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


Open Access: patients are seen without an appointment as they present to the clinic.

High risk groups: target groups with known high oral disease rates

Patients of record: patients with a comprehensive dental examination within the last 3 years


High Risk Groups

High risk groups including [insert current high risk groups such as Head Start children, children age 0-3, diabetes patients] will have Open Access to the dental clinic for preventive services including [insert services such as screening, fluoride varnish, OHI, exams].
Patients of Record

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

  1. 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.

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

Revised 1994

Fluoride Level (Home Water)


Less than 0.3 ppm

0.3 – 0.6 ppm

Greater than 0.6 ppm

Birth to 6 months




6 months to 3 years




3 years to 6 years




Breast fed




*milligrams of fluoride per day

2.2 mg sodium fluoride = 1 mg fluoride (F )
** Jointly endorsed by: American Academy of Pediatric Dentistry

American Dental Association

American Academy of Pediatrics

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

Sample: l mg. Fluoride daily #60 Refill 1 year
4 When fluoride rinse is indicated the patient will be given a recommendation for an over-the-counter daily rinse. It will be necessary for the patient to obtain the rinse at his/her own expense. Fluoride rinse will be used only for clients six (6) years or older. Moderate or high risk patients who cannot use a home rinse will receive fluoride varnish treatments appropriate to their risk category.
5 Unless medically contraindicated, all dentate dental patients will be advised to use fluoride toothpaste.
6 Topical fluoride may be applied using either a fluoride varnish or 1.23% acidulated phosphate gel. Patients considered moderate risk will be given a semi-annual topical fluoride treatment. Patients considered high risk will be given more frequent applications up to 4 treatments per year.


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 guidelines.
11 OHI will be re-evaluated at each subsequent dental visit. Appropriate educational services will be provided as needed. (e.g. Plaque removal, dietary instructions, completion of dental treatment plans, fluoride use, denture care.)
12 The patient will be informed of their periodontal status; if CPITN score is 3 or 4 the patient will be treated with non-surgical intervention and reassessed with recall appointments. Information on periodontal disease will be given to the patient. All education will be documented in the dental chart.
13 Patients age six to twenty (6 – 20) years will be informed of the need for orthodontic treatment, and that any orthodontic treatment will have to be at the patient’s or parent's expense

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

15. Newly diagnosed diabetics or other special needs patients will be referred from the outpatient clinic. Upon receiving the referral an examination appointment will be given to the patients. At the first appointment the patient will be informed of the effect of diabetes on the oral tissues as well as receive the treatment given to all new patients.
16. Patients in a known high risk group may be included in community based prevention programs. In community based programs, all participants will receive identical services. Referrals will be based on individual risk assessment.
17. Recall intervals will be based on each patient’s risk category.

Low Risk: 12 month recall

Moderate Risk: 6-12 month recall

High Risk: 2-3 month recall


To establish procedures for the safe and effective use of nitrous oxide in the Dental Clinic.


Patient Selection

This facility adheres to the American Academy of Pediatric Dentistry (AAPD) guidelines for nitrous oxide. All sections of this policy will apply to patients of all ages. According to the AAPD’s 2005 guideline:
The following are the patient selection and contraindication recommendations according to the American Academy of Pediatric Dentistry. If necessary, add any additional monitoring requirements of the facility.

“Indications for use of nitrous oxide/oxygen analegesia/anxiolysis include:

  1. a fearful, anxious or obstreperous patient

  2. certain mentally, physically, or medically compromised patients

  3. a patient whose gag reflex interferes with dental care

  4. a patient for whom profound local anesthetic cannot be obtained

  5. an uncooperative child undergoing a lengthy dental procedure

Contraindications for Use of nitrous oxide/oxygen analgesia/anxiolysis

  1. some chronic obstructive pulmonary diseases

  2. severe emotional disturbances or drug related dependencies

  3. first trimester of pregnancy

  4. treatment with bleomycin sulfate”

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

Qualifications of Providers

According to the AAPD’s 2009 Guideline,

“The practitioner who utilized nitrous oxide anesthesia/analgesia for a pediatric dental patients shall possess appropriate training and skills and have available the proper facilities, personnel, and equipment to manage any reasonable foreseeable emergency. Training and certification in basic life support are required for all clinical personnel.”

All dental providers using nitrous oxide must have a record stating that training was received in nitrous oxide. This will be filed [appropriate location].


Describe procedures used to ensure provider competency, if any]


According to the AAPD’s 2009 Guideline: If necessary, add any additional monitoring requirements of the facility.

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


According to the AAPD’s 2009 Guideline: If necessary, add any additional monitoring requirements of the facility.

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


According to the AAPD’s 2009 Guideline, If necessary, add any additional monitoring requirements of the facility.

“All newly installed facilities for delivering nitrous oxide/oxygen must be checked for proper gas delivery and fail safe function prior to use. Inhalation equipment must have the capacity for delivering 100% and never less than 30% oxygen concentration at a flow rate appropriate to the child’s size. Additionally, inhalation equipment must have a fail safe system that is checked and calibrated…” [inset manufacturer’s recommended calibration and maintenance schedule].

Nitrous Oxide scavenging mask and equipment must be working at the time of analgesia initiation.

Nitrous Oxide equipment must be stored in a restricted area at all times when not in use. Maintenance of this equipment will be checked on a routine weekly inspection and before each usage. All rubber equipment will be checked for contaminated waste, and cracking. Back pressure will be tested for discovery of leaking hoses and manifolds.

The scavenger system will always be utilized when administering nitrous oxide.

The dental clinic will be locked at night and during the weekends to secure all nitrous oxide   oxygen equipment.

The equipment, which is used to administer nitrous oxide oxygen, should be checked weekly for gas leaks. Any hoses or bags that leak should be replaced. Each month, the hoses and bags will be checked.

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