Oral diagnosis

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I. Rationale for the public health approach in the provision of dental services.
Public health dentistry is not simply the provision of clinical services in a public health setting (i.e., tribal facility), but represents a commitment and responsibility of the dentist to provide services to a community rather than to individual patients. Some of the major problems in our tribal settings include a severe limitation on access to care for the majority of patients, inadequate staffing, and inadequate resources. The public health dentist must, each and every day, take into account these problems while at the same time addressing the historical disparities in oral health care provided to our Native American patients.
Each of our dental facilities in the Schurz Service Unit should operate under the guidelines of the IHS Oral Health Program Guide, using sound public health principles in increasing access to care for all patients as well as responsibly allocating the limited resources and staffing we possess. As a result of this strategy, we may not fully address all of the oral health problems of a particular individual patient, but we will strive to address many of the oral health problems of a particular community.
What follows are the guidelines for the provision of clinical services in the Schurz Service Unit – standards of care.
II. Clinical Procedures.

  1. Diagnostic procedures

  • A Comprehensive Dental Examination (ADA Code 0150) will consist of a hard tissue (caries) examination, periodontal screening and recording (PSR/CPITN), soft tissue/oral cancer screening, TMJ evaluation, at least two bitewing radiographs (over age 5, under age 5 if possible), and a signed treatment plan.

  • A Limited Dental Examination (ADA Code 0140) will consist of a problem-focused examination (emergency) and a radiograph (if applicable) of the problem area.

  • A Periodic Dental Examination (ADA Code 0120) will consist of a recall examination that includes a caries examination, a periodontal screening, soft tissue/oral cancer screening, TMJ evaluation, and a signed treatment plan. This code may also be used for an initial examination when the requirements of a comprehensive dental examination as set forth above (such as no radiographs taken) are not met.

  • The dentist should strive to perform at least one annual examination (comprehensive preferably) on all patients entering the facility – this addresses all oral health needs of the patient and is documented on the treatment plan. Patients interested in emergency care should be encouraged to return for a complete evaluation; however, if patients desire only irregular emergency care, this should be so indicated in the patient record.

  • If a facility has panoramic radiograph capabilities, a panoramic radiograph should be taken at least every three years in the mixed and early adult dentition.

  • Service unit dentists should strive to increase access to care for certain target groups that are at higher risk for disease development, including patients with diabetes (periodontal disease), children under six years of age and their mothers (early childhood caries), prenatal moms (periodontal disease, ECC education), elderly people (at risk for nutritional deficiencies due to tooth loss), and adolescents (at risk due to traumatic dental injuries from sports or accidents). This selective targeting can best be done working in collaboration with other clinic entities such as the public health nurse, well-child clinic, diabetes coordinator, etc.

  • If a patient has been previously diagnosed with periodontal disease or the periodontal screening indicates the need for further evaluation, the clinician should prescribe at least two vertical bitewing radiographs at either the examination or follow-up appointment.

  • If the clinician performs pulp vitality tests (ADA Code 0460), he/she should record in the “O” of the SOAP record the results of such tests as well as a control tooth.

0Preventive procedures

  • Routine rubber-cup prophylaxes are discouraged, as they have been shown to be ineffective in significantly reducing plaque. However, if the facility does offer this service as a way of increasing patient satisfaction, and this procedure (ADA Codes 1110, 1120, 1201, and 1205) can be done in 15 minutes or less at the examination/recall appointment, then it is within the established standards of care. Conversely, if the procedure must be scheduled, or the dentist takes excessive time to perform the procedure, this procedure represents a poor allocation of resources (staff time, supply costs) and cannot be justified.

  • The dentist, if at all possible, should perform all routine preventive procedures at the examination appointment, including prophylaxis, sealants, and any other preventive procedures. Only in rare circumstances should a patient be scheduled an appointment for routine preventive services. Note that the dentist or dental assistant should be providing prophylaxes (some scaling of subgingival and supragingival calculus), and the dental hygienist (if available) should not be used for these routine procedures. Instead the dental hygienist should be utilized for more severe adult prophylaxes that require a lot of time, for scaling and root planing procedures, for the provision of the diabetic periodontal protocols, and for periodontal maintenance appointments.

  • Fluoride varnish (ADA Codes 1201, 1203, 1204, 1205) should be routinely applied to children at moderate to high risk of developing carious lesions (see below) and to adults who have root exposure or report hypersensitivity. Fluoride varnish will not be routinely applied to all patients. Fluoride varnish applied to children will be in unit doses.

  • Fluoride prescriptions (ADA Code 1208) will be given to those patients at high risk of developing caries and where access to fluoridated water is not available – it is the dentist’s responsibility to determine fluoride exposure.

  • All patients reporting a history of tobacco use should be queried as to their interest in tobacco cessation counseling (ADA Code 1320) and this should be documented in the record.

  • Pit and fissure sealants (ADA Code 1351) will be applied to patients at moderate to high risk of developing caries (see below) and will be unfilled resin material (no glass ionomer to be used). When applying sealants, the entire pit and fissure system on the tooth must be sealed (i.e., for a mandibular molar, the occlusal surface and buccal pit). Regardless of risk classification, the dentist should not apply sealants to patients he/she does not feel will return at regular recall appointments (such as patients who have a history of broken appointments or a history of frequent moves), due to the expected failure rate of 10-20% per year for sealants.

  • Although athletic mouth guards are coded miscellaneous (ADA Code 9940/9941), they are preventive appliances, and should be fabricated for all patients that request them and who are aged 8-18 and engaged in a sport or recreational activity that puts them at risk of dental trauma. Additionally, those patients presenting with malocclusion, especially maxillary protrusion, should be encouraged to wear protective mouth guards.

  • Risk classification. To be precise, taking into account several different models of caries risk classification, the standard for the Schurz Service Unit will be as follows:

  • Low caries risk – no current lesions, a possible history of caries but adequate hygiene and regular appointments.

  • Moderate caries risk – no current large carious lesions (maybe a small buccal pit), history of several lesions (or tooth loss due to caries), or inadequate hygiene (moderate to heavy plaque at the appointment)

  • For the purposes of standardizing procedures, and of targeting certain risk groups, the only distinction that will be made is whether the patient is at low risk or moderate/high risk of developing future caries (see above statements on targeting). If a patient is determined to be at low caries risk, the use of preventive procedures (sealants, varnish, etc.) is not recommended as it uses up resources that can be better used on targeting moderate to high caries risk patients in the community.

  1. Restorative procedures

  • Amalgam restorative materials (ADA Codes 2100 series) will not be used in restoring primary teeth.

  • Primary teeth will be restored using primarily glass ionomer materials (Fuji II, Fuji IX, Fuji Triage), especially if the Atraumatic Restorative Technique (ART) is used in preparing the tooth.

  • Either composite resin or amalgam may used in service unit clinics, at the discretion of the treating dentist. However, no compomer materials (Dyract) may be used at all.

  • All primary teeth with caries extending interproximally should be restored using a stainless steel crown (ADA Code 2930).

  • Stainless steel crowns should be cemented with a glass ionomer cement and not IRM.

  • Preparing teeth for crowns typically is the most (or 2nd most) time-consuming procedure performed in our dental facilities. Consequently, crown preparation and delivery, especially if routinely performed, hinders access to care for other patients. Therefore, crown preparation will follow these general guidelines:

  • Crown fabrication solely for the purpose of improving esthetics should not be performed.

  • Crown fabrication (or coronal coverage of some type) must be done following endodontic therapy of the permanent dentition.

  • Crown fabrication may also be performed for other legitimate reasons such as a removable prosthesis abutment, for fractured teeth, to restore vertical dimension after diagnosed bite collapse (anterior or posterior), or due to large restorations with a probability of fracture.

  • Crown fabrication solely for the purpose of treating temporo-mandibular joint dysfunction is not recommended.

  • Before any crown procedure, the dentist must determine the patient’s periodontal status – it is considered medical malpractice to prepare a crown for a tooth that has periodontal disease.

  • In developing a treatment plan, the dentist must use sound reason to determine which, if any, teeth should be crowned. Factors that play a role in this determination include the patient load at the particular dental facility, the patient’s past compliance in keeping appointments, the patient’s oral hygiene status, the overall condition of the mouth, and the patient’s ability to pay for the crown and/or the follow-up prosthesis (in certain service unit clinics, the patient must pay for laboratory fees for prosthetics).

  • The use of prefabricated posts is not recommended, as research has shown that often retention is poor and the use of these posts predisposes teeth to fracture. However, prefabricated posts can be used as provisional posts following endodontic therapy.

  • Temporary crowns may be provided to the patient for fractured teeth (ADA Code 2970), but only if a follow-up appointment for the patient is made to resolve – extract, restore by another material, or crown preparation – the problem.

  • The miscellaneous restorative code (ADA Code 2999) should not be used in the Schurz Service Unit.

  • Sedative fillings (ADA Code 2940) are discouraged in the Schurz Service Unit. However, when used, these materials can provide some relief of discomfort and allow the dentist more time for an accurate diagnosis. Therefore:

  • Sedative fillings may be used to cover teeth where caries excavation is within 2 mm of the pulp, but does not extend into the pulp – additionally the sedative may be used as a liner for a permanent restorative material.

  • When a sedative filling is placed, the dentist is responsible for ensuring the patient is set up for a follow-up appointment for final determination/final restoration.

Endodontic procedures

  • All patients desiring root canal therapy must have the Root Canal Therapy Consent Form thoroughly explained to them and sign the form prior to the initial access.

  • It is up to the treating dentist to determine the viability of successful endodontic treatment for his/her patient.

  • The dentist, once he/she has initiated root canal therapy, is responsible for completing treatment – which means that the dentist or dental staff should set the patient up for a follow-up visit for obturation prior to the patient leaving the clinic that day. If this is not possible, the dentist should not initiate root canal therapy. Several recent cases of litigation in the IHS have occurred as a result of the dentist not completing root canal therapy.

  • The dentist must prescribe, and the dental staff take, a minimum of four radiographs during root canal therapy – initial radiograph (prior to access), initial file/working distance, final apical file, and final radiograph following obturation and placement of a provisional restoration.

  • If a patient is unable to – for whatever reason, whether it be inability to pay or inability to set up an appointment – have a crown or onlay fabricated following endodontic therapy for posterior teeth in occlusion (stress-bearing areas), the dentist is discouraged from initiating root canal therapy due to the possibility of tooth fracture.

  • Endodontic therapy will not include second or third molars in the Schurz Service Unit. For patients requiring root canal therapy on second or third molars, the patient will be given the option of either having the tooth extracted or receiving root canal therapy on the tooth outside the service unit dental clinics, in which case the patient will be responsible for payment.

  • The use of the miscellaneous endodontic code (ADA Code 3999) is prohibited in the Schurz Service Unit.

  • All patients receiving root canal therapy must be recalled at least annually, and the annual exam should include a radiograph of the endodontically-treated tooth, adequate patient history of the tooth, and clinical evaluation of the tooth.

  • The dentist should include two additional statements on the endodontic informed consent:

    • “I understand that he/she is responsible for setting up a final appointment to complete root canal therapy, and understands that if an appointment is not set up, the tooth has a greater chance of root canal failure requiring an extraction in the future”

    • {For posterior teeth in occlusion} “I understand that teeth requiring root canal therapy may require the fabrication of a crown (cap), and that I am required to pre-pay for this crown before root canal therapy can be completed.”

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