Policy Manual Final_2016

dental facility without success. Once that criterion has been met, those patients that may fall into
this category would include:

 Children under age six with multiple areas of decay who are uncooperative in office
setting. In many states patients of this age are frequently pre-approved for this service,
under Medicaid and other plans, based upon their age alone.

 Children over six who may require a total of six or more teeth extractions, restorations,
other procedures performed in two or more quadrants of the mouth, and one of the
following:
o A high-risk medical condition that does not permit the procedure to be
performed safely under local anesthesia.

o Infection that does not allow the use of local anesthesia.

o Extensive oral-facial and/or dental trauma for which treatment under local
anesthesia would be ineffective or compromised.

o A developmental disability which prevents cooperation or creates an unsafe
environment for patient or care providers.

 For children age six and over, treatment should be attempted under some type of
conscious sedation, such as nitrous.

 Adults are limited to a hospital benefit only when developmentally
disabled/medically compromised conditions are present. In almost every case
Medicaid will deny a benefit based upon anxiety alone.

 It must be determined that the risk of general anesthesia is outweighed by the
benefit.

Radiographic Exam Guidelines

Best Practice Policy on Radiographs

Proper and current radiographs are necessary to properly document existing conditions and
diagnose disease. Exposing a patient to radiographs should always be based upon medical
necessity. The guidelines which are presented here are modeled after the most current ADA
guidelines. It is understood that these recommendations may be modified based upon the unique
circumstances of a given individual. These film guidelines should be considered policy unless
documented conditions warrant otherwise. In general, one set of bitewings is allowed every 12
months. A complete series and panoramic film is allowed every five years (these films should be
repeated at five-year intervals). From an office and patient financial aspect it is important to
understand that insurance generally will not allow the provider to bill for bitewings or periapical
films in conjunction with a panoramic film.

In most offices, including public health, a panoramic film and bitewings are generally considered
36

the gold standard. They are considered the gold standard relative to the diagnostic information
provided, reducing patient exposure, and maximizing office efficiency. Obtaining and exposing a
patient to a traditional full-mouth series of periapical radiographs would be the exception to the
rule. When this series of films are obtained appropriate entry should be made in the patient chart
for the deviation from the standard.

Radiographic Exam Standards of Practice

Dental Age 9 & Under Dental Age 10-15 Dental Age 16-Adult

New  2 bitewing films  Panoramic film as  Panoramic film and
Patient necessary indicated periapical films
Exam  2 anterior periapical
films  2 bitewing films  Full mouth series is taken in
place of panoramic where
 4 posterior periapical  Upper and lower periodontal disease or gross
films periapical films as decay and apical infection is
necessary suspected

 4 bitewing films

Re-care  2 bitewing films every  2 bitewing films every  4 bitewing films every 12

Exam 12 months 12 months months

 Occlusal film every 12  Panoramic or Full Series
months (Must use every 5 years (do not take in
occlusal size film) conjunction with BW’S)

Quality Control Chart Review Guidelines

The Complete Clinical Note

A proper patient chart with accurate notes is vital to both the patient and the organization. A well-
documented chart will provide for the following: the best opportunity for care for the patient,
proper documentation to provide to insurance and protect against audit, and finally, the defense of
a provider, should a medical-legal issue surface. It is important to note that a patient note has the
responsibility of being maintained by the doctor or provider rendering treatment, but should be
delegated to a trained and responsible clinic staff member. A dental chart should be inclusive of the
following:

37

Background Information
1. Patient Name, Chart Number.
2. Treating Dentist or Hygienist.
3. Clinic location or hospital where services were rendered.
4. All identification including insurance coverage filled out.
5. Forms all signed by patient or responsible party.

Medical History

1. All “yes” answers highlighted and reviewed by operator.

2. Significant items result in “Medical Alert” in electronic chart.

3. Notation that history was reviewed at each recall.

4. Blood pressure and heart rate recorded and taken at every appointment for hypertensive
patients.

5. Cancer screening completed and recorded.

6. All current medications noted with dosage(s) and times taken.

7. Pain level is recorded (at each appointment for patients presenting with pain).

8. Each entry should contain a statement of the patient’s specific complaints and conditions
requiring examination.

Patient History

1. Medication and dental history (can use form).
2. Prior dental treatment.
3. If undertaking general care with names of patient:

a. Previous dental treatment with names of provider.
b. Previous oral surgery, orthodontics, endodontics, etc., with names of providers.
c. Note all previous periodontal care and names of providers.
d. TMJ history with names of providers, if any.
4. If undertaking special care, minimum dental history should include history of problem,
treatment being sought, previous treatment of same, and names of providers.
5. Obtain prior dental records/X-rays, if needed.

Dental Exam
1. Unknown lesions are described, measured and photographed.
2. Existing conditions recorded.

38

3. Periodontal charting completed for at-risk adults.
4. Appropriate radiographs taken and labeled.
5. Patient attitude/experience with dentistry noted.
6. Specific testing done, i.e., endodontic exam – pulp testing, sensitivity, and results of same.
7. Finding observed—even if X-rays taken, make written note of what you see on X-rays and

on clinical exam.
8. Note findings observed not related to specific condition for which treatment is sought.
9. Note all findings of conditions which require monitoring and plan for monitoring.
10. Oral hygiene compliance (non-compliance) recorded.
11. Note persons present during discussions.
12. Note all information given to patient.
13. Note patient’s response.
14. Note all treatment options advised and elected.

Treatment Plan
1. Referral is advised/made for unknown suspicious lesions.
2. An evidenced-based diagnosis is prepared for each patient.
3. An appropriate treatment plan is devised for every patient based on the diagnosis(es) of the
disease present.
4. Preventive/interceptive treatment utilized when indicated such as:
a. Fluoride
b. OHI
c. Habit control/smoking cessation
d. Diet counseling

Treatment
1. Services are rendered following the treatment plan where possible.
2. All aspects of services rendered are recorded. All entries should be initialed by writer; all
providers should be identified by initials.
3. Never change (including later additions):

39

a. Nitrous oxide level if used. The local anesthetic type, amount, and location.
b. All materials used.
c. All complications.
d. Prescription(s) given, instructions, refills if any.
e. If additional treatment required, note treatment plan in record and that patient

advised.
f. Missed or late appointments noted.
g. Response/tolerance to treatment indicated.
h. Notation if patient instructions were given.
i. If using written instruction sheet, put copy in chart or scan into the electronic

record with the date given to patient and signed.
j. Document all instances of patient failing/refusing to follow instructions or advice.

Broken/Cancelled Appointments
1. Note in chart.

Phone Calls
1. Document all phone calls with patient complaints, when treatment advice given, medication
prescribed, conversations regarding bills, insurance, etc.

Chart Audit Guidelines
Chart audits are conducted to insure a basic standard of care, as well as provide for an ever-
improving level of quality. Information obtained from these audits allows for benchmarking of the
current status of care rendered and the development of strategies for improvement. Chart audits
can be accomplished in a variety of ways, and should be conducted by a dentist. One suggestion is
to complete an audit of a dentist choosing a “typical” day at random. Within that day, a minimum of
eight patients may be selected for review including emergencies. The following is a recommended
list for evaluation and compliance with policy and a standard of care:

1. Procedure(s): those done on the day patients reviewed were actually treated and how
the code for those procedures was reported. Examples:
a. What type examination led up to the procedure done on this date?
i. Was this an emergency? Was a comprehensive exam ever completed? Was a
treatment plan completed according to the type of exam done?

40

b. Check that all three parts of the exam are documented: health history, dental
history/charting and treatment plan. For emergency exam, the treatment plan
would only be to resolve the chief complaint. For comprehensive and periodic
exams, the treatment plan should be for the following six months.

c. Were the appropriate radiographs taken according to the exam done? Were those
radiographs clinically acceptable? Example: Do the apices show in the periapical
films? Are the contacts open in the bitewings? If an FMX is taken, along with
additional individual periapical films, is only the FMX billed?

d. From the radiographs, if something fairly obvious is present, such as a periapical
abscess, is it addressed in the treatment plan? Options of endo vs. extraction
explained to patient?

e. Extractions—type and appropriateness relative to code submitted.
i. If the extractions are in preparation for denture or partial, are “simple”
extractions coded?
ii. If the extraction is surgical, is the need adequately documented according to
the CDT code? Bone removal and/or tooth sectioned?

iii. Following extractions, was there an alveoloplasty done? If so, was there
prosthesis in the treatment plan? Were there enough teeth removed to even
justify an alveoloplasty according to the CDT code?

f. Endodontics—is there a pre- and post-op radiograph?
g. Pulpotomy—is there a pre-op film indicating need for the procedure? Is there a

post-op film showing the completed treatment?
h. Operative and Restorative (fillings and crowns): Were the restorations routine? If

deep or questionable outcome, was patient advised of possible outcomes? Will tooth
likely exfoliate within six months? As part of a quality improvement initiative,
consider mandated before and after radiographs of treated teeth on adult patients.
i. Prostheses: Was a prior authorization obtained? If a second prosthesis, is the need
for a new one documented and time interval from the first recorded?
2. Progress notes: Have the defaults been changed appropriately according to the chief
complaint, history, clinical findings, etc.? Examples: Comprehensive exam—has the caries
risk assessment been changed from the default (low, medium, high)? Is the number of
restorations and/or extractions related to the caries incidence? Has the periodontal
status been evaluated and a diagnosis recorded?
3. Clinical notes: Have the defaults been changed appropriately? Examples: if a patient
presents with a chief complaint of pain, has the pain level (default 0) been changed to
reflect the patient’s current pain level? Description: Is anything recorded?

4. Other:
a. Prescriptions—justified and written appropriately?
b. Co-pays—are they current?
c. Broken/cancelled appointments—documented and action taken?
d. Attitude/behavior—documented when needed?
e. Local anesthetic—documented and recorded?

41

f. Everything billed—example: dry socket. Was proper code used and billed?
g. Space maintainers—do radiographs demonstrate or notes document need?
h. Notes in the record—is there some indication of who wrote them? Initials?
i. Referrals – is the reason for them documented?

5. Specific quality control audit guidelines.

6. Background Information
a. Patient name, chart number.
b. Treating dentist or hygienist.
c. Clinic location or hospital where services were rendered.
d. All identification including insurance coverage filled out.
e. Forms all signed by patient or responsible party.

7. Medical History
a. All “yes” answers highlighted and reviewed by operator.
b. Significant items result in “Medical Alert” in electronic chart.
c. Notation that history was reviewed at each recall.
d. Blood pressure and heart rate recorded and taken at every appointment for
hypertensive, CAD patients.
e. Cancer screening completed and recorded.
f. All current medications noted with dosage(s) and times taken.
g. Pain level is recorded (at each appointment for patients presenting with pain).

8. Dental Exam
a. Unknown lesions are described, measured and photographed.
b. Existing conditions recorded.
c. Periodontal charting completed for at risk adults.
d. Appropriate radiographs taken and labeled.
e. Patient attitude/experience with dentistry noted.

42

9. Treatment Plan
a. Referral is advised/made for unknown suspicious lesions.
b. An evidenced-based diagnosis(es) is prepared for each patient.
c. An appropriate treatment plan is devised for every patient based on the diagnosis(es) of
the disease present.
d. Preventive/interceptive treatment utilized when indicated such as:
a. Fluoride
b. OHI
c. Habit control/smoking cessation
d. Diet counseling

10. Treatment
a. Services are rendered following the treatment plan where possible.
b. All aspects of services rendered are recorded.
1. Nitrous oxide level if used. The LA type, amount, and location.
2. Notation if patient instructions were given.
3. Prescription(s) given, instructions, refills if any.
4. Missed or late appointments noted.
5. Oral hygiene compliance (noncompliance) recorded.
6. Response/tolerance to treatment indicated.

11. Consent Forms
a. Appropriate consent forms

Retreatment Policy

From time to time it is necessary for dental work completed to be retreated. This may be for any
number of reasons. This policy is to address under whom and under what circumstances that work
will be completed and considered a retreatment. For purposes of discussion, work is considered a
retreatment if the original is less than 24 months old. Retreatment may vary from a failed root
canal, to a defective restoration, to an ill-fitting prosthesis. Treatment provided more than 24
months afterward does not fall into this category.

43

Under some scenarios, a doctor in agreement and disclosure with the patient may provide a service
which may knowingly not last one year. An example may include a dental restoration on a “meth
mouth” patient. In these cases it is important to adequately document the doctor’s concern in the
patient chart and inform the patient of such. The patient is instructed that in the event of a failure
of the dental treatment, the responsibility for that failure rests solely with the patient. This type of
work often falls into the “heroic” category, and dentists are advised to give special consideration to
the treatment they are considering offering to these patients. Any failure of this treatment will
require patient payment for providing any additional services. It is important to document this
type of conversation in the patient chart, and their acknowledgement of the limitations of the
treatment being provided. In these cases there is no retreatment provision.

In the event that the treatment failure is the result of patient-controlled factors, such as poor oral
hygiene, dietary considerations, or other non-compliance, the patient would be responsible for the
cost of the retreatment. In these scenarios, the patient should be advised of the financial
responsibility prior to initiation of retreatment and be counseled on how to best ensure success of
the retreatment.

Before initiating a retreatment, the following should be considered:

 Reason for treatment. Has the treatment failed due to patient controlled factors, failure
during initial placement/treatment, or other external factors? Identification and
addressment of the suspected reason for treatment failure will help facilitate success of the
retreatment.

 The time elapsed since the original treatment. If possible, wait until two years has elapsed
to avoid a “redo,” a possible financial charge to the patient, and the redistribution of
production.

 Surfaces submitted. Make sure expected treatment is truly a redo of what was done
originally. Explore the possibility that current surfaces being treated cannot be submitted
without overlapping previously submitted surfaces, if possible.



In cases where possible, the original doctor of treatment is to provide the retreatment. As a result
of emergent needs (severe pain, infection, or a debilitating condition), geographical challenges, or
personality conflicts, it may not be possible to have the original doctor provide the retreatment. In
these cases, the original doctor must be informed of the need for retreatment and consent to it. The
retreating doctor should be the one to make contact with the original doctor. Once consent is
obtained from the original doctor, the service may be provided and the retreatment is entered in
the dental system like any other treatment with the appropriate fee.

44

Section 4

Patient Finance

The retreating doctor or designated administrative team member will notify the appropriate billing
department to make the appropriate adjustment. If the original doctor of treatment does not give
consent, the central administrative office should be informed.

If the doctor who originally provided the treatment is no longer an employee, the proper
administrate staff is to be informed and may authorize reimbursement to another provider.

Retreatments become more difficult to manage in group practices. One of the strengths of a group
practice can be strict quality control. If any doctors of the group suspect treatment which may have
been rendered beneath the standard of care, they are in a position to share that concern with their
colleague. The person in a Quality Improvement department should be informed in cases of suspect
treatment that otherwise cannot be adequately explained.

Finance
Background
Issues related to finance with the patient and third-party payers will have great variance between
organizations, especially between the private and public health sector. Federally Qualified
Healthcare Centers have a different model of remuneration than other public and private systems.
Often the financing mechanism for an operation will drive some of the systems related to providing
care. This has both positive and negative consequences for both the organization and the patient.
Finance matters need to be evaluated in this context and strategies for the organization should be
crafted around the remuneration model in consideration of both the patient and the organization.

When setting office finance policies, strong consideration should be given to a policy which requires
payment at the time the appointment is made. This should not supersede any state law. Some
states indicate it is a discriminatory practice to require any copayments in advance for a service
rendered.

Patient Financial Brochure
Every office should have a mechanism to inform both patients and staff as to the policies regarding
financial matters. This should include items such as explanations regarding patient responsibility

45

in the event of loss or deficient insurance coverage, payment plans (if extended), when payment is
due for services rendered, and policy regarding broken appointments. An additional purpose of
having this brochure is to inform the guests of the limitations and benefits of their insurance
coverage.

The brochure and its information will be reviewed for every new patient upon completion of the
exam. It will also be reviewed with every existing patient when questions arise regarding insurance
or when the patient has any non-routine dental treatment. The brochure will be given to the
patient at the new patient visit, when necessary to review, or when policies and procedures change.
This may also be mailed if a new patient packet is sent.

Recommended Scripts:

The dental brochure will explain, in writing, what dental insurance is and how we will help you to
maximize your benefits. Dental insurance is a highly complex area that creates confusion for many
dental patients. Our goal is to help you achieve and maintain optimal dental care, which is not
necessarily the goal of your dental insurance company. Our office will do everything possible to
help you understand and make the most of your dental insurance benefits. We will complete and
submit your dental insurance forms to the company to achieve the maximum reimbursement to
which you are entitled. We will work to make this happen as quickly as possible. If you have any
questions about your dental insurance, please feel free to ask.

Financial Management of Emergency Patients

This system should be utilized when a guest calls the office and is experiencing a dental emergency
requiring immediate attention. The purpose of this system is to maintain a consistent way to
accommodate patients who need immediate attention and at the same time keep control of the
financial interest of the clinic. Anticipated costs, as well as collection policies, should be shared
with the patient prior to arrival. When it is required to estimate the cost of the visit, it is wise to
overestimate rather than underestimate.

Recommended Scripts:

Mrs. Jones, please understand that today’s visit is for an evaluation and to minimize your pain
until definitive treatment can be accomplished. An X-ray may be taken of the area you are
having problems with to help us diagnose what treatment is needed. Before you leave today, we
will schedule an appointment for you to have the treatment completed. I also want to let you
know that the fee is due today and could range from $A to $Z. If you have Medicaid dental
insurance, we will submit the claim. So, Mrs. Jones, should we let the doctor know you are
coming right over?

46

Case Presentation

Being a Patient Advocate for Treatment

Case presentation is another area of wide variability among both providers and organizations. We
must remember to practice beneficence and advocate on behalf of the patient rather than direct a
patient. The gamut of presentations runs from “overkill” to “underwhelm.” While presentations
may vary, the most important consideration is remembering who the audience is. Articles have
been published that put the reading level of the general population between 6th and 8th grade. It has
also been documented that the reading levels of the socio-economic class that typically will visit a
public health facility are between 2nd and 3rd grade. It is important to understand who the audience
is and talk to them at a level easily understood. It can be a challenge to many dentists with over 25
years of formal education to speak at the 2nd and 3rd grade level. For public health facilities, visuals
prove of great benefit in educating and communicating with patients. Additionally keeping
information short and to the point (2 to 5 minutes), utilizing language appropriate for the 2nd and
3rd grade reading level, is critical. Note that it is not being suggested that one talks “down” to a
patient but to rather talk “to” a patient at their level. As an example, “gums” should always be used
over “periodontium.”

Hygienist Case Presentation of Soft Tissue Management

The hygienist can be invaluable in reducing the time spent by the dentist on the presentation of a
treatment plan and offers additional credibility to the plan by offering her endorsement. Hygienists
are often inhibited about presenting possible treatment. Unfortunately, this will result in a
decrease in treatment plan acceptance. Without the hygienist’s assistance in presenting needed
dentistry (to be confirmed by and in conjunction with the dentist), the amount of accepted
treatment by the patient will likely decrease. Also noted is that, without the utilization of the
hygienist in this regard, a longer period of time for the dentist to present treatment will be
required. This occurs since the patients will not have been prepared in advance by the hygienist.

Hygienists should encourage patients to accept necessary treatment. The treatment presented by
the hygienist should include both tooth therapy as well as gum therapy.

Review the script below and take note of how the hygienist supports the dentist. She performed a
full-level assessment, educated the patient and answered objections and questions. Remember,
hygienists are not allowed to diagnose, but when the doctor enters the operatory, he/she will not
have to give detailed explanations, education and become involved in an entire discussion. This
patient is basically “sold” on the decision to keep her teeth, and that is because the hygienist has
done such an excellent job of presenting the needs and possible ways to address them.

47

Recommended Script:
Hygienist: Mrs. Jones, as we discussed at your last visit, you had a quite a bit of bleeding and
the space between your gums and teeth in many areas is very deep. I am concerned about
the health of your gums, and I don’t want you to lose any teeth. It’s time to take an
aggressive approach to treating this oral infection. The doctor will probably recommend
that I perform a series of deep scaling and root planing. You remember that root planing is
the removal of debris in and around the area and smoothing your roots. It will take four
visits and the cost is $500. I’m sure you have some questions.
Patient: Will my insurance cover this?
Hygienist: Unfortunately, at this time there is no coverage available for these services we
discussed. We are hoping that this will change in the future, but for right now these costs
will be out of pocket.
Patient: I just don’t know how I will afford it.
Hygienist: We will have our front desk receptionist work with you to see if there is a
possible way to coordinate treatment with your ability to pay. If we can fit it into your
budget, is this the type of treatment you are willing to have to achieve oral health again?
Patient: Yes.
Hygienist: Great. If the doctor confirms that this is the best treatment for you, then we can
talk to our front desk person about the insurance and possible payment options that can
make payment for the treatment as comfortable as possible for you.

Hygienist Case Presentation of Required Dentistry

Hygienists as Advocates for Treatment
By law, hygienists are not permitted to diagnose. Therefore, they should refrain from offering a
diagnosis, but rather inform patients of their observations. All treatment planning should be
planned and authorized in a doctor-patient conversation.

Hygienists have a viable opportunity to educate patients about all necessary treatment. They can
plant seeds that make it easier for the doctor to discuss treatment. Hygienists should become
comfortable talking to patients about potential treatment. They must clarify the available options
with the doctor in advance. This eliminates contradictions. Treatment planning becomes more
efficient because the patient has already been oriented by a trusted professional.

48

A review of the script below indicates how a conversation might progress between a patient and a
hygienist regarding dental treatment. The hygienist was able to offer information about possible
treatment while waiting for the doctor to confirm the need for that treatment. The entire dialogue
can be very pleasant as indicated here. Note how the patient was convinced to have treatment even
prior to talking with the doctor. While there still may be an obstacle related to the fees, at least the
patient will not hear from the doctor that there is a problem and be shocked about the necessity to
consider treatment options. Instead, the patient has heard from the hygienist about the need for
treatment, and that will be confirmed by the doctor. This is almost like getting the second opinion
as the first.

Treatment Plan Presentation – Verbal Skills
It is beyond the scope of this book to address all of the factors in treatment planning. There are
certain key verbal skills that can be used when treatment planning with patients. One of the most
important is to ask questions and assess the patient’s interest level for the services you want to
provide.

You may notice in the exchange below, the patient in this case has specific needs. The dentist
addresses those needs through the use of questions to determine the patient’s interest level in
having dental care performed. The patient was interested in addressing needs, discomfort and
cosmetics and clearly expressed an interest in dental care.

The first step in any treatment presentation is to perform an interest assessment regarding the
patient’s motivational level. Once the patient has demonstrated interest, you can then create
excitement for the patient by offering an enthusiastic presentation of techniques that will help the
patient with specific needs.

49

Recommended Script:
Hygienist: Mrs. Jones, I see fillings breaking down in two teeth. Usually, when fillings this size
start to break down, the doctor recommends that you consider crowns. Otherwise you might find
that the teeth break down more severely, and you could end up needing additional treatment like
root canals or periodontal surgery. This makes the case more complex and endangers the teeth.
Right now you can have a simple straightforward procedure performed, such as crowns, to help
you keep those teeth for a lifetime.
Patient: Well, I’m glad that you saw those. Naturally I want to keep my teeth, but you really
think I need to have crowns? Couldn’t the teeth just be repaired?
Hygienist: If they were my teeth, I would definitely want the crowns; however, the doctor is the
one to make the final decision. I know that a crown placed on each of these teeth would result
in a permanently stable situation. Otherwise, I’m afraid that you’re going to have additional
problems with those teeth. Fortunately, the crowns are very easy to do at this point because the
teeth are not so broken down that it will be a complex problem.
Patient: Okay then. I guess I need to consider that. How much are we talking about?
Hygienist: Well that depends. The doctor is really the one to determine what type of crowns
would be appropriate for your situation. We will give you the fees once he has confirmed my
observation and made a decision about what is in your best interest. Why don’t we let him talk
to you about that?
Patient: Okay. When he comes in, I’ll ask for all the information.

Treatment Plan Presentation – Enthusiasm
Enthusiasm is critical in the treatment planning process. Any good salesperson knows that
enthusiasm is read by the customer as credibility. Patients have a high trust level for dentists and
are likely to accept the proposed treatment, if it is clearly understood, exciting, and if the patient
chooses to afford it.

Notice the enthusiastic positive exchange between the doctor and the patient. Do not expect your
patients to generate enthusiasm for procedures that they do not really understand. Instead, you
will have to let them know how excited you are about dentistry, so that they can believe this
proposal is in their best interest. Motivated and enthusiastic patients accept treatment planning
gratefully and graciously.

50

Recommended Script:
Doctor: Mrs. Jones, I am pleased that you have come to our practice. We have the exact
services that will help you achieve your goal of improving the condition of your mouth. I don’t
blame you one bit for your concern about your current situation, and once we have addressed
that, you will probably be the happiest dental patient anywhere.
Patient: Do you really think you can help me?
Doctor: Absolutely. In fact, if I were in your situation, I would do exactly the same thing. We
can begin treatment next Thursday morning. How will that work for your schedule?
Patient: That sounds great. I am really excited about this.

Treatment Plan Presentation Part – Obtaining Commitment
One of the main reasons that dental practices do not have a high treatment plan acceptance rate is
because they fail to close a case. Treatment planning requires asking for a specific commitment
once you believe the patient is ready to accept care.

Once the treatment needs have been presented to the patient, based on exam findings and further
studies of radiographs, case-closing scripts provide a friendly way for the doctor to guide the
patient to case acceptance that day. It is important that the prognosis of the case and oral health
are detailed if treatment is not accomplished.

It is important the coordination occur between the doctor and the front desk receptionist in order
to close the treatment plan. It is impossible to close a treatment plan without giving the patient the
fee and discussing payment options. Many times the doctor thinks that the patient has accepted
treatment, only to find that the patient changes his or her mind when they start to talk about
money. It is important to disclose summary fees in the back office prior to patient dismissal.

Often it is a financial consideration that serves as the ultimate decision-maker for the patient. Once
the patient commits to an option that fits within his or her budget, you can be better assured that
the patient will follow through with treatment. It is important for financial coordinators or front
desk coordinators to recognize that they play a major role in closing treatment plans based upon
this financial consideration.

These are examples of scripts which can be utilized by the doctor or hygienist in a non-
confrontational discussion with a patient regarding treatment.

51

Recommended Script:
Doctor: Mrs. Jones, I know that you are going to really benefit from the treatment I am
recommending. I know that your health will improve, you will feel better, your confidence will
increase and you will need to get used to all the comments you are going to receive on your new
smile. Your fee for this treatment is $2,700. I am excited for you. Does this sound like a plan you
would like to move forward on?
Patient: Well, I may need to think about it. It’s a lot of money.
Doctor: I understand this would be a considerable investment for you. Is there anything specific
that you would like to think about or any questions that I can answer for you at this time?
Patient: Well, I was wondering if I can work out a payment plan.
Doctor: There may be a few options to help make the finances for this treatment comfortable. If
we can work with you on agreeable financial options, is this the type of treatment that you will
want to achieve a healthy mouth?
Patient: Oh yes.
Doctor: Then let me get our front desk receptionist, so that she can review our options and
determine if we can set up a plan that will for you. As soon as you two are finished, why don’t
Thyeoruesmchaeydbueleinasntaanpcpeosinintmwehnicthsoa wpaetmienatyibneugninw?illing to commit to treatment options as
recommended by the doctor. In these instances, all potential barriers to treatment should be
idPenattiifeiendt:aOnkdaeyv. eTrhyartesaosuonndabs laeseifffiotrwt moualddewtoorrkemouotv. e(Ftrhoenbtadrersiekrrseacnedptfiaocniliisttattaekreesnodveerrintgheof care.
If cthoenspualttiaetniotnis. sSteilel sacvreirpstes toonpfuinrasnuciniagl raercroamngmemenednetdptrreesaetnmtaetniot,nt.h)e patient should be informed of
potential health risks and outcomes. An “Informed Refusal of Treatment” form should be
completed and signed by both the patient and the doctor so that the recommendations and
discussion have been thoroughly documented.
Example:

Informed Refusal of Treatment Recommendation

Contrary to the professional advice of the Dentist, I voluntarily elect to not have the following service(s) or
consultation(s) performed. ________________ (enter procedure) _________.

I have discussed the matter with the Dentist, and all of my questions have been answered. I fully
understand why the recommendation has been made, and the possible consequences of my refusal.

I agree to hold the Dental Organization, its Agents, and Employees harmless for any unfortunate outcome
or disease process that I may suffer as a result of this refusal.

Patient Signature and Date

The patient should be made aware that, when ready to proceed with treatment, he or she will be

52

welcome to return to the office for care.

Patient Financial Options Scripts
The purpose of having scripts for financial options is to be able to consistently and effectively
handle objections patients may have to the financial portion of needed or wanted treatment. With a
system in place, when an objection occurs, it can be handled in a positive manner that will enable
the patient to proceed with treatment.

At the presentation of fees, if a person objects to paying a fee up front, a well-thought-out script will
help overcome patient objections about the fee for their treatment. These types of discussions are
best held in a private room during the financial arrangement portion of the visit.

Additional Recommended Scripts:

Doctor: Mrs. Jones, how would you like us to find a time for you before you leave to get that
treatment scheduled so we can...

- Eliminate your uncomfortable removable partial?
- Give you a beautiful, healthy smile?
- Correct the wear problem?
- Whiten your teeth?
- Get your mouth in a state of health that is maintainable.
- Let’s go ahead and get your next appointment scheduled.
- How do you feel about all of this?
- Do you have any more questions?
- Do you think that all of this will be good for you?
- If money were no object, would you have this treatment?
- Is there any reason why we should not go ahead and schedule this treatment today?
- Are there any questions or concerns that would keep you from scheduling this

treatment today?

Patient: I’d love to, but how much will all this cost and do you take payment plans?

Doctor: Mrs. Jones, let me have the front desk receptionist speak to you about your available
options. I look forward to seeing you soon! (Allow assistant to dismiss and escort patient to
financial office.)

Medicaid Co-Payments (Varies State by State)
Medicaid Facts:

53

 It is generally considered to be illegal to write off co-payments and deductibles either
before or after billing the insurance company.

 Insurance companies require provider to bill all co-payments and deductibles. Failure
to collect co-payments violates the contract providers have with the insurance
company. When they accept payment they are also agreeing to bill the patient the co-
payment amount. If a provider has a contract with an insurance company, the insurance
company can cancel the contract if the provider writes off the co-payments.

 In the case of Medicaid, it is generally illegal to write off any unpaid amounts without
making every effort at collection of the account, and having full documentation to that
effect.

 The Michigan Medicaid provider manual states “a Medicaid co-payment is required.
However, a provider cannot refuse to render service if the beneficiary is unable to pay
the required co-payment on the date of service.” Future visits may be limited to
patients based upon an unpaid patient balance.

 In most states it cannot be required that a patient make a co-payment to obtain an
appointment. Given this state policy, understand there is no violation to ask for
payment up front (as long as it is not a condition of getting an appointment). Payment
in advance is a major mitigation factor in minimizing broken appointments.

Recommended Scripts:

Front Desk Receptionist: The fee for the treatment we discussed with you is…. Do you have any
questions regarding this fee?

Guest: I don't think I can come up with that much cash right now.

Front Desk Receptionist: I can certainly understand. That is why we also accept Visa, MasterCard,
and Discover. Which would you prefer?

Guest: It sounds good, but my credit cards are already over-extended. Don't you offer some sort of
payment plan?

Front Desk Receptionist: Let’s talk about what might work for you so I can help you figure out
which program may be best for you. We do use outside third-party payers which may be able to
extend credit to create a monthly payment for you. It is also possible that you may qualify for
financial aid.

There are certain beneficiaries excluded from the co-payment requirements. As pertaining to
dentistry, those individuals are as follows:

 Beneficiaries age 19 and younger.

54

 Medicare / Medicaid dual-eligible beneficiaries.
 Children’s Special Health Care Services beneficiaries. (Because we are dentists, the only

time this would affect us would be if the CSHCS diagnosis were the reason they were at our
office- very rare!)

Medicaid Provider Manuals are often specific on when to charge a co-payment. Generally:
 An office is only allowed to charge one co-payment per visit.
 Where several visits are required to complete a service such as dentures, only one co-
payment may be charged. If, however, a completely unrelated service that is billable to
Medicaid on the same day is accomplished, a charge can be rightfully made for the co-
payment.
 An office cannot charge for items such as infection control, sterilization, or other routine
procedures that are considered part of normal office operations.

If patients are seen for non-covered services, or services that will not be billed to Medicaid, a co-
payment should not be charged. In place of the co-payment, the normal fee for the service should
be rendered.

It is often questioned how an organization should handle a Medicaid patient with an unpaid debt.

State Medicaid laws traditionally state that a provider cannot refuse to see patients who do not
have the required co-payment on the date of service. However they can be refused further
appointments until a previous debt is cleared. To do this, strict guidelines must be followed.

 One must first give the beneficiary notice of the debt (including documentation such as a
billing statement, invoice, cash register receipt, or other writing showing the co-payment
amount owed).

 A reasonable opportunity to pay the debt must be extended.

The following is an example flow chart utilized for Medicaid in the state of Michigan. Your state
program is likely to vary.

55

Cash Handling

All cash is to be kept in a lockbox that should remain locked at all times. Checks and credit card
receipts should also remain in the lockbox until deposits are made. Keys to the lockbox should
remain with the front desk personnel. The lockbox should always be double-verified at night that it
is locked. Keys to the lockbox should either go home with front desk personnel or should be locked
into a separate cabinet, with that key going home. Cash change should never be given to a patient
that has paid with a check. Checks should be endorsed with the endorsement stamp. Credit card
machines should be programmed to automatically batch every night. Settlement reports should be
kept with receipts.

Deposits should be made when cash on hand is exceeding $300.00, but at a minimum of once a
week, and on the last day of the month before 3 p.m. Daily deposits are acceptable. See below for
more detail on preparing deposits.

56

Every clinic is generally supplied with a small petty cash fund for emergency purchases. This cash
should also be locked in a cash box (either with the cash for change, or in a separate cash box). If
kept with cash for change, then petty cash should be kept separate (under money tray works well).
When petty cash is expensed it is important to keep all receipts and complete a petty cash voucher
for auditing purposes of the cash. The voucher and receipts should be sent to the administrative
office as the petty cash box requires the funds replenished.

 Deposits should be prepared at the end of every day.
 Run the deposit slip for that day from the dental software.
 Verify it matches what monies you have collected from the patients.
 Save the slip for actual bank deposit backup.
 At the end of the week, compile the week’s deposit slips that you have previously run each

day. Prepare bank deposit slip for cash and checks to be deposited. Fill out any required
deposit summary.
 Take the deposit to the bank.
 Attach bank receipt, deposit summary, credit card receipts and settlements, and deposit
slips together and send to the administrative office.

Insurance Write-Offs

Insurance write-offs are required to be completed from time to time in the dental office. It is
important to implement an insurance write-off procedure that works with dental accounting
procedures and software as well as any productivity remuneration policies.

It is suggested that the insurance write-offs will be entered as an accounting code in the dental
accounting software and be completed by the appropriate front office staff or administrative billers.
The responsibilities of these individuals would include:

 Utilizing the appropriate software, the billers will enter the procedure code and provider
production adjustment in the client’s ledger, with a negative production amount or enter
payments when a procedure is rejected by an insurance company.

 Billers then will date the production adjustment procedure code with the following day to
notify the clinic and provider, and to allow time for schedule changes.

 Billers will indicate the reason the procedure was rejected, and also enter a write-off
adjustment.

 When notified by the clinic via email that a procedure can be re-billed, billers will delete the
provider production adjust procedure code and write-off adjustment, correct the procedure
with information provided by the clinic and re-bill the procedure.

On a daily basis it is the direct responsibility of the clinic personnel to insure that all staff members
have reviewed each day’s production summary report.

57

Refund Policy
Any fees paid toward any reduced-fee membership programs are generally non-refundable. The
organization should always refund any amount paid for treatment that a patient did not receive.
Individual exceptions may exist, such as interrupted denture services. Any refund requested for
denture, or other procedures requiring the use of a dental lab, should be processed less the lab
charges already incurred and as communicated with the patient. Policies along this line should be
shared with the patient prior to originating the service.
Any requests for a refund for services already provided should be directed initially to the dentist
who provided the service. Any requests for a refund for services not provided should be directed to
the front desk personnel of the clinic location where the patient has previously obtained treatment.
Patient refund requests are processed through the organization on a weekly basis. Insurance
refunds are processed through monthly. In an effort to follow proper accounting practices all
refunds should be made by check.

58

Section 5

Patient Management

Pain Management

The Concept Of Pain Control

Patient concerns regarding their perception of pain, or the pain that may be inflicted upon
them is the number one concern. This concern needs to be duly understood to manage pain
and expectations appropriately. Proper pain control both during and following a procedure is
necessary for both patient and clinician. The alleviation of human suffering should be the
primary concern of all health care professionals. Patients often justly or unjustly will judge a
dentist by her ability to provide treatment that is “painless.” The same holds true for post-
operative discomfort. A procedure which can be conducted in a painless manner reduces stress
for both the patient and the clinician. Pain can be controlled by a combination of local
anesthetic, oral medications, IV medications, distraction techniques, and inhaled gases such as
nitrous.

Local Anesthetic

The administration of local anesthetic is the primary means to provide for comfortable
treatment in the dental setting. When administered properly even the administration of
anesthetic can be virtually painless. Some key concepts that allow for a painless injection
would include:

 Appropriate use of topical anesthetic (just enough to color the cotton tipped applicator)
 Allow topical anesthetic to have contact with the tissue for approximately 30 seconds,

about the same time it takes an average doctor to glove
 Make use of the smallest-gauge needle which can be safely used
 Avoid the use of words like pain, shot, sting, and hurt
 Make use of words such as uncomfortable and pressure
 Avoid phrases such as, “I am going to give you your shot now.” Instead, make use of

lighthearted phrases such as, “I am now going to squirt some sleepy juice around your
tooth.” This phrase can be appropriate for children and adults alike.
 S-L-O-W all injections down. Each ml of anesthetic should take one minute to deposit
for both safety and comfort level. Thus each carpule of dental anesthetic should take
approximately 2 minutes to deposit. This is perhaps the most KEY ingredient to the
painless injection.


Clinicians who may have difficulty administering local anesthetic in this regard are encouraged
59

to seek professional assistance in this area.
General Local Anesthetic Dosage Recommendations*

Patient 2% Lidocaine 4% Prilocaine 4% Articaine 3% Mepivacaine
Weight (Xylocaine) (Citanest) (Septocaine) (Carbocaine)
in lbs. with 1:100,000 or
with with our without with our without
1:100,000 epinephrine 1:200,000 1:20,000 levonordefrin
epinephrine (2.7 mg. /lb.) epinephrine
(3.2 mg. /lb.) (3.2 mg. /lb.) (2.0 mg. /lb.)
Prilocaine = 72mg/carp
Lidocaine = 36 mg/carp Articaine = 72 mg/carp Mepivacaine = 54 mg. /carp.

30 ~2.5 1 ~1.25 ~1

50 ~ 4.5 ~1.75 ~ 2.25 ~2

70 ~6.25 ~ 2.5 ~3 ~2.5

90 8 ~ 3.25 4 ~ 3.25

110 ~ 9.75 4 ~4.75 ~4

130 ~ 11.5 ~4.75 ~5.75 ~4.75

Adults ~13 carps. ~5.5 Carps. 7 Carps. 5.5 Carps.
>150 Absolute Max Absolute Max Absolute Max Absolute Max

*Maximum dose per body weight Abbreviations used: ~ = approximately

Handbook of Local Anesthesia by Stanley Malamed, 2013

Nitrous Oxide Sedation

In the 1960s, nitrous oxide-oxygen experienced resurgence in popularity as a sedative agent, due
principally to improvements in delivery systems which allowed very accurate control of flow rate
and mixture proportions. Nitrous oxide is unique in that it is the only acceptable inhalation agent
available for conscious sedation.

Nitrous oxide has become the agent of choice for the management of a child’s anxiety toward
dentistry. Although proponents originally recommended it for its analgesic effect, it was not long
before children’s dentists learned to appreciate it more for its remarkable ability to reduce
anxiety—an effect obtained at lower dosages with fewer side effects. In addition to rapid onset and
recovery times, it is easily tractable and usually more acceptable to children and their parents than
enteral or parenteral forms of sedative administration. Most importantly, nitrous oxide-oxygen has
a safety record unmatched by any other agent used for conscious sedation.

60

Young children who are receiving nitrous oxide sedation for the first time do not require a detailed
explanation of what to expect. Most potentially cooperative children have less apprehension about
accepting the nasal hood than adults do. Children also do not seem to share adults’ unwarranted
fears of “losing control” and possibly doing something foolish or embarrassing during nitrous oxide
sedation. One condition regarding nitrous oxide administration does prevail with pediatric
patients—the child must be under control at the start. Attempts to “breathe down” a struggling or
hysterical child by forcefully trying to maintain the nasal hood over the nose and mouth are usually
doomed to failure. Minimal cooperation requirements include acceptance of the nasal hood and
obeying instructions to breathe through the nose.

A protocol for conscious sedation with nitrous oxide-oxygen in pediatric dentistry can be discussed
in four phases: Introduction, Induction, Maintenance, and Recovery.

Introduction: The introduction phase is applicable in pediatric patients about to experience
nitrous oxide for the first time. The introduction serves to explain the purpose of the nasal hood,
how it is to be used, and how the patient is expected to respond. The explanation will vary
accordingly to the age and sophistication of the patient, but for the very young child it must be
simple and brief. Ideally, the child and dentist are already acquainted from previous diagnostic and
preventative visits. The dentist enlists the child’s aid in positioning the nasal hood while 100%
oxygen is being delivered at a 5 liter/minute flow rate. The child is instructed to breathe only
through her nose. Conversation should be “one way” from the dentist to the child so that the child
is not obligated to respond to questions. The mood in the office should be quiet and calm.
Unnecessary noise and movement detract from the effect of sedation. Quiet praise and reassurance
from the dentist and assistant facilitate it.

Recommended Doctor Script:

(The gas mixture is adjusted incrementally from 100% oxygen to 50% oxygen over a two or three
minute period. Along with praise and reassurance, the dentist should anticipate the sensations the
child is experiencing and mention them.) You may feel like you’re floating on a cloud now and your
hands may feel like they’re tingly. That’s good. That’s what’s supposed to happen. (Then the
50/50 mixture is reached and the child appears completely relaxed.) Now Katy, I’m going to put
your tooth to sleep so we can fix it while it’s sleeping. When I put it to sleep, you might feel a little
pinch in your mouth like this (pinches the child’s lip firmly but not painfully). Now I want you to
open your mouth for me so I can put your tooth to sleep, but please keep breathing through your
nose. (After local anesthesia is given, the nitrous oxide should ordinarily be reduced to a
maintenance phase level.)

Maintenance: When treatment procedures requiring more than a very few minutes are planned,
the nitrous oxide dosage should be adjusted downward to a level between 30-40% with a

61

corresponding increase in the oxygen percentage. The flow rate remains at 5 liters/minute. This
maintenance level will greatly reduce the possibility of unpleasant side effects (primarily nausea
and vomiting) while still providing effective sedation. For very brief procedures such as a simple
extraction or incision and drainage, the nitrous oxide may be kept at a 50% level.

An optimally sedated child patient will respond readily to requests such as, “Open your eyes,
please,” or “Can you open a little wider?” Relaxation should be evident from minimal movement of
the body and extremities. Monitoring should be continuous and focus on the patient’s facial
expression, respiratory excursions, skin color, and response to occasional requests. Pallor,
perspiration, restlessness, a hard or tense facial expression, and unsolicited vocalizations are
indications the nitrous dosage is excessive and should be lowered immediately. The maintenance
phase for administration to pediatric patients should be limited to 45 minutes, preferably less for
very young children.

Recovery: Children usually require about 5 minutes of 100% oxygen for full psychomotor
recovery from the maintenance phase. In addition to psychomotor recovery, research has shown
that adequate postoperative oxygenation will significantly reduce the incidence of adverse effects
such as headache, nausea, or dysphoria. To save time, the 100% oxygenation may be started prior
to completion of the dental procedure.

Children may appear withdrawn or irritable following nitrous oxide administration. This response
is analogous to their behavior when wakened from a nap and should not cause concern.

Nitrous Oxide Sedation in Children

Nitrous oxide sedation is most applicable when used for potentially cooperative (3 years old)
children who exhibit mild to moderate apprehension about routine dental care. Frequently, it may
be used effectively in treating children with certain handicapping conditions such as cerebral palsy.
It is also useful in controlling the gag reflex when impressions are taken and in reducing the
discomfort associated with band fitting, fixed appliance cementation, and removal of very mobile
primary teeth without local anesthesia. Because nitrous oxide sedation produces a more relaxed
and quiescent patient, it also facilitates technique-sensitive procedures such as placement of
sealants or bonded brackets. Most authorities agree that it is not advisable to attempt treatment of
the recalcitrant or hysterical child with nitrous oxide as the sole sedative agent. Pediatric dentists
often use nitrous oxide as a supplement to enteral or parenteral agents to achieve conscious
sedation in patients in instances where nitrous oxide-oxygen alone would be inadequate. These
regimens, however, carry added risks and demand more sophisticated patient monitoring and
emergency capabilities.

62

Complications of Nitrous Oxide

Complications associated with nitrous oxide-oxygen sedation in children are infrequent and almost
invariably associated with poor technique. Few problems occur if the maintenance dose is kept
between 30 and 40% nitrous oxide. Dosages above 50% for prolonged periods lead to sharp
increases in adverse side effects. The most common side effect found with nitrous oxide-oxygen
sedation in children is vomiting. As stated previously, such episodes are nearly always ascribable
to over-dosage or prolonged administration. This side effect also seems to be age related in that it
occurs more frequently in younger children. Children who are especially sensitive to motion
sickness or who have a concurrent gastrointestinal infection may also be more susceptible. Some
dentists insist their child patients come to the appointment with empty stomachs but the concept
that a recent meal may contribute to the likelihood of vomiting is questionable. It may be that the
effect of emesis with a full stomach is simply more dramatic and memorable.

The dentist and office staff should be prepared to react efficiently when vomiting occurs. Vomiting
in itself is not serious, but aspiration of vomit is. The patient, if in the usual reclining position,
should be turned toward the assistant side where the vomiting is intercepted with high volume
evacuation and an emesis basin. A rubber dam, if present, is quickly removed or retracted and the
flow meter set at 100% oxygen. The interrupted procedure should then be completed as
expeditiously as possible.

Contraindications of Nitrous Oxide

There are very few medical contraindications to the use of nitrous oxide-oxygen sedation in
pediatric patients. In cases of possible compromised respiratory function, as found in multiple
sclerosis and tuberculosis, consultation with the patient’s physician may be advised.
Administration should be avoided in children experiencing otitis media since nitrous oxide rapidly
diffuses into the middle ear, increasing pressure and the potential for tympanic membrane rupture.
Nitrous oxide is not usually contraindicated in the presence of cardiac disease, sickle-cell anemia, or
asthma.

Billing and Insurance Coverage for Nitrous Oxide

Generally speaking, nitrous oxide is not a covered benefit under any insurance plan, including most
state Medicaid plans. Every state and carrier will have different benefits and limitations. Insurance
benefit aside, nitrous remains an effective agent and can be offered in situations where the patient
would benefit. Nitrous oxide is an expensive agent to administer. These costs are made up of the
hard costs associated with plumbing and fixtures, and the soft costs of the gas itself and the extra
chair time required. Most offices do charge and require a fee for the administration of this agent.
The current code is D9230. This fee should be collected UP FRONT.

63

In many states there are specific guidelines regarding use of and charging for nitrous oxide for the
Medicaid patient. Some of those guidelines will include circumstances where one may not be able
to charge for the administration of nitrous oxide:

1. If nitrous oxide is used alone to accomplish a procedure (in lieu of using local
anesthesia), the patient cannot be charged. The Medicaid Manual states, “Nitrous oxide
inhalation, in combination with oxygen alone, is classified as analgesia and is not a
separately reimbursable procedure. It is included in the reimbursement of the
procedure performed.”

2. If after a procedure has already started and local anesthesia administered, it was then
determined for some reason that nitrous oxide was needed, the patient cannot be
charged for the nitrous oxide. In this case, the patient had not been notified ahead of
time or told that nitrous oxide could be used to supplement local anesthesia.

3. If we do not charge our regular paying patients (such as our Dental Plan patients) for
the same service, we cannot charge Medicaid patients.

Circumstances where it is appropriate to charge for the use of nitrous oxide in a Medicaid patient
would include:

1. If a procedure can be done with local anesthesia, but:

a. The patient requests nitrous oxide be used and

b. If they understand that nitrous oxide is not a reimbursable Medicaid expense and

c. They understand they will have to pay for use of nitrous, then we can charge the
patient this expense.

Prescription and OTC Medications

Prescribing Policy

As part of an ongoing quality assurance review, it is not uncommon to find isolated problems with
prescriptions which are written (most often phoned in) and not entered in the patient chart. This
includes refills to existing prescriptions. As you might imagine, this could be an area for Medicaid
audit, malpractice liability, and other patient quality of care issues. It is critically vital that any
prescriptions authorized by any of an organization’s doctors be entered accurately into the patient
record.

To help eliminate missing prescription information from being entered into the computer, and
given that this most often occurs with new prescriptions or refills authorized over the phone, a
refined protocol is required. A policy for prescription refill authorization or new prescriptions is

64

that every prescription must be entered into the patient record first. The prescription is then
written, printed, faxed, or emailed off to either hand to the patient or to the pharmacy. Calling in
prescriptions or refill authorizations, while a popular practice, is generally not a good practice and
its used should be curtailed. Phoning in of prescriptions creates venues for abuse on several levels.
The use of phoned-in prescriptions should be the rare exception to the rule.

Analgesic Medications

In an effort to effectively treat patients with pain control and to minimize the amount of unused
narcotics in our respective communities, careful consideration must be implemented before opiates
are prescribed. The potential for substance abuse seems to be higher today than ever before and it
is the responsibility of the dental provider to safely provide reasonable analgesia while minimizing
narcotic misuse.

Some important points to consider are:

 Pain, at least in its initial stages, can be a good thing, as it makes people aware of problems
and drives them to action. The goal of the healthcare provider should be to eliminate pain,
or moderate it to the extent possible while receiving care.

 NSAIDS and non-narcotics should always be considered first before prescribing. One
suggestion for consideration might include 325mg acetaminophen/200mg ibuprofen in
combination. If pain is not modified by 25%, give another dosage of 325/200. (Toxicity to
the liver occurs at 4000mg acetaminophen/3200mg ibuprofen). This double dose of
650/400 can be safely taken 4 times per day. That way, if you need a rescue dose
(additional pain therapy), add your narcotic for stronger modification and patient won’t
surpass the overdosing threshold. Advise patients to take analgesics with food or yogurt to
counteract GI upset. Prilosec also works. Modify this further if allergies exist.

 Avoid narcotics if patient has documented history of depression or suicide.
 Be cognizant of drug-drug interactions.
 Narcotics should be carefully prescribed when treatment is not rendered.
 No narcotics to children; use OTC liquid Motrin or Tylenol.
 Pregnant women should have a note from OB-GYN if narcotic is prescribed.
 When narcotics are prescribed, give enough supply for 48-72 hours. If patients are upset

about this quantity they should be advised that their pain will subside within this time
period, after which OTC pain medications will control their discomfort. If they continue to
raise an issue, this may be a red flag for abuse problems. Abusers will many times act out.
Be firm about how you prescribe. The best bet is to discuss what will be prescribed prior to
the procedure. This gives the patient the option of seeking treatment with us or going
elsewhere.
 If patients use up their prescription faster than it was prescribed, then they aren’t following
your directions. Be very wary about refilling their script.

65

 If patients are still in severe pain after prescriptions have run out, ask them to come into
office. Something could genuinely be wrong (i.e., alveolitis or dry socket) which may
require further treatment and intervention. Use of discretion is required.

 Talk with your local ERs and come to a consensus about how acute dental pain should be
treated and properly resolved.

 Patients with chronic pain issues (back problems, fibromyalgia, TMD) are usually already
taking daily pain meds. What we prescribe them will typically not help. In situations like
this, we need to offer a lot of supportive therapy (TLC). Frequently, only time will heal
these patients. Simply doubling the dosages of narcotics or NSAIDS can be harmful, even
fatal, due to overdose. Patient education can go a long way here if we inform these patients
of the problem ahead of time.

 If patients have dental pain of unknown origin, refer them! In this regard, patients should
be referred to their family physician for further evaluation. Blindly prescribing without
knowing the source problem is not considered a good practice.

This list of “considerations” is in no way all-inclusive for each and every need a patient may present
with, but it’s a tool that can be used by practitioners to help keep patients and communities
healthier. There will always be individual instances where doctor discretion is needed, advised,
and utilized. Public health organizations treat a large and diverse population of people. This
population generally falls into categories which involve unhealthy lifestyles, chronic debilitating
disease, and a lack of resources needed to obtain elective or necessary care. The geriatric portion of
the population base is getting larger and these patients can have very complex medical histories.
The organization and its doctors must be proactive in treating patients with caution and integrity—
it is a sacred duty and obligation as healthcare providers.

Treatment of the Pregnant Patient

To Treat or Not to Treat

There is widespread discourse among dentist as to when pregnant patients may be treated and
how. Much of this results from lack of proper education and history with dealing with this segment
of the population. In general, OB-GYN practitioners have reported and complained that far too
often they receive consult requests for permission to treat pregnant patients for routine dental
procedures. Dentists owe it to themselves, their patients, and their physician colleagues to become
educated. By not doing so, pregnant patients far too often have treatment delayed or denied
without just cause. This is not a case of “when in doubt, refer it out,” but rather, “when in doubt, get
educated and accept responsibility for the care rendered.” A physician consult should be a request
to mitigate a current medical condition in order for the patient to receive dental treatment, or a
clarification of an existing condition. It should not be a request for permission to treat, which shirks
the responsibility of the dental practitioner.

66

In order to standardize the variability of professional opinion among dentists, a great source of
information is Dental Management of the Medically Compromised Patient, by James W. Little,
DMD, MS, et al, published by Mosby in 2002. This reference will provide guidance both as to the
timing of dental care during pregnancy, as well as what drugs may be prescribed or dispensed with
safety. It also offers guidance as to when to consult with the client’s obstetrician. After a review of
this information, the provider would be expected to develop the confidence to reserve the medical
consults for those circumstances of pregnancy that truly require consultation. While we do practice
in litigious times, using consults does not absolve one from professional responsibility to one’s
patients. Nor can we abdicate our responsibility to treat those who need us most, in their greatest
time of need.

Please keep in mind that this information is provided as a guideline only. It is not intended to be a
policy or procedural mandate for clinical decision-making. The objective is to create an
environment for patient care that provides safety with a minimum of bureaucratic precautions.

In the end, common sense and sound professional judgment, using the best information available,
must direct one’s practice.

Dental Treatment Guidelines for Pregnant Patients
In order to reduce early childhood caries, it is recommended that pregnant women receive any
needed dental care to reduce the possible transfer of Streptococcal Mutans to their newborn. It is
also desirable to reduce the possibility of dental infections, which may cause complications for the
pregnancy and may be related to preterm births.

The American Dental Association and the American College of Obstetricians and Gynecologists
encourage women to see their dentists early in their pregnancy. In numerous publications of both
organizations, they have indicated the relative safety of dental treatment rendered at any time
during pregnancy; however, the middle trimester is preferred.

In a published survey conducted in a 1992 survey of obstetricians, 91% of respondents indicated
that they preferred not to be consulted in regard to “routine” dental care. However, 88% wanted to
be consulted before the dentist prescribed antibiotics and 54% wanted a consultation before the
dentist prescribed analgesics.

This survey is similar to one conducted by MCDC for northern Michigan. The OB-GYNs in the
district were contacted in an effort to set up “standing orders” for the dental treatment of pregnant
women. Overwhelmingly, the respondents reported that their patients could safely receive dental

67

treatment during the course of pregnancy, but that precautions should be taken for exposure to X-
rays.

Whenever possible, dental radiographs should be avoided during the first trimester because the
developing fetus is particularly vulnerable to radiation damage. Should dental treatment become
necessary, radiographs may be required to adequately diagnose and treat the patient. The minimal
amount of exposure that the fetus receives during a full-mouth series when a lead apron is used is
well below the limits for safety. Data clearly supports that radiation exposure less than 5 to 10
CentiGray (cGy) will not increase congenital abnormalities. A typical full-mouth series of
radiographs results in 0.00001 cGy of exposure.

As mentioned, it is generally agreed upon that the second trimester is the safest period in which to
provide routine dental care. Emphasis should be placed on controlling active disease and
eliminating potential problems that could occur later in pregnancy, or in the immediate postpartum
period. Providing dental care during these periods may be difficult. The table below is a general
guideline, which is not intended to replace individualized and professional judgment.

Considerations as to Timing Treatment in the Pregnant Patient

First Trimester Second Trimester Third Trimester

Plaque control Plaque control Plaque control

Oral Hygiene Instruction Oral Hygiene Instruction Oral Hygiene Instruction

Scaling, polishing, curettage Scaling, polishing, curettage Scaling, polishing, curettage

Avoid elective treatment Routine dental care Routine dental care

Urgent care only

As with all patients, monitoring vital signs is important—particularly blood pressure due to the fact
that prolonged time in the dental chair may cause supine hypotension. Scheduling shorter
appointments may help minimize problems.

Drug Administration and Drug Categories in Pregnancy
Before prescribing or administering a drug to a pregnant patient, the dentist should be familiar
with the FDA categorization of prescription drugs for pregnancy based on their potential risks. A
provider should be familiar with the categories and which categories the medications they
prescribe fall into. The categories are summarized as follows:

68

 Category A: Controlled studies in women fail to demonstrate a risk to the fetus in the first
trimester (and there is no evidence of a risk in later trimesters), and the possibility of fetal
harm appears remote.

 Category B: Either animal-reproduction studies have not demonstrated a fetal risk but
there are no controlled studies in pregnant women or animal-reproduction studies have
shown an adverse effect (other than decrease in fertility) that was not confirmed in
controlled studies in women in the first trimester (and there is no evidence of a risk in later
trimesters).

 Category C: Either studies in animals have revealed adverse effects on the fetus
(teratogenic or embryocidal or other) and there are no controlled studies in women or
studies in women and animals are not available. Drugs should be given only if the potential
benefit justifies the potential risk to the fetus.

 Category D: There is positive evidence of human fetal risk, but the benefits from use in
pregnant women may be acceptable despite the risk (e.g., if the drug is needed in a life-
threatening situation or for a serious disease for which safer drugs cannot be used or are
ineffective).

 Category X: Studies in animals or human beings have demonstrated fetal abnormalities or
there is evidence of fetal risk based on human experience or both, and the risk of the use of
the drug in pregnant women clearly outweighs any possible benefit. The drug is
contraindicated in women who are or may become pregnant.

Drug Administration during Pregnancy and Breast-Feeding
This table is provided as a generalization of commonly prescribed medications dispensed to
pregnant patients.

69

70

Caring for Children in the Dental Office

Policy Statement for Children’s Care

Pleasant visits to the dental office promote the establishment of trust and confidence in children
that can last a lifetime and lead to improved oral health. The establishment of a comfortable “dental
home,” as endorsed by the ADA and the American Academy of Pediatric Dentistry, is central to a
lifetime of good oral health habits.

It is great fortune when a dental public health organization is able to retain pediatric dentists on
their professional staff. The rigorous training required during a pediatric residency prepares these
dental specialists to meet the unique needs of infants, children, and adolescents, including those
with special healthcare needs. They are current on the latest advances in oral health care for
children, are well versed in guiding proper growth and development, and are able to deliver the
highest quality care possible. Additionally, many of the younger patients benefit from the advanced
behavior modification and guidance techniques that pediatric dentists are experienced in.

With a pediatric dentist among the professional staff, children eight years old and younger should
be seen by the pediatric dentist at their initial comprehensive exam. For existing patients of this
age category, every effort should be made so that at the preventive visit the re-care exam is
conducted by the specialist. At that time the pediatric dentist should make the determination if that
patient would be best cared for by continuing to see the pediatric dentist for future operative
appointments, or if that patient can “graduate” to the care of a general dentist. In those clinics
where there are no pediatric dentists, children should continue to be seen by a general dentist
unless a specialty referral is deemed appropriate.

A policy such as this will provide for exemplary care for the patients and adhere to the best practice
policies set forth by the American Dental Association and the American Academy of Pediatric
Dentistry.

Guidelines for the Care of Children in the Hospital Setting

In some instances it is not possible to render quality care in the office setting to children and adults
that may have mental or emotional challenges that cannot be adequately addressed in the
operatory. In this scenario the patient is best referred for treatment in the hospital setting.
Generally for Medicaid and other insurance carriers to extend a benefit for hospital care, it is
usually required that a documented attempt was made to treat the patient in the operatory of the
dental facility without success. Once that criterion has been met, those patients that may fall into

71

this category would include:

 Children under age four with multiple areas of decay who are uncooperative in office
setting. In many states patients of this age are frequently pre-approved for this service,
under Medicaid and other plans, based upon their age alone.

 Another category would be children over four who may require a total of six or more
teeth extractions, restorations, other procedures performed in two or more quadrants
of the mouth, and one of the following:

o Patients have a high-risk medical condition that does not permit the
procedure to be performed safely under local anesthesia.

o Infection that does not allow the use of local anesthesia.

o Extensive oral-facial and/or dental trauma for which treatment under local
anesthesia would be ineffective or compromised.

 For children age five and over, treatment should be attempted under some type of
conscious sedation, such as nitrous.

 Adults are generally limited to a hospital benefit only when developmentally
disabled/medically compromised conditions are present. In almost every case
Medicaid will deny a benefit based upon anxiety alone.

Treatment of Patients with a Medically Compromised Status

Patients and Systemic Health
When viewed as a whole, patients seeking care within a public health center are generally sicker
and on more medications than the population at large and those visiting a private dental office.
Given this reality it is prudent for the public health dentist to remain vigilant to the medical status
of every patient and mitigate medical concerns with proper treatment and accommodations for
treatment. Below are suggestions for consideration with patients presenting with the stated
conditions. These protocols were published by Peter L. Jacobsen, Ph.D., D.D.S. at the University of
the Pacific, School of Dentistry.

Bleeding Problems or Patients on Anticoagulants

Pertinent questions to consider with this patient would include:

 How long have you had a bleeding problem or, depending on the situation, how long have
you been on anticoagulant medication?

 Describe your bleeding problem.
 Have you had problems with previous dental appointments?

72

 What is the cause of your bleeding problem or why are you on anticoagulants?

 Are your anticoagulants or bleeding problems due to low platelets?

 What are your most recent laboratory results relative to your anticoagulation or bleeding
problem status?

Pertinent diagnostic tests to consider for the stated conditions would include:

 A patient with bleeding problems secondary to liver disease
o PT-prothrombin time
o PTT-partial thromboplastin time
o INR-international normalized ratios

 A patient on aspirin and other non-steroidal anti-inflammatory agents
o Bleeding time

 A patient with thrombocytopenia
o CBC with a differential (which will give platelet count)
o Bleeding time

 A patient on anticoagulant or Warfarin therapy
o PT
o INR

Management of a patient with potential bleeding problems during dental treatment

 No type of dental treatment should be rendered that has the potential for severe bleeding
(i.e. multiple extractions, scale/root plane)
o If bleeding time greater than 10 minutes
o If platelet count less than 60,000
o If PTT greater than 45 seconds
o If PT greater than 22 seconds
o If INR greater than 3.5

 If bleeding parameters are greater than above, medical coordination is required. For
example, physician should decrease anticoagulant or provide packed platelets or prescribe
supplemental vitamin K until bleeding parameters are brought into line consistent with
dental treatment.

 If hemophilic, consider having physician administer proper replacement factors and run
necessary test to insure patient is within safe parameters.

 During dental procedures minimize physical trauma and pack extraction sites that have the
potential to bleed with local pressures and other coagulation procedures, i.e., Gelfoam.
Obtain primary closure on any surgical sites, if possible.

 Establish primary closure and/or put pressure on potential/actual bleeding site.

With bleeding problems be on the alert for:

 Easy or prolonged bleeding with minimal trauma (i.e., probing, wedge placed between teeth
for amalgam matrix).

 Easy bruising/multiple bruises.

With bleeding problems consider these preventive measures and precautions

73

 Assure the patient is aware of necessary lab tests that should be done close to the time of
dental treatment (within a week, or closer if they have had previous problems). Some
bleeding parameters can change quickly.

 Avoid drugs that may cause interaction, such as erythromycin and ketoconazole, which
inhibit Warfarin metabolism. Also avoid drugs that can prolong bleeding, such as aspirin or
other non-steroidal anti-inflammatories.

 Encourage patient to keep you informed of any drug changes and use of any over-the-
counter medications.

 If patient calls from home following treatment, instruct her to apply pressure with gauze or
cloth to bleeding site for 10-30 minutes. If bleeding persists, have patient come into office
immediately or go to a medical emergency room.

Patients with Cardiac Problems, Heart Murmurs, and other Adverse Cardiac Effects

Questions to Ask/Necessary Information

 Can you tell me when your heart condition was first diagnosed?
 Have you ever been hospitalized because of your heart problem?
 Did the doctor ever say you needed prophylactic antibiotics prior to dental treatment?
 Did the doctor ever say you didn’t need prophylactic antibiotics prior to dental treatment?

Diagnostic Tests

In the event a patient cannot relate a history of the specific cardiac problem, a medical consult may
be initiated to identify the type of heart problem and whether prophylactic antibiotics are needed.

ADA Prophylactic Infective Endocarditis Guidelines

For decades, the American Heart Association (AHA) recommended that patients with certain heart
conditions take antibiotics shortly before dental treatment. This was done with the belief that
antibiotics would prevent Infective Endocarditis (IE), previously referred to as Bacterial
Endocarditis. The AHA’s latest guidelines were published in the Journal of the American Dental
Association in 2008 139(1) Special Supplement. The AHA recommends that most of these patients
no longer need short-term antibiotics as a preventative measure before their dental treatment.

The American Dental Association participated in the development of the new guidelines and has
approved those portions relevant in dentistry. The guidelines were also endorsed by the Infectious
Disease Society of America and by the Podiatric Infectious Diseases Society. These guidelines can
change any time and it behooves the practitioner to stay abreast of the most current thinking and
recommendations in this area.

The guidelines, published in 2008, are based on a growing body of scientific evidence that shows
the risks of taking preventative antibiotics outweigh the benefits of most patients. The risks include
adverse reactions to antibiotics that range from mild to potentially severe and, in very rare cases,

74

death. Inappropriate use of antibiotics can also lead to the development of drug-resistant bacteria.

Research scientists have also found no compelling evidence that taking antibiotics prior to a dental
procedure prevents IE in patients who are at risk of developing a heart infection. Their hearts are
already often exposed to bacteria from the mouth, which can enter their bloodstream during basic
daily activities such as brushing and flossing. The new guidelines are based on a comprehensive
review of published studies that suggests IE is more likely to occur as a result of these everyday
activities than from a dental procedure.

The guidelines of 2008 now exclude the majority of patients who were previously recommended to
receive prophylactic antibiotics, including patients 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 2008 guidelines are aimed at patients who would have the greatest danger of bad sequelae if
they were to develop a heart infection. Given this, preventative antibiotics prior to dental
procedure are now only routinely advised for patients with:

 Artificial heart valves
 A history of IE
 Certain specific, serious congenital heart conditions, including:

o Unrepaired or incompletely repaired cyanotic congenital heart disease, including
those with palliative shunts and conduits.

o A completely repaired congenital heart defect with prosthetic material or device,
whether placed by surgery or catheter intervention, during the first six months after
the procedure.

o Any repaired congenital heart defect with residual defect at the site or adjacent to
the site of a prosthetic patch or a prosthetic device.

 A cardiac transplant that develops a problem in a heart valve.

Practitioners should always use sound clinical judgment and check with a patient’s cardiologist
when there are concerns regarding an individual patient’s need that are not adequately addressed
within the current guidelines. The ADA maintains the most current recommendations and the
practitioner may contact the ADA Division of Science for further information. The
recommendations here are based upon the 2008 American Heart Association Guidelines for the
prevention of IE.

75

Standard AHA Regimen
76

If patient is unsure whether prophylactic antibiotics are needed and contact with the physician is
not possible, then treat with standard guidelines (if emergency) or refer patient for medical consult
to establish need or lack of need for antibiotic prophylaxis. Proper documentation in the chart
should include the time and dosage of antibiotics taken for prophylaxis.

Even with SBE prophylaxis it is always prudent to observe patients. What is first observed is that
flu-like symptoms can occur within two days, most commonly within two weeks, and rarely within
four weeks following dental procedures. Such symptoms can be signs of bacterial endocarditis,
even if the patient has been properly administered a prophylaxis antibiotic. If such symptoms are
present, the patient should see his/her physician.

Treating Patients with Other Cardiovascular Disease and Related Problems

Patients in this category include high blood pressure, arrhythmia, congestive heart disease and
angina pectoris.

Questions to Ask/Necessary Information

High Blood Pressure

 How high does your blood pressure get?
 Do you know what your blood pressure usually is?
 What is your blood pressure when you are taking medications?
 Have you had any problems/side effects with your blood pressure medication?
 Have there been any recent changes in your medications?
 Have you ever had hypertensive episodes when the high blood pressure could not be

controlled?
 Have you ever had to postpone dental treatment or had any problems with dental care,

relative to your blood pressure?
 Did you take your medication today?

Arrhythmia

 What kind of arrhythmia do you have?
 What triggers the arrhythmia episodes?
 Do you take your medication for your arrhythmia? If so, what medication, and did you take

it today?
 Is the arrhythmia effectively controlled with medication?

Congestive Heart Disease

 Do you get chest pains on exertion?
 Can you walk up a flight of stairs without needing to rest to catch your breath or getting

chest pains?
 Do you take medications for your congestive heart failure? If so, did you take them today?

77

Diagnostic Tests

 High Blood Pressure
o Take blood pressure.
o Depending on situation, take blood pressure at beginning and end of appointment.

 Arrhythmias
o Take patient’s peripheral (radial, carotid) pulse and feel for arrhythmia.

 Congestive Heart Disease
o Stress test by M.D.

Management of a Hypertensive Patient during Dental Treatment:

In patients with controlled high blood pressure, using local anesthetic with a vasoconstrictor such
as 1:100,000 epinephrine or its equivalent is appropriate. The ADA suggests a maximum of 40 mg
(=2 cartridges of 1:100,000 epi) then waiting for at least 10 minutes. If no problems arise,
additional cartridges can be administered. For patients with blood pressure above 140/90,
epinephrine impregnated retraction cord should be avoided.

Blood Pressure Classifications and Dental Treatment Recommendations

Blood Pressure Systolic BP mm Diastolic BP mm Dental Txt Significance Blood Pressure
Recording
Classification Hg Hg

Normal <120 And <80 OK Annually

Pre- 120-139 Or 80-90 OK – advise MD consult Annually
hypertension

Stage 1 140-159 Or 90-99 OK – refer to MD for Every visit
hypertension consult

Stage 2 ≥160 ≥100 OK to txt emergency only Every visit
hypertension – no elective care; refer
to MD for txt of
hypertension

Major Concern ≥210 and/or ≥120 DO NOT TXT – get to MD N/A
ASAP

Arrhythmia or Congestive Heart Failure
 If patient’s arrhythmia or congestive heart failure is controlled, no special precautions
necessary.

78

 If patient has an arrhythmic or congestive heart failure (angina pectoris) episode, dental
treatment should be delayed. If arrhythmia occurs in the midst of treatment and it must be
completed, discontinue until heart rhythm stabilized (may require hospitalization for cardio
version), then complete treatment quickly and calmly.

 If angina pectoris occurs, stop treatment, administer oxygen, minimize stress and wait until
the pain resolves. Continue as needed, if necessary and patient feels capable of completing
to a safe stopping point.

 Local anesthetic with vasoconstrictor (1:100,000 epinephrine or equivalent) is appropriate.
1:50,000 concentration of epinephrine or equivalent should be avoided. Epinephrine
impregnated retraction cord should not be used.

Be Alert For High Blood Pressure

 Request patients inform you if they feel as though their blood pressure is increasing or if
they are getting a headache. Some patients feel jittery; others feel as though there is
increased pressure behind the eyes.

 Profuse bleeding, beyond what would be expected.

Be Alert for Arrhythmia

 Request patients inform you if they feel an arrhythmia. Sometimes this manifests as a
coughing or catching feeling in the chest. Other times it is a feeling of light-headedness.

Preventative/Precautions
Be reassuring with the patient. Under no circumstances should you panic, as that will only increase
the patient’s anxiety, which will cause the blood pressure to increase or the arrhythmia to intensify
or be prolonged. An alert, concerned, everything-is-in-control, we-know-what-is-happening-and-
everything-will-be-fine, professional demure is appropriate.

Central Nervous System (Seizures, Stroke)

Questions to Ask/Necessary Information

Stroke
 When did you have your stroke?
 What loss of function occurred?
 Have you recovered some function over time?
 Have you ever had trouble with dental appointments or medical appointments?
 Is there anything I need to know that will make you more comfortable or make it easier for
you to deal with the dental appointment?
 Are you taking any medication related to the stroke or to prevent another stroke? If so,
what medication?
 Good oral hygiene should be strongly encouraged. It is found that the better the patient’s
oral hygiene, the less likely or less severe gingival hyperplasia will occur secondary to
Dilantin use.

79

Seizures

 What type of seizure do you have?
 What stimulates a seizure and do you have an aura prior to the seizure?
 What is the cause of your seizures? (i.e., head injury, born with problem)
 How frequently and when (time of day) do they usually occur?
 What type of medications are you taking to control the seizures?
 Does the medication work?
 Do you take the medication regularly or do you discontinue it at times? If you did

discontinue, was it your decision or your doctor’s and what happened?

Diagnostic Tests

Stroke

 If patient taking anticoagulant, then assess bleeding status (see bleeding problems
management protocol).

Seizure

 If patient unclear about types of seizure or medications, and seizures are poorly controlled,
then medical consultation for the above information will be needed.

Management during Dental Treatment

Stroke
 No special treatment considerations are necessary except those that the patient notes could
be of value (modifying dental treatment procedures based on the patient’s perceived needs
has an enormous positive psychological benefit for the patient).
 Depending on what areas have lost function, especially if the head and neck or oral cavity
area are affected, certain types of dental prostheses may or may not be effective, i.e.,
removable prostheses may not be effectively retained without adequate muscle tone, so
fixed prostheses or implant may be needed.

Seizures

 Schedule patient early morning when they are well rested.
 Patient should be instructed to take their medication properly for at least the several days

prior to the dental appointment.
 Patient should be questioned at dental appointment whether in fact they have taken the

medication correctly.
 If seizure occurs, it should be allowed to run its course. The primary concern will be

protection of the patient and protection of the dentist and staff so the patient doesn’t hurt
them.
 Following a seizure, the decision to continue or discontinue treatment is based on the
patient’s condition (does the patient feel like he/she can complete the procedure?) and the
treatment needed.

80

Be Alert For Stroke

 Signs of recurrence of stroke, such as slurred speech, confusion, loss of balance and inability
to hold saliva in mouth, and transient ischemic attacks (TIA) manifest as fainting and
dizziness, with spontaneous recovery.

 Alert patient’s guardian to any new stroke signs or symptoms so physician can follow up.
 If patient taking anticoagulants, review bleeding problem protocol for additional alerts.
 If stroke has affected swallowing, suction frequently.
 If stroke has affected eyelids, protect/cover eyes as needed.

Be Alert for Seizures

 Be alert to dental/oral damage secondary to seizure.
 Be aware of possible gingival hyperplasia secondary to Dilantin.

Preventative/Precautions

Strokes and Seizures

 Minimize stress, avoid procedures that may cause spiking of blood pressure, and consider
pre-procedural anti-anxiety medication such as Valium, if patient is fearful.

Diabetes

Questions to Ask/Necessary Information

 Age first diagnosed?
 Type of diabetes?
 Medication being taken?
 If insulin is being taken, what is time interval and amount?
 How often do you check your blood sugar?
 Have you been hospitalized during the past year for problems related to your diabetes?
 Is your diabetes well controlled or does it get out of control at times?

Diagnostic Tests

 Fasting blood sugar (reflects current control, that day) (>126 mg/dL).
 Random plasma glucose > 200 mg/dL with symptoms (polyuria, polydipsia, unexplained

weight loss).
 Two-hour plasma glucose > 200 mg/dL following a 75g glucose load.
 Frutosamine test (reflects average control over last 2-3 weeks).
 Glycated hemoglobin (reflects average control over last 6-8 weeks) (>7%=problem).

Management during Dental Treatment
 Patient should have eaten a balanced meal (includes fat and protein as well as
carbohydrates) within the last two hours before coming to the dental appointment.

81

 Patient should have taken their medications (if they take medications).
 Food (Power Bar or some other balanced nutritional supplement) should be available if

appointment lasts longer than two hours.
 Early morning appointments.

Be Alert For

 Periodontal problems.
 Candidiasis/Xerostomia.
 Poor response to treatment, especially periodontal therapy.
 Poor healing.
 Slow healing.
 Any dental infection should be treated promptly, i.e. with antibiotics and appropriate

incision and drainage.

Preventative/Precautions

 Good home care.
 Good glucose control.
 Take medications predictably.

Immunosuppression

Diseases – HIV, Leukemia, Primary Immunosuppressive Diseases
Medications – Cancer chemotherapeutic agents, immunosuppression drugs used in organ
transplant patients, corticosteroids to suppress severe auto-immune diseases.

Questions to Ask/Necessary Information

Questions should be designed to evaluate the severity of the immunosuppression and the reason
for it. Questions will vary depending on the reason the patient reports for immunosuppression.

 Why are you immunosuppressed?
 How long have you been immunosuppressed?
 Have you been hospitalized because of problems resulting from your immunosuppression,

i.e., infections?
 Are you taking any prophylactic medication to prevent infections because of your

immunosuppression?
 Has your doctor said that any special precautions should be taken during medical or dental

treatment to prevent prophylaxis against possible infections?

Diagnostic Tests

 CBC with a differential (especially platelet count, if planning surgery).
 T-suppressor cell count (HIV patients).
 Viral load (HIV patients).

82

Management during Dental Treatment

 Depending on severity of immunosuppression, laboratory tests, primarily CBC with
differential, should be done immediately (within 5 days) of major invasive procedure, i.e.,
extractions, scaling and root planning, periodontal surgery.

 If white count below 2,000, no elective treatment until white count restored.
 If platelet count is less than 60,000, no elective treatment. If emergency treatment is

needed with the risk of bleeding, then have physician give the patient packed platelets prior
to procedure.
 If patient is severely immunosuppressed and infection is present, consider prophylactic
antibiotics prior to surgical or periodontal surgical procedures.
 Institute aggressive treatment of any dental infection, including antibiotics, incise and drain,
and proceed with any necessary endodontic procedure of extraction.
 Aggressively control any periodontal disease with proper cleaning and supplemental
medication such as chlorhexidine rinse.

Be Alert For

 Periodontal infections.
 Yeast infections.
 Viral infections.
 Periapical problems, impacted teeth, poorly done endodontic procedures, oral ulcerations.

Preventative/Precautions

 Prior to organ transplant or when patient is most immunocompetent, consider aggressive
dental therapy to remove/resolve any possible dental problems, i.e., scale/root plane for
periodontal disease, extract impacted teeth, complete any needed or expected endodontic
procedures. Consider extracting teeth with compromised endodontic prognosis.

 Good oral hygiene.
 Prophylaxis for viral and fungal infections.

Patient told to alert dentist or physician at first sign of any infection.

Infectious Diseases

(Tuberculosis, Hepatitis, HIV, Herpes, the Flu)

Questions to Ask/Necessary Information

Tuberculosis

 When were you diagnosed?
 Are you still having symptoms of active infection, such as coughing? Night sweats?
 What medications have you taken and for how long?

83

 Have you taken them as directed?

Hepatitis

 What type of hepatitis do you have?
 Are you actively infected at this time?
 Have you had any signs or symptoms of your hepatitis?
 Have you had any change in your liver function tests?
 Have you taken any medications specifically to treat your hepatitis?
 If you had hepatitis B, do you know your hepatitis antigen status?

HIV

 When do you believe you may have been first infected?
 What is your current CD4 t-cell count?
 What is your current viral load?
 Have you had any bleeding problems?
 Have you had any specific diseases related to HIV infection?
 Are you taking any specific medications for HIV infection?

Herpes/Flu (risk associated with these diseases is transmission to the healthcare provider)
 Are you actively infected at this time?

Diagnostic Tests

Tuberculosis

 If tuberculin test is positive, then an X-ray should be done.
 If X-ray is positive or if there is obvious active infection, then sputum test for tuberculosis

bacilli should be done.

Hepatitis

 Hepatitis antigens and antibodies should be run.
 If patient has active hepatitis, then liver function should be run or request physician provide

information as to liver function and coagulation status.

HIV
 Current laboratory tests including t-cell count, viral load, CBC with a differential to give to
give platelet count and white count should be done (see protocol for immunosuppression).

Herpes/Flu
 No specific laboratory tests need to be run.

84

 If patient is interested in which type of herpes they have, type 1 versus type 2, then
antibody tests can be run.

Management during Dental Treatment
Tuberculosis

 No elective treatment rendered until physician says patient is not infectious (sputum
negative).

 If emergency treatment is necessary, patient should be treated in a level 3 infection control
facility with hepa filter mask and laminar airflow.

 In an actively infected patient, the air expelled when coughing is infectious and should be
avoided.

Hepatitis

 Since all patients are treated as though they are infectious and universal precautions are
applied, no special precautions are necessary when treating a patient actively infected with
the hepatitis virus (if patient is having liver problems secondary to hepatitis, then review
liver protocol).

HIV

 If patient has HIV but has had no medical problems, then no special precautions are needed.
 Since all patients are treated as though they are infectious, the usual universal precautions

are adequate for management.
 If patient has signs and symptoms of immunosuppression, refer to protocols for patients

with immunosuppression.
 Review the patient’s medications and any dental medications that may be used, to ensure

no drug interaction.

Herpes/Flu

 Since all patients are treated as though they are infectious, the normal universal
precautions apply and patient is safe for treatment.

 If patient doesn’t feel strong enough for dental treatment, he/she should be re-appointed.
 If patient having herpes attack, no special precaution is necessary, though patient may want

to have herpetic ulcer lubricated or even topical anesthetic applied to minimize discomfort
associated with manipulation of oral activity.

Be Alert For
Tuberculosis

 Oral ulceration or head and neck ulceration. Advanced forms of tuberculosis can manifest as
what is termed caseating necrosis. Clinically it appears as an ulceration. These ulcers have

85