Medical Records Policies and Procedures Guideline Manual

Document Sample
Medical Records Policies and Procedures Guideline Manual Powered By Docstoc

     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


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
Cherokee Indian Hospital Authority

Harry Brown, MD
Nashville Area Office

Cherokee Indian Hospital Authority
Dental Policy and Procedures Manual

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

John Otteson, DDS
Oneida Nation Health Center

Pat Planck, RDH
Oneida Nation Health Center

Tim Ricks, DDS, MPH
Nashville Area Office

Jerrfey Stuart, DDS
Catawba Health Center

Michael Vito, DDS
Cattauagus Health Center
Seneca Nation

Nick Porcello
Lionel R. John Health Center
Seneca Nation

 Table of Contents

Section A: Administration
A.1. Dental Program Policies and Procedures .................................. 5
A.2. Organizational Chart .................................................................. 8
A.3. Dental Program Summary ......................................................... 9
A.4. New Employee Orientation ........................................................ 11
A.5. Privileging/Credentialing ............................................................ 14
A.6. Documentation ........................................................................... 15
A.7. Pain Documentation................................................................... 17
A.8. Medical Records ........................................................................ 20
A.9. Staff Assignments and Duties .................................................... 21
A.10. Staff Training............................................................................ 22
A.11. Students, Trainees and Volunteers .......................................... 23
A.12. Leave ....................................................................................... 26
A.13. Dress Code .............................................................................. 28
A.14. Patient Satisfaction .................................................................. 29

Section B: Clinical Services

B.1. Appointment Procedures ........................................................... 32
B.2. Guidelines for Prenatal Oral Health Care ................................... 36
B.3. Ordering/Requisitioning Supplies ............................................... 37
B.4. Intoxicated Persons ................................................................... 38
B.5. Emergency Dental Care and Triage........................................... 39
B.6. Standing Orders for Dental Auxiliary Staff ................................. 42
B.7. Medical History .......................................................................... 43
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. Informed Consent .................................................................... 58
B.14. Radiography............................................................................. 62
B.15. Pharmacy/Prescriptions ........................................................... 67
B.16. Extracted Teeth........................................................................ 68
B.17. Hypertension Screening and Treatment Guidelines................. 69
B.18. Premedication to Prevent Infective Endocarditis ...................... 70
B.19. Premedication for Patients with Complete Joint Replacement . 73
B.20. Medical Emergencies in the Dental Clinic ................................ 76
B.21. Reporting Domestic Violence ................................................... 79
B.22. Pathology ................................................................................. 81
B.23. Oral Disease Prevention/Health Promotion ............................. 82
B.24. Nitrous Oxide ........................................................................... 85
B.25. Conscious Sedation ................................................................. 88

Section C: Environment

C.1. Radiological Protection .............................................................. 99
C.2. Equipment Maintenance and Product Recalls ........................... 100
C.3. Nitrous Oxide Safety .................................................................. 101
C.4. Fire Plan .................................................................................... 103
C.5. Monitoring Water Quality in Dental Unit Lines ........................... 104
C.6. Mercury Hygiene........................................................................ 105
C.7. Safety ........................................................................................ 109
C.8. Precious Metal Recovery ........................................................... 111
C.9. Hazardous Communications ...................................................... 112

Section D: Quality Assurance
D.1. Continuous Quality Improvement (Clinical) ................................ 139
D.2. Risk Management/Program Monitoring ..................................... 142
     Program Monitoring Tool w/ Instructions ................................... 143
     Sample Employee Training Tracking Form ............................... 150
     Sample Facility Review Tracking Form ..................................... 152
D.3. Infection Control Monitoring ....................................................... 153

[Insert facility’s Policy Header Information]

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.


        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
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.

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 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.

[Insert facility’s Policy Header Information]


[Insert facility’s Policy Header Information]
To identify staff lines of authority and responsibility, describe the physical components of the
dental program, and general principles of oral health care delivery.

        Description and Organization
The [Facility] Dental Program is directly responsible to the health director. The Dental Program
is the responsibility of the [individual].
[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 2007 definition of MNC:
 ―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 orofacial disfiguration or
dysfunction. Medically necessary care (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 of 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 AAP
       1. recommends that oral health care be included in the design and provision of
          individual and community-based health care programs to achieve comprehensive
          health care.
       2. encourages establishment of a dental home for all children by 12 months of age in
          order to institute an individualized preventive oral health program based upon each
          patient‘s unique caries risk assessment

       3. recommends that health care providers who diagnose oral disease either provide
          therapy or refer the patient to an appropriately trained individual for treatment.
          Immediate intervention is necessary to prevent further dental destruction, as well as
          more widespread health problems.
       4. recognizes evaluation and care provided for an infant, child or adolescent by a cleft
          lip/palate, orofacial, orcraniofacial deformities team as the optimal way to coordinate
          and deliver complex services.
       5. believes that the dentist providing oral health care determines the medical indication
          and justification for treatment. The dental care provider must assess the patient‘s
          developmental level and comprehensive 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.‖
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.
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 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.

[Insert facility’s Policy Header Information]
To ensure each dental clinic employee receives personnel policies of [facility] and all
information necessary to deliver quality dental care.

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].

[Sample Orientation Checklist. Revise as needed]
Name: _______________________________________
Employed On Date: _________________________

























[Insert facility’s Policy Header Information]

To ensure licensed dental providers are compliant with State licensing laws and with the
[facility] Medical/Dental Bylaws.

[Facility] Dental Program will follow Medical/Dental Staff Bylaws and the IHS Oral Health
Program Guide. 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. 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 Dental Privileges Request Form. Dentists [and hygienists
if appropriate] requesting privileges for clinical services must specify each [technique or
procedure code] 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]

[Insert facility’s Policy Header Information]
To ensure adequate record keeping for all services provided by the dental clinic.

       Dental Record
The dental record will contain the following:[insert appropriate forms and other items]
Example: HSA 42-1, HSA 42-2, panoramic x-ray, bitewing and periapical X-rays, a dental
health history form, and referral, laboratory prescriptions and results, and consultation forms as
The dental records will be placed in a designated section [insert appropriate location in the
record] Example: on the left side of the patient's medical record in the following order - top to
[Describe Order of documentation in the record]
1.    All 42-2's (or other progress notes forms) together, newest on top
2.    Examination and treatment plan form
3.    Medical history
4.    Consultations and referrals
5.    Laboratory prescriptions and results
6.    Radiographs
[Insert description of obtaining records for appointed and walk-in patients}
By 2:30 p.m. the dental receptionist will give medical records a list of patients’ names having
appointments the next working day. In the event that medical records personnel cannot pull the
medical charts, the dental clinic will send the receptionist or other auxiliary to assist in obtaining
the patient charts.

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.
Progress notes will include: all services provided, dosages of drugs (including local anesthetics),
materials used, provider‘s signature with credentials and dispensation (next services needed).

       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
On all emergency procedures the dentist will use the S.O.A.P. format in record keeping.
                                DIAGNOSTIC TESTS
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.

To establish consistent procedures for assessing and documenting patient‘s pain, using an age
appropriate assessment tool.


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.

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           Possible
                                                                        Pain              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
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            Worst
                 Bit              More              More                Lot

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
10 = Hurts Worst – WORST PAIN POSSIBLE, UNBEARABLE – unable to do any activities because of

[Insert facility’s Policy Header Information]

To ensure confidentiality and patient privacy and prevent loss, tampering and unauthorized
access, the [Facility] Medical Records policies will be followed.
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).
All patient visit data must be entered into the dental chart 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

[Insert facility’s Policy Header Information]
To describe staff requirements necessary to provide quality oral health services.

                             [Develop your own Staffing requirements]

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.

[Insert facility’s Policy Header Information]

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.
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.
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
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.

[Insert facility’s Policy Header Information]


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.


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)

                                       Indian Health Service
                              PATIENT CONSENT TO TREATMENT BY A

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

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)

[Insert facility’s Policy Header Information]
To ensure compliance with [facility] leave policies.

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

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
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.
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
      Leave Without Pay (LWOP)
Leave without pay will be considered on an individual basis within regulatory requirements.

[Insert facility’s Policy Header Information]

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


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.

[Insert facility’s Policy Header Information]

To solicit patient attitudes and level of satisfaction regarding oral health services provided by

[Frequency] patients will be asked to complete a Patient Satisfaction survey.
Describe Process.
Patient satisfaction surveys forms will be given to patients who visit the dental clinic in the 1st
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 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

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
Receiving treatment options
Dentist (courteous and
Dental hygienist (courteous and
Dental Assistant (courteous and
Receptionist (courteous and
Quality of dental care provided
Ability to ask questions
Receiving a follow up appointment
Referral policy
Pain control
Overall Dental Care

Section B: Clinical Services

[Insert facility’s Policy Header Information]
The purpose of this policy is to create a mechanism of efficient scheduling to ensure timely
dental services for eligible recipients.


       This clinic will care for acute emergencies on a daily basis [hours]. This clinic will also
       handle some treatment of routine patients.
       This is a patient that has received a scheduled appointment.
       This is when a patient is unable to come for a scheduled appointment and phones one
       day in advance to reschedule their 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.
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.

       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
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
   1) Emergency dental needs (See Policy B.4)
   2) Severe Medically compromised (e.g.,pre-organ transplant, or pre-chemo/radiation
   3) Children
   4) Deploying military personnel
   5) Students (to accommodate school schedule/breaks)
   6) Adults

       Broken and Canceled Appointments
[Insert Broken Appointment Procedures]
The dental clinic is a complex and dynamic care delivery system. It runs by scheduling
appointments with the assumption that those appointments will be kept. Appointments are
made with the direction of a dental provider estimating the need of the patient and the amount of
time that will be needed at the next appointment. If a patient does not keep his/her
appointment, the dental staff cannot deliver care and the community suffers because some
member of the community could have been seen in that spot.
This policy enables the community to get the best use of dental services. This policy will allow a
greater number of tribal members to be seen in a shorter amount of waiting time.
This policy it designed so that:
       Emergency services will always be available to patients on a walk-in clinic basis.
       Patients will not be abandoned if care is deferred for a period of time

       Patient Notification
Each adult patient or parent/guardian of a minor patient will be given a copy of the Broken
Appointment Policy upon patient registration, and sign to indicate they have received, read and
understand the policy. The policy will be restated to patients in the event of a broken

        Children (18 Years of Age and Younger)
A child who does not come on time to the clinic for their first scheduled appointment will be
considered a BROKEN appointment and will be given another appointment.

A child in routine care who has two BROKEN appointments is the past six months will not be
rescheduled for routine dental care for a period of six months from the 2nd BROKEN
CANCELED appointments will have no effect on a child's' ability to receive routine dental care.

       Adults (19 YEARS OF AGE AND OLDER)

An adult who does not come on time to the clinic for their first scheduled appointment will be
considered a BROKEN appointment and must sign up on the Waiting List to wait until called
again from the list.
An adult in routine care who has two BROKEN appointments in the past six months will not be
rescheduled for routine dental care and must sign up on the Waiting List to be rescheduled at a
later date. CANCELED appointments will have no effect on an adult’s ability to receive routine
dental care.
A note will be made in the patient's chart stating they BROKE an appointment. Patients
BREAKING two appointments will be sent a letter informing them of their ineligibility to be
Exceptions to the above policy will be at the discretion of the treating dental officer and in
agreement with the [Program Director].
Patients who break two appointments will still be eligible for emergency care.
A canceled appointment is one in which the dental clinic has been notified 24 hours in advance
that the patient will not be able to keep that appointment. Patients reporting their inability to
keep their appointment will be rescheduled at a more convenient time. Habitual canceling of
scheduled appointments will result in emergency care only for a period of one year.

To increase services to all patients the following policy is in effect. You can be rescheduled only
twice. If you are credited with two broken appointments you WILL NOT be scheduled for
another appointment for at least six months. You will be charged with a broken appointment
       You do not come to the dental clinic for your appointment.
       When you sign in at the dental clinic 15 minutes or more after your appointment time.
       When you do not cancel your appointment at least 1 day ( 24 hours ) before your
       appointment time.
I understand the above policy.


       Date                                                           CLINIC HOURS
Dental services will be available Monday through Friday [hours]. The clinics will be closed
[hours]. The clinic is also closed every [hours if applicable] for maintenance, cleaning,
meetings and training
Persons with a dental emergency that occurs outside normal clinic hours should report to
[Insert location].


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

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
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 14th and 20th week of pregnancy is the best time to provide
           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

[Insert facility’s Policy Header Information]

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

The [appropriate staff] will be responsible for maintaining the supply system, the [appropriate
staff] shall act as the alternate.
      Ordering Supplies
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.

Describe system of monitoring inventory

[Insert facility’s Policy Header Information]

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

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

       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


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

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.

[Insert facility’s Policy Header Information]

To establish criteria and procedures for emergency dental treatment.

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)
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.
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

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

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

(Use this form as a template or develop a patient handout
for your facility)

Patients who are having uncontrollable pain from their teeth or their gums need to sign in at the
dental clinic. Emergency patients are urged to report to the dental clinic [hours]. Emergency
patients do not have appointments and will not be given appointments for emergency treatment.
s for emergency treatment will not be accepted after [time].
Each day‘s schedule for the dental clinic has been arranged so as to provide the maximum
amount of dental work to the most patients, and emergency patients will be worked into this
We will do everything possible to see you as soon as we can. Emergency patients will be
worked into the schedule as soon as possible to relieve the pain.
Emergency services are NOT routine or comprehensive care. ONLY the tooth or area causing
pain will be treated. Following emergency care, all patients are encouraged to seek
comprehensive dental care. If we cannot treat you here for medical, dental, eligibility or time
reasons, you will be referred to the appropriate source.
Patients having uncontrollable pain on the weekend should report to an emergency room where
pain-relieving treatment will be given. You must notify the Contract Health Service (CHS) Office
immediately, but no later than 72 hours of an emergency service.

CHS Office Phone #: _______________
[Facility] Dental Department Phone #: ________

[Insert facility’s Policy Header Information]

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

       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.
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.

[Insert facility’s Policy Header Information]

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.

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
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.
[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)

[Insert facility’s Policy Header Information]


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

       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
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

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

   •     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

[Insert facility’s Policy Header Information]

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

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] 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.
A dentist or hygienist may recall a patient as frequently as he/she feels it is necessary to
maintain oral health.

[Insert facility’s Policy Header Information]

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

     Intra-Facility Referrals
     Emergency Patients Referred to Dental
[Insert facility procedures]
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, 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
       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 addressed 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
       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
       Contract money will not be used to provide orthodontic treatment.
       Contract funds will not be used to provide surgical TMJ "treatments" or care.

[Insert facility’s Policy Header Information]

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

              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
              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

[Insert facility’s Policy Header Information]

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

    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
         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
       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
      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. ―


[Insert facility’s Policy Header Information]
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.

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:
Tooth extraction
Invasive surgical intervention
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
       INSERT Appropriate Forms

Sample Information Handout. Revise as needed for specific
Information for Parents/Guardians
Informed consent indicates your awareness of enough information to allow you to make an
informed personal choice concerning your child's dental treatment after considering the risks,
benefits, options and consequences of non-treatment. Please read this form carefully and ask
about anything you do not understand. We will be pleased to explain it. It is our intent that all
professional care delivered in our dental clinic shall be of the best possible quality we can
provide for each child. Providing a high quality of care can sometimes be made very difficult, or
even impossible, because of the lack of cooperation of some child patients. Among the
behaviors that can interfere with the proper provision of quality dental care are: hyperactivity,
resistive movements, refusing to open the mouth or keep it open long enough to perform the
necessary dental treatment, and even aggressive or physical resistance to treatment such as
kicking, screaming and grabbing the dentist's hands or the sharp dental instruments.
All efforts will be made to obtain the cooperation of child dental patients by the use of warmth,
friendliness, persuasion, humor, charm, gentleness, kindness and understanding.
There are several behavioral management techniques that are used by dentists to gain the
cooperation of child patients to eliminate disruptive behavior or prevent patients from causing
injury to themselves due to uncontrollable movements. The more frequently used pediatric
dentistry behavior management techniques are as follows:
The dentist or assistant explains to the child what is to be done using simple words and
repetition and then shows the child what is to be done by demonstrating with instruments on a
model on the child's or dentist's finger. Then the procedure is performed in the child's mouth as
described. Praise is used to reinforce cooperative behavior.
       Positive Reinforcement
This technique rewards the child who displays any behavior, which is desirable. Rewards
include compliments, praise, a pat on the back, a hug or a prize.
       Voice Control
Changing the tone or increasing the volume of the dentist‘s voice gains the attention of a
disruptive child. Content of the conversation is less important than the abrupt or sudden nature
of the command.
       Mouth Prop
A rubber or plastic device is placed in the child's mouth to prevent closing when a child refuses
or has difficulty maintaining an open mouth.
       Physical Restraint by the Dentist
The dentist restrains the child from movement by holding down the child's hands or upper body,
stabilizing the child's head between the dentist's arm and body, or positioning the child firmly in
the dental chair.

       Physical Restraint by the Assistant
The assistant restrains the child from movement by holding the child's hands, stabilizing the
head, and/or controlling leg movements.
       Papoose Board and Pedi-Wraps
These are restraining devices for limiting the disruptive child's movements to prevent injury and
to enable the dentist to provide the necessary treatment. The child is wrapped in these devices
and placed in a reclined dental chair.
Sometimes drugs are used to relax a child who does not respond to other behavior
management techniques or who is unable to comprehend or cooperate for dental procedures.
These drugs may be administered orally or by gas (nitrous oxide and oxygen). The child does
not become unconscious. Your child will not be sedated without your being further informed
and obtaining your specific consent for such procedure.

[Insert facility’s Policy Header Information]

To set general guidelines for prescribing dental radiographs.
       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) guidelines for dental radiographic examinations. See
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
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
disease                                         3. Selected periapical films    symptoms
                2. Posterior
and/or                          3. Selected
dental                          periapical
Recall* with    1. Posterior bitewings at 6-12 month interval                   Not
clinical                                                                        applicable
                2. Selected periapical films as needed
caries or
risk of
Recall with     1. Posterior bitewings at 12-36 month intervals                 Not
no clinical                                                                     applicable
                2. Selected periapical films as needed
caries and
not at
risk for

                                      Patient Age and Developmental Stage
                  Children         Child with          Adolescent      Adult         Edentulous
                  with             Transitional        Dentition       Dentate or    Adult
                  Primary          Dentition           (prior to the   Partially
                  Dentition                            eruption of     Edentulous
                  (prior to the                        3rd molars)
                  eruption of
Type of           the 1st
Encounter         permanent
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
                                                       growth and
                                                       Panoramic or
                                                       exam to
                                                       of third
Patients with Clinical judgment as to the type and need of radiographic images for
other         evaluating and/or monitoring specific patient 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

[Insert facility’s Policy Header Information]

To maintain adequate communication between the Pharmacy and Dental Department.

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
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
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.

[Insert facility’s Policy Header Information]


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


   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.

  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.

[Insert facility’s Policy Header Information]

  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.

   Blood pressure will be taken using an automated blood pressure monitor on all patients over
   the age of ** at each dental appointment.
          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
                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

[Insert facility’s Policy Header Information]


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.

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.)


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
                         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
   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

  * IM–intramuscular; IV–intravenous.
  ** or other first or second generation oral cephalosporin in equivalent adult or pediatric
  + 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

  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.

[Insert facility’s Policy Header Information]

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.


This facility adheres to the American Academy of Orthopaedic Surgeons guidelines for
premedication of patient with total joint replacement.

According to the AAOS 2009 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 life3-5 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.

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

Table 2.

[Insert facility’s Policy Header Information]
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.
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.

      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]
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
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
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

[Insert facility’s Policy Header Information]

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)

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
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
       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
Dental providers will refer cases to Social Services for investigation.


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


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.

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).

[Insert facility’s Policy Header Information]
To establish a uniform method of performing, documenting, and informing patients of the results
of tissue biopsy.

       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].

[Insert facility’s Policy Header Information]
To establish oral health promotion/disease prevention (HP/DP) procedures consistent with
current science and Indian Health Service priorities.

Current HP/DP Program of the [Facility] Health Department Dental Clinic.

1.   Examination results of hard and soft tissues, periodontal status and needs, orthodontic
     needs, and other prevention needs will be recorded on the [exam form] 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 checked 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.
               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 periodontal
       status will receive appropriate periodontal services according to the IHS periodontal

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
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.

(Oneida Nation Health Center, Dr. John Otteson, Pat Planck, RDH)

[Insert facility’s Policy Header Information]
To establish procedures for the safe and effective use of nitrous oxide in the Dental Department.
      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

      Qualifications of Providers
According to the AAPD‘s 2005 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].

Describe procedures used to ensure provider competency, if any]


According to the AAPD‘s 2005 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.‖
According to the AAPD‘s 2005 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.‖

According to the AAPD‘s 2005 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
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.25 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
[Insert facility’s Policy Header Information]


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.


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
       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

   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

    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

―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
    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
    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
   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
   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).

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


   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
            Able to deep breathe and cough freely                                                  2
            Dyspnoea, shallow or limited breathing                                                 1
            Apnoeic                                                                                0
            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
            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 89-91

Sedation Techniques, Specific Criteria


-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].

-No additional staffs beyond those needed for the routine dental procedure are required

-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.

-No additional monitoring beyond visual and verbal monitoring is required

-Documentation should include drug and dose used and its effectiveness.

Moderate Sedation

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

-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)

-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

-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.

-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.


[Insert facility’s Policy Header Information]
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.

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
[Insert competency procedure}
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

[Insert facility’s Policy Header Information]

To establish procedures that ensure the safe operation of all equipment, comply with facility
safety policies, and comply with applicable State and federal regulations.
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.


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

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.
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                 Procedure                                      Control
  1    Visually inspect all N2O equipment Replace defective equipment and/or parts.
       (reservoir bag, hoses, mask,
       connectors) for worn parts, cracks,
       holes, or tears.
  2    Turn on the N2O tank and check all    Determine leak source and fix. If tank valve leaks,
       high to low pressure connections      replace tank; if O-rings, gaskets, valves, hoses, or
       for leaks. Use a non-oil-based soap   fittings, replace. Contact the manufacturer for parts
       worn solution to check for bubbles    tact the manufacturer for parts replacement. For
       at high pressure connectors, or use   threaded pipe fittings, use Teflon tape. Do not use
       a portable infrared gas analyzer.     this tape on compression fittings.
  3    Select scavenging system and          Provide a range of mask sizes for patients. Check to
       mask. Mask should come in             see that noise levels at the mask are acceptable
       various sizes to patients.            when the scavenging system exhaust rate is
       Scavenging systems should operate     operated at 45 lpm.

    at air flow rate of 45 lpm.
4   Connect mask to hose and turn on       Determine proper vacuum pump size for
    vacuum pump before turning on          maintaining 45 lpm flowrates, especially when
    N2O. Scavenging system vacuum          interconnected with other dental scavenging
    pump must have capacity to             systems. If undersized, replace pump.
    scavenge 45 lpm per dental
5   Place mask on patient and assure a     Secure mask with "slip" ring Secure mask with
    good, comfortable fit. Make sure       "slip" ring for "good activity" from patient
    reservoir bag is not over or under     breathing.
    inflated while the patient is
6   Check general ventilation for good     If smoke from smoke tubes indicate room air
    room air mixing. Exhaust vents         mixing is poor, then increase the airflow or
    should not be close to air supply      redesign. If exhaust vents are close to air supply
    vents (use smoke tubes to observe      vents, relocate (check with ventilation engineers to
    air movement in room.)                 make adjustments).
7   Conduct personal sampling of           If personal exposures exceed 150 ppm during
    dentist and dental assistant for N2O   administration, improve mask fit and make sure it is
    exposure. Use diffusive sampler or     secure over the patient's nose. Minimize patient
    infrared gas analyzer (see sampling    talking while N2O is administered.
8   Repeat procedure in step 7.            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.

[Insert facility’s Policy Header Information]
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.

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.


[Insert facility’s Policy Header Information]


To establish a procedure for the regular monitoring of biofilm present in dental unit water lines.
Regular monitoring is included in the Recommendations for Infection Control in Dental Health
Care Settings by the Centers for Disease Control and Prevention (CDC) should be done
according to manufacturer‘s specifications.


   1. Frequency of monitoring is done at least quarterly or as determined by manufacturer‘s
   2. Water test kits are available from dental supply companies. Follow individual test kit
   3. Interpretation:
          a. Public water standards require <500 bacterial colony forming units(CFU)/ml (EPA
              standard for safe drinking water)
          b. Water lines with <500 are at least as safe as public water supplies
          c. Dental units with water lines with >500 bacterial CFU/ml should be thoroughly
              disinfected and retested.
          d. (Note: The American Dental Association recommends <200 CFU/ml for dental
              water lines.)
          e. If test reveals 200-500 CFU/ml- contact dental unit manufacturer or
              representative for cleaning instructions.
   4. A log containing dental unit number, date of test, initials of tester and results test will be
      maintained in the dental clinic.

[Insert facility’s Policy Header Information]
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.
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
    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
    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
     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
     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

                                   American Dental Association (ADA)
                             Do’s and Don’ts for Dealing with Amalgam Waste

                     DO                                              DON’T
Do use precapsulated alloys and stock a variety    Don’t use bulk mercury.
of capsule sizes.
Do recycle used disposable amalgam capsules.       Don’t put used disposable amalgam capsules
                                                   in biohazard containers, infectious waste
                                                   containers (red bags) or regular garbage.
Do salvage, store, and recycle noncontact          Don’t put non-contact amalgam waste in
amalgam (scrap amalgam).                           biohazard containers, infectious waste
                                                   containers (red bags), or regular garbage.
Do salvage contact amalgam pieces from             Don’t put contact amalgam waste in
restorations after removal and recycle the         biohazard containers, infectious waste
amalgam waste.                                     containers (red bags), or regular garbage.
Do use side-chair traps to retain amalgam and      Don’t rinse chair-side traps containing
recycle the contents.                              amalgam over drains or sinks.
Do recycle contents retained by the vacuum         Don’t rinse vacuum pump filters containing
pump filter or other amalgam collection devices,   amalgam or other amalgam collection devices
if they contain amalgam.                           over drains or sinks.
Do recycle teeth that contain amalgam              Don’t dispose of extracted teeth that contain
restorations. (Note: Ask your recycler whether     amalgam restorations in biohazard containers,
or not extracted teeth with amalgam restorations   infectious waste containers (red bags), sharps
require disinfection)                              containers, or regular garbage.
Do manage amalgam waste through recycling          Don’t flush amalgam waste down the drain or
as much as possible.                               toilet.
Do use line cleaners that minimize the             Don’t use bleach or chlorine-containing
dissolution of amalgam.                            cleaners to flush waste water lines.

   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
    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.

[Insert facility’s Policy Header Information]
To establish procedures that ensure the safety of both patients and dental staff, and comply with
facility safety regulations.
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
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
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.

[Insert facility’s Policy Header Information]

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.
The [appropriate individual] will be responsible for all scrap precious metal collected in the
dental clinic to specific officials for their disposal.
       See Mercury Hygiene Policy

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.

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

[Insert facility’s Policy Header Information]
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.

       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):


        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.)


       Occupational Safety and Health Administration (OSHA) 29 CFR 1910.1200

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


       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

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


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.

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

   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.


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)


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

  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

 *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)


  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)


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

     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

     *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)


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

     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


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


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

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


       (person/position designated) is responsible for responding to requests from members of the
       community on hazardous substances used in the facility.


       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.


       [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

Completed By: _________________________________________________________Date: _____________________________

TO:     Chemical Manufacturer, Vendor, Distributor
FROM:           (Agency Name, Address)
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.


TO:       Chemical Manufacturer, Vendor, Distributor

FROM: (Agency Name, Address)


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.

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:


TO:        Chemical Manufacturer, Vendor, Distributor
FROM: (Agency Name, Address)
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.


TO:       Chemical Manufacturer, Vendor, Distributor

FROM: (Agency Name, Address)


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.


TO:       Chemical Manufacturer, Vendor, Distributor

FROM: (Agency Name, Address)


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.


TO:       Chemical Manufacturer, Vendor, Distributor

FROM: (Agency Name, Address)


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.

Form #9

                            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

TO:       Chemical Manufacturer, Vendor, Distributor
FROM: Organization Name and Address
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)


Form #10
(Use a separate form for eachchemical/material)

Name of Requester (S):         Date:

Social Security Number:


Name of Chemical/Material:


                               (Please describe the material as completely as possible)

       Date                              Employee or Union Representative Signature

Received copy of MSDS: Yes             No

Copy provided by:      Date:

Form #11

Name of New Chemical/Substance:

Vendor's Name:


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

1.     6.

2.     7.

3.     8.

4.     9.

5.     10.

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
                                   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

Facility: _____________________________________ Location: ________________________________________

     Date             Contractor              Information Given            Contractor’s Signature

Form #15

                            LETTER TO CONTRACTORS


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).


Form #16
                        PROGRAM SUMMARY

                                    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: ________________________

Form #17

Date of Interview:

Interview conducted by:
!Unexpected End of Formula


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 ____

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

     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?


[Insert facility’s Policy Header Information]

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].
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.
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.
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.
      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,
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
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.

      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].

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

[Insert facility’s Policy Header Information]
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].
       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.
[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].

Sample Program Review Checklist
                          IHS QA GUIDELINES & CRITERIA FOR
                            DENTAL FACILITY MANAGEMENT


     1. Patients have privacy for treatment and confidential conversations in the operatory area.
     (In open bays signs may be posted informing patients of the opportunity for more privacy if
     2. Facilities are clean, neat, and in good repair.
     3. The disabled have access to the dental clinic and operatory area.


     1. Staff has been received HIPAA training
     2. Facility has procedures in place to ensure HIPAA compliance (e.g. business agreements
        with appropriate entities as defined by medical records or HIPAA compliance officer)
     3. Workplace practices ensure patient confidentiality for protected medical information

C. Policies and Procedures

     1. Facility has policy and procedure manual for dental department
     2. Policy and Procedure Manual is updated annually
     3. At a minimum P&P manual covers:
            a. Definition of services available
            b. Protocols for referral of routine and emergency procedures
            c. Standards and procedures for routine clinic operations including each element
                listed .
D.      STAFF

     1. There is a minimum of one FTE chair-side assistant per FTE dentist.
     2. Staff maintains current State licensure, registration, or certification required for the
        position description.
     3. Dentist has a current unrestricted DEA number.
     4. Staff has completed continuing education requirements for the past calendar year
        consistent with licensure.
     5. Staff practices within their Dental Practice Act or follow IHS practice guidelines defined
        in the IHS Program Guide.

E.      ACCESS

     1. Patients with dental emergencies are seen in a timely manner.
     2. A recall system is utilized when appropriate (high risk patients). Intervals are based on
        the dental need of the individual patient.
     3. The facility accommodates patients who require dental clearance for medical treatments
        (transplants, joint replacements, ect)
     4. The Secretary’s Regulations on IHS Eligibility (42 CFR, Section 36.12, 36.23-24,
        Section 813, IHCIA) are adhered too.


     1. Infection Control QA has been completed within the last year
     2. Deficiencies have been corrected
     3. Deficiencies and/or changes have been reviewed with the dental staff


     1. All staff has current CPR certification.
     2. An oxygen tank with an appropriate valve, tubing, and mask is available. Dental staff is
        familiar with its location and use.
     3. Blood pressure is taken on all patients over the age of 16 at least once per year.
     4. An emergency kit is readily available, appropriate to Dental Clinic needs. If drugs are
        kept in the clinic, all dental staff knows its location and how to use the contents. The
        expiration dates of the drugs are current. If no drugs are kept, each staff member knows
        what is available and how to summon appropriate medical support.
     5. Emergency phone numbers are prominently posted.
     6. The facility has an emergency management protocol.
     7. The staff reviews the emergency management protocol at least annually.


     1. X-ray machines are inspected at the required 3-year intervals. Deficiencies are corrected
     in a timely manner.
     2. Lead aprons are used on all patients receiving radiographs. The aprons are x-rayed
         annually to assure that no damage occurred to the lead lining during storage and/or use.
         This service can usually be obtained at a local hospital. Lead aprons are not stored folded
         which may increase risk of compromised integrity.
     3. Film positioners are used. Neither patient nor staff holds the film during exposure.
     4. Staff is protected from scattered radiation during film exposure.


     1. Premeasured, disposable amalgam capsules are used.
     2. The agitator of the amalgamator functions under a protective cover.
     3. Amalgam scrap is stored in tightly closed containers and recycled properly.


     1. Staff complies with the OSHA Hazard Communication Standard. (Evaluate by using the
     Hazard Communication Compliance Checklist.)
     2. A written Hazard Communication Program (HCP) is on file and accessible to staff. The
        HCP is reviewed at least annually and updated as necessary.
     3. Material safety data sheets (MSDS) are on file for each hazardous chemical. Any missing
        MSDS has been requested in writing, and a copy of the request is on file. MSDSs no
        longer in use are archived and kept for thirty years.
     4. The inventory of chemicals, materials, and supplies and the list of hazardous chemicals in
        the HCP accurately reflect all the hazardous chemicals and products that are present in
        the dental clinic.
     5. Staff participates in hazard communication training at least annually.


       Clinic Site _______________________        Reviewer______________________

  CRITERIA                                      Yes         No   NA         Comments
   1. Privacy
   2. Clean, Neat, and in Good Repair
   3. Access to the Disabled
   1. HIPAA training
   2. Privacy Ensured
   3. Confidentiality ensured
C. Policies and Procedures
   1. Facility has Pol & Pro Manual
   2. Manual Updated annually
   3. Includes Policies Covering:
           a.   Services
           b.   Referral procedures
           c.   Clinic operations
           d.   Procedures requiring informed
           e.   Equipment maintenance
           f.   Handling tissue specimens
           g.   Continuing education
           h.   Credentialing/ Privileging
           i.   Medical Emergency Plan
           j.   Standing orders
           k.   Inventory
           l.   Prescription Procedures

  CRITERIA                                   Yes         No   NA   Comments
           m. Mercury safety, radiological
              protection and N2O policies
           n. Patient eligibility
           o. Appointments
           p. Clinic hours
           q. Leave Policies
           r. Emergencies (fire,
           s. Laboratory procedures
              (including privacy issues)
   1. One Assistant per Dentist
   2. Current Licenses
   3. Unrestricted DEA Number
   4. Continuing Education
   5. Policies, Rules, and Regulations
   1. Emergencies
   2. Recall
   3. Accommodates special needs
   4. Eligibility Regulation Compliance
   1. Infection control review
   2. Deficiencies corrected
   3. Staff update

 CRITERIA                                  Yes         No   NA   Comments
  1. Current CPR
  2. Oxygen Tank
        a. O2 tank available
        b. O2 tank in good repair
        c. Staff can operate O2 tank
  3. Blood Pressure
        a. BP equipment available
        b. Staff can take and record BP
  4. Emergency Kit
        a. Kit available
        b. Contents are current
        c. Staff knows how to use all
  5. Emergency Phone Numbers
  6. Clinic has a medical emergency plan
  7. Annual Emergency Plan Review
  1. Inspection Current on XY-Ray
  2. Lead Apron
         a. Lead aprons available
         b. Lead aprons inspected
         c. Stored appropriately
  3. Film Positioners are used
  4. Scatter Protection
  1. Premeasured amalgam capsules
  2. Agitator Covered
  3. Storage of Scrap Amalgam
  4. Recycling Procedures

     CRITERIA                                Yes         No   NA   Comments
     1. OSHA compliance of Hazard
        Communication Standard
     2. Plan updated annually
     3. MSDSs
     4. Supply Inventory/List of Chemicals
     5. Annual Training

                          SUMMARY AND RECOMMENDATIONS

  Clinic Site _______________________        Reviewer______________________

  Scoring: Count numbered elements only. For those criterion with lettered sub-categories, ALL
  lettered elements must be met for a “Yes” to be scored for the numbered criterion.

  Compliance Score: (Total number of Criteria: 41)
  % Compliant=Y/[(Y+N)-NA]
    1. Count number of “Yes”                                _________
    2. Count Number of “No”                                 _________
    3. Add Yes + No                                         _________
    4. Count Number of NA                                   _________
    5. Subtract Line 4 (NA) from Line 3 (Y+N)               _________
    6. Divide Line 1 (Yes) by Line 5 ([(Y+N)-NA]            _________
    7. % Compliance= Line 6 x 100                           _________

  N= 10
  Compliance = 30/[(30+10)-1)=.76
  % Compliance= .76 x 100= 76%

                       FINDINGS and RECOMMENDATIONS
Criterion                   Deficiency                           Recommendation

  Sample Employee Training Tracking Form
Employee Name___________________ Position _______________

 ANNUAL          (Year)   Year   Year   Year    Year








 (List others)


Sample Facility Review Tracking Form





[Insert facility’s Policy Header Information]
To ensure compliance with current IHS and Centers for Disease Control recommendations
regarding infection control in dental healthcare settings.
Infection Control Policies and Procedures will be maintained according to current Centers for
Disease Control Recommendations for infection Control in Dental Health care Settings. An
annual Infection Control review will be conducted by [appropriate individual] and reported to
[appropriate individual]. Deficiencies will be corrected through staff in-services, continuing
education of other appropriate means.
All Infection Control procedures are included in the Infection Control Manual maintained in
[location]. The manual will be updated as needed to remain current with CDC


Description: Medical Records Policies and Procedures Guideline Manual document sample