To be eligible to apply for core privileges in dentistry, the applicant must meet the following qualifications



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Dentistry Clinical Privileges

Name: ______________________________________



To be eligible to apply for core privileges in dentistry, the applicant must meet the following qualifications:
Mark “x” all that apply
DDS or DMD: Successful completion of an ADA accredited school of dentistry

Certificate Advanced General Practice Residency AGPR (Date) __________

Certificate one year General Practice Residency (Date)___________

Specialty Residency in Dentistry (type) ___________

 Board Certified (Date) __________

 Board eligible or qualified

• Current certification or active participation in the examination process leading to certification by the relevant American Dental Board.

• New applicants may be requested to provide documentation of the number and types of cases during the past 24 months. Applicants have the burden of producing information deemed adequate by the hospital for a proper evaluation of current competence and other qualifications.


AHA PALS certified (Date) __________
AHA ACLS certified (Date) __________
AHA CPR certified (Date) __________
Other clinical certification (State certification and date) ______________________
Although the following requested privileges are generally applicable across a broad range of dental / medical conditions, they are never intended to abrogate the following principle: In every specific situation, the dentist’s practice and exercise of clinical privileges are based upon each unique case and situation. This is the assertion by the dentist, according to her/his best clinical judgment, and in accord with other hospital governance, that at any particular moment, the patient’s illness and problems are within the prudent dentist’s, and the institution’s scope of requisite skills and services. When there is a prudent cause for doubt, the dentist will consult medical references, colleagues, specialists, or other disciplines formally and/or informally and/or request additional institutional resources. Furthermore, whenever such means do not rectify the perceived need of additional medical expertise the provider will assist the patient in finding an appropriate alternate provider or treatment.

Dentistry core privileges
Requested Category one: General Dentistry core privileges

General dental privileges are those competencies appropriate for and expected from the graduate of an ADA accredited dental school. Such as: oral diagnosis, and diagnostic procedures, treatment planning, operative dentistry, fixed and removable prosthodontics, endodontics, periodontal treatment, occlusal adjustment and treatment, pediatric patient treatment and behavior management, non-surgical management of temporomandibular disorders, anxiolysis, oral surgery to include: extractions, soft tissue impactions, alveloplasty, biopsy minor tumor removal, and treatment of minor dento-alveolar trauma. Co-admission is to be done in conjunction with a staff Oral and Maxillofacial Surgeon or staff physician of an appropriate specialty.

Special procedures/techniques (see Qualifications and/or specific criteria*)

To be eligible to apply for a special procedure listed below, the applicant must demonstrate successful completion of an approved, recognized course when such exists, or acceptable supervised training in residency, fellowship or other acceptable experience, and provide documentation of competence in performing that procedure consistent with the criteria set forth in medical staff policies governing the exercise of specific privileges.



Category two: Advanced General Dentistry


Advanced general dental privileges are those competencies appropriate for general dentists with additional training and experience, and include the general dental core privileges and, depending on the applicant’s training, some or all of the following:

Procedure Requested:


Surgical endodontics Partial bony impactions

Complete bony impactions  Closed reduction of jaw fracture

Removal of hard and soft tissue lesions  Minor orthodontic treatment

Treatment in OR  Periodontal surgery

Pre-prosthetic surgery  Mucogingival surgery
 Requested Administration of moderate sedation

See Credentialing Policy for Sedation and Analgesia by Non-Anesthesiologists. This policy requires proficiency in airway management in patients over 12 years of age: by either completion of ACLS provider course and successful completion of a written exam on Moderate Sedation/Analgesia or demonstrated airway management competency as evaluated by Anesthesiology in the Operating Room and successful completion of a written exam on Moderate Sedation/Analgesia. For patients over 6 months and under 12 years of age: by either completion of PALS provider course and successful completion of a written exam on Moderate Sedation/Analgesia or demonstrated airway management competency as evaluated by Anesthesiology in the Operating Room and successful completion of a written exam on Moderate Sedation/Analgesia. Maintenance of Privilege: Practice meets acceptable standards of care as documented by provider profile of outcomes of sedation for the previous two years and assessed by the individuals Department Chief.



Category three Dental Specialties

Dental specialists privileges are those competencies appropriate for and expected from the graduate of an ADA accredited program in their respective specialty. They include the general core privileges, and may include supplemental privileges requested in category two.


Requested: Periodontics

Privileges include hard and soft tissue periodontal surgery, Complete occlusal adjustment, root resective procedures, mucogingival surgery, Surgical placement and management of dental implants. Qualifying requirements The provider must be a graduate of an ADA accredited program in periodontics.


Requested: Oral Surgery

Privileges reflect competency in dento-alveolar surgery, hard and soft tissue oral and maxillofacial trauma, ambulatory anesthesia, management of odontogenic infections, orthognathic, reconstructive, preprosthetic and TMJ surgeries, surgical placement of dental implants, with grafting and/or sinus lifts, and hospital tertiary care. Qualifying Requirements The provider must be a graduate of an ADA accredited program in oral surgery.
Requested: Pediatric Dentistry

Privileges include core privileges plus straight wire, minor orthodontic treatment, palatal expansion, treatment of patients in the O.R. Qualifying Requirements: The provider must be a graduate of an ADA accredited program in pediatric dentistry.



Dental implant surgery

Requested Completion of an approved 36 hour minimum CME course in implant principles, implant placement, tissue interactions, implant prosthetic considerations. A letter outlining the content and successful completion of course must be submitted, or documentation of successful completion of an approved residency in a specialty or subspecialty which included training in implant placement and implant prosthetics.




Clinical Privileges Approval Sheet
Name: _______________________________________
1. Acknowledgement of practitioner

I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise at the __________Health Clinic, and I understand that


(a) In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies and rules applicable generally and any applicable to the particular situation
(b) Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation the applicable section of the medical staff bylaws or related documents governs my actions.
Signed: ______________________________________Date: ________________________
2. Dental Program Manager’s recommendation

I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and make the following recommendation(s):




Recommend all requested privileges

Recommend all requested privileges with the following conditions/modifications:


 Do not recommend the following requested privileges:






Privilege

Condition/Modification/Explanation

1.




2.




3.




4.




Notes:




Department Chair Signature: _____________________________Date: __________________________


Please place original in employee personnel record and provide dentist/hygienist with copy.


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