition Dentate or Adult
Dentition Dentition (prior to the Partially
(prior to the eruption of Edentulous
eruption of 3rd molars)
the 1st
Type of permanent
Encounter tooth)
Recall* with Clinical judgment as to the need for and type of Not
periodontal radiographic images for the evaluation of periodontal applicable
disease disease.

Patient for Clinical judgment as to the Clinical Usually not Not

monitoring type and need of judgment as indicated applicable
growth and radiographic images to to the type
development monitor growth and and need of
development. radiographic
images to
monitor
growth and
development.
Panoramic or
periapical
exam to
assess
development
of third
molars.
Patients with Clinical judgment as to the type and need of radiographic images for
other evaluating and/or monitoring specific patient circumstances.
circumstances
Note: A new patient is an individual who is new to the facility, has not received regular dental
care, has had significant changes in medical or dental history, or has not received any dental
services in the facility for a significant period of time.
*Clinical situations for which radiographs may be indicated include but are not limited to:
A. Positive Historical Findings
1. Previous periodontal or endodontic treatment
2. History of pain or trauma
3. Familial history of dental anomalies
4. Postoperative evaluation of healing
5. Remineralization monitoring
 6. Presence of implants
B. Positive Clinical Signs and Symptoms
1. Clinical evidence of periodontal disease
2. Large or deep restorations
3. Deep carious lesions
4. Malposed or clinically impacted teeth
5. Swelling
6. Evidence of dental/facial trauma
7. Mobility of teeth
8. Sinus tract (“fistula”)
9. Clinically suspected sinus pathology
10. Growth abnormalities
11. Oral involvement in known or suspected systemic disease
12. Positive neurologic findings in the head and neck
13. Evidence of foreign objects
14. Pain and/or dysfunction of the tempopomandibular joint
15. Facial asymmetry
16. Abutment for fixed or removable partial prosthesis
17. Unexplained bleeding
18. Unexplained sensitivity of teeth
19. Unusual eruption, spacing, or migration of teeth
20. Unusual morphology, calcification or color
21. Unexplained absence of teeth
22. Clinical erosion
** Factors for increased risk of caries may include but not be limited to:
1. High level of caries experience or demineralization
2. History of recurrent caries
3. High titers of cariogenic bacteria
4. Existing restoration(s) of poor quality
5. Poor oral hygiene
6. Inadequate fluoride exposure
7. Prolonged nursing (bottle or breast)
8. Frequent high sucrose content in diet
9. Poor family dental health
10. Developmental or acquired dental defects
11. Developmental or acquired disability
12. Xerostomia
13. Genetic abnormality of teeth
14. Many multisurface restorations
15. Chemo/radiation therapy
16. Eating disorders
17. Drug/alcohol abuse
18. Irregular dental care
B.16 PHARMACY/PRESCRIPTIONS

PURPOSE
To maintain adequate communication between the Pharmacy and Dental Department.

PROCEDURE
When it is determined by a dentist that a patient will require medication prior to or after
treatment, a prescription shall be written on [appropriate form] and transported by
[mechanism] to the pharmacy. The pharmacists will notify patients when the prescription is
filled.
The prescription shall be written in standard form in the outpatient notes or on 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 dentist to call the pharmacy chosen by the patient 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.
B.17 DENTAL PAIN MANAGEMENT

PURPOSE.

The purpose of this document is to establish a policy for a Pain Management Program for
the [Facility] Dental Program.

BACKGROUND.

Pain is a common part of the dental patient experience. There is a growing body of
evidence that unrelieved pain carries with it great physiological and psychological risks,
including increased metabolic rate, blood clotting, water retention, impaired immune
function, anxiety, depression, loss of hope, and even suicide. Aggressive pain prevention
and control can yield both short and long term benefits.

Control of orofacial pain is not only a moral responsibility of the dental provider, but it is
also a national priority within the DHHS. One strategy that has been used to assure
optimal pain management is to develop formal means within dental programs to evaluate
pain management practices and work to continuously improve outcomes.

A) Each [Facility] Dental Program will develop a pain management policy that will include
as a minimum, the following:

1) Philosophy of Care and Patient’s Rights for pain management and palliative care. If
possible, this should be incorporated within the Patient Bill of Rights in each clinic,
or if not incorporated, should be posted in a flyer in a conspicuous location in the
dental clinic. (Exhibit 1)

2) An ad-hoc Pain Management Committee with an interdisciplinary approach to pain

management utilizing non-pharmaceutical and pharmaceutical therapies should be
developed for each [Facility] dental program. This may be a part of the Medical
Staff bylaws and include all medical staff, but at a minimum under the auspices of a
dental pain management plan, the committee should consist of the dental chief, the
clinic pharmacist, the clinic Medical Director, and a patient advocate that may or
may not be a staff member (but should not be a medical provider). This committee
should meet at least on a quarterly basis to discuss (from a dental perspective)
current pain management issues on patients.

3) A mechanism to document that dental staff review of the efficacy of treatment. This
may range from noting the patient’s perceptions of pain management on the dental
progress note to a more formal inquiry through a referral to another clinical provider.

4) Drug formulary appropriate for pain management and treatment of drug side
effects. (Exhibit 2)

5) Identification of non-pharmaceutical and environmental therapies. (Exhibit 3)

6) Patient educational tools and sources for community resources for referrals.
(Exhibit 4)
 7) Identification of resources for assessment and management of addiction. (Exhibit
4)

8) Quality monitoring tools to evaluate the appropriateness and effectiveness of pain

management. These may include: patient satisfaction, drug usage, length of
therapy, and impact on quality of life, etc. (Exhibit 5)

9) Orientation plan for dental and other providers.

B) Each [Facility] Dental Program will develop policies and procedures that address, as
needed depending on services provided, safe medication prescriptions.

DEFINITIONS (IHS).

Pain: “An unpleasant sensory and emotional experience associated with actual or
potential tissue damage or described in terms of such damage.”

Acute Pain: Acute pain is “the normal, predicted physiological response to an adverse
chemical, thermal, or mechanical stimulus and is associated with surgery, trauma, and
acute illness.” It is generally time-limited and responsive to pharmacotherapy or direct
dental intervention. Examples in a dental setting where a patient may experience acute
pain include, but are not limited to: severe orofacial trauma, vital tooth fracture, irreversible
pulpitis with or without hyperemia, acute apical abscesses, or severe dental caries.

Chronic Pain: “A pain state which is persistent (more a month) and in which the cause of
the pain cannot be removed or otherwise treated.” Chronic pain may be associated with a
long-term, incurable, or intractable medical conditions or diseases, or, in a dental setting, a
chronic periodontal or pulpal infection, rampant tooth decay, or dentinal hypersensitivity
(not all inclusive).

Palliative Care: “An interdisciplinary approach to the study and care of patients with
active, progressive, far advanced disease for whom the prognosis is limited and the focus
of care is quality of life” (medical definition). In a dental setting, palliative care is offered to
patients for whom the tooth condition is not easily diagnosed (e.g., cracked tooth
syndrome), the condition may be reversible (e.g., pulpitis), or time to complete care is a
limiting factor (e.g., walk-in patients). Examples of palliative care offered in a dental setting
include the placement of a temporary or intermediate restorative material (pulpitis), root
canal access (pulpitis), emergency extraction (acute infection, fractured root, etc.), or the
prescribing of appropriate pharmacotherapies (for chronic infections or for pain relief).

Physical Dependence: “Physical dependence on a controlled substance is a state of

adaptation that is manifested by a drug class specific withdrawal syndrome that can be
produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug,
and/or administration of an antagonist. Physical dependence is expected with extended
use of opioids and, by itself, does not equate with addiction.” In a dental setting, many of
our patients may be on long-term pain management plans through their primary health care
provider, and this may affect the efficacy of dental analgesic/anesthesia therapies.

Addiction: “A primary, chronic, neurobiologic disease, with genetic, psychosocial, and

environmental factors influencing its development and manifestations. It is characterized
by behaviors that include one or more of the following: impaired control over drug use,
compulsive use, continued use despite harm, and craving.” In a dental setting, it is
important to not single-handedly make a diagnosis of “addiction” without first consulting the
patient’s primary health care provider; some patients returning unexpectedly for additional
analgesics or stronger medications may in fact be suffering from tolerance (see below) or
pseudo-addiction (see below).

Tolerance: “Tolerance is a state of adaptation in which exposure to a drug induces

changes that result in a diminution of one or more of the drug’s effects over time. This may
include the need to increase the dose of an opioid to achieve the same level of analgesia.
Such tolerance may or may not be evident during opioid treatment and does not equate
with addiction.”

Pseudoaddiction: “Pattern of drug-seeking behavior of pain patients who are receiving

inadequate pain management that can be mistaken for addiction.” This is a primary
consideration of all dental providers, as often dental providers attribute a patient seeking
additional analgesics to addiction.

Substance Abuse: “Substance abuse is a maladaptive pattern of substance use

manifested by recurrent and significant adverse consequences related to the repeated use
of substances. It may include the use of any substance(s) for non-therapeutic purposes or
use of medication for purposes other than those for which it is prescribed.” Signs of
substance abuse in a dental setting may be demonstrated either through controlled
analgesics or illegal drugs, and the dental care provider must recognize the signs of
substance abuse and collaborate with other clinic health providers, mental health
professionals, pharmacists, or substance abuse counselors if they perceive a problem
(methamphetamine use, for example, creates the clinical “meth mouth” appearance, and
other illicit drugs also have definitive clinical manifestations in the mouth).

PROCEDURE

The [Facility] Dental Program will promote and provide a standardized approach to the
patient with pain that emphasizes a non-judgmental, multi-modal and individualized
treatment plan. Such plans should increase access to known therapies, improve continuity
of care, maximize communication and education for the relief of acute and chronic pain in
all stages of a person’s life. Specifically, each dental program will consider the following
guidelines in developing their pain management programs:

A) Initial assessment and regular reassessment of pain. Pain screening and evaluation
will be part of all dental patient encounters. When patient screening indicates the
presence of pain, the patient’s self-report of the level of pain will be assessed (scale of
1-10 on the Dental Medical History Form). When pain is identified, the patient can be
treated within the clinic or referred for treatment, depending on the professional
judgment of the dental provider. The scope of treatment in a dental setting is based on
a variety of factors - the setting, the services available, time available, staffing available.
At a minimum, the dental provider should assess pain intensity and quality (for
example, pain character, frequency, location, duration), based on both patient self-
reporting and clinical measurements. An addiction history and/or assessment will be
performed as indicated. Addiction is not a contraindication to treatment for pain, but
 can be a co-occurring condition that warrants medical attention. The potential for
diversion of controlled substances will not preclude their use but instead will mandate
responsible and responsive health care. When assessing pain, the dental provider
may perform a variety of clinical tests such as electric pulp testing (EPT), cold response
(Endo-Ice), percussion sensitivity, palpation of the affected region, or, in some cases,
access with a dental handpiece.

B) Patient involvement in care decisions in order to facilitate effective management of the

pain. Patient and provider must enter into a therapeutic alliance with mutual consent
when pain is identified. Once a pattern of pain has been co-documented by the patient
and provider, the standardized process for assessment and interdisciplinary treatment
will be implemented and followed with documented evaluations for outcomes of relief of
pain and improvement of functions.

C) Education of patients, and families when appropriate, regarding risks and benefits and
limitations of chosen pain relief modalities. Education of patients and families about
their roles in effective pain management as well as side effects of pain treatment.

D) Discussion about community and traditional beliefs and practices regarding pain,
medication, and disability should be sought and respected by health care providers and
administrators.

E) Education of relevant practitioners in pain assessment and management.

RESPONSIBILITIES

A) [Facility] Dental Chief – will provide guidelines to [Facility] dental programs, and
provide orientation to new dental staff.

B) Clinic Dental Chief – will post pain policies in the clinic, train dental staff, and implement
policies and procedures in collaboration with each clinic’s policies and the [Facility]
dental policies.

(1) The Dental Clinic Chief is responsible for the overall implementation and
monitoring of the Pain Management/Palliative Care Program. Annual performance
improvement reports documenting the on-going data collection and assessment
process with impact of data analysis on improved outcomes will be prepared as
part of each clinic’s reports to the [Facility] dental chief.

(2) The Dental Clinic Chief is responsible for the formation of an interdisciplinary pain
management/palliative care team that will develop the required [Facility]
policy/procedures. The interdisciplinary team, at a minimum, will include a Medical
Director of the facility, the pharmacist, the dental chief, and a patient advocate
appointed by the clinic dental chief (may be a non-medical staff member).

REFERENCES. Public Law 94-437; Health Care Improvement Act; Joint Commission of
Accreditation of Healthcare Organizations Home Care/Hospice/Hospital/Ambulatory Care
Standards; Patient Self Determination Act 1990; CFR 21-Food and Drugs – Volume 9, Part
1306 – Prescriptions; Model Guidelines for the Use of Controlled Substances for the
Treatment of Pain; Federation of State Medical Boards of the U.S., Inc. 1998; American
Academy of Pain Management; American Pain Society; American Society of Addiction
 Medicine, 2001; Billings Area Pain Management/Palliative Medicine Program, Chronic Pain
Management Strategies, both available at www.ihs.gov.

(This item is optional. All policies may be updated and authorized on the Title page, or
on each individual policy)

EFFECTIVE DATE. This policy is effective upon date of signature of the [Facility] dental
chief, and shall remain in effect until cancelled or superseded.

SSU Dental Chief: ______________________________________ Date:

_____________

Reviewed by:
(1) SSU Clinical Director: ____________________________ Date:
_____________

(2) SSU Chief Pharmacist: ____________________________ Date:

_____________

(3) SSU CEO: ______________________________________ Date:

_____________

(4) AAAHC Representative: ___________________________ Date:

_____________

EXHIBITS.
Exhibit 1 – philosophy of care/bill of rights
Regarding dental pain management

This patient Bill of Rights may be used in conjunction with each clinic’s published Bill of
Rights, and should be posted in the dental clinic.

*************** YOUR RIGHTS AS A PATIENT ***************

1. You have the right to appropriate assessment and management of orofacial pain.

2. You have the right to be treated as an individual with respect, concern, and dignity.

3. You have the right to uphold your cultural, psychosocial, spiritual, and ethical beliefs as
these pertain to your state of health, your perception of your illness or injury, and to the health
care provided, including medications prescribed by your dental provider.

4. You have the right to understand the nature of your illness, prognosis, the effects of the
treatment, including full and prompt disclosure of adverse or unexpected outcomes to
treatment, to ask for a second medical opinion concerning your state of illness and the type of
treatment that is required and the risks involved. This means that you have the right to
understand why medication is being prescribed for you.
5. You have the right to make a decision concerning your condition after you have been given
the following under the informed consent clause (approval to do certain
procedures/treatments):

a. Complete information on the nature of your illness, treatments, alternatives, and the
risks involved;

b. The effects of the treatments/procedures as they may restrict you from normal
activity;

c. The name and qualification of the clinical provider performing the treatment;

6. You have the right to refuse treatment to the extent permitted by law, and to be informed of
the risks involved in so doing.

7. You have the right to confidentiality, privacy, and security of your medical record and all
other individually identifiable health information, including medications prescribed for your
dental condition. You, or your legally designated representative, have the right to access
information contained in your medical record, within limits of the law.

8. You have the right to know certain policies and protocols exist that apply to the identification
of perceived painkiller addiction or tolerance, and that the dental provider may request
additional resources from other providers to better be able to manage your orofacial pain.

9. You have the right to have your designee (you guardian, next of kin, or legally authorized
responsible person) exercise, to the extent permitted by law, your rights if you have been
judged incompetent in accordance with law, have been found by your physician to be medically
incapable of understanding the proposed treatment or procedure or make a treatment
decision, are unable to communicate your wishes regarding treatment, or are a non-
emancipated minor.

*************** YOUR RESPONSIBILITIES ***************

In addition to your rights, you have certain responsibilities as a patient to contribute to your oral
health care at the clinic. These responsibilities include:

1. Provide accurate and complete information about present complaints, past medical history,
any medications you are or were taking, and other health matters as requested by the clinical
provider, to the best of your knowledge.

2. Be compliant with the care plan and treatment recommended by the clinical provider, and
agreed upon by you at the time of treatment.

3. Be responsible for your actions if you refuse treatment or are non-compliant with your care
plan.

4. Make and keep your appointments.

5. Be ultimately responsible for your own health by taking necessary preventive steps,
complying with medical treatment, and participating fully in your treatment plan.

6. Tell the dentist or dental staff if you have concerns about the management of your dental
pain so that effective changes can be made if possible.

This dental facility is committed to providing you and your family with quality oral health
care in a relaxed, respectful, and professional atmosphere. We believe that you and your
health care provider are equal partners in your health care and that a favorable outcome
can best be achieved by you fully participating in all aspects of your health care.

Exhibit 2 – dental pain pharmaceutical protocol

The following is the analgesic protocol for the [Facility] Dental Program. This protocol is only
a recommendation, as it is the responsibility of the treating dentist to use his or her
professional experience and the specific patient experience to determine the best course of
therapy for that patient; it is inaccurate to assume that each and every patient should receive
the same analgesics for the same dental condition. Each clinic is encouraged to devise a pain
management plan customized to their clinical setting and patient population.

Procedure Most common analgesic prescribed Other analgesic modalities

Simple extraction Ibuprofen, 600mg, 20-30 tabs Tylenol #3, Vicodin 5/500
(ADA Code 7140) Acetominophen, 325mg, <30

Surgical extraction Ibuprofen, 600mg, 20-30 tabs + Vicodin 5/500

(ADA Code 7210) Tylenol #3, 12-20 tabs Acetominophen, 325mg, <30

Restorations-multiple Ibuprofen, 600 mg, 10-20 tabs Acetominophen, 325, 10-20

(ADA Codes 2100)

Pulpitis-reversible Ibuprofen, 600 mg, 10-20 tabs + Acetominophen, 325, 10-20

Dental therapy (IRM, Fl-, desensitizer)

Pulpitis-irreversible Ibuprofen, 600mg, 20-30 tabs + Vicodin 5/500

Or Abscess Tylenol #3, 12-20 tabs
Acetominophen,
325mg, <30

TMJD Ibuprofen, 600mg, 20-30 tabs or more Steroid therapy (through

+ Dental therapy (splint, manipulation) medical department)

Tooth fracture Ibuprofen, 600mg, 20-30 tabs or more + Vicodin 5/500

Tylenol #3, 12-20 tabs + Acetominophen, 325mg, <30
 Dental therapy (extraction, restoration)

Endodontic therapy Tylenol #3, 12-20 tabs Vicodin 5/500

(ADA Codes 3200) Acetominophen, 325mg, <30

Other potential pharmaceutical therapies for the relief of orofacial pain include Darvocet N-50
and N-100, Ultram 50-100 mg, and Percocet (for multiple extractions or large abscesses;
however, as a Schedule II controlled substance, Percocet should rarely be used in a dental
setting).

Again, the above guidelines are only recommendations, as each provider has the autonomy to
prescribe appropriate pharmaceutical therapies based on the level of pain, etc.
Exhibit 3 – non-pharmaceutical dental therapies

The following non-pharmaceutical dental therapies are available from [Facility] Dental Clinics
for pain management (most actually include a pharmaceutical component, but do require a
pharmacy prescription alone, although the dentist may combine “pharmaceutical” and “non-
pharmaceutical” therapies for effective pain management):

(1) Endodontic access – where pulpitis exists, the dentist has deemed the tooth
salvageable, and the patient desires to save the tooth, the dentist may access the
tooth pulp and remove the major dental nerves to the tooth, usually under local
anesthesia. Limiting factors for this treatment option include time (usually more
than 15 minutes is required to perform this procedure), diagnosis (irreversible
pulpitis or necrosis/abscess), patient desires (to save tooth), medical condition (if a
patient requires SBE prophylaxis prior to dental work, this procedure may not be
done on a walk-in basis), staffing (a dental assistant and dentist must be present),
and informed consent (the patient, if over age 18, or if under 18, the parent or
LEGAL guardian must consent to the treatment).

(2) Intermediate Restorative Material (IRM) – where pulpitis exists, but the dentist is
unable to determine if it is reversible or irreversible, an IRM may be placed on the
tooth with or without local anesthesia. Limiting factors for this treatment option
include time (usually more than 10 minutes is required), diagnosis (reversible
pulpitis), patient desires (to save tooth), medical condition (if anesthesia is to be
done, and the patient requires SBE prophylaxis), staffing (a dentist must be
present to diagnose the condition), availability of the material (IRM), and informed
consent (see above).

(3) Extraction – where pulpitis, necrosis/abscess, or severe periodontal disease is

diagnosed, the dentist may extract the affected tooth to manage the patient’s pain.
However, limiting factors for this treatment option include time (usually more than
15 minutes is required to extract a tooth), patient desires (to remove tooth), medical
condition (see above), staffing (a dentist and dental assistant must be present),
and informed consent (see above). In most [Facility] dental clinics, extractions are
not usually the treatment of choice for dental walk-ins due to the time constraint.
 (4) Anesthesia – one short-term pain management is through the delivery of
anesthesia to the affected site, although this is usually used in conjunction with
another treatment modality.

(5) Temporo-mandibular joint manipulation – if pain is present in the TMJ, the dentist
may either physically manipulate the TMJ or massage gently available muscles of
mastication (temporalis, masseter, etc.). This may be combined with
pharmaceutical therapy or may in itself relieve the patient’s pain.

(6) Occlusal adjustment – if pain is present due to bruxism or occlusal trauma, the
dentist may adjust the occlusion with a dental handpiece for effective pain
management.

(7) Denture adjustment – if pain is present in the edentulous patient, the dentist or
dental assistant may adjust the patient’s denture, and the dentist may cauterize the
ulcerated region of tissue affected by the ill-fitting denture (silver nitrate stick, etc.).

(8) Other – the dentist, through his or her experience, may choose other non-
pharmaceutical therapies that effectively manage pain.

Exhibit 4 – community resources ([Facility] Dental program)

Resources that may be available to assist patients with addiction problems:

NAME OF FACILITY CONTACT phone

Substance Abuse Programs:

Other Tribal Resources:

State and Local Resources:

 Exhibit 5 – Quality Assurance Tool – Survey

Each clinic is encouraged to periodically monitor patient satisfaction regarding dental policies
on pain management. What follows is an example of a simple pain management survey that
can be used or modified in order to assess current dental policies. The steps in quality
assurance are: (1) identify a problem or issue (pain management); (2) assess the issue
(through this survey); (3) discuss the survey and make recommendations for changes (through
the Pain Management Committee at the clinic level); (4) implement the recommended changes
(in policy or protocol); (5) re-assess the issue (through a follow-up survey instrument); (6)
report re-assessment and make further recommendations for changes (through the Pain
Management Committee); and so on – the point is that quality assurance in pain management
is a continuous process for the dental team.

Instructions to patient: At your last dental visit, we provided you with pain medication or
other therapies to relieve your pain. This short survey is designed to help us improve on how
we treat pain in the dental office. Your honest and candid responses will help us review our
existing policies on pain management for all of our valued patients.

1. At your last dental visit, what type of pain management therapy did the dentist perform?
Please check ALL that apply.
□ Pain medication (that you received from the pharmacy)
□ Temporary filling was placed
□ Tooth was pulled
□ A root canal was started
□ The dentist gave me anesthesia (a shot)
□ The dentist adjusted my teeth or denture
□ Nothing – the dentist did not attempt to relieve my pain

2. When you came into the dental office LAST TIME, how much pain did you have (on a scale
from 1-10, with 10 being the highest)? ___ (write a number here)

3. When you left the dental office LAST TIME, how much pain did you have (on a scale from
1-10, with 10 being the highest)? ___ (write a number here)

4. Two to three days after your LAST dental visit, how much pain did you have (on a scale
from 1-10, with 10 being the highest)? ___ (write a number here)

5. For the same tooth problem that you had last time, how much pain do you have TODAY (on
a scale from 1-10, with 10 being the highest)? ___ (write a number here)

6. Based on your previous experiences with dental pain, how do you think the dental
clinic/dentist managed your pain at your LAST VISIT? (Check only one box)
□ Very good, pain was managed
□ Good
 □ Okay, about average
□ Not good
□ Poor, pain was not managed

7. What suggestions do you have for the dentist/dental staff regarding dental pain for patients
at this clinic?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
____________

Answer these questions if you received a prescription for pain medicine at your last
dental visit.

8. If you received pain medication at your LAST VISIT, was it enough to handle your pain
(were enough pills given)? ___ YES ___ NO ___ NOT SURE

9. If you received pain medication at your LAST VISIT, was it strong enough to handle your
pain? ___ YES ___ NO ___ NOT SURE

10. What suggestions do you have regarding the strength and amount of pain medication
prescribed by the dentist to patients with dental pain?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
____________

Thank you for your participation in this survey. The results from this patient survey will
be discussed with our Pain Management Committee, who may make recommendations
for improving our pain management plan in the dental office. This survey will NOT affect
the quality of care you receive in the dental office and is anonymous. If you wish to
specifically discuss this survey or your own pain with your dental provider, however, you
are welcome to talk with your dentist about this issue.
B.18 PHARMACOLOGIC MANAGEMENT of ORAL INFECTIONS

Background
The most common infections of the oral cavity can be attributed to resident oral
microflora, namely Streptococcus and Staphylococcus species (gram positive bacteria). Oral
infections may occur as tooth infections, pharyngeal infections, as post-surgical complications,
or as unusual infections due to a patient’s immunocompromised status. When choosing an
antibiotic, the dental provider must choose an antibiotic that targets the suspected
microorganism, has low host toxicity, has low host sensitivity, is bacteriocidal, and has low
resistance potential, all with a minimum of side effects to the patient.

Indications/Contraindications for antibiotic therapy

Antibiotics may be prescribed when all of the following conditions are met:
1. The patient presents to one of the service unit dental facilities or has previously been
diagnosed by a service unit dentist with an oral infection (within the past month);
2. The dentist performs diagnostic tests to confirm a diagnosis of an abscess or cellulitis,
to include at a minimum a clinical examination and radiographs or pulp testing if
possible; or in the absence of a dentist on site, a medical provider performing
diagnostic testing to confirm a diagnosis of oral infection;
3. The patient record contains an updated health history (either medical or dental forms)
that details any allergies that the patient may have had in the past.
Antibiotics may not be prescribed under the following conditions:
1. The patient does not present (show up) to the service unit dental or medical facility, and
where there is no documentation to support antibiotic therapy (in other words, the
dentist is precluded from making diagnoses by triaging the patient over the phone
without a sufficient documented history of infection).
2. The patient presents to the clinic but the dentist (or in his/her absence, the medical
provider) cannot make a definitive diagnosis of an oral infection based on the available
clinical evidence (for example, if the patient is afebrile and diagnostic tests are
negative).
3. The patient record does not contain an up-to-date health history (within the past year).

Characteristics of common antibiotics

Because most oral infections are caused by resident gram positive bacteria, a broad
spectrum antibiotic that targets gram positive bacteria should be prescribed in most situations.

Penicillin V with potassium (Pen VK) is THE drug of choice for most facial infections,
according to the Centers for Disease Control and Prevention. Penicillin V is bactericidal, is
acid stable (isn’t broken down easily by gastric acid), and is beta lactamase labile. Although
the chemical composition of Penicillin V contains sulfur, it is safe to prescribe Pen V to patients
with sulfur allergy as the sulfur is in elemental form. When prescribing penicillin, it is very
important to have the patient take the antiobiotic on an empty stomach if possible to increase a
rapid absorption, even though many pharmacists will encourage patients to take the antibiotics
with food or water. In addition, Pen V should be prescribed in a manner to give the patient a
maximum load at the beginning of therapy, and, since 75% of penicillin is excreted in the first
four hours, patients should be encouraged to take the antibiotic every six hours, not simply
four times daily – if the patient takes the antibiotic q.i.d., and takes the antibiotic at mealtimes
only, two things will happen: absorption of Pen V will be delayed due to taking it with food, and
there will be no antibiotic coverage late in the evening (if the patient takes the last tablet at 9
p.m., for example, the patient would not have antibiotic coverage from 1 a.m. the next morning
until they take the next tablet). Therefore, the prescription for Penicillin V would appear as:
 Rx: Penicillin V-K, 500 mg tablets
Disp: 30 tablets
Sig: Take two tablets to start, then one tablet every six hours until all
tablets are gone
Penicillin is contraindicated in those patients that report a history of an allergic reaction to it.

Amoxicillin is a penicillin antiobiotic that is bacericidal, is of a broader spectrum than

Penicillin V, is acide stable, and beta lactamase labile. It is not the drug of choice for most oral
infections, although most dentists try to use it in this way. However, amoxillin is the preferable
regimen for prophylaxis for subacute bacterial endocarditis (SBE), according to the American
Heart Association. The SBE prophylaxis prescription for amoxillin would appear as:
Rx: Amoxicillin, 500 mg tablets
Disp: 4 tablets
Sig: Take four tablets one hour before dental appointment
For SBE prophylaxis, the AHA states that prophylactic antibiotics be taken one hour before a
dental appointment. Dentists and pharmacists have questioned whether this time frame can
be changed to say, 30 minutes. However, in the absence of clear, written guidance from the
AHA or CDC regarding this, the dental provider must adhere to the one-hour timeline before
any procedures are begun.

What should be done when a patient does not respond to Pen V? Often, dentists
immediately prescribe another class of antibiotics. However, two other choices are more
appropriate if the patient does not respond to Pen V within 48 hours. First, the dentist may
prescribe 875 or 1000 mg Augmentin (every 12 hours). Augmentin is also acid stable and
bactericidal, is a broad spectrum antibiotic, and is a combination of amoxicillin and clavulanic
acid. Secondly, the dentist may prescribe 500 Penicillin V plus a broad-spectrum antibiotic
such as Flagyl (metronidazole). However, the dentist should be mindful of the potential
adverse effects of Flagyl (see Metronidazole section).

Cephalosporin antibiotics are bactericidal, broad spectrum, acid stable, and beta
lactamase stable or labile (depending on cross-sensitivity with penicillin), but are NOT
preferable antibiotics for oral infections. For patients with sensitivity to penicillin, 6-8% of those
patients may have a delayed reaction to the cephalosporins (if the patient reported that they
had a history of a “mild” reaction to penicillin), but >20% of the patients may have a Type I
reaction (anaphylaxis) if they reported a similar Type I reaction to penicillin in the past.
Therefore, the dentist should refrain from using cephalosporin antibiotics as an alternative to
penicillin due to penicillin sensitivity. However, if the dentist does wish to prescribe a
cephalosporin, a first generation cephalosporin (Keflex, Duricef) should be prescribed, such as
an alternative to penicillin for SBE prophylaxis, the prescriptioon should be written such as
follows:
Rx: Cephalexin, 500 mg tablets
Disp: 4 tablets
Sig: Take four tablets by mouth one hour before dental appointment
Bottom line: If a patient is allergic to penicillin, the dentist shouldn’t even attempt to prescribe
cephalosporin, and should prescribe clindamycin as an alternative instead.

Erythromycin (Ery-tab) has no use in dentistry at all, according to Dr. Harold Crossley
from the University of Maryland Dental School. Additionally, erythromycin is NOT one of the
alternative antibiotics that can be used for SBE prophylaxis.
 Clindamycin (Cleocin) is bacteriostatic and bacteriocidal, is acid stable, and is a broad
spectrum antibiotic. One published adverse effect of clindamycin is pseudomembranous colitis
(PMC)/ulcerative colitis. Approximately 80% of PMC cases are nosocomial, and patients are at
very low risk of having this side effect in a dental setting. However, if a patient reports diarrhea
after starting clindamycin therapy, the dental provider should tell the patient to immediately
cease taking the antibiotic, and if the diarrhea or GI symptoms continue (for 72 hours), the
dentist should refer the patient to a physician (internist) for follow-up care. Clindamycin is the
drug of choice for patients allergic to penicillin, and should be written as follows:
Rx: Clindamycin, 300 mg capsules
Disp: 16 capsules (or 32 if 150 mg capsules are prescribed)
Sig: Take 2 (4) capsules to start, and then one capsule (2) every 12
hours for seven days
The dentist may prescribe clindamycin for SBE prophylaxis as follows:
Rx: Clindamycin, 300 mg capsules
Disp: 2 capsules
Sig: Take 2 capsules one hour before dental appointment

Azithromycin is an extended spectrum antibiotic that can be used as an alternative

regimen for SBE prophylaxis as follows:
Rx: Azithromycin, 250 mg tablets
Disp: 2 tablets
Sig: Take 2 tablets one hour before dental appointment

Tetracyclines are broad-spectrum bacteriostatic antibiotics that target gram positive

and gram-negative bacterial infections. However, due to the many adverse reactions possible
with tetracyclines, they should not be routinely be used for most oral infections. Adverse
reactions possible include gastointestinal distress and nausea, hepatic and renal toxicity,
tetragenecity in pregnant women, the possibility of superinfections such as candidiasis, and
photosensitivity (even in subtherapeutic doses). Due to the GI problems, which may be as
severe as esophagitis, patients receiving tetracyclines should drink lots of water when taking
the antibiotic. Tetracycline is contraindicated for patients with orthopedic prostheses, and are
contraindicated for patients taking penicillin (for example, if an adolescent is taking a
tetracylcline for acne, the dentist should not prescribe a penicillin for that patient, but rather
clindamycin). Tetracyclines are also contraindicated for patients on oral anticoagulant therapy
(coumadin), and patients prescribed tetracycline in any dosage should be told to not take the
antibiotic with antacids or with milk or other dairy products. For patients receiving the IHS
Diabetic Protocol, the dentist should warn the patient of these adverse properties, and the
prescription should look as follows:
Rx: Doxycycline, 100 mg
Disp: 28 tabs
Sig: Take 1 tab every 12 hours for two weeks (while undergoing
periodontal therapy)

Metronidazole (Flagyl) is a broad spectrum bacteriocidal antibiotic that also has

several adverse effects possible. These include GI effects, oral effects (ulcerations, metallic
taste), CNS effects, and renal toxicity. Most importantly, alcohol use (even swishing with an
alcohol-based mouthwash) is contraindicated with metonidazole.

Quinolones and fluoroquinolones (Cipro, Floxin) are broad spectrum, bacteriocidal

antibiotics that are not routinely used to treat dental infections, especially in light of the fact
that due to the 9/11 aftermath, there has been a 40% increase in bacterial resistance to these
drugs just within the last two years.

Fluconazole (Diflucan) is a systemic antifungal agent that is the drug of choice for oral
candidiasis. It is important for the dental provider to also treat the denture of the edentulous
patient when prescribing Diflucan, which may be prescribed as follows:
Rx: Diflucan, 100mg tablets
Disp: 15 tablets
Sig: Take 2 tablets the first day, then 1 tablet daily for 13 days

Acyclovir (Zovirax) is an antiviral drug that is the drug of choice for treating herpetic
lesions, and can be prescribed as follows:
Rx: Zovirax Ointment, 5%
Disp: 15 g
Sig: Apply small amount to affected area every three hours six times a
day for 7 days
At this time, there is inconclusive evidence of the efficacy of Acyclovir, and this drug is not on
the service unit formulary.
An alternative, Abreva (10% cream), is available as an over-the-counter topical preparation,
but is quite expensive to the patient (around $17 per tube).
Frequently asked questions (FAQ’s)
1. My patient is already taking antibiotics for an infection. How do I provide, or do I need
to provide, SBE prophylaxis?
The dentist will need to provide SBE prophylaxis as recommended by the

AHA guidelines as if the patient weren’t taking other antibiotics, with one
exception: if the patient has taken amoxicillin for seven days or more, then the
dentist should prescribe an antibiotic other than amoxicillin for SBE prophylaxis.
2. If the patient’s physician dictates that a certain antibiotic be used for SBE prophylaxis,
and this contradicts with current AHA guidelines, who do you follow?
The AHA guidelines should be followed.
3. What antibiotics should never be used for SBE prophylaxis?
Erythromycins and tetracyclines.
4. Should patients with total joint replacements, should SBE prophylaxis be provided?
Although there is no conclusive evidence that prophylactic antibiotics are necessary for

patients with total joint replacements, many physicians and orthopedists request

prophylactic coverage for high-risk dental procedures. AHA and CDC guidelines state that

high-risk patients be covered with prophylactic antibiotics before high-risk dental

procedures.

5. Who is considered to be a high-risk patient in regard to prophylaxis for joint

replacements?
Patients that are otherwise immunocompromised – HIV, Type I diabetics, rheumatoid

arthritis, joint replacement within the past two years.

6. What is considered to be a high-risk dental procedure in regard to prophylaxis for joint
replacements?
Extractions or other oral surgery, scaling and root planing, endodontics. Periodontal

probing may be considered a high-risk dental procedure.

Schematic diagram for prescribing antibiotics for oral infections

Patient presents to clinic with pain

S/S of oral infection No S/S of oral infection

Antibiotic prescription Continue to monitor

Patient not allergic to penicillin Patient allergic to penicillin

Patient taking tetracycline

Pen V (500 mg) – 30 Clindamycin (300 mg) - 30

2 tabs to start, then q6h X 7 days 2 tabs to start, then q6h X 7d
Be aware of PMC!
or
Infection does not respond to Pen V
Within 48 hours Azithromycin (250 mg) - 4
Once daily for 3-4 days

Augmentin (875 mg) – 10 or

2 tabs to start, then q12h X 4 days
Ketek (800 mg) - 1
or One tab for 1 day
Not yet formulary item
Pen V (500 mg) + Flagyl (500mg)-28
Q6h X 7 days or
Be aware of alcohol!
Cephalexin (500) - 30
Infection does not respond to either regimen 2 tabs to start, then q6h X7d

or

Amoxicillin (500) – 32
2 tabs to start, then tid X 10d
B.19 EXTRACTED TEETH

PURPOSE

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

PROCEDURE

All patients will be offered the opportunity to keep their extracted teeth or oral tissue
removed during a dental surgery (if the tooth or tissue is not being analyzed for pathology,
See Policy B.22). If a patient wishes to save an extracted tooth it will be cleaned and
surface-disinfected with an EPA-registered hospital disinfectant with intermediate-level
activity and placed in a water-resistant bag or other suitable container.

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

Extracted teeth that are being discarded are subject to the containerization and labeling
provisions outlined by OSHA's bloodborne pathogens standard. OSHA considers extracted
teeth to be potentially infectious material that should be disposed in medical waste
containers. Extracted teeth sent to a dental laboratory for shade or size comparisons should
be cleaned, surface-disinfected with an EPA-registered hospital disinfectant with
intermediate-level activity (i.e., tuberculocidal claim), and transported in a manner consistent
with OSHA regulations. However, extracted teeth can be returned to patients on request, at
which time provisions of the standard no longer apply. Extracted teeth containing dental
amalgam should be placed in the “Contact Scrap Amalgam” container, which will be sent to
an amalgam recycler.

Teeth saved for educational purposes

Extracted teeth are occasionally collected for use in pre-clinical educational training.
Written consent from the patient shall be obtained for teeth collected for use in training or
research. These teeth should be cleaned of visible blood and gross debris and maintained
in a hydrated state in a well-constructed closed container during transport. The container
should be labeled with the biohazard symbol. Because these teeth will be autoclaved
before clinical exercises or study, use of the most economical storage solution (e.g., water
or saline) is practical. Liquid chemical germicides can also be used but do not reliably
disinfect both external surface and interior pulp tissue. Before being used in an educational
setting, the teeth should be heat-sterilized to allow safe handling. Microbial growth can be
eliminated by using an autoclave cycle for 40 minutes.
B.20 HYPERTENSION SCREENING AND TREATMENT GUIDELINES

PURPOSE
According to ADA recommendations, “BP [blood pressure] readings should be taken for all
new patients and for all recall patients on at least an annual basis. People who have
hypertension should have BP assessed at each visit in which significant dental procedures
are accomplished”. (JADA, 2004;135: 576-584) The purpose of this policy is to establish
protocols for monitoring blood pressure for dental patients in accordance with American
Dental Association recommendations.

PROCEDURE
Blood pressure will be taken [state method such as: using an automated blood pressure
monitor] on all new patients and for all recall patients on at least an annual basis. People
who have hypertension will have BP assessed at each visit in which significant dental
procedures are accomplished.

A. Blood pressure will be recorded on the [appropriate form] or progress note in

the chart.
B. Referral:
i. Emergency Treatment: Patients with Systolic over 180 and/or diastolic
over 100 should have pain controlled with local anesthesia (without
vasoconstrictor). If BP does not improve, call the [appropriate referral
site] or the patient’s physician for a consultation. Following emergency
dental treatment, the patient should be referred to [appropriate referral
site] for evaluation.
ii. Routine care (elective dental treatment, patient is not in pain): Patients
with systolic over 180 and/or diastolic over 100, call the [appropriate
referral site] clinic or the patient’s physician for a consultation.
Appropriate dental care will be rendered according to physician’s
recommendations.
iii. Any patient with systolic over 200 and/or diastolic over 110 should be
referred immediately to the[appropriate referral site]. (Dental provider
should first call [referral site] for a phone consult and to advise the
[referral site] a patient is being referred.)
iv. Alternatively the dental provider may consult with the patient’s physician
regarding need for treatment and/or dental considerations
B.21 PREMEDICATION TO PREVENT INFECTIVE ENDOCARDITIS

PURPOSE

The purpose of this policy is to set guidelines for premedicating dental patients to prevent
Infective Endocarditis (IE) that may result from dental treatment. The policy adheres to the
2007 recommendations by the American Heart Association (AHA) and is endorsed by the
American Dental Association. Primary reasons for revising IE Prophylaxis guidelines are:
 IE is much more likely to result from frequent exposure to random bacteremias
associated with daily activities than from bacteremia caused by a dental, Gastro
Intestinal (GI) tract or Gastro Urinary (GU) tract procedure.
 Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in
individuals who undergo a dental, GI tract, or GU tract procedure.
 The risk of antibiotic-associated adverse events exceeds the benefit, if any, from
prophylactic antibiotic therapy.
 Maintenance of optimal oral health and hygiene may reduce the incidence of
bacteremia from daily activities and is more important than prophylactic antibiotics for a
dental procedure to reduce the risk of IE.

PROCEDURE
The 2007 AHA guidelines say patients who have taken prophylactic antibiotics routinely in
the past but no longer need them include people with:
 mitral valve prolapse

 rheumatic heart disease

 bicuspid valve disease

 calcified aortic stenosis

 congenital heart conditions such as ventricular septal defect, atrial septal defect
and hypertrophic cardiomyopathy.

(The new guidelines are aimed at patients who would have the greatest danger of a
bad outcome if they developed a heart infection.)
 Procedures:

1. All dental patients or parent/guardian of dental patients will complete and sign a written
medical history annually. The medical history will be reviewed at each appointment and
updated as needed.

2. Patients with the following conditions will receive preventive antibiotics prior to a dental
procedure that requires antibiotic prophylaxis: (see item #3):
a. artificial heart valves
b. a history of infective endocarditis
c. certain specific, serious congenital (present from birth) heart conditions,
including
i. unrepaired or incompletely repaired cyanotic congenital heart disease,
including those with palliative shunts and conduits
ii. a completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the
first six months after the procedure
iii. any repaired congenital heart defect with residual defect at the site or
adjacent to the site of a prosthetic patch or a prosthetic device
d. a cardiac transplant that develops a problem in a heart valve.

3. Dental Procedures that require antibiotic prophylaxis:

All dental procedures that involve manipulation of gingival tissue or the periapical
region of teeth or perforation of the oral mucosa *
*The following procedures and events do not need prophylaxis: routine anesthetic
injections through noninfected tissue, taking dental radiographs, placement of
removable prosthodontic or orthodontic appliances, adjustment of orthodontic
appliances, placement of orthodontic brackets, shedding of deciduous teeth and
bleeding from trauma to the lips or oral mucosa.
 4. Premedication Regimen for Dental patients who meet the criteria listed in item #2:

Situation Agent Regimen- Single dose 30-60

minutes before procedure
Adults Children
Oral Amoxicillin 2 gm 50 mg/kg

Ampicillin 2 g IM or IV* 50 mg/kg IM or IV

Unable to take oral OR
medication Cefazolin or 1 g IM or IV 50 mg/kg IM or IV
ceftriaxone
Cephalexin** + 2g 50 mg/kg
Allergic to OR
penicillins or Clindamycin 600 mg 20 mg/kg
ampicillin OR
Oral Azithromycin or 500 mg 15 mg/kg
clarithromycin
Allergic to Cefazolin or 1 g IM or IV 50 mg/kg IM or IV
penicillins or ceftriaxone
ampicillin AND OR
unable to take oral Clindamycin 600 mg IM or IV 20 mg/kg IM or IV
medication

* IM–intramuscular; IV–intravenous.
** or other first or second generation oral cephalosporin in equivalent adult or pediatric
dosage.
+ Cephalosporins should not be used in an individual with a history of anaphylaxis,
angioedema, or urticaria with penicillins or ampicillin

5. An antibiotic for prophylaxis should be administered in a single dose before the

procedure. If the dosage of antibiotic is inadvertently not administered before the
procedure, the dosage may be administered up to 2 hours after the procedure.
However, administration of the dosage after the procedure should be considered only
when the patient did not receive the pre-procedural dose.

6. If a patient is already receiving chronic antibiotic therapy with an antibiotic that is also
recommended for IE prophylaxis for a dental procedure, whenever possible an
antibiotic from a different class will be used rather than to increase the dosage of the
current antibiotic.

7. Patients with congenital heart disease can have complicated circumstances. Prior
beginning to any dental treatment requiring antibiotic prophylaxis, the dental provider
should check with the patient’s cardiologist or primary care provider to determine
antibiotic prophylaxis needs or other considerations pertaining to dental treatment or
progression of oral disease.
B.22 PREMEDICATION FOR PATIENTS WITH COMPLETE JOINT REPLACEMENT

PURPOSE
The purpose of this policy is to set guidelines for premedicating dental patients to prevent joint
infection that may result from dental treatment that may cause bacteremia.

Note: The American Academy of Orthopaedic Surgeons and the Association of Oral and
Maxillofacial Surgeons differ in their recommendation for antibiotic prophylaxis for
patients with total joint replacement. The dental chief should consider each protocol, and
in consultation with the facility’s medical staff, determine which protocol to follow.

POLICY #1: American Academy of Orthopaedic Surgeons

This facility adheres to the American Academy of Orthopaedic Surgeons guidelines for
premedication of patient with total joint replacement.
http://www.aaos.org/about/papers/advistmt/1033.asp

According to the AAOS 2010 Information Statement and Clinical Guidelines:

“More than 1,000,000 total joint arthroplasties are performed annually in the United States, of
which approximately 7 percent are revision procedures. Deep infections of total joint
replacements usually result in failure of the initial operation and the need for extensive
revision, treatment and cost. Due to the use of perioperative antibiotic prophylaxis and other
technical advances, deep infection occurring in the immediate postoperative period resulting
from intraoperative contamination has been markedly reduced in the past 20 years.

Bacteremia from a variety of sources can cause hematogenous seeding of bacteria onto joint
implants, both in the early postoperative period and for many years following implantation. 2 In
addition, bacteremia may occur in the course of normal daily life 3-5 and concurrently with
dental, urologic and other surgical and medical procedures. The analogy of late prosthetic joint
infections with infective endocarditis is invalid as the anatomy, blood supply, microorganisms
and mechanisms of infection are all different.

It is likely that bacteremia associated with acute infection in the oral cavity,skin, respiratory,
gastrointestinal and urogenital systems and/or other sites can and do cause late implant
infection. Practitioners should maintain a high index of suspicion for any change or unusual
signs and symptoms (e.g. pain, swelling, fever, joint warm to touch) in patients with total joint
prostheses. Any patient with an acute prosthetic joint infection should be vigorously treated
with elimination of the source of the infection and appropriate therapeutic antibiotics.

Patients with joint replacements who are having invasive procedures or who have other
infections are at increased risk of hematogenous seeding of their prosthesis. Antibiotic
prophylaxis may be considered, for those patients who have had previous prosthetic joint
infections, and for those with other conditions that may predispose the patient to infection
(Table 1). 8,10-16 There is evidence that some immunocompromised patients with total joint
replacements may be at higher risk for hematogenous infections. 10-18 However, patients with
pins, plates and screws, or other orthopaedic hardware that is not within a synovial joint are
not at increased risk for hematogenous seeding by microorganisms.

Given the potential adverse outcomes and cost of treating an infected joint replacement,
the AAOS recommends that clinicians consider antibiotic prophylaxis for joint
replacement patients with one or more of the following risk factors prior to any invasive
procedure that may cause bacteremia.

Table 1. Patients at Potential Increased Risk of Hematogenous Total Joint Infection8,10-16,18

 All patients with prosthetic joint replacement

 Immunocompromised/immunosuppressed patients
 Inflammatory arthropathies (e.g.: rheumatoid arthritis, systemic lupus erythematosus)
 Drug-induced immunosuppression
 Radiation-induced immunosuppression
 Patients with co-morbidities (e.g.: diabetes, obesity, HIV, smoking)
 Previous prosthetic joint infections
 Malnourishment
 Hemophilia
 HIV infection
 Insulin-dependent (Type 1) diabetes
 Malignancy
 Megaprostheses
Prophylactic antibiotics prior to any procedure that may cause bacteremia are chosen on the
basis of its activity against endogenous flora that would likely to be encountered from any
secondary other source of bacteremia, its toxicity, and its cost. In order to prevent bacteremia,
an appropriate dose of a prophylactic antibiotic should be given prior to the procedure so that
an effective tissue concentration is present at the time of instrumentation or incision in order to
protect the patient’s prosthetic joint from a bacteremia induced periprosthetic sepsis. Current
prophylactic antibiotic recommendations for these different procedures are listed in Table 2. 19

Occasionally, a patient with a joint prosthesis may present to a given clinician with a
recommendation from his/her orthopaedic surgeon that is not consistent with these
recommendations. This could be due to lack of familiarity with the recommendations or to
special considerations about the patient's medical condition which are not known to either the
clinician or orthopaedic surgeon. In this situation, the clinician is encouraged to consult with the
orthopaedic surgeon to determine if there are any special considerations that might affect the
clinician’s decision on whether or not to pre-medicate, and may wish to share a copy of these
recommendations with the physician, if appropriate. After this consultation, the clinician may
decide to follow the orthopaedic surgeon’s recommendation, or, if in the clinician’s professional
judgment, antibiotic prophylaxis is not indicated, may decide to proceed without antibiotic
prophylaxis.”

Prophylactic antibiotics prior to any procedure that may cause bacteremia are chosen on the
basis of its activity against endogenous flora that would likely to be encountered from any
secondary other source of bacteremia, its toxicity, and its cost. In order to prevent bacteremia,
an appropriate dose of a prophylactic antibiotic should be given prior to the procedure so that
an effective tissue concentration is present at the time of instrumentation or incision in order to
protect the patient’s prosthetic joint from a bacteremia induced periprosthetic sepsis. Current
prophylactic antibiotic recommendations for these different procedures are listed in Table 2. 19
Occasionally, a patient with a joint prosthesis may present to a given clinician with a
recommendation from his/her orthopaedic surgeon that is not consistent with these
recommendations. This could be due to lack of familiarity with the recommendations or to
special considerations about the patient's medical condition which are not known to either the
clinician or orthopaedic surgeon. In this situation, the clinician is encouraged to consult with the
orthopaedic surgeon to determine if there are any special considerations that might affect the
clinician’s decision on whether or not to pre-medicate, and may wish to share a copy of these
recommendations with the physician, if appropriate. After this consultation, the clinician may
decide to follow the orthopaedic surgeon’s recommendation, or, if in the clinician’s professional
judgment, antibiotic prophylaxis is not indicated, may decide to proceed without antibiotic
prophylaxis.
Table 2.
POLICY #2: American Dental Association and Association of Oral and Maxillofacial
Surgeons
This facility adheres to the American Dental Association (ADA) and Association of Oral and
Maxillofacial Surgeons (AAOMS) guidelines for premedication of patient with total joint
replacement. The [Facility] dental clinic will follow the ADA and AAOMS Advisory Statement and
use the following clinical guidelines to determine the need for, drugs, and regimens of antibiotic
prophylaxis for patients with total joint replacement.

According to the ADA and AAOMS 2003 Advisory Statement: “There is limited evidence that
some immunocompromised patients with total joint replacements (Table 1) may be at
higher risk of experiencing hematogenous infections.12,16-23 Antibiotic prophylaxis for such
patients undergoing dental procedures with a higher bacteremic risk (as defined in Table 2)
should be considered using an empirical regimen (Table 3). In addition, antibiotic prophylaxis
may be considered when the higher-risk dental procedures (again, as defined in Table 2) are
performed on dental patients within two years post–implant surgery,3 on those who have had
previous prosthetic joint infections and on those with some other conditions” JADA, Vol. 134,
July 2003 p 895
(Table 1).

PATIENTS AT POTENTIAL INCREASED RISK OF EXPERIENCING HEMOTOGENOUS

TOTAL JOINT INFECTION*

PATIENT TYPE CONDITION PLACING PATIENT AT RISK

All patients during first two years following N/A†
joint replacement
Immunocompromised/immunosuppressed Inflammatory arthropathies such as
patients rheumatoid arthritis, systemic
lupus erythematosus
Drug- or radiation-induced
immunosuppression

Patients with comorbidities‡ Previous prosthetic joint infections

Malnourishment
Hemophilia
HIV infection
Insulin-dependent (type 1) diabetes
Malignancy
* Based on Ching and colleagues,12 Brause,16 Murray and colleagues,17 Poss and
colleagues,18 Jacobson and colleagues,19 Johnson and Bannister,20 Jacobson and
colleagues21 and Berbari and colleagues.22
† N/A: Not applicable.
‡ Conditions shown for patients in this category are examples only; there may be additional
conditions that place such patients at risk of experiencing hematogenous total joint infection.

Table 2
INCIDENCE STRATIFICATION OF BACTEREMIC DENTAL PROCEDURES
Incidence Dental Procedure
Higher Incidence* Dental extractions
Periodontal procedures, including surgery, subgingival placement of
antibiotic fibers/strips,
scaling and root planing, probing, recall maintenance
Dental implant placement and replantation of avulsed teeth
Endodontic (root canal) instrumentation or surgery only beyond the apex
Initial placement of orthodontic bands but not brackets
Intraligamentary and intraosseous local anesthetic injections
Prophylactic cleaning of teeth or implants where bleeding is anticipated
Lower Incidence Restorative dentistry¶ (operative and prosthodontic) with/without
retraction cord
Local anesthetic injections (nonintraligamentary and nonintraosseous)
Intracanal endodontic treatment; post placement and buildup
Placement of rubber dam
Postoperative suture removal
Placement of removable prosthodontic/orthodontic appliances
Taking of oral impressions
Fluoride treatments
Taking of oral radiographs
Orthodontic appliance adjustment
* Adapted with permission of the publisher from Dajani AS, Taubert KA, Wilson W, et al.23
† Prophylaxis should be considered for patients with total joint replacement who meet the
criteria in Table 1. No other patients with orthopedic
implants should be considered for antibiotic prophylaxis prior to dental treatment/procedures.
‡ Prophylaxis not indicated.
§ Clinical judgment may indicate antibiotic use in selected circumstances that may create
significant bleeding.
¶ Includes restoration of carious (decayed) or missing teeth.
Table 3
SUGGESTED ANTIBIOTIC PROPHYLACXIS REGIMENS.*
Patient Type Suggested Drug Regimen
Patients not allergic to Cephalexin, cephradine or 2 grams orally 1 hour prior to
penicillin amoxicillin dental procedure
Patients not allergic to Cefazolin or ampicillin Cefazolin 1 g or ampicillin 2 g
penicillin and intramuscularly or
unable to take oral intravenously 1 hour prior to
medications the dental procedure
Patients allergic to penicillin Clindamycin 600 milligrams orally 1 hour
prior to the dental
procedure
Patients allergic to penicillin Clindamycin 600 mg intravenously 1 hour
and unable prior to the dental
to take oral medications procedure*
* No second doses are recommended for any of these dosing regimens.
B.23 MEDICAL EMERGENCIES IN THE DENTAL CLINIC

PURPOSE
Patients in the dental clinic should be protected while receiving dental care in the [Facility]
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.
PROCEDURE
Dental providers 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.

Training
Basic Life Support (BLS)
All dental staff will maintain certification in Basic Life Support (BLS). Certification may be
sponsored by either the American Heart Association or the American Red Cross. When a
patient, visitor or other individual is observed in distress, staff will respond according to current
BLS recommendations. [Insert other specific requirements for emergency response]

In-Service Training
Annually the emergency response plan and staff assignments listed below will be held for all
dental staff. In-service training will be provided as needed to review appropriate responses to
medical emergencies including but not limited to: seizures, syncope (fainting), hyperventilation,
cardiac and respiratory distress, chest pain, drug related emergencies, allergic or toxic
reaction, asthma, insulin shock, diabetic coma or airway obstruction.

Emergency Response Plan

Staff Assignments
In case of a medical emergency in the dental clinic, staff assignments are as follows:
[Describe clinic specific procedures for response to medical emergencies]
Example:
1. Provider treating the patient with the medical emergency will stay with the patient and call
for help. The provider will monitor the patient’s vital signs and maintain airway, support
breathing and monitor circulation until medical assistance arrives.
2. The nearest dental assistant will get the oxygen tank and set it up for the provider to
administer oxygen to the patient.
3. The receptionist or nearest dental assistant will phone for help.

Equipment and Medications

Equipment for providing supplemental oxygen to hypoxic patients should be available in all
dental clinics. This equipment should provide capabilities for forced respiration through the use
of an 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. Oxygen and ambu-bags are located
[state location]
Automated External Defibrillators (AED) will be available, in good repair, and maintained ready
for use. Automated External Defibrillators are located [state location]
[The Council on Scientific Affairs of the American Dental Association recommends that
each dental office examine local needs and determine appropriate emergency kit needs.
Kit contents should be based on individual practitioner training and requirements.
Dental staff may elect to keep emergency drugs, or to defer to medical staff for
emergency services. Select the procedures that best serve the facility. Some State
Practice Acts specify required equipment or drugs be available to the dental staff. Check
the appropriate State Dental Practice act for requirements]
Emergency Drugs (For those clinics that elect to maintain an Emergency Drug Kit)
Emergency medications will be checked monthly for expiration and a log will be maintained of
Emergency Kit monitoring. Expired drugs will be replaced at least 2 months prior to the
expiration date. Annually, the dental staff will have an in-service on all emergency kit drugs,
dosage, and administration.
The dental emergency kit will include:
1. Positive pressure oxygen
2. Ambu-bag
3. Sphygmomanometer and Stethoscope
4. Benadryl 50 mg/ml injectable
5. Tubex Hypodermic Syringe
6. 5% Dextrose
7. Butterfly I-V set
8. Epinephrine 1:1000 Tubex x 2
9. Glucose

Option for Dental Clinics that defer to Medical Department for Emergency Services

Emergency Kit without Emergency Drugs

The dental clinic will maintain an emergency kit containing an Epi pen and a source of glucose.
No emergency drugs will be kept in the dental clinic. In case of an emergency, the dental staff
will notify the medical department or call Emergency Services for medical support.
The dental emergency kit will contain:
1. Positive pressure oxygen
2. Ambu-bag
3. Epi pen
4. Glucose
Documentation
All emergency procedures will be recorded in the patients chart including: symptoms, time of
onset of symptoms, support services, drugs administered (time and dosage), referrals or
calls for support services, progression of patient’s signs and symptoms and instructions
given to the patient.
B.24 REPORTING DOMESTIC VIOLENCE and NEGLECT

PURPOSE
This policy is to ensure 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 protect those from civil and criminal liability if the report is
made in good faith. (Check State laws to ensure protection from liability)

PROCEDURE
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."[modify as
needed to meet state requirements]
The physician or dental provider will notify the [appropriate referral agency], Tribal Police
Department and the Social Services Department of their suspicions.

Circumstances Requiring Investigation

 Frequent visits to the Emergency Department with un-explained injuries
 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
 Poor or malnutrition
 Multiple fractures or soft tissue injuries from any source including cigarette burns, or
belt buckle origin
 Unexplained head injuries

Dental Neglect

Severe dental decay in a child will not in itself be considered neglect, unless other
circumstances lead the dental provider to suspect overall neglect. However, if the
parent/guardian is informed of the child’s dental treatment needs and fails to complete
treatment available through the [Facility] dental clinic or through CHS within a reasonable
time, dental neglect may be suspected and reported.

If Abuse or Neglect is Suspected:

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 #]

Describe Reporting and Follow Up Procedures

Example:
Dental providers will refer cases to Social Services for investigation.
OR

Dental providers will refer cases to Community Health Representatives to encourage parents
tot keep dental appointments. If unsuccessful, cases will be referred to Social Services for
further investigation.

OR

Dental providers will request an examination by the medical staff. The medical provider 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.

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 [appropriate referral agency] 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 [Agency] 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.

Documentation
Provider will record all pertinent information in the patient’s health record. Patient information
that should be recorded: Health History, physical examination, clinical observations, history of
the injury provided by all parties, laboratory tests, radiographs, and photographs of the injury.
(Radiographs must only be taken when medically necessary, and never for the sole purpose of
separating parent/guardian from the child to conduct separate interviews.)

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

B.25 PATHOLOGY

PURPOSE
To establish a uniform method of performing, documenting, and informing patients of the
results of tissue biopsy.

PROCEDURE
Brush Biopsy
The dentist will perform the brush biopsy according to manufacturer’s instructions. Samples
are then sent to the Brush Biopsy manufacturer for analysis. Results are reported to the
patients by phone or my mail if unavailable by phone. Reports are maintained in the patient’s
chart.
Excisional Biopsy

Form [form #] 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 other
appropriate laboratory]
When the report is returned from the pathologist, the dentist 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].
B.26 CLINICAL ORAL DISEASE PREVENTION/HEALTH PROMOTION
PURPOSE
To establish clinical oral health promotion/disease prevention (HP/DP) procedures consistent
with current science and Indian Health Service priorities.

Definitions
Open Access: patients are seen without an appointment as they present to the clinic.
High risk groups: target groups with known high oral disease rates
Patients of record: patients with a comprehensive dental examination within the last 3
years
PROCEDURE.
High Risk Groups
High risk groups including [insert current high risk groups such as Head Start
children, children age 0-3, diabetes patients] will have Open Access to the dental clinic
for preventive services including [insert services such as screening, fluoride varnish,
OHI, exams].

Patients of Record

1. Examination results of hard and soft tissues, periodontal status and needs, orthodontic
needs, risk for caries and periodontal disease, and other prevention needs will be
recorded at the comprehensive examination appointment.

2. Patients will be assessed for caries risk, periodontal status, risk for traumatic injury (sport
activities), or other oral health risk at the examination appointments. Elevated risk status
will be documented on the examination form. Treatment plans will be developed as
appropriate for risk category.

3. Supplemental fluoride will be based on the following**:

Revised 1994 Fluoride Level (Home Water)

Age Less than 0.3 0.3 – 0.6 Greater than 0.6
ppm ppm ppm
Birth to 6 months 0* 0 0
6 months to 3 years 0.25 0 0
3 years to 6 years 0.5 0.25 0
Breast fed 1.0 0.5 0

*milligrams of fluoride per day

2.2 mg sodium fluoride = 1 mg fluoride (F )

** Jointly endorsed by: American Academy of Pediatric Dentistry

American Dental Association
American Academy of Pediatrics
 Patient’s home water supply will be tested for fluoride content prior to prescribing
supplemental fluoride. Prescriptions will be refilled for a period of one year without
further dental evaluation unless that patient changes addresses and water source.

Sample: l mg. Fluoride daily #60 Refill 1 year

4 When fluoride rinse is indicated the patient will be given a recommendation for an over-
the-counter daily rinse. It will be necessary for the patient to obtain the rinse at his/her
own expense. Fluoride rinse will be used only for clients six (6) years or older.
Moderate or high risk patients who cannot use a home rinse will receive fluoride varnish
treatments appropriate to their risk category.

5 Unless medically contraindicated, all dentate dental patients will be advised to use
fluoride toothpaste.

6 Topical fluoride may be applied using either a fluoride varnish or 1.23% acidulated
phosphate gel. Patients considered moderate risk will be given a semi-annual topical
fluoride treatment. Patients considered high risk will be given more frequent
applications up to 4 treatments per year.
Procedures:
a. Gel: 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. Patients will be instructed not to eat or drink for 30 minutes.
B. Varnish: After removal of excessive plaque, teeth will be dried with 4x4
gauze, then varnish will be applied to all tooth surfaces. Patients should not
drink hot liquids or eat for approximately 2 hours.

7 Teeth needing sealants will be marked with an "NS" on the examination form. Teeth with
sealants in place will be marked with "S" on the examination form. Need for sealants
will be based on caries risk.

8. Dietary counseling will be implemented for high risk patients. A referral shall be made to
the clinic's nutritionist. Moderate risk patients will receive nutritional counseling by
dental staff (coded D1310). All records of nutritional education and recommendations
provided by dental staff will be maintained in the patient’s dental record.

9 CPITN (Community Periodontal Index Treatment Needs): Perio screening will be

documented all new patients over the age of 12 for each sextant of the mouth based
on the most severe pocket in the sextant.

10. Scaling will be done by the dentist or hygienist. All patients with type II and III perio-
dontal status will receive appropriate periodontal services according to the IHS
periodontal guidelines.

11 OHI will be re-evaluated at each subsequent dental visit. Appropriate educational

services will be provided as needed. (e.g. Plaque removal, dietary instructions,
completion of dental treatment plans, fluoride use, denture care.)
12 The patient will be informed of their periodontal status; if CPITN score is 3 or 4 the
patient will be treated with non-surgical intervention and reassessed with recall
appointments. Information on periodontal disease will be given to the patient. All
education will be documented in the dental chart.

13 Patients age six to twenty (6 – 20) years will be informed of the need for orthodontic
treatment, and that any orthodontic treatment will have to be at the patient’s or parent's
expense

14. Patients who are at increased risk for caries or periodontal disease due to
medical conditions will be given priority treatment.

15. Newly diagnosed diabetics or other special needs patients will be referred from the
outpatient clinic. Upon receiving the referral an examination appointment will be given
to the patients. At the first appointment the patient will be informed of the effect of
diabetes on the oral tissues as well as receive the treatment given to all new patients.

16. Patients in a known high risk group may be included in community based prevention
programs. In community based programs, all participants will receive identical services.
Referrals will be based on individual risk assessment.

17. Recall intervals will be based on each patient’s risk category.

Low Risk: 12 month recall
Moderate Risk: 6-12 month recall
High Risk: 2-3 month recall
B.27 NITROUS OXIDE
PURPOSE
To establish procedures for the safe and effective use of nitrous oxide in the Dental Clinic.
PROCEDURE
Patient Selection
This facility adheres to the American Academy of Pediatric Dentistry (AAPD) guidelines for
nitrous oxide. All sections of this policy will apply to patients of all ages. According to the
AAPD’s 2005 guideline:

The following are the patient selection and contraindication recommendations according to the
American Academy of Pediatric Dentistry. If necessary, add any additional monitoring
requirements of the facility.
“Indications for use of nitrous oxide/oxygen analegesia/anxiolysis include:
1. a fearful, anxious or obstreperous patient
2. certain mentally, physically, or medically compromised patients
3. a patient whose gag reflex interferes with dental care
4. a patient for whom profound local anesthetic cannot be obtained
5. an uncooperative child undergoing a lengthy dental procedure

Contraindications for Use of nitrous oxide/oxygen analgesia/anxiolysis

1. some chronic obstructive pulmonary diseases
2. severe emotional disturbances or drug related dependencies
3. first trimester of pregnancy
4. treatment with bleomycin sulfate”

The patient’s medical provider must be consulted in cases with significant underlying medical
conditions.

Qualifications of Providers
According to the AAPD’s 2009 Guideline,
“The practitioner who utilized nitrous oxide anesthesia/analgesia for a pediatric dental patients
shall possess appropriate training and skills and have available the proper facilities, personnel,
and equipment to manage any reasonable foreseeable emergency. Training and certification in
basic life support are required for all clinical personnel.”
All dental providers using nitrous oxide must have a record stating that training was received in
nitrous oxide. This will be filed [appropriate location].

Competency
Describe procedures used to ensure provider competency, if any]

Monitoring
According to the AAPD’s 2009 Guideline: If necessary, add any additional monitoring
requirements of the facility.
“The response of patients to commands during procedures performed with
anxiolysis/analgesia serves as a guide to their level of consciousness. Clinical observation of
the patient must be done during any dental procedure. During nitrous oxide/oxygen
analgesia/anxiolysis, continual clinical observation of the patient’s responsiveness, color, and
respiratory rate and rhythm must be performed. Spoken response provide an indication that
the patient is breathing. If any other pharmacologic agent is used in addition to nitrous
oxide/oxygen and a local anesthetic, monitoring guidelines for the appropriate level of sedation
must be followed.”
Documentation
According to the AAPD’s 2009 Guideline: If necessary, add any additional monitoring
requirements of the facility.

“Informed consent must be obtained from the parent and documented in the patient’s
record prior to the administration of nitrous oxide/oxygen. The practitioner should provide
instructions to the parent regarding pretreatment dietary, if indicated. In addition, the patient’s
record must include indication for use of nitrous oxide/oxygen inhalation, nitrous oxide dosage
(ie. Percent of nitrous oxide/oxygen and/or flow rate), duration of the procedure, and
posttreatment oxygenation procedures.”

Equipment
According to the AAPD’s 2009 Guideline, If necessary, add any additional monitoring
requirements of the facility.
“All newly installed facilities for delivering nitrous oxide/oxygen must be checked for proper
gas delivery and fail safe function prior to use. Inhalation equipment must have the capacity for
delivering 100% and never less than 30% oxygen concentration at a flow rate appropriate to
the child’s size. Additionally, inhalation equipment must have a fail safe system that is checked
and calibrated…” [inset manufacturer’s recommended calibration and maintenance
schedule].
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.
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.
B.28 CONSCIOUS SEDATION [if applicable for your clinic, Omit this section if
Conscious Sedation is not used in the dental facility or retain only those
procedures used in the facility]

PURPOSE

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 [accreditation agency, if applicable] 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 American Society of Anesthesiologists and the
practitioner is urged to review the most recent guidelines.

PROCEDURE

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

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

 ASA Classification:
ASA stands for American Society of Anesthesiologists. In 1963 the ASA adopted a 5 category
physical status classification system for assessing a patient before surgery. The first 4 classes
are:
1) A normal healthy patient.
2) A patient with mild systemic disease.
3) A patient with severe systemic disease.
4) A patient with severe systemic disease that is a constant threat to life.

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

 Conscious Sedation: A drug induced depression of consciousness during which patients

respond purposefully to verbal command, either alone or accompanied by light tactile
stimulation. No interventions are required to maintain a patent airway, and spontaneous
ventilation is adequate. Cardiovascular function is usually maintained.

 Deep Sedation: A drug-induced depression of consciousness during which patients cannot

be easily aroused but respond purposefully following repeated or painful stimulation. The
ability to independently maintain ventilatory function may be impaired. Patients may require
 assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate.
Cardiovascular function is usually maintained. .

 General Anesthesia: A drug-induced loss of consciousness during which patients are not
arousable, even by painful stimulation. The ability to independently maintain ventilatory
function is often impaired. Patients often require assistance in maintaining a patent airway,
and positive pressure ventilation may be required because of depressed spontaneous
ventilation or drug-induced depression of neuromuscular function. Cardiovascular function
may be impaired.

 Moderate Sedation: Conscious 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.

 Rescue: Rescue of a patient from a deeper level of sedation than intended is an

intervention by a practitioner proficient in airway management and advanced life support.
The qualified practitioner corrects adverse physiologic consequences of the deeper-than
intended level of sedation (such as hypoventilation, hypoxia and hypotension) and returns
the patient to the originally intended level of sedation.

General Considerations

 Applicability: These guidelines should be considered as minimum guidelines. More

stringent procedures may be required for individual patients.

 Practitioners. According to the ASA 2006 Guidelines, “Only physicians, dentists or

podiatrists who are qualified by education, training and licensure to administer moderate
sedation should supervise the administration of moderate sedation. Nonanesthesiologist
sedation practitioners may directly supervise patient monitoring and the administration of
sedative and analgesic medications by a supervised sedation professional. Alternatively,
they may personally perform these functions, with the proviso that the individual monitoring
the patient should be distinct from the individual performing the diagnostic or therapeutic
procedure.”

 Local Anesthesia used in conjunction with pharmaco-sedation: 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 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 must accompany adult patients who receive moderate, deep or general
anesthesia. An adult who receives only nitrous oxide/oxygen or local anesthesia need not
be accompanied by another adult.

Education and Training

This facility adheres to the American Society of Anesthesiologist (ASA) guidelines for education
and training for nonanesthesiologist sedation practitioners. According to the ASA’s 2006
guidelines:

“The nonanesthesiologist sedation practitioner who is to supervise or personally administer

medications for moderate sedation should have satisfactorily completed a formal training
program in: (1) the safe administration of sedative and analgesic drugs used to establish a
level of moderate sedation, and (2) rescue of patients who exhibit adverse physiologic
consequences of a deeper-than-expected level of sedation. This training may be a part of a
recently completed residency or fellowship training (e.g. within two years), or may be a
separate educational program. A knowledge-based test may be used to verify the practitioner’s
understanding of these concepts. The following subject areas should be included:
1) Contents of the following ASA documents that should be understood by practitioners
who administer sedative and analgesic drugs to establish a level of moderate sedation:
a. Practice Guidelines for Sedation and Analgesia by Nonanesthesiologists
b. Continuum of Depth of Sedation—Definition of General Anesthesia and Levels
of Sedation/Analgesia
2) Appropriate methods for obtaining informed consent through pre-procedure counseling
of patients regarding risks, benefits, and alternatives to the administration of sedative
and analgesic drugs to establish a level of moderate sedation.
3) Skills for obtaining the patient’s medical history and performing a physical examination
to assess risks and co-morbidities, including assessment of the airway for anatomic and
mobility characteristics suggestive of potentially difficult airway management. The
nonanesthesiologist sedation practitioner should be able to recognize those patients
whose medical condition suggests that sedation should be provided by an anesthesia
professional.
4) Assessment of the patient’s risk for aspiration of gastric contents as described the ASA
Practice Guidelines for Preoperative Fasting: ‘In urgent, emergent or other situations
where gastric emptying is impaired, the potential for pulmonary aspiration of gastric
contents must be considered in determining (1) the target level of sedation, (2) whether
the procedure should be delayed or (3) whether the trachea should be protected by
intubation.’
 5) The pharmacology of (1) all sedative and analgesic drugs the practitioner requests
privileges to administer to establish a level of moderate sedation, (2) pharmacological
antagonists to the sedative and analgesic drugs and (3) vasoactive drugs and
antiarrhythmics.
6) The benefits and risks of supplemental oxygen.
7) Proficiency of airway management with facemask and positive pressure ventilation.
This training should include appropriately supervised experience in managing the
airway of patients, or qualified instruction on an airway simulator (or both).
8) Monitoring of physiologic variables, including the following:
a. Blood pressure
b. Respiratory rate
c. Oxygen saturation by pulse oximetry
d. Electrocardiographic monitoring. Education in electrocardiographic (EKG)
monitoring should include instruction in the most common arrythmias seen
during sedation and anesthesia, their causes and their potential clinical
implications (e.g. hypercapnia), as well as electrocardiographic signs of cardiac
ischemia.
e. Depth of sedation. The depth of sedation should be based on the ASA
definitions of ‘moderate sedation’ and ‘deep sedation’. (See above)
f. Capnography—if moderate sedation is to be administered in settings where
patients’ ventilatory functions cannot be directly monitored (e.g. MRI suite).
9) The importance of continuous use of appropriately set audible alarms on physiologic
monitoring equipment.
10) Documenting the drugs administered, the patient’s physiologic condition and the depth
of sedation at regular intervals throughout the period of sedation and analgesia, using a
graphical, tabular or automated record.
11) If moderate sedation is to be administered in a setting where individual(s) with
advanced life support skills will not be immediately available (1-5 minutes; e.g., code
team), then the nonanesthesiologist sedation practitioner should have advanced life
support skills such as those required for American Heart Association certification in
Advanced Cardiac Life Support (ACLS). When granting privileges to administer
moderate sedation to pediatric patients, the nonanesthesiologist sedation practitioner
should have advanced life support skills such as those required for certification in
Pediatric Advanced Life Support (PALS).
When the practitioner is being granted privileges to administer sedative and analgesic drugs
to pediatric patients to establish a level of moderate sedation, the education and training
requirements enumerated in #1-9 above should be appropriately tailored to qualify the
practitioner to administer sedative and analgesic drugs to pediatric patients.”

An individual trained and competent in the monitoring of sedated patients shall 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
moderate or deeper levels of sedation should be administered outside of the clinical setting.

Supplemental oxygen is recommended for all sedated patients (not including anxiolysis).

Competency
Providers should demonstrate current competence via [insert facility’s competency
evaluation procedures]
Table 1

Local Anesthetic Dosages

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

Lidocaine Xylocaine 2 4.4

36
Mepivacaine Carbocaine 2 6.6 36
Mepivacaine Carbocaine 3 6.6 54
Prilocaine Citanest 4 7.9 72
Bupivacaine Marcaine 0.5 2.0 9

Facilities

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

 Staffing: The staff required to safely conduct a sedation procedure will vary with the
technique used. (See education and training section above)

 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. An Automated External
Defibrillator will be available. Additionally, strong consideration should be given to having a
crash cart.

 Nitrous Oxide: See Section B.22.

Emergency Services

Back-up emergency services should be identified. See Section B-18 (Medical Emergencies in
the Dental Clinic).

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. (See Section B.12.—Informed Consent)

 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: See Section B.11.

 Prescriptions: See Section B. 14.

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: See Section B. 11.

The condition of the patient and the time of discharge from the treatment facility should be
documented in the record. Documentation should include that appropriate discharge criteria
have been met. The record should also identify the responsible adult to whose care the
patient was discharged. (Table 2)
Table 2: The Modified Aldrete Scoring System for Determining when Patients are Ready for Discharge 
from the PACU. A Score = 9 was Considered Necessary for Discharge
Activity: Able to move voluntarily or on command
4 extremities 2
2 extremities 1
0 extremities 0
Respiration
Able to deep breathe and cough freely 2
Dyspnoea, shallow or limited breathing 1
Apnoeic 0
Circulation
BP +/­ 20 mm of pre anaesthetic level 2
BP +/­ 20 to 50 mm of pre anaesthesia level 1
BP +/­ 50 mm of pre anaesthesia level 0
Consciousness
Fully awake 2
arousable on calling 1
not responding 0
O2 Saturation
Able to maintain O2 saturation>92% on room air 2
Needs O2 inhalation to maintain 
O2 saturation>90% 1
O2 saturation<90% even with O2 supplementation 0
Aldrete JA The post anaesthesia recovery score revisited. (Letter) J. Clin. Anesth. (7) 1995 89­91
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
[requirements according to IHS guidelines or State dental practice act].

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.

Moderate Sedation

Training
See Education and Training section above.
-[Requirements according to State practice act, additional requirements of facility]

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. (See Education and Training section above)

-In addition to the operating practitioner, an individual trained to monitor appropriate

physiologic parameters and to assist in any supportive or resuscitation measures required
should be present. Both individuals must have training in basic life support, should have
specific assignments, and should have current knowledge of the emergency cart (kit) inventory.
(See Education and Training section above)

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.

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. The dental practitioner will follow all Policies and
Procedures of the facility regarding General Anesthesia.
SECTION C: ENVIRONMENT
C.1 INFECTION CONTROL

Purpose:

To establish policies and procedures to protect dental personnel from work related exposures
to infectious diseases and to protect dental patients from exposures to infectious diseases
resulting from dental treatment.

Authority:

1. Centers for Disease Control and Prevention. Guidelines for Infection Control in
Dental Health-Care settings-2003. MMWR 2003;52 (No. RR-17)
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

2. (Handpiece manufacturer name) recommendation for maintenance and

sterilization of high speed and low speed handpieces
3. Atest manufacturer’s instructions
4. (Facility Name) infection control policies relating to ambulatory patient care
5. (Facility Name) safety policies relating to infection control
6. (Facility Name) personnel policies relating to infection control
7. HIPAA act of 1998

Procedure:

1. Policies are numbered as IC/D (Infection Control/ Dental).

2. All policies in the Dental Infection Control Policy Guide are consistent with
manufacturer’s recommendations, CDC, IHS(if applicable), and (Facility Name)
recommendations and regulations.
3. Authority for all policies can be located in one of the above listed sources
4. Whenever possible, policies will defer to (Facility name) wide policies. Specific
questions should be directed to the (Facility Name) Safety Officer, the (Facility
Name) Infection Control Officer, Medical Records Chief (HIPPA regulations), or
other appropriate authorities at (Facility Name).
5. When updating policies and procedures, current authoritative sources should be
referenced and if possible, copied and placed in this guide as a reference.
6. Guide should be updated annually or as soon as new recommendations become
available
7. Copies of the Dental Infection Control Policy Guide will be maintained at
(Facility(ies) Name(s))
8. Periodic quality assurance studies will be conducted to ensure compliance with this
guide. Lack of compliance or changes in procedures will be discussed at dental
staff meetings. The Chief- Dental Services will approve changes to the guide prior
to implementation
9. Recommendations may be classified by the following categories:
Category IA. Strongly recommended for implementation and strongly supported by well-
designed experimental, clinical, or epidemiologic studies.
Category IB. Strongly recommended for implementation and supported by experimental,
clinical, or epidemiologic studies and a strong theoretical rationale.

Category IC. Required for implementation as mandated by federal or state regulation or

standard. When IC is used, a second rating can be included to provide the basis of existing
scientific data, theoretical rationale, and applicability. Because of state differences, the reader
should not assume that the absence of a IC implies the absence of state regulations.

Category II. Suggested for implementation and supported by suggestive clinical or

epidemiologic studies or a theoretical rationale.

Personnel Health Elements of of an Infection Control Program

A. General Recommendations

1. Develop a written health program for DHCP that includes policies, procedures, and
guidelines for education and training; immunizations; exposure prevention and
postexposure management; medical conditions, work-related illness, and associated
work restrictions; contact dermatitis and latex hypersensitivity; and maintenance of
records, data management, and confidentiality (IB).
2. Establish referral arrangements with qualified health-care professionals to ensure
prompt and appropriate provision of preventive services, occupationally related medical
services, and postexposure management with medical follow-up (IB, IC).

B. Education and Training

1. Provide DHCP 1) on initial employment, 2) when new tasks or procedures affect the
employee's occupational exposure, and 3) at a minimum, annually, with education and
training regarding occupational exposure to potentially infectious agents and infection-
control procedures/protocols appropriate for and specific to their assigned duties (IB,
IC).
2. Provide educational information appropriate in content and vocabulary to the
educational level, literacy, and language of DHCP (IB, IC).

C. Immunization Programs

1. Develop a written comprehensive policy regarding immunizing DHCP, including a list

of all required and recommended immunizations (IB).
2. Refer DHCP to a prearranged qualified health-care professional or to their own
health-care professional to receive all appropriate immunizations based on the latest
recommendations as well as their medical history and risk for occupational exposure
(IB).

D. Exposure Prevention and Postexposure Management

1. Develop a comprehensive postexposure management and medical follow-up

program (IB, IC).

a. Include policies and procedures for prompt reporting, evaluation, counseling,

treatment, and medical follow-up of occupational exposures.
 b. Establish mechanisms for referral to a qualified health-care professional for
medical evaluation and follow-up.
c. Conduct a baseline TST, preferably by using a two-step test, for all DHCP
who might have contact with persons with suspected or confirmed infectious TB,
regardless of the risk classification of the setting (IB).

E. Medical Conditions, Work-Related Illness, and Work Restrictions

1. Develop and have readily available to all DHCP comprehensive written policies
regarding work restriction and exclusion that include a statement of authority defining
who can implement such policies (IB).
2. Develop policies for work restriction and exclusion that encourage DHCP to seek
appropriate preventive and curative care and report their illnesses, medical conditions,
or treatments that can render them more susceptible to opportunistic infection or
exposures; do not penalize DHCP with loss of wages, benefits, or job status (IB).
3. Develop policies and procedures for evaluation, diagnosis, and management of
DHCP with suspected or known occupational contact dermatitis (IB).
4. Seek definitive diagnosis by a qualified health-care professional for any DHCP with
suspected latex allergy to carefully determine its specific etiology and appropriate
treatment as well as work restrictions and accommodations (IB).

F. Records Maintenance, Data Management, and Confidentiality

1. Establish and maintain confidential medical records (e.g., immunization records and
documentation of tests received as a result of occupational exposure) for all DHCP (IB,
IC).
2. Ensure that the practice complies with all applicable federal, state, and local laws
regarding medical recordkeeping and confidentiality (IC).

Preventing Transmission of Bloodborne Pathogens

A. HBV Vaccination

1. Offer the HBV vaccination series to all DHCP with potential occupational exposure to
blood or other potentially infectious material (IA, IC).
2. Always follow U.S. Public Health Service/CDC recommendations for hepatitis B
vaccination, serologic testing, follow-up, and booster dosing (IA, IC).
3. Test DHCP for anti-HBs 1--2 months after completion of the 3-dose vaccination
series (IA, IC).
4. DHCP should complete a second 3-dose vaccine series or be evaluated to determine
if they are HBsAg-positive if no antibody response occurs to the primary vaccine series
(IA, IC).
5. Retest for anti-HBs at the completion of the second vaccine series. If no response to
the second 3-dose series occurs, nonresponders should be tested for HBsAg (IC).
6. Counsel nonresponders to vaccination who are HBsAg-negative regarding their
susceptibility to HBV infection and precautions to take (IA, IC).
7. Provide employees appropriate education regarding the risks of HBV transmission
and the availability of the vaccine. Employees who decline the vaccination should sign
a declination form to be kept on file with the employer (IC).
B. Preventing Exposures to Blood and OPIM

1. General recommendations

a. Use standard precautions (OSHA's bloodborne pathogen standard retains the

term universal precautions) for all patient encounters (IA, IC).
b. Consider sharp items (e.g., needles, scalers, burs, lab knives, and wires) that
are contaminated with patient blood and saliva as potentially infective and
establish engineering controls and work practices to prevent injuries (IB, IC).
c. Implement a written, comprehensive program designed to minimize and
manage DHCP exposures to blood and body fluids (IB, IC).

2. Engineering and work-practice controls

a. Identify, evaluate, and select devices with engineered safety features at least
annually and as they become available on the market (e.g., safer anesthetic
syringes, blunt suture needle, retractable scalpel, or needleless IV systems)
(IC).
b. Place used disposable syringes and needles, scalpel blades, and other sharp
items in appropriate puncture-resistant containers located as close as feasible
to the area in which the items are used (IA, IC).
c. Do not recap used needles by using both hands or any other technique that
involves directing the point of a needle toward any part of the body. Do not
bend, break, or remove needles before disposal (IA, IC).
d. Use either a one-handed scoop technique or a mechanical device designed
for holding the needle cap when recapping needles (e.g., between multiple
injections and before removing from a nondisposable aspirating syringe) (IA,
IC).

3. Postexposure management and prophylaxis

a. Follow CDC recommendations after percutaneous, mucous membrane, or

nonintact skin exposure to blood or other potentially infectious material (IA, IC).

Hand Hygiene

A. General Considerations
1. Perform hand hygiene with either a nonantimicrobial or antimicrobial soap and water
when hands are visibly dirty or contaminated with blood or other potentially infectious
material. If hands are not visibly soiled, an alcohol-based hand rub can also be used.
Follow the manufacturer's instructions (1A)
2. Indications for hand hygiene include
a. when hands are visibly soiled
b. after barehanded touching of inanimate objects likely to be contaminated by
blood, saliva, or respiratory secretions
(IA, IC);
c. before and after treating each patient (IB);
d. before donning gloves (IB); and
e. immediately after removing gloves (IB, IC)
3. For oral surgical procedures, perform surgical hand antisepsis before donning sterile
 surgeon's gloves. Follow the manufacturer's instructions by using either an
antimicrobial soap and water, or soap and water followed by drying hands and
application of an alcohol-based surgical hand-scrub product with persistent activity (IB)

4. Store liquid hand-care products in either disposable closed containers or closed

containers that can be washed and dried before refilling. Do not add soap or lotion to
(i.e., top off) a partially empty dispenser.

B. Special Considerations for Hand Hygiene and Glove Use

1. Use hand lotions to prevent skin dryness associated with handwashing (IA).
2. Consider the compatibility of lotion and antiseptic products and the effect of
petroleum or other oil emollients on the integrity of gloves during product selection and
glove use (IB)
3. Keep fingernails short with smooth, filed edges to allow thorough cleaning and
prevent glove tears (II)
4. Do not wear artificial fingernails or extenders when having direct contact with
patients at high risk (e.g., those in intensive care units or operating rooms) (IA)
5. Use of artificial fingernails is usually not recommended (II)
6. Do not wear hand or nail jewelry if it makes donning gloves more difficult or
compromises the fit and integrity of the glove (II)

Personal Protective Equipment (PPE)

A. Masks, Protective Eyewear, and Face Shields

1. Wear a surgical mask and eye protection with solid side shields or a face shield to
protect mucous membranes of the eyes, nose, and mouth during procedures likely to
generate splashing or spattering of blood or other body fluids (IB, IC).
2. Change masks between patients or during patient treatment if the mask becomes
wet (IB).
3. Clean with soap and water, or if visibly soiled, clean and disinfect reusable facial
protective equipment (e.g., clinician and patient protective eyewear or face shields)
between patients (II).

B. Protective Clothing

1. Wear protective clothing (e.g., reusable or disposable gown, laboratory coat, or

uniform) that covers personal clothing and skin (e.g., forearms) likely to be soiled with
blood, saliva, or OPIM (IB, IC).
2. Change protective clothing if visibly soiled; change immediately or as soon as
feasible if penetrated by blood or other potentially infectious fluids (IB, IC).
3. Remove barrier protection, including gloves, mask, eyewear, and gown before
departing work area (e.g., dental patient care, instrument processing, or laboratory
areas) (IC).

C. Gloves

1. Wear medical gloves when a potential exists for contacting blood, saliva, OPIM, or
mucous membranes (IB, IC).
 2. Wear a new pair of medical gloves for each patient, remove them promptly after use,
and wash hands immediately to avoid transfer of microorganisms to other patients or
environments (IB).
3. Remove gloves that are torn, cut, or punctured as soon as feasible and wash hands
before regloving (IB, IC).
4. Do not wash surgeon's or patient examination gloves before use or wash, disinfect,
or sterilize gloves for reuse (IB, IC).
5. Ensure that appropriate gloves in the correct size are readily accessible (IC).
6. Use appropriate gloves (e.g., puncture- and chemical-resistant utility gloves) when
cleaning instruments and performing housekeeping tasks involving contact with blood
or OPIM (IB, IC).
7. Consult with glove manufacturers regarding the chemical compatibility of glove
material and dental materials used (II).

D. Sterile Surgeon's Gloves and Double Gloving During Oral Surgical Procedures

1. Wear sterile surgeon's gloves when performing oral surgical procedures (IB).
2. No recommendation is offered regarding the effectiveness of wearing two pairs of
gloves to prevent disease transmission during oral surgical procedures. The majority of
studies among HCP and DHCP have demonstrated a lower frequency of inner glove
perforation and visible blood on the surgeon's hands when double gloves are worn;
however, the effectiveness of wearing two pairs of gloves in preventing disease
transmission has not been demonstrated (Unresolved issue).
E. PPE Provided
1. (Facility name) will provide suitable gowns, eye protection, masks, gloves, hair
covers, and shoe covers needed to provide dental treatment.

F. Protection for Patients

1. Patients will be provided safety glasses to be worn throughout dental treatment.
2. When the introduction of minimal contaminants would compromise dental
treatment, additional protection such as towel draped over the patient may be used.

Contact Dermatitis and Latex Sensitivity

1. Educate DHCP regarding the signs, symptoms, and diagnoses of skin reactions
associated with frequent hand hygiene and glove use (IB)
2. Screen all patients for latex allergy (e.g., take health history and refer for medical
consultation when latex allergy is suspected) (IB)
3. Ensure a latex-safe environment for patients and DHCP with latex allergy (IB)
4. Have emergency treatment kits with latex-free products available at all times (II)
Sterilization and Disinfection of Patient-Care Items

Definitions:

Infection Control Categories of Patient-Care Instruments

Category Definition Dental Instrument or Item

Critical Penetrates soft tissues,
contacts bone, enters into
to contacts the blood
stream or other normally
sterile tissue.
Semicritical Contacts mucous
membranes or nonintact
skin; will not penetrate soft
tissue, contact bone, enter
into or contact the
bloodstream or other
normally sterile tissue.
Noncritical Contacts intact skin
CDC, 2003, p. 20Levels of Sterilization and Disinfection
Surgical instruments,
periodontal scalers, scalpel
blades, surgical dental burs
Dental mouth mirror,
amalgam condenser,
reusable dental impression
trays, dental handpieces
Radiograph head/cone,
blood pressure cuff,
facebow

Sterilization (autoclave)- used for heat-tolerant critical and semi-critical patient care items

High-level disinfection- liquid immersion

Intermediate-level disinfection- Liquid contact- EPA registered hospital disinfectant with lable
claim of tuberculocidal activity (Chlorine containing products - 1:100 dilution (1/4 cup of 5.25%
household chlorine bleach to 1 gallon of water)
Alternative products may be biocide or Lysol-IC for surfaces that may be damaged by bleach
products

Low level disinfection- liquid contact- EPA registered disinfectant with no claim of
tuberculocidal activity (soap and water, alcohol)

CDC, 2003, p. 66
A. General Recommendations

1. Use only FDA-cleared medical devices for sterilization and follow the manufacturer's
instructions for correct use (IB).
2. Clean and heat-sterilize critical dental instruments before each use (IA).
3. Clean and heat-sterilize semicritical items before each use (IB).
4. Allow packages to dry in the sterilizer before they are handled to avoid contamination
(IB).
5. Use of heat-stable semicritical alternatives is encouraged (IB).
6. Reprocess heat-sensitive critical and semi-critical instruments by using FDA-cleared
 sterilant/high-level disinfectants or an FDA-cleared low-temperature sterilization method
(e.g., ethylene oxide). Follow manufacturer's instructions for use of chemical
sterilants/high-level disinfectants (IB).
7. Single-use disposable instruments are acceptable alternatives if they are used only
once and disposed of correctly (IB, IC).
8. Do not use liquid chemical sterilants/high-level disinfectants for environmental
surface disinfection or as holding solutions (IB, IC).
9. Ensure that . If visibly contaminated with blood, use an EPA-registered hospital
disinfectant with a tuberculocidal claim (i.e., intermediate level) (IB).
10. Inform DHCP of all OSHA guidelines for exposure to chemical agents used for
disinfection and sterilization. Using this report, identify areas and tasks that have
potential for exposure (IC).

B. Instrument Processing Area

1. Designate a central processing area. Divide the instrument processing area,

physically or, at a minimum, spatially, into distinct areas for 1) receiving, cleaning, and
decontamination; 2) preparation and packaging; 3) sterilization; and 4) storage. Do not
store instruments in an area where contaminated instruments are held or cleaned (II).
2. Train DHCP to employ work practices that prevent contamination of clean areas (II).

C. Receiving, Cleaning, and Decontamination Work Area

1. Minimize handling of loose contaminated instruments during transport to the

instrument processing area. Use work-practice controls (e.g., carry instruments in a
covered container) to minimize exposure potential (II). Clean all visible blood and other
contamination from dental instruments and devices before sterilization or disinfection
procedures (IA).
2. Use automated cleaning equipment (e.g., ultrasonic cleaner or washer-disinfector) to
remove debris to improve cleaning effectiveness and decrease worker exposure to
blood (IB).
3. Use work-practice controls that minimize contact with sharp instruments if manual
cleaning is necessary (e.g., long-handled brush) (IC).
4. Wear puncture- and chemical-resistant/heavy-duty utility gloves for instrument
cleaning and decontamination procedures (IB).
5. Wear appropriate PPE (e.g., mask, protective eyewear, and gown) when splashing or
spraying is anticipated during cleaning (IC).

D. Preparation and Packaging

1. Use an internal chemical indicator in each package. If the internal indicator cannot be
seen from outside the package, also use an external indicator (II) .

2. Use a container system or wrapping compatible with the type of sterilization process
used and that has received FDA clearance (IB).

3. Before sterilization of critical and semicritical instruments, inspect instruments for

cleanliness, then wrap or place them in containers designed to maintain sterility during
storage (e.g., cassettes and organizing trays) (IA).
E. Sterilization of Unwrapped Instruments

1. Clean and dry instruments before the unwrapped sterilization cycle (IB).
2. Use mechanical and chemical indicators for each unwrapped sterilization cycle (i.e.,
place an internal chemical indicator among the instruments or items to be sterilized)
(IB).
3. Allow unwrapped instruments to dry and cool in the sterilizer before they are handled
to avoid contamination and thermal injury (II).
4. Semicritical instruments that will be used immediately or within a short time can be
sterilized unwrapped on a tray or in a container system, provided that the instruments
are handled aseptically during removal from the sterilizer and transport to the point of
use (II).
5. Critical instruments intended for immediate reuse can be sterilized unwrapped if the
instruments are maintained sterile during removal from the sterilizer and transport to the
point of use (e.g., transported in a sterile covered container) (IB).
6. Do not sterilize implantable devices unwrapped (IB).
7. Do not store critical instruments unwrapped (IB).

F. Sterilization Monitoring

1. Use mechanical, chemical, and biological monitors according to the manufacturer's

instructions to ensure the effectiveness of the sterilization process (IB).
2. Monitor each load with mechanical (e.g., time, temperature, and pressure) and
chemical indicators (II).
3. Place a chemical indicator on the inside of each package. If the internal indicator is
not visible from the outside, also place an exterior chemical indicator on the package
(II).
4. Place items/packages correctly and loosely into the sterilizer so as not to impede
penetration of the sterilant (IB).
5. Do not use instrument packs if mechanical or chemical indicators indicate
inadequate processing (IB).
6. Monitor sterilizers at least weekly by using a biological indicator with a matching
control (i.e., biological indicator and control from same lot number) (IB).
7. Use a biological indicator for every sterilizer load that contains an implantable device.
Verify results before using the implantable device, whenever possible (IB).
8. The following are recommended in the case of a positive spore test:

a. Remove the sterilizer from service and review sterilization procedures (e.g.,
work practices and use of mechanical and chemical indicators) to determine
whether operator error could be responsible (II).
b. Retest the sterilizer by using biological, mechanical, and chemical indicators
after correcting any identified procedural problems (II).
c. If the repeat spore test is negative, and mechanical and chemical indicators
are within normal limits, put the sterilizer back in service (II).

9. The following are recommended if the repeat spore test is positive:

a. Do not use the sterilizer until it has been inspected or repaired or the exact
reason for the positive test has been determined (II).
b. Recall, to the extent possible, and reprocess all items processed since the
last negative spore test (II).
 c. Before placing the sterilizer back in service, rechallenge the sterilizer with
biological indicator tests in three consecutive empty chamber sterilization cycles
after the cause of the sterilizer failure has been determined and corrected (II) .

10. Maintain sterilization records (i.e., mechanical, chemical, and biological) in

compliance with state and local regulations (IB) .

G. Storage Area for Sterilized Items and Clean Dental Supplies

1. Implement practices on the basis of date- or event-related shelf-life for storage of

wrapped, sterilized instruments and devices (IB).
2. Even for event-related packaging, at a minimum, place the date of sterilization, and if
multiple sterilizers are used in the facility, the sterilizer used, on the outside of the
packaging material to facilitate the retrieval of processed items in the event of a
sterilization failure (IB).
3. Examine wrapped packages of sterilized instruments before opening them to ensure
the barrier wrap has not been compromised during storage (II).
4. Reclean, repack, and resterilize any instrument package that has been compromised
(II).
5. Store sterile items and dental supplies in covered or closed cabinets, if possible (II).

Environmental Infection Control

A. General Recommendations

1. Follow the manufacturers' instructions for correct use of cleaning and EPA-registered
hospital disinfecting products (IB, IC).
2. Do not use liquid chemical sterilants/high-level disinfectants for disinfection of
environmental surfaces (clinical contact or housekeeping) (IB, IC).
3. Use PPE, as appropriate, when cleaning and disinfecting environmental surfaces.
Such equipment might include gloves (e.g., puncture- and chemical-resistant utility),
protective clothing (e.g., gown, jacket, or lab coat), and protective eyewear/face shield,
and mask (IC).

B. Clinical Contact Surfaces

1. Use surface barriers to protect clinical contact surfaces, particularly those that are
difficult to clean (e.g., switches on dental chairs) and change surface barriers between
patients (II).
2. Clean and disinfect clinical contact surfaces that are not barrier-protected, by using
an EPA-registered hospital disinfectant with a low- (i.e., HIV and HBV label claims) to
intermediate-level (i.e., tuberculocidal claim) activity after each patient. Use an
intermediate-level disinfectant if visibly contaminated with blood (IB).

C. Housekeeping Surfaces

1. Clean housekeeping surfaces (e.g., floors, walls, and sinks) with a detergent and
water or an EPA-registered hospital disinfectant/detergent on a routine basis,
depending on the nature of the surface and type and degree of contamination, and as
appropriate, based on the location in the facility, and when visibly soiled (IB).
2. Clean mops and cloths after use and allow to dry before reuse; or use single-use,
 disposable mop heads or cloths (II).
3. Prepare fresh cleaning or EPA-registered disinfecting solutions daily and as
instructed by the manufacturer. (II).
4. Clean walls, blinds, and window curtains in patient-care areas when they are visibly
dusty or soiled (II).

D. Spills of Blood and Body Substances

1. Clean spills of blood or OPIM and decontaminate surface with an EPA-registered

hospital disinfectant with low- (i.e., HBV and HIV label claims) to intermediate-level (i.e.,
tuberculocidal claim) activity, depending on size of spill and surface porosity (IB, IC).

E. Carpet and Cloth Furnishings

1. Avoid using carpeting and cloth-upholstered furnishings in dental operatories,

laboratories, and instrument processing areas (II).

F. Regulated Medical Waste

1. General Recommendations

a. Develop a medical waste management program. Disposal of regulated

medical waste must follow federal, state, and local regulations (IC).
b. Ensure that DHCP who handle and dispose of regulated medical waste are
trained in appropriate handling and disposal methods and informed of the
possible health and safety hazards (IC).

2. Management of Regulated Medical Waste in Dental Health-Care Facilities

a. Use a color-coded or labeled container that prevents leakage (e.g., biohazard

bag) to contain nonsharp regulated medical waste (IC).
b. Place sharp items (e.g., needles, scalpel blades, orthodontic bands, broken
metal instruments, and burs) in an appropriate sharps container (e.g., puncture
resistant, color-coded, and leakproof). Close container immediately before
removal or replacement to prevent spillage or protrusion of contents during
handling, storage, transport, or shipping (IC).
c. Pour blood, suctioned fluids or other liquid waste carefully into a drain
connected to a sanitary sewer system, if local sewage discharge requirements
are met and the state has declared this an acceptable method of disposal. Wear
appropriate PPE while performing this task (IC).

Dental Waterlines, Biofilm, and Water Quality

A. General Recommendations
1. Use water that meets EPA regulatory standards for drinking water (i.e., <500
CFU/mL of heterotrophic water bacteria) for routine dental treatment output water
(IB, IC).
2. Consult with the dental unit manufacturer for appropriate methods and
equipment to maintain the recommended quality of dental water (II).
3. Follow recommendations for monitoring water quality provided by the
manufacturer of the unit or waterline treatment product (II).
 4. Discharge water and air for a minimum of 20--30 seconds after each patient,
from any device connected to the dental water system that enters the patient's
mouth (e.g., handpieces, ultrasonic scalers, and air/water syringes) (II).
5. Consult with the dental unit manufacturer on the need for periodic maintenance
of antiretraction mechanisms (IB).
6. Maintain a log of water line test results in the dental clinic.

B. Boil-Water Advisories

1. The following apply while a boil-water advisory is in effect:

a. Do not deliver water from the public water system to the patient through the
dental operative unit, ultrasonic scaler, or other dental equipment that uses the
public water system (IB, IC).
b. Do not use water from the public water system for dental treatment, patient
rinsing, or handwashing (IB, IC).
c. For handwashing, use antimicrobial-containing products that do not require
water for use (e.g., alcohol-based hand rubs). If hands are visibly contaminated,
use bottled water, if available, and soap for handwashing or an antiseptic
towelette (IB, IC).

2. The following apply when the boil-water advisory is cancelled:

a. Follow guidance given by the local water utility regarding adequate flushing of
waterlines. If no guidance is provided, flush dental waterlines and faucets for 1--
5 minutes before using for patient care (IC).
b. Disinfect dental waterlines as recommended by the dental unit manufacturer
(II).

Special Considerations

A. Dental Handpieces and Other Devices Attached to Air and Waterlines

1. Clean and heat-sterilize handpieces and other intraoral instruments that can be
removed from the air and waterlines of dental units between patients (IB, IC).
2. Follow the manufacturer's instructions for cleaning, lubrication, and sterilization of
handpieces and other intraoral instruments that can be removed from the air and
waterlines of dental units (IB).
3. Do not surface-disinfect, use liquid chemical sterilants, or ethylene oxide on
handpieces and other intraoral instruments that can be removed from the air and
waterlines of dental units (IC).
4. Do not advise patients to close their lips tightly around the tip of the saliva ejector to
evacuate oral fluids (II).

B. Dental Radiology

1. Wear gloves when exposing radiographs and handling contaminated film packets.
Use other PPE (e.g., protective eyewear, mask, and gown) as appropriate if spattering
of blood or other body fluids is likely (IA, IC).
 2. Use heat-tolerant or disposable intraoral devices whenever possible (e.g., film-
holding and positioning devices). Clean and heat-sterilize heat-tolerant devices
between patients. At a minimum, high-level disinfect semicritical heat-sensitive devices,
according to manufacturer's instructions (IB).
3. Transport and handle exposed radiographs in an aseptic manner to prevent
contamination of developing equipment (II).
4. The following apply for digital radiography sensors:

a. Use FDA-cleared barriers (IB).

b. Clean and heat-sterilize, or high-level disinfect, between patients, barrier-
protected semicritical items. If the item cannot tolerate these procedures then, at
a minimum, protect with an FDA-cleared barrier and clean and disinfect with an
EPA-registered hospital disinfectant with intermediate-level (i.e., tuberculocidal
claim) activity, between patients. Consult with the manufacturer for methods of
disinfection and sterilization of digital radiology sensors and for protection of
associated computer hardware (IB).

C. Aseptic Technique for Parenteral Medications

1. Do not administer medication from a syringe to multiple patients, even if the needle
on the syringe is changed (IA). 2. Use single-dose vials for parenteral medications
when possible (II).
3. Do not combine the leftover contents of single-use vials for later use (IA).
4. The following apply if multidose vials are used:

a. Cleanse the access diaphragm with 70% alcohol before inserting a device
into the vial (IA).
b. Use a sterile device to access a multiple-dose vial and avoid touching the
access diaphragm. Both the needle and syringe used to access the multidose
vial should be sterile. Do not reuse a syringe even if the needle is changed (IA).
c. Keep multidose vials away from the immediate patient treatment area to
prevent inadvertent contamination by spray or spatter (II).
d. Discard the multidose vial if sterility is compromised (IA).

5. Use fluid infusion and administration sets (i.e., IV bags, tubings and connections) for
one patient only and dispose of appropriately (IB).

D. Single-Use (Disposable) Devices

1. Use single-use devices for one patient only and dispose of them appropriately (IC).

E. Preprocedural Mouth Rinses

1. No recommendation is offered regarding use of preprocedural antimicrobial mouth

rinses to prevent clinical infections among DHCP or patients. Although studies have
demonstrated that a preprocedural antimicrobial rinse (e.g., chlorhexidine gluconate,
essential oils, or povidone-iodine) can reduce the level of oral microorganisms in
aerosols and spatter generated during routine dental procedures and can decrease the
number of microorganisms introduced in the patient's bloodstream during invasive
dental procedures, the scientific evidence is inconclusive that using these rinses
 prevents clinical infections among DHCP or patients (see discussion, Preprocedural
Mouth Rinses) (Unresolved issue).

F. Oral Surgical Procedures

1. The following apply when performing oral surgical procedures:

a. Perform surgical hand antisepsis by using an antimicrobial product (e.g.,

antimicrobial soap and water, or soap and water followed by alcohol-based hand
scrub with persistent activity) before donning sterile surgeon's gloves (IB).

b. Use sterile surgeon's gloves (IB).

c. Use sterile saline or sterile water as a coolant/irrigatant when performing oral
surgical procedures. Use devices specifically designed for delivering sterile
irrigating fluids (e.g., bulb syringe, single-use disposable products, and
sterilizable tubing) (IB).

G. Handling of Biopsy Specimens

1. During transport, place biopsy specimens in a sturdy, leakproof container labeled

with the biohazard symbol (IC).
2. If a biopsy specimen container is visibly contaminated, clean and disinfect the
outside of a container or place it in an impervious bag labeled with the biohazard
symbol, (IC).

H. Handling of Extracted Teeth

1. Dispose of extracted teeth as regulated medical waste unless returned to the patient
(IC).
2. Do not dispose of extracted teeth containing amalgam in regulated medical waste
intended for incineration (II).
3. Clean and place extracted teeth in a leakproof container, labeled with a biohazard
symbol, and maintain hydration for transport to educational institutions or a dental
laboratory (IC).
4. Heat-sterilize teeth that do not contain amalgam before they are used for educational
purposes (IB).

I. Dental Laboratory

1. Use PPE when handling items received in the laboratory until they have been
decontaminated (IA, IC)

2. Before they are handled in the laboratory, clean, disinfect, and rinse all dental
prostheses and prosthodontic materials (e.g., impressions, bite registrations, occlusal
rims, and extracted teeth) by using an EPA-registered hospital disinfectant having at
least an intermediate-level (i.e., tuberculocidal claim) activity (IB).
3. Consult with manufacturers regarding the stability of specific materials (e.g.,
impression materials) relative to disinfection procedures (II).
4. Include specific information regarding disinfection techniques used (e.g., solution
used and duration), when laboratory cases are sent off-site and on their return (II).
5. Clean and heat-sterilize heat-tolerant items used in the mouth (e.g., metal impression
trays and face-bow forks) (IB).
 6. Follow manufacturers' instructions for cleaning and sterilizing or disinfecting items
that become contaminated but do not normally contact the patient (e.g., burs, polishing
points, rag wheels, articulators, case pans, and lathes). If manufacturer instructions are
unavailable, clean and heat-sterilize heat-tolerant items or clean and disinfect with an
EPA-registered hospital disinfectant with low- (HIV, HBV effectiveness claim) to
intermediate-level (tuberculocidal claim) activity, depending on the degree of
contamination (II).

J. Laser/Electrosurgery Plumes/Surgical Smoke

1. No recommendation is offered regarding practices to reduce DHCP exposure to

laser plumes/surgical smoke when using lasers in dental practice. Practices to reduce
HCP exposure to laser plumes/surgical smoke have been suggested, including use of
a) standard precautions (e.g., high-filtration surgical masks and possibly full face
shields) (437); b) central room suction units with in-line filters to collect particulate
matter from minimal plumes; and c) dedicated mechanical smoke exhaust systems with
a high-efficiency filter to remove substantial amounts of laser-plume particles. The
effect of the exposure (e.g., disease transmission or adverse respiratory effects) on
DHCP from dental applications of lasers has not been adequately evaluated (see
previous discussion, Laser/Electrosurgery Plumes or Surgical Smoke) (Unresolved
issue).

K. Mycobacterium tuberculosis

1. General Recommendations

a. Educate all DHCP regarding the recognition of signs, symptoms, and

transmission of TB (IB).
b. Conduct a baseline TST, preferably by using a two-step test, for all DHCP
who might have contact with persons with suspected or confirmed active TB,
regardless of the risk classification of the setting (IB).
c. Assess each patient for a history of TB as well as symptoms indicative of TB
and document on the medical history form (IB).
d. Follow CDC recommendations for 1) developing, maintaining, and
implementing a written TB infection-control plan; 2) managing a patient with
suspected or active TB; 3) completing a community risk-assessment to guide
employee TSTs and follow-up; and 4) managing DHCP with TB disease (IB).

2. The following apply for patients known or suspected to have active TB:

a. Evaluate the patient away from other patients and DHCP. When not being
evaluated, the patient should wear a surgical mask or be instructed to cover
mouth and nose when coughing or sneezing (IB).
b. Defer elective dental treatment until the patient is noninfectious (IB).
c. Refer patients requiring urgent dental treatment to a previously identified
facility with TB engineering controls and a respiratory protection program (IB).

L. Creutzfeldt-Jakob Disease (CJD) and Other Prion Diseases

1. No recommendation is offered regarding use of special precautions in addition to

standard precautions when treating known CJD or vCJD patients. Potential infectivity of
 oral tissues in CJD or vCJD patients is an unresolved issue. Scientific data indicate the
risk, if any, of sporadic CJD transmission during dental and oral surgical procedures is
low to nil. Until additional information exists regarding the transmissibility of CJD or
vCJD during dental procedures, special precautions in addition to standard precautions
might be indicated when treating known CJD or vCJD patients; a list of such
precautions is provided for consideration without recommendation (see Creutzfeldt-
Jakob Disease and Other Prion Diseases) (Unresolved issue).
Program Evaluation

1. Establish routine evaluation of the infection-control program, including evaluation of

performance indicators, at an established frequency (II).

2. Monitoring Tool is included in the Quality Assurance Section

C.2 RADIOLOGICAL PROTECTION
PURPOSE
To establish procedures that ensure the safe operation of all radiology equipment, minimize
radiation exposure to both patients and dental staff, and comply with State regulations.

PROCEDURE
Appropriate lead aprons will be placed over the patient for all radiographs. Lead aprons will be
stored hanging; they will not be folded or creased when not in use, as this will increase the risk
of holes or tears in the lead shield. Every year all lead aprons used for x-ray protection will be
sent to [appropriate location] for evaluation. All aprons, which fail the inspection, will be
discarded. Records of testing will be maintained by [appropriate staff].
[If the facility uses a monitoring service] 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
[appropriate staff] will keep a copy on file.
"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.
All radiographs will be taken using a film positioner. At no time will a patient hold a film to
position that film during x-ray exposure.
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".
[Insert competency procedure}
Example:
The dental assistants shall yearly be evaluated on their clinical radiographs and radiological
safety according to the IHS radiological criteria for quality care.

X-Ray Machine Certification

Insert appropriate State regulations and procedures

C.3 EQUIPMENT MAINTENANCE AND PRODUCT RECALLS

PURPOSE
To establish procedures that ensure the safe operation of all equipment, comply with facility
safety policies, and comply with applicable State and federal regulations.
PROCEDURE
Maintenance
Each dental unit will have a logbook pertaining to maintenance. Any maintenance that is
required is entered into the book for that particular unit. The [appropriate individual] for
maintenance required will check the logbooks weekly. If maintenance is required the
[designated individual] will complete the necessary maintenance requests, refer them to
[appropriate source for repairs such as :bio-medical engineering or refer them to
maintenance personnel]. The [designated individual] 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.
Alternative Procedure
A contracted vendor makes quarterly maintenance visits. The vendor shall provide a copy of
maintenance performed for each dental unit and the [designated individual] will maintain
these records.

Product Recalls
When the dental department receives notice that a product is subject to a recall
[designated individual] will check lot numbers, serial numbers or other
product designators, gather all affected products, and comply with
manufacturer’s instructions regarding the recall.
C.4 NITROUS OXIDE SAFETY

PURPOSE
To establish procedures for the safe and effective use of nitrous oxide/oxygen therapy to
protect patients and facility employees.

PROCEDURE
The following National Institute for Occupational Safety and Health recommendations will be
observed when using nitrous oxide/oxygen.
System maintenance
Inspect and maintain the anesthetic delivery system to prevent N2O leaks in all hoses,
connections and fittings. Repair all leaks immediately.
Ventilation
Scavenging system used will maintain a flow rate of 45 LPM, measured by a calibrated flow
device, and vented outdoors.
Work Practices
Select scavenging masks of proper size to fit patients.
Prudent use of N2O to appropriately sedate patients is encouraged.
Monitor the air concentration of N2O to insure Controls are effective in achieving low levels
during dental operations.

 STEP BY STEP APPROACH FOR CONTROLLING N2O

Step Procedure Control

1 Visually inspect all N2O equipment
(reservoir bag, hoses, mask,
connectors) for worn parts, cracks,
holes, or tears.
2 Turn on the N2O tank and check all
high to low pressure connections
for leaks. Use a non-oil-based soap
worn solution to check for bubbles
at high pressure connectors, or use
a portable infrared gas analyzer.
3 Select scavenging system and mask.
Mask should come in various sizes
to patients. Scavenging systems
should operate at air flow rate of 45
lpm.
Replace defective equipment and/or parts.
Determine leak source and fix. If tank valve leaks,
replace tank; if O-rings, gaskets, valves, hoses, or
fittings, replace. Contact the manufacturer for parts
tact the manufacturer for parts replacement. For
threaded pipe fittings, use Teflon tape. Do not use
this tape on compression fittings.
Provide a range of mask sizes for patients. Check to
see that noise levels at the mask are acceptable when
the scavenging system exhaust rate is operated at 45
lpm.
4 Connect mask to hose and turn on
vacuum pump before turning on
N2O. Scavenging system vacuum
pump must have capacity to
scavenge 45 lpm per dental
operation.
5 Place mask on patient and assure a
good, comfortable fit. Make sure
reservoir bag is not over or under
inflated while the patient is
breathing.
6 Check general ventilation for good
room air mixing. Exhaust vents
should not be close to air supply
vents (use smoke tubes to observe
air movement in room.)
7 Conduct personal sampling of
dentist and dental assistant for N2O
exposure. Use diffusive sampler or
infrared gas analyzer (see sampling
methods).
8 Repeat procedure in step 7.
Determine proper vacuum pump size for maintaining
45 lpm flowrates, especially when interconnected
with other dental scavenging systems. If undersized,
replace pump.
Secure mask with "slip" ring Secure mask with "slip"
ring for "good activity" from patient breathing.
If smoke from smoke tubes indicate room air mixing
is poor, then increase the airflow or redesign. If
exhaust vents are close to air supply vents, relocate
(check with ventilation engineers to make
adjustments).
If personal exposures exceed 150 ppm during
administration, improve mask fit and make sure it is
secure over the patient's nose. Minimize patient
talking while N2O is administered.
If personal exposures are less than 150 ppm but
greater than 25 ppm, implement auxiliary exhaust
ventilation near the patient's mouth. Capture distance
should no greater than 10 inches from the patient's
nose and mouth area and exhaust no less than 250
cfm at the hood opening. Avoid getting between the
auxiliary exhaust hood and patient's mouth and nose
area.
C.5 FIRE PLAN
[Insert facility’s Policy Header Information]
PURPOSE
To establish procedures that ensure the safe evacuation in case of a fire, minimize risk of injury
to both patients and dental staff, and comply with facility safety regulations.
PROCEDURE
FIRE EVACUATION PLAN

The dental clinic will comply with all Fire Procedures set by the [Facility] Health Department.
A copy of the [Facility] Fire Plan is located [location].
The evacuation of the dental clinic in care of fire is outlined in the Facility’s Fire and Safety
Manual. A map of primary and secondary escape routes is posted [state location(s)]. All staff
will become familiar with this map and evacuation procedures. A copy of the evacuation plan
is located in the [location]. 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 [insert
appropriate procedures].
If a fire is announced in another part of the facility [insert facility policies regarding
response and evacuation procedures]
Patients in the area will be moved out of the fire area following the primary exit. If that exit is
not accessible, the secondary route will be used. All dental staff and dental patients will gather
[state primary gathering location] to facilitate accounting for all persons present in the dental
clinic at the time of the evacuation.
C.5 MERCURY HYGIENE
PURPOSE
To establish procedures that ensure the recycling of products containing mercury, minimize
mercury exposure to both patients and dental staff, and comply with State regulations.
PROCEDURE
Dentists and their staff use certain toxic substances that may lead to the contamination of
water systems and the environment. In order to prevent contamination, dental offices should
implement proper waste management procedures. Subsequently Indian Health Service (IHS)
has developed waste management guidelines for the use of mercury amalgam.

Dental amalgam can contain up to 50 percent mercury. Although mercury in amalgam form is
very stable, it should not be disposed of or rinsed down the drain. This is important because
the amalgam waste could end up in municipal garbage, medical waste, or in the sewer system.
If the waste is incinerated the mercury could be released to the environment, and if it reaches
the sewer system it could contaminate drinking water or accumulate in fish. The best method
of dealing with amalgam waste is by recycling it. Mercury can be recovered through a
distillation process and reused in other products.

If required by State regulations: “Amalgam waste will be collected using amalgam

separators in wastewater.”

The following document summarizes the different types of mercury amalgam wastes,
management practices for dealing with amalgam waste that conform to IHS guidelines, and
some Do’s and Don’ts when dealing with amalgam waste as outlined by the American Dental
Association (ADA).

Types of Amalgam Wastes

 Non-contact amalgam (scrap): Excess mixture that is left over after a dental
procedure.
 Contact amalgam: Amalgam that has been in contact with the patient. Examples
include extracted teeth with amalgam restorations, carving scrap collected at the chair,
and amalgam captured by the chair side traps, filters or screens.
 Chair side traps: Amalgam that is captured during amalgam placement or removal
procedures.
 Vacuum pump filters: Filters and traps contain amalgam sludge or water. Some
recyclers will accept whole filters, while others may require special handling
requirements for this material.
 Amalgam sludge: This is a mixture of liquid and solid material collected within the
vacuum pump filters.
 Empty amalgam capsules: Amalgam that may be left over in the capsules after
mixing the precapsulated dental amalgam.
 Amalgam Waste Management Practices
Scrap Amalgam Handling
 Dental scrap amalgam should be collected and stored in two designated, air-tight, wide-
mouthed plastic containers. One should be labeled CONTACT AMALGAM (amalgam
that has been in contact with the patient’s mouth), and the other should be labeled
NONCONTACT AMALGAM.
 NOTE: some recyclers may require special handling requirements for extracted teeth
such as shipping the tooth in a disinfectant.
 Make sure that the container lid is tightly sealed.
Amalgam Capsule Handling
 Stock capsules in a variety of different sizes.
 After mixing the amalgam, place the empty capsules in a wide-mouthed, airtight
container that is labeled AMALGAM CAPSULE WASTE.
 Capsules that cannot be emptied should also be placed in containers labeled AMALGAM
CAPSULE WASTE.
 Make sure that the container lid is tightly sealed.
Disposable chair-side traps
 Open the chair-side unit to expose the trap.
 Remove the trap and empty its contents into a wide-mouthed, airtight container that is
marked CONTACT AMALGAM.
 Make sure that the container lid is tightly sealed.
 Chair-side traps that are only used for procedures not involving amalgam can be thrown
in the regular garbage.
 Different states have different requirements for the disposal of infectious waste that is in
the traps with the amalgam such as blood or saliva. Check with your local recycler or
contact the Area Office of Environmental Health for the proper procedures.
Reusable Chair-side Traps
 Open the chair-side unit to expose the trap.
 Remove the trap and empty its contents into a wide-mouthed, airtight container that is
marked CONTACT AMALGAM.
 Make sure that the container lid is tightly sealed.
 DO NOT rinse the trap under running water.
 Replace the trap into the chair-side compartment.
 Different states have different requirements for the disposal of infectious waste that is in
the traps with the amalgam such as blood or saliva. Check with your local recycler or
contact the Area Office of Environmental Health for the proper procedures.
Vacuum Pump Filters
 Change the filter to the manufacturers suggested schedule.
 Remove the filter. Hold the filter over a tray or another container that can catch any
spills. Next pour out as much liquid as possible without losing any noticeable amalgam.
The amalgam-free liquid can then be rinsed down the drain.
 Place the lid on the filter and put it in the box in which it was originally shipped. Once
the box is full, the filters can be recycled.
Line Cleaners
 Use only non-bleach, non-chlorine containing solutions when flushing the wastewater
lines and vacuum systems. A list of ADA approved cleaners is posted at the end of this
document.
 American Dental Association (ADA)
Do’s and Don’ts for Dealing with Amalgam Waste
DO
Do use precapsulated alloys and stock a variety
of capsule sizes.
Do recycle used disposable amalgam capsules.
Do salvage, store, and recycle noncontact
amalgam (scrap amalgam).
Do salvage contact amalgam pieces from
restorations after removal and recycle the
amalgam waste.
Do use side-chair traps to retain amalgam and
recycle the contents.
Do recycle contents retained by the vacuum
pump filter or other amalgam collection
devices, if they contain amalgam.
Do recycle teeth that contain amalgam
restorations. (Note: Ask your recycler whether
or not extracted teeth with amalgam
restorations require disinfection)
Do manage amalgam waste through recycling
as much as possible.
Do use line cleaners that minimize the
dissolution of amalgam.
DON’T
Don’t use bulk mercury.
Don’t put used disposable amalgam capsules
in biohazard containers, infectious waste
containers (red bags) or regular garbage.
Don’t put non-contact amalgam waste in
biohazard containers, infectious waste
containers (red bags), or regular garbage.
Don’t put contact amalgam waste in
biohazard containers, infectious waste
containers (red bags), or regular garbage.
Don’t rinse chair-side traps containing
amalgam over drains or sinks.
Don’t rinse vacuum pump filters containing
amalgam or other amalgam collection
devices over drains or sinks.
Don’t dispose of extracted teeth that contain
amalgam restorations in biohazard
containers, infectious waste containers (red
bags), sharps containers, or regular garbage.
Don’t flush amalgam waste down the drain or
toilet.
Don’t use bleach or chlorine-containing
cleaners to flush waste water lines.
 Recycling
As mentioned earlier the recommended method for amalgam disposal is by recycling the
waste through an Environmental Protection Agency (EPA) approved vendor. The following
actions should be taken to properly recycle your amalgam waste.
 Carry the amalgam capsules in a variety of different sizes to reduce the amount of
waste produced.
 Personal protective equipment such as gloves, masks, and protective eyewear should
be worn when handling amalgam waste.
 Some vendors have special requirements for the handling, storing, and transportation
of amalgam waste, so be aware of any special conditions. Dental clinics that need to
find a recycler should contact their county or local waste authority to inquire about an
amalgam waste recycling program.
 Amalgam waste should be stored in covered plastic containers that are clearly labeled.
 Always store different types of amalgam waste (e.g., contact and noncontact) in
separate containers.
 Do not store amalgam waste under liquid. This would require the liquid to be treated as
hazardous waste. Storage in tight-fitting covered containers and routine recycling
should minimize any occupational exposures.

ADA Approved Line Cleaners

The following line cleaners do not contain bleach or chlorine:
Biocide (Biotrol International), BirexSe (Biotrol International), DRNA Vac (Dental
Recycling North American Inc.), E-Vac (L&R Manufacturing Co.), Fresh-Vac
(Huntington), GC Spray-Cide (GC America Inc.), Green and Clean (Metasys),
Microstat 2 (Septodont USA), Patterson Brand Concentrated Ultrasonic
Cleaner/Disinfectant Solution (Patterson Dental Supply, Inc.), ProE-Vac (Cottrell Ltd.),
Pure-Vac (Sultan Chemists Inc.), Sani-Treet Plus (Enzyme Industries Inc.), SRG
Evacuation (Icon Labs), Stay Clean (Apollo Dental Products), Turbo-Vac (Pinnacle
Products), Vacusol Ultra (Biotrol International), Cavicide (Metrex Research Corp.),
Vacuum Clean (Palmero Health Care).
Use of a chlorine free cleaner will reduce the dissolution of amalgam. Check with your
manufacturer to determine which line cleaner would be appropriate for use with your
equipment.
C.6 SAFETY
PURPOSE
To establish procedures that ensure the safety of both patients and dental staff, and comply
with facility safety regulations.
PROCEDURE
All dental personnel will have eye protection such as safety glasses, safety side shields for
prescription glasses, full face shields, goggles or other eye protection approved by [Facility].
Eye protection will be worn when the individual is using the high or slow speed handpiece or is
assisting when these headpieces are being used. The [program director] will delegate the
authority of requiring protective wear for dental personnel to the provider in charge of their
assigned area of dental care delivery.
Appropriate eye protection 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.
No open toed shoes will be worn in the patient care or dental laboratory areas (See Dress
Code, Section A.12)
The Facility Safety Policy and Procedure will be adhered to on all occasions and a copy of this
document is found in [location].
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 [facility].
(see document [appropriate document])
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 [location].
Eye wash stations are located [state location] for quick access as needed.

Other Individuals in Treatment Areas

The dental provider will determine if an individual not receiving dental treatment may be
present in the dental operatory during treatment. Family, siblings, or other individuals who pose
a safety threat to themselves or others, or who potentially interfere with safe and effective
dental treatment may be asked to wait outside the treatment area. Insert any instructions or
handouts to parents/guardians.
C.7. PRECIOUS METAL RECOVERY
PURPOSE
To establish procedures that ensure the safe recovery and recycling of all precious metals
used in dental clinic operations, minimize metal exposure to both patients and dental staff, and
comply with State regulations.
PROCEDURE
The [appropriate individual] will be responsible for all scrap precious metal collected in the
dental clinic to specific officials for their disposal.
Amalgam
See Mercury Hygiene Policy

Silver (Omit this section if x-rays are not processed in the dental clinic)
A silver recovery system will be installed on all X-ray film processors. The discharge from this
system will be maintained by [appropriate individual] [frequency] according to
manufacturer’s instructions. Recycling of recovered materials will be done according to
manufacturer’s instructions and facility policies. To confirm that silver recovery is effective
[appropriate individual] will test the effluent being discharged. Test papers and procedures
will be obtained from silver recovery system manufacturer.
All out of date and non-diagnostic radiographs will be collected and given to the [appropriate
individual] for recycling.

Gold
All gold removed from a patient will be given to the patient. If the patient does not want the
gold it will be placed with the amalgam scrap.
[Check with your amalgam recycler to confirm gold may be accepted with scrap
amalgam]
C.8 HAZARDOUS COMMUNICATIONS
Review this policy to ensure conformity with general facility Hazardous Communications
policies and forms. Forms or procedures covered in the General Facility Policies and
Procedures may be omitted from the Dental Specific Policy and Procedure Manual.
PURPOSE

The purpose of this Written Hazard Communication program is to ensure that:

1. Hazardous substances present in the work place are properly identified and labeled.

2. Employees have access to information on the hazards of these substances.

3. Employees are provided with information on how to prevent injuries or illnesses due to
exposure to these substances.

4. Identify by job title who has the responsibility for maintaining the program, the MSDS
sheets, conduct training, etc.

Note: This program will be available to all employees for review and a copy will be located
in the following area(s):

Location:
1.
2.
3.

PROCEDURE
The dental clinic will follow all Hazardous Communications policies and procedures in
place at [facility]. [Insert dental specific HazCom procedures]

(If the facility does not have a comprehensive Haz Com policy, or if the dental clinic chooses
to have a separate policy, use the OHSA recommended procedures below.)

AUTHORITY AND REFERENCE

Occupational Safety and Health Administration (OSHA) 29 CFR 1910.1200

Dept. of Commerce (Chapter 32) (COMM) 32.15

HAZARD DETERMINATION

A. A "hazardous substance" is a physical or health hazard that is listed as such in either:

1. 29 CFR Part 1910, Subpart Z, Toxic and Hazardous Substances, Occupational

Safety and Health Administration.

2. Threshold Limit Values for Chemical Substances and Physical Agents in the Work
Environment (latest edition), American Conference of Governmental Industrial
Hygienists (ACGIH).

B. A "hazardous substance" is regarded as a carcinogen or potential carcinogen if it is

 identified as such by:

1. National Toxicology Program (NTP), Annual Report on Carcinogens (latest edition).

2. International Agency for Research on Cancer (IARC) Monographs (latest edition).

3. 29 CFR Part 1910, Subpart Z, Toxic and Hazardous Substances, Occupational

Safety and Health Administration.

C. Manufacturers, importers and distributors will be relied upon to perform the appropriate
hazard determination for the substances they produce or sell.

D. The following materials are not covered by the Hazard Communication Standard:

1. Any hazardous waste as defined by the Solid Waste Disposal Act, as amended by
the Resource Conservation and Recovery Act of 1976, as amended (42 USC 6901
et seq.) when subject to regulations issued under that act by the Environmental
Protection Agency.

2. Tobacco or tobacco products.

3. Wood or wood products. NOTE: Wood dust is not exempt since the hazards of
wood dust are not "self-evident" as are the hazards of wood or wood products.

4. Consumer products (including pens, pencils, adhesive tape) used in the work place
under typical consumer usage.

5. Articles (i.e. plastic chairs).

6. Foods, drugs, or cosmetics intended for personal consumption by employees while

in the work place.

7. Foods, drugs, cosmetics, or alcoholic beverages in retail stores packaged for retail
sale.

8. Any drug in solid form used for direct administration to the patient (i.e. tablets or
pills).

APPLICATION

This program applies to the use of any hazardous substance which is known to be
present in the workplace in such a manner that employees may be exposed under normal
conditions of use or in a foreseeable emergency.

RESPONSIBILITY FOR COMPLIANCE

A. The administration of this program will be the responsibility of (person/position

designated). The administrative responsibilities of this individual/position will include:

1. Identification of the employees to be included in the Hazard Communication

 Program.

2. Development and maintenance of a hazardous substance master inventory.

3. Coordination and supervision of employee training.

4. Coordination and supervision of the facility's container labeling program.

5. Coordination of any necessary exposure monitoring.

6. Coordination and supervision of required recordkeeping.

7. Periodic evaluation of the overall program.

B. Employees are responsible for following all safe work practices and using proper
precautions required by the guidelines in this program.

HAZARDOUS SUBSTANCE INVENTORY

A. (person/position designated) is responsible for compiling, maintaining, and updating,

when necessary, a master list of hazardous substances used or produced in the
facility. The inventory list will include the common identity or trade name of the product
and the name and address of the manufacturer. Hazardous substances will be listed
alphabetically by manufacturer. Substances which are not in containers will also be
included on the inventory list, e.g., welding fumes, carbon monoxide from a fork lift,
etc. (See Form #1)

LABELING

A. (person/position designated) is responsible for evaluating labels on incoming

containers. Each label must contain the following information:

1. Identity of the substance.

2. Appropriate hazard warning.

3. Name and address of the manufacturer.

B. If the label is not appropriate, (person/position designated) will notify the manufacturer
(or supplier) that the label is not adequate. (See Form #2)

(person/position designated) will send a second request to the manufacturer if the

correct label is not received within 30 days. (See Form #3)

(person/position designated) is responsible for preparing an appropriate label if one is

not supplied by the manufacturer within the second 30 days.

A container will not be released for use until an appropriate label is affixed to the
container.

C. Labels will be removed if they are incorrect. When the container is empty it may be
used for other materials provided it is properly cleaned and relabled.
 D. Each department supervisor is responsible for ensuring that all containers used in
his/her department are labeled properly and remain legible. Defacing labels or using
them improperly is prohibited.

E. Unlabled portable containers, such as pails and buckets, should be used by one
employee and emptied at the end of each shift. If the secondary containers are used
by more than one employee and/or its contents are not emptied at the end of the shift,
the department supervisor is responsible for labeling the container with either a copy of
the original label or with a generic label which has a space available for appropriate
hazard warnings.

*F. Piping systems shall be painted at access points and every 10 feet where the piping is
8 feet or closer to employee contact.

1. Piping shall be painted as follows:

a. (substance)(color)
b. (e.g., oxygen) (e.g., green)

MATERIAL SAFETY DATA SHEETS

A. MSDS's will be available to the employees on all hazardous substances to which there
is potential or actual exposure. (person/position designated) is responsible for
ensuring that MSDS are available on all incoming products. A product will not be
released for use until a completed MSDS is on file. (See Form #4)

If the MSDS is not available, (person/position designated) will notify the manufacturer
that MSDS is needed. (See Form #5).

(person/position designated) will send a second request to the manufacturer if the

MSDS is not received within 30 days. (See Form #6)

B. (person/position designated) is responsible for the review of all incoming MSDS's. If

the MSDS is not complete, it will be returned to the manufacturer with a request for the
missing information. (See Form #7)

(person/position designated) will send a second request for the missing information if a
complete MSDS is not received within 30 days. (See Form #8)

*C. (person/position designated) will request an MSDS on the purchase orders of all new
products. (See Form #9)

D. (person/position designated) is responsible for compiling and updating the master

MSDS file. This file will be kept at (Name of location).

Copies of MSDS's will be kept in the following areas:

Department Location

[state department] [state location]

E. Employees will have access to these MSDS's during all work shifts. Copies will be
 made available upon request to (person/position designated). (See Form #10)

F. (person/position designated) is responsible for updating the data sheets to include

new information as it is received. A notice will be posted to inform employees that
revised information has been received. (See Form #11)

EMPLOYEE TRAINING

A. Prior to starting work with hazardous substances, each employee will attend a Hazard
Communication Training Session where they will receive information on the following
topics:

1. Policies and procedures related to the Hazard Communication Standard.

2. Location of the written Hazard Communication Program.

3. How to read and interpret an MSDS.

4. Location of MSDS's.

5. Physical and health hazards of hazardous substances in their work area.

6. Methods and observation techniques to determine the presence or release of

hazardous chemicals.

7. Work practices that may result in exposure.

8. How to prevent or reduce exposure to hazardous substances.

9. Personal protective equipment.

10. Procedures to follow if exposure occurs.

11. Emergency response procedures for hazardous chemical spills.

B. Upon completion of the training program, each employee will sign a form documenting
that he/she has received the training. (See Form 12)

C. Whenever a new employee is transferred or hired, he/she will be provided training

regarding the Hazard Communication Standard. The training session will be
conducted by _________________ before the start of his/her employment if possible.

D. (person/position designated) is responsible for identifying and listing any non-routine

hazardous task performed at this facility. (person/position designated) will conduct
training on the specific hazards of the job and the appropriate personal protective
equipment and safety precautions and procedures. (See Form 13)

E. When a new substance is added to the inventory list, (person/position designated) is

responsible for reviewing the MSDS for potential health effects. If the product presents
a new health hazard (causes health effects unlike those covered in the training
session), the ((person/position designated)) is responsible for notifying all affected
employees about the new health effects which result from exposure to the new
substance.
 *A copy of the new Material Safety Data Sheet (MSDS) will be posted by
(person/position designated) for 30 days. Both the new Material Safety Data Sheet
and the Employees New Substance Signature Form will be placed above or near the
MSDS information binder. Each affected employee must read the MSDS and sign the
signature form. (See Form #11)

INFORMATION TO CONTRACTORS

A. (person/position designated) is responsible for providing outside contractors with the

following information:

1. Hazardous chemicals to which they may be exposed as a result of working in this

facility.

2. Suggestions for appropriate protective measures.

B. Contractors that are potentially exposed to hazardous chemicals present at the

facility will not be allowed to begin work until they have been provided information
concerning these hazards and have signed a form to document this exchange.
(See Form #14)

C. (person/position designated) is responsible for obtaining information from

contractors on all hazardous substances to which State employees may be
exposed as a result of the contractor's work at the facility. (See Form #15).
(person/position designated) will notify affected
employees about the health affects that may result from exposure to each
substance.

PERSONNEL POLICIES

When an employee is not following safety and health rules regarding working with a
hazardous substance, disciplinary action will be taken.

RECORD KEEPING

A. All MSDS's will be kept for a period of ____ years after the use of the substance
has been discontinued. EXCEPTION: If an employee exposure to a particular
hazardous chemical occurs, the MSDS for that product will become part of the
employee's medical records.
Medical records must be kept for 30 years.

Note: “Exposure” or “exposed” means that an employee is subjected to a toxic

substance or harmful physical agent in the course of employment through any
route of entry (inhalation, ingestion, skin contact or absorbtion, etc.), and
includes past exposure,
but does not include situations where the employer can demonstrate that
the toxic substance or harmful physical agent is not used, handled, stored,
generated, or present
in the workplace in any manner different from typical non-occupational
situations.

*B. The master inventory list will also be kept for ____ years.
 COMMUNITY HAZARD COMMUNICATION

(person/position designated) is responsible for responding to requests from members of

the community on hazardous substances used in the facility.

EMERGENCY RESPONSE PROCEDURES FOR HAZARDOUS CHEMICAL SPILLS

A. When a hazardous chemical spill occurs, follow these procedures:

1. Move all employees away from spill to a safe environment.

2. Call 911 or the designated emergency response number in your area to notify the
necessary response team for the hazardous chemical spill.

3. Retrieve the Hazard Communication Information Binder, if possible.

a. Locate the MSDS for the hazardous chemical which spilled.

b. If requested, provide the MSDS to the Emergency Response Team.

Note: Do not try to contain the spill. The Emergency or Hazardous Material
Response Team is trained to deal with hazardous chemical spills.

PROGRAM EVALUATION

[person/position designated] will conduct an evaluation of the Hazard Communication

program annually. The individual responsible for the items identified for improvement will
be notified in writing. It is expected that action will be taken to correct the item within five
working days. (See Form #16)

* At least annually, ___(indicate number) employees will be interviewed to determine

the effectiveness of the Hazard Communication Program. Each interview will access
the employee's retention of information given during the training session, use of
MSDS's and response to chemical spills (if applicable). The results of each interview
will be recorded on the Employee Interview Form. (See Form #17) The Employee
Interview Form will be retained on file for 12 months.

This written program has been developed by the Bureau of State Risk Management, Department
of Administration and is available on computer disk. (File name a:\hazcom.doc). It may be
adapted to fit the particular needs of your facility. The program was adapted from a written
program originally developed by the Occupational Safety and Health Administration (OSHA).

Note: When there is an asterisk (*) placed in front of a guideline, then this policy is not
required by the Hazard Communication Standard or the Employees Right-To-Know Law.
Form #1
HAZARDOUS SUBSTANCE INVENTORY

Organization :_______________________________________________ Location: ____________________________________

Manufacturer Product Name Quantity MSDS Work Area

Yes/No

Completed By: _________________________________________________________Date: _____________________________

Form #2 LETTER TO REQUEST A COMPLETE LABEL

TO: Chemical Manufacturer, Vendor, Distributor

FROM: (Agency Name, Address)
DATE:
RE: Chemical Labels
We are using (number) of your products and in evaluating the label(s) on (this/these)
product(s), we determined that the label(s) (is/are) not appropriate for the following reason(s):

Product Name Reason Label Is Not Appropriate

Please clarify the wording on (this/these) label(s) or send (a) revised label(s). Your prompt
attention is necessary for us to fully implement our Hazard Communication Program. Please
respond to this request no later than (date 14 days after the date of this letter).

Thank you for your cooperation.

* A tickler file should be established to notify the responsible individual in 14 days that their
request for a revised label has not been received and that a second notice is needed.

152
Form #3 SECOND REQUEST FOR A COMPLETE LABEL

TO: Chemical Manufacturer, Vendor, Distributor

FROM: (Agency Name, Address)

DATE:

RE: Labels

On (date) we notified you that the warning label for your product(s) was incomplete. The
label is not appropriate for the following reason(s):

Product Name Reason Label Is Not Appropriate

We requested that you supply us with this information by (date). Please clarify the wording
on (this/these) label(s) or send (a) revised label(s). Your prompt attention is necessary for us to
fully implement our Hazard Communication Program. Please respond to this request no later
than (date 14 days after the date of this letter).

Thank you for your cooperation.

153
Form #4 CHECKLIST OF REQUIRED MSDS INFORMATION
The Hazard Communication Standard 1910.1200 requires that 13 items of information be
included in Material Safety Data Sheets provided to purchasers. There is no specified order
for these items; they may be found anywhere on the MSDS. If the preparer of the MSDS has
found no relevant information for a given item, the MSDS must be marked to indicate that no
applicable information was found. This checklist should be used to determine the
completeness of the MSDS. It does not assess the accuracy of the information.

Check Box If Item Is Complete

1. The identity used on the label.

2. Chemical and common names - may be the same as #1.

3. Physical and chemical characteristics of the hazardous ingredients (e.g., flash

point, appearance and odor).

4. Physical hazards (e.g., combustible, unstable).

5. Health hazards (e.g., corrosive) plus signs and symptoms of exposure and medical
conditions aggravated by exposure.

6. Primary route(s) of entry (e.g., inhalation).

7. Air exposure limits (e.g., PEL, TLV).

8. Carcinogenicity.

9. Precautions for safe handling and use (e.g., storage, waste disposal).

10. Control measures (e.g., personal protection).

11. Emergency and first aid procedures.

12. Date of preparation of MSDS.

13. Name/address/phone number of responsible party.

PRODUCT: MANUFACTURER:

DATE OF MSDS: CHECKED BY:

154
Form #5 LETTER TO REQUEST MSDS

TO: Chemical Manufacturer, Vendor, Distributor

FROM: (Agency Name, Address)
DATE:
RE: Material Safety Data Sheets (MSDS)

We are using (number) of your products and need (a) Material Safety Data Sheet(s) in order
to complete our Hazard Communication Program.

Please send (a) Material Safety Data Sheet(s) on the following products:

Your prompt attention is necessary for us to fully implement our Hazard Communication
Program. Please send the MSDS(s) no later than (date 15 days after the date of this letter).

Thank you for your cooperation.

* A tickler file should be established to notify the responsible individual in 15 days that their
request for an MSDS has not been received and that a second notice is needed.

155
Form #6 SECOND REQUEST FOR MSDS

TO: Chemical Manufacturer, Vendor, Distributor

FROM: (Agency Name, Address)

DATE:

RE: Material Safety Data Sheets (MSDS)

On (date) we requested (an) Material Safety Data Sheet(s) on the following product(s):

We have not received (it/them). Your prompt attention to this is necessary for us to complete
our Hazard Communication Program. Please respond to this second request by (date 15 days
after the date of this letter).

Thank you for your cooperation.

156
Form #7 LETTER TO REQUEST A COMPLETE MSDS

TO: Chemical Manufacturer, Vendor, Distributor

FROM: (Agency Name, Address)

DATE:

RE: Material Safety Data Sheets (MSDS)

In reviewing the Material Safety Data Sheet(s) for your product(s), the following required
information (according to the OSHA Hazard Communication Standard 1910.1200) was not on
the MSDS:

Product Name Reason MSDS Is Not Complete

Please supply us with this information. Your prompt attention to this is necessary for us to
fully implement our Hazard Communication Program. Please send this information by (date
15 days after the date of this letter).

Thank you for your cooperation.

* A tickler file should be established to notify the responsible individual in 15 days that their
request for a revised MSDS has not been received and that a second notice is needed.

157
Form #8 SECOND REQUEST FOR A COMPLETE MSDS

TO: Chemical Manufacturer, Vendor, Distributor

FROM: (Agency Name, Address)

DATE:

RE: Material Safety Data Sheets (MSDS)

On (date) we notified you that the Material Safety Data Sheet(s) for your product(s)
(was/were) incomplete. The following required information was not on the MSDS(s):

Product Name Reason MSDS Is Not Complete

We requested that you supply us with this information by (date) . We have not received this
information. Your prompt attention to this is necessary for us to complete our Hazard
Communication Program. Please respond to this second request by (date 15 days after the
date of this letter).

Thank you for your cooperation.

158
Form #9
LETTER TO ACCOMPANY PURCHASE ORDERS

This is a notice to chemical vendors

concerning the need for MSDS’s and
container labeling. This letter should be
attached to purchase orders for all
chemicals or other hazardous
substances.

TO: Chemical Manufacturer, Vendor, Distributor

FROM: Organization Name and Address
DATE:
RE: Hazard Communication Responsibilities

Attached to this letter is a purchase order for the chemicals which we plan to utilize in our
facility. Our receiving personnel have been instructed to accept only containers which have
been properly labeled and identified. Improperly labeled containers will result in refusal of
the shipment. We would appreciate your cooperation in this matter.

We expect to receive Material Safety Data Sheets (MSDS) prior to receipt of our initial order
and/or when an MSDS has been revised. If your policy is different, or has changed since our
last order, please notify us as soon as possible. To assist us, we would appreciate if you would
record the responsible party information on the shipping papers.

If you have any questions, please do not hesitate to contact me. Thank you for your
cooperation. I look forward to working with you in the future.

Yours truly,

(Name of Purchasing Director/Program Director)

NOTE: THIS LETTER SHOULD BE ATTACHED TO THE INITIAL AND/OR TO

EACH PURCHASE ORDER FOR CHEMICALS OR HAZARDOUS SUBSTANCES

Form #10

159
 REQUEST FOR CHEMICAL HAZARD INFORMATION

(Use a separate form for eachchemical/material)

Name of Requester (S): Date:

Social Security Number:

Department:

Name of Chemical/Material:

Manufacturer:

Description:
(Please describe the material as completely as possible)

Date Employee or Union Representative Signature

Received copy of MSDS: Yes No

Copy provided by: Date:

160
Form #11

EMPLOYEE'S NEW CHEMICAL/SUBSTANCE SIGNATURE FORM

Name of New Chemical/Substance:

Vendor's Name:

Location:

Date the Chemical Arrived:

Date of Posting (MSDS) Form:

This chemical may have health effects not covered during your initial Hazard Communication
Training Session. Each affected employee is asked to read the attached Material Safety Data
Sheet (MSDS) to understand the new health effects for the following chemical:

Upon reading the Material Safety Data Sheet (MSDS), each employee must sign and date this
form.

1. 6.

2. 7.

3. 8.

4. 9.

5. 10.

161
Form #12 EMPLOYEE HAZARD COMMUNICATION TRAINING RECORD

The following employee(s) have completed training in Hazard Communication. Each trained employee is now knowledgeable in all
11 different training topics covered in the Hazard Communication Written Training Program.

 Policies and procedures related to the Hazard Communication Standard.

 Location of the written Hazard Communication Program.
 Physical and health hazards of hazardous substances in their work area.
 How to prevent or reduce exposure to hazardous substances.
 Personal protective equipment.
 Methods/observation/techniques to determine the presence or release of hazardous chemicals.
 How to read and interpret MSDS.
 Location of MSDS.
 Work practices that result in exposure.
 Procedures to follow if exposure occurs.
 Emergency response procedures for hazardous chemical spills.

Employee's Name Employee's Signature Date of Training Trainer Trainer's Signature

Form #13
162
 NON-ROUTINE HAZARDOUS TASK
TRAINING DOCUMENTATION FORM

The following employee(s) has/have been trained to perform work in what is considered a "non-routine hazardous task."

Nonroutine Hazardous Task Employee(s) Name Date of Training Trainer

Form #14
DOCUMENTATION OF INFORMATION GIVEN

163
 TO CONTRACTORS PERTAINING TO HAZARD COMMUNICATION

Facility: _____________________________________ Location: ________________________________________

Date Contractor Information Given Contractor’s Signature

164
Form #15

LETTER TO CONTRACTORS

Subject: OSHA HAZARD COMMUNICATION STANDARD

To Whom it May Concern:

The Occupational Safety & Health Administration (OSHA) Hazard Communication

Standard (29CFR 1910.1200) states that contractors/suppliers must be informed of the
hazardous chemicals their employees may be exposed to while performing their work and
any appropriate protective measures. In order to comply with this requirement, (Name of
facility) has developed a list of all the hazardous chemicals known to be present in our
facility. A Material Safety Data Sheet (MSDS) is also on file for each of these chemicals
and/or hazardous substances. This information is available to you and to your employees
upon request.

In order to protect the safety and health of our own employes, contractors/suppliers must
provide (upon request) an MSDS on any hazardous chemical(s) or material(s) which they
bring into this facility. Failure to provide this information in a timely manner will result in
the removal of the contractor/supplier from the premises.

Each employer is also responsible for notifying any subcontractor they employ regarding
the requirements of OSHA's Hazard Communication Standard and other provisions
described in this letter.

If we can be of any further assistance, please feel free to contact me at (phone number).

Sincerely,

165
Form #16
HAZARD COMMUNICATION ANNUAL
PROGRAM SUMMARY
Training
Number of Training Number of Employees
Courses Presented: Trained:

New-employee training:
Work-area-specific training:
New-substance training:
Other training:
Total courses/employees

Hazardous Substances

# of Different Hazardous # of MSDS on File:

Substances in Use:
Previous Total:
New This Year:
Revised Total:

The following activities have been completed:

Written plan is up to date.

Hazardous substance inventory has been updated.
All training is up to date.
All MSDS are up to date.
All products are properly labeled.
All portable containers are properly labeled.

If any of the above activities are not complete, explain:

Completed By: __________________________________________ Date: ________________________

166
Form #17

EMPLOYEE HAZARD COMMUNICATION INTERVIEW

Date of Interview:

Interview conducted
!Unexpected by:
End of Formula

Agency:

Location: ________________________________________________________________________

1. Do you feel that your organization's Hazard Communication Program is successful

overall? Yes ____ No ____ Why?
______________________________________________________________________________
______________________________________________________________________________

2.What was the subject of the last training session you attended?
_______________________________________________________________________
__________________________________________________________________________

3.Have you applied the information from that session? Yes ____ No ______ If yes,
how? _____________________________________________________________________
________________________________________________________________________

4. Have you had an occasion to refer to an MSDS in the last month? Yes ____ No _____
Which one?
a. Was the MSDS easy to understand? Yes ____ No ____
b. Why did you refer to the MSDS?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
c. Did the MSDS have the information you were looking for? Yes ___ No ______
If no, what information was missing? ____________________________
___________________________________________________________________

5. Have all of the containers in your work area been properly labeled and marked?
Yes ____ No ____

167
6. Over the last six months, has your work area been involved in any chemical spill or
emergency? Yes ____ No ____ If yes, describe

7. Were you prepared? Yes ____ No ____ If not, why not?

____________________________
________________________________________________________________________
________________________________________________________________________

168
 Form # 18
HAZARD COMMUNICATION CHECKLIST

Has a program for hazard communication training been established? Yes No

Has a program for hazard communication procedures been established
and is the program reviewed on an annual basis?
Are chemical injuries tracked for program improvement?
Have chemical hazard control procedures developed for each job?
Has a chemical inventory of the facility been conducted?
Are the procedures reviewed on an annual basis?
Do the hazard communication procedures include the following:
 A statement of the intended use?
 Steps for labeling of containers?
 Steps for safe issuance, use, transfer and disposal of chemicals?
Are control procedures inspected at least annually?
Are periodic inspections conducted by a competent employee?
Is the inspection designed to correct deviations or inadequacies?
Is the inspection documented?
Have MSDSs been produced in accordance with 29CFR 1910.1200?
Have employees been informed of:
 The requirements of 29 CFR 1910.1200?
 Any operations in their work area where hazardous chemicals are present?
 The location and availability of the written HAZCOM program?
 The location and availability of the lists of hazardous chemicals?
Does employee training include at least:
 Methods & means necessary to detect the presence or release of a chemical?
 The physical and health hazards of the chemicals in the work area?
 The steps employees can take to protect themselves from the chemicals?
 The details of the written program?
Have criteria for recurrent training been developed?
Is the training documented?
Is the training conducted by a competent person?
Is retraining required whenever there is a change in job assignments?

169
Section D: QUALITY ASSURANCE

170
D.1 CONTINUOUS QUALITY IMPROVEMENT (CQI):
CLINICAL QUALITY

PURPOSE
The purpose of this CQI plan is to continuously improve the quality of care provided to patients
by members of the Dental Department. This will be accomplished thought the efforts of the
Dental Staff both inter- and intra- departmentally within [facility].
PROCEDURE
Describe CQI plan including all activities, indicators, data collection, frequency of
activities and reporting.

For assistance with developing a CQI plan in an Indian Health Service/Tribal/Urban

facility, contact your Dental Support Center or Area Dental Officer.
Responsibility
The individual responsible for the quality assurance and improvement activities of the Dental
Department is [appropriate individual]. The [individual] may delegate this responsibility to
other members of the dental staff. 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.
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. Indicators must be easily replicated in
order to track improvement. 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.
Modifying Indicators
Indictors will be reviewed regularly. Indicators that are consistently met may be considered to
be removed and other issues examined.
Sentinel Events
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:
 Deaths in the dental clinic
 Allergic reactions/anaphylactic reactions to medications.
 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.
171
 Threshold for Evaluation
Each indicator in focused studies will have thresholds established based on QA documents,
national averages, recommendations of appropriate experts, and other generally accepted
sources. 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 Data
Routine collection of information in the Dental Department concerning important aspects of
patient care will be made utilizing [identify routine reports such as Service Minutes, RVUs,
equipment maintenance, others] [identify sources such as medical and dental records,
monthly computer printouts, appointment logs, recall files, RPMS, environmental health
reports, maintenance records, patient 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 patient 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.
Corrective Actions
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:
 Insufficient knowledge, skills or attitudes
 Defects in the system;
 Deficient behavior or performance.

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.

172
 Communication of Results to the Staff

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 [appropriate individual] 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.
Annual Appraisal

The effectiveness of the Dental Department's CQI Program will be evaluated annually by the
[appropriate individual(s)]. 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 [appropriate
individual].
Confidentiality

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

173
D.2 RISK MANAGEMENT/PROGRAM MONITORING
[Insert facility’s Policy Header Information]
PURPOSE
The purpose of this Risk Management plan is to continuously improve the quality of dental
program and reduce risk that may be introduced through dental care provided at [facility].
PROCEDURE
Program Elements
[Appropriate individual] will coordinate risk management with [administration or appropriate
individual e.g. safety officer]. Incident and accident reports will be completed and processed
as per Facility policy. Valid patient and employee complaints will be referred to the appropriate
staff for appropriate management.
A program review and infection control review will be conducted annually. Results will be
submitted to [appropriate individual]. Deficiencies will be address in a staff meeting, through
continuing education, or other appropriate means.
See Attachment * for program review tools or forms.
Tracking
[CE coordinator or appropriate individual] will ensure appropriate certifications such as
CPR, radiology, CE, and other mandatory certifications are maintained by dental staff.
Additionally, dental staff is responsible for maintaining facility required training such as
Electrical Safety, Fire Safety, Infection Control, MSDS, Blood Borne Pathogens, and Hazard
Communications training as per facility safety guidelines
[Frequency as required by the facility] quality assurance activity report will be submitted to
the [appropriate individual].

174
 Nashville Area Dental Program Review Tool
Nashville Area Dental Officer & USET Dental Support Center

Tribe/Date:
Reviewer:

No Some minor Major

Executive Summary recommendations improvements improvements Score
for improvement recommended recommended
Elements and ranked according to importance using industry and IHS standards.
1. Credentialing & Privileging
2. Patient Safety
(Combined score for a-d below)
a. Hazard Communications
b. Infection Control
c. Emergency Preparedness
d. Other Considerations
3. Documentation
4. Policies and Procedures
5. Quality Assurance & Improvement
6. Productivity & Efficiency
7. HP/DP
8. Employee Development
Top 3 program strengths
1.
2.
3.
Top 3 program recommendations
1.
2.
3.

175
Summary Narrative

I. Credentialing and Privileging

II. Patient Safety:
III. Documentation
IV. Policies and Procedures
V. Quality Improvement and Assurance
VI. HPDP
VII. Clinical Productivity
VIII. Employee Development

176
 Recommendations Checklist

Category Recommendation Completi

on Date

Credentialing
& Privileging

Patient Safety

Documentati
on

Policies and
Procedures

Quality
Improvement
and
Assurance

HPDP

177
 Category Recommendation Completi
on Date

Productivity
& Efficiency

Employee
Development

178
 Ye N
Scoring Element Notes
s o
a) All dentists in the facility have an active, unrestricted
license to practice in their profession, with proof of
licensure on record at the clinic.
b) All dentists in the facility have been credentialed in
accordance with the clinic’s credentialing policies.
c) Credentialing files contain a NPDB query, a criminal
background check, and verification of a DEA license,
dental license, and dental degree(s).
d) Continuing education is updated in the credentialing
file, or according to clinic policies.
e) All dentists in the facility have been granted privileges
for the clinical procedures they perform by the facility’s
governing body/health board; hygienists are either
privileged or written scope of work. Providers that
administer local anesthesia or nitrous oxide are
privileged to do so.
f) Re-credentialing and re-privileging procedures are
completed on all dentists at least every two years.
g) All dental assistants have been properly trained,
certified, and current in the taking of radiographs and
other services that they provide.
h) Peer reviews are used to evaluate providers prior to
re-credentialing.

Hazard Communications
a) The program has a hazard communication program in
the facility.
b) Staff understands and can use the MSDS book.
c) The program has an updated MSDS book, and a
random sample of chemicals in the clinic shows no
deficiencies.
d) Staff receives annual Hazard Communication training
per OSHA regulations.
e) The program adheres to local environmental guidelines
on the disposal of mercury.
f) Staff can demonstrate what to do in a hazard spill. The
program has practiced or discussed a hazard spill at
least once in the past year.
g) The program maintains incident reports on reportable
events.
Score

179
 Ye N
Scoring Element Notes
s o
Infection Control
a) Facility has a written, updated Infection Control Policy
b) Each employee has received training on infection
control
c) Facility has a written policy of required vaccinations
d) Facility has a post-exposure management plan
e) Facility has a policy regarding work related illnesses
and work restrictions
f) Facility has a policy for maintaining the confidentiality
of employee medical records
g) Each employee has received, is in process of
receiving or has documentation of declination of
Hepatitis B vaccination
h) Standard precautions are used for all patients
i) Used sharps are placed in a puncture resistant
container
j) Needles are recapped using either a one-handed
scoop technique or a mechanical device designed for
holding the needle cap
k) Hands are washed with soap and water or cleaned with
an alcohol gel before and after each patient
l) Sterile gloves are used for appropriate procedures
m) Fingernails and/or jewelry do not impair the proper use
of gloves
n) A surgical mask and eye protection with solid side
shields or a face shield to protect mucous membranes
of the eyes, nose, and mouth are worn during
procedures likely to generate splashing or spattering of
blood or other body fluids
o) Masks are changed between patients or if the mask
becomes wet
p) Protective wear (gown, lab coat, uniform) is worn when
skin or personal clothing is likely to become soiled
q) Protective clothing is removed before leaving work
area
r) Gloves are worn when a potential exists for contacting
blood, saliva, or mucous membrane
s) Gloves are changed if they become torn and between
each patient
t) Patients are given protective eyewear when spatter is
expected.
u) Patients are screened for latex sensitivity

180
v) The facility can provide a latex-free environment for
patients with latex sensitivity
w) The facility has an emergency kit with latex free items
x) Critical and semi-critical items are heat sterilized
before each use

181
 Ye N
Scoring Element Notes
s o
Infection Control
y) Sterilized items are allowed to dry before handling
z) Disposable items are not reused
aa) Noncritical patient-care items are barrier-protected or
cleaned, or if visibly soiled, cleaned and disinfected
after each use with an EPA-registered hospital
disinfectant.
bb) Instrument processing area is divided into a “Clean”
and “Dirty” area or measures are taken to avoid
contamination of clean instruments
cc) Instruments are debrided prior to sterilization
dd) Puncture resistant gloves are used for instrument
processing
ee) Internal and external chemical indicators are used for
each instrument package or load of unwrapped
instruments
ff) Container or wrapping system is compatible with
method of sterilization
gg) Unwrapped instruments are cleaned and dried prior to
sterilization
hh) Chemical and biological monitors are used
ii) In the case of a positive spore test: problem is
corrected, and another spore test is run to confirm
sterilization effectiveness. All affected instruments are
re-sterilized
jj) Wrapped instruments are marked for date of
sterilization, sterilizer, and load
kk) Sterile packages are inspected before use,
compromised packages are re-sterilized prior to use
ll) Sterile packages are stored in a closed or covered
cabinet
mm) Cleaning and EPA-registered hospital disinfecting
products are used correctly
nn) Liquid chemical sterilants/high-level disinfectants for
disinfection of environmental surfaces are not used for
environmental surfaces
oo) PPE, as appropriate, is used when cleaning and
disinfecting environmental surfaces.
pp) Surface barriers are used on surfaces difficult to clean
and changed between patients
qq) Contaminated environmental surfaces are
appropriately cleaned
rr) Spills of blood or other potentially infectious materials
are cleaned and decontaminated with an EPA-
182
 registered hospital disinfectant with low- (i.e., HBV and
HIV label claims) to intermediate-level (i.e.,
tuberculocidal claim) activity
ss) Facility has an infected waste management plan

183
 Ye N
Scoring Element Notes
s o
Infection Control
tt) Contaminated non-sharp waste is stored in a puncture
resistant, color coded bag
uu) Liquid waste is disposed of in a sanitary sewer system
or in a manner in accordance with state regulations
vv) Water used for routine dental treatment meets EPA
standards for drinking water
ww) Any device connected to a water system that
enters the patient’s mouth is flushed for 20-30
seconds between patients
xx) Water lines are monitored according to manufacturer’s
instructions
yy) Handpieces are removed, cleaned and sterilized
between each patient
zz) Patients are not instructed to close lips around suction
devices
aaa) Gloves are worn when exposing radiographs and
when handling contaminated packets
bbb) Radiography film holders are disposed of, heat
sterilized or disinfected appropriately between patients
ccc) Aseptic procedures are used when transporting and
developing films
ddd) Dispensing medication from multi-dose vials: a)
sterile needles and syringe are used for each patient
and b) vials are kept out of patient care areas.
eee) Biopsy specimens are stored in a sterile, leakproof
container labeled with the biohazard symbol
fff) Extracted teeth are handled as regulated medical
waste unless returned to the patient
ggg) Extracted teeth to be used for educational purposes
are appropriately sterilized
hhh) Appropriate PPE is used for all laboratory procedures
iii) Prostheses and impressions are sterilized before
handled in the laboratory
jjj) Facility conducts periodic infection control monitoring
kkk) Practices not in compliance with infection control
standards are addressed
Score

184
 Scoring Element Yes No Notes
Emergency Preparedness
a) The program has a written fire/disaster emergency
plan.
b) The program has a written medical emergency plan for
the dental clinic, and staff has participated in at least 1
medical emergency drill in the past year in dental.
c) Emergency codes are accessible and prominently
displayed in the clinic and reviewed with staff.
d) Emergency phone numbers are prominently displayed
in the clinic.
e) An emergency kit is readily available, appropriate to
Dental Clinic needs.
f) If drugs are kept in the clinic, all dental staff knows its
location and how to use the contents.
g) The expiration dates of the drugs in the emergency kit
are current.
h) An oxygen tank with an appropriate valve, tubing, and
mask is available. Dental staff is familiar with its
location and use.
i) The oxygen/nitrous oxide tank is checked routinely for
leaks and function and this is documented.
j) All dental staff is currently BLS certified, and
documentation is maintained of BLS certification.
k) A crash cart is available in the facility.
Score
Other Safety Considerations
a) X-ray machines are inspected at the required 3-year
intervals. Deficiencies are corrected in a timely
manner
b) Lead aprons are used on all patients receiving
radiographs.
c) The aprons are x-rayed annually to assure that no
damage occurred to the lead lining during storage
and/or use.
d) Radiograph frequency adheres to ADA guidelines.
e) Film positioners are used. Neither patient nor staff
holds the film during exposure.
f) Staff and other patients are protected from scatter
radiation during film exposure.
g) The agitator of the amalgamator functions under a
protective cover.
h) Amalgam scrap is stored in tightly closed containers
i) Amalgam scrap is recycled properly.
j) Medication and product recalls are documented.

185
k) Expired drugs are removed from inventory in a timely
manner.
Score

186
 Scoring Element Yes No Notes
a) A health questionnaire completed by the patient and
signed by the provider within the past 12 months is
present and documentation exists that it was reviewed
at each visit with the changes or the phrase “no
changes” recorded. Medical alerts are highlighted.
b) Appropriate measures have been taken to ensure
patient safety and appropriate treatment. (eg- blood
pressure, blood sugar, consultations when necessary).
c) Appropriate ADA codes are recorded (including tooth
number, surface, or pocket depths when appropriate)
and documentation exists in the progress note to justify
all codes.
d) Dental Progress Notes include:
a. date of treatment
b. signature of the provider(s)
c. if signature is illegible, printed or stamped
name of provider(s)
d. degree of the provider(s)
e. If the patient was seen as a dental emergency,
the SOAP format was used
e) Dental progress notes include a disposition (what the
patient needs next) at the end of each visit.
f) Informed consent contains risks, benefits, and
alternate treatments, and in language the patient can
understand.
g) The informed consent form is signed by the dental
provider and patient/parent/guardian.
h) Pain documentation is included on the progress note.
Documentation is consistent with the facility policies. If
pain is indicated, additional information on the
management, treatment, or referral for tx is included.
i) All hard tissue findings (normal, pathology, or
abnormalities) are recorded in the dental record.
j) Documentation that radiographs have been read exists
in the patient record. This may be either in the
progress note or on the Exam Form.
k) Evidence of soft tissue exam is present, either by
listing of abnormalities or designation of “STN” (Soft
Tissues Normal) or “WNL” (Within Normal Limits).
l) Periodontal status (CPITN or PSR) and diagnosis for
patients age 15 and older is noted on the dental exam.
m) Orthodontic status (for patients ages 6 to 20) is noted
on the dental exam sheet.
Score (% yes)

187
 Scoring Element Yes No Notes
n) Written treatment plan exists for all patients receiving
initial or recall dental exams.
a. Treatment plan is easily understood
b. Follows a logical sequence
c. Is revised as needed, revisions are dated and
initialed
o) If a full scope of services is not available at the facility,
a chart notation is made that the patient has been
informed of his/her need for treatment at another
facility.
p) The patient is placed in a recall program based on
his/her individual risks and clinic resources, rather than
arbitrary time intervals.
q) Pre-operative x-rays are evident for appropriate
procedures.
r) Documentation of the behavior for all children under
the age of 6 is documented.
s) Behavior management techniques used and their level
of effectiveness are documented.
t) When definitive periodontal therapy is planned for
patients with CPITN/PSR of 2 “4’s”, a periodontal work-
up is conducted. This includes probing pocket depths,
furca involvement, mobility, and occlusal features, with
documentation.
u) The dental record contains an individualized dental
disease prevention plan.
Score

188
 Chart Review
Facility:_______________________ Provider: _____________
Record Number
CRITERIA
Y-Yes Note: Threshold for
N- No success is 80%
NA- Not Applicable
A. Every Visit (Total=__)
1) Completed and Signed Medical History, Updated
2) Precautions appropriate for PS
3) Appropriate Codes
4) Complete progress notes(SOAP for Emer)
5) Disposition
6) Informed consent contains risks, benefits, and
alternate treatments, and in language the patient
can understand.
7) Informed consent is signed by provider and
patient/parent/guardian.
8) Pain Documentation
B. Exam and Treatment plan (Total=__)
1) Hard tissue findings recorded
2) X-rays read
3) Soft tissue findings recorded
4) Periodontal status and diagnosis
5) Orthodontic status
6) Treatment Plan Complete
7) Notation of needed, unavailable services
8) Follow up/ recall consistent with patient needs
9) The dental record includes an individualized
dental disease prevention plan.
C. Treatment Documentation
1) 1)Pre-operative x-rays are evident for appropriate
procedures.
2) 2) Documentation of behavior is evident for all
children under the age of 6.
3) Behavior management techniques used ant their
level of effectiveness is documented.
4) When definitive periodontal therapy is planned for
patients with CPITN/PSR of 2 quadrants of “4” or
more, a periodontal workup is conducted. This
includes probing pocket depths, furca
involvement, mobility, and occlusal features with
cumentation.

189
 Scoring Element Yes No Notes
a) The facility has a policy and procedure manual for
dental department.
b) The policy manual must include the following critical
policies/procedures:
a. Patient eligibility including determination of
eligibility for services and CHS is in the P&P
Manual.
b. Scope of services is included in the P&P
Manual.
c. Standing orders for auxiliaries are included in
the P&P Manual.
d. The clinic has an appointment/broken
appointment policy.
e. The clinic has a pain management policy.
f. The clinic has a behavioral
management/restraint policy and procedure.
g. Identifies procedures for which a separate
informed consent is required.
h. Identifies management of patients with
medical issues such as hypertension, diabetes,
etc.
i. Identifies documentation guidelines (required
documentation for clinical care).

l) The Policy and Procedure Manual is updated annually.

m) Staff has received an update on Policies and
Procedures within the last year.
n) The dental program operates under a written, readily
available, working copy of a P&P Manual.
o) The clinic has standard protocols for common
services.
Additional Notes Score

190
 Scoring Element Yes No Notes
a) The clinic has a quality assurance and improvement
plan. The clinic demonstrates local facility quality
benchmarking against best practices, professional
practice guidelines, overall health care goals, or
performance measures.
b) Department regularly monitors quality of care (delivery
of care) through internal activities (quality assurance).
c) The program has conducted at least one patient
satisfaction/customer service survey in the past year.
d) Nitrous oxide/oxygen administration is monitored
annually for exposed workers and for leaks.
e) The dental clinic has conducted at least one quality
improvement program in the past year, with
documentation of evaluation (PDSA or similar).
f) The dental program actively participates in the facility’s
quality assurance/improvement program.
Additional Notes Score

191
 Not
Scoring Element Yes No
es
3. Clinical Productivity and Efficiency
Productivity
a) The average number of patient visits in the year
preceding the review is greater than 1,926 per dentist.
b) More than 40% of registered users at the facility have
utilized dental services in the past year (this is different
than the GPRA user population).
c) The average number of total services in the year
preceding the review is greater than 7,000 per dentist.
d) The average number of relative value units (RVUs)
produced by the clinic in the year preceding the review
is greater than 10,146 per dentist.
Efficiency & Effectiveness
a) The clinic has a dentist to population ratio of 1:1200 or
better.
b) The dental clinic has a full time equivalent (FTE) staff
to population ratio of 1:500 or better.
c) Excluding chairs dedicated solely to dental hygienists,
the dental clinic has an operatory to dentist ratio of 2:1
or better.
d) The dental clinic has a dental assistant to dentist ratio
of 2:1 or better.
e) The dental clinic produces at least an average of 5.3
RVUs per patient visit or more.
f) The dental clinic produces 2,697 RVUs per FTE staff
or more.
g) The dental clinic produces 3,467 RVUs per operatory
or more.
h) The dental clinic has a broken appointment rate of
23% or lower.
i) 63% or higher of patients seen in the dental clinic have
been treatment planned.
j) 48% or higher of patients receiving exams (0145,
0150, 0120) have completed treatment.
k) The clinic produces 10.9 RVUs per patient.
l) The clinic produces 792 or more patient visits per
operatory per year.
m) The average dentist productivity is 8.68 or higher
patient visits per dentist per day.
n) 80% or higher of all services were Level I-III (basic)
services for the past year.
o) The clinic produces a minimum of 5 RVU’s per dentist
and 3.5 RVUs per hygienist per hour.

192
 Scoring Element Yes No Notes
a) The dental program has overall HP/DP goals or has
identified high priority areas.
b) At least one HP/DP program has been conducted in
the past year by dental staff utilizing the POARE
(Problem, Objectives, Activities, Results, and
Evaluation) or similar program planning model or
similar model.
c) The program regularly evaluates community-based
prevention activities.
d) There is evidence of sharing goals and results of
HP/DP programs conducted with tribal leaders, facility
administration, dental staff, and the community.
e) Dental staff is aware of the clinic’s HP/DP goals and
current project(s).
f) The dental program is actively collaborating with non-
dental staff (in the facility) on an HP/DP project.
g) An ongoing fluoride program is established at the
community level, involving non-health care partners.
This includes water fluoridation or topical fluorides
(i.e., fluoride varnish) and collaborative partners may
include Head Start, schools, or the water resource
department.
h) The program has built collaborations within the
community and facility (i.e., medical, Head Start,
daycare, schools, WIC, etc.).
i) The dental program achieved its access to care GPRA
goal in the last reporting year.
j) The dental program achieved its dental sealant GPRA
goal in the last reporting year.
k) The dental program achieved its fluoride GPRA goal in
the last reporting year.
Score
Scoring Element Yes No Notes
a) The dental program has performance plans/individual
development plans for all dental staff.
b) The dental program provides evidence of regular
dental staff meetings.
c) All dental staff is given opportunities for continuing
education during the year.
d) Staff has received HIPAA and Privacy Act training in
the past year.
e) All licensed or certified dental staff has met continuing
education requirements in the past year.
Score

193
Sample Employee Training Tracking Form
Employee Name___________________ Position _______________

ANNUAL (Year) Year Year Year Year

CPR CERT

RADIOLOGY CERT

SAFETY

INFECTION
CONTROL

M.S.D.S.

MED
EMERGENCY

BLOOD BORNE
PATHOGENS

(List others)

Comments:

194
Sample Facility Review Tracking Form

Frequency

QA REPORT

PROGRAM
REVIEW
INFECTION
CONTROL
RADIOLOGY
CERTIFICATION

Comments:

195
SECTION E: COMMUNITY HEALTH

196
E.1 COMMUNITY ORAL HEALTH PROMOTION/DISEASE PREVENTION

PURPOSE
To establish community oral health promotion/disease prevention (HP/DP) procedures
consistent with current science and Indian Health Service priorities.

PROCEDURE

1. Written Plan: the dental staff will develop a written community HPDP plan that will
include:
a. Priorities: The dental staff will establish oral HP/DP priority areas based on local
needs and IHS focus areas.
b. Target Groups: The dental staff will determine high risk groups that will most
benefit from community based HP/DP programs.
c. Evidence Based Activities: The dental staff will select evidence based activities
to address oral health needs for the priority areas and target groups.
d. Evaluation: The dental staff will regularly monitor the effectiveness of the
programs, collect data on the program operation and outcome, and revise the
program as needed to ensure maximum effectiveness.
2. Annually, the dental staff will review the plan and revise as needed.
Insert Community HPDP Plan

197
Example:
[Facility] Dental Prevention Plan
Oral Health Partners Target Frequenc Services Fundin Evaluation/Trackin
Condition Group y *Current g g
#Planned
ECC/ Caries Head Children 4-9 *Annual USET # of children seen
Prevention Start age 3-4 Days Screening Mini- Fluoride treatments
teachers /Year *Fluoride Award Untreated decay
and staff Varnish Treatment urgency
*OHI Education provided
*Tobacco
Prevention
*Nutritional
*Counseling
*Health
Advisory
Committee
#Performanc
e Standard
assessment
#Teacher in-
services
Caries, Perio, Elem School 2-3 *Annual Dental # of children seen
and Tobacco School Age Days Screening budget Untreated Decay
Prevention Children /Year *Fluoride Treatment Urgency
Varnish Education provided
*OHI
*Nutritional
Counseling
*Tobacco
Prevention
#Newly Visit in last year
diagnosed pt (DM audit)
screening Patients with
Perio Medical DM #Current DM urgent dental
Prevention dept Patients patient needs
Dietician screening &
Ed

ECC Medical Pregnan #Prenatal Dental # Screened#

Prevention/Peri Dept t women education budget w/urgent needs
o and #Screening &
families OHI
#Caries
stabilization
#Prevention
services
198
E.2 HEAD START/PRESCHOOL

PURPOSE
To support the IHS Head Start mission and goals, which are, “The mission of the Indian Health
Service (IHS) Head Start Program is to promote healthy activities that will improve health
outcomes for the Early Head Start and Head Start child, family, staff and community. Our goals
will help to improve children's health, decrease health disparities, and increase health provider
outreach.” (IHS 2012, Available online at: http://www.ihs.gov/headstart/)

The IHS Head Start Program goals are:

o To support the Office of Head Start, including its health objectives and
Performance Standard requirements.
o To assist American Indian/Alaska Native (AI/AN) recipients in the development of
health programs for children, families, staff and community.
o To assist AI/AN programs in developing local and community partnerships.
o To develop programs that promote healthy lifestyles.

PROCEDURE
The dental clinic staff will provide training and technical support to the [IHS Head Start or
Tribal preschool] to facilitate the use of IHS Best Practices for Head Start centers.( Available
online at: http://www.ihs.gov/headstart/index.cfm?module=hs_resources)

The dental clinic staff will assist Head Start staff maintain dental performance standards
required by IHS Head Start.
Insert other services provided to Head Start or preschools.
Examples:
Provide direct access to dental examinations in the dental clinic
Screen Head Start children in the classroom and apply fluoride varnish
Serve on Head Start Health Advisory Board
Consult on classroom issues such as infection control for toothbrushing programs, oral health
education, or healthy snacks

199
E.3 INFECTION CONTROL FOR PORTABLE SETTINGS

PURPOSE
To comply with Centers of Disease Control and Prevention (CDC) and Organization for
Sterilization and Aseptic Procedures (OSAP) recommendations for infection control for portable
settings.

DEFINITIONS

Portable dental settings: All procedures conducted outside of the dental clinic including
but not limited to: operative dentistry, sealants, fluoride treatments, dental screenings,
or oral hygiene instructions that fall within the levels of exposure.

Levels of Exposure: Classification of anticipated exposure to saliva, blood, or bodily

fluids.,

PROCEDURE

1. Levels of Exposure

a. All infection control practices will conform to the recommendations according

to the level of exposure anticipated in the procedures.

i. Level I: Anticipated contact with the patient’s mucous membranes,

blood or saliva visibly contaminated with blood.

ii. Level II: Anticipated with the patient’s mucous membranes but not
with blood or saliva visibly contaminated with blood.

iii. Level III: No anticipated contact with the patient’s mucous

membranes, blood, or saliva visibly contaminated with blood.

2. Personnel

a. The dental program will appoint a point person responsible for site
assessment, fielding questions, training all field personnel, and facilitating
follow-up for exposures

3. Assessment

a. The point person will conduct an infection control assessment prior to

beginning any dental procedures.

b. Assessment will follow current OSAP guidelines. Available online at:

http://www.osap.org/resource/resmgr/Checklists/OSAP.checklist.portableden
ta.pdf?hhSearchTerms=portable+and+dental+and+settings

200
4. Training

a. The point person will review all portable site infection control procedures
with all staff, volunteers, or other personnel present during the procedures

5. Documentation

a. The point person will complete the site assessment worksheet before
beginning a new program and at least annually thereafter.

b. Exposures will be reported and followed up using the established

procedures for the facility.

201
E.4 ORAL HEALTH SURVEILLANCE

PURPOSE
The purpose of local oral health surveillance is to establish a system that can be used within
the community to measure the prevalence and severity of oral diseases, the oral disease
burden on the (AI/AN) population, and the impact that our efforts in prevention, education, and
early intervention and treatment has made on the population. The Surveillance Plan
establishes the core health indicators which will be measured, the frequency of measurement,
and comparability with other national oral health surveillance systems. Local surveillance
should consider local, state or national data that may be used for comparison and/or determine
oral health disparities.

PROCEDURE

1. Determine local, state, or national data sources that may be used for comparison.
(Consult the National Oral Health Surveillance System at http://www.cdc.gov/nohss/ to
find data sources for your state) Possible sources:

a. State Basic Screening Survey

b. IHS National or Area survey

2. Determine surveillance frequency

3. Determine the target groups for surveillance

4. Determine oral health indicators to be measured and select survey tool such as:
a. IHS Oral Health Survey form
b. BSS Screening forms (Manual available online at
http://www.astdd.org/docs/BSSChildren'sManual20081revised2.9.2010.pdf

5. Contact community partners to schedule screening days and times

6. Select consent (active or passive) methods and distribute appropriate forms

7. Conduct screening, record results, and calculate disease prevalence using simple
percentages (This is not as accurate as a weighted sample, but it is within the
capabilities of most local programs)

8. Report the findings to local partners, community groups, and clinic administration

202
203