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B.4 GUIDELINES for PRENATAL ORAL HEALTH CARE

PURPOSE

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

PROCEDURE

This facility adheres to the National Maternal and Child Oral Health Resource Center guidelines for treatment during pregnancy. Recommendations of the NMCOHRD’s 2008 guidelines include:


General Dental Health Services:

  • Oral hygiene and oral health during pregnancy is important to overall health of the mother and fetus

  • Oral health care during pregnancy is safe and effective and is essential for the pregnant woman and the fetus

  • Diagnosis (including necessary dental X-rays) and treatment for conditions requiring immediate attention are safe during the first trimester of pregnancy

  • Necessary treatment can be provided throughout pregnancy; however the period between the 14th and 20th week of pregnancy is the best time to provide treatment

  • Delaying necessary treatment could result in significant risk to the mother and indirectly to the fetus

Dental provider will consult with the prenatal care Heath Professional in cases of:



  • Deferring treatment because of pregnancy

  • Co-morbid conditions or medication use (e.g. diabetes, hypertension, heparin use) that may affect management of oral problems

  • Intravenous sedation or general anesthesia to complete dental procedures

B.5 INTOXICATED PERSONS

PURPOSE


To provide a protocol for the treatment of intoxicated persons who present themselves to the dental clinic requesting care.

This policy is necessary for the following reasons:


1. Intoxicated patients are often unable to remember or to follow post operative instructions.
2. Intoxicated patients are more likely to become nauseated during or after dental treatment.
3. Intoxicated patients cannot give adequate medical histories.
4. Intoxicated patients cannot be given appropriate pain medications due to the possible interactions between the pain medication and the intoxicating substance.
5. Intoxicated patients may become abusive, unmanageable and violent while receiving treatment.

PROCEDURE


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


If a patient, in the judgment of the treating dental provider, is under the influence of alcohol or other intoxicating substances, he/she will be asked to leave the clinic and return when no longer impaired for care. Security will be called to remove the intoxicated patient if he should become belligerent or abusive.
Other dental staff such as receptionists who observe behavior believed to be caused by alcohol or other intoxicating substances will alert the dental provider who will then make the decision to treat the patient or defer treatment until the patient is no longer impaired.
Patients who repeatedly present to the dental clinic in an intoxicated state will be referred to their medical provider or appropriate behavioral health program.


B.6 STANDING ORDERS FOR DENTAL AUXILIARY STAFF

PURPOSE


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

PROCEDURE



Dental Receptionist

The dental receptionist or dental staff member who checks patients or parent/guardian in for dental treatment will give all new patients and emergency patients a Dental Health History Form to complete. The dental staff member who seats the patient will check the form for completeness and help the patient complete the form if needed.



Dental Assistants

Dental assistants trained to take blood pressures will take and record in the patient’s health record blood pressures on all new patients 30 years old and older with a history of hypertension. This will be done on the patient's first visit of the year and on emergency patients 30 years old or older at each emergency visit if a reading taken within 30 days cannot be found in the patient’s medical or dental record.

Dental assistants trained and certified in dental radiography shall take a periapical x ray in the area of the chief complaint for emergency patients. The dentist shall be consulted in the case of "loose", exfoliating primary teeth prior to taking a periapical radiograph.

Dental assistants who perform direct services for patients (e.g. oral hygiene instructions, patient counseling for tobacco cessation, sealants, fluoride treatments, etc.) shall have the charts reviewed and signed by the supervising dentists.

Dental Hygienists

Initial Treatment

Dental hygienists will follow treatment plans determined at the initial exam and perform all services allowed by [IHS guidelines for sites following IHS guidelines, or State Practice acts for tribal sites.] [For States or IHS sites allowing unsupervised dental hygiene services or assessments, insert allowed services and procedures here.] Hygienists may assess for and place sealants on pits and fissures on teeth that have not been treatment planned for restoration. OR Hygienists may review medical history and provide appropriate basic preventive services including prophylaxis, fluoride treatments, and determine the need for and place sealants prior to a comprehensive dental examination.



Recall

The dental hygienist may determine the patient’s risk category and establish an appropriate recall schedule. For patients of record, X-rays and clinical services will be provided without a reassessment by a dentist. (See Radiography Policy B.14. for radiography frequency guidelines) Upon completion of treatment, dental hygienists will complete the patient record and sign the chart with name and credentials. No co-signature is needed for services provided by a dental hygienist.



B.7 MEDICAL HISTORY

PURPOSE

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

PROCEDURE

All patients presenting to the Facility Dental Clinic will be given a medical history to complete. New patients or those patients that have not been seen in the past 12 months will be required to complete and sign and date this form. A new form must be completed at least every 24 months.

As the patient enters the clinic, the receptionists will give them a blank form and instructions for completing the form. If the individual completing the form is unable to complete the form because of the nature of the question, they are instructed to leave it blank to be filled in on interview with the dental provider. Family members or staff members may assist patients with literacy, language or sight issues who cannot read or understand the form. The patient’s or parent/guardian signature on the Medical History form indicates that all statements are true and gives consent for the dental provider to initiate screening, examination and diagnostic services. Informed consent including a full discussion of treatment needs, risks, benefits and alternative treatments will be obtained following the completion of the examination form. (See Informed Consent Policy B.13)

When the patient is seated in the dental operatory, the dental assistant and later the dental provider will interview the individual or their guardian as to the questions on the form.

If there is inadequate information to determine appropriate precautions for dental treatment based on the responses or if there is a discrepancy in the replies to the dental provider’s questions, further investigation is initiated. If necessary the medical chart is obtained. If the dental provider is still unable to answer the question to his/her satisfaction, the patient will be referred to the [appropriate clinic or referral site] with a completed referral form indicating the specific medical evaluation request. The examination by the medical provider is followed by a routing of the results via [appropriate mechanism] or verbal consult with the dental provider to answer to the initial question.

Dental procedures will not be initiated until there are no questions remaining in the health history.


If medical alerts are found, precautions for those alerts are determined and initiated. These alerts and/or precautions are noted on the bottom of the Examination Form and a medical caution sticker is placed on the front of the individual's dental chart. Notation will also be made to print a current Health Summary at each dental visit.

Patients for subsequent visits to the dental clinic, within one year of the initial completion of the medical history, are asked if there is any change in their health statues. The dental provider initials the form in the proper location. For EDR clinics: Completed and signed medical history forms are scanned into the Electronic Dental Record.



[Delete this paragraph if not applicable]

Sedation patient's medical histories are examined prior to the suggestion or scheduling the individual for dental procedures. If there is any question, the patient is sent to the out patient clinic for examination and clearance. For these individuals, a pre sedation appraisal of their health is determined. (See Sedation Policy B.25 for a full description of required documentation)


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